In situ calibration of passive sampling methods for urban micropollutants using targeted multiresidue GC and LC screening systems

In this study, Chemcatcher^TM (CC) and Polar Organic Chemical Integrative Samplers (POCIS) passive samplers were chosen to investigate trace organic chemical residues in urban streams of the megacity of Sydney, Australia. In situ calibration with these passive samplers investigated 1392 organic chemicals. Six sets of CC passive samplers fitted with SDB-XC or SDB-RPS disks and six POCIS containing Oasis HLB sorbent were deployed at three sites. Every week for six weeks across three deployments, composite water samples were retrieved from autosamplers, along with one set of CC/POCIS passive samplers. Samples were analysed by Automated Identification and Quantification System (AIQS) GC/MS or LC/QTOF-MS database methods with 254 chemicals detected. The most frequently detected compounds under GC/MS analysis were aliphatic, pesticides, phenols, PAHs, sterols and fatty acid methyl esters while from LC/QTOF-MS analysis these were pesticides, pharmaceuticals, and personal care products. Sampling rates (R_s) ranged between <0.001 - 0.132 L day^-1 (CC SDB-XC, 18 chemicals), <0.001 - 0.291 L day^-1 (CC SDB-RPS, 28 chemicals), and <0.001 - 0.576 L day^-1 (POCIS Oasis HLB, 30 chemicals). Assessment of deployment duration indicated that about half of the chemicals that were continuously detected across all deployment weeks had maximal simple linear regression R² values at four weeks for CC SDB-RPS (seven of 13 chemicals) and at three weeks for POCIS Oasis HLB (seven of 14 chemicals). Where ranges of R_s recorded from the estuarine site were able to be compared to ranges of R_s from one or both freshwater sites, only tributyl phosphate had a higher range of R_s out of 21 possible chemical comparisons, and suggested salinity was an unlikely influence on R_s. Whereas relatively higher rainfall of the third round of deployment aligned with higher R_s across the estuarine and freshwater sites for CC SDB-RPS and POCIS for nearly all possible comparisons.

Atomic-Scale Characterization of Planar Selective-Area-Grown InAs/InGaAs Nanowires

Atomic-scale information about the structural and compositional properties of novel semiconductor nanowires is essential to tailoring their properties for specific applications, but characterization at this length scale remains a challenging task. Here, quasi-1D InAs/InGaAs semiconductor nanowire arrays were grown by selective area epitaxy (SAE) using molecular beam epitaxy (MBE), and their subsequent properties were analyzed by a combination of atom probe tomography (APT) and aberration-corrected transmission electron microscopy (TEM). Results revealed the chemical composition of the outermost thin InAs layer, a fine variation in the indium content at the InAs/InGaAs interface, and lightly incorporated element tracing. The results highlight the importance of correlative microscopy approaches in revealing complex nanoscale structures, with TEM being uniquely suited to interrogating the crystallography of InGaAs NWs, whereas APT is capable of three-dimensional (3D) elemental mapping, revealing the subtle compositional variation near the boundary region. This work demonstrates a detailed pathway for the nanoscale structural assessment of novel one-dimensional (1D) nanomaterials.

294 INTEGRATION OF MUSIC THERAPY WITHIN A MULTIDISCIPLINARY TEAM FOR OLDER ADULTS IN AN ACUTE HOSPITAL

Background

Music Therapy (MT) is an evidence-based intervention in which a music therapist uses music within a therapeutic relationship to achieve targeted goals. Studies show that MT may improve patient communication, cognition and mood, and facilitate rehabilitation by improving motor skills, particularly in those with stroke and Parkinson’s disease. We aimed to integrate MT within our geriatric multidisciplinary team (MDT) by: (1) promoting knowledge of MT among MDT staff; and (2) developing and implementing a MT referral pathway for patients. Furthermore, we aimed to assess its overall impact.

Methods

Music therapists delivered oral presentations and experiential learning through creative workshops, collaboration and feedback to allied health therapists in our geriatric MDT. Criteria for referrals for MT and a referral pathway were developed. Data on patients who received MT was collated.

