Culture, conditions and care support mental health of healthcare workers during crises

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has presented immense challenges to health systems worldwide and significantly impacted the mental health of frontline healthcare workers.

AIMS

This study drew on the experiences of frontline healthcare workers to examine organizational strategies needed to support the mental health and well-being of healthcare workers during times of crisis.

METHODS

Semi-structured focus groups or individual interviews were conducted with healthcare workers to examine their perspectives on organizational strategies for enhancing staff mental health and well-being during crises. Data were analysed thematically. Following this, evidence for the identified strategies was reviewed to assess alignment with participant views and recommendations.

RESULTS

Thirty-two healthcare workers from diverse disciplines (10 allied health, 11 nursing, 11 medical) participated in the study. Data analysis identified three broad themes contributing to supporting mental health and well-being. These themes can be encapsulated as the 'Three Cs'-culture (building an organizational culture that prioritizes mental health); conditions (implementing proactive organizational strategies during crises) and care (ensuring fit-for-purpose strategies to support mental health and well-being).

CONCLUSIONS

Study findings underscore the necessity of an integrated and systemic organizational approach to address mental health and well-being in the healthcare workplace. This approach must be long term with the components of the 'Three Cs', particularly cultural change and conditions, viewed as a part of a suite of strategies to ensure crisis preparedness. It is imperative that organizations collaborate with their staff, providing support and fostering a safe and inclusive work environment that ultimately benefits patients, their care and staff well-being.

Diagnostic accuracy and cost analysis of the Alere™ i Influenza A&B near-patient test using throat swabs

BACKGROUND

Clinical diagnostic sensitivity alone is inadequate in the diagnosis of influenza. Polymerase chain reaction (PCR) testing is sensitive but the inherent delays in result availability potentially prolong time to isolation and treatment. Until recently no near-patient test (NPT) has demonstrated adequate sensitivity for routine clinical use.

AIM

To evaluate diagnostic accuracy, time to result availability, clinical impact, and cost consequences of Alere™ i Influenza A&B NPT (Alere Inc., Waltham, MA, USA) using off-label throat swabs.

METHODS

Prospective, multi-centre [four UK National Health Service (NHS) hospitals], diagnostic accuracy cohort study with cost modelling. Throat swab samples from suspected influenza patients were tested for influenza using the reference standard of PCR; a second throat swab was tested using NPT.

FINDINGS

A total of 827 participants were recruited; 589 were suitable for analysis: sensitivity was 75.8% [95% confidence interval (CI): 67.0-84.6]; specificity was 96.8% (95% CI: 95.2-98.3). Sensitivity varied between Sheffield (Northern General Hospital: 82.1%; Royal Hallamshire Hospital: 83.3%) and other sites (Doncaster Royal Infirmary: 71.4%; Newcastle's Royal Victoria Infirmary: 50.0%) whereas specificity was high (92-100%). Positive predictive value (PPV) was 81.2% (95% CI: 72.9-89.5) with negative predictive value 95.6% (95% CI: 93.9-97.4) with observed prevalence of 15.4%. Median time to result for PCR was 1.1 days (on-site laboratories) and 5.2 days (remote laboratories). Isolation findings: 75% influenza positive not isolated; 69% of isolated participants did not have influenza. For a cohort of 1000 participants, annual estimated non-diagnostic cost savings with NPT are £215,040.

CONCLUSION

This first prospective study of the Alere i NPT using throat swabs demonstrates high specificity, high PPV during seasonal epidemics, and rapid result availability which could lead to substantial cost savings.

What is the evidence for the management of patients along the pathway from the emergency department to acute admission to reduce unplanned attendance and admission? An evidence synthesis

Background

Globally, the rate of emergency hospital admissions is increasing. However, little evidence exists to inform the development of interventions to reduce unplanned Emergency Department (ED) attendances and hospital admissions. The objective of this evidence synthesis was to review the evidence for interventions, conducted during the patient’s journey through the ED or acute care setting, to manage people with an exacerbation of a medical condition to reduce unplanned emergency hospital attendance and admissions.

Methods

A rapid evidence synthesis, using a systematic literature search, was undertaken in the electronic data bases of MEDLINE, EMBASE, CINAHL, the Cochrane Library and Web of Science, for the years 2000–2014. Evidence included in this review was restricted to Randomised Controlled Trials (RCTs) and observational studies (with a control arm) reported in peer-reviewed journals. Studies evaluating interventions for patients with an acute exacerbation of a medical condition in the ED or acute care setting which reported at least one outcome related to ED attendance or unplanned admission were included.

