Are we overusing ultrasound in non-traumatic acute abdominal pain?

BACKGROUND

Ultrasound is being used increasingly in the assessment of acute non-traumatic abdominal pain as it is non-invasive and does not carry the risk of radiation. However, the inappropriate use of ultrasound can lead to a delayed or incorrect diagnosis, more work for the personnel involved, and increased hospital costs.

METHODS

A prospective study was conducted to analyse the clinical indications for requesting an ultrasound in those admitted to a district general hospital with acute non-traumatic abdominal pain, and to assess whether there is a correlation between clinical and laboratory findings and ultrasound results. A total of 110 patients were studied during a three month period.

RESULTS

The results suggest that ultrasound is useful in the investigation of suspected biliary colic and abdominal masses. However, the yield of ultrasound in other patients with acute non-traumatic abdominal pain is low. This study also suggests that the yield of "positive" reports on ultrasound is significantly higher in patients with localised abdominal pain and tenderness and in those with acute abdominal pain and a raised white cell count or raised liver function tests. The yield of positive reports in patients with acute abdominal pain was found to be lower those less than 25 years of age than in older patients.

Intra-operative monitoring in scoliosis surgery with multi-pulse cortical stimuli and desflurane anesthesia

STUDY DESIGN

Prospective, observational study.

SETTING

Country General Hospital, Singapore.

OBJECTIVE

Intraoperative monitoring (IOM) with motor-evoked potentials (MEPs) assesses the integrity of cortical spinal tracts during scoliosis surgery. MEPs are sensitive to the effects of inhalational anesthetic agents. We evaluate the use of desflurane in combination with multipulse cortical stimulation in this study.

METHODS

In all, 10 consecutive neurologically normal subjects underwent scoliosis surgery with desflurane anesthesia (0.5 maximum alveolar concentration) and five pulse cortical stimulation (250 Hz) from two stimulators in parallel configuration, delivering a maximum intensity of 160 mA.

RESULTS

Consistent MEPs were obtained from the abductor hallucis and tibialis anterior in nine of ten and five of five of subjects, respectively. Baseline coefficients of variations were below 16% for both muscles.

CONCLUSION

This combination of anesthetic and stimulation protocols is efficacious for IOM during spinal cord surgery. Our findings support the use of desflurane for successful acquisition of MEPs during scoliois surgery as an alternative anesthetic regime.

Social, cultural and environmental influences on child activity and eating in Australian migrant communities

AIM

This study set out to examine the socio-cultural, familial and environmental factors influencing health, eating habits and patterns of physical activity contributing to child and adolescent overweight and obesity.

METHODS

Semi-structured, community-based interviews were conducted with contrasting key informant three-generation families; and generation by generation focus groups of grandparents, parents and children from four cultural communities in the state of Victoria, Australia. Purposive sampling occurred from Turkish, Greek, Indian and Chinese communities that have migrated to Australia within the last three generations (n = 160, eight families, 47 children aged 5-15 years, 29 parents, 42 grandparents).

RESULTS

Evidence of two-way influences on eating and physical activity across three generations was evident, with children reporting the greatest cross-cultural diversity. A range of dietary restrictions was reported across all cultural groups. Efforts to foster healthy eating and lifestyle patterns within communities were evident. Parents, as a generation in particular, felt the need for more access to education and support regarding healthy limits for pre-puberty and puberty stages.

CONCLUSION

There is a dynamic influence of culture on many aspects of family lifestyle across three generations. To achieve successful intervention design, childhood obesity researchers need to collaborate with diverse groups and communities. Considering the role and influence of extended family, a multigenerational, whole-of-community approach beyond that of parent and child populations ought to be considered.

Sengstaken-Blakemore tube to control massive postpartum haemorrhage

Massive postpartum haemorrhage after Cesarean section for placenta previa is a common occurrence. The bleeding is usually from the placental bed at the lower uterine segment. Uterine tamponade has a role in the management of such patients especially when fertility is desired. We describe here a case of massive postpartum haemorrhage, which was managed, with the use of a Sengstaken-Blakemore tube. This allowed us to avoid a hysterectomy for a young primiparous patient.