Results

There were 70 referrals for MT from our MDT. 61% were female, mean age 77 years. Referral sources were occupational therapists (45%), speech therapists (34%), medical social workers (13%), physiotherapists (8%). Patients included those with stroke (41%), general medical conditions (23%), dementia (16%), Parkinson's (11%) and mental health concerns (9%). There were 16 joint MDT sessions and a mean of 5 MT sessions per patient (about 40 minutes in duration). Interventions included: Melodic Intonation Therapy (MIT), singing and vocal exercises, Rhythmic Auditory Stimulation (RAS), Musical Neglect Training (MNT), Therapeutic Instrumental Musical Performance (TIMP), reminiscence and song-writing. Overall, we identified better engagement with rehabilitation and improvements in mood, speech (voice strength and verbal fluency) and upper and lower limb co-ordination.

Conclusion

MT was successfully integrated into a geriatric MDT and had beneficial effects on patient mood, speech, communication and motor function. Education of MDT members was crucial in achieving appropriate MT referrals. Joint MDT’s also facilitated individualised MT interventions. Findings strongly support our model that incorporates MT within an MDT.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

External validity and reliability of the Psychosocial Assessment Tool (PAT) among Canadian parents of children newly diagnosed with cancer

BACKGROUND

The Psychosocial Screening Tool (PAT) was developed and validated with a sample of caregivers of children newly diagnosed with cancer in the United States. This study aimed to assess cultural adaptation (Phase 1) and validity and reliability of the revised PAT (PATrev) with a Canadian sample (Phase 2).

PROCEDURE

In Phase 1, a convenience sample of seven parents of children who were treated for cancer and six pediatric oncology healthcare experts participated. In Phase 2, 67 parents of children newly diagnosed with cancer from 4 Canadian pediatric cancer centers participated. To assess reliability and validity of the PATrev, parents completed behavioral (BASC-2) and quality of life (PedsQL) instruments about the child and an anxiety inventory (STAI) about themselves.

RESULTS

The PAT required minor changes to be culturally adapted for the Canadian population. The PATrev had strong inter-rater (0.77) test-retest (0.75), and internal consistency reliability (0.85), as well as moderate to strong validity comparing PATrev child's problems and PedsQL total (-0.49), PedsQL anxiety (-0.47), BASC-2 internalizing (0.64), behavioral (0.63), and adaptive scores (-0.56). PATrev discriminative validity was confirmed with BASC-2 scores (AUR scores of 0.70-0.74). PATrev parental stressors were strongly correlated to STAI scores (0.53). Finally, agreement between PATrev child's problems and parental anxiety scores was moderate (0.47).

CONCLUSION

This study supports the original PAT, demonstrates PATrev is a reliable and valid psychosocial screening tool, and provides unique evidence regarding early psychosocial risk in the family, which have important implications for guiding psychosocial practice.

Does the use of the revised psychosocial assessment tool (PATrev) result in improved quality of life and reduced psychosocial risk in Canadian families with a child newly diagnosed with cancer?

OBJECTIVES

Early psychosocial screening may guide interventions and ameliorate the adverse psychosocial effects of childhood cancer. The revised psychosocial assessment tool provides risk information - Universal (typical distress), Targeted (additional specific distress), and Clinical (severe distress) - about the child with cancer and his or her family. This pilot study investigated the benefits of providing a summary of family psychosocial risk information to the medical team treating the newly diagnosed child (Experimental Group, EG).

METHOD

We conducted a pilot randomized control trial with a sample of 67 parents, comparing the EG to the control group (CG) on parental perception of family psychosocial difficulties (revised psychosocial assessment tool risk levels), child behavior (behavior assessment scale for children-2), pediatric quality of life (PedsQL), and parental anxiety (state-anxiety scale of the state-trait anxiety inventory ), 2-4 weeks after diagnosis (Time 1) and 6 months later (Time 2).

RESULTS

Compared to the CG, participants in the EG had significantly reduced targeted and clinical risk (p < 0.001), and improved pain related PedsQL at Time 2 (p < 0.05). Scores for PedsQL total and nearly all subscales improved over time in both groups (p < 0.05 to p < 0.001). No changes in behavior scores were noted.

CONCLUSION

Preliminary findings suggest that providing a summary of the Psychosocial Assessment Tool to the treating team shortly after diagnosis may help reduce family wide psychosocial risk 6 months later and improve quality of life related to pain for children who are undergoing treatment for cancer.

Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third-degree tears (EBAPT Trial)

OBJECTIVE

To compare early home biofeedback physiotherapy with pelvic floor exercises (PFEs) for the initial management of women sustaining a primary third-degree tear.

DESIGN

Single centre, randomised trial.

SETTING

National Maternity Hospital, Dublin, Ireland.

POPULATION

A total of 120 women sustaining a primary third-degree tear.

METHODS

Women were randomised in a one to three ratio: 30 to early postpartum home biofeedback physiotherapy and 90 to PFEs.

MAIN OUTCOME MEASURES

Differences in anorectal manometry results, Cleveland Clinic continence scores and Rockwood faecal incontinence quality of life scale scores after 3 months of postpartum treatment.

RESULTS

The mean anal resting pressure was 39 ± 13 mmHg in the early biofeedback physiotherapy group and 43 ± 17 mmHg in the PFE group. The mean anal squeeze pressure was 64 ± 17 mmHg in the biofeedback group and 62 ± 23 mmHg in the PFE group. There was no significant difference in anal resting and squeeze pressure values between the groups (P = 0.123 and P = 0.68, respectively). There were no differences in symptom score and quality of life measurements between the groups.

CONCLUSIONS

This study demonstrates no added value in using early home biofeedback physiotherapy in the management of women sustaining third-degree tears. Poor compliance may have contributed because women found it difficult to designate time to using biofeedback.

The contribution of alcohol to fatal traumatic head injuries in the forensic setting

Excessive drinking increases the risk of dying unnaturally. In the Republic of Ireland such deaths are referred to the State Pathologist. Blood alcohol concentration (BAC) is routinely measured. We created a database of cases presenting to the State Pathologist over a nine year period (2000-2008 inclusive) to evaluate the relationship between alcohol and fatal traumatic brain injuries (FTBI). Of a total of 1778 cases, 332 (275 Male [M]; 57 Female [F]) died of head injuries. Fatalities were highest in males aged 36-50 (N = 97) and 26-35 (N = 73). Assaults (N = 147), falls (N = 95), road traffic accidents (RTA) (N = 50) and suicide (N = 15) were the commonest modes of presentation. A positive blood alcohol concentration (BAC) was found in 36% of assaults, 41% of falls and 40% of suicides. In the RTA group BAC was positive in 59% of pedestrians, 33% of drivers and 14% of passengers. Alcohol clearly plays a significant role in FTBI in the forensic setting.

Kikuchi disease in a child

Kikuchi disease, also called histocytic necrotizing lymphadenitis or focal histiocytic lymphadenitis, is a rare, idiopathic and generally self limited cause of lymphadenitis. It was first described in 1972 in Japan. The most common clinical manifestation is cervical lymphadenopathy with or without systemic symptoms & signs. It almost always runs a benign course and resolves in several weeks to months.

Exploring historical Canadian foodborne outbreak data sets for human illness attribution

Human illness attribution has been recently recognized as an important tool to better inform food safety decisions. Analysis of outbreak data sets has been used for that purpose. This study was conducted to explore the usefulness of three comprehensive Canadian foodborne outbreak data sets covering 30 years for estimating food attribution in cases of gastrointestinal illness, providing Canadian food attribution estimates from a historical perspective. Information concerning the microbiological etiology and food vehicles recorded for each outbreak was standardized between the data sets. The agent-food vehicle combinations were described and analyzed for changes over time by using multiple correspondence analysis. Overall, 6,908 foodborne outbreaks were available for three decades (1976 through 2005), but the agent and the food vehicle were identified in only 2,107 of these outbreaks. Differences between the data sets were found in the distribution of the cause, the vehicle, and the location or size of the outbreaks. Multiple correspondence analysis revealed an association between Clostridium botulinum and wild meat and between C. botulinum and seafood. This analysis also highlighted changes in food attribution over time and generated the most up-to-date food attribution values for salmonellosis (29% of cases associated with produce, 15% with poultry, and 15% with meat other than poultry, pork, and beef), campylobacteriosis (56% of cases associated with poultry and 22% with dairy products other than fluid milk), and Escherichia coli infection (37% of cases associated with beef, 23% with cooked multi-ingredient dishes, and 11% with meat other than beef, poultry, and pork). Because of the inherent limitations of this approach, only the main findings should be considered for policy making. The use of other human illness attribution approaches may provide further clarification.

