Evaluation of autologous shed blood for autotransfusion after orthopaedic surgery

Autologous shed blood for autotransfusion was evaluated at four medical centers in a prospective randomized study. One hundred twenty-eight patients were studied after hip replacement, knee replacement, or spine fusion. The efficacy of autologous shed blood in reducing homologous transfusion was evaluated. The relative risk of transfusion with homologous blood was 0.4 in patients who received shed blood compared with patients who did not receive shed blood. The reinfusion of shed blood reduced the requirement for homologous blood by 60%. Two filter systems were evaluated in reinfusing autologous shed blood. The Pall RC100 filter appeared to be more effective than the Pall 40-mu screen filter in removing fat particles and white blood cells. No significant clinical abnormalities were discovered after autotransfusion with autologous shed blood. Evaluation of clotting studies showed no significant differences between patients who received shed blood and patients who received liquid-preserved red blood cells. These data indicate that unwashed autologous shed blood from orthopaedic wound drainage is a safe and effective substitute for transfusion of autologous predonated blood or homologous liquid-preserved red blood cells.

'not Passing Through': Aboriginal Stakeholders in the Rangelands

Comparison of Aboriginal interests in rangelands in western New South Wales with those in north- western Northern Temtory and the Kimberley of Western Australia reveals little difference in their history, aspirations for land acquisition, or plans for multiple use management. Throughout Australia, Aboriginal people who are traditional owners of rangelands continue to live on or near the land they regard as traditionally theirs. This is true of the more closely settled rangelands as well as remote regions. In all the rangeland areas Aboriginal people now wish (and following the Mabo decision may more realistically expect to gain) some form of freehold title to at least some of their land. Aboriginal people whose traditional lands are located in western New South Wales have access to very little of their land but have maintained their connection to it. They have aspirations of obtaining access to and control over portions of it, with plans to manage it under a multiple use regime that would include small-scale sustainable pastoralism and agriculture, while living in dispersed family groups on the land. Aboriginal people's desire to retain access to their traditional land for non-economic reasons (spiritual, social, historical) is paramount. Should the Commonwealth Land Fund legislation be enacted, cultural imperatives as well as economic viability will need to be taken into account in the purchase of land. Planning for future management should incorporate traditional ecological knowledge and should involve Aboriginal traditional owners and their organisations, such as land councils and resource agencies, in local and regional planning.

Effects of alcohol, carbon tetrachloride, and choline deficiency on iron metabolism in the rat

The effects of alcohol on hepatic iron uptake and intestinal iron transport were studied in rats fed a nutritionally replete liquid diet containing varying quantities of ethanol. Results were compared with those from animals exposed to carbon tetrachloride (CCl4) to produce hepatocellular necrosis or a choline-deficient diet to produce steatosis and cirrhosis. A high ethanol intake for 4 or 10 weeks produced hepatic steatosis. CCl4 produced hepatocellular necrosis. Choline deficiency was associated with steatosis +/- cirrhosis. Intestinal iron transport was unaffected by ethanol, CCl4, or choline deficiency. Hepatic iron uptake was significantly depressed in rats consuming 11.7 g/kg/day ethanol (p < 0.01) for 4 weeks. Choline-deficient animals studied at 14 weeks also had significantly decreased hepatic iron uptake (p < 0.01); results were similar in the cirrhotic and noncirrhotic animals. Conversely, CCl4 exposure produced a significant 5-fold increase in hepatic iron uptake (p < 0.001). Results suggest that ethanol consumption, fatty liver, and cirrhosis are not responsible for any increase in iron absorption or of hepatic iron uptake in the rat model. Acute hepatocellular injury is followed by increased hepatic iron uptake.

