Long-term scarring outcomes and safety of patients treated with NovoSorbⓇ Biodegradable Temporizing Matrix (BTM): An observational cohort study

Background/Aim

NovoSorb^Ⓡ Biodegradable Temporizing Matrix (BTM) is a relatively novel, biodegradable polyurethane-based dermal regeneration template. The aim of this study was to evaluate the long-term scarring outcomes and safety of BTM in patients who underwent dermal reconstruction involving ≥5% of the total body surface area.

Methods

This was a postmarket, multicenter, observational cohort study involving evaluation of long-term outcomes in patients treated with BTM. A total of 55 patients (35 from Royal Adelaide Hospital, South Australia, and 20 from Victoria Adult Burns Service, The Alfred, Victoria) who underwent dermal repair with BTM between 2011 and 2017 were screened for inclusion in this study. All patients had BTM implanted for ≥18 months.

Results

Fifteen eligible patients with a mean (SD) age of 49.1 (14.3) years completed study assessments. These patients had a total of 39 areas treated with BTM. Using the Patient and Observer Scar Assessment Scale, scar quality was reported to be good by both observers and patients, with a mean (SD) observer score across all lesions of 3.6 (1.2) and mean (SD) overall opinion of 3.8 (1.2) as well as a mean (SD) patient score of 3.5 (1.2) and overall opinion of 5.0 (2.2). No adverse events or adverse device effects were reported or identified.

Conclusion

The long-term scar quality is comparable to published studies. BTM is safe in the long term with no additional risks or adverse consequences being identified.

42 EXPLORING THE IMPACT OF AGE AND FRAILTY STATUS ON THE IMMUNE RESPONSE TO COVID-19 ILLNESS USING DETAILED IMMUNO-PHENOTYPING

Background

Methods

Results

Conclusion

Bowel Disease after Radiotherapy

The clinical presentation, operative findings and outcome in 40 patients who required surgery for bowel disease after radiotherapy are presented. The type of presentation varied according to the time after radiotherapy. In the first month, many patients had a proctitis but none required surgery. Five patients were operated on within one month, 2 for radiation-induced acute ileitis and 3 for exacerbations of pre-existing disease (diverticular disease 2, ulcerative colitis 1). The commonest time of presentation was between 3 and 18 months after radiotherapy, when 20 patients needed surgery for bowel disease caused by radiation-induced local ischaemia. Twelve of these patients had chronic perforation, 6 had severe rectal bleeding and 2 had painful anorectal ulceration. Fifteen patients presented between 2 and 24 years after radiotherapy, usually with incomplete intestinal obstruction due to a fibrous stricture, but 2 patients had rectal carcinoma.

Wide resection of the involved bowel was the principal method of treatment but any anastomosis was protected by a proximal defunctioning stoma. There was no operative mortality but 10 patients have died subsequently. The danger of dismissing these patients as having incurable malignancy is stressed because, although the condition is infrequent, it is usually amenable to adequate surgery.

Predictors of ambulance use in patients with acute myocardial infarction in Australia

AIMS

To determine ambulance transport rates and investigate predictors for ambulance use by patients with acute myocardial infarction (AMI) in Australia.

METHODS

A prospective, cross-sectional descriptive survey using structured interviews. It included patients who were admitted to two hospitals (Western, Bendigo, Melbourne, Victoria, Australia) with AMI between 1 October 2004 and 31 March 2005, and data were collected by semistructured interview and medical record review. Data were analysed by descriptive statistics, univariate and multivariate analysis using SPSS.

RESULTS

105 patients were interviewed. 48 (46%) participants called for an ambulance as their initial medical contact. Participants who called for an ambulance had a shorter interval between symptom onset and presentation to hospital than those who did not (non-ambulance participants)(median 2.1 v 7.8 h; p = 0.001). Predictors of ambulance transport were older age (p = 0.008), symptom onset on the weekend (p = 0.022), presence of sharp chest pain (p = 0.011), self-administered anginine (p = 0.007), symptom onset at home (p = 0.027) and having a lower income (<dollarsA20 000; p = 0.022). After multivariate analysis, self-administered anginine, sharp chest pain and occurrence of symptom onset at home remained as independent predictors of ambulance use.