Results

Thirty papers met our inclusion criteria: 19 intervention studies (14 RCTs) and 11 controlled observational studies. Sixteen studies were set in the ED and 14 were conducted in an acute setting. Two studies (one RCT), set in the ED were effective in reducing ED attendance and hospital admission. Both of these interventions were initiated in the ED and included a post-discharge community component. Paradoxically 3 ED initiated interventions showed an increase in ED re-attendance. Six studies (1 RCT) set in acute care settings were effective in reducing: hospital admission, ED re-attendance or re-admission (two in an observation ward, one in an ED assessment unit and three in which the intervention was conducted within 72 h of admission).

Conclusions

There is no clear evidence that specific interventions along the patient journey from ED arrival to 72 h after admission benefit ED re-attendance or readmission. Interventions targeted at high-risk patients, particularly the elderly, may reduce ED utilization and warrant future research. Some interventions showing effectiveness in reducing unplanned ED attendances and admissions are delivered by appropriately trained personnel in an environment that allows sufficient time to assess and manage patients.

Onset of CT scan morphological changes in metastatic lesions and associated responses in gastric patients treated with telatinib

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Background: Response to the antiangiogenic agent, bevacizumab, by CT has been associated with a unique morphologic change in liver metastasis (mets) where heterogeneous attenuation, variable degree of enhancement and ill-defined borders before treatment transform into homogeneous, hypoattenuating lesions with well defined borders, mimicking a cyst. CT-based morphologic criteria in colorectal cancer (CRC) had a statistically significant association with pathologic response and overall survival, (Chun, JAMA 2009). The CT changes likely reflect the replacement of mets by fibroconnective tissue rather than tumor necrosis. Telatinib (tel) is a novel orally available kinase inhibitor that is highly selective for the VEGFR, PDGFR, and KIT tyrosine kinases at nanomolar concentrations with potent antiangiogenic activity.

Methods: TEL0805, a Phase 2 study administered tel with capecitabine (X) and cisplatin (P) in previously untreated metastatic or unresectable gastric or GEJ adenocarcinoma pts. Response assessments were every 2 cycles (6 weeks). The ORR in response evaluable pts was 69% (1 CR, 21 PR in 32 pts). CT films from 16/32 response evaluable pts were analyzed and reviewed by a radiologist at a single institution, 10 pts had liver mets.

Results: The median onset of response was 49 days. CT changes of mets at week 6 scans included: decreased attenuation and/or a sharp interface with rapid reduction of mets (n=6); mixed response, with decreased attenuation but persistent borders, and/or slight increase in mets followed by onset of response week 12 (n=3), and PD (n=1). CT changes correlate with durable responses.

Conclusions: Telatinib + XP produces rapid onset of tumor response with morphologic CT changes in gastric cancer liver mets similar to those observed in CRC pts with bevacizumab, consistent with antiangiogenic activity. Further analyses in a randomized setting to correlate CT morphologic response with survival are planned.

[Table: see text]

Pharmacokinetic and pharmacodynamic analysis of gastric cancer patients treated with telatinib

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Background: The soluble form of the VEGFR2 receptor (sVEGFR2) neutralizes circulating VEGF, and functions as a negative feedback mechanism to enable partial inhibition of VEGF-stimulated endothelial cell migration and proliferation. In response to inhibition of VEGFR2 tyrosine kinase activity, up-regulation of VEGF expression and down-regulation of sVEGFR2 expression levels have been observed (Murukesh et al., 2010). Telatinib (tel) is a novel orally available kinase inhibitor that is highly selective for the VEGFR, PDGFR, and KIT tyrosine kinases at nanomolar concentrations with potent antiangiogenic activity. Correlation between telatinib exposure and reduction in plasma sVEGFR2 levels from baseline has previously been demonstrated in patient serum samples in phase I studies.

Methods: TEL0805, a phase II study administered tel with capecitabine (X) and cisplatin (P) in previously untreated metastatic or unresectable gastric or GEJ adenocarcinoma pts. Patient serum samples were obtained on day -7, [6 plasma samples (pre-dose, and at 30 min, 1, 2, 3 and 4 hours)] and on day 1, [4 plasma samples (pre-dose and at 1, 2 and 3 hours)] and evaluated for the levels of telatinib and its M2 metabolite (M2). Additional serum samples were collected every 42 days and evaluated for VEGF and sVEGFR2 levels.

