Immunodeficiency and infantile bone and joint infection

Fifteen patients with infantile bone and joint infections were studied immunologically and clinically, 3 at the time of illness and 12 later. Abnormality of immunoglobulins, or complement, or phagocytes was found in 9 patients; 6 were within normal limits for the tests undertaken. Immunodeficiency is probably responsible for the subdued clinical signs of infection and for delayed diagnosis in some patients. It was also related to the extent of femoral head damage in infective arthritis of the hip and to the incidence of wound infection in late elective surgery.     

Use of tocolytics: what is the benefit of gaining 48 hours for the fetus?

Preterm birth remains one of the serious problems in perinatal medicine and is associated with an increased risk of neonatal complications and long-term morbidity. Although each day that delivery is delayed between 22 and 28 weeks of gestation increases survival by 3%, since most spontaneous preterm labour occurs between 28 and 34 weeks of gestation, this is of secondary concern; the primary goal of delay is to improve the function of certain systems in the fetus and to balance the risks of a hostile intrauterine environment with the complications of extrauterine preterm life. Although there is a lack of definitive evidence that tocolytic drugs improve outcome following spontaneous preterm labour and preterm birth, there is ample evidence that tocolysis delays delivery for long enough to permit administration of a complete course of antepartum glucocorticoids and to facilitate in utero transfer to a tertiary care unit where neonatal care will be optimal. Both these measures have been associated with improved outcomes; antepartum glucocorticoids reduce the incidence of respiratory distress syndrome, intraventricular haemorrhage, periventricular leucomalacia and necrotising enterocolitis, and in utero transfer is associated with decreased morbidity and mortality and less hospital-based intervention compared with postnatal transportation. Consequently, women who are more likely to benefit from tocolysis are those at early gestational ages, those needing transfer to a hospital that can provide neonatal intensive care and those who have not yet received a full course of antepartum glucocorticosteroids. In these cases, delaying labour for at least 48 hours with drugs such as atosiban should be considered, since it offers clear advantages for the fetus.     

Decision making in palliative surgery

BACKGROUND: Palliative surgery for advanced cancer patients involves complex decision making. Surgeons with a cancer-focused practice were surveyed to determine the extent to which palliative surgery was currently practiced, to identify ethical dilemmas and barriers they faced in performing palliative surgery, and to evaluate their treatment choices in four different clinical scenarios. STUDY DESIGN: A 110-item survey was devised after extensive review of the palliative care and palliative surgery literature to evaluate current practices and attitudes regarding palliative surgery. Case vignettes were devised to evaluate dinical factors influencing surgeons' selection of treatment for symptomatic patients with advanced malignancy. RESULTS: Survey response rate was 24% (419 of 1,740). Respondents reported 74% of their surgery caseload as cancer related, and 21% of these as palliative. On a scale of 1 (uncommon problem) to 7 (common problem), surgeons reported that the most common ethical dilemmas in palliative surgery were providing patients with honest information without destroying hope (5.6 +/- 1.4) (mean +/- standard deviation), and preserving patient choice (5.0 +/- 1.7). Bound on error of the average frequency estimate for ethical dilemmas, based on response rate, was 0.08. On a scale of 1 (not a barrier) to 7 (a severe barrier), surgeons rated the most severe barriers to optimum use of palliative surgery as limitations of managed care (4.1 +/- 2.0) and referral to surgery by other specialists (3.9 +/- 1.8). Bound on error of the estimate for average severity of barriers, based on response rate, was 0.09. They rated the least severe barriers to palliative surgery as surgeon avoidance of dying patients (3.0 +/- 1.8) and surgery department reluctance to perform palliative surgery (2.6 +/- 1.6). Analysis of surgeons' treatment selection in case vignettes indicated that patient age, aggressiveness of tumor biology, local extent of disease, and severity of patient symptoms were all variables of influence for treatment selection in patients with advanced malignancies. CONCLUSIONS: Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. We have identified variables of major influence to surgeons in the palliative treatment selection for patients with advanced, solid malignancies. Validation of these variables as meaningful will require future studies focusing on patient outcomes.     

