C-reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study

BACKGROUND

Anastomotic leak is a common complication after colorectal surgery, associated with increased morbidity and mortality, and poorer long-term survival after oncological resections. Early diagnosis improves short-term outcomes, and may translate into reduced cancer recurrence. Multiple studies have attempted to identify biomarkers to enable earlier diagnosis of anastomotic leak. One study demonstrated that the trajectory of C-reactive protein (CRP) levels was highly predictive of anastomotic leak requiring intervention, with an area under the curve of 0·961. The aim of the present study was to validate this finding externally.

METHODS

This was a prospective international multicentre observational study of adults undergoing elective colorectal resection with an anastomosis. CRP levels were measured before operation and for 5 days afterwards, or until day of discharge if earlier than this. The primary outcome was anastomotic leak requiring operative or radiological intervention.

RESULTS

Between March 2017 and July 2018, 933 patients were recruited from 20 hospitals across Australia, New Zealand, England and Scotland. Some 833 patients had complete CRP data and were included in the primary analysis, of whom 41 (4·9 per cent) developed an anastomotic leak. A change in CRP level exceeding 50 mg/l between any two postoperative days had a sensitivity of 0·85 for detecting a leak, and a high negative predictive value of 0·99 for ruling it out. A change in CRP concentration of more than 50 mg/l between either days 3 and 4 or days 4 and 5 after surgery had a high specificity of 0·96-0·97, with positive likelihood ratios of 4·99-6·44 for a leak requiring intervention.

CONCLUSION

This study confirmed the value of CRP trajectory in accurately ruling out an anastomotic leak after colorectal resection.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas

Background

Schwannomas are rare tumours that pose a significant management challenge in the abdomen, retroperitoneum and pelvis. No data are available to inform management strategy.

Methods

A collaborative international cohort study, across specialist sarcoma units, was conducted to include adults presenting between 2000 and 2017 with histopathologically confirmed schwannomas within the abdomen, retroperitoneum or pelvis.

Results

Of 485 patients across 12 centres, 38 (7·8 per cent) were discharged without follow-up, 199 (41·0 per cent) underwent early resection and 248 (51·1 per cent) had radiological monitoring. Of these 248 patients, 96 (38·7 per cent) eventually had surgery, giving an overall resection rate of 60·8 per cent (295 of 485). At baseline, median tumour volume was 90·1 (i.q.r. 26·5–262·0) cm3. The estimated growth rate was 10·5 (95 per cent c.i. 9·4 to 11·6) per cent per year, and was consistent in the short term (within 2 years of diagnosis) and long term (beyond 2 years) (ρ = 0·405, P = 0·021). A decision to operate was more common in symptomatic patients (P < 0·001) and for rapidly growing tumours (growth rate more than 20 per cent per year) (P = 0·025). R0/R1 resection was achieved in 91·6 per cent of patients (263 of 287). Kaplan–Meier long-term recurrence rates after R0/R1 resection were 2·3 and 6·7 per cent at 3 and 5 years respectively.

Conclusion

Specific recommendations include: indications for early surgery, prediction of growth from radiological monitoring, promotion of selective submacroscopic resection and cessation of postoperative imaging surveillance.

A primary germ cell tumour in the gastrointestinal tract: a caecal lesion of yolk-sac morphology in a young patient

A 24-year-old man with a history of Crohns disease, whilst undergoing surveillance colonoscopy was found to have an ulcerated caecal lesion. The histopathology from the mucosal biopsy was suggestive of a yolk sac tumour. After thorough re-examination, the patient had no radiological evidence of malignancy in his testes or retroperitoneum. His alpha-fetoprotein levels returned as 2145, whilst his carcinoembryonic antigen was negligible. The patient was therefore consented for and underwent a laparoscopic right hemi-colectomy with an ileocolic anastomosis, without any complications. The formal histopathology confirmed the results from the biopsy, of a yolk sac non seminous germ cell tumour with positive lymph nodes and lymphovascular invasion. The patient was referred on to medical oncology for neoadjuvant chemotherapy. As the literature in his instance is scarce, the patient's overall prognosis remains unclear. To the best of our knowledge this is the first reported primary germ cell tumour of the gastrointestinal tract.

'Test n Treat' (TnT): a cluster randomized feasibility trial of on-site rapid Chlamydia trachomatis tests and treatment in ethnically diverse, sexually active teenagers attending technical colleges

OBJECTIVES

We conducted a cluster-randomized feasibility trial of 90-minute Chlamydia trachomatis tests and same day on-site treatment ('Test n Treat/TnT') in six technical colleges in London, England, to assess TnT uptake rates; follow-up rates; prevalence of C. trachomatis at baseline and 7 months; time to treatment; acceptability of TnT.