Regulation of human lung fibroblast alpha 1(I) procollagen gene expression by tumor necrosis factor alpha, interleukin-1 beta, and prostaglandin E2

We investigated the participation of prostaglandin (PG) E2 in the regulation of the alpha 1(I) procollagen gene expression by tumor necrosis factor alpha (TNF alpha), and interleukin-1 beta (IL-1 beta) in normal adult human lung fibroblasts. TNF alpha (100 units/ml) and IL-1 beta (100 units/ml) stimulated the production of PGE2 and caused a dose-dependent inhibition of up to 54 and 66%, respectively, of the production of type I procollagen. Preincubation of cultures with indomethacin partially reversed the inhibition of procollagen production induced by the cytokines. Cytokine-stimulated endogenous fibroblast PG accounted for 35 and 68% of the inhibition induced by TNF alpha and IL-1 beta, respectively. Steady-state mRNA levels for alpha 1(I) procollagen paralleled the changes in collagen production. The transcription rate of the alpha 1(I) procollagen gene was reduced by 58% by TNF alpha and by 43% by IL-1 beta. Cytokine-stimulated endogenous PG production accounted for half of these effects. These results indicate that TNF alpha and IL-1 beta inhibit the expression of the alpha 1(I) procollagen gene in human lung fibroblasts at the transcriptional level by a PGE2-independent effect as well as through the effect of endogenous fibroblast PGE2 released under the stimulus of the cytokines.

One-year outcome of elderly and young patients admitted to intensive care units

OBJECTIVE

To compare the outcome of patients over and under age 65 admitted to two intensive care units (ICUs).

DESIGN

Prospective, two-center study. Convenience sample of all admissions to two adult ICUs for a 1-yr period, with a 1-yr follow-up.

SETTING

Adult multidisciplinary closed ICUs.

PATIENTS

All patients (n = 1,040) admitted to two ICUs during a 1-yr period were entered into the study, except patients with self-induced poisoning. Of these patients, 145 patients were lost to follow-up.

INTERVENTIONS

Admission statistics on all patients included demographic, case mix, and severity data. Variables associated with intensive care unit outcomes at discharge (length of stay, mortality) and at 1 yr from admission (mortality, functional capacity, health attitudes) were analyzed. Vital status was confirmed from both Alberta Vital Statistics and Alberta Health. Follow-up interviews were conducted with all available survivors.

RESULTS

The elderly group (> 65 yrs) comprised 46% of patients studied. Both age groups (> 65 yrs and < 65 yrs) had comparable demographics and illness severity measures. Although ICU and 1-yr mortality rates differed between groups (16% of > 65 yrs vs. 12.9% of < 65 yrs ICU mortality and 49% of > 65 yrs vs. 31% of < 65 yrs 1-yr mortality), age was not a major contributor to the variance in outcome. At 1 yr, 65% of patients admitted to the study were alive. Follow-up interviews were conducted with 75% of survivors. Assessment of activities of daily living showed that the elderly patients were similar to younger patients. The elderly demonstrated more positive health attitudes than younger survivors. Functional capacity was significantly associated with health attitudes of younger patients, but not for older survivors.

CONCLUSIONS

Age does not have an important impact on outcome from critical illness, which is most strongly predicted by severity of illness, length of stay, prior ICU admission and respiratory failure. Satisfaction with personal health should not be inferred from the functional status of elderly survivors of intensive care.

Efficacy and safety of b.i.d. doses of venlafaxine in a dose-response study

In this study, 312 depressed outpatients received either placebo or one of three venlafaxine doses twice daily (b.i.d.) for up to 6 weeks. The total daily doses of venlafaxine were 25, 50-75, and 150-200 mg/day. Hamilton Rating Scale for Depression (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS) total scores at Week 6 were significantly lower for the high-dose group than for the placebo group. A positive dose-response trend for the primary efficacy parameters was demonstrated as early as Week 1. Venlafaxine was well tolerated at all dose levels. The most common side effects of clinical interest were nausea and dry mouth. The frequency of nausea in the venlafaxine groups was essentially the same (25-29%), whereas the frequencies of dry mouth, somnolence, and sweating were dose related. The results indicate that b.i.d. doses of venlafaxine are safe and effective in treating depression.