Results: Measurement of tel and M2 levels confirmed previous pharmacokinetic findings and demonstrated no drug accumulation following continuous daily dosing. Baseline plasma sVEGFR2 levels have previously not been reported for advanced gastric cancer patients and displayed a wide range at disease presentation. Reduction in sVEGFR2 levels were noted for nearly all treated patients and correlated with the duration of stay on tel therapy.

Conclusions: Telatinib continuous dosing is possible in combination with XP with little effect on tel exposure or accumulation. Reduction in sVEGFR2 levels may be useful in identifying patients who may benefit from tel treatment in this combination setting.

[Table: see text]

Anaphylactic shock: no time to think

Anaphylaxis is the quintessential medical emergency where prompt recognition and treatment is life-saving. In the UK the incidence is increasing year on year, and is most common in the sixth and seventh decades of life. More than half of cases are iatrogenic in nature, most of the rest are caused by venom (stings) and food substances. The clinical signs can be subtle, but an acute onset of skin or mucosal oedema with respiratory compromise or reduced blood pressure should alert the physician to the diagnosis. The management revolves around the use of adrenaline after an initial airway, breathing and circulation approach, in a dose of 0.5 mg 1:1,000 intramuscularly, repeated five minutes later if there has been no response. Any delay in treatment is associated with increased risk of adverse outcome. Steroids and antihistamines are often given, although there is no convincing evidence of their effect in the acute setting. Where diagnostic uncertainty arises, serum tryptase levels can confirm or refute the diagnosis.

Using reports of bee mortality in the field to calibrate laboratory-derived pesticide risk indices

Mounting evidence suggests that pollinators worldwide are experiencing dramatic population declines, and exposure to pesticides is one of the factors that can account for this. By making use of a database containing more than two decades of honey bee (Apis mellifera) hive poisoning incidents from the United Kingdom (Wildlife Incident Investigation Scheme [WIIS]) and corresponding pesticide use surveys, we attempted to explain honey bee poisoning incidents in the field using models derived from pesticide use information, laboratory-generated bee toxicity data (defined as a hazard ratio; application rate divided by LD(50)), and physico-chemical properties of the applied pesticides. Logistic regression analyses were used to assess the relationship between honey bee poisoning incidents in the field and these parameters. In analyzing models with multiple dimensions, we selected the best model by the best subset method, an iterative method based on maximum likelihood estimation, and Akaike's information criterion. Results suggested that the size of the area treated and hazard ratios calculated from application rates and oral or contact toxicity (but the latter especially) can be used to predict the likelihood that honey bee mortality will occur. Model predictions also suggest that some insecticides carry an extreme risk for bees, despite the lack of documented incidents.

Localized folate and vitamin B-12 deficiency in squamous cell lung cancer is associated with global DNA hypomethylation

We measured the concentrations of folate and vitamin B-12 in paired tissue samples of squamous cell cancer (SCC) and adjacent grossly normal-appearing uninvolved bronchial mucosa (from which SCC developed and also "at risk" of developing SCC) of the lung in 12 subjects to determine the involvement of these vitamins in 1) lung carcinogenesis and 2) global DNA methylation. The folate concentrations were significantly lower in SCCs than in uninvolved tissues (p = 0.03). The vitamin B-12 concentrations were also significantly lower in SCCs than in uninvolved tissues (p = 0.02). The radiolabeled methyl incorporation (inversely related to the degree of in vivo DNA methylation) was significantly higher in SCCs than in uninvolved tissues (p < 0.0001). The correlation between folate and radiolabeled methyl incorporation was inverse and statistically significant in SCCs (p = 0.03). The correlation between vitamin B-12 and radiolabeled methyl incorporation also was inverse and statistically significant in SCCs (p = 0.009). The relationship between tissue vitamin B-12 and DNA methylation was minimal in uninvolved tissues. The relationship between folate and DNA methylation, however, was inverse in uninvolved tissues. In the multiple regression models that included both vitamins, only folate was inversely associated with radiolabeled methyl incorporation in uninvolved and cancerous tissues. These results suggested that folate might be the limiting vitamin for proper DNA methylation in SCC as well as in tissues at risk of developing SCC. Several possible mechanisms of folate deficiency, including inactivation of the vitamin by exposure to carcinogens of cigarette smoke and underexpression or absence of folate receptor in SCCs and associated premalignant lesions, are discussed in light of these findings.

