56 A Quality Improvement Project to Assess and Refine the Handover Process at Morning Trauma Meetings

Aim

Poor handover and inadequate transmission of clinical information between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK district general hospital.

Method

A prospective single centre observational study was performed at an acute NHS trust, using the define, measure, analyse, improve and control (DMAIC) methodology. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeon’s recommendations for effective handover (2007) to create a standard operating protocol (SOP). Following the implementation of the SOP, a further eight consecutive weekday trauma meetings, involving a further 47 patients, were observed. The data collection was performed by five trained independent observers. The data was analysed using t-test for quantitative variables and chi-square or Fisher’s exact tests for categorical variables.

Results

An improvement in the trauma handover was demonstrated in multiple aspects of handover including patient’s past medical history, injury date, results, diagnosis, consent, mark and starvation status (all p < 0.001). Subgroup analyses showed that handover of neck of femur patients including information on mobility (p = 0.04), Nottingham Hip Fracture Score (p = 0.01), next of kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following our interventions.

Conclusions

These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.

49 A Quality Improvement Project to Assess and Refine the Handover Process at Morning Trauma Meetings

Introduction

Poor handover between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK hospital.

Method

A prospective single-centre observational study was performed at an NHS Trust. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeons’ recommendations for effective handover (2007) to create and implement a standard operating protocol (SOP). Following its implementation, a further 8 consecutive meetings, involving a further 47 patients, were observed. The data was analysed using t-test for quantitative variables and chi-square or Fisher’s exact tests for categorical variables.

Results

An improvement was demonstrated in multiple aspects of trauma handover including past medical history, injury date, results, diagnosis, consent, mark, and starvation status (all p < 0.001). Subgroup analyses showed that handover of neck-of-femur fracture patients including information on baseline mobility (p = 0.04), Nottingham-Hip-Fracture Score (p = 0.01), next-of-kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following the intervention.

Conclusions

These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.

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.

15 Structured Geriatric Liaison Services in Mental Health Inpatient Facilities

Introduction

Older people admitted to mental health facilities may be at increased risk of deterioration in the physical co-morbidities and increased rates of mortality when admitted in acute medical settings. Our model of care focuses on intervening in the physical aspect of patients admitted in the mental health unit addressing their comorbidities and polypharmacy and offering staff support during the admission process. Our Older Mental Health Unit is based in the district hospital with a total of 22 beds for people over 65 years old distributed in two areas: dementia with behavioral and psychological symptoms (BPS) and functional disorders.

Methods

Allocated geriatrician once a week to attend MDT and medical ward rounds. 5 working days telephone consultations for advice and supporting trainees in teaching and research. We measure the impact of our intervention comparing the data predating our intervention comparing 20 patients in each period 2016 and 2018.

Results

Mean age increased from 74.3 to 77.8 in a two year period with an average of 3.5 medical co-morbidities. Reduction in polypharmacy from 7.15 to 5.5 number of medication, 58% reduction in the number of hospital transfers and 90% reduction in specialty referrals.

Conclusions

Structured Geriatric Liaison Services in Mental Health in inpatient facilities are shown to be effective in reducing acute hospital and outpatient clinic attendances minimising the challenges of management of these patients in non-mental health facilities.

Extraction of the same novel homoglycan mixture from two different strains of Bifidobacterium animalis and three strains of Bifidobacterium breve

