Fluid resuscitation of hypotensive emergency patients with and without an algorithm

Seventy-seven consecutive hypotensive (mean arterial pressure (MAP) less than 80 mmHg) surgical emergency patients were resuscitated according to either physicians' individual orders (38 patients) or an algorithm (39 patients). The shock was mainly caused by accidental injuries or acute gastrointestinal bleeding. The patients of the algorithm group were given more plasma expanders than the patients of the control group, while the total amount of fluids administered was similar in both groups. The primary goal of the resuscitation (MAP greater than 80 mmHg) was reached within 30 min in three cases in the control group and in seven cases in the algorithm group. The treatment times at the emergency department and the intensive care unit were similar for the groups. The number of severe and moderate pulmonary disturbances was the same, but mild disturbances were significantly more common in the control group. Renal failure was somewhat more common in the control group and the renal function disturbances were significantly more severe among the control patients. The results suggest that the physicians in some extent altered their practices in fluid resuscitation when the algorithm was put to use, and that this change, perhaps, produced the somewhat better outcome of the patients. The authors recommend the algorithm to be used as a basis of shock treatment and particularly in those emergency departments where the resuscitation of hypotensive patients is performed by junior or inexperienced physicians.     

Homing behavior of hippocampus and parahippocampus lesioned pigeons following short-distance releases

The avian hippocampal formation has been proposed to play a critical role in the neural regulation of a navigational system used by homing pigeons to locate their loft once in the familiar area near home. In support of this hypothesis, the homing performance of pigeons with target lesions of either the hippocampus or parahippocampus was found to be impaired compared to controls following releases of about 10 km. Further, radio tracking revealed that the in-flight behavior of the hippocampal lesioned homing pigeons was characterized by numerous direction changes and generally poor orientation with respect to the home loft. The results identify a local navigational impairment on the part of the hippocampal lesioned pigeons in the vicinity of the loft where landmark cues are thought to be important. Additionally, target lesions of the hippocampus or parahippocampus were found to be similarly effective in causing homing deficits.     

Breast cancer patients with p53 Pro72 homozygous genotype have a poorer survival.

PURPOSE: The p53 R72P polymorphism has been suggested to play a role in many cancers, including breast cancer. Our aim was to evaluate association of R72P with breast cancer risk as well as histopathologic features of the breast tumors and survival. EXPERIMENTAL DESIGN: The germ line R72P genotype was defined among 939 Finnish familial and 888 unselected breast cancer patients and 736 healthy population controls. The clinical and biological variables were tested for association by univariate analysis and the effects of several variables on survival by Cox's proportional hazards regression model. RESULTS: The distribution of the genotypes was similar in all groups studied, suggesting no association with breast cancer risk. Unselected breast cancer patients with 72P homozygous genotype presented significantly more often with lobular carcinoma, whereas R72 allele carriers had a significantly higher frequency of ductal carcinomas (P = 0.004). No significant association with other histopathologic variables, like tumor grade, hormone receptor status (estrogen and progesterone receptors), or tumor-node-metastasis stage, was observed. Survival analysis showed that unselected breast cancer patients with 72P homozygous genotype had significantly poorer survival than patients with other genotypes (P = 0.003). This effect on survival was independent of p53 expression in the tumors and multivariate analysis showed that 72P homozygous genotype was overall an independent prognostic factor (risk ratio of death, 2.1; 95% confidence interval, 1.4-3.3; P = 0.001). CONCLUSIONS: These results suggest no effect of either R72P allele on breast cancer risk but a significantly reduced survival for 72P homozygous breast cancer patients. The finding of codon 72 genotype as an independent prognostic marker for breast cancer warrants further studies.     