CONCLUSION

A substantial number of patients do not call for an ambulance as their first medical contact after the onset of AMI symptoms. Public education on the benefits of ambulance transport and early treatment, as well as recognition of AMI symptoms, is required.

Sex-specific antenatal reference growth charts for uncomplicated singleton pregnancies at 15-40 weeks of gestation

OBJECTIVE

Female fetuses, on average, weigh less than male fetuses at all gestational ages. The purpose of this study was to compare female and male fetuses in terms of intrauterine ultrasound growth measurements and to develop gestational-age-related charts based on a computerized perinatal database.

METHODS

This was a retrospective study of unselected women in the second and third trimesters of pregnancy, who had a normal scan at 10-14 weeks. Data analysis was performed using measurements obtained from a mixed-race population of 4234 women, who underwent 5198 ultrasound examinations. The scans were performed by four trained sonographers, according to a standardized protocol. Routine measurements included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL). The main end-points were sex- and race-specific differences in fetal biometry, which were also used to estimate fetal weight.

RESULTS

The base-line demographic characteristics and risk factors were comparable in female and male fetuses. Significant differences in fetal BPD, HC, AC and estimated fetal weight, but not FL, were seen between male and female fetuses. Centile charts for each of these variables were constructed for both male and female fetuses.

CONCLUSIONS

This study suggests that small but consistent sex-related differences in prenatal BPD, HC and AC measurements are established by as early as 15 weeks of gestation. The use of sex-specific nomograms may improve the prenatal assessment of fetal growth as well as the diagnosis of structural abnormalities.

Sterile nodular panniculitis and pansteatitis in three weimaraners

The clinical and pathological findings in three unrelated weimaraners with pyrexia and multiple subcutaneous nodules are reported. Abdominal pain was an additional feature in two of the dogs and clinical investigations revealed inflammation of subcutaneous, mesenteric and falciform fat. Histopathological findings were consistent with pansteatitis. In the third dog, lesions were apparently limited to the subcutis and, hence, a diagnosis of nodular panniculitis was made. Microbiological examination of tissues was negative in all dogs, and there was no evidence of pancreatic disease. This report thus describes a presumed sterile and idiopathic panniculitis/pansteatitis complex in weimaraner dogs. Although the aetiology is unknown, this may represent an immune-mediated disorder.

Differential effect of oestrogen on post-exercise cardiac muscle myeloperoxidase and calpain activities in female rats

The effects of oestrogen administration on 1 h post-exercise cardiac muscle myeloperoxidase (MPO) and calpain activities were determined in female rats. Rats were ovariectomized and implanted for 2 weeks with either oestrogen (25 mg 17-oestradiol) or placebo pellets or left with ovaries intact. Rats were then run for 1 h at 21 m min-1, 12% grade, killed 1 h post-exercise and cardiac muscle and blood samples were removed. Control animals from each group were killed without prior exercise. Serum oestrogen levels in the order of the highest to lowest were; ovariectomized oestrogen replaced rats > intact ovaries rats > ovariectomized placebo rats. Oestrogen induced significant (P < 0.05) elevations in cardiac MPO activity at rest and at 1 h post-exercise in ovariectomized rats. No significant elevations in cardiac MPO activity were evident in placebo ovariectomized or normal ovary rats at rest or post-exercise. Cardiac calpain activities were similar in all unexercised groups. Ovariectomized placebo and intact ovary rats had significantly (P < 0.05) elevated cardiac calpain activities 1 h post-exercise while calpain activity was not significantly elevated in hearts from ovariectomized oestrogen rats. These results demonstrate that oestrogen supplementation in ovariectomized rats induces elevations in cardiac muscle MPO activities at rest and at 1 h post-exercise. This is opposite to the effect of oestrogen in post-exercise skeletal muscle and implies a greater neutrophil infiltration into cardiac muscle caused by oestrogen. This effect cannot be explained by changes in 1 h post-exercise cardiac muscle calpain activity, the elevation of which was suppressed by oestrogen administration. Oestrogen influences cardiac calpain activity similarly to its effect in skeletal muscle. Thus, oestrogen administration to ovariectomized rats induces elevations in cardiac MPO activity while suppressing cardiac calpain activity.