METHODS

Participants completed questionnaires and provided genitourinary samples at baseline and 7 months. Participants were informed that baseline samples would not be tested for 7 months and were advised to get screened independently. Colleges were randomly allocated 1:1 to intervention (TnT) or control (no TnT). One month and 4 months post recruitment, participants at intervention colleges were texted invitations for on-site free C. trachomatis tests. A purposive sample of students who did/did not attend for screening were interviewed (n = 26).

RESULTS

Five hundred and nine sexually active students were recruited: median age 17.9 years, 47% male, 50% black ethnicity, 55% reporting two or more sexual partners in the previous year. TnT uptake was 13% (33/259; 95% CI 8.9-17.4%) at 1 month and 10% (26/259; 6.7-14.4%) at 4 months with overall C. trachomatis positivity 5.1% (3/59; 1.1-14.2%). Follow-up at 7 months was 62% (317/509) for questionnaires and 52% (264/509) for samples. C. trachomatis prevalence was 6.2% (31/503) at baseline and 6.1% (16/264) at 7 months. Median time from test to treatment was 15 h. Interviews suggested low test uptake was associated with not feeling at risk, perceptions of stigma, and little knowledge of sexually transmitted infections (STIs).

CONCLUSIONS

Despite high C. trachomatis rates at baseline and follow-up, uptake of testing was low. Like many countries, England urgently needs better sex education, including making STI testing routine/normal. Trial registration ISRCTN58038795.

The Case of the Septic Fitness Instructor: Exercise Immunology in Action?

A 20 year old fitness instructor was admitted with abdominal pain and rapidly developed severe systemic inflammatory response syndrome and multi-organ dysfunction requiring ventilation and inotropic support. The cause was a histologically early appendicitis. Investigations excluded any underlying immunological or connective tissue disorder.

Intense exercise is known to cause changes in the physiology and function of the immune system. Innate and adaptive immune function, both in cellular numbers and function, has been shown to be impaired. An acute phase response similar to that seen with physical stressors such as sepsis and trauma has also been observed with elevation of pro-inflammatory and anti-inflammatory cytokines. This has led to the ‘open window’ theory of transient immunosuppresion following intense exercise. In this case presented, regular vigorous aerobic exercise was being performed whilst the patient was symptomatic up until 4 hours prior to admission. We propose that exercise induced immunosuppresion and priming of the inflammatory response led to a florid systemic inflammatory response developing and contributed to the rapid progression towards multi-organ dysfunction syndrome.

Chlamydia related bacteria (Chlamydiales) in early pregnancy: community-based cohort study

Objectives

Serological case–control studies suggest that certain chlamydia-related bacteria (Chlamydiales) which cause cows to abort may do the same in humans. Chlamydiales include Waddlia chondrophila, Chlamydia abortus and Chlamydia trachomatis. Data on prevalence of Chlamydiales in pregnancy are sparse. Using stored urine samples from a carefully characterised cohort of 847 newly pregnant women recruited from 37 general practices in London, UK, we aimed to investigate the prevalence and types of Chlamydiales infections. We also explored possible associations with miscarriage or spontaneous preterm birth.

Methods

Samples were tested using W. chondrophila and pan-Chlamydiales specific real-time PCRs targeting the 16S rRNA gene. Samples positive on either PCR were subjected to DNA sequencing and C. trachomatis PCR.

Results

The overall prevalence of Chlamydiales was 4.3% (36/847, 95% CI 3.0% to 5.8%). The prevalence of W. chondrophila was 0.6% (n = 5), C. trachomatis 1.7% (n = 14), and other Chlamydiales species 2.0% (n = 17). Infection with C. trachomatis was more common in women aged <25, of black ethnicity or with bacterial vaginosis, but this did not apply to W. chondrophila or other Chlamydiales.

Follow up was 99.9% at 16 weeks gestation and 90% at term. No infection was significantly associated with miscarriage at ≤12 weeks (prevalence 10%, 81/827) or preterm birth <37 weeks (prevalence 4%, 23/628). Of 25 samples sequenced, seven (28%) were positive for Chlamydiales bacterium sequences associated with respiratory tract infections in children.

Conclusion

In the first study to use the pan-Chlamydiales assay on female urine samples, 4% of pregnant women tested positive for Chlamydiales, including species known to be pathogenic in mothers and neonates.

