CT appearance of intercostal nerve neurotisation.

A nerve transfer or neurotisation procedure is performed to repair damaged nerves, in particular those of the brachial plexus following an avulsion injury. An intercostal to phrenic nerve transfer to re-innervate the diaphragm in patients with high cervical spine injury has also been reported in the literature. We present the imaging finding in a 65-year-old female who had an intercostal nerve transfer for a damaged phrenic nerve following a resection for a non-small cell lung carcinoma.

Endovascular treatment of chronic arterial mesenteric ischemia: a changing perspective?

Endovascular treatment for chronic mesenteric ischemia is growing in popularity because of its lower periprocedural morbidity and mortality than open surgery. It is especially suitable for the high-risk surgical candidate and for those who have a poor nutritional state, although endovascular surgery may not be possible in patients with ostial occlusions or heavily calcified vessels. A positive response to angioplasty is helpful to secure a diagnosis in patients with slightly atypical symptoms. There are little data at present to suggest that primary stenting is better than angioplasty alone, but insertion of a stent may be valuable as a rescue procedure following dissection, vascular recoil, or thrombosis during angioplasty. The superior mesenteric artery is probably the most important vessel to treat but, where this is impossible, celiac or inferior mesenteric artery dilatation may have therapeutic benefit. However, there is some evidence at present favoring multiple, as opposed to single-vessel, angioplasty or stenting. Long-term patency is better after mesenteric bypass, which may be preferred in the younger and fitter patient. Treatment of the celiac artery compression syndrome is primarily surgical, but stent insertion may have a role as a secondary procedure where there is a residual stenosis after median arcuate ligament division.

Treatment of steal syndrome complicating a proximal arteriovenous bridge graft fistula by simple distal artery ligation without revascularization using intraoperative pressure measurements.

This case report describes the treatment of a patient with a steal syndrome complicating a brachioaxillary prosthetic bridge graft AV fistula by simple ligation of the brachial artery beyond the fistula. Intraoperative pressure measurements showed concomitant distal revascularization to be unnecessary.

Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection.

BACKGROUND: Conventional treatment of mycotic aneurysms or graft infections of the aortoiliac segment by in situ or extra-anatomic prosthetic reconstruction has a high mortality and morbidity rate, with a substantial risk of persistent graft infection. The use of autologous vein may reduce this. METHODS: Eleven patients with suprainguinal arterial infections including two with mycotic aortic aneurysms, four with aortic graft infections, four infected femorofemoral grafts and an infected axillofemoral graft were treated by debridement and in situ reconstruction with autologous superficial femoropopliteal vein. All patients received appropriate antibiotic therapy and were followed by regular postoperative duplex imaging. Preoperative femoral vein duplex imaging was performed in eight of the 11 patients. RESULTS: Ten of the 11 patients survived with a functioning graft and without limb loss or evidence of infection at 4-33 months. One patient died from myocardial infarction after operation. Three patients had minor swelling of one leg. Four patients required subsequent angioplasty of anastomotic stenoses detected by duplex surveillance. CONCLUSION: Superficial femoropopliteal vein is an excellent conduit for suprainguinal reconstruction in the presence of infection. Duplex imaging is useful for confirming the suitability of deep veins for use as a graft and for postoperative surveillance.

Selective induction of protective MHC class I-restricted CTL in the intestinal lamina propria of rhesus monkeys by transient SIV infection of the colonic mucosa.