Three strains of Bifidobacterium breve (JCM 7017, JCM 7019 and JCM 2258) and two strains of Bifidobacterium animalis subsp. lactis (AD011 and A1dOxR) were grown in broth cultures or on plates, and a standard exopolysaccharide extraction method was used in an attempt to recover exocellular polysaccharides. When the extracted materials were analysed by NMR it was clear that mixtures of polysaccharides were being isolated including exopolysaccharides (EPS) cell wall polysaccharides and intracellular polysaccharides. Treatment of the cell biomass from the B. breve strains, or the B. animalis subsp. lactis AD011 strain, with aqueous sodium hydroxide provided a very similar mixture of polysaccharides but without the EPS. The different polysaccharides were partially fractionated by selective precipitation from an aqueous solution upon the addition of increasing percentages of ethanol. The polysaccharides extracted from B. breve JCM 7017 grown in HBM media supplemented with glucose (or isotopically labelled D-glucose-1-¹³C) were characterised using 1D and 2D-NMR spectroscopy. Addition of one volume of ethanol generated a medium molecular weight glycogen (Mw=1×10⁵ Da, yield 200 mg/l). The addition of two volumes of ethanol precipitated an intimate mixture of a low molecular weight β-(1→6)-glucan and a low molecular weight β-(1→6)-galactofuranan which could not be separated (combined yield 46 mg/l). When labelled D-glucose-1-¹³C was used as a carbon supplement, the label was incorporated into >95% of the anomeric carbons of each polysaccharide confirming they were being synthesised in situ. Similar ¹H NMR profiles were obtained for polysaccharides recovered from the cells of B. animalis subsp. lactis AD011and A1dOxR (in combination with an EPS), B. breve JCM 7017, B. breve JCM 7019, B. breve JCM 2258 and from an EPS (-ve) mutant of B. breve 7017 (a non-EPS producer).

Efficient generation of myelinating oligodendrocytes from primary progressive multiple sclerosis patients by induced pluripotent stem cells

Multiple sclerosis (MS) is a chronic demyelinating disease of unknown etiology that affects the CNS. While current therapies are primarily directed against the immune system, the new challenge is to address progressive MS with remyelinating and neuroprotective strategies. Here, we develop a highly reproducible protocol to efficiently derive oligodendrocyte progenitor cells (OPCs) and mature oligodendrocytes from induced pluripotent stem cells (iPSCs). Key elements of our protocol include adherent cultures, dual SMAD inhibition, and addition of retinoids from the beginning of differentiation, which lead to increased yields of OLIG2 progenitors and high numbers of OPCs within 75 days. Furthermore, we show the generation of viral and integration-free iPSCs from primary progressive MS (PPMS) patients and their efficient differentiation to oligodendrocytes. PPMS OPCs are functional, as demonstrated by in vivo myelination in the shiverer mouse. These results provide encouraging advances toward the development of autologous cell therapies using iPSCs.

Intrathecal baclofen in multiple sclerosis: Too little, too late?

The majority of patients with multiple sclerosis (MS) have symptoms of spasticity that increasingly impair function as the disease progresses. With appropriate treatment, however, quality of life can be improved. Oral antispasticity medications are useful in managing mild spasticity but are frequently ineffective in controlling moderate to severe spasticity, because patients often cannot tolerate the adverse effects of increasing doses. Intrathecal baclofen (ITB) therapy can be an effective alternative to oral medications in patients who have a suboptimal response to oral medications or who cannot tolerate dose escalation or multidrug oral regimens. ITB therapy may be underutilized in the MS population because clinicians (a) are more focused on disease-modifying therapies rather than symptom control, (b) underestimate the impact of spasticity on quality of life, and (c) have concerns about the cost and safety of ITB therapy. Delivery of ITB therapy requires expertly trained staff and proper facilities for pump management. This article summarizes the findings and recommendations of an expert panel on the use of ITB therapy in the MS population and the role of the physician and comprehensive care team in patient selection, screening, and management.

Association of common mitochondrial DNA variants with multiple sclerosis and systemic lupus erythematosus

Mitochondrial dysfunction has been implicated in the pathogenesis of multiple sclerosis (MS) and systemic lupus erythematosus (SLE). This study re-investigates the roles of previously suggested candidate genes of energy metabolism (Complex I genes located in the nucleus and in the mitochondria) in patients with MS relative to ethnically matched SLE patients and healthy controls. After stringent correction for multiple testing, we reproduce the association of the mitochondrial (mt)DNA haplotype K* with MS, but reject the importance of previously suggested borderline associations with nuclear genes of Complex I. In addition, we detect the association of common variants of the mitochondrial ND2 and ATP6 genes with both MS and SLE, which raises the possibility of a shared mitochondrial genetic background of these two autoimmune diseases.