High throughput solution-based measurement of antibody-antigen affinity and epitope binning

Advances in human antibody discovery have allowed for the selection of hundreds of high affinity antibodies against many therapeutically relevant targets. This has necessitated the development of reproducible, high throughput analytical techniques to characterize the output from these selections. Among these characterizations, epitopic coverage and affinity are among the most critical properties for lead identification. Biolayer interferometry (BLI) is an attractive technique for epitope binning due to its speed and low antigen consumption. While surface-based methods such as BLI and surface plasmon resonance (SPR) are commonly used for affinity determinations, sensor chemistry and surface related artifacts can limit the accuracy of high affinity measurements. When comparing BLI and solution equilibrium based kinetic exclusion assays, significant differences in measured affinity (10-fold and above) were observed. KinExA direct association (k_a) rate constant measurements suggest that this is mainly caused by inaccurate k_a measurements associated with BLI related surface phenomena. Based on the kinetic exclusion assay principle used for KinExA, we developed a high throughput 96-well plate format assay, using a Meso Scale Discovery (MSD) instrument, to measure solution equilibrium affinity. This improved method combines the accuracy of solution-based methods with the throughput formerly only achievable with surface-based methods.

High-throughput screening for developability during early-stage antibody discovery using self-interaction nanoparticle spectroscopy

The discovery of monoclonal antibodies (mAbs) that bind to a particular molecular target is now regarded a routine exercise. However, the successful development of mAbs that (1) express well, (2) elicit a desirable biological effect upon binding, and (3) remain soluble and display low viscosity at high concentrations is often far more challenging. Therefore, high throughput screening assays that assess self-association and aggregation early in the selection process are likely to yield mAbs with superior biophysical properties. Here, we report an improved version of affinity-capture self-interaction nanoparticle spectroscopy (AC-SINS) that is capable of screening large panels of antibodies for their propensity to self-associate. AC-SINS is based on concentrating mAbs from dilute solutions around gold nanoparticles pre-coated with polyclonal capture (e.g., anti-Fc) antibodies. Interactions between immobilized mAbs lead to reduced inter-particle distances and increased plasmon wavelengths (wavelengths of maximum absorbance), which can be readily measured by optical means. This method is attractive because it is compatible with dilute and unpurified mAb solutions that are typical during early antibody discovery. In addition, we have improved multiple aspects of this assay for increased throughput and reproducibility. A data set comprising over 400 mAbs suggests that our modified assay yields self-interaction measurements that are well-correlated with other lower throughput assays such as cross-interaction chromatography. We expect that the simplicity and throughput of our improved AC-SINS method will lead to improved selection of mAbs with excellent biophysical properties during early antibody discovery.

High throughput detection of antibody self-interaction by bio-layer interferometry

Self-interaction of an antibody may lead to aggregation, low solubility or high viscosity. Rapid identification of highly developable leads remains challenging, even though progress has been made with the introduction of techniques such as self-interaction chromatography (SIC) and cross-interaction chromatography (CIC). Here, we report a high throughput method to detect antibody clone self-interaction (CSI) using bio-layer interferometry (BLI) technology. Antibodies with strong self-interaction responses in the CSI-BLI assay also show delayed retention times in SIC and CIC. This method allows hundreds of candidates to be screened in a matter of hours with minimal material consumption.

Identification of the need for pharmaceutical care within the prevention strategy of CHD: a study in acute MI patients

Focal points

Scalp psoriasis: European consensus on grading and treatment algorithm

The scalp is a common site of involvement of psoriasis and, for many patients, is a challenging aspect of their disease. This can be attributed not only to the scaling, itching and cosmetic embarrassment that go with scalp psoriasis, but also to the fact that the scalp skin is relatively inaccessible, making topical therapies difficult to apply. The proximity of sensitive facial skin can also limit the use of potentially irritating topical treatments. Nevertheless, the specific challenges of scalp psoriasis are often neglected by treatment guidelines. This paper summarizes the discussions that took place at an international conference of experts convened in Geneva, Switzerland, in March 2008. The objective of the meeting was to review the available treatments for scalp psoriasis in terms of efficacy, safety, convenience, and the implications for patient compliance with treatment. In addition, definitions of mild, moderate and severe scalp psoriasis were agreed. This paper presents a treatment algorithm that includes recommendations for patients in all three categories. It considers the role of potent topical corticosteroids, vitamin D3 derivatives, salicylic acid preparations, and photo- and radiotherapy, as well as systemic therapies, including newer biological agents, for patients with widespread psoriasis with scalp involvement. Data from clinical trials indicate that a potent topical corticosteroid in a short-contact formulation is the most appropriate treatment for most patients with scalp psoriasis.

Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease

BACKGROUND

Health literacy (HL) has been recognized as an important public health issue in other developed countries such as the US. There is currently no HL screening tool valid for use in the UK. This study aimed to validate a US-developed HL screening tool (the Rapid Estimate for Adult Literacy in Medicine; REALM) for use in the UK against the UK's general literacy screening tool (the Basic Skills Agency Initial Assessment Test, BSAIT).

METHODS

A cross-sectional survey involving 300 adult patients admitted to hospital for investigation of coronary heart disease were given the REALM and BSAIT tools to complete as well as specific questions considered likely to predict HL. These questions relate to the difficulty in understanding medical information, medical forms or instructions on tablets, frequency of reading books and whether the participant's job involves reading.