Urinary incontinence and hysterectomy in a large prospective cohort study in American women

PURPOSE: We investigated the effects of hysterectomy with and without concomitant urinary incontinence repair on incontinence severity in one of the largest prospective studies of hysterectomy outcomes performed in the United States. MATERIALS AND METHODS: We administered the Urinary Symptoms Scale for Women to 1,299 women before hysterectomy done for benign conditions, and 6, 12, 18 and 24 months postoperatively to measure the presence, severity and type of urinary incontinence. RESULTS: Before hysterectomy 29.5% of participants had severe urinary incontinence, which decreased to 10% 12 and 24 months after hysterectomy. Most women with severe incontinence before hysterectomy showed improved incontinence 1 year after surgery (89.1%) and were still improved after 2 years (86.5%). The majority of women with moderate incontinence before hysterectomy showed improved incontinence 1 year after surgery (62.4%) and were still improved after 2 years (61.2%). However, some women with mild or no incontinence before hysterectomy had new onset incontinence or the condition had worsened 1 year after surgery (16.7%) and was still worse after 2 years (14.4%). A concomitant urinary incontinence repair procedure significantly increased the probability that a woman with severe incontinence would have improved incontinence 1 year after hysterectomy and significantly decreased the probability that a woman with mild or no incontinence would have worse incontinence after 2 years. CONCLUSIONS: The majority of women who undergo hysterectomy for nonmalignant indications experienced improved urinary incontinence during the first 2 years after surgery.     

Parental and primary care physicians'views on the management of chronic diseases: a study in Italy

A survey on the burden and quality of care and the parental and primary care physicians'views on management of eight chronic illnesses and disabilities was conducted from 1990 to 1993. Data were collected on 993 children and adolescents from family interviews and physicians'postal questionnaires. Approximately 70% of patients used two or more services for care management and 149 children were treated outside their region. Only 36% of the physicians were case managers and half of these agreed that better communication with other care providers could facilitate their role. A wide difference in parental satisfaction was found between medical and disabling conditions. Approximately 90% of the parents expressed satisfaction with care for children with coeliac disease (112/120), asthma (80/89) and diabetes (98/111), whereas approximately one-third of parents of children with cerebral palsy and Down's syndrome were dissatisfied (88/242 and 72/189, respectively). Primary care physicians expressed similar satisfaction with case management. Distance from hospital, the need for more information on disease management and financial aid were the sources of greatest dissatisfaction. Children with disabling diseases had more problems integrating at school than children with other chronic disorders. Closer interaction between health services, providers and families is necessary to manage the needs of disabled (Italian) children better. Chronic illness, disability, family, primary care, quality of care, special needs     

Reference ranges for bone densitometers adopted Australia‐wide: Geelong osteoporosis study

Bone densitometry reports a measure of fracture risk in comparison with young adults (T‐scores) and age‐matched peers (Z‐scores). To date, each manufacturer has provided its own reference range resulting in lack of uniformity. The Australia and New Zealand Bone and Mineral Society and Osteoporosis Australia have recognized the need to standardize the reference range and have recommended that data generated by the Geelong Osteoporosis Study (GOS) be used Australia‐wide. The GOS recruited a random, population‐based sample of adult women and measured bone mineral density (BMD) at the proximal femur and spine using a Lunar DPX‐L. These data were used to establish reference ranges for Lunar machines and, using conversion equations, for Norland and Hologic machines. The new standardized Australian reference ranges for BMD will enable consistent diagnosis of osteoporosis and categorization of fracture risk across different types of densitometers.     

酪氨酸相关肽的合成及抗孕酮生成活性

利用固相法合成了二十个含羟基氨基酸的小肽。其中,以0.5mol·L^-1二甲二氯硅烷/1.5mol·L^-1苯酚/DCM*为脱除Boc试剂,以TFMSA为切除树脂试剂。经C-18反相柱纯化后,全部产物均通过氨基酸分析要求。体外黄体细胞分泌孕酮实验表明有八个肽化物GlyTyrAlaLys,(SarSer)₂Lys及其申酯,TyrLys,HisTyr-NH₂,ThrProTyrLys-NH₂,TyrThrProArgLys,AspHisProThr-PheLys显示较强的抑制hCG致孕酮分泌的活性,而且前三个肽还能显著抑制基础孕酮的分泌,相反,GlySerTyr能刺激基础孕酮的分泌。目前尚未建立合理的结构一活性关系。     

抑制素βa亚基片段的合成及活性的初步测定

以固相多肽合成方法合成了抑制素β_a亚基的六个片段:Ⅰb-βA(37～39)-NH₂(Ⅰ),Ⅰb-βA(34～39)-NH₂(Ⅱ),Ⅰb-β_A(30～39)-NH₂(Ⅲ),Ⅰb-β_A(23～39)-NH₂(Ⅳ),Ⅰb-β_A(16～39)-NH₂(Ⅴ)和Ⅰb-β_A(14-39)-NH₂(Ⅵ),对产物进行了分离纯化。用垂体细胞培养方法对其中Ⅰ,Ⅱ和Ⅲ进行生物活性测定,表明它们不能抑制由LHRH诱导的FSH分泌,Ⅳ,Ⅴ和Ⅵ三个太肽片段由于难溶于中性介质,需要寻求其它方法对其进行生物活性测定。