Estrogen effect on post-exercise skeletal muscle neutrophil infiltration and calpain activity

We hypothesized that estrogen administration would attenuate skeletal muscle neutrophil infiltration, indices of muscle membrane disruption, and muscle calpain activity shortly after the termination of exercise. Ovariectomized female rats were implanted with either an estogen pellet (25 mg beta-estradiol) or a placebo pellet. Two weeks postimplant, animals were killed either at rest or 1 h after running exercise (60 min at 21 m x min(-1), 12% grade). The 4 experimental groups (n = 12) used were: unexercised placebo (UP), unexercised estrogen (UE), exercised placebo (EP), and exercised estrogen (EE). Blood samples were analyzed for creatine kinase (CK) activity and estradiol content. Plantaris and gastrocnemius muscles were removed and histochemical determination of neutrophil content or biochemical determination of myeloperoxidase (MPO), glucose-6-phosphate dehydrogenase (G6PD), and calpain-like activity determined. Estrogen supplemented animals had 10-20-fold higher circulating estradiol levels than placebo animals. EP animals had significantly higher (P < 0.05) circulating CK activities than EE or unexercised animals. Muscle neutrophil concentrations were significantly (P < 0.01) elevated in EP and EE groups compared with unexercised controls, with EP muscle neutrophil levels also being over 60% greater (P < 0.05) than in EE animals. EP animals also had higher (P < 0.05) muscle MPO activities than unexercised or EE animals. Muscle G6PD activities were not significantly different between any groups. Muscle caplain-like activities were 80% higher (P < 0.01) in EP animals than EE animals with calpain-like activities in EE animals similar to unexercised groups. These results indicate that estrogen supplementation in ovariectomized rats attenuated 1-h post-exercise serum CK activities, muscle neutrophil infiltration, MPO activities, and calpain-like activities when compared with exercised, unsupplemented animals. This supports the possibility of a relationship between estrogen, calpain dependent production of neutrophil chemo-attractant peptides, and 1-h post-exercise skeletal muscle neutrophil infiltration.

Intraobserver and interobserver variability of transabdominal Doppler velocimetry measurements of the fetal ductus venosus between 10 and 14 weeks of gestation

OBJECTIVE

To assess the intraobserver repeatability and interobserver reproducibility of transabdominal Doppler ultrasound measurements of ductus venosus blood flow in fetuses between 10 and 14 weeks of gestation.

DESIGN

A prospective study with the following end-points: coefficient of variation, intraclass correlation coefficients within and between observers, repeatability coefficient and Cohen's kappa coefficient.

SUBJECTS AND METHODS

Doppler velocimetry indices (maximum peak systolic velocity during ventricular systole, end-diastolic velocity during atrial contraction, peak systolic velocity/end-diastolic velocity ratio and pulsatility index for veins) were successfully measured three times by the same trained observer in 67 fetuses. Of these, in 24 fetuses, the measurements were then repeated by a second trained observer. In addition, both observers classified qualitatively the blood flow as being normal or abnormal with regard to the presence or absence/reversal of flow during atrial contraction.

RESULTS

The intraobserver repeatability of the pulsatility index for veins measurements was considered good with a coefficient of variation of 8.9% and an intraclass correlation coefficient value of 0.62. However, inconsistencies occurred in maximum peak systolic velocity, end-diastolic velocity and systolic/diastolic ratio measurements, which had coefficients of variation of 19%, 28.5%, and 25.4%, respectively. The corresponding intraclass correlation coefficient values were 0.70, 0.69 and 0.60. Interobserver reproducibility of these indices was unsatisfactory, the coefficient of variation varying between 11.5% and 47.2% and the intraclass correlation coefficient between 0.18 and 0.44. Agreement between the repeated observations with regard to interpretation of normal or abnormal blood flow varied from moderate (interobserver) to very good (intraobserver).

CONCLUSIONS

There was considerable variability in all Doppler indices except for the intraobserver repeatability of the pulsatility index for veins measurement. This makes the implementation of the semiquantitative Doppler indices in a screening setting difficult. On the contrary, qualitative classification of the flow velocity waveforms seemed to be a reproducible method.

Three-week delayed delivery in a triplet pregnancy at full dilatation with aggressive tocolysis

We describe our aggressive management of a woman with a triplet pregnancy resulting from in vitro fertilization who presented at 22 weeks' gestation in labor with full cervical dilation. Successful multiagent tocolysis and delayed delivery of the two remaining fetuses after delivery of the presenting fetus led to an improved outcome for all three babies.

