Surgery in a geriatric population.

A prospective audit of 1111 general surgical procedures undertaken on 1040 elderly patients (over 64 years) revealed a mortality of 3.5% in potentially viable patients. Aged patients (over 74 years) had twice the mortality of old patients (65-74 years). Emergency surgery carried a sevenfold risk factor which is greater than is usually described. Of those patients who died (n = 56) 20 had a laparotomy for surgically incurable disease. Although the four grades of surgeon achieved similar mortality rates (range 4-5.8%), senior surgeons performed more major procedures (Consultants, 40%; SHOs, 19%). There was a low supervision rate of SHOs (37/100 overall, and 9/19 major cases). Of the 26 patients dying from medical disorders 17 had a previous history of that disorder, and only nine of these patients were admitted to our high dependency care unit. We conclude that mortality rates in the elderly could be improved by encouraging elective surgery and avoiding diagnostic laparatomy in patients with incurable surgical disease. We also suggest that no inexperienced surgeon should operate unsupervised on any elderly patient who is in ASA category 4 or 5, or who undergoes major or intermediate surgery. Further, all elderly patients in ASA category 4 or 5, or those with previous medical problems who have major emergency procedures should be managed postoperatively in a high dependency care unit.     

Diffuse anterior scleritis during OKT3 monoclonal antibody therapy for renal transplant rejection.

OKT3, a murine monoclonal antibody, is a potent, specific immunosuppressive agent used in solid-organ transplantation both as an adjunct during induction therapy and for treatment of steroid-resistant graft rejection. Minor, self-limiting ocular complications are often seen with this drug, of which conjunctivitis is the most common, occurring in approximately three-quarters of patients. We describe the more serious and previously unreported complication of diffuse anterior scleritis, which developed on the fifth day of OKT3 therapy in a 47-year-old man who had undergone cadaveric renal transplantation. Despite continuation of OKT3 treatment the scleritis resolved rapidly with increased dosages of prednisone.     

Pseudomonas aeruginosa flagellar antibodies in patients with cystic fibrosis.

An enzyme-linked immunosorbent assay specific for flagellum type (a or b) of Pseudomonas aeruginosa was used to detect serum immunoglobulin antibodies in 98 random outpatients and 14 colonized cystic fibrosis patients. Antibodies were detected to both types of flagella in addition to M-2 lipopolysaccharide. Titers to both flagellar antigens (FlAg) were 10 to 100 times higher in cystic fibrosis patients than in random outpatients of a comparable age group. Mean antibody titers against b-type FlAg were 454 for outpatients (ages newborn to 21 years), whereas the mean titer for cystic fibrosis patients (ages 6 to 21 years) was 51,520. Titers against a-type FlAg were generally lower, with mean outpatient titers of 68 and mean cystic fibrosis patient titers of 34,323. Differences were also seen in antibody titer against M-2 lipopolysaccharide, but these differences did not correspond to M-2 FlAg titers. In 98 random outpatients (ages newborn to 86 years), FlAg titers generally increased with age. To demonstrate further specificity of the enzyme-linked immunosorbent assay for flagellum antibody, Western blots were performed with selected high-titer cystic fibrosis patient sera. Sera that had a high titer (greater than 25,600) for b- or a-type FlAg showed a corresponding reactive band. These results demonstrate that flagellum antibodies are produced in humans in response to P. aeruginosa infection.     

Depressant effect of marihuana smoke on antibactericidal activity of pulmonary alveolar macrophages.

Other than the potentially therapeutic bronchodilatory influences of marihuana, very little is known of its biologic effects on the lung. To evaluate this problem, alveolar macrophages were harvested from rats by bronchopulmonary lavage and incubated in vitro with Staphylococcus albus and marihuana smoke of standardized 2.2-percent tetrahydrocannabinol content in graded amounts. After three hours, control alveolar macrophages inactivated 78.0 +/- 5.0 percent of the staphylococcal challenge. There was a dose-dependent depression of alveolar macrophage bactericidal activity, with 66.7 +/- 7.1 percent, 23.7 +/- 7.0 percent, 20.5 +/- 7.0 percent, and 11.4 +/- 7.6 percent of the bacteria killed following exposures to 2 ml, 4 ml, 6 ml, or 8 ml of marihuana smoke, respectively. Differential filtration of marihuana smoke revealed that the alveolar macrophage cytotoxin was present in the gas phase of the smoke and was water-soluble. Studies on purified tetrahydrocannabinol and on tetrahydrocannoabinol-extracted marihuana revealed that the impairment in alveolar macrophage function was not related to the psychomimetic or bronchodilatory components of marihuana.     

Hepatitis A associated with a hardware store water fountain and a contaminated well in Lancaster County, Pennsylvania, 1980

In August-October 1980, a sudden increase occurred in the number of cases of jaundice reported among residents of a rural, agricultural section of Lancaster County, Pennsylvania. Investigation confirmed the cases as hepatitis A and showed that the outbreak was associated with consumption of water from a water fountain in a hardware store and water from the adjacent family home, both of which came from a well contaminated with feces. A total of 49 cases occurred from August 11 to October 21 in store customers, employees, family members, and persons visiting the family residence. Unusual features of the outbreak included an epidemic curve with two peaks, a very high attack rate in susceptibles at highest risk (greater than 90%), a high proportion of cases with jaundice (85%), absence of asymptomatic cases, and a high male to female ratio due to the makeup of the group at risk.     

Changes in normal polymorphonuclear leucocyte motility after ingestion of IgG aggregates.

Changes in normal polymorphonuclear leucocyte (PMN) motility after membrane-binding and internalisation of IgG aggregates (a model of soluble immune complexes) have been studied by the micropore filter assay. The results have confirmed that IgG aggregates stimulate as well as inhibit PMN chemotaxis. These effects are dependent on the size and concentration of the IgG aggregates in solution as well as the length of time of incubation. Stimulated chemotaxis was observed in a small subset of the whole PMN population which was apparent only when cell distribution through the filters was analysed. These results indicate the need for caution when drawing conclusions about PMN function from results obtained by these assay techniques.     

Essential fatty acid deficiency in critically III surgical patients

Plasma fatty acid profiles of 33 critically ill surgical patients receiving fat-free parenteral nutrition were examined at weekly intervals up to 28 days. While plasma total fatty acid concentration remained relatively constant and within the normal range, marked compositional alterations were apparent. Levels of linoleate (18:2ω6), the major essential fatty acid in man, fell below normal values (754 ± 259 μg/ml) in 67 percent of patients within 1 week after cessation of oral intake. Decreases in other ω6 unsaturated fatty acids, derived from linoleate, were also apparent. In contrast, gradual increases were observed in levels of endogenously synthesized fatty acids, palmitate (16:0), palmitoleate (16:1) and oleate (18:1ω9). A fatty acid unique to essential fatty acid deficiency, 5,8,11 eicosatrienoate (20:3ω9), appeared in 25 percent of the patients during the first week and in all patients by the third week of study. Considering the rapid appearance and progression of these bio-chemical changes, early initiation of linoleate supplementation appears justified to forestall the development of related clinical sequelae.