Comparison of PT and aPTT values drawn by venipuncture and arterial line using three discard volumes

BACKGROUND: Blood samples obtained through heparinized arterial catheters are used routinely for a variety of laboratory tests. Accuracy of coagulation studies performed from samples obtained in this fashion continues to be questioned, particularly in regard to the minimum discard volume necessary to clear the catheter of heparinized solution. OBJECTIVE: To examine differences between prothrombin time and activated partial thromboplastin time values obtained from blood drawn by venipuncture and from an indwelling intra-arterial line using three discard volumes. METHODS: Prothrombin time and activated partial thromboplastin time samples were drawn by venipuncture from 41 critically ill adult patients. Simultaneously, three consecutive blood samples of 2.3 mL were drawn from the arterial line after an initial discard volume of 3 mL (discard volumes of 3.0, 5.3 and 7.6 mL). RESULTS: Significant differences were found between arterial and venous prothrombin time values for the 3-mL discard volume group, as well as between arterial and venous activated partial thromboplastin time values for all three discard volume groups (paired t-test, Bonferroni correction). CONCLUSION: We recommend that when drawing prothrombin time and activated partial thromboplastin time samples from an arterial line, a 5.3-mL discard volume be used.

Comparison of PT and aPTT values drawn by venipuncture and arterial line using three discard volumes

BACKGROUND

Blood samples obtained through heparinized arterial catheters are used routinely for a variety of laboratory tests. Accuracy of coagulation studies performed from samples obtained in this fashion continues to be questioned, particularly in regard to the minimum discard volume necessary to clear the catheter of heparinized solution.

OBJECTIVE

To examine differences between prothrombin time and activated partial thromboplastin time values obtained from blood drawn by venipuncture and from an indwelling intra-arterial line using three discard volumes.

METHODS

Prothrombin time and activated partial thromboplastin time samples were drawn by venipuncture from 41 critically ill adult patients. Simultaneously, three consecutive blood samples of 2.3 mL were drawn from the arterial line after an initial discard volume of 3 mL (discard volumes of 3.0, 5.3 and 7.6 mL).

RESULTS

Significant differences were found between arterial and venous prothrombin time values for the 3-mL discard volume group, as well as between arterial and venous activated partial thromboplastin time values for all three discard volume groups (paired t-test, Bonferroni correction).

CONCLUSION

We recommend that when drawing prothrombin time and activated partial thromboplastin time samples from an arterial line, a 5.3-mL discard volume be used.

Elevation of the medical plateau of the tibia in the treatment of Blount disease

Seven children, between ten and thirteen years old, had elevation of the medial plateau of the tibia for correction of severe varus deformity secondary to Blount disease. The deformity was severe (grade V or VI according to the system of Langenskiöld and Riska) in all patients; the average preoperative varus deformity, determined by the angle formed by the femoral shaft and the tibial shaft, was 25 degrees. The goal of the operation was restoration of a more normal configuration of the articular surface of the proximal end of the tibia. This was accomplished by direct elevation of the depressed medial tibial plateau. All patients had an osteotomy to correct the alignment of the tibia. The osteotomy was performed concomitant with the elevation of the plateau in three patients, before the elevation in three, and after the elevation in one patient. Four patients had a concomitant osteotomy of the femur to align the knee joint parallel to the floor. The results were good in five patients and fair in two.

Ulnar nerve decompression at the cubital tunnel

A limited surgical decompression of the ulnar nerve within the cubital tunnel by incision of the arcuate ligament was effective in relieving pain and dysesthesia in 22 of 27 patients. No patient had any apparent muscle weakness or atrophy preoperatively. Twenty-five patients had evidence of compression of the ulnar nerve within the cubital tunnel at surgery, as noted by narrowing, hyperemia, or attachment of adhesions to the nerve. Three of four patients who had a subsequent anterior transposition obtained partial relief of symptoms.

Profile of selected bacterial counts and Salmonella prevalence on raw poultry in a poultry slaughter establishment

The USDA Food Safety and Inspection Service determined populations of bacteria on poultry during processing at a slaughter plant in Puerto Rico in November and December 1987. The plant was selected because of its management's willingness to support important changes in equipment and processing procedures. The plant was representative of modern slaughter facilities. Eight-hundred samples were collected over 20 consecutive 8-hour days of operation from 5 sites in the processing plant. Results indicated that slaughter, dressing, and chilling practices significantly decreased the bacterial contamination on poultry carcasses, as determined by counts of aerobic bacteria, Enterobacteriaceae, and Escherichia coli. Salmonella was not enumerated; rather, it was determined to be present or absent by culturing almost the entire rinse. The prevalence of Salmonella in the study decreased during evisceration, then increased during immersion chilling.