The identification of mucosal immune responses required for protection against sexual transmission of HIV is essential for the development of an efficacious vaccine. To gain a better understanding of these responses, we have characterized the immune responses in the lamina propria (LP) and epithelium of the jejunum, the mesenteric lymph nodes, and peripheral blood (PBMC) of 11 rhesus monkeys following colonic exposure to two molecular clones of SIV. Two monkeys had no signs of infection. Three monkeys became persistently infected. Transient infections, characterized by the sporadic detection of virus in the periphery and/or detection of SIV-specific immune responses in either the gut-associated tissues or PBMC, were induced in six of the monkeys. One persistently infected and three transiently infected monkeys had high levels of SIV env-specific MHC class I restricted CTL in the jejunal LP. Another transiently infected monkey had SIV-specific IgA secreting B cells in the LP. Three or six months postexposure, these animals and four naive controls were challenged intracolonically with the heterologous primary isolate, SIV/DeltaB670. All four monkeys with strong SIV env-specific MHC-restricted CTL in the LP were protected, whereas none of the naive controls or the remaining seven monkeys with little or no CTL in the LP were protected. These experiments provide the first direct evidence that transient mucosal infection can induce SIV-specific immunity that remains localized to the gut-associated tissues. Furthermore, a strong correlation between SIV env-specific MHC-restricted CTL in the LP and protection against colonic mucosal challenge was observed.

Postoperative laboratory and imaging investigations in intensive care units following coronary artery bypass grafting: a comparison of two Canadian hospitals.

OBJECTIVES: To compare the utilization and cost of common laboratory and imaging tests following admission to the intensive care unit (ICU) after coronary artery bypass surgery in two hospitals. The hospitals use different strategies to order tests postoperatively: one hospital uses a mandated protocol while the other does not. DESIGN: Demographic and testing data were prospectively collected in both hospitals as part of an ongoing ICU management program. Thirteen commonly performed laboratory tests or imaging procedures were compared. Average costs for each test were calculated, and utilization and cost of testing were compared per admission and per day in ICU. SETTING: Two tertiary care ICUs in different Canadian cities. PATIENTS: Consecutive patients admitted to ICU following coronary artery bypass graft surgery over a two-year period. MAIN RESULTS: There were 415 admissions to the Health Sciences Centre in Winnipeg, Manitoba and 504 to the Jewish General Hospital (JGH) in Montreal, Quebec. There were no demographic, length of stay or ICU mortality differences. A postoperative protocol for ordering investigations is used at JGH. Striking differences in test utilization were noted, with more investigations performed per admission and per unit day at JGH (P < 0.001). The average cost of the investigations was greater at JGH ($160 more per admission; $75 more per intensive care day). CONCLUSIONS: There are marked differences in the investigation pattern and costs for coronary artery bypass patients admitted to ICU in these hospitals. It is suggested that the benefits of frequent routine determinations of bloodwork, electrocardiograms and chest radiographs should be reevaluated in this patient population.

A comparison of opioid solutions for patient-controlled epidural analgesia.

Sixty patients took part in a randomised, double-blind study to compare the analgesic and side effects of three opioid-containing solutions for patient-controlled epidural analgesia following abdominal surgery. Patients in group 1 received a solution containing bupivacaine 0.125% with fentanyl 10 micrograms.ml-1, group 2 bupivacaine 0.125% with diamorphine 125 micrograms.ml-1, group 3 pethidine 2.5 mg.ml-1. All groups received 4 ml.h-1 background infusion and 3 ml boluses every 20 min if necessary. There were no significant differences between the groups in visual analogue scale pain scores (p = 0.537) or volumes of solution used at 24 h (p = 0.351) or 48 h (p = 0.105). Motor block was significantly higher in group 2 (p < 0.004) and pruritus occurred significantly less in group 3 (p < 0.05). We conclude that these three solutions produce equivalent analgesia but that pethidine 2.5 mg.ml-1 may be associated with fewer side effects.

Antineutrophil cytoplasmic autoantibodies in the immunodiagnosis of systemic necrotizing vasculitis.

If testing of ethanol-fixed neutrophils remains the most commonly used method to screen for ANCA. C-ANCA is highly sensitive and specific for Wegener's granulomatosis if strict criteria in defining this IF pattern are followed. P-ANCA is not specific for MPO-ANCA, when used as a screening test. Because of the increasing recognition of atypical cytoplasmic staining patterns and the lack of specificity of nuclear staining of neutrophils for MPO-ANCA, confirmatory testing by ELISA is advisable in all cases of atypical neutrophil cytoplasmic staining and in all cases of neutrophil nuclear or perinuclear staining.