Periprosthetic femoral fractures treated with a modular distally cemented stem

PURPOSE

To assess the treatment outcome of revision hip arthroplasty for Vancouver type B3 periprosthetic femoral fractures using a modular distally cemented stem.

METHODS

22 men and 14 women (37 hips) aged 66 to 79 (mean, 70) years underwent revision hip arthroplasty for Vancouver type B3 periprosthetic femoral fractures. The indication for surgery was periprosthetic fracture with stem loosening and loss of proximal bone stock. The patients were referred from other hospitals after previous surgeries had failed: 8 with 3 previous surgeries, 19 with 2, and 9 with one. Using a transtrochanteric approach, the existing prosthesis was removed and a modular proximal femoral replacement stem was inserted, bypassing the area of proximal femoral fracture and bone loss. The stem was distally cemented. Patients were immobilised within 48 hours of surgery.

RESULTS

Patients were followed up for a mean of 14 (range, 8-18) years. The mean Harris hip score improved from 29 (range, 5-40) to 78 (range, 56-88); 24 patients attained excellent or good scores (>80), 10 attained fair, and 2 attained poor scores. The mean healing time was 7 (range, 6-14) months; there was no non-union. Improvement in proximal bone stock was noted on serial radiographs. None of the stems had cement fracture or migration, requiring revision. Two (5%) of the patients had dislocations.

CONCLUSION

Vancouver type B3 periprosthetic femoral fractures can be successfully treated with a distally cemented modular proximal femoral replacement prosthesis.

Detection of HIV-1 DNA in microglia/macrophages, astrocytes and neurons isolated from brain tissue with HIV-1 encephalitis by laser capture microdissection

In HIV-1 encephalitis, HIV-1 replicates predominantly in macrophages and microglia. Astrocytes also carry HIV-1, but the infection of oligodendrocytes and neurons is debated. In this study we examined the presence of HIV-1 DNA in different brain cell types in 6 paraffin embedded, archival post-mortem pediatric and adult brain tissues with HIV-1 encephalitis by Laser Capture Microdissection (LCM). Sections from frontal cortex and basal ganglia were stained by immunohistochemistry for CD68 (microglia), GFAP (astrocytes), MAP2 (neurons), and p24 (HIV-1 positive cells) and different cell types were microdissected by LCM. Individual cells or pools of same type of cells were lysed, the cell lysates were subjected to PCR using HIV-1 gag SK38/SK39 primers, and presence of HIV-1 DNA was confirmed by Southern blotting. HIV-1 gag DNA was consistently detected by this procedure in the frontal cortex and basal ganglia in 1 to 20 p24 HIV-1 capsid positive cells, and in pools of 50 to 100 microglia/macrophage cells, 100 to 200 astrocytes, and 100 to 200 neurons in HIV-1 positive cases but not in HIV-1 negative controls. These findings suggest that in addition to microglia, the infection of astrocytes and neurons by HIV-1 may contribute to the development of HIV-1 disease in the brain.