Feasibility of the second-trimester fetal ultrasound examination in an unselected population at 18, 20 or 22 weeks of pregnancy: a randomized trial

OBJECTIVE

To date, there have been no studies on the optimal timing of second-trimester ultrasound screening for fetal abnormalities. The purpose of this study was to investigate whether, of three gestational ages (18, 20 and 22 weeks), any one was associated with a significant advantage in terms of identification of abnormalities or need for further ultrasound assessment.

DESIGN

Prospective, randomized study of second-trimester unselected pregnant women, who had had an ultrasound examination with normal results at 10-14 weeks.

SUBJECTS AND METHODS

A total of 1206 women were randomized into three mutually exclusive groups relating to their second-trimester appointment for a screening ultrasound examination for fetal abnormalities in the second trimester of pregnancy: Group 1 at 18-18 + 6 weeks, Group 2 at 20-20 + 6 weeks and Group 3 at 22-22 + 6 weeks. The anomaly scans were carried out according to a standardized protocol. The fetuses were examined for structural and developmental abnormalities. Uterine artery Doppler measurements, including waveform recordings, were performed in all cases. The main end-points were the need for rescanning of all or part of the fetal anatomy, fetal outcome, placental localization, and incidence of notches in the uterine artery waveform.

RESULTS

The baseline demographic characteristics and risk factors in the three groups were similar and gestational age-related fetal measurements were comparable. There were significantly higher percentages of completed scans in Group 2 (90%) and Group 3 (88%) than in Group 1 (76%; p < 0.001), but no significant difference between those scanned at 20 and at 22 weeks. This was associated with a higher incidence of non-cephalic presentation in Group 1 (46%) than in the other two groups (36%, p < 0.001). Significant differences in completing the assessment of the thorax, heart, spine and skeleton were also observed. There was no significant difference in maternal body habitus, fetal movements or the occurrence of uterine fibroids between the study groups. The incidences of low-lying placenta and of abnormal uterine artery Doppler screening were also higher at 18 weeks than at 20 and 22 weeks (p < 0.001 for both variables), with no difference seen between Groups 2 and 3. The numbers of fetal anomalies detected in the three groups were three, two and two, respectively; these did not differ significantly between the groups.

CONCLUSIONS

This study suggests that, in an unselected pregnant population, second-trimester ultrasound screening is easier to perform and less likely to require an additional scan at 20-22 weeks than at 18 weeks.

Evaluation of Salmonella typhimurium mutants in a model of experimental gastroenteritis

Salmonella typhimurium strains harboring independent, defined mutations in aroA, invA, ssrA, or msbB were assessed for their ability to induce fluid accumulation, tissue damage, and local inflammation in rabbit ileal loops. Three wild-type strains of S. typhimurium, TML, HWSH, and SL1344, and two mutant strains, S. typhimurium SL1344 ssrA and S. typhimurium SL1344 msbB, consistently induced fluid accumulation in the lumen of loops and inflammation of loop-associated tissues. In contrast, three different S. typhimurium aroA strains and an invA mutant of SL1344 did not induce significant fluid accumulation in the rabbit ileal loops. However, the S. typhimurium aroA strains did induce an inflammatory infiltrate and some local villus-associated damage, but the invA mutant did not. Histologically, wild-type S. typhimurium, S. typhimurium SL1344 ssrA, and S. typhimurium SL1344 msbB demonstrated more severe effects on villus architecture than S. typhimurium aroA strains, whereas S. typhimurium invA-infected loops showed no detectable damage. This suggests that villus damage most likely contributes to fluid accumulation within the loop.

Decision training: the effects of complex instruction, variable practice and reduced delayed feedback on the acquisition and transfer of a motor skill

Novice, intermediate and advanced baseball hitters followed a 7-week training programme, in which they received either behavioural training or decision training. Participants in the behavioural training group received simple-to-complex instruction, variable practice and an abundance of feedback throughout the acquisition period; the decision training group received complex instruction, variable practice and reduced delayed feedback. As predicted, the intermediate and advanced hitters who received decision training hit at a lower level (%) during acquisition but at a higher level during a transfer test in week 7. Novices in the behavioural training group were better than novices in the decision training group over both acquisition and transfer trials.