Investigation into the standard of autopsy procedures performed on Irish nationals worldwide

For the purpose of this study twenty cases, involving the deaths of Irish nationals while abroad, were examined. The aims of the report were 1) to observe whether autopsy guidelines are being implemented by countries throughout the world investigating the deaths of foreign citizens, particularly Irish nationals, 2) to compare/contrast the cause(s) of death established in Ireland and the countries where the deaths occurred and 3) where appropriate, suggest improvements to the current system. The results revealed that where a complete autopsy is not performed then the chance of forming a correct cause of death, or any cause of death, decreases from 100% to 0%. The standard of autopsies on foreign nationals varies from country to country and within countries. Currently there are many different autopsy procedure guidelines available. The time may have come to formulate one universal set of guidelines that are to be implemented worldwide.

Does telephone triage of emergency (999) calls using Advanced Medical Priority Dispatch (AMPDS) with Department of Health (DH) call prioritisation effectively identify patients with an acute coronary syndrome? An audit of 42,657 emergency calls to Hampshire Ambulance Service NHS Trust

INTRODUCTION

The National Service Framework for Coronary Heart Disease requires identification of patients with an acute coronary syndrome (ACS) to enable prompt identification of those who may subsequently require pre-hospital thrombolysis. The Advanced Medical Priority Dispatch System (AMPDS) with Department of Health (DH) call prioritisation is now the common triage tool for emergency ('999') calls in the UK. We retrospectively examined patients with ACS to identify whether this triage tool had been able to allocate an appropriate emergency response.

METHODS

All emergency calls to Hampshire Ambulance Service NHS Trust (HAST) from the Southampton area over an 8 month period (January to August 2004) were analysed. The classification allocated to the patient by AMPDS (version 10.4) was specifically identified. Data from the Myocardial Infarct National Audit Project) were obtained from the receiving hospital in Southampton to identify the actual number of patients with a true ACS.

RESULTS

In total, 42 657 emergency calls were made to HAST from the Southampton area. Of these, 263 patients were subsequently diagnosed in hospital as having an ACS. Of these 263 patients, 76 presented without chest pain. Sensitivity of AMPDS for detecting ACS in this sample was 71.1% and specificity 92.5%. Positive predictive value was 5.6% (95% confidence interval 4.8 to 6.4%), and 12.5% (33/263) of patients with confirmed ACS were classified as non-life threatening (category B) incidents.

CONCLUSION

Only one of approximately every 18 patients with chest pain has an ACS. AMPDS with DH call prioritisation is not a tool designed for clinical diagnosis, and its extension into this field does not enable accurate identification of patients with ACS.

Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics

OBJECTIVES

The recent introduction of a disposable laryngeal mask airway has provided paramedics with an alternative to endotracheal intubation. Time taken to secure the airway with each device was compared in patients undergoing elective surgery.

METHODS

Patients undergoing general anaesthesia were studied. Paramedics trained in laryngeal mask use and endotracheal intubation participated in the study. A Portex disposable laryngeal mask was inserted and removed, followed by a Portex endotracheal tube. Time taken from beginning of the procedure to ventilation of the patient was recorded.

RESULTS

Laryngeal mask insertion and endotracheal intubation was attempted on 52 patients. Median age was 63.5 years (range 39-83). Laryngeal mask insertion was successful in 88.5% (46 of 52) patients; endotracheal intubation was successful in 71.2% (37 of 52) patients (after no more than two attempts), p = 0.049. Intubation success was related to laryngoscopic view (87.5% grade 1, 56.3% grade 2, 0.0% grade 3. p<0.0001). When laryngeal mask/endotracheal tube insertion were both successful (n = 35 of 52), there was no significant difference in median time to secure the airway (laryngeal mask 47.0 seconds (range 24-126) compared with endotracheal tube 52.0 seconds (range 27-148) p = 0.22). Laryngeal mask insertion was successful in 80.0% (12 of 15) patients in whom endotracheal intubation had failed.

CONCLUSIONS

Even under optimal conditions, 30% of attempts at intubation by paramedics were unsuccessful. A disposable laryngeal mask has a higher success rate in securing the airway and overall, secures the airway more reliably than endotracheal intubation.