Altered subicular MAP2 immunoreactivity in schizophrenia

We wished to test independently a previously reported loss of subicular microtubule-associated protein 2 (MAP2) in the brains of deceased individuals who had suffered from schizophrenia, and to determine whether there were any clinical characteristics attached to such a loss. Immunohistochemistry for MAP2 was examined in the hippocampal region from 94 psychiatric patients: 64 with a primary diagnosis of schizophrenia or schizoaffective disorder, 12 with a primary diagnosis of major depressive or bipolar disorders, and 18 with a primary diagnosis of dementia; and from 17 individuals without psychiatric disease. Lifelong symptomatology was evaluated with the modified Diagnostic Evaluation After Death. Subicular MAP2 immunoreactivity was prominently depressed in 20% of schizophrenia cases, 8% of mood disorder cases, 22% of dementia cases, and in no nonpsychiatric cases. Among dementia cases, those with loss of subicular MAP2 immunoreactivity displayed more subicular gliosis, while among the schizophrenia cases, there was no such association. Among schizophrenia subjects, loss of subicular MAP2 immunoreactivity was associated with fewer positive and negative symptoms over the course of the illness. Subicular MAP2 immunoreactivity is markedly diminished in a significant proportion of individuals chronically institutionalized for schizophrenia, and this does not represent a generalized destruction of subicular neurons. In contrast, among individuals institutionalized for dementia, loss of subicular MAP2 immunoreactivity is accompanied by gliosis. The loss of MAP2 immunoreactivity is associated with fewer clinical symptoms, suggesting that it may represent an adaptive response to schizophrenia. The chemical or structural abnormalities underlying decreased MAP2 immunoreactivity in schizophrenia remain to be determined.

Use of interventional radiology in the management of mediastinitis of odontogenic origin

Descending necrotising mediastinitis is a rare complication of odontogenic infection. The key to diagnosis is to maintain a high index of suspicion when antibiotics and adequate surgical drainage do not lead to resolution of symptoms. Open thoracic operation to drain mediastinal collections is potentially lethal and interventional radiological techniques are thought to reduce mortality. We report the use of interventional radiology in the diagnosis, monitoring and treatment of this condition and illustrate our experience with three case reports.

Success of cannulated screw fixation of subcapital neck of femur fractures

In this study we retrospectively reviewed 251 patients who had internal fixation for neck of femur fracture using cannulated screws. Twenty were lost to follow-up or died soon after surgery. The fracture was displaced in 114 (49.9%) and undisplaced in 117 (50.6%) patients. There were 65 males and 171 females with an average age of 75.7 years. Average follow-up was 12 months. Of the 117 patients with undisplaced fractures 75 (64.1%) healed uneventfully. Further surgery was performed in 21 (17.9%) patients. In the 114 patients with displaced fractures, satisfactory reduction was achieved in 74 patients and of these 54 had good screw placement. Fifty-one (44.7%) patients healed uneventfully. Twenty-two (20%) of the 114 displaced fracture patients required further surgery. Forty (35%) had an unsatisfactory reduction and, of these, 26 (65%) had poor screw placement. Re-operation rates were 17.9% and 20% respectively. The rate of AVN was similar in both fracture types (10.3%-11%), but the rate of non-union was four times higher (2.6%-11.5%) in displaced subcapital fractures. The most important factors within the control of the surgeon that influence the rate of healing are adequate reduction and correct placement of the screws. In this series the reduction was unsatisfactory in 40 (35%) cases of the displaced NOF fractures, and the screws were incorrectly positioned in 46 (40.4%) of the 114 displaced fractures compared with 11 (9.4%) of the 117 undisplaced fractures. This highlights the importance of adequate reduction to enable correct screw placement in displaced fractures. (Hip International 2004; 14: 244-8).

Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee

Septic arthritis is a potential catastrophic complication of intra-articular steroid injection. There is lack of evidence regarding the precautions that should be taken to avoid such a complication, as well as how often it is encountered. The aim of this study was to evaluate the antiseptic precautions taken during intra-articular steroid injection of the knee in the United Kingdom (UK), and estimate how often septic arthritis is encountered by health professionals in the UK following steroid injection of the knee. A questionnaire was posted to 100 orthopaedic surgeons, 100 rheumatologists and 50 general practitioners (GPs), asking them about the cases of septic arthritis following intra-articular steroid injection of the knee that they encountered during their practice and the precautions they take when injecting knees. The response rate was 76.4%; 57.6% of the respondents used alcohol swabs to clean the skin, and the remaining 42.4% used chlorhexidine or Betadine. Only 16.3% used sterile towels to isolate the injection site. There were 32.5% of respondents who routinely used sterile gloves when injecting, and a total of 46.6% used either sterile or non-sterile gloves. Also, 91.1% changed needles between drawing the steroid and injecting it into the joint. Only 24 respondents (12.6%) had encountered septic arthritis after steroid injection of the knee (18 once, 3 twice, 2 three times, 1 several times). We concluded that septic arthritis post intra-articular steroid injection of the knee is probably rare. There is a wide variation in the precautions taken to avoid such a complication. However, the trend seems to be towards minimal use of antiseptic techniques. Further large prospective studies are needed to determine how frequently septic arthritis of the knee is encountered post steroid injection, and the exact precautions that should be taken to avoid it.