RESULTS

The REALM was significantly correlated with the BSAIT (r = 0.70; P < 0.001), and significantly related to seven of the eight questions likely to be predictive of HL.

CONCLUSIONS

This study has shown that the REALM has face, criterion and construct validity for use as an HL screening tool in the UK, in research and in everyday clinical practice. Further studies are needed to assess the prevalence of low HL in a wider population and to explore the links that may exist between low HL and poor health in the UK.

Laparoscopic versus open colposuspension--results of a prospective randomised controlled trial

OBJECTIVE

To compare the effectiveness and cost effectiveness of open and laparoscopic colposuspension in the treatment of stress urinary incontinence.

DESIGN

A randomised controlled trial. Women were randomised between March 1999 and February 2002 and were seen for assessment at 6, 12 and 24 months, postoperatively.

SETTING

Women were recruited from six gynaecology units in the UK.

POPULATION

Women with proven stress urinary incontinence requiring surgery.

METHODS

Open abdominal retropubic colposuspension or laparoscopic colposuspension.

MAIN OUTCOME MEASURES

Primary outcomes were subjective (satisfaction with outcome) and objective (negative 1-hour pad test). Secondary outcomes were operative and postoperative morbidity and quality of life. The study was powered to demonstrate noninferiority, i.e. that the absolute cure rate of laparoscopic colposuspension was no more than 15% below that of open colposuspension.

RESULTS

A total of 291 women were randomised, with 24-month data on subjective and objective outcomes in 88 and 82.5%, respectively. The intention-to-treat analysis indicated no significant difference in cure rates between open and laparoscopic surgery. The objective cure rates for open and laparoscopic were 70.1 and 79.7%, respectively. Subjective cure rates by satisfaction were lower than objective cure; 54.6 and 54.9%, respectively, and there was considerable nonconcordance both ways.

CONCLUSIONS

Laparoscopic colposuspension is not inferior to open colposuspension in terms of curing stress urinary incontinence.

Stratification of foot ulcer risk in patients with diabetes: a population-based study

This trial assessed whether a simple clinical tool can be used to stratify patients with diabetes, according to risk of developing foot ulceration. This was a prospective, observational follow-up study of 3526 patients with diabetes (91% type 2 diabetes) attending for routine diabetes care. Mean age was 64.7 (range 15-101) years and duration of diabetes was 8.8 (+/-1.5 SD) years. Patients were categorised into 'low' (64%), 'moderate' (23%) or 'high' (13%) risk of developing foot ulcers by trained staff using five clinical criteria during routine patient care. During follow-up (1.7 years), 166 (4.7%) patients developed an ulcer. Foot ulceration was 83 times more common in high risk and six times more in moderate risk, compared with low-risk patients. The negative predictive value of a 'low-risk score' was 99.6% (99.5-99.7%; 95% confidence interval). This clinical tool accurately predicted foot ulceration in routine practice and could be used direct scarce podiatry resources towards those at greatest need.

Recent increases in incidence of echoviruses 13 and 30 around Europe

A report in Eurosurveillance Weekly in September 2001 discussed the concurrent increases in the incidence of echovirus 30 in Germany and the United Kingdom in 2001 (1). Outbreaks of echovirus 13 infection had also occurred in both England and Wales, and Germany, in 2000. Other European countries informed the Eurosurveillance team that they had experienced similar outbreaks, and it was decided to conduct a small study through Eurosurveillance of echovirus incidence in European and other countries.

Evaluation of the implementation of a local treatment guideline in secondary prevention post-myocardial infarction

OBJECTIVE

To validate and implement an audit tool to assess quality and appropriateness of prescribing. To compare inpatient prescribing of secondary prevention in post myocardial infarction patients before and after introduction of a local treatment guideline.

METHOD

Descriptive, non-experimental retrospective case note review comparing patients treated before and after the implementation of a clinical guideline.

MAIN OUTCOME

Comparison of quality of prescribing in two patient groups.

RESULTS

Analysis of Group 1 patients showed that 41% required treatment with an angiotensin converting enzyme inhibitor (ACE-I), and 23% of those did not receive treatment, 20% of patients on ACE-I received sub-therapeutic doses. Seventy-two per cent of patients required treatment with a statin and 22% of those did not receive a statin. Comparison of the treatment of Group 2 showed that, of 53 patients (50% of Group 2) requiring an ACE-I, 100% received it, although 15% received sub-therapeutic doses. Of 69 patients (64% of Group 2) requiring treatment with a statin 96% were prescribed a statin. Improvements in prescribing of beta-Blockers, ACE-I and statins were statistically significant.

