Successful Use of Surgically Placed Impella 5.0 and Central Extracorporeal Membrane Oxygenation Circuit in a Patient with Postcardiotomy Shock

The Impella 5.0, a percutaneously inserted left ventricular assist device, has been used to support patients who have severe heart failure or who are undergoing high-risk percutaneous coronary intervention. We report our surgical placement of the Impella 5.0, through a graft sewn to the aorta, to unload the left ventricle of a 59-year-old man who was undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy shock. The patient underwent successful placement of a long-term left ventricular assist device before his discharge from the hospital. The versatility of the Impella 5.0 is exemplified in this patient who was successfully bridged to long-term support.     

Circulating Pancreatic Polypeptide in Patients with Adenocarcinoma of the Bile Duct

Using radioimmunoassay methods, the blood of patients with pancreatic tumors was screened for circulating polypeptide hormones. This screening discovered pancreatic polypeptide in abnormally high concentration in the serum of six of seven patients with adenocarcinomas of the bile duct. the assay appears to be very sensitive finding excessive residual pancreatic polypeptide production after palliative resections. Serum pancreatic polypeptide assays warrant evaluation as an aid in the diagnosis and management of patients with bile duct tumors.     

The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults

The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.     

Legionella pneumophila serogroup 4 isolated from joint tissue

We report the isolation of Legionella pneumophila serogroup 4 from synovial tissue obtained from an 80-year-old female with chronic swelling of her right metacarpophalangeal joint. Synovial tissue infections caused by L. pneumophila are rare. Interestingly, this isolate was recovered from chocolate agar after 5 days of incubation.     

Evaluation of intestinal parasite morphology in polyvinyl alcohol preservative: comparison of copper sulfate and mercuric chloride bases for use in Schaudinn fixative.

As a result of disposal problems inherent in the use of mercury compounds, many laboratories have considered using copper sulfate as a substitute for mercuric chloride in polyvinyl alcohol (PVA) preservative. The primary use for PVA-preserved specimens is the permanent stained smear, the most important technique for the identification of intestinal protozoa. A comparison of organism recovery and morphology was undertaken with PVA containing either copper sulfate or mercuric chloride base. Paired fecal specimens (417 pairs) were collected and examined with the Formalin-ether concentration and Trichrome stain techniques. Numbers of organisms recovered and helminth egg and protozoan morphology were assessed from the concentration sediment. Morphology, clarity of nuclear and cytoplasmic detail, overall color differences, and the ease or difficulty in detecting organisms in fecal debris were assessed from the permanent stained smear. No significant differences were found in the numbers and morphology of organisms seen in the concentration sediment. However, when the trichrome stain was used, the overall morphology of the intestinal protozoa preserved in PVA with copper sulfate was not equal to that seen with PVA with mercuric chloride. We do not recommend switching from mercuric chloride base to copper sulfate base unless that is the only option available for the preparation of permanent stained smears.     

Clinical evaluation of three rapid methods for the detection of significant bacteriuria.

Random urine specimens (848) were screened for significant bacteriuria by using the 30-min Lumac (3M, St. Paul, Minn.), the 2-min Bac-T-Screen (Marion Laboratories, Inc., Kansas City, Mo.), and the 13-h AutoMicrobic system (AMS) urine identification card (Vitek Systems, Inc., Hazelwood, Mo.). MacConkey and 5% sheep blood agar plates were inoculated with a 10(-4) dilution of urine and used for the reference method. Bac-T-Screen results were uninterpretable for 9.1% of the specimens owing to either urine sample pigmentation (5.3%) or clogging of the filter (3.8%). Screen-negative urine specimens made up 49.6, 57.2, and 48.5% of the total number of specimens evaluated with AMS, Lumac, and Bac-T-Screen, respectively. False-positive results with Lumac and Bac-T-Screen were 20.6 and 22.3%, respectively. False-negative results for cultures with greater than or equal to 10(4) CFU/ml were 22.0% with AMS, 29.4% with Lumac, and 25.5% with Bac-T-Screen, and false-negative results for cultures with greater than or equal to 10(5) CFU/ml were 29.6% with AMS, 9.9% with Lumac, and 7.0% with Bac-T-Screen. For each system, greater than 70% of false-negatives at greater than or equal to 10(5) CFU/ml consisted of mixed or pure cultures of common contaminants. With any of these screening methods, a clinically significant isolate at greater than or equal to 10(5) CFU/ml would rarely be missed (less than or equal to 1.7% for all systems). A cost-effective and rapid approach to urine microbiology could consist of screening out negative specimens by either Lumac or Bac-T-Screen and processing only screen-positive specimens by the AMS.     