Executive summary: developing objectives, content, and competencies for the training of emergency medical technicians, emergency physicians, and emergency nurses to care for casualties resulting from nuclear, biological, or chemical incidents

STUDY OBJECTIVE

The task force assessed the needs, demands, feasibility, and content of training for US civilian emergency medical responders (paramedics, nurses, and physicians) for nuclear/biological/chemical (NBC) terrorism.

METHODS

A task force representing key professional organizations, stakeholders, and disciplines involved in emergency medical response conducted an iterated instructional-design analysis on the feasibility and content of such training with input from educational professionals. We then analyzed 6 previously developed training courses for their congruence with our recommendations.

RESULTS

The task force produced descriptions of learning groups, content and learning objectives, and barriers and challenges to NBC education. Access to training and sustainment of learning (retention of knowledge) represent the significant barriers. The courses analyzed by the task force did not meet all objectives and challenges addressed.

CONCLUSION

The task force recommends training programs and materials need to be developed to overcome the identified barriers and challenges to learning for these audiences. Furthermore, the task force recommends incorporating NBC training into standard training programs for emergency medical professionals.

Phospholipid-bound beta 2-glycoprotein I induces the production of anti-phospholipid antibodies

Apoptotic-cell-bound beta2-glycoprotein I (beta2GPI), but not apoptotic cells or beta2GPI alone, can induce the production of anti-phospholipid (anti-PL) antibodies (Ab) in normal mice. Although it is presumed that beta2GPI binds to anionic phospholipid (PL) exposed on the apoptotic cell membrane, the precise nature of this complex and its immunogenicity is unclear. To address these issues, we investigated the structure and immunogenicity of human beta2GPI in the presence of different PL that may be expressed on the surface of apoptotic cells. BALB/c mice were immunized intravenously (iv) with beta2GPI in the presence of cardiolipin (CL), phosphatidylglycerol (PG), phosphatidylserine (PS), phosphatidylcholine (PC), or PS/PC (25%/75%) vesicles. Cardiolipin+beta2GPI induced the highest levels of anti-beta2GPI and anti-CL IgG Ab and lupus anticoagulant (LA) activity, while beta2GPI with PC or PS/PC vesicles produced no significant anti-PL Ab. PS+beta2GPI was somewhat immunogenic, but less so than PG+beta2GPI. beta2GPI was immunogenic in the presence of native (CL(N)), but not hydrogenated (CL(H)), CL. Circular dichroism analysis demonstrated that the structure of beta2GPI was altered specifically by interaction with CL(N), but not other anionic PL, including CL(H). Similarly, the structure of CL(N)was affected by interaction with beta2GPI, as detected by(31)P nuclear magnetic resonance. These findings demonstrate that beta2GPI complexed with CL(N)is structurally altered, highly immunogenic, and induces the production of IgG anti-PL Ab. Furthermore, the structural modification and the generation of immunogenic epitopes on beta2GPI upon interaction with CL(N)require the presence of unsaturated fatty acid chains, suggesting a role for oxidation in this process.

Methylenetetrahydrofolate reductase (MTHFR) polymorphism increases the risk of cervical intraepithelial neoplasia