CONCLUSIONS

Prescribing improved significantly for beta-Blockers, ACE-I and statins after guideline introduction with anticipated benefits to patient outcomes.

Serum apolipoprotein H and its relationship to blood pressure, serum lipids, fasting plasma glucose and insulin in normal individuals

Apolipoprotein H (apo H), also known as beta2-glycoprotein 1, has recently become of interest in the field of haemostasis. As apo H is elevated in diabetes mellitus and dyslipidaemia, we wished to test the hypothesis that serum apo H concentration was related to fasting plasma glucose and insulin as well as blood pressure, body mass index, hip/waist ratio and serum lipids in normal individuals. Eighty-one healthy young individuals (46 females and 35 males) were studied. Their age was 20.7 +/- 0.75 years. Serum apo H significantly correlated with fasting plasma glucose (r = 0.24, P = 0.03) and serum LDL cholesterol (r = 0.30, P = 0.006). In the females serum apo H significantly correlated with serum cholesterol concentration (r = 0.30, P = 0.04) and in males with serum HDL cholesterol concentration (r = 0.35, P = 0.04). In multifactorial regression analysis for serum apo H and the other variables for the 81 subjects, only gender and fasting plasma glucose remained statistically significant in the model. Serum apo H concentrations would be expected to increase by 21.7 mg/L for each single mmol/L increase in fasting plasma glucose (95% CI 2.3-41 2), P = 0.029, and to increase by 17.0 mg/L if the gender is male (95% Cl 0.7-332), P= 0.041.

Human chorionic gonadotropin-to-oocyte collection interval in a superovulation IVF program. A prospective study

PURPOSE

The aim of this study was to investigate whether the hCG-oocyte collection interval has any influence on the oocyte recovery rate, fertilization rate, and outcome of IVF-ET cycles.

METHODS

Five hundred thirty-three consecutive patients undergoing their first IVF-ET treatment cycle at King's Assisted Conception Unit between 1993 and 1995 were included in this study.

RESULTS

There was no significant difference in the oocyte recovery rates, fertilization rates, or outcome of IVF-ET treatment among the hCG-oocyte collection intervals examined (33-41 hr). None of the 533 women studied had ovulated before oocyte collection.

CONCLUSIONS

The results do not suggest a trend toward increased ovulation more than 36 hr after hCG administration.

Comparison of RAP-PCR analysis of gene expression in fresh and immortalised rat hepatocyte cell lines

Primary rat hepatocytes dedifferentiate rapidly losing theactivities of the drug metabolising enzymes involved in thedetoxification of xenobiotics in the liver. An alternativeapproach to using primary hepatocytes for toxicity testing isthe development of immortalised hepatocyte cell lines via thetransfection of primary hepatocytes with SV40 DNA. In order toassess the suitability of immortalised lines as an alternativeto primary cell cultures we have used RNA arbitrarily primedpolymerase chain reaction to compare gene expression inimmortalised rat hepatocyte cell lines with that in primary rathepatocytes. We have found that differences exist in the RNAtranscripts between fresh and immortalised hepatocyteshighlighting RNA arbitrarily primed polymerase chain reaction asa useful screening method for identifying immortalised lineswhich retain the most ;normal' phenotype in relation to theprimary cells from which they originated.

GP referral to an eating disorder service: why the wide variation?

BACKGROUND

Early detection and management of patients with eating disorders is thought to improve prognosis, yet little is known about the factors associated with referral of these patients to treatment centres.

AIM

To calculate general practitioner (GP) referral rates to a specialist eating disorder service and determine the association between referral rate and general practice and practitioner factors.

METHOD

Referral rate was calculated from a database of routine referrals to St George's Hospital Eating Disorder Service from January 1990 to May 1996 and correlated with practice and practitioner details obtained from medical directories and health authority data.

RESULTS

There was a wide variation in referral rates. A higher referral rate was found to be associated with practice size, proximity to the clinic, female GPs, GPs having the MRCGP qualification, being United Kingdom qualified, and offering full contraceptive services. Fundholding was associated with lower rates of referral.

CONCLUSION

Patients with eating disorders may be at a disadvantage in certain practices. Educational interventions could be targeted towards low referrals.

Prothrombin 20210 G-->A, MTHFR C677T mutations in women with venous thromboembolism associated with pregnancy

Over 50 unselected women with maternal venous thromboembolism were screened for the prothrombin 20210 G-->A and MTHFR C677T mutations, in addition to screening for other thrombophilias. The prevalence of thrombophilia in these women was compared with its prevalence in the general population in our area. The prothrombin (OR 4.4; 95% CI 1.2-16) and factor V Leiden (OR 4.5; 95% CI 2.1-14.5) mutations were more common in our patients, compared with the general population, whereas women homozygous for the C677T mutation in the methylene tetrahydrofolate reductase gene (OR 0.45; 95% CI 0.13-1.58) were not. It is recommended that women with a personal or strong family history of venous thromboembolism should be screened for the prothrombin mutation either before or early in pregnancy, in addition to screening for other thrombophilias. Screening for the MTHFR mutation does not appear to identify women at increased risk of maternal venous thrombosis.