Potential utility of BCG test in excluding tuberculosis in adults

In developing countries, many sputum-negative suspects of pulmonary tuberculosis (PTB) are given antituberculous medication just because tuberculosis (TB) could not be excluded in them. Many studies have shown that BCG test is nearly 100% sensitive, except in those with severe malnutrition, steroid therapy and other causes of immunosuppression. The aim of the present study was to find out the proportion of PTB suspects in whom BCG test may be useful in excluding diagnosis of TB. The study was carried out on adult subjects attending District Tuberculosis Clinic (DTC), Pali, Rajasthan, India. Out of 104 subjects studied, all 18 sputum-positive subjects showed a positive BCG test indicating 100% sensitivity of the test. The result of BCG test was negative in 16.28% of 86 sputum-negative suspects of TB. The BCG test did not show any adverse reactions among these cases except for adenitis of axillary or cervical lymph nodes in 6.7% subjects. The study raises the possibility that BCG test may be useful in excluding diagnosis of tuberculosis in a proportion of adult sputum negative-suspects of PTB in developing countries like India. More studies are needed in this direction.

Unusual case of bowel infarction with invasive Aspergillus in an immunocompromised patient

INTRODUCTION

We report a patient with bowel infarction due to invasive Aspergillus infection as a result of prolonged chemotherapy-induced neutropenia.

CLINICAL PICTURE

The patient was given neoadjuvant chemotherapy with doxorubicin, docetaxel, and capecitabine for a breast tumour. She developed prolonged neutropenia, Escherichia coli and Candida krusei sepsis, acute arterial thrombosis of the left lower limb, and invasive aspergillus infection.

TREATMENT

She underwent a subtotal colectomy, small intestine resection and an above-knee amputation.

OUTCOME

The hospitalisation was complicated with methicillin-resistant Staphylococcus aureus pneumonia and short gut syndrome. She subsequently underwent simple mastectomy with axillary clearance and received adjuvant chemotherapy and radiation without complication.

CONCLUSION

Chemotherapy should be protocol-directed. In a non-trial situation, protocol must have a sound basis, proven safety, and efficacy. Aspergillus infection is uncommon in patients with solid tumours; prompt treatment must be started on high suspicion.

Concepts of disablement in documents guiding physical therapy practice

PURPOSE

To describe disability concepts used within documents guiding physical therapist practice.

METHODS

Content analysis was performed on the Guide to Physical Therapist Practice, second edition; A Normative Model of Physical Therapist Professional Education, version 2000; APTA House of Delegates Standards, Policies, Positions and Guidelines; APTA Board of Directors Policies, Positions and Guidelines; The Model Practice Act for Physical Therapy and The Illinois Physical Therapy Act. Using a word sense framework, text-in-context lists were compiled, from which contextual themes and counts for all occurrences of disability terms were developed.

RESULTS

Across documents, contextual themes with number of occurrences were: disability as role performance limitations within specific contexts: 819; disability resulting from health status: 39, disability law: 29; and rights of individuals with disabilities: 25.

CONCLUSIONS

Documents guiding physical therapist practice commonly conceptualize disability as individual limitations within specific contexts and infrequently conceptualize disability as a societal phenomenon affecting persons across most settings and circumstances. It is believed that a concept of disability that is more inclusive of broad, as well as specific, contexts of disability may lead to improved physical therapy management for individuals with a wide range of performance capacities.

Necrotizing fasciitis: an unusual cause

A 76-year-old woman was admitted through the accident and emergency department with a paraumbilical lump of 2 weeks' duration and a sinus which was discharging foul-smelling pus since that morning. One month before this, she was treated for abdominal pain with diarrhoea and vomiting by her GP with loperamide. On examination, she was febrile but was stable. Abdominal examination revealed a 10 cm x 5 cm fluctuant paraumbilical swelling with a sinus discharging foul-smelling pus. The surrounding skin was erythematous with patchy blackened areas. The provisional diagnosis at this stage was of an abdominal wall abscess with a possible colocutaneous fistula.

School immunisation certificates--a review over time in a disadvantaged community

OBJECTIVES

To compare proportions of kindergarten children in Auburn presenting School Immunisation Certificates (SIC) or other school-entry immunisation documentation over time, and to examine the immunisation status of these children.