The conservative management of first trimester miscarriages and the use of colour Doppler sonography for patient selection

This study of patients with first trimester miscarriage evaluates whether conservative management is a feasible strategy and assesses the value of colour Doppler ultrasonography for patient selection. After confirmation of the diagnosis by transvaginal sonography all patients were offered the choice of immediate dilatation and curettage or conservative management. The presence of a gestational sac, the occurrence of spontaneous complete miscarriage within 28 days, detectable pulsatile blood flow within the placenta in the presumed region of the intervillous space and post-treatment complications were the main end-points. Out of a total of 108 women recruited, 23 (21.3%) elected to undergo immediate dilatation and curettage and 85 (78.7%) chose conservative management. The treatment groups were similar in age, gestational age, gestational sac diameter, serum concentrations of human chorionic gonadotrophin (HCG) and progesterone, and proportion of patients who had post-treatment complications (12-13%). Of patients in the conservative management group, 71 out of 85 (84%) had a spontaneous, complete abortion, while 37 out of 46 cases (80%) with detectable presumed intervillous pulsatile blood flow had a complete, spontaneous abortion within 1 week; this occurred in 23% of cases with no detectable flow. This suggests that conservative management is a successful approach for many patients with first trimester miscarriage; colour Doppler ultrasonography can be used to select the most suitable patients for this strategy, and thus reduce the need for hospital admission and surgery.

Pathogen virulence genes--implications for vaccines and drug therapy

The emergence and spread of bacteria resistant to antimicrobial drugs is a major public health problem with a growing number of infections becoming virtually untreatable. There is a need to develop interventions both to prevent and to treat diseases caused by multi-resistant microbes. We review some recently developed methods (including whole genome nucleotide sequencing projects) to study bacterial pathogenesis, and discuss how knowledge gained from understanding the molecular mechanisms of disease can be applied to combat the threat of infectious diseases.

Regulatory volume increase in rat pancreatic beta-cells

This study investigated regulatory volume increase (RVI) in rat pancreatic beta-cells. Volume changes in isolated beta-cells were measured by a video-imaging method. Cell shrinkage was induced by exposure to solutions made hypertonic by the addition of 100 mM mannitol. In HEPES-buffered solutions, beta-cells exhibited an RVI which was almost completely abolished by 10 microM bumetanide. These data indicate that Na+-2Cl--K+ cotransporters make a major contribution to RVI in beta-cells. In HCO3--buffered solutions, however, an RVI was observed in the presence of 10 microM bumetanide. This bumetanide-insensitive component of RVI was inhibited by 100 microM amiloride or 100 microM 4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid (DIDS). These data suggest that, in addition to the Na+-2Cl--K+ cotransporter, functionally coupled Na+-H+ exchangers and Cl--HCO3- exchangers may also contribute to RVI in pancreatic beta-cells.

Structure Solution of C-Reactive Proteins: Molecular Replacement With a Twist

The pentameric structure of C-reactive proteins (CRP) has been derived by a combination of automated and manual molecular-replacement techniques. The method is generally applicable to other multimeric assemblies. The highly homologous human serum amyloid P component (hSAP) structure fails to provide a pentameric molecular-replacement solution for CRP. In the absence of a significant signal from an individual protomer, the hSAP structure has been manually modified in terms of protomer assembly to provide the true pentameric model of CRP. The CRP protomers are rotated or twisted by 14 degrees about an axis, through the protomer centre, which is approximately perpendicular to the pentamer radius and the molecular fivefold axis. The results demonstrate clearly that protomers with very similar folds arising from high sequence homology need not necessarily be assembled together in the same way although the symmetry of the resulting oligomer may be maintained. In a curious twist the CRP structure which provided the general CRP model remains unsolved, while the model itself has so far provided the solution of two other CRP structures.

Use of recombinant human follicle-stimulating hormone for in vitro fertilization-embryo transfer after severe systemic immunoglobulin E-mediated reaction to urofollitropin

OBJECTIVE

To report the successful use of recombinant human FSH in a patient with a history of a severe systemic immunoglobulin E (IgE)-mediated reaction to urofollitropin.

SETTING

University hospital.

PATIENT

A 38-year-old infertility patient who had experienced a whole-body rash with hives, tachycardia, fever, and other symptoms after urofollitropin administration, with confirmation of IgE-mediated sensitivity to urofollitropin by intradermal skin testing.

