Carbon dioxide embolism during laser endometrial ablation.

A patient undergoing endometrial ablation with an Nd-YAG laser, a carbon-dioxide-cooled coaxial fibre and an exposed fibre tip suffered a carbon dioxide embolism resulting in cardiac arrest. A full recovery was made with no neurological deficit.

Isoenzyme comparison of axenic Giardia lamblia strains.

We obtained isoenzyme patterns by polyacrylamide gradient gel electrophoresis (PGGE) of water-soluble protein fractions prepared from trophozoites of 11 axenic G. lamblia strains. The strains were isolated from animals and humans (both symptomatic and asymptomatic) from various geographic locations. Isoenzymes were also separated by isoelectric focusing. Of 12 enzymes attempted, eight exhibited well-defined and reproducible isoenzyme patterns by PGGE, based on which the strains were grouped into four zymodemes. Although the 11 strains were grouped into four zymodemes based on PGGE, no correlation between zymodeme and the known characteristics of the strains existed. Thus, a high degree of characteristic sharing appears to occur among genetically different G. lamblia strains.

Problems in day care surgery.

In-patient admission represents a failure of a day care service. The hospital records of 105 patients transferred from the day ward to the in-patient wards were studied retrospectively. Of 2,039 patients treated in the day care ward, 105 (5%) required in-patient admission over a 12 month period. Of these 105 admissions, 17% did not fulfil the criteria for day care patients, 46% had surgical problems, and 35% anaesthetic-associated problems. The in-patient admission rate could be reduced by improved out-patient selection of cases, use of a separate day care theatre, increased use of local anaesthetic techniques, reduction in the use of parenteral opioids, the use of simple oral analgesics or non-steroidal anti-inflammatory agents as pre-emptive analgesia and a wider use of propofol as an induction agent which provides superior recovery from anaesthesia.

Evaluation of a commercially available enzyme-linked immunosorbent assay for Giardia lamblia antigen in stool.

The lack of a quick, simple, and inexpensive diagnostic test has limited the ability of public health officials to rapidly assess and control outbreaks of Giardia lamblia in child day-care centers. We evaluated the performance of a commercially available enzyme-linked immunosorbent assay (ELISA) for the detection of a G. lamblia-associated antigen in stool. Stool specimens were collected from the diapers of 426 children attending 20 day-care centers, fixed in 10% Formalin and polyvinyl alcohol, and examined by microscopy by Formalin concentration and trichrome staining techniques. Specimens were also tested visually and spectrophotometrically by ELISA. Of 99 tests positive by microscopy, 93 were visually positive by ELISA (sensitivity, 93.9%). Of 534 tests negative for G. lamblia by microscopy, 32 (6.0%) were ELISA positive. However, on the basis of examination of multiple specimens from the same child, none of these could be considered false-positive ELISAs; the specificity of the ELISA was therefore 100%. The sensitivity of both microscopy and ELISA improved as the number of specimens per child increased. An optical density value of greater than 0.040 was 98.0% sensitive and 100% specific for G. lamblia. This ELISA, which appeared to be more sensitive for G. lamblia than did microscopic examination of stool, should be useful as an epidemiologic tool, particularly in day-care settings, and may also have a role in confirming clinical diagnoses of giardiasis.

Purification and characterization of Giardia lamblia antigens in the feces of Mongolian gerbils.