Safety and efficacy of intra-articular injection of the hip

The aim of the present study was twofold: a) to establish the therapeutic efficacy of the hip injection with marcaine and steroid; (b) to establish the safety of the procedure with respect to possible bacterial contamination at the time of passage of needle into the hip joint. Thirty-five patients with osteoarthritis of the hip were injected. All patients were admitted as day cases and the procedure was performed in a laminar flow theatre under full aseptic conditions. The hip was aspirated before injection. Aspirate and injecting needles were sent for microbiological examination. Both aerobic and anaerobic cultures were performed. All patients were followed up for three months after hip injection. Microbiology results were not revealed to reviewing clinicians. All patients were reviewed at two weeks and at twelve weeks. Thirty-three patients (94.3%) had no growth in the samples. Two cases out of thirty-five hips had a positive culture but none of the patients went on to develop clinical sepsis. Patient response for pain in the hip was graded using a 10 point visual analogue scale (VAS) with 10 point as maximum pain and 0 points as no pain. Pre-injection the patient VAS for pain was a mean value of 6.4 0.77 (median, 6). The mean value of VAS score at 2 weeks dropped to 2.6 2.7 with median of 2. This difference was highly significant (p=0.003). At 12 weeks mean VAS score was 2.7 2.5 with median value of 2 (p=001). Three patients were worse after the injection. We found the hip injection to be safe. The risk of bacterial contamination is low provided a strict aseptic protocol is observed. In this study, one third of the patients had excellent pain relief for 3 months after the injection but in two thirds of cases it failed to provide complete, long-term pain relief (> 3 months). (Hip International 2002; 4: 378-82).

Weight bearing following intra-articular steroid injection of the knee: survey of current practice and review of the available evidence

INTRODUCTION

Intra-articular steroid therapy is one of the most common clinical procedures performed by rheumatologists. There is wide variation in the postoperative instructions given to patients following such injections.

AIM

The aim of this study was to determine what advice is given with regards to non-weight-bearing following steroid injections of the knee by rheumatologists, orthopaedic surgeons, and general practitioners (GPs).

METHOD

A questionnaire examining advice on non-weight-bearing following knee steroid injections was posted to 100 rheumatologists, 100 orthopaedic surgeons, and 50 GPs.

RESULTS

A significant proportion of respondents advised patients to avoid weight bearing after injection (42.4%). Most of these advised patients to do so for one (16.3%) or two (25.1%) days. As compared to 57.1% of general practitioners and 2.8% of orthopaedic surgeons, 70.7% of rheumatologists advised patients to avoid weight bearing (P < 0.05).

CONCLUSION

A significant proportion of rheumatologists and general practitioners performing steroid injections of the knee advise patients not to weight-bear postinjection. Examination of the available literature fails to reveal strong evidence to support such a practice, which has potentially significant implications with regards to loss of working days, costs of mobility aids, and patient inconvenience.