Haemophilus influenzae infection of human respiratory mucosa in low concentrations of antibiotics.

We examined the effects of 0.25 and 0.5 minimal inhibitory concentrations (MIC) of amoxicillin, loracarbef, and ciprofloxacin on the interaction of a clinical isolate of nontypable Haemophilus influenzae (NTHi) with human adenoid organ culture. Adenoid tissue was embedded in agar so that only the mucosal surface was exposed. Minimum essential medium containing NTHi with or without antibiotics was added to the organ culture and incubated with 5% CO2 at 37 degrees C for 24 h. The organ cultures (n = 6) were assessed for several parameters by light microscopy (LM) and transmission electron microscopy (TEM). Bacterial viable counts after 24 h were not significantly different in all organ cultures. Compared with uninfected controls at 24 h, infection with NTHi caused significant (p < 0.05) damage to epithelium as assessed by LM: reduced ciliary beat frequency (CBF), disruption of epithelium integrity, and reduced number of ciliated sites. TEM showed extrusion of cells from the epithelial surface, loss of cilia from ciliated cells, cytoplasmic blebbing, and mitochondrial damage. In the presence of 0.25 and 0.5 MIC of all three antibiotics, the mucosal damage was significantly less (p < 0.05). We conclude that in the presence of sub-MIC levels of amoxicillin, loracarbef, and ciprofloxacin, NTHi infection causes less functional (CBF) and structural damage.

Is there a need for improved pharmacy services to the operating theatre?

A study to assess the control and handling of drugs within an operating theatre complex (10 theatres) of an 850-bed hospital, has revealed the presence of unusable medication and thus highlighted the need for improved pharmacy services. The aims and objectives of the pharmacy department to enhance such services included improvement of drug control of stock medication and the introduction of clinical pharmacy services within the operating theatre. To undertake this, three systems were evaluated with reference to systems already in use in the U.S.A. Operating theatre visits by a clinical pharmacist, coupled with the expansion of the existing drug distribution service, were identified as the most cost-effective methods that would allow the objectives to be met. Consequently, this has now been implemented within the operating theatre complex.

Policy for controlling pain after surgery: effect of sequential changes in management.

OBJECTIVE: To observe the effects of introducing an acute pain service to the general surgical wards of a large teaching hospital. DESIGN: A study in seven stages: (1) an audit of current hospital practice succeeded by the sequential introduction to the general surgical wards of (2) pain assessment charts; (3) an algorithm to allow more frequent use of intramuscular analgesia; (4) increased use of local anaesthetic techniques of wound infiltration and nerve blocks; (5) an information sheet for patients about postoperative pain; (6) the introduction of patient controlled analgesia; (7) a repeat audit of hospital practice. Data were collected on each patient 24 hours after operation. SETTING: University Hospital of Wales, which has both district general and tertiary referral functions. PATIENTS: 2035 patients over nine months from all surgical specialties (excluding cardiac) at the hospital. General surgical operations were studied in detail and separated into major, intermediate, and minor for data collection. MAIN OUTCOME MEASURES: A change in the median visual analogue pain scores 24 hours after surgery for pain during relaxation, pain on movement, and pain on deep inspiration at each stage of the study. RESULTS: There was a reduction in median visual analogue scores during the study. The median (95% confidence interval) scores for pain during relaxation decreased from 45 (34 to 53) in stage 1 to 16 (10 to 20) in stage 7 for major surgical procedures. Pain on movement decreased from 78 (66 to 80) to 46 (38 to 48), and pain on deep inspiration decreased from 64 (48 to 78) to 36 (31 to 38). The reductions in median scores for intermediate and minor operative procedures showed similar patterns. CONCLUSIONS: The introduction of an acute pain service to the general surgical wards led to considerable improvement in the level of postoperative pain as assessed by visual analogue scores. Simple techniques of regular pain assessment and the more frequent use of intramuscular analgesia as a result of using an algorithm were particularly effective.