INTERVENTION

In vitro fertilization-ET after the use of recombinant human FSH to stimulate ovarian follicular development.

RESULTS

Establishment of a clinical pregnancy.

CONCLUSIONS

Our case provides evidence for the involvement of nongonadotropin proteins as the direct cause of some adverse reactions from conventional urine-derived human FSH preparations.

Three dimensional structure of human C-reactive protein

The structure of the classical acute phase reactant human C-reactive protein provides evidence that phosphocholine binding is mediated through calcium and a hydrophobic pocket centred on Phe 66. The residue Glu 81 is suitably positioned to interact with the choline group. A cleft on the pentameric face opposite to that containing the calcium site may have an important functional role. The structure provides insights into the molecular mechanisms by which this highly conserved plasma protein, for which no polymorphism or deficiency state is known, may exert its biological role.

Patients with limited-stage small-cell lung cancer treated with concurrent twice-daily chest radiotherapy and etoposide/cisplatin followed by cyclophosphamide, doxorubicin, and vincristine

PURPOSE

A phase II trial in patients with limited-stage small-cell lung cancer treated with induction etoposide/cisplatin plus twice-daily chest radiotherapy was conducted in an attempt to increase response rates and prolong survival.

PATIENTS AND METHODS

Fifty-four previously untreated patients with limited-stage small-cell cancer were treated with etoposide/cisplatin and concurrent radiotherapy at 1.5 Gy twice daily for 3 weeks to a total dose of 45 Gy. Patients then received three more cycles of etoposide/cisplatin followed by four cycles of vincristine, doxorubicin, and cyclophosphamide or an individualized chemotherapy regimen.

RESULTS

Nine patients are alive and free of cancer a median of 4 years (range, 2 to 7) from the start of treatment. Thirty-eight have had progression of their cancer at a median of 1.2 years (range, 0.5 to 5.4) and all have died of small-cell cancer. Thirteen of these 38 patients' (34%) only site of initial relapse was in the CNS and all died of CNS metastases. Five patients died during therapy or from its complications and two patients died of causes other than relapsed small-cell lung cancer and toxicity. The median survival time is 21.3 months, with an actual survival rate of 83% at 1 year, and actuarial survival rates of 43% at 2 years and 19% at 5 years.

CONCLUSION

This combined modality regimen for patients with limited-stage small-cell lung cancer results in a 2-year survival rate of 43%, but the principal cause of death in these patients is still relapse of the original cancer. Isolated CNS metastases caused more than 30% of the cancer deaths.

Onset, natural history and outcome in idiopathic adult motor neuron disease

Cases of adult-onset idiopathic motor neuron disease (MND) identified from January 1970 through December 1986 were studied in a defined area of California. The patients were followed prospectively throughout the illness in 99% of cases. Among 708 cases aged 25-74 years at onset, the most common type (86%) was typical, sporadic amyotrophic lateral sclerosis (SporALS). The risk of bulbar onset and shorter survival times increased with age in both men and women. About 4%, mainly younger men, experienced unusually long courses with milder paralysis, but could not be identified early in the illness. They probably represent one extreme of the ALS spectrum rather than a distinct subtype. Familial ALS (FamALS) was diagnosed in 7%. It developed earlier in life but ran a slightly longer course, which suggests a different disease process. Overall there was a statistically significant predominance of males, especially in 17 cases (2%) of progressive muscular atrophy (PMA). There were 26 cases (4%) classified as primary lateral sclerosis (PLS). Progressive bulbar palsy was not found; that diagnosis usually denotes merely the bulbar onset of ALS.