Comparative evaluation of the Eiken and API 20E systems and conventional methods for identification of members of the family Enterobacteriaceae

To evaluate the accuracy and utility of the Eiken Systek No. 1 (Eiken system; Eiken Chemical Co., Ltd., Tokyo, Japan), we conducted a clinical comparison, with 345 Enterobacteriaceae isolates, of the Eiken System with API 20E (Analytab Products, Inc., Plainview, N.Y.) and conventional methods. The Eiken system is a 21-biochemical-test battery tray stored at 25 degrees C and inoculated in one step. It is similar to the API 20E except that the Eiken system contains malonate, adonitol, and maltose; lacks gelatin, sucrose, melibiose, amygdalin, and arabinose; and uses reagent strips instead of liquid reagents. The API 20E and Eiken systems correctly identified 339 (97.7%) and 276 (79.5%), respectively, and misidentified 3 (0.9%) and 13 (3.7%), respectively, of the isolates. There were no identification codes for 5 (1.4%) organisms with the API 20E and 58 (16.7%) organisms with the Eiken system; of these latter unidentified organisms, 42 were identified as Proteus spp., Morganella sp., and Providencia rettgeri by conventional methods. There was no significant difference between the two rapid systems in total time required for inoculation and reading. Modifications for interpretation of decarboxylase and oxidase tests were needed for the Eiken system, and manipulation of reagent strips required considerable dexterity. However, the Eiken system was easier to inoculate than the API 20E, and, with minor increases in the data base to include more of the Proteus and Morganella spp. and P. rettgeri, the system should be reliable for identification of members of the family Enterobacteriaceae.     

Amebiasis.

Entamoeba histolytica, the causative agent of amebiasis, was first described in 1875. Although a large number of people throughout the world are infected with this organism, only a small percentage will develop clinical symptoms. Morbidity and mortality due to E. histolytica vary from area to area and person to person. Recent findings have suggested that there are pathogenic and nonpathogenic strains of E. histolytica that can be differentiated by isoenzyme (zymodeme) analysis, monoclonal antibodies, and DNA probes. Whether pathogenicity is a genotypic trait or can be changed by environmental influences has not been resolved. Exchange of genetic material between strains of amebae can influence zymodeme patterns. Currently, detection of E. histolytica infections depends on examinations for ova and parasites and on serologic tests; however, the development of monoclonal antibodies and DNA probes specific for pathogenic zymodemes may be beneficial for clinical laboratory testing and therapeutic decisions when approved tests become available. A better understanding of the mechanisms of pathogenicity at the molecular level is evolving and should promote the development of vaccines and better target selection for therapeutic agents.     

Heterogeneity ofin vitro chemosensitivity in perioperative breast cancer cells to mitoxantroneversus doxorubicin evaluated by a microplate ATP bioluminescence assay

Summary Apart from clinical trials, mitoxantrone (MX) is rarely used in breast cancer (BC) due to the anticipated anthracycline cross-resistance. We have examined this drug versus doxorubicin (DOX) using data obtained fromin vitro microplate ATP tumor chemosensitivity assays (ATP-TCA) of BC cells which were derived from 55 chemotherapy-naive patients at time of primary surgery. Both drugs were tested at 6 different concentrations ranging from 6.25% to 200% peak plasma concentrationin vivo (PPC). Differences between DOX and MX observed for mean IC₅₀, IC₉₀, and a sensitivity index (SI) were not statistically significant.In vitro response rates were 44% for DOX and 52% for MX. 34 of 52 eligible assays (65%) showed comparable activity of both drugs whereas a lack of cross-resistance was observed in the remaining 18 (35%) tumors as indicated by differences for SI. Cumulative concentration-response plots of tumors respondingin vitro with a 50 percent or 90 percent tumor cell inhibition showed a strong dose-dependence for both DOX and MX at concentrations which normally can be achieved within clinical tumors (i.e. 6.25%-50% PPC). At higher concentrations, however, cytotoxicity of DOX and MX could not be improved by furtherin vitro dose escalation. Moreover, a substantial proportion of BC specimens (DOX: 48.1%; MX: 40.4%) did not experience a 90 tumor cell inhibition at 200% PPC. In conclusion,in vitro results obtained by ATP-TCA indicate that there is no cross-resistance between MX and DOX in a substantial proportion of BC patients. This may be clinically useful and suggests that combinations including MX should be tested in patients clinically resistant to DOX containing regimens. Since both drugs produced sigmoidal concentration-response curves, dose escalation beyond a certain point may not produce increased sensitivity.