Sequential endoscopic/laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis

We reviewed the medical records of 17 patients with sickle hemoglobinopathy-associated cholelithiasis who were candidates for laparoscopic cholecystectomy (LC) between 1991 and 1994. Eight patients with suspected choledocholithiasis (CDL) were identified, all of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP), which revealed CDL in 3 patients (18%), all of whom had endoscopic ductal clearance. Choledocholithiasis was suspected because of hyperbilirubinemia or serum liver enzyme abnormalities. Incremental hyperbilirubinemia exceeding "baseline" values by > 5 mg/dL was the best predictor of CDL. Subsequent LC was successful with discharge within 2 days of LC in all but one patient, who was converted to open cholecystectomy. This small series suggests that in sickle hemoglobinopathy patients with cholelithiasis (1) CDL is relatively common among patients with an increase above baseline hyperbilirubinemia, (2) bile duct dilatation, alkaline phosphatase, and serum aminotransferase levels are poor predictors of CDL, and (3) sequential endoscopic/laparoscopic management of cholelithiasis and suspected CDL is successful.

SWORD '94: surveillance of work-related and occupational respiratory disease in the UK

Chest and occupational physicians participating in SWORD are estimated to have seen some 3300 cases of work-related respiratory disease in 1994, similar to the totals for 1992-1993. Occupational asthma was the single most frequent diagnosis (941 cases), but asbestos exposure was considered the cause in 1529 cases of diseases of long latency. Large-scale follow-up studies showed (i) that most patients with occupational asthma failed to recover and that half had left their employer, and (ii) that many patients had long-term respiratory illness including asthma following inhalation accidents. Over the six years of the scheme there have been slight changes in attributed agents for occupational asthma and in the frequency of various diagnoses; for example, there has been a gradual reduction in reports of pneumoconiosis. A decline with birth cohort in the proportion of mesotheliomas in men employed in shipyards is shown, with some evidence of a compensatory trend in construction trades.

Soluble class I HLA antigens in patients with rheumatoid arthritis and their families

OBJECTIVE

To study Class I soluble HLA in black patients with rheumatoid arthritis (RA) and their families, and to compare the findings to a group of healthy families of the same racial background.

METHODS

ELISA was developed measure soluble HLA Class I (sHLAI) in the serum of 25 patients with RA. Family studies were performed in seven patients with RA and their 28 first degree relatives. These family studies were compared to similar measurements for 66 members of 13 healthy families.

RESULTS

Mean sHLAI values were higher in patients with RA than those observed in healthy black individuals. Patients with RA were characterized by elevated serum HLAI, while no change was observed between patients with RA positive or negative for rheumatoid factor. The relatives of patients with RA had high concentrations of sHLAI, compared to families without RA. Highest serum concentrations of sHLAI were found in individuals who were HLA-A23 or HLA-Aw33 positive.

CONCLUSION

sHLAI may play a role in the pathophysiology of RA, and there is an association between either augmented release or production of sHLAI and specific HLA allotypes.

A critical review of the Couinaud technique of hepatic resection

The Couinaud technique of left hepatic lobectomy involves the isolation and division of portal vein, hepatic artery, and biliary tributaries as a unit within the liver parenchyma. It saves time and minimizes blood loss by virtue of the common investment of the portal structures in a thick connective tissue sheath. Right hepatic lobectomy can be performed in a similar manner based on the same assumption that the biliary and vascular tributaries maintain a constant anatomic relationship with one another. We describe a patient who underwent right hepatic lobectomy by the Couinaud technique who (in retrospect) had congenital absence of a left hepatic duct. Because small bile ducts from the left lobe drained into the right hepatic duct deep to the sight of resection, obstructive jaundice resulted postoperatively, necessitating orthotopic liver transplantation. Presently, the patient is doing well 1 year after transplantation. When the Couinaud technique is used in the setting of a biliary anatomic variant, the results can be disastrous. This case illustrates that the Couinaud technique is unsafe unless biliary anatomic variants are excluded prior to hepatic lobectomy.

Soluble HLA class II concentrations in normal individuals and transplant recipients. Comparison with soluble HLA class I concentrations

We developed an ELISA to quantify soluble HLA class II (S-HLA-II) in 702 sera obtained from normal subjects, patients with end-stage renal disease, and recipients of renal, hepatic, and cardiac transplants. Concentrations of S-HLA-II were detectable in 124 of 126 normal individuals. The distribution of normal values described a monophasic curve with a skewed distribution. In transplant recipients, there were no differences between preoperative and posttransplant values, but values in liver patients were significantly higher than in kidney patients, and values for heart patients were lowest of all groups. There were periodic variations in concentrations in individual patients, but these were unrelated to rejection, infection, or any other apparent clinical event. S-HLA-II was consistently present in the urine. All of these observations contrast with previous observations concerning soluble HLA class I (S-HLA-I) molecules, which were almost the precise reverse. It seems likely that these clear differences in S-HLA-II and S-HLA-I concentrations relate to different physiologic processes in either production, function, or elimination.