The role of transferrin saturation as a screening test for hereditary haemochromatosis in an Irish population seeking medical care

BACKGROUND

Genetic studies have indicated a high prevalence of mutations for hereditary haemochromatosis (HH) in Irish populations. Given the high cost of genetic screening and the ethical implications thereof, we assessed the role of transferrin saturation (TS) as a primary screening test for HH in an Irish population seeking medical care.

METHODS

TS and ferritin were measured on 330 consecutive blood specimens received in the laboratory for routine screening. Patients with TS > 45% were genetically screened for the C282Y and H63D mutations.

RESULTS

Twenty-six patients had TS values > 45%. Of these, specimens were available for genetic screening on 20 patients. Three previously undiagnosed patients were found to be C282Y homozygotes and one a compound heterozygote (C282Y/H63D). The prevalence of C282Y homozygotes was 0.93%, which is similar to the reported prevalence found in Irish populations by genetic screening.

CONCLUSION

Given the number of positive findings in this study, we conclude that, in the absence of a national programme, TS could be used as part of a health-screening panel in the Irish setting. Patients expressing iron overload would be detected before organ damage occurred, leading to less severe clinical disease and better patient prognosis.

Ruptured abdominal aortic aneurysm in a 12-month-old boy

A rare case of abdominal aortic aneurysm in a 12-month-old boy is reported. The clinical presentation was one of acute catastrophic rupture. The morphologic and histologic findings suggested an idiopathic etiology.

The effect of a change from conventional cardiac enzymes to troponin I on overall hospital costs in patients with suspected myocardial infarction

A random sample of patients presenting to this hospital in 1996 and 2000 with chest pain was assessed retrospectively with respect to patient bed stay and associated costs. The laboratory testing protocol had been changed from traditional cardiac markers AST, CK and CKMB, to troponin I, in the intervening period. The average bed stay for patients with chest pain of non-AMI origin was reduced by 2 days, as a result of the change in testing protocol. As ward costs contribute 49% of total cost of treatment, this resulted in decreased cost per patient, and more efficient use of hospital beds.

Advantages of a posterior fourchette incision in anal sphincter repair

PURPOSE

Delayed repair of obstetric-related anal sphincter injury remains problematic, and perineal wound breakdown is common. The aim of this study was to assess the outcome after overlap anal sphincter repair and to determine the advantages, if any, of a posterior fourchette incision (n = 18) compared with a conventional perineal incision (n = 32).

METHODS

Fifty females of mean parity 2.8 (standard deviation, 1.6) underwent repair in a five-year period. The mean follow-up was 23 months. Assessment was by anal vector manometry, endoanal ultrasound, and continence scoring.

RESULTS

Functional outcomes were similar in the two groups. Repair increased squeeze-pressure increment and improved continence scores in both groups. Postoperative wound complications were fewer when a posterior fourchette incision was used compared with a perineal incision (11 vs. 44 percent, respectively; P < 0.05).

CONCLUSIONS

Delayed anal sphincter repair improves continence. A posterior fourchette approach is associated with fewer postoperative wound complications without compromising the quality of repair and the functional outcome.

Evaluation of methods for detection of toxins in specimens of feces submitted for diagnosis of Clostridium difficile-associated diarrhea

Clostridium difficile is the principal pathogen associated with hospital-acquired acute diarrheal disease. We have evaluated the performances of six approaches for diagnosis of C. difficile-associated diarrhea (CDAD). Consecutive stool specimens (n = 200) from 133 patients were examined by cytotoxin assay, by culture of C. difficile on cycloserine-cefoxitin-fructose agar, and by toxin detection using four rapid immunoassay systems (Oxoid Toxin A test, ImmunoCard Toxin A test, TechLab Tox A/B II test, and Premier Toxins A&B test). A diagnosis of CDAD was established for 35 (27%) patients (representing 29% of specimens). The adjusted sensitivity and specificity of the methods were, respectively, 98 and 99% for the cytotoxin assay, 54 and 99% for ImmunoCard, 50 and 98% for Oxoid, 79 and 98% for TechLab, 80 and 98% for Premier, and 57 and 100% for culture. The TechLab and Premier assays are acceptable tests for diagnosis of CDAD but are not equivalent to the cytotoxin assay.