Anorexia nervosa: changes in sexuality during weight restoration

OBJECTIVE

We examined changes in sexual drive during weight restoration in patients with anorexia nervosa.

METHODS

Eleven women with anorexia nervosa prospectively completed the Sexual Daydreaming Questionnaire (SDQ) and the Hospital Anxiety and Depression Scale (HADS) at five time points during inpatient treatment involving weight restoration. SDQ and HADS scores were recorded every 4 weeks until 8 weeks after subjects had reached the mean matched population weight (MMPW), which was monitored against body mass index (BMI). Histories were 'taken for purging, self-cutting, childhood sexual abuse, and number of sexual partners. Repeated-measures analysis of variance, regression analyses, and t tests were performed.

RESULTS

BMI and sexual daydreaming were closely associated (p < .001). BMI and depression also achieved a statistically significant association (p = .046), with "caseness" for anxiety disorder throughout. Higher levels of sexual drive at MMPW seemed to be associated with purging, self-cutting, and childhood sexual abuse but not at low weight. Levels of sexual drive did not reflect previous sexual behavior.

CONCLUSIONS

An increase in sexual drive accompanies weight restoration in patients with anorexia nervosa, which is consistent with psychological and physiological explanations of altered sexuality. Transient depression is also associated with weight gain. Changes in sexuality should be considered in both recovery and treatment failure.

Intraocular lens implants and risk of endophthalmitis

AIM

To investigate the possible association between the use of three piece foldable silicone polypropylene (SPP) intraocular lenses (IOLs) and an increased risk of postoperative endophthalmitis.

METHODS

A retrospective analysis was conducted of all cases of postoperative endophthalmitis following phacoemulsification surgery in a single unit over a 3 year period. The incidence of postoperative endophthalmitis in eyes with SPP IOLs was compared with the incidence in eyes with single piece polymethylmethacrylate (PMMA) IOLs.

RESULTS

772 cataract extractions by phacoemulsification were performed. One (0.16%) of the 622 patients with PMMA IOLs developed endophthalmitis. Excluding one patient who had aplastic anaemia, five (3.33%) of 150 patients with SPP IOLs developed endophthalmitis. The relative risk for postoperative endophthalmitis associated with the use of the SPP IOL compared with the PMMA IOL was 20.1 (p = 0.015).

CONCLUSION

This study adds further evidence to the concept that SPP IOLs can be a significant risk factor in the development of postoperative endophthamitis.

Coronary stenting in unstable angina: early and late clinical outcomes

OBJECTIVE

To examine the procedural and long term success of coronary stenting in patients presenting with unstable angina and the effect of warfarin on the clinical outcome of these high risk patients.

DESIGN

A nonrandomized, retrospective analysis of patients presenting with unstable angina.

SETTING

A tertiary care, Canadian university-affiliated teaching hospital.

PATIENTS

Of 1250 patients who underwent percutaneous transluminal coronary angioplasty between January 1994 and June 1995, 365 underwent coronary stenting. The study population consisted of the 156 patients presenting with unstable angina who underwent coronary stenting. Patients with Canadian Cardiovascular Society class IV and postinfarction angina were included.

INTERVENTIONS

Stent delivery by standard techniques to the target lesion was successful in all patients. At discharge, 88 patients were prescribed warfarin, ticlopidine and acetylsalicylic acid (ASA); the remaining 68 patients received only ticlopidine and ASA. Late clinical outcomes were assessed by telephone interview.

RESULTS

The overall procedural success rate was 96%. One patient died in hospital (0.6%). Other events were abrupt closure (1.9%), myocardial infarction (1.9%) and urgent bypass surgery (1.9%). During follow-up, target vessel reintervention was needed in 19.6% of patients. Early and late clinical outcomes did not differ significantly between anticoagulated patients and those treated with antiplatelet agents alone, but anticoagulated patients had a significantly longer hospital stay.

CONCLUSIONS

Coronary stenting in patients with unstable angina was associated with excellent procedural success and favourable late clinical outcomes. Warfarin added no apparent additional clinical benefit to antiplatelet agents in this high risk population.