The entire nucleotide sequence of foxtail mosaic virus RNA

The nucleotide sequence of the RNA genome of foxtail mosaic virus (FMV), a member of the potexvirus family, is 6151 nucleotides long, exclusive of a poly(A) tail. The RNA contains five principal open reading frames (ORFs), designated from the 5' terminus as encoding proteins with Mr values of 152.3K (ORF1), 26.4K (ORF2) which overlaps an 11.3K (ORF3) product, 5.8K (ORF4) which overlaps a 28.8K readthrough protein (ORF5A) which leads into the coat protein cistron of 23.7K (ORF5). The sizes and composition of the proteins encoded by the ORFs are generally similar to those found in other potexviruses; the least similar is the coat protein which nonetheless retains apparently critical consensus regions. The 5' terminus of the previously reported 0.9 kb subgenomic (sg) RNA was determined by S1 nuclease mapping and shown to begin with the sequence GAAGA, 43 nucleotides upstream from the first nucleotide of the coat protein initiation codon. The positions of the 5' end of this sgRNA and of that deduced from the nucleotide sequence for a 1.9 kb sgRNA are entirely consistent with the previously published sizes of these sgRNAs.

Current concepts in hip joint replacement

The authors present an overview of the 'state of the art' in hip joint replacement. Short and long-term success rates are discussed.

Cerebral radiation necrosis complicating stereotactic radiosurgery for arteriovenous malformation

A patient presented with symptoms and signs of raised intracranial pressure and increasing focal deficit 13 months after stereotactic radiosurgical treatment of an arteriovenous malformation (AVM). Computed Tomography (CT) showed a mass lesion at the site of the previous abnormality typical of radiation necrosis, but with features identical to those of a malignant neoplasm. Biopsy confirmed cerebral radiation necrosis. The radiation dose was 25 Gray to the periphery of two overlapping 14 mm collimator fields, delivered in a single dose. Treatment with steroids led to improvement in the symptoms and signs of raised intracranial pressure, but not the focal deficit. Radiation necrosis is a consequence of the large doses required to obliterate AVMs and is a limiting factor in their treatment. It is important for clinicians referring patients for stereotactic radiosurgery to be aware of this complication, and to be able to recognise and treat it.

Double giant fusiform aneurysms of the posterior cerebral artery

Subarachnoid hemorrhage in a patient with two giant fusiform aneurysms arising from the posterior cerebral artery was treated by clipping the P2 segment of the artery, proximal to the first aneurysm. This combination of aneurysms has not previously been reported.

Dissolution of gallstones using methyl tertiary-butyl ether in an animal model

Human gallstones were surgically implanted in the gallbladders of six pigs. Through cholecystostomy catheters, methyl tertiary-butyl ether (MTBE) was infused from 3 to 5 days. MTBE successfully dissolved 19 of the 20 cholesterol stones and partially dissolved one mixed cholesterol-bilirubin stone. Gross and microscopic examination of abdominal organs revealed mild superficial ulcerations of the gallbladder and mild to moderate chronic inflammatory changes in the gallbladder of animals treated with MTBE infusion. There were no other significant changes within other abdominal organs except for mild inflammation of the duodenum in one animal and of the common bile duct in another. Because of its efficacy and limited deleterious effects, MTBE may be a good solvent when dissolving pure cholesterol gallstones in the gallbladder.