Epidemiological significance of mineral fiber persistence in human lung tissue

For the experimentalist, mineral fiber persistence may provide clues to disease mechanisms, for the epidemiologist, to the measurement of exposure. Qualitatively, this can be valuable when unsuspected exposures have been demonstrated as, for example, MMMF workers exposed to amosite or chrysotile workers to tremolite. Quantitatively, the potential of lung burden analyses to assess lifetime mineral fiber exposure has yet to be achieved with confidence. The difficulties are 2-fold, the first related to sampling and the second to the dynamics of biopersistence. Until some noninvasive method is found to identify and quantify numerically inorganic fibers in human tissue during life, epidemiological studies must depend on lung samples obtained at autopsy or thoracic surgery. This source is inevitably subject to seriously large and indefinable bias of various kinds. Of equal importance is the present uncertain state of knowledge concerning factors that determine what is present in the lung at any time. These determinants clearly include the dimensional features of airborne environmental particulates and characteristics that affect their durability in tissue.

Chronic abdominal pain as the initial manifestation of pancreatic injury due to remote blunt trauma of the abdomen

Three patients were admitted with severe abdominal pain that began after an asymptomatic latent period following blunt trauma to the abdomen. During initial medical evaluation 3 months to 1 year after the trauma, serum amylase levels were normal or minimally elevated, and computed tomography scanning revealed edema and/or pseudocyst formation in the tail of the pancreas. Pancreatography showed ductal stenosis or obstruction in the midbody of the pancreas in each patient. At surgery, chronic pancreatitis in the tail was clearly demarcated from the normal head of the gland. Distal pancreatectomy was curative. Blunt traumatic pancreatic ductal injury may occur without typical immediate posttraumatic acute pancreatitis. Chronic distal pancreatitis following an asymptomatic latent period may culminate in delayed admission months to years after the initial injury. Endoscopic retrograde cholangiopancreatography should be considered for evaluation of patients with chronic abdominal pain and prior blunt trauma to the abdomen.

An internal dosimetry intercomparison study

Pacific Northwest Laboratory performed a study to evaluate the consistency of internal dosimetry assessments. A total of eleven laboratories, including DOE sites and NRC licensees, participated in this intercomparison study. Participants were asked to respond to five actual exposure scenarios, previously used in a similar European study. The participating dosimetrists assessed the data of the test scenarios and calculated results in terms of estimated radionuclide intake and the resulting internal doses. To maintain confidentiality, results are given without identifying any site. Except for one scenario, the results showed that the standard deviation of the final results on committed effective dose equivalent for each exposure scenario was about 30-50% of the mean value, giving a consistency slightly greater variant than that of the European study. The discrepancies can be attributed to variations in 1) the interpretation and statistical treatment of the bioassay data; 2) the biokinetic models applied; and 3) the computational tools used. This represents a preliminary study; further intercomparison testing is needed to fully evaluate the problem of dose-assessment inconsistency.

Dust and flour aeroallergen exposure in flour mills and bakeries

As part of an epidemiological study among workers exposed to flour total dust and flour aeroallergen concentrations were measured with personal samplers over a workshift in three large bakeries and four flour mills and packing stations. In the bakeries geometric means for total dust concentrations ranged from 0.4 mg/m3 in the bread wrapping area up to 6.4 mg/m3 at the dough brake. The flour aeroallergen concentrations ranged from 45.5 micrograms/m3 in the bread wrapping area up to 252.0 micrograms/m3 in the confectionary area. In the flour mills and packing stations the concentrations were higher with geometric means for total dust ranging from 0.5 mg/m3 in the office up to 16.9 mg/m3 for hygiene workers in an old mill. The flour aeroallergen concentrations ranged from 101.5 micrograms/m3 for transport workers up to 1728.2 micrograms/m3 for hygiene workers. The relation between total dust and flour aeroallergen concentrations varied for different areas and depended on the use of products other than flour.