Detection of Aspergillus fumigatus by polymerase chain reaction

Aspergillus fumigatus is an opportunistic nosocomial pathogen causing an often fatal pneumonia, invasive aspergillosis (IA), in immunosuppressed patients. Oligonucleotide primers were used to amplify a 401-bp fragment spanning the 26S/intergenic spacer region of the rDNA complex of A. fumigatus by the polymerase chain reaction (PCR). The primers were highly sensitive and specific: as little as 1 pg of A. fumigatus genomic DNA could be detected, and the primers only amplified DNA from A. fumigatus and not any other fungal, bacterial, viral, or human DNA tested. Using the PCR, we were able to detect A. fumigatus DNA in lung homogenates from immunosuppressed mice experimentally infected with A. fumigatus but not from immunosuppressed uninfected controls. There was 93% correlation between the culture results and the PCR results. In a retrospective clinical study, the sensitivity of the PCR for the detection of A. fumigatus in clinical samples was confirmed by positive amplification in three of three culture-positive respiratory samples from confirmed cases of IA. Because isolation of Aspergillus spp. may reflect contamination and colonization without infection, the feasibility of using the PCR was evaluated by analyzing culture-negative samples from both immunosuppressed patients at high risk for IA and immunocompetent patients with other lung infections. Only 2 of 10 patients were culture negative and PCR positive in the high-risk group, and 2 of 7 patients were culture negative and PCR positive in the immunocompetent group. The results indicate that PCR detection might be a valuable adjunct to current laboratory methods to diagnose IA.

Relationship between bladder morphology and long-term outcome of treatment in patients with high pressure chronic retention of urine

A group of 32 men undergoing bladder outflow surgery for high pressure chronic retention (HPCR) of urine were studied prospectively. At the time of treatment marked morphological changes in the bladder wall were demonstrated histologically, but after a mean follow-up of 42.9 months residual urine had decreased significantly and renal function had improved or stabilised in 28 patients (84%). Four patients deteriorated but in 3 of these another potential cause for loss of renal function was present. The majority of patients have a good long-term prognosis following treatment for HPCR.

Management of staghorn stones using a combination of lithotripsy, percutaneous nephrolithotomy and Solution R irrigation

The treatment of staghorn and partial staghorn calculi remains complex despite modern methods of stone removal. We describe the results following treatment of 112 stones. Three methods were used: percutaneous nephrolithotomy, extracorporeal shockwave lithotripsy and Solution R irrigation, either alone or in combination; 57 stones (55.8%) were completely cleared, with Solution R irrigation helping to achieve complete clearance in 6 of these. A further 24 stones were not completely cleared (small asymptomatic fragments less than 3 mm remained). A satisfactory outcome (stone-free or asymptomatic fragments less than 3 mm) was achieved in 81 stones (79%).

Identification of urinary stone composition by pulsed dye laser

Stones were recovered from the urinary tract and their composition determined by X-ray diffraction before exposure to a pulsed dye laser beam. The resultant fluorescent emissions were recorded using a scanning reticon and they appeared to be specifically related to the composition of each stone. This technique has a practical application as it may allow identification of the composition of urinary tract stones in vivo, and so indicate the best mode of lithotripsy.

Ureteral stones: the results of primary in situ extracorporeal shock wave lithotripsy

The use of a Siemens Lithostar* for in situ disintegration of 212 ureteral stones in 207 patients was evaluated. Followup data were available on 133 patients (136 stones). Of the stones 121 (88.1 per cent) have been cleared with in situ extracorporeal shock wave lithotripsy alone. These results strongly suggest that in situ extracorporeal shock wave lithotripsy is an effective and noninvasive method to treat ureteral stones.

Central nervous system vasculitis in Behçet's syndrome: angiographic improvement after therapy with cytotoxic agents

We describe a patient with Behçet's syndrome who had clinical and angiographic features of widespread cerebral angiitis of small- and medium-caliber vessels. We report the successful treatment of this condition with a combination of cytotoxic agents and steroids, and demonstrate angiographically the resolution of these abnormalities in neuro-Behçet's disease.

Mechanism of upper tract dilatation in patients with thick walled bladders, chronic retention of urine and associated hydroureteronephrosis

The mechanism of upper tract dilatation in patients with obstructive uropathy associated with thick walled trabeculated bladders and painless retention of urine has been determined in 9 cases by simultaneous measurement of renal pelvic and bladder pressures under baseline conditions and after administration of different stresses to the urinary tract. Under basal conditions no pelvic pressure increase was observed during detrusor contraction or other alteration of lower urinary tract pressure. However, after the flow in the upper tract was increased by oral water load, intravenous furosemide or direct pelvic perfusion, pelvic pressures were markedly elevated and reflected accurately any change in intravesical pressure. Under such conditions, pelvic pressures frequently exceeded 40 cm. water. These observations provide an explanation for the increasing size of the upper tract and a clarification of the mechanism whereby renal function might gradually deteriorate in these patients.