Task-related EEG-EEG coherence depends on dopaminergic activity in Parkinson's disease

We investigated whether functional coupling between different cortical areas is impaired in Parkinson's disease, using corticocortical coherence as a surrogate measure of coupling. We recorded scalp EEG from different sites in seven parkinsonian patients while they tracked a visual target using their wrist, or copied the same movement from memory. Differences in EEG-EEG coherence between the tracking and copying tasks and their respective controls, visual tracking alone and fixation of a stationary target, were determined on and off levodopa. After levodopa we found extensive task-specific and broad band cortico-cortical coherence. Off levodopa cortico-cortical coherence was much reduced. Ascending dopaminergic projections from the ventral mesencephalon may therefore be important in determining the pattern and extent of corticocortical coupling during executive tasks.

High-dose chemotherapy (CTM) for breast cancer

We designed and implemented a new mitoxantrone-based high-dose chemotherapy regimen to minimize pulmonary injury (seen in carmustine-based regimens) in patients with breast cancer. One hundred and ninety-one breast cancer patients (99 stage II/IIIA; 27 stage IIIB; 65 stage IV responsive to conventional-dose chemotherapy) were treated with high-dose chemotherapy (CTM) delivered over 4 days (cyclophosphamide (6 g/m2), thiotepa (600 mg/m2), and mitoxantrone (24-60 mg/m2)) followed by autologous hematopoietic stem cell rescue. Stage II/III patients received chest wall radiation and tamoxifen (if hormone-receptor positive) after CTM. The 5-year event-free survival (EFS) for stage II/IIIA patients with 10 or more involved axillary lymph nodes (n = 80) was 62 +/- 12%. Hormone receptor-positive patients with 10 or more nodes did significantly better than negative patients. The EFS for stage IIIB patients at 5 years was 44 +/- 19%; for stage IV patients at 5 years was 17 +/- 10%. Stage IV patients achieving complete response in viscera and/or soft tissue prior to CTM did significantly better than those achieving a partial response. There were six (3%) treatment-related deaths including two due to diffuse alveolar hemorrhage. There were no episodes of delayed interstitial pneumonitis. There were six severe cardiac events in 91 patients (6.6%) but none after instituting mitoxantrone dose-adjustment in the final 100 patients. We conclude that CTM is associated with a low treatment-related mortality and little pulmonary toxicity. CTM produces excellent outcomes in stage II/IIIA patients with 10 or more involved axillary lymph nodes.

Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury

OBJECTIVE

To determine the influence of parity and method of primary anal sphincter repair on outcome following obstetrical third degree perineal tear.

STUDY DESIGN

Prospective study of 154 women after primary repair following third degree tear conducted over 2 years. Postpartum evaluation included a continence questionnaire, anal manometry and endoanal ultrasound.

RESULTS

Third degree tears occurred in 1.6% primiparae and 0.6% multiparae during the study period; in 42/112 (38%) primiparae and 10/42 (24%) multiparae, these tears occurred at instrumental deliveries. Mean birthweight (3.8+/-0. 43 kg) was similar in both groups, but prolonged latent second stage of labour (P=0.003), use of epidural analgesia (P<0.0001) and episiotomy extension (P1 quadrant) anal sphincter defect.

CONCLUSION

Outcome of anal sphincter repair was not influenced by parity or mode of repair. Despite good symptomatic outcomes, ultrasound evidence of significant anal sphincter injury was found in one-third of patients.

A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma

PURPOSE

This study was designed to compare prospectively the effects of augmented biofeedback with those of sensory biofeedback alone on fecal incontinence and anorectal manometry after obstetric trauma.

METHODS

A consecutive cohort of 40 females with impaired fecal continence after obstetric anal sphincter injury were recruited from a dedicated perineal clinic. Patients were randomly assigned to receive either augmented biofeedback or sensory biofeedback alone. All patients were assessed before and after twelve weeks of biofeedback training, using a fecal continence questionnaire and anorectal manometry.

RESULTS

Thirty-nine of 40 females recruited completed the study. Continence scores improved in both treatment groups, but the results were better for those who received augmented biofeedback. Anorectal manometry was unchanged by sensory biofeedback, whereas anal resting and squeeze pressures increased with augmented biofeedback. No change in anal vector symmetry was observed in either group.

CONCLUSION

Augmented biofeedback training is superior to sensory biofeedback alone in the treatment of impaired fecal continence after obstetric trauma.