In a recent study, we identified Giardia lamblia 65- and 70-kDa antigens in the feces of infected Mongolian gerbils. The 65-kDa antigen was from a strain isolated from a human with symptoms of giardiasis, and the 70-kDa antigen was from a strain isolated from a human with no symptoms of giardiasis. In this study, we used preparative electrophoresis and electroelution techniques to purify these antigens to a degree which showed a single discrete protein band on silver-stained polyacrylamide gels. By enzyme-linked immunoelectrotransfer blot, common epitopes on the 65- and 70-kDa antigens were indicated by their cross-reactivity with rabbit anti-65-kDa and anti-70-kDa sera. By indirect immunofluorescence assay, the cysts and trophozoites of the two strains cross-reacted with these sera. Of seven lectins tested, only concanavalin A bound to the 70-kDa antigen, suggesting a glycoprotein, and it possessed a low isoelectric point as assessed by preparative isoelectric focusing. Molecular mass estimations of these antigens by sodium dodecyl sulfate-polyacrylamide gradient gel electrophoresis were similar to the 65- and 70-kDa estimations obtained by native polyacrylamide gradient gel electrophoresis. Although the 65- and 70-kDa antigens proved to be resistant to 100 degrees C heat and stable in storage for up to 25 months at -20 degrees C, neither appeared to be the same as a fecal G. lamblia antigen with similar molecular mass found by other investigators. This suggests that variable G. lamblia antigens may be found in the feces of infected humans.

Antigenic variation of Giardia lamblia in the feces of Mongolian gerbils.

Enzyme-linked immunoelectrotransfer blot was used to study variations in Giardia lamblia antigens in extracts of feces from infected Mongolian gerbils. A 65-kilodalton antigen was found in feces that contained strain WB (ATCC 30957) cysts and in axenic culture of strains WB and CDC:0284:1 that contained trophozoites. The 65-kilodalton antigen from trophozoites of both strains was membrane associated. A 70-kilodalton antigen was found in feces that contained strain CDC:0284:1 cysts. It was persistent in 16 fecal collections and may be strain specific. Similar variations in antigens may occur in human feces. Coproimmunodiagnostic assays that use monoclonal antibodies will have to include all varieties of G. lamblia antigens present in the feces of giardiasis patients.

Sodium bicarbonate as a single dose antacid in obstetric anaesthesia.

Gastric pH and volumes were measured in 84 women who had general anaesthesia for emergency Caesarean section. Forty-eight received only 20 ml 8.4% sodium bicarbonate immediately before induction of anaesthesia and 36 ranitidine 150 mg 6-hourly during labour in combination with NaHCO3. Gastric pH was less than 2.5 in four women who received only bicarbonate. All aspirates from the ranitidine plus bicarbonate group had a pH greater than 2.5. Mean volumes of gastric content aspirated were 87 (SD 87.4) and 60 (SD 46.3) ml for the bicarbonate alone and bicarbonate plus ranitidine series respectively. These differences were not significant. Twenty millilitres of 8.4% NaHCO3 cannot be recommended as a single dose antacid for emergency Caesarean section. Ranitidine plus bicarbonate is considered a reliable antacid regimen to ensure elevation of gastric pH to safe levels.

A pharmacokinetic study of midazolam in paediatric patients undergoing cardiac surgery.

Midazolam 0.3 mg kg-1 was given as a single dose to three groups of children undergoing cardiac surgery to determine its pharmacokinetic profile in this situation. The first group, undergoing closed heart surgery, received the midazolam during the operation. The other groups underwent cardiopulmonary bypass (CPB) with and without complete circulatory arrest. Mean clearance was 512 ml kg-1 h-1 and mean elimination half-lives were 3.3 h following CPB, with a tendency to a higher clearance in those children who had not undergone bypass. In a subsequent part of the study, 10 children received an infusion of midazolam 0.05 mg kg-1 h-1, in combination with intermittent doses of morphine, in the postoperative period. Mean plasma midazolam concentrations consistent with adequate sedation were 80-100 ng ml-1 during the infusion. One child who had not undergone CPB had very low plasma concentrations of midazolam with the same rate of infusion, consistent with the tendency for higher clearance in this group in the bolus pharmacokinetic study.

Diclofenac sodium for post-tonsillectomy pain in children.

Diclofenac sodium was assessed as an analgesic for postoperative pain following paediatric tonsillectomy in a randomised double blind trial. In a comparison made with both a pethidine and a control group diclofenac was shown to be an effective analgesic. No significant difference in analgesic efficacy was demonstrated between the two drugs, although patients who received diclofenac tended to be less drowsy postoperatively than those who received pethidine. There were no significant differences between the two drugs in respect of time to awaken from anaesthesia or incidence of postoperative vomiting.