Single- and double-stranded viral RNAs in plants infected with the potexviruses papaya mosaic virus and foxtail mosaic virus

Three classes of viral RNA were recovered from polyribosomes purified from papaya leaves infected with papaya mosaic virus (PapMV) and from barley leaves infected with foxtail mosaic virus (FoMV): full-length viral RNAs [6.8 and 6.2 kilobases (kb), respectively]; less abundant intermediate subgenomic RNAs (2.2 and 1.9 kb), and abundant, small subgenomic RNAs (1 and 0.9 kb). Small amounts of the PapMV-specified 1.0-kb subgenomic RNA were encapsidated, whereas no encapsidated subgenomic RNAs could be found in preparations of FoMV. Immunoprecipitation of the products of in vitro translation of the small subgenomic RNA of both viruses showed that it codes for the corresponding viral coat protein. FoMV genomic RNA isolated from polyribosomes also directed the efficient synthesis of a 37- to 38-kilodalton protein which was immunoprecipitated by an antiserum raised against the coat protein. We presume this product to be a readthrough protein initiated to the 5' side of and in the same reading frame as the coat protein-coding sequences in FoMV RNA. The predominant double-stranded viral-specified RNAs in tissues infected with PapMV, FoMV, and clover yellow mosaic virus were genome sized (6.8, 6.2, and 7.0 kb pairs, respectively). If double-stranded RNAs corresponding to coat protein subgenomic RNAs exist, they must be present in much lower relative abundances.

MRI measurement of syrinx size before and after operation

When patients with syringomyelia fail to improve after operation, factors such as incomplete cyst decompression or type of operation are often implicated. MRI has been used to confirm adequate syrinx decompression post-operatively and to compare the degree of collapse with the type of operation. Foramen magnum decompression was at least as effective in reducing cyst size as syringo-subarachnoid shunting. MRI may also provide a better classification of syringomyelia.

Evaluation of Swab and Tissue Excision Methods for Recovering Microorganisms from Washed and Sanitized Beef Carcasses 1, 2

Samples taken from dressed beef carcasses by swabbing surfaces or excising tissues were plated to produce counts of aerobic bacteria, Enterobacteriaceae , and Escherichia coli . Counts were compared to determine efficiencies of the two sampling methods. Excised tissues produced much higher counts than did swabs, especially when washed and sanitized carcasses were sampled. Percentages recovered by swabbing appeared to be influenced by characteristics of the area sampled on the carcass. Numbers of Enterobacteriaceae and E. coli recovered by swabbing washed and sanitized carcasses were usually too few to be countable, whereas excision usually produced countable plates. The excision sampling method permitted differentiation among treatment effects of washing and sanitizing.

A double-blind comparison of lisinopril with captopril in patients with symptomatic congestive heart failure

Angiotensin-converting enzyme (ACE) inhibition with captopril is accepted therapy for the treatment of symptomatic congestive heart failure. In this trial, we compared the new ACE inhibitor, lisinopril, to captopril during a 12-week randomized double-blind study. One hundred twenty-nine patients with New York Heart Association class II, III, or IV congestive heart failure were randomized to receive either lisinopril 5 mg/day (n = 64) or captopril 37.5 mg/day (n = 65) in 15 centers. Drug doses could be titrated upwards every 4 weeks. The primary measure of drug efficacy was improvement in treadmill exercise time using a modified Naughton protocol. Secondary measures of efficacy and the development of adverse effects were also examined. Lisinopril improved exercise time (following 12 weeks of therapy) more than captopril [from 500 +/- 30 to 682 +/- 34 sec (mean +/- SEM) with lisinopril versus 480 +/- 26 to 600 +/- 35 sec with captopril; difference between groups, p less than 0.05]. Adverse drug effects were unusual and similar in frequency in the two groups, although an increase in blood urea nitrogen was more common with lisinopril than with captopril (p less than 0.05). These results indicate that using the doses and treatment regimens studied, lisinopril is more effective than captopril for the treatment of symptomatic congestive heart failure. Adverse experiences with lisinopril were infrequent and similar in incidence to those observed with captopril.

Neuroleptic bioavailability, psychosocial factors, and clinical status: a 1-year study of schizophrenic outpatients after dose reduction

Serum neuroleptic levels, prolactin levels, and clinical state were assessed for 1 year in 29 schizophrenic outpatients whose clinically determined neuroleptic dose had been reduced by 50%. Fifty-five percent of the subjects remained stable. Neuroleptic dose did not differ between relapsed and stable patients. Serum prolactin (PRL) assessed 2 weeks after dose reduction and mean PRL after reduction were significantly lower among relapsers. Serum neuroleptic levels were significantly lower for relapsers in patients on haloperidol. Among relapsers, there were no serum PRL or neuroleptic level differences between stable periods and the relapse episode. Among patients with relatively low neuroleptic bioavailability, relapsers reported lower levels of social activity and had social networks that were less enjoyable, more aversive, and less helpful than those of stable patients.

