Massive scrotal haematoma: a complication of percutaneous transluminal angioplasty

Scrotal haematoma is an unusual complication following percutaneous transluminal angioplasty. It carries significant morbidity and causes extreme discomfort to the patient. We describe the case of a 75-year-old diabetic man who developed this complication. Recommendations are made for investigation and management of this problem, which is so infrequently encountered in clinical practice.

Development and validation of a self-report symptom inventory to assess the severity of oral-pharyngeal dysphagia

BACKGROUND & AIMS

The aim of this study was to develop and evaluate the validity and reliability of a self-report inventory to measure symptomatic severity of oral-pharyngeal dysphagia.

METHODS

Test-retest reliability and face, content, and construct validity of a prototype visual analogue scale inventory were assessed in 45 patients who had stable, neuromyogenic dysphagia.

RESULTS

Normalized scores varied over time by -0.5% +/- 17.6% (95% confidence interval, -9.2% to 8.2%). Factor analysis identified a single factor (dysphagia), to which 18 of 19 questions contributed significantly, that accounted for 56% of total variance (P < 0.0001). After deletion of 2 questions with poor face validity and patient compliance, this proportion increased to 59%; mean test-retest change was -2% (95% confidence interval, -11% to 7%); and total score correlated highly with an independent global assessment severity score (r = 0.7; P < 0.0001). A mean 70% reduction in score (P < 0.0001) was observed after surgery in patients with Zenker's diverticulum (discriminant validity).

CONCLUSIONS

Applied to patients with neuromyogenic dysphagia, the 17-question inventory shows strong test-retest reliability over 2 weeks as well as face, content, and construct validity. Discriminant validity (responsiveness) has been demonstrated in a population with a correctable, structural cricopharyngeal disorder. Responsiveness of the instrument to treatment in neuromyogenic dysphagia remains to be quantified.

Outcome evaluation in nursing in Australia, 1960-1980

While empirical evaluation of the outcome of patient care has come to the fore in recent years due to political initiatives, there has always been a professional interest by nurses in the end result of their care. A review of the literature shows that outcome evaluation was advocated for nursing as early as the 1860s by Florence Nightingale. This article explores the evolvement of outcome evaluation within nursing in Australia, discussing its origins during the 1960s and 1970s. The measurement of patient outcomes is more relevant than ever before, with the recent drive for an evidence-based approach to nursing care.

Measuring outcomes from the patients' perspective

This descriptive study examines the outcomes of care from the perspective of patients following a recent orthopaedic admission at a teaching hospital in Sydney. Results were extracted and analysed from transcripts of audio-taped focus groups. Participants identified five nursing activities that made a positive difference to patient outcomes. These activities were: (i) patient-controlled analgesia; (ii) water-filled gloves placed under patients' heels; (iii) cream rubbed into patients' heels; (iv) an explanation, at pre-admission clinic, of the impending operation; and (v) being informed about the details of their treatment while in hospital. Three activities that participants felt made a negative difference to their outcome were also identified, as were seven activities not performed by nursing staff that participants felt would have made a positive difference to their outcome. The results from this study reinforce the importance of basic nursing care, and the value of measuring outcomes, not only from the professional perspective, but also from the patients' viewpoint.

Comparing professional and patient outcomes for the same episode of care

Following an acute hospital admission, patients' perceptions of the acceptability of their own outcomes were compared with professionally derived outcomes of care developed for the same patients by nurses. Professional opinion was obtained from the Nursing Practice--Casemix and Outcomes Project undertaken by the Sydney Metropolitan Teaching Hospitals Nursing Consortium, where patient outcomes were classified by nurses into three groups: Outcomes Acceptable; Outcomes Not Acceptable but Justified and Outcomes Not Acceptable and Not Justified. Fifteen male patients in the present study discussed their outcomes following recent orthopaedic surgery at a series of focus groups organised according to the three outcome categories. Findings from the study showed the majority of patients were satisfied with their outcomes. Patient agreement with nurses regarding the acceptability of outcomes was highest for patients from the Outcomes Acceptable group and lowest for those from the Outcomes Not Acceptable and Not Justified group. This work is significant in that it is one of the first nursing studies to compare outcomes developed by practitioners for a particular group of patients with actual outcomes experienced by the same group of patients.