Annual injection of vitamin D and fractures of aged bones

Summary In order to investigate the effect of a supplementation of vitamin D in the prophylaxis of fractures of the bones of aged people, an annual intramuscular injection of ergocalciferol (150,000–300,000 IU) was given to two series of aged subjects: first to 199 (45 male) of 479 subjects (110 male) aged more than 85 years who were living in their own home, and second to 142 (29 male) of 320 (58 male) subjects aged 75–84 and living in a home for aged people. This prospective series was divided into treatment groups according to month of birth. These injections were given annually from September to December in the years 1985–1989, two to five times to each participant. The fracture rates, laboratory values, vitamin D levels, possible side effects, and mortality were followed until October 1990. A total of 56 fractures occurred in the 341 vitamin D recipients (16.4%) and 100 in 458 controls (21.8%) (P=0.034). The fracture rate was about the same in both outpatient and municipal home series. Fractures of the upper limb were fewer in the vitamin D recipients, 10/341=2.9% (P=0.025), than in the controls, 28/458=6.1%, during the follow-up. A similar result was obtained in fractures of ribs, 3/341=0.9% and 12/458=2.6%, respectively. Fractures of the lower limbs occurred almost as frequently, 31/341=9.1%, among the vitamin D recipients as among the controls, 49/458=10.7%. The fracture rate was higher in females (22.2%) than in males (9.5%). The fractures were fewer in the vitamin D recipients only in females. No significant differences were found in total mortality, or due to any group of diseases, between the two treatment groups. No deleterious effects of the vitamin D injections were seen. The authors recommend the supplementation of vitamin D in aged people, at least in northernmost latitudes (e.g., as an annual intramuscular injection).     

Nuclear DNA content and its prognostic value in lymphoma of the stomach

Nuclear DNA content of 27 primary lymphomas of the stomach was determined by flow cytometry from paraffin-embedded tissue. Thirteen (50%) of the 26 non-Hodgkin's lymphomas were aneuploid. The only case with Hodgkin's disease was diploid. The mean age of patients with aneuploid lymphoma was less than that of patients with diploid lymphoma (53 years versus 63 years, P = 0.02). DNA aneuploidy was more common in tumors with extragastric spread into the adjacent organs or the upper abdominal lymph nodes than in intragastric lymphomas (73% versus 17%; P = 0.003). Patients with aneuploid lymphoma had both inferior crude recurrence-free survival rate (P = 0.05) and survival rate corrected for known intercurrent diseases (P = 0.02) than patients with diploid lymphoma. Extragastric spread of lymphoma into the adjacent organs or the upper abdominal lymph nodes was, however, the most important prognostic factor by a multivariate analysis.     

Frequent involvement of the internal cuff segment in CAPD peritonitis and exit-site infection--an ultrasound study

BACKGROUND.: The extent of involvement of the subcutaneous Tenckhoff cathetertract in CAPD peritonitis and catheter-related infections isof major therapeutic importance. By definition, both peritonitisand exit-site infections do not involve the catheter tract.However, diagnosis of these infections as well as the more sinistertunnel infection is based mainly on clinical signs. METHODS.: We examined the usefulness of ultrasound examination (US) ofthe catheter tract in delineating catheter-related (exit-siteand tunnel) infections, and their relationship to each otherand to peritonitis. CAPD patients with no evidence of peritonitisor catheter-related infections for 6 months prior to examinationserved as controls. US were performed by one of two experiencedradiologists using the Acuson 128XP/10 scanner with a 7-MHzlinear transducer. A positive US was defined as an area of hypoechogenicity(indicative of fluid collection) >2 mm in width along anyportion of the catheter tract. Findings were localized intosegments (S) as follows: S1, limited to external cuff; S2, intercuffsegment adjacent to the external cuff; S3, intercuff segmentadjacent to the internal cuff; S4, limited to the internal cuff;and S5, involvement extending throughout the catheter tract. RESULTS.: Between March 1993 and January 1995, 39 CAPD patients, all witha double-cuff straight Tenckhoff catheter with the exit sitesituated above the point of entry into the peritoneum were studied.A total of 56 US were performed divided among 26 episodes ofperitonitis, four tunnel infections, 13 exit-site infections,and 13 controls. There were 30 positive US distributed among16 peritonitis, four tunnel, eight exit site infections andtwo control patients. The two positive controls went on to develop peritonitis within1 month of the US. The majority of the US findings (13/16 inepisodes of peritonitis and 5/8 exit site infections) were localizedto segment 4, that is, to the internal cuff region. Apart from a significant increase in width in all infected segmentsversus a normal tunnel, no differences in size were seen betweenperitonitis, exit-site, or tunnel infections, nor were thereany differences in size and localization in these infectionswhen comparing the offending organism (Gram-positive, negative,or culture negative). CONCLUSIONS.: We conclude that peritonitis and exit-site infections are frequentlyaccompanied by involvement of the catheter tract. The localizationof infection to the internal cuff region in cases of exit-siteinfection probably occurred as a result of downward migrationalong the catheter tract. This supports the notion that ideallythe exit site should be pointing caudally or that the peritonealcatheter have a swan-neck configuration. With regard to peritonitis,infection within the peritoneal cavity appears to extend andinvolve the internal cuff region. Thus both the internal andexternal cuffs do not seem to pose an effective barrier againstthe spread of infection. Based on our data, we recommend thatUS be performed as a routine investigation in all cases of exit-siteinfection and in cases of refractory or relapsing peritonitis.     