Work related symptoms, sensitisation, and estimated exposure in workers not previously exposed to laboratory rats

Findings are presented from the initial cross sectional phase of a cohort study of employees exposed to laboratory rats. Of 366 eligible workers at four sites 323 (88%) were surveyed; symptoms assessed by self completed questionnaire and sensitisation measured by the response to skin prick tests were related to intensity of exposure both to total dust and to rat urinary aeroallergen. Among 238 workers, without previous occupational exposure to rats, work related symptoms, which started after first employment at the site were related to exposure intensity (expressed either in terms of dust or of aeroallergen) at the time of onset of symptoms. These relations were stronger in atopic subjects but were unrelated to smoking. Positive skin tests to rat urinary extract were also more frequent with increased exposure, a relation found in both atopic subjects and in smokers. There was a strong association between work related symptoms and specific sensitisation.

Exposure to dust and rat urinary aeroallergens in research establishments

As part of an epidemiological study rat urinary aeroallergen (RUA) and total dust concentrations were measured at three research establishments. Personal RUA measurements in nine exposure groups over a workshift showed highest exposure for animal technicians (geometric mean (GM) = 32.4 micrograms/m3) and lowest for workers in slide production and office (GM > or = 0.1 micrograms/m3). Except for slide production workers, contact with rats, their tissues, faeces, or urine comprised less than half the work shift. Exposure during contact with rats was considerably higher. Personal RUA measurements in nine task categories showed high RUA concentrations for handling rats (GM = 68.0 micrograms/m3) and cleaning out (GM = 53.6 micrograms/m3). Traces of RUA could still be measured in tearooms inside and near offices outside the animal houses. Total dust concentrations were low.

SWORD '93. Surveillance of work-related and occupational respiratory disease in the UK

Some 3500 new cases of occupational respiratory disease are estimated to have been seen annually by SWORD participants in 1992 and 1993 with little important difference between the two years. As the number of new cases recognized and reported by chest physicians is close to complete, the estimated incidence is essentially correct. The pattern of disease which clearly emerges shows that at least half is attributable to asbestos exposure, despite the fact that lung cancer from this cause may be under-reported. Benign pleural disease comprises a large proportion of the cases, the long-term implications of which are unknown. Almost 40% of the cases reported are of occupational asthma or inhalation accidents, both due to a very large number of different agents and affecting many and varied occupations. These cases are preventable providing their occupational aetiology is recognized and appropriate measures of control are intensified.

Work related symptoms, sensitisation, and estimated exposure in workers not previously exposed to flour

Findings are presented from the initial cross sectional phase of a cohort study of employees exposed to flour in bakeries or mills. Of 401 eligible workers in seven sites 344 (86%) were surveyed; symptoms assessed by self completed questionnaire, and sensitisation measured by the response to skin prick tests, were related to intensity of exposure both to total dust and to flour aeroallergen. Among 264 subjects without previous occupational exposure to flour, work related symptoms which started after first employment at the site were related to exposure intensity, especially when exposure was expressed in terms of flour aeroallergen. The relations with eye/nose and skin symptoms were independent of atopic status and cigarette smoking. Positive skin test responses to mixed flour and to alpha amylase were also more frequent with increasing exposure intensity, although this was confounded by atopic status. There was only a weak association between symptoms and specific sensitisation.

Work-related respiratory disease in the United Kingdom, 1989-1992: report on the SWORD project

The objective of this project is the creation of a reliable and cost-effective national system of surveillance for work-related respiratory disease as a basis for control and simple epidemiological research. With the voluntary participation of almost 800 chest and occupational physicians from throughout the UK, newly diagnosed cases of respiratory illness thought to be due to occupational factors have been reported regularly since January 1989. Since January 1992, reports from chest physicians have been submitted monthly by a core group with special interest in occupational lung disease (n = 32) and rotating random samples of the remainder. Between 1989 and 1991, 5576 new cases were reported, of which half were diseases of long latency mainly due to asbestos, 28% were occupational asthma, and the rest were divided between inhalation accidents (10%) and a variety of other acute diseases (14%). Disease incidence rates, with denominators from the Labour Force Survey, showed a very high risk of asthma among paint sprayers, chemical and food processors, laboratory staff, plastics and metal treatment workers, and in welding and electronic assembly. Some of the same groups also experienced high rates of inhalation accidents and bronchitis. The risk of diseases of long latency, using denominators from the 1961 census, was highest in shipyard and dock workers, miners and construction workers. The SWORD scheme has provided estimates of disease incidence not previously available, has encouraged awareness of occupational factors among chest physicians, has assisted those responsible for prevention and control, and has demonstrated the feasibility of this approach to surveillance.