Comparison of sufentanil-oxygen and fentanyl-oxygen anaesthesia for coronary artery bypass grafting.

Haemodynamic variables were compared in 40 adults undergoing coronary artery bypass grafting during anaesthesia induced with either sufentanil 5 micrograms kg-1 or fentanyl 25 micrograms kg-1 in combination with pancuronium 0.1 mg kg-1. Further doses of sufentanil 2.5 micrograms kg-1 or fentanyl 12.5 micrograms kg-1 were given before skin incision and again before sternotomy. All patients were receiving beta-adrenoceptor blocking therapy. Satisfactory induction of anaesthesia was produced with both drugs and opioid supplementation prevented any marked haemodynamic response to skin incision and to sternotomy. Following induction of anaesthesia, sufentanil produced the greater decrease in mean arterial pressure and left ventricular stroke work index which continued throughout the study. This suggests that, in the doses used in this study, sufentanil is preferable to fentanyl in patients with coronary artery disease.

High-resolution polyacrylamide gradient gel electrophoresis (PGGE) of isoenzymes from five Naegleria species.

High-resolution polyacrylamide gradient gel electrophoresis (PGGE) was used to separate isoenzymes of 12 Naegleria strains: one N. australiensis, two N. lovaniensis, one N. jadini, two N. gruberi isolated from environmental samples, and six N. fowleri strains isolated from patients with primary amoebic meningoencephalitis. Of the eight enzymes studied, seven showed zymograms with interspecific variation that identified all the species tested. Although the six N. fowleri strains were biochemically the most homogeneous, they showed intraspecific isoenzyme variation that allowed them to be grouped into four zymodemes. The PGGE technique, which separates isoenzymes by their molecular shape, is both sensitive and economical. It offers an addition or an attractive alternative to isoelectric focusing which has commonly been used to aid species identification of Naegleria by separating isoenzymes by their isoelectric point.

A fast electrophoretic isoenzyme technique for the identification of invasive and non-invasive Entamoeba histolytica and "E. histolytica-like" organisms.

Cellulose acetate electrophoresis (CAE) was used to separate glucosephosphate isomerase, hexokinase, malic enzyme, and phosphoglucomutase extracted from invasive and non-invasive Entamoeba histolytica and "E. histolytica-like" organisms. Each of these morphologically similar organisms possessed a unique CAE isoenzyme profile that can be used as an aid in their identification. The CAE technique used to obtain these isoenzyme profiles is rapid, simple, and economical, and it requires neither specialized training nor elaborate equipment.

Human serologic response to subcellular antigens of Trichomonas vaginalis.

Trichomonas vaginalis organisms were processed by differential centrifugation to yield defined subcellular fractions. The various fractions were processed by methods to enhance solubility of membranes and other components. The soluble materials were analyzed for immunogenicity by a quantitative kinetic enzyme-linked immunosorbent assay (k-ELISA) and the enzyme-linked immunoelectrotransfer blot (EITB) technique using human patient serum. The principal antibodies in the human serum were directed toward cytosol components, not against membrane components, although all fractions contained multiple antigenic moieties.

Midazolam sedation following open heart surgery.

Midazolam given as hourly intermittent injections was compared with the same dose given by infusion for postoperative sedation in patients after cardiopulmonary bypass. A stable concentration was rapidly attained with the infusion whereas 6-8 h was required to attain stable plasma (trough) concentrations in the intermittent injection group. Plasma concentrations decreased rapidly to low values within 6 h of discontinuation of therapy. High plasma concentrations and a long (16 h) half-life were noted in one patient who may be a slow metabolizer of the drug.

Combination treatment with ranitidine and sodium bicarbonate prior to obstetric anaesthesia.