Activated monocytes induce arthritis-associated changes in mitochondria of cultured synovial fibroblasts

We have recently shown that synovial fibroblasts cultured from patients with reactive or rheumatoid arthritis exhibit increased autofluorescence when compared with controls. Morphological studies suggested that this increase was related to the anomalous structure of mitochondria in cells cultured from rheumatoid or non-rheumatoid inflammatory synovial tissue. The present study describes attempts to find an explanation for these observations. The effects of conditioned media of cultured mononuclear cells were tested on normal synovial fibroblasts. Conditioned media of monocytes stimulated with lipopolysaccharide or poly-IC induced an increase in the cellular autofluorescence and changes in the morphology of mitochondria in normal fibroblasts. These changes were indistinguishable from those seen in synovial fibroblasts cultured from various arthritides. Indomethacin or gold salts did not abolish the effects of monocyte-conditioned media. Abnormal mitochondria could not be induced in the presence of cycloheximide. This study describes a new aspect of monocyte-fibroblast interactions during rheumatoid and non-rheumatoid inflammation of synovial tissue.     

Modelling rubella in Europe

The prevention of congenital rubella syndrome (CRS), as a complication of rubella infection during pregnancy, is the main aim of rubella vaccination programmes. However, as vaccination of infants leads to an increase in the average age at which those who were not immunized become infected, certain rubella vaccination programmes can lead to an increase in the incidence of CRS. In this paper we use a mathematical model of the transmission dynamics of rubella virus to investigate the likely impact of different vaccination policies in Europe. The model was able to capture pre- and post-vaccination patterns of infection and prevalence of serological markers under a wide variety of scenarios, suggesting that the model structure and parameter estimates were appropriate. Analytical and numerical results suggest that endemic circulation of rubella is unlikely in Finland, the United Kingdom, The Netherlands, and perhaps Denmark, provided vaccine coverage is uniform across geographical and social groups. In Italy and Germany vaccine coverage in infancy has not been sufficient to interrupt rubella transmission, and continued epidemics of CRS seem probable. It seems unlikely that the immunization programmes in these countries are doing more harm than good, but this may be partly as a result of selective immunization of schoolgirls. Indeed, in both these countries, selective vaccination of schoolgirls with inadequate vaccination histories is likely to be an important mechanism by which CRS incidence is suppressed (unlike the other countries, which have had sufficiently high infant coverage rates to withdraw this option). Reducing inequalities in the uptake of rubella vaccine may bring greater health benefits than increasing the mean level of coverage.     

Dietary therapy with Lactobacillus GG, bovine colostrum or bovine immune colostrum in patients with juvenile chronic arthritis: Evaluation of effect on gut defence mechanisms

The effect of dietary therapy with a human Lactobacillus strain GG (ATCC 53103), bovine colostrum, or bovine immune colostrum with specific antibodies against anaerobic intestinal bacteria on gut defence mechanisms were studied in juvenile chronic arthritis. Thirty patients with juvenile chronic arthritis were randomly allocated to receive a freeze-dried powder of Lactobacillus GG, or bovine colostrum, or bovine immune colostrum, for a two-week period. Immunologic and non-immunologic gut defence mechanisms were indirectly investigated in blood and faecal samples. In patients receiving Lactobacillus GG, the median (interquartile range) frequency of immunoglobulin-secreting cells, determined by enzyme-linked immunospot assay, increased in the IgA class from 1840 (690–2530) to 3480 (1030–13 170)/10⁶ cells; p=0.02. Likewise the median (interquartile range) frequency of specific antibody-secreting cells against dietary antigens increased during the Lactobacillus GG therapy in the IgM class from 3.8 (1.4–5.0) to 11.2 (5.0–30.0)/10⁶ cells; p=0.02. In addition, Lactobacillus GG therapy decreased the median (interquartile range) activity of faecal urease, which has been associated with mucosal tissue damage, from 40.3 (21.7–54.3) to 28.6 (24.5–49.4) nmol. min⁻¹ (mg protein)⁻¹; p=0.10, while, in patients receiving bovine colostrum, faecal urease activity increased (from 42.2 to 80.6; p=0.04). All findings were transient. We suggest that gut defence mechanisms are disturbed in juvenile chronic arthritis and we further suggest that orally administered Lactobacillus GG has a potential to reinforce the mucosal barrier mechanisms in juvenile chronic arthritis.