Myasthenia gravis after allogeneic bone marrow transplantation: relationship to chronic graft-versus-host disease

Three patients with chronic graft-versus-host disease (GVHD) developed myasthenia gravis (MG) 762 to 1,180 days after allogeneic bone marrow transplantation. Symptoms of MG were observed after taper or discontinuation of immunosuppressive treatment of chronic GVHD. All patients developed antibodies to acetylcholine receptor, and one had antibody formation to striated muscle. One patient died of complications of treatment of MG. The severity of disease underscores the importance of the differential diagnosis and the need for prompt therapy of this late complication after human bone marrow transplantation.

A new resuscitation apparatus providing 70% oxygen

Images

Ultrastructural features of minute chromosomes in a methotrexate-resistant mouse 3T3 cell line

The Miller spreading procedure was applied to mouse metaphase spreads of methotrexate-resistant 3T3 cells that contain large numbers of minute chromosomes and dihydrofolate reductase genes. There is substantial variation in both size and numbers of minutes in individual cells, the smallest of which (estimated as 5 X 10(3) kilobase pairs) would be undetected by standard light microscopic analyses. Minute chromosomes are composed of nucleosomal chromatin, which is organized into typical higher order fibers that are folded to form rosette-like structures characteristic of normal chromosome organization. There is no evidence that the DNA in minutes is linear. Minutes exist singly and in pairs, and members of a pair are connected by higher order chromatin fibers, suggesting that they are topologically interlocked. They are often closely apposed to chromosomal telomeres or arms, a configuration that may be involved in their distribution at mitosis. In addition to typical minutes, which do not possess kinetochores, a small marker chromosome possessing all of the features of a centromere region is present in parental and resistant cells. An unusual feature of this cell line is the retention of resistance, minute chromosomes, and amplified dihydrofolate reductase genes; most methotrexate-resistant mouse cell lines with minute chromosomes lose these properties when grown in the absence of methotrexate.

Sheath impaction as a cause of defective intra-aortic balloon pump action in man

Intra-aortic balloon counterpulsation became ineffective in a 63 inch (160 cm) 14 year old girl while console operation proceeded almost normally. The problem was simulated in a hydraulic model of the aorta and could be reproduced when the proximal end of the balloon engaged in the introducing sheath. Measurements of the balloon catheter and sheath against the patient indicated that such engagement had occurred during counterpulsation. The findings provide an explanation for apparent catheter 'kinkage' in other patients where there was difficulty running the Kontron console in automatic mode. Problems are preventable by total or partial withdrawal of the inserting sheath.

Out-of-plan use by Medicare enrollees in a risk-sharing health maintenance organization

In this study, we analyzed the cost and volume effects of a waiver that eliminated lock-in restrictions on out-of-plan use in a health maintenance organization (HMO) with a Medicare risk-sharing contract. We compared out-of-plan cost and number of claims during a 15-month base line period when the lock-in was in effect, with a 24-month waiver period when the lock-in was removed. The results demonstrate that average per capita cost and claims increased significantly for both Medicare Part A (hospital insurance) and Part B (supplementary medical insurance) out-of-plan services during the waiver. Self-referred out-of-plan use normally prohibited by lock-in, accounted for 20 percent of all out-of-plan costs during the waiver and 57 percent of the increase in out-of-plan costs from the lock-in to the waiver. The combination of risk-sharing and lock-in provisions holds promise as a method for reducing expenditures for the Medicare program.

Oligodendroglioma and cerebral cavernous angioma. Case report

The authors report a case of frontal lobe oligodendroglioma associated with a cavernous angioma. The patient presented with signs and symptoms of raised intracranial pressure. Computerized tomography with contrast enhancement failed to detect the vascular component. The clinical and pathological significance of the presence of this vascular malformation in an oligodendroglioma is discussed.