Glutamine oxidation and utilization by rat and human oesophagus and duodenum

The rates of utilization and oxidation of glutamine and glucose by oesophageal and duodenal tissues have been investigated in both rats and human subjects. In the rat, glutamine utilization by oesophageal tissue was 2-3-fold lower than that in the duodenum, and this substrate contributed less than 10% to the total oxidative metabolism of the tissue, even when glutamine was the only substrate provided. In contrast, rat duodenal tissue derived about 34% of the total CO2 production from glutamine-C, and this contribution was not suppressed by the addition of either glucose or a mixture of the other substrates. Rates of glucose utilization and oxidation by the duodenum were lower than those for glutamine, and were significantly (P < 0.001) suppressed by addition of glutamine. In both oesophageal and duodenal tissues, less than 10% of the glutamine-C utilized was fully oxidized, approximately 60-70% was converted to glutamate, and 30-40% to alanine. Results obtained using human biopsy tissue samples were similar to those observed in the rat. Glutamine oxidation contributed 34 (SD 4)% of the total CO2 production by the duodenal tissue, but only 8 (SD 4)% to oesophageal tissue oxidation. The findings suggest that glutamine is not an important or preferred fuel for oesophageal tissue, whereas it is for duodenal tissue. Thus, these tissues can be expected to respond differently to glutamine administration.

[Value of human colonic cancer models by surgical cecal implantation in nude mice]

A better understanding of the nature and treatment of colon cancer, and of by metastatic dissemination should be achieved by the use and study of appropriate animal models. Such models can be created by grafting human cancer cells or tumour fragments orthotopically into the colon or caecum of nude mice. This review examines the rationale behind these models and the principal results of orthotopic transplantation. Despite the fact that they require surgical expertise and are time-consuming, they provide valuable information on the mechanism of metastasis and the efficacy of novel treatments.

Fibrinogen-coated albumin microcapsules reduce bleeding in severely thrombocytopenic rabbits

Severe thrombocytopenia frequently occurs in patients receiving chemotherapy and in patients with autoimmune disorders. Thrombocytopenia is associated with bleeding, which may be serious and life threatening. Current treatment strategies for thrombocytopenia may require transfusion of allogeneic platelets, which is associated with serious drawbacks. These include the occurrence of anti-platelet antibodies, which may result in refractoriness to further platelet transfusions, and the potential risk of transfer of blood-borne diseases. Therefore, we have recently developed a platelet substitute product (Synthocytes), which is composed of human albumin microcapsules with fibrinogen immobilized on their surface. Here we show that the intravenous administration of these microcapsules not only corrects the prolonged bleeding time in rabbits rendered thrombocytopenic either by anti-platelet antibodies or by chemotherapy, but also reduces bleeding from surgical wounds inflicted in the abdominal skin and musculature. No potential systemic prothrombotic effect of the microcapsules was observed in a model of rabbit venous thrombosis. As for the mechanism of action, experiments with normal and thrombocytopenic human blood in an endothelial cell matrix-coated perfusion chamber demonstrated an interaction between the fibrinogen-coated albumin microcapsules and native platelets. It was shown that the fibrinogen-coated albumin microcapsules could facilitate platelet adhesion to endothelial cell matrix and correct the impaired formation of platelet aggregates in relatively platelet-poor blood. This study indicates that fibrinogen-coated albumin microcapsules can act to improve primary hemostasis under thrombocytopenic conditions and may eventually be a promising agent for prophylaxis and treatment of bleeding in patients with severe thrombocytopenia.

Exploring the precursors of outcome evaluation in Australia: linking structure, process and outcome by peer review

Reviews of the structure of the health system and the processes that contributed to them were the main forms of evaluation within nursing in Australia during the 1970s and 1980s. The documentation of the end result of care, or outcome evaluation, was rarely undertaken until more recent times. The development and implementation of formal assessment tools such as Qualpacs, the Phaneuf Nursing Audit, the Rush Medicus Nursing Process Methodology, Monitor, and Senior Monitor indicated the focus on structure and process evaluation. This paper examines how nursing care delivered to patients during the l970s and 1980s was evaluated, and explores why structure and process review were necessary precursors to outcome evaluation in the nineties. The necessity of linking structure and process analysis is discussed, in order to perform effective outcome evaluation to close the feedback loop between quality assessment and quality improvement. Peer review is one mechanism that can be used to achieve this. How this may also be a form of evidence-based practice which results in health gains for patients is also explored.