Tracking drug-resistant Streptococcus pneumoniae in Oregon: an alternative surveillance method

With the emergence of drug-resistant Streptococcus pneumoniae, community-specific antimicrobial susceptibility patterns have become valuable determinants of empiric therapy for S. pneumoniae infections. Traditionally, these patterns are tracked by active surveillance for invasive disease, collection of isolates, and centralized susceptibility testing. We investigated whether a simpler and less expensive method aggregating existing hospital antibiograms--could provide community-specific antimicrobial susceptibility data. We compared 1996 active surveillance data with antibiogram data from hospital laboratories in Portland, Oregon. Of the 178 S. pneumoniae active surveillance isolates, 153 (86% [95% confidence interval (CI) = 80% to 91%]) were susceptible to penicillin. Of the 1,092 aggregated isolates used by hospitals to generate antibiograms, 921 (84% [95% CI = 82%-87%]) were susceptible to penicillin. With the exception of one hospital's erythromycin susceptibility results, hospital-specific S. pneumoniae susceptibilities to penicillin, cefotaxime, trimethoprim-sulfamethoxazole, and erythromycin from the two methods were statistically comparable. Although yielding fewer data than active surveillance, antibiograms provided accurate, community-specific drug-resistant S. pneumoniae data in Oregon.

Comparison of high-resolution endoluminal sonography to video endoscopy in the detection and evaluation of esophageal varices

High-resolution endoluminal sonography (HRES) was used to image and measure esophageal varices in control subjects and patients with portal hypertension and compared with endoscopic findings. Nine control patients and 68 patients with known cirrhosis or noncirrhotic portal hypertension underwent videotaped HRES and videotaped esophagoscopy (EGD). Two blinded investigators reviewed the videotapes to determine the presence and size of the largest esophageal varix in each patient. The largest varix by HRES was measured with the esophagus at rest at a point where the varix appeared most circular. The largest varix seen on EGD was graded on a 5-point scale. All nine of the control patients were correctly identified by both EGD and HRES as grade I (no varices). Eight of the 10 patients with no varices seen on EGD had varices identified by HRES. The interobserver correlation for HRES was r = .88 and for EGD was r = .79. The correlation between EGD and HRES was r = .50. High resolution endoluminal sonography allows quantitative measurement of variceal size, is a more sensitive and reproducible imaging modality than esophagoscopy for the detection and sizing of esophageal varices. There is poor correlation between monographic measurement and endoscopic grading of esophageal varices. Assessment of esophageal variceal presence and the measurement of variceal size by high resolution endoluminal sonography is an accurate, reproducible method of determining the size of esophageal varices.

Serum neuron-specific enolase and immunohistochemical markers of neuroendocrine differentiation in lung cancer

An enzyme immunoassay for serum neuron-specific enolase (NSE) was evaluated with respect to analytical performance and clinical utility and compared with immunohistochemical evaluation of neuroendocrine differentiation. Values obtained agreed well with values obtained using a radioimmunoassay method giving a correlation coefficient of 0.934. Analytical performance of the enzyme immunoassay was good but the diagnostic sensitivity of 82% in extensive and 67% in limited disease was insufficient for serum NSE to be of value in the diagnosis of small cell lung cancer (SCLC). Serum NSE decreased significantly in 11 of 15 patients with SCLC following institution of chemotherapy. Classification of lung cancers into SCLC and non small cell lung cancer (NSCLC) types is largely based on tumour morphology. Neuroendocrine differentiation may not be morphologically evident. Immunohistochemical staining of tumour tissue with markers of neuroendocrine differentiation, i.e. NSE (both monoclonal and polyclonal antibodies) Leu 7, Chromogranin A and P G P 9.5 was performed in both patients with SCLC and NSCLC. 38 per cent of patients with NSCLC had both raised serum NSE and positive NSE (polyclonal) immunoperoxidase staining of lung tissue. A further 35 per cent of patients showed a raised serum NSE or positive immunohistochemistry but not both. The presence of two positive immunoperoxidase markers in lung tissue has been suggested as an indicator of responsiveness to chemotherapy in NSCLC patients. A number of factors may affect immunohistochemical positivity in tissue sections and the additional use of a serum marker may better define chemotherapy responsive groups.