Single or double plating for nonunion of the clavicle

Between January 1982 and January 1999, 684 patients presented with a fracture of the clavicle to the accident and emergency departments of the Tamside and Bury District General Hospitals. Twenty patients (3%) subsequently developed symptomatic nonunion of the clavicle. The original injury resulted from a road traffic accident in 13 patients, from a fall on an outstretched hand in five patients, and two patients had sports related injuries. Mean age of the patients was 39 years (range, 17 to 76 years). Mean time from injury to surgery was 2.5 years (range, 6 months to 8 years). Fifteen patients underwent open reduction and internal fixation of the nonunion of the clavicle with a single plate (DCP or AO plate) and in the remaining five patients two plates were used. The clavicle went on to unite both clinically and radiographically in all patients. Mean time for clinical recovery of symptoms was 4 weeks (range, 3 to 15 weeks) and mean time for radiological union was 17 weeks (range, 15 to 35 weeks). The Constant score component for pain rose from a preoperative score of 0.71 to 13.8 +/- 3.5 (p < 0.0001, paired t-test). There was significant improvement for the level of activity of daily living from a preoperative score of 2.95 +/- 1.63 to 19.0 +/- 3.9. (p < 0.0001, paired t-test). The Imatani score for shoulder function rose from a preoperative score of 56.75 +/- 5.9, to a postoperative score of 98.39 +/- 4.0. No complications related to surgery were noted in the immediate postoperative period. Three patients required removal of the metal work. After removal of the plates there were no refractures of the clavicle. In conclusion, single or double plating of the clavicle is an effective technique in dealing with nonunions of both middle and distal thirds of the clavicle.

Thromboembolism complicating thrombin injection of femoral artery pseudoaneurysm: management with intraarterial thrombolysis

Ultrasound (US)-guided compression of pseudoaneurysms is being rapidly replaced by US-guided percutaneous treatment with thrombin injection because of the less intensive nature of this procedure. Thromboembolism after percutaneous treatment with thrombin injection is rare and has been described in brachial artery pseudoaneurysms. These were managed with intravenous administration of heparin and surgical thrombectomy. In this report, the authors describe thromboembolic complication of thrombin injection after treatment of a femoral artery pseudoaneurysm. This was managed by intraarterial thrombolysis with use of recombinant tissue plasminogen activator (rt-PA) with resolution of all major occlusive changes. A lower dose of thrombin injection and frequent postprocedural monitoring of distal pulses is recommended.

Arterial pressure measurements using infrared photosensors: comparison with CW Doppler

We evaluated the accuracy of modern infrared photosensors (IPs) from a photoplethysmography (PPG) machine as flow detector in determining the systolic arterial pressures and ankle/brachial indices (ABIs) in comparison to the traditional continuous wave Doppler (Doppler) method. Pressures were obtained by placing an appropriate pneumatic cuff above the elbow and ankle. The Doppler probe was placed at brachial artery, posterior tibial artery and dorsalis pedis artery, and the IP was placed on the pad of the index finger and great toe. The two techniques were compared in 181 limbs in our non-invasive vascular laboratory, 133 limbs with normal and 48 limbs with abnormal ABIs. The accuracy of absolute ankle pressure measurements was also compared by both methods. We found that IPs from PPG machine have a good correlation (linear regression r=0.96 for normal and r=0.95 for abnormal ankle pressures) with the Doppler method. There was no significant difference (P< or =0.0001) in the ABIs calculated by two methods in either normal or abnormal subjects. The PPG method was easier, quicker and automated as compared with the cumbersome Doppler method. While PPG method does not differentiate between occlusive disease of posterior tibial and anterior tibial/dorsalis pedis arteries, it is better suited for non-compliant patients and is superior to Doppler method in advanced occlusive arterial disease. We recommend that it be used on a routine basis.