Distribution of glutaminase and glutamine synthetase activities in the human gastrointestinal tract

1. The activities of the two key enzymes involved in glutamine metabolism, glutaminase and glutamine synthetase, were measured in mucosal biopsies taken from different sites throughout the human gastrointestinal tract, from oesophagus to rectum. 2. The specific activity of glutamine synthetase was highest in the stomach (4.5 nmol glutamine formed per minute per mg of protein), but both small and large intestine and the oesophagus had little synthesizing capacity (less than 0.3 nmol of glutamine formed per minute per mg of protein). 3. Glutaminase specific activity was highest in the small intestine (53 nmol glutamate formed per minute per mg of protein by duodenal mucosa), intermediate in the large intestine and lowest in the oesophagus and stomach (less than 13 nmol of glutamate formed per minute per mg of protein). 4. The glutamine concentration in the mucosa was lower in the duodenum than in the colon (0.62 and 0.95 mmol/kg wet weight respectively), but both were much lower than the measured K(m) values of glutaminases obtained from these sites (3.8 and 4.0 nmol/kg wet weight respectively). 5. The concentration of glutamine in saliva, stomach juice, bile and duodenal juice suggests that very little glutamine passes into the gastrointestinal tract via these secretions. 6. The study provides the most complete information on the distribution of glutamine synthetase and glutaminase along the human gastrointestinal tract, and suggests that (i) both the small and large intestines have a high potential for glutamine metabolism, but little synthesizing capacity, thus both must derive their glutamine from other sources, and (ii) neither the stomach nor the oesophagus have a high glutaminase activity, although the stomach has substantial capacity to synthesize glutamine. The distribution of the enzymes along the gastrointestinal tract may help rationalize the use of glutamine for treating diseases that affect different parts of the gastrointestinal tract.

Rat plasma triglycerides and hepatic fatty acid synthetase mRNA, but not apolipoprotein B and A-IV mRNA, respond to dietary fat content

The objective was to determine whether apolipoprotein B and A-IV mRNA abundance or plasma lipid concentrations would be altered by chronic or acute consumption of diets that differed in fat content. Forty Wistar male rats were fed either a low fat (5 g/ 100 g) or high fat (20 g/100 g) diet for 4 wk. Animals were killed unfed or 3 h after consumption of a test meal of the diet to which they had been adapted (n = 8). In addition, a low fat diet-adapted group was fed a high fat test meal and killed 3 h after the meal. Adaptation to the high or low fat diets did not result in differences in triglyceride or cholesterol concentrations in the plasma of unfed rats. In fed animals, plasma, VLDL, and LDL triglyceride concentrations were significantly higher in those fed the high fat test meal than in those fed the low fat test meal. Feeding did not alter plasma cholesterol concentrations; however, LDL cholesterol concentrations in the groups fed the high fat meals were significantly higher than in the group fed the low fat meal. There were no differences in plasma apolipoproteins B, A-IV, E, and A-I nor in the liver or intestinal apolipoprotein B and A-IV mRNA contents. Fatty acid synthetase (FAS) activity was significantly higher in rats adapted to the low fat diet, and no increase in activity due to feeding was observed. Hepatic FAS mRNA was higher in fed than unfed rats, and the low fat test meal resulted in a higher level than the high fat test meal. Plasma lipid concentrations were affected by the fat content of test meals rather than by the adaptation diet fat content. Apolipoprotein B and A-IV mRNA do not seem to respond to dietary fat or meal feeding.

The incidence of testicular cancer in Royal Air Force personnel

OBJECTIVES

To review the incidence of testicular cancer within the Royal Air Force (RAF) compared with the national incidence.

METHODS

The medical statistics for RAF personnel (supplied by the Central Statistics Office, categorized by occupation) were reviewed for the incidence of testicular cancer and compared to the national rate.

RESULTS

A significantly elevated incidence of testicular neoplasm was detected in RAF personnel, which was well above the national rate. The increased incidence appeared most marked in those personnel working directly with aircraft.

CONCLUSION

The only cause of the significantly higher incidence of testicular cancer in RAF personnel is probably related to working with aircraft. This concurs with a finding that aircraft technicians in the US Navy had an increased incidence of testicular cancer, and the exposure to hydrocarbon carcinogens in the workplace was implicated.

Nutrient infusion into the ileum of rats does not lower plasma lipids or alter apolipoprotein mRNA abundance

Viscous polysaccharides enhance the delivery of nutrients to the ileum. Our objective was to determine if the presence of nutrients in the ileum, in the absence of fiber, alters plasma and hepatic lipids. Twenty-four Wistar male rats weighing 150-160 g were fed a fiber-free purified diet (30% of energy as fat) for 7 d. The small intestine was cannulated 30 cm proximal to the ileo-cecal junction. The animals consumed the purified diet ad libitum and the intestine was infused (3 mL/h) with saline, or an enteral solution contributing 10, 20 or 30% total energy for half of a 12-h feeding period. Infusion was performed for 14 d, after which the animals were killed. The animals adjusted their food intake so that each group had an equivalent energy intake and weight gain over the experimental period. The relative ileal mucosa weight was increased with nutrient infusion indicating hypertrophy. Plasma cholesterol in the nutrient-infused animals tended to be higher than in the saline-infused animals (P < 0.06). Apolipoprotein B and A-IV mRNA were not affected by ileal infusion. Thus, enhanced delivery of nutrients to the ileum, without fiber present in the diet, does not lower plasma cholesterol.