Prednisolone in acute childhood asthma: clinical responses to three dosages

Ninety-eight children aged 1-15 years entered a randomized double-blind study investigating an appropriate dose of oral prednisolone in children admitted to hospital with an acute exacerbation of asthma. None of the children had recently been treated with oral prednisolone. Following admission, the children were randomized to receive prednisolone 0.5 mg kg-1, 1.0 mg kg-1 or 2.0 mg kg-1 in a single daily dose in addition to nebulized bronchodilators. Clinical asthma scores, oxygen saturations, pulse rate, duration of admission and number of nebulizers given were compared in the three treatment groups. Thirty-five children received 0.5 mg kg-1, 33 received 1.0 mg kg-1 and 30 received 2.0 mg kg-1. There were no significant differences in the pattern of recovery between the three treatment groups. There were no advantages in using higher doses of prednisolone. We recommend 0.5 mg kg-1 day-1 of prednisolone as an appropriate dose for treating an acute exacerbation of asthma.

Hepatic artery resistance index can predict early death in children with biliary atresia

Hepatic artery resistance index has been measured by ultrasonography Doppler and has been found to predict rapid deterioration and death in children with biliary atresia. Clinical, biochemical, ultrasonographic, and outcome data were collected prospectively and retrieved on 32 patients with resistance index of > or = 1.0 (group A). These were compared with the same data for 32 age- and sex-matched patients with biliary atresia and a resistance index of < 1.0 (group B). Group A was found to have significantly worse liver function tests than group B. In group A, all patients died (n = 11) or underwent transplantation (n = 21; of whom 4 died) compared with only 2 patients who died in group B and 4 patients who underwent transplantation without fatality. Survival at 2 years was 52% in group A v 94% in group B. It is suggested that regular ultrasonography Doppler examination in patients with biliary atresia can detect a group with a resistance index of > 1.0 who have a very high risk of early mortality. Such patients require early evaluation and listing for transplantation. Those listed for liver transplantation on other grounds require ultrasonography examinations every 2 to 3 months with immediate upgrading of the priority of those patients found to have a resistance index of > or = 1.0.

Autoimmune hepatitis in childhood: a 20-year experience

To determine the clinical, biochemical, and histological features, and outcome of childhood autoimmune hepatitis (AIH), we reviewed the medical records of 52 children with AIH, 32 (median age: 10 [2-15] years) anti-nuclear and/or smooth muscle antibody (ANA/SMA) positive, 20 (7 [0.8-14] years) liver/kidney microsomal antibody (LKM-1) positive, with median follow-up of 5 years (range 0.3-19). At presentation: 56% had symptoms of prolonged acute hepatitis; LKM-1 positive were younger (P = .011), with higher bilirubin (P = .007), and AST (P = .047); ANA/SMA positive had lower albumin (P = .023); 69% ANA/SMA positive, and 38% LKM-1 positive were cirrhotic (P = .080). ANA/SMA positive had increased frequency of HLA haplotype A1/B8/DR3/DR52a compared with controls (53% vs. 14%, P < .001). Of six (5 LKM-1 positive) with fulminant hepatitis, four were transplanted, one died, and one ANA/SMA positive improved with immunosuppression. Of 47 treated with immunosuppression, 2 (1 LKM-1 positive) died with no remission and 4 (2 LKM-1 positive) were transplanted 8 to 14 years after diagnosis. Immunosuppression was stopped successfully in 19% of ANA/SMA positive after a median of 3 years of treatment, but in none of LKM-1 positive. Baseline bilirubin and international normalized prothrombin ratio (INR) were independent variables predictive of outcome. In conclusion, ANA/SMA positive and LKM-1 positive AIH in childhood have clinical, biochemical, and histological differences, but similar severity and long-term outcome.

Primary care in the accident and emergency department: I. Prospective identification of patients

OBJECTIVE

To compare patient characteristics and consultation activities for attenders at accident and emergency departments assessed by nurse triage as presenting with "primary care" or "accident and emergency" type problems.

DESIGN

One year prospective study.

SETTING

A busy, inner city accident and emergency department in south London.

SUBJECTS

Of the 5658 patients treated for new problems during a stratified random sample of 204 three hour sessions between 10 am and 9 pm during June 1989 to May 1990, all "primary care" (2065 patients) and a 10% random sample of "accident and emergency" (291 patients) were included in the analysis.

MAIN OUTCOME MEASURES

Patient's age, sex, duration of presenting problem, diagnosis, laboratory and radiographic investigations, treatments, and referrals.

RESULTS

40.9% of attenders with new problems were classified by triage as presenting with "primary care" problems (95% confidence interval 39.6% to 42.2%). Primary care attenders were more likely than accident and emergency patients to be young adults, to have symptoms with a duration of longer than 24 hours, and to present problems not related to injury (all P < 0.001). Accident and emergency patients were considerably more likely to be referred to on call teams and to be admitted. Even so, 9.7% of primary care patients were referred to on call teams and a further 8.9% were referred to the fracture clinic or advised to return to the accident and emergency department for follow up.