Effect of gamma-L-glutamyl-L-dopa on phosphate excretion

gamma-L-glutamyl-L-DOPA (gludopa) is a dopamine prodrug that is relatively specific for the kidney. Because dopamine is phosphaturic, the present study compared the phosphaturic effects of the infusion of equimolar doses of gludopa (n = 8), L-DOPA (n = 8), and gamma-L-glutamyl-L-tyrosine (glutyrosine, n = 6). Glutyrosine was used as a control to evaluate the effect of the glutamyl portion of gludopa on phosphate excretion. Sprague-Dawley rats (350 to 400 g) were anesthetized with 5-sec-butylethyl-2-thyobarbituric acid (Inactin; 100 mg/kg, IP) and underwent thyroparathyroidectomy. Clearances were taken during the infusion of normal saline vehicle, followed by the infusion of gludopa, L-DOPA, or glutyrosine, all infused at the rate of 10 nmol/kg bolus and 0.8 nmol/kg/min (iv). To determine the contribution of glutamyl derivative to phosphate excretion, gludopa or L-DOPA was infused in the presence of SCH23390, a DA-1 receptor antagonist. Gludopa infusion significantly increased dopamine excretion (from 1.9+/-0.2 ng/min to 17.0+/-3.9 ng/min, delta15.0+/-3.9 ng/min, P < .008) and fractional excretion of phosphate (from 2.6%+/-0.6% to 34.8%+/-1.8%, delta32.0%+/-1.6%, P < .001). L-DOPA infusion significantly increased dopamine excretion (from 1.4+/- 0.4 ng/min to 9.7+/-1.6 ng/min, delta8.3+/-1.5 ng/min, P < .001) and fractional excretion of phosphate (from 1.7%+/-0.6% to 8.2%+/-2.0%, delta6.4%+/-1.5%, P < .004). Glutyrosine infusion significantly increased fractional excretion of phosphate (from 2.8%+/-0.8% to 17.5%+/-5.2%, delta14.6%+/-4.8%, P < .03) without changing dopamine excretion (delta0.5+/-0.2 ng/min). Infusion of gludopa in the presence of SCH23390 increased fractional excretion of phosphate (from 5.7%+/-2.5% to 12.6%+/-3.5%, delta6.8%+/-2.3%, n = 6, P < .03), whereas SCH23390 completely blocked the phosphaturic effect of L-DOPA. We conclude that gamma-L-glutamyl-L-DOPA is more phosphaturic than L-DOPA in the rat because of the combined effects of dopamine and the glutamyl moiety.

Elevation of CD5+ B lymphocytes in schizophrenia

BACKGROUND

A variety of immunologic alterations have been observed in patients with schizophrenia. These findings have lent support to theories that autoimmune mechanisms may be important in some patients with the illness. The CD5+ B lymphocyte, a B-cell subset associated with autoimmune disease, has been the subject of two previously published studies yielding disparate results.

METHODS

In this study, we used immunofluorescent flow cytometry to measure CD5+ B cells, total B and T cells, and CD4 and CD8 subsets in patients with schizophrenia and in normal control subjects.

RESULTS

A significantly higher percentage of patients with schizophrenia, relative to normal control subjects, exhibited an elevated level of CD5+ B cells (27.6% vs 6.7%). Antipsychotic withdrawal had no effect on CD5+ B-cell levels, suggesting that medication effects were not the cause of this difference. No other studied lymphocyte subsets differed between the two groups.

CONCLUSIONS

A subset of patients with schizophrenia have elevated levels of CD5+ B cells. This finding replicates an earlier study by another group and provides further evidence suggestive of autoimmune manifestations in schizophrenia.

Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip

We report the results of proximal femoral osteotomy that was performed to treat osteoarthrosis in twenty-three consecutive young adults (twenty-five hips) who had a mean age of thirty-eight years (range, eighteen to fifty-three years). The mean duration of follow-up was seven years (range, two to twelve years). With conversion to a total hip replacement as the end point, the rate of survival at twelve years was 67 per cent (95 per cent confidence interval, 37 to 88 per cent). Four hips (16 per cent) were converted to a total hip replacement at a mean of eight years after the osteotomy. For the patients who did not have conversion to a total hip replacement, the mean score for pain, according to the system of Merle d'Aubigné and Postel as modified by Charnley, improved from 3.4 points preoperatively to 5.1 points postoperatively, the mean score for walking ability improved from 3.9 to 4.7 points, and the mean score for range of motion improved from 3.2 to 4.2 points. These results compare favorably with those following other forms of operative treatment of osteoarthrosis of the hip in young adults. In addition, the osteotomy does not preclude subsequent replacement arthroplasty if one is necessary.