A CQI approach to the investigation of noise levels within the intensive care unit environment

In February 1991, the Intensive Care Unit (ICU) at Liverpool Hospital was extended and relocated to a larger area. It soon became apparent that noise levels within the newly renovated unit were particularly worrying to patients, staff and relatives. A Continuous Quality Improvement (CQI) group was formed to investigate, and develop measures to reduce these noise levels. Through the implementation of various CQI tools a study plan was developed to investigate the noise problem. The study plan included: a patient, relative and staff questionnaire; a literature search; identification of levels of noise using a sound level meter; contracting a noise consultant to visit and review the ICU environment. The results of the CQI investigations revealed that there was an inappropriately high level of noise in the ICU. Several key contributing factors were also identified. These findings provided the basis for several positive measures to be undertaken including: the installation of sound absorbing ceilings; removal of rubbish bin lids; revision of the telephone ringing system; revision of the mobile x-ray machine; prioritisation of audible machine alarms; education of staff in noise level awareness; The application of the Continuous Quality Improvement (CQI) process to the noise problem facilitated the exploration of the source of noise, the effects on staff and patients, and ways to reduce noise levels in the intensive care environment.

Human cartilage aggrecan CS1 region contains cryptic T-cell recognition sites

Cartilage proteoglycan aggregates (PG) are candidate T-cell autoantigens in the pathogenesis of rheumatoid arthritis (RA). We have investigated the possibility that responses to class II-restricted T-cell recognition sites in human cartilage aggrecan (core protein) may depend upon whether these sites are available as free peptide antigens or as part of intact monomers. Analysis of mouse T-cell responses to intact or deglycosylated monomers, purified from human articular cartilage, and to synthetic peptides of the chondroitin sulphate (CS) attachment region homologous repeat sequence showed that recognition of T-cell epitopes in the CS1 region was strongly dependent upon the form of antigen used. The results show that the CS1 region contains cryptic T-cell recognition sites and raise the possibility that fragments of PG, released through the action of extracellular proteases in inflamed joints, may be capable of activating T cells with specificities for epitopes which are not made available following processing of intact PG. T cells with specificities for cryptic epitopes in PG may play a role in the pathogenesis of RA.

Laboratory automation: a model

Today's health care providers are keenly aware of the need to do "better with less" in an environment of shrinking resources. This article describes a process for automating laboratory services that is based on expertise, safety, productivity, and a set of guiding principles. The process used to create this model, which integrates people with the flow of information and materials, can be used to re-engineer any knowledge-based process.

Comparative analysis of murine T lymphocyte responses to cartilage proteoglycans

Cartilage proteoglycans are large molecules consisting of several sub-regions each of which comprises homologous repeating subunits. Comparisons of murine primed popliteal lymph node responses to human cartilage proteoglycans in BALB and B10 congenic mice showed that the major histocompatibility complex (MHC) influences T cell responsiveness to this antigen. H-2k and H-2d were higher responders than H-2b. Responses were MHC class II-restricted, and human cartilage proteoglycans were cross-reactive with mouse cartilage proteoglycans for a BALB/c T cell line. The proportion of proteoglycan-specific T lymphocytes in BALB/c primed popliteal lymph nodes was about 45% lower in females than males. These results show that in mice both MHC haplotype and sex can determine T lymphocyte responsiveness to cartilage proteoglycans. If the same mechanisms apply in humans they could be important in determining the HLA-DR haplotype associations and the predilection of rheumatoid arthritis for females.

Short stature, brachydactyly, and Peters' anomaly (Peters'-plus syndrome): confirmation of autosomal recessive inheritance

Two sibs with a phenotype characterised by short stature, brachydactyly, and ocular anomalies (Peters' anomaly) are reported (Peters'-plus syndrome). The consanguinity is in agreement with the proposed autosomal recessive inheritance.

[Francisco Hoffmann, pioneer of physiological research in Chile]

Francisco Hoffmann MD became a Professor of Physiology at the University of Chile School of Medicine in 1934. After postgraduate studies in Germany he came back to Chile in 1931 when he began proposing the creation of an Institute of Physiology. This became a reality in 1936. He was a proponent of full time job and of greater participation of students in the learning process. The main research interest of the Institute was centered on thyroid function and its relation to the nervous and circulatory systems. Professor Hoffmann was made a corresponding member of the Royal and the Spanish Academies of Medicine. In 1960 he retired from the Institute to help develop an Anthropology Center leaving many of his disciples to continue his work in physiology.