METHODS

Immunisation records of kindergarten children enrolled in all primary schools in the Auburn local government area were reviewed in 1994 and 1998.

RESULTS

Eight hundred and thirty-three and 737 school entry records of children enrolled in kindergarten were reviewed in 1998 and 1994 respectively. There was no change in the overall proportion of children with immunisation documentation and SICs. Sixty-nine per cent (571/833) of children had SICs in 1998, compared with 72% (531/737) in 1994. Thirteen per cent of children had other immunisation documentation in 1998, compared with 11% in 1994. The proportion of invalid certificates fell from 39.2% in 1994 to 12.6% in 1998 (p<0.001). The 1998 survey indicated that 80.2% of children provided a certificate indicating they were completely immunised compared with 56.7% in 1994 (p<0.001).

IMPLICATIONS

Although SICs play an important role in promoting the importance of immunisation among parents and in the school community, there continues to be a substantial number of children whose immunisation status is unknown. In the event of an outbreak, an effective public health response may need to incorporate the use of additional objective measures, such as the Australian Childhood Immunisation Register or personal health records.

The alternative sigma factor SigH regulates major components of oxidative and heat stress responses in Mycobacterium tuberculosis

Mycobacterium tuberculosis is a specialized intracellular pathogen that must regulate gene expression to overcome stresses produced by host defenses during infection. SigH is an alternative sigma factor that we have previously shown plays a role in the response to stress of the saprophyte Mycobacterium smegmatis. In this work we investigated the role of sigH in the M. tuberculosis response to heat and oxidative stress. We determined that a M. tuberculosis sigH mutant is more susceptible to oxidative stresses and that the inducible expression of the thioredoxin reductase/thioredoxin genes trxB2/trxC and a gene of unknown function, Rv2466c, is regulated by sigH via expression from promoters directly recognized by SigH. We also determined that the sigH mutant is more susceptible to heat stress and that inducible expression of the heat shock genes dnaK and clpB is positively regulated by sigH. The induction of these heat shock gene promoters but not of other SigH-dependent promoters was markedly greater in response to heat versus oxidative stress, consistent with their additional regulation by a heat-labile repressor. To further understand the role of sigH in the M. tuberculosis stress response, we investigated the regulation of the stress-responsive sigma factor genes sigE and sigB. We determined that inducible expression of sigE is regulated by sigH and that basal and inducible expression of sigB is dependent on sigE and sigH. These data indicate that sigH plays a central role in a network that regulates heat and oxidative-stress responses that are likely to be important in M. tuberculosis pathogenesis.

Wireless telephone-hearing aid electromagnetic compatibility research at the University of Oklahoma

A multiphase study examining electromagnetic compatibility (EMC) between wireless digital telephones and hearing aids has been under way at the University of Oklahoma EMC Center since May 1995. In a phase 1 clinical study involving 68 hearing aid wearers, interference varied significantly by telephone technology, hearing aid type, and hearing loss characteristics. More than 80 percent of the tests resulted in either no interference or a detection threshold distance less than 1 meter. Metallic shielding of the units yielded positive results. Various elements of phase 2 involved instrument-based tests of hearing aid interference using telephones in a sound-isolation chamber and radio frequency signals in a waveguide, along with clinical studies of speech-to-interference ratios, all leading to the development of standards of measurement and performance criteria for telephone emissions and hearing aid immunity. Results to date confirm that bystander interference is of less concern than user interference, which is the focus of continuing research.

Characterization of human symptomatic rotavirus isolates MP409 and MP480 having 'long' RNA electropherotype and subgroup I specificity, highly related to the P6[1],G8 type bovine rotavirus A5, from Mysore, India