Although cervical cancer is a common female cancer, little attention has been given to genetic susceptibility factors. The present case-control study was undertaken to examine MTHFR polymorphism as a potential molecular marker of cervical intraepithelial neoplasia (CIN) susceptibility and to relate the findings to smoking, HPV infection, ethnicity, parity and oral contraceptive use, which are known risk factors for cervical cancer. A base change from C to T at the nucleotide position 677 of the MTHFR gene results in substitution of valine (GTC) for alanine (GCC). The homozygous normal (Ala/Ala), homozygous mutant (Val/Val), and heterozygous mutant (Ala/Val) genotypes for the MTHFR gene were determined in cervical tissues of 64 cases of CIN lesions and 31 controls. The genotype frequencies of both Val/Val (17%) and Ala/Val (56%) were significantly higher in subjects with CIN lesions compared to controls with Val/Val (10%) and Ala/Val (39%), (trend p = 0.03). The results suggested a significantly increased CIN risk with an alanine to valine substitution at amino acid 223 of MTHFR with an odds ratio of 2.9 (95% confidence interval: 1.2-7.9, p = 0.02). Age, ethnicity, smoking and oral contraceptive use were weakly and nonsignificantly associated with CIN risk. HPV infection was associated with a statistically nonsignificant threefold increase in CIN risk. Parity and MTHFR genotype displayed a strong interaction. Neither nulliparous women with MTHFR polymorphism nor parous women without the polymorphism were at higher risk than women who did not have children and were MTHFR homozygous normal (the reference category). Women with mutant MTHFR genotype who had children, however, showed a significantly higher risk of CIN, with an odds ratio of 23 (95% confidence interval: 2.3-225) as compared to the reference category. No other factors displayed such a strong pattern of interaction. Since MTHFR polymorphism and pregnancy increases folate requirements and can impair folate status, this association could reflect an inadequate response of mutant MTHFR genotype carriers to the increased demand for folate imposed by pregnancy. Tissue folate deficiency, in turn, could increase the risk of CIN in the affected women.

Cyclooxygenase 2 mRNA expression in rat brain after peripheral injection of lipopolysaccharide

Inducible cyclooxygenase 2 (COX 2) converts arachidonic acid to prostaglandins, which are thought to mediate various peripheral lipopolysaccharide (LPS)-induced central effects, including generation of fever and activation of the hypothalamic-pituitary-adrenal axis. To localize prostaglandin production in the brain following peripheral LPS administration, COX 2 mRNA expression was examined by in situ hybridization histochemistry in rats injected intraperitoneally (i.p.) or intravenously (i.v.) with various doses of LPS or saline. Constitutive expression of COX 2 mRNA was found in neurons of cortex, hippocampus, and amygdala, but not in cells of the blood vessels. COX 2 mRNA levels were not altered in saline-injected animals as compared to non-injected controls. In LPS-injected animals, no consistent changes of neuronal COX 2 mRNA expression were observed. COX 2 mRNA expression appeared ex novo at 0.5-h post-injection in cells closely associated with blood vessels, however, ex novo labeling of the number of labeled cells increased to a peak at 2 h and subsided gradually to basal levels by 24 h. Initially, labeling was observed in cells comprising major surface-lying blood vessels and meninges. Later, vascular and perivascular cells associated with smaller penetrating blood vessels were labeled. This pattern of COX 2 mRNA induction is independent of the route and dose of the LPS injection. The induced COX 2 mRNA producing cells are identified as endothelial and leptomeningeal cells. Changes in COX 2 mRNA expression were not observed in circumventricular organs. These results suggest that peripheral LPS induces a rapid increase in COX 2 production throughout the vasculatures of the brain, which could affect the neuronal activity of widespread brain regions by elevating the levels of prostaglandins.

Time course and localization patterns of interleukin-1β messenger rna expression in brain and pituitary after peripheral administration of lipopolysaccharide

The inflammatory cytokine interleukin-1 has been implicated as a mediator of many centrally controlled responses, such as fever and increased activity of the hypothalamic-pituitary adrenal axis, after systemic infections. To identify the neuroanatomical loci of brain interleukin-1-producing cells during infection, we investigated interleukin-1beta messenger RNA expression by in situ hybridization histochemistry using a 500 nt ribonucleotide probe applied on brain sections from rats injected intraperitoneally with 2.5 mg/kg bacterial lipopolysaccharide or saline. In control animals, interleukin-1beta messenger RNA was not detectable. In the brains of lipopolysaccharide-injected animals, two temporally and spatially distinct waves of interleukin-1beta messenger RNA induction were observed. First, cell labelling appeared at 0.5 h, peaked at 2 h, and declined at 4-8 h. The labelled cells were concentrated in circumventricular organs--organum vasculosum of the lamina terminalis, subfornical organ, median eminence, and area postrema--and in choroid plexus, meninges, and blood vessels. Second, at 8-12 h, scattered small cells became labelled throughout the entire brain parenchyma; the labelling subsided by 24 h. Labelling was not observed in any neurons. In the pituitary, lipopolysaccharide induced strong interleukin-1beta messenger RNA expression initially in the anterior lobe at 0.5-1 h, and later in the neural lobe at 1-2 h, and subsiding thereafter. The results show that at early time points, peripheral lipopolysaccharide induces interleukin-1beta message production at the blood brain barrier and in circumventricular organs where the blood brain barrier is leaky. After a time delay of 6-10 h, however, interleukin-1beta messenger RNA is primarily expressed by non-neuronal cells of the brain in the brain parenchyma. These results suggest that the source of initial brain IL-1 activity after peripheral lipopolysaccharide injection derives from cells of the blood-brain barrier and the circumventricular organs, and the sustained interleukin-1 activity in the central nervous system thereafter is derived from glia.