The gastric pH and volume were measured in 175 patients undergoing elective, and 313 undergoing emergency, obstetric procedures. Ranitidine 150 mg was administered orally every 6 hours in labour and at least 2 hours before elective Caesarean section. Patients received 20 ml of 8.4% sodium bicarbonate orally immediately prior to induction of anaesthesia. The combination of ranitidine and sodium bicarbonate produced marked alkalinisation of gastric contents (mean pH 8.9). The administration of sodium bicarbonate pre-operatively in patients who received ranitidine less than 2 hours before operation led to satisfactory elevation of gastric pH. Only four patients had a gastric pH less than 2.5, one patient refused any medication, two received only ranitidine and one patient had a long interval from administration of bicarbonate to aspiration of gastric contents. Gastric volumes were high in labouring patients (mean 84 ml) despite administration of ranitidine. The effectiveness of sodium bicarbonate as a single dose antacid therapy prior to obstetric anaesthesia requires further study.

Analysis of antigens from membrane and soluble fractions of Entamoeba histolytica.

Axenic cultures of Entamoeba histolytica strains HK-9, HM-1, and Rahman were fractionated to provide plasma membranes, internal, vesiculated membranes, and a soluble cytosol. Each particulate fraction was solubilized and all fractions were analyzed by techniques designed to demonstrate molecular complexity and serologic reactivity. The cytosol contained more antigenic moieties than either membrane fraction; however, the antigens associated with the membranes had very high reactivity and lower nonspecific activity than the cytosol.

Isoenzyme analysis of Babesia microti infections in humans.

We used high-resolution polyacrylamide gradient gel electrophoresis (PGGE) to separate four babesial enzymes to aid in the identification of two Babesia microti isolates established in hamsters. The isolates were compared to two different hamsters passages of the "Gray" strain. All isoenzymes patterns from the two isolates and the "Gray" strain were similar except glucose phosphate isomerase (GPI) from one of the "Gray" strain passages. It showed a polymorphic GPI pattern as opposed to a monomorphic GPI pattern seen in the other "Gray" strain passage and the two isolates. The observed differences suggested that some population of B. microti are capable of having polymorphic GPI, that the "Gray" strain originally contained (and may still contain) a heterogeneous population of B. microti, and that the population possessing polymorphic GPI was selected over that with monomorphic GPI. This information was obtained by a PGGE method that eliminated hemoglobin from gels and allowed, for the first time, detection of babesial leucine amino peptidase (LAP) and isocitrate dehydrogenase (IDH). In addition, this method provided molecular weight estimations on babesial GPI, LAP, IDH, and glutamate dehydrogenase (GDH), and it proved useful in the identification and characterization of the B. microti isolates.

Microvolume, kinetic-dependent enzyme-linked immunosorbent assay for amoeba antibodies.

We describe a microvolume enzyme-linked immunosorbent assay based on enzyme rate kinetics. Antigens from Entamoeba histolytica were adsorbed in wells of disposable polystyrene strips containing 12 flat-bottom wells. After exposure to the serum of a patient and peroxidase-labeled anti-human immunoglobulin G, the rate of color change in specific substrate was determined by eight sequential readings of individual wells over a 2-min period with a microcomputer-controlled model MR-600 automated plate reader. The changes in absorbance readings were converted to slope values for each well by the microcomputer. Thus, 12 samples were read, and results were printed in ca. 3.5 min. Assay conditions are described and data are presented to show that this assay is quantitative for antibody and antigen concentration with a single-tube (well) dilution.

Isolation of two strains of Acanthamoeba castellanii from human tissue and their pathogenicity and isoenzyme profiles.

Two strains of amoebae, one (CDC:0180:1) from the lung tissue of a patient who died of granulomatous amoebic encephalitis and the other (CDC:0179:1) from the debrided tissue of a mandibular autograft, were isolated and identified as Acanthamoeba castellanii based on the morphological and immunofluorescent staining characteristics of the trophozoites and cysts. Both strains of amoebae caused cytopathic effects in mammalian cell cultures and destroyed the cell sheet. However, only the CDC:0180:1 strain, on intranasal instillation into mice, produced the disease manifested by ruffled fur and aimless wandering, followed by coma and death within 30 days. The CDC:0180:1 strain also differed consistently from CDC:0179:1 and another nonpathogenic A. castellanii strain (ATCC 30,011) in isoenzyme makeup, a dissimilarity which probably reflects its pathogenic potential.