CONCLUSION

Accident and emergency triage can be developed to identify patients with problems that are more likely to be of a primary care type, and these patients are less likely to receive an investigation, minor surgical procedure, or referral. Many patients in this category, however, receive interventions likely to support their decision to attend accident and emergency rather than general practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.

Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors

OBJECTIVE

To compare the process and outcome of "primary care" consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department.

DESIGN

Prospective, controlled intervention study.

SETTING

A busy, inner city accident and emergency department in south London.

SUBJECTS

Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars.

MAIN OUTCOME MEASURES

Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations.

RESULTS

Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners.

CONCLUSION

Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

Decisional conflict in general practice: strategies of patient management

Exploratory interviews were carried out with 37 general practitioners as an initial stage of a larger project investigating medical decision making in primary care. Qualitative analysis of free responses to a set of semi-structured questions revealed a common set of variables which influence decisions about patient management. These included: time pressure, uncertainty and patient characteristics. Results corroborate previously reported findings and may have important implications for the variation of management decisions about similar patient complaints. Strategies of patient management are identified, and the correspondence between these and the postulates of decisional conflict theory explored.

Deterioration in the accuracy of the pulsair non-contact tonometer with use: need for regular calibration

The Pulsair non-contact tonometer (Keeler Pulsair: Keeler UK) has been shown to be a versatile instrument particularly suitable for screening for raised intraocular pressure. Although demonstrated to be accurate initially when compared to the Goldmann applanation tonometer no study has examined its long-term accuracy. Comparisons of three Pulsair tonometers with different degrees of usage with the Goldmann tonometer are described. Measurements were obtained from 64, 116, and 223 eyes in three separate comparative studies. Correlation coefficients of between 0.78 and 0.90 were obtained, the least used instrument being significantly more accurate than the two more extensively used instruments. Taking the Goldmann tonometer as the standard tonometer, and the aim to detect intraocular pressures of greater than 21 mmHg, sensitivities of 40%, 48%, and 85% for the three Pulsair tonometers respectively were shown. The Pulsair tonometer appears liable to a long-term drift in accuracy with use, and we suggest that provision is made for the regular re-calibration of the instrument.

Transmission window near 2400 cm(-1): an experimental and modeling study

The absorption in the 2400-cm(-1) region is dominated by continuum absorptions from carbon dioxide and nitrogen, and it is important to be able to describe the temperature dependence of these two continua. A series of measurements of atmospheric transmission over a 5.7-km range were carried out during the summer and winter seasons of 1988. Following a brief description of the experiments a selected number of spectra, covering the temperature range from -21.4 to 30.3 degrees C, are presented. These measurements are compared with predictions by the atmospheric transmission model FASCOD2 and modified versions using models of the carbon dioxide and the nitrogen continua derived from experimental laboratory measurements. Finally, an improved temperature-dependent model for the nitrogen continuum is derived from atmospheric transmission measurements. The model covers the range of temperatures found in the troposphere and differs significantly from laboratory-based measurements.

Atmospheric transmission in the 2.8-5.5-microm region: description of the Fourier interferometric transmissometer and typical result at low temperatures

A study of moderate resolution (1 cm(-1)) atmospheric transmission measurements made over a 5.7-km path and under a wide range of temperatures and humidities is presented. A description of the Fourier interferometric transmissometer (FIT) used for this study and a detailed analysis of the experimental protocol developed for that type of instrument are given. Results for the 2.8-5.5-microm spectral window are compared to calculations using the LOWTRANG and FASCOD2 transmission codes. We examine the accuracy with which these codes predict transmittance in spectral domains (1800-2000 and 3200-3500 cm(-1)) strongly affected by water vapor concentration. Preliminary analysis, indicates that although LOWTRAN6 predicts well the summer transmittance (+30.3 degrees C) there are significant divergences for the winter case (-21.4 degrees C). The comparison of FASCOD2 with experimental results shows much closer agreement than LOWTRANG for both summer and winter cases.

Missing ingredients: aging and the discrimination of flavor

An experiment explored how well young, middle-aged, and elderly subjects could discriminate the presence or absence of the spice marjoram in a soup prepared according to a published recipe. Whereas most young made the discrimination at a level above chance, most middle-aged and elderly failed to. A clinical test that entails odor threshold and identification revealed that olfactory ability also diminished with age among these subjects. Furthermore, the odor thresholds measured in the test correlated significantly with the subjects' ability to discriminate flavor. Subsequent testing wherein subjects sought to discriminate flavor with their noses blocked confirmed that olfactory ability largely underlay the discrimination. The results emphasize that losses in olfaction measured most commonly with environmental odors are serious enough to have an impact on discrimination of flavors in everyday foods, even among persons of middle age. Loss of such discriminative capacity may entail risks of avoiding dangerous and overlooking beneficial ingredients in foods.