Induction of inhibitory factor kappaBalpha mRNA in the central nervous system after peripheral lipopolysaccharide administration: an in situ hybridization histochemistry study in the rat

In this study we investigate the mRNA expression of inhibitory factor kappaBalpha (IkappaBalpha) in cells of the rat brain induced by an intraperitoneal (i.p.) injection of lipopolysaccharide (LPS). IkappaB controls the activity of nuclear factor kappaB, which regulates the transcription of many immune signal molecules. The detection of IkappaB induction, therefore, would reveal the extent and the cellular location of brain-derived immune molecules in response to peripheral immune challenges. Low levels of IkappaBalpha mRNA were found in the large blood vessels and in circumventricular organs (CVOs) of saline-injected control animals. After an i.p. LPS injection (2.5 mg/kg), dramatic induction of IkappaBalpha mRNA occurred in four spatio-temporal patterns. Induced signals were first detected at 0.5 hr in the lumen of large blood vessels and in blood vessels of the choroid plexus and CVOs. Second, at 1-2 hr, labeling dramatically increased in the CVOs and choroid plexus and spread to small vascular and glial cells throughout the entire brain; these responses peaked at 2 hr and declined thereafter. Third, cells of the meninges became activated at 2 hr and persisted until 12 hr after the LPS injection. Finally, only at 12 hr, induced signals were present in ventricular ependyma. Thus, IkappaBalpha mRNA is induced in brain after peripheral LPS injection, beginning in cells lining the blood side of the blood-brain barrier and progressing to cells inside brain. The spatiotemporal patterns suggest that cells of the blood-brain barrier synthesize immune signal molecules to activate cells inside the central nervous system in response to peripheral LPS. The cerebrospinal fluid appears to be a conduit for these signal molecules.

An effective age-unrestricted m-AMSA-based second-line regimen for poor prognosis acute myeloid leukaemia

The efficacy and toxicity of a regimen consisting of amsacrine (m-AMSA), cytarabine, and thioguanine for remission-induction therapy in poor prognosis categories of acute myeloid leukaemia (AML) were determined in a single arm study of 46 patients. The study group consisted of 17 patients with disease refractory to daunorubicin plus cytarabine-based induction regimens, 22 patients with disease which had relapsed during daunorubicin plus cytarabine maintenance therapy, or following completion of this maintenance programme after receiving > or = 500 mg daunorubicin/m2, and 7 previously untreated patients where cardiac disease contraindicated anthracycline therapy. Complete remission (CR) was attained in 46%, and probability of survival was comparable to published results for first-line treatment with daunorubicin plus cytarabine regimens. There was no statistically significant difference in CR rate or probability of survival between these three categories of poor prognosis AML, and cardiotoxic complications were uncommon despite extensive anthracycline exposure in the majority. In the 43% of patients who were 60-76 years of age, there was no statistically significant difference in CR rate or probability of survival relative to patients < 60 years. This observation fails to support the view that less myelotoxic regimens with lesser efficacy should be the basic approach to treatment of AML in patients > or = 60 years of age.

Cardiac dysrhythmia in total thoracic oesophagectomy. A prospective study

A prospective controlled randomized clinical study of 50 patients undergoing total thoracic oesophagectomy by one surgical team is described, in which one group of patients was given prophylactic digoxin and the other was not. The incidence of cardiac dysrhythmia in each group was compared. Fourteen (56%) of 25 patients digitalized, compared to 16 (64%) of 25 patients not digitalized, suffered cardiac dysrhythmia, with a total incidence of 30 patients (60%). The first onset of dysrhythmia occurred within 48 h in 89% of the patients who suffered this complication. These results indicate a high incidence of cardiac dysrhythmia in patients undergoing this operative procedure, which is not significantly reduced by prophylactic digitalization and which is likely to occur within 2 days of surgery.