Antineutrophil cytoplasmic autoantibodies.

The identification of ANCA and their association with systemic vascular inflammation has become quite useful in both the diagnosis and management of patients with necrotizing vasculitic conditions. Primary autoantibody specificities have been identified, and many more await further characterization. As with ANA, it is highly probable that ANCA will not only complement patient care, but will provide means helpful in exploring the molecular structures and biochemical pathways within granulocytic phagocytes.

Simple method of monitoring colonising microbial load in chronic bronchial sepsis: pilot comparison of reduction in colonising microbial load with antibiotics given intermittently and continuously.

Aerobic and anaerobic culture of sputum on selective bacteriological media, combined with a new method of plating and plate reading, permitted rapid identification and quantitation of three genera of bacteria commonly associated with chronic bronchial sepsis (Haemophilus spp, Pseudomonas aeruginosa, and Staphylococcus aureus) and avoided time consuming serial dilution of sputum and subculture of organisms. The accuracy of this new technique was assessed in patients with chronic bronchial sepsis and was used to detect changes in the colonising microbial load of Haemophilus spp and Ps aeruginosa in patients with bronchiectasis receiving one of three different antibiotic regimens: intermittent seven day courses of amoxycillin for exacerbations; or a six month course of continuous oral or nebulised amoxycillin. The colonising microbial load of Haemophilus spp was reduced only temporarily (+++ to ++) after each intermittent course of antibiotic, but a sustained and greater reduction in the colonising microbial load of both Haemophilus spp (+++ to +) and antibiotic resistant P aeruginosa (+++ to +) was seen during both continuous treatments. Sputum purulence decreased in parallel with colonising microbial load, reflecting a reduction in host inflammatory response to the colonising microbial load.

Selective medium that distinguishes Haemophilus influenzae from Haemophilus parainfluenzae in clinical specimens: its value in investigating respiratory sepsis.

A medium is described, which is selective for the haemophilus genus and also distinguishes between the species Haemophilus influenzae and Haemophilus parainfluenzae isolated in primary culture from clinical material.

Monoclonal antibody analysis of lipopolysaccharide from Neisseria gonorrhoeae and Neisseria meningitidis.

A hybridoma produced by the polyethylene glycol fusion of the NS-1 variant of the P3x63Ag8 BALB/c plasmacytoma to splenocytes harvested from a BALB/c mouse immunized with whole gonococci was found to be producing antibody to a common region on gonococcal lipopolysaccharide (LPS). Enzyme-linked immunosorbent assay inhibition systems were established by utilizing this antibody, designated 3F11, and 100% inhibition occurred with both LPS and the LPS-LPS and LPS-derived polysaccharides partially inhibited the enzyme-linked immunosorbent assay, whereas similar preparations isolated from Escherichia coli O:111, the J-5 mutant of this strain, and Salmonella minnesota Re595 failed to inhibit the assay. Studies utilizing whole gonococcal strains 4505 and the isogenic variant 4505r, which lacks both the LPS serotype and common determinants as inhibitors, demonstrated that the determinant recognized by the 3F11 antibody was present on the surface of 4505 and absent on 4505r. Inhibition studies were performed with beta-glucose, beta-galactose, D-glucosamine, D-galactosamine, heptose, 2-keto-3-deoxyoctanoate, N-acetylglucosamine, N-acetylgalactosamine, alpha-lactose, and beta-lactose. Complete inhibition of the enzyme-linked immunosorbent assay occurred with D-galactosamine, and partial inhibition was achieved with both alpha-lactose and beta-lactose. Based on these observations, the 3F11 antibody recognizes a site common to gonococcal LPS which is partially shared by meningococcal LPS. The chemical structure of the determinant appears to be a D-galactosamine-O-D-galactopyranosyl-(1-4)-D-glucopyranose. Additional specificity may be conferred by the steric relationship of the determinant on the intact LPS.