Use of intrathecal baclofen in the treatment of patients with dystonia

BACKGROUND

Continuous infusion of intrathecal (IT) baclofen is a highly effective standard therapy for severe spasticity of spinal origin. By contrast, there is limited clinical experience regarding the use of IT baclofen in treating patients with dystonia, and little is known regarding the indications for treatment, efficacy, and safety of IT baclofen in this disorder.

OBJECTIVE

To study retrospectively the effects of IT baclofen in treating 25 patients with severe segmental or generalized dystonia.

SETTING

Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY.

PATIENTS

Twenty-five patients with severe segmental or generalized dystonia that was refractory to oral medications underwent IT baclofen test dosing. In addition to dystonia, 17 patients had spasticity or painful spasms. Thirteen of 25 patients responded to the test doses of IT baclofen, according to unblinded neurological assessments that included the patient's subjective report; all 13 underwent implantation of a pump for continuous IT baclofen infusion.

RESULTS

In contrast to reports of patients with spasticity of spinal origin, those with dystonia in the present series had a lower response rate to bolus IT baclofen doses and a smaller degree of clinical improvement. For 10 of the 13 responders to the test doses of IT baclofen, dystonia rating scale scores of videotaped examinations by blinded observers detected no significant change (P < .07) in severity of dystonia. Retrospective data from 11 of 13 patients with implantable pumps, followed up for a mean interval of 21 months after pump insertion, showed continuing efficacy in 6 individuals (55%), based on a determination of patient satisfaction; however, only 3 patients (27%) reported a sustained improvement in functional capacity. Five (38%) of the 13 patients with implantable pumps experienced severe complications that required hospitalization.

CONCLUSIONS

Despite recent reports that have described the benefit in small numbers of patients with dystonia, we concluded that the role of IT baclofen in treating severe dystonia remains uncertain. Intrathecal baclofen may be more effective when dystonia is associated with spasticity or pain. In the present series, we detected no significant difference in the response to IT baclofen in patients with or without spasticity or pain, perhaps owing to the small sample size.

Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study

We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed part of a prospective longitudinal study. Our purpose was to detect the prevalence of scoliosis and to investigate associated factors. On the basis of the initial screening, 934 children (5.9 per cent) were referred for additional clinical and radiographic examinations; 896 children returned for this second evaluation. A lateral spinal curve with a Cobb angle of more than 5 degrees was seen in 431 children (2.7 per cent of the 15,799 children). Only seventy-six children (0.5 per cent) had a curve that met our definition of idiopathic scoliosis (a curve of more than 10 degrees with concordant apical rotation). The point-prevalence rate was higher in girls, and it increased with age. The rate was 0.1 per cent (four of 5246) in the age-group of six to eight years, 0.3 per cent (sixteen of 5831) in the age-group of nine to eleven years, and 1.2 per cent (fifty-six of 4722) in the age-group of twelve to fourteen years old. With allowance for the fact that different definitions of idiopathic scoliosis have been used in earlier studies, our results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously.

Removal of endobronchial mucormycosis lesion through a rigid bronchoscope

A 44 year old man with poorly controlled diabetes mellitus developed endobronchial mucormycosis, which totally obstructed the right lower lobe bronchus. The lesion was removed through a rigid bronchoscope. Two weeks later the bronchus was free of mucormycosis histologically and on culture.

Bilateral angiosarcoma of the breast--a case report

A case of a 42 year old multiparous female with bilateral angiosarcoma of the breast without any evidence of dissemination, who later also developed a psammomatous meningioma, is described herein. The world literature on angiosarcoma is reviewed and a discussion presented on the incidence of bilaterality, hormonal stimulation, diagnostic difficulty, prognostic factors and treatment modalities.

Paraganglioma of the cauda equina: case report and review of the literature

A rare paraganglioma of the cauda equina is reported. The clinical, radiological and histological features of this neoplasm are described. Diagnosis was resolved by the absence of glial fibrillary acid protein and electron microscopic evidence of neurosecretory features. Relevant literature is reviewed.