Prophylactic digitalization fails to control dysrhythmia in thoracic esophageal operations

A prospective, controlled, randomized study of 80 patients undergoing esophageal operations was undertaken, in which one group of patients was given digoxin and the other was not. The incidence of cardiac dysrhythmia was compared in each group. Twenty-six patients underwent operation for benign disease. Equal numbers were digitalized or not and no dysrhythmias occurred. Fifty-four patients underwent operation for malignant disease. Of 26 in the group digitalized, 12 suffered dysrhythmia (46%). Of 28 not digitalized, 9 suffered dysrhythmia (32%). Overall, 39% of patients with malignant disease suffered a dysrhythmia compared with none with benign disease (p < 0.002 by chi 2).

A child with nocturnal croup

The domiciliary management of a four-year-old with suspected croup is difficult. The differential diagnosis ranges from relatively benign viral illnesses to acute epiglottitis and even diphtheria. Complete obstruction can occur with little warning, and the social situation may further complicate arrangements. As it is not possible to admit every patient with such symptoms, clinical judgement is vitally important.

Transient platelet and HLA antibody formation in multitransfused patients with malignancy

Fifty-nine patients receiving platelet transfusions for bone marrow failure secondary to malignancy were screened at regular intervals for the presence of antibodies to human leucocyte (HLA) and platelet specific antigens. HLA antibodies occurred in 19 patients, 10 of whom also developed platelet specific antibodies. The HLA antibodies disappeared in 10 of 15 patients followed for periods of 2-14 months. In two patients this occurred whilst still receiving platelet transfusions. Antibody reappeared in only two of six patients subsequently transfused. Antibodies to platelet specific antigens were detected in 28 patients. They were transient, often appeared in association with infection, and in 50% of cases tested demonstrated autoantibody activity. There was no association with antibiotic drug therapy, or PFA/EDTA-dependent cryptantigens. Platelet recovery at 1 h or 20 h post transfusion was not significantly reduced in the presence of platelet specific antibodies. These findings have important implications for the selection of platelet donors for alloimmunized recipients.

An investigation of enterococcal bacteremia

Records of all 34 patients with positive blood cultures for enterococcus at Mount Sinai Medical Center of Greater Miami in 1981 were reviewed. Twenty-four true bacteremias were identified from sources including the pelvis/abdomen (9), urinary tract (6), wounds (2), IV catheter (2), contaminated needle (1), endocarditis (1), and primary bacteremia (3). Sixteen of the 24 true bacteremias were hospital acquired, and these infections accounted for 7 of 9 (78%) fatal outcomes. Fourteen of 16 patients with hospital-acquired infection received prior antibiotic therapy. Eight (24%) of the original 34 patients had positive blood cultures for enterococcus as a result of cross-contamination from an automated blood culture analyzer. The rate of cross-contamination per positive blood culture for enterococcus in 1981 was 22%. Two remaining patients in the original series could not be placed in a category of true infection or cross-contaminant. Although there was a real increase in the number of enterococcal bacteremias in 1981, a much larger apparent increase was explained by several episodes of pseudobacteremia.

Diagnostic information derived from immunotyping 1000 patients with leukemia and lymphoma

Immunotyping analysis has been performed on cells from 1000 patients with leukemia or lymphoma using 14 markers of cell lineage or differentiation stage over a 4 yr period. Results showed considerable heterogeneity of cell type among these groups of malignant diseases not readily apparent by morphology and histochemistry. Immunotyping contributed additional diagnostic information in 30% of patients and should be a routine procedure in 8 disease categories. These are: acute leukemia, cell type not determined; acute lymphoblastic leukemia; lymphocytosis of undetermined origin; chronic myeloid leukemia-terminal blast crisis; chronic lymphocytic leukemia; malignant lymphoma-leukemic phase; Sézary syndrome, mycosis fungoides and chronic T cell leukemia; malignant lymphoma and lymphadenopathy- ? lymphoma. Immunotyping provided information on cell lineage and differentiation stage of major leukemic cell populations. Abnormal monoclonal proliferations of B lymphocytes and the presence of primitive cells amongst normally mature tissue cells were identified. Disturbances in normal lymphoid and monocytic cell populations in blood, marrow or tissues could also be demonstrated. Many of the reagents used in this period are now replaced by monoclonal antibody reagents to human lineage and differentiation antigens. These are expected to increase diagnostic usefulness of these techniques.