Transplantation and quality of care for end-stage renal disease: 1993

We describe a group of renal transplant recipients whose allografts are in general considered to be successful statistically, but who are not greatly benefitted clinically. Grafts in these recipients survive somewhat longer than 6 months, but generally less than 3 years. Many of these individuals are chronically ill. They have many hospitalizations, experience most of the complications associated with transplantation, and incur more mortality and less benefit. Research initiatives need to be focused on this group of patients. A major study of more sensitive methods of detecting presensitization might be beneficial.

Recent advances in the management of gallstones

Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.

Traumatic pancreatitis in a patient with pancreas divisum: clinical and radiographic features

A previously healthy patient with chronic hyperamylasemia and epigastric pain following blunt abdominal trauma complicated by retroperitoneal hematoma is reported. Endoscopic retrograde cholangiopancreatographic and computerized tomographic examinations revealed pancreatographic characteristics of pancreas divisum with traumatic disruption of the duct of Santorini and adjacent pseudocyst formation. Distal pancreatectomy with cystjejunostomy resulted in total recovery. This represents the first documented case of traumatic pancreatitis in a patient with pancreas divisum.

Infections due to parainfluenza virus type 4 in children

Parainfluenza viruses are a major cause of hospitalization for respiratory illness in children. The spectrum of clinical illness associated with infection due to parainfluenza type 4 virus has not been well defined. It is technically difficult to isolate the virus in tissue culture, and because illness is generally reported to be mild, in many cases, patients may not seek medical attention. We describe a series of 10 children with parainfluenza type 4 virus infection who were seen at the Montreal Children's Hospital between 1988 and 1992. There were five males and five females whose average age was 29.7 months. Infection was associated with symptoms of bronchiolitis or pneumonia in 5 children, paroxysmal coughing in 3 infants, apnea in 1 newborn, and aseptic meningitis in 1 child. Hospitalization was required for 8 of the 10 children. It appears that infection with parainfluenza type 4 virus may be more common than previously recognized, and it may be associated with more severe infections.

The 1891-1920 birth cohort of Quebec chrysotile miners and millers: mortality 1976-88

A cohort of some 11,000 men born 1891-1920 and employed for at least one month in the chrysotile mines and mills of Quebec, was established in 1966 and has been followed ever since. Of the 5351 men surviving into 1976, only 16 could not be traced; 2508 were still alive in 1989, and 2827 had died; by the end of 1992 a further 698 were known to have died, giving an overall mortality of almost 80%. This paper presents the results of analysis of mortality for the period 1976 to 1988 inclusive, obtained by the subject-years method, with Quebec mortality for reference. In many respects the standardised mortality ratios (SMRs) 20 years or more after first employment were similar to those for the period 1951-75--namely, all causes 1.07 (1951-75, 1.09); heart disease 1.02 (1.04); cerebrovascular disease 1.06 (1.07); external causes 1.17 (1.17). The SMR for lung cancer, however, rose from 1.25 to 1.39 and deaths from mesothelioma increased from eight (10 before review) to 25; deaths from respiratory tuberculosis fell from 57 to five. Among men whose exposure by age 55 was at least 300 million particles per cubic foot x years (mpcf.y), the SMR (all causes) was elevated in the two main mining regions, Asbestos and Thetford Mines, and for the small factory in Asbestos; so were the SMRs for lung cancer, ischaemic heart disease, cerebrovascular disease, and respiratory disease other than pneumoconiosis. Except for lung cancer, however, there was little convincing evidence of gradients over four classes of exposure, divided at 30, 100, and 300 mpcf.y. Over seven narrower categories of exposure up to 300 mpcf.y the SMR for lung cancer fluctuated around 1.27 with no indication of trend, but increased steeply above that level. Mortality form pneumoconiosis was strongly related to exposure, and the trend for mesothelioma was not dissimilar. Mortality generally was related systematically to cigarette smoking habit, recorded in life from 99% of survivors into 1976; smokers of 20 or more cigarettes a day had the highest SMRs not only for lung cancer but also for all causes, cancer of the stomach, pancreas, and larynx, and ischaemic heart disease. For lung cancer SMRs increased fivefold with smoking, but the increase with dust exposure was comparatively slight for non-smokers, lower again for ex-smokers, and negligible for smokers of at least 20 cigarettes a day; thus the asbestos-smoking interaction was less than multiplicative. Of the 33 deaths from mesothelioma in the cohort to date, 28 were in miners and millers and five were in employees of a small asbestos products factory where commercial amphiboles had also been used. Preliminary analysis also suggest that the risk of mesothelioma was higher in the mines and mills at Thetford Mines than in those at Asbestos. More detailed studies of these differences and of exposure-response relations for lung cancer are under way.