In an epidemiological study of symptomatic human rotaviruses in Mysore, India during 1993 and 1994, isolates MP409 and MP480 were isolated from two children suffering from severe, acute dehydrating diarrhea. Both isolates exhibited 'long' RNA pattern and subgroup I specificity suggesting the likelihood of their animal origin. Both isolates did not react with monoclonal antibodies (MAbs) specific for serotypes G1 to G6 as well as G10. To determine the genetic origin of these isolates, complete nucleotide sequences of genes encoding the outer capsid proteins VP4 and VP7, nonstructural proteins NSP1 and NSP3 and viral enterotoxin protein NSP4 from MP409 and partial sequences of genes from MP480 were determined. Comparison of the 5' and 3' terminal sequences of 250 nucleotides revealed complete identity of the gene sequences in both strains suggesting that MP409 and MP480 are two different isolates of a single strain. Comparison of the nucleotide and deduced amino acid sequences of VP4, VP7, NSP1 and NSP3 of MP409 with published sequences of strains belonging to different serotypes revealed that both outer capsid proteins VP4 and VP7 and NSPI are highly related to the respective proteins from the P6[1], G8 type bovine rotavirus A5 isolated from a calf with diarrhoea in Thailand and that the NSP3 is highly homologous to that of bovine rotaviruses. The NSP4 protein showed greatest sequence identity with NSP4s belonging to the KUN genetic group to which NSP4s from human G2 type strains and bovine rotaviruses belong. MP409 and MP480 likely signify interspecies transmission of P6[1], G8 type strains from cattle to humans and represent the first P6[1] type rotaviruses isolated in humans. These and our previous studies on the asymptomatic neonatal strain 1321 are of evolutionary and epidemiological significance in the context of close association of majority of the Indian population with cattle.

Mutations in ATRX, encoding a SWI/SNF-like protein, cause diverse changes in the pattern of DNA methylation

A goal of molecular genetics is to understand the relationship between basic nuclear processes, epigenetic changes and the numerous proteins that orchestrate these effects. One such protein, ATRX, contains a highly conserved plant homeodomain (PHD)-like domain, present in many chromatin-associated proteins, and a carboxy-terminal domain which identifies it as a member of the SNF2 family of helicase/ATPases. Mutations in ATRX give rise to characteristic developmental abnormalities including severe mental retardation, facial dysmorphism, urogenital abnormalities and alpha-thalassaemia. This circumstantial evidence suggests that ATRX may act as a transcriptional regulator through an effect on chromatin. We have recently shown that ATRX is localized to pericentromeric heterochromatin during interphase and mitosis, suggesting that ATRX might exert other chromatin-mediated effects in the nucleus. Moreover, at metaphase, some ATRX is localized at or close to the ribosomal DNA (rDNA) arrays on the short arms of human acrocentric chromosomes. Here we show that mutations in ATRX give rise to changes in the pattern of methylation of several highly repeated sequences including the rDNA arrays, a Y-specific satellite and subtelomeric repeats. Our findings provide a potential link between the processes of chromatin remodelling, DNA methylation and gene expression in mammalian development.

Relationship between fetal femur diaphysis length and neonatal crown-heel length: the effect of race

OBJECTIVE

To determine whether racial differences affect the relationship between the fetal femur diaphysis length and the neonatal crown-heel length.

DESIGN

A prospective study in a teaching hospital with a multiracial population.

SUBJECTS

Four hundred and fifty pregnant women (150 Malays, 150 Chinese and 150 Indians) who delivered live infants.

METHODS

Ultrasound scan measurement of the fetal femur diaphysis length was carried out within 48 h of delivery in all cases. The relationship between the neonatal crown-heel length and the femur diaphysis length was obtained by regression using the method of least squares. Dummy or indicator variables were used to determine the effect of race on the relationship.

RESULTS

The relationship between the neonatal crown-heel length and the femur diaphysis length in all three races was well described by a linear model but a quadratic model described the relationship better. There was no significant difference in relationship of the neonatal crown-heel length and the femur diaphysis length between the Malay and Chinese populations, but the relationship in the Indian population was significantly different was from both the Chinese and Malay. For a given femur diaphysis length, the crown-heel length of the Indian population was found on average to be 1.1 cm shorter than the crown-heel length of the Malay and Chinese populations.

CONCLUSION

Differences in fetal body proportions exist between some races. The longer femur diaphysis length noted in certain races does not necessarily imply that the corresponding crown-heel length is longer. These inter-racial differences may increase the error of fetal weight and length estimates if formulae, which have been derived from samples racially dissimilar to that of the target population are used.