Injectional anthrax at a Scottish district general hospital.

This retrospective, descriptive case-series reviews the clinical presentations and significant laboratory findings of patients diagnosed with and treated for injectional anthrax (IA) since December 2009 at Monklands Hospital in Central Scotland and represents the largest series of IA cases to be described from a single location. Twenty-one patients who fulfilled National Anthrax Control Team standardized case definitions of confirmed, probable or possible IA are reported. All cases survived and none required limb amputation in contrast to an overall mortality of 28% being experienced for this condition in Scotland. We document the spectrum of presentations of soft tissue infection ranging from mild cases which were managed predominantly with oral antibiotics to severe cases with significant oedema, organ failure and coagulopathy. We describe the surgical management, intensive care management and antibiotic management including the first description of daptomycin being used to treat human anthrax. It is noted that some people who had injected heroin infected with Bacillus anthracis did not develop evidence of IA. Also highlighted are biochemical and haematological parameters which proved useful in identifying deteriorating patients who required greater levels of support and surgical debridement.

Validation and clinical application of molecular methods for the identification of molds in tissue.

BACKGROUND: Invasive fungal infections due to less-common molds are an increasing problem, and accurate diagnosis is difficult. METHODS: We used our previously established molecular method, which allows species identification of molds in histological tissue sections, to test sequential specimens from 56 patients with invasive fungal infections who were treated at our institution from 1982 to 2000. RESULTS: The validity of the method was demonstrated with the establishment of a molecular diagnosis in 52 cases (93%). Confirmation of the causative organism was made in all cases in which a mold had been cultured from the tissue specimen. Less-common molds were identified in 7% of cases and appear to be an increasing problem. CONCLUSIONS: Our previously established method has proven to be of value in determining the incidence of invasive infection caused by less-common molds. Institutions should continue to pursue diagnosis of invasive fungal infections by means of tissue culture and microbiologic analysis.

Toxoplasmosis in bone marrow transplantation: a report of two cases and systematic review of the literature.

Toxoplasma infection represents a rare but often fatal complication in bone marrow transplant (BMT) recipients. We report two cases of toxoplasmosis: one of successfully treated cerebral toxoplasmosis after peripheral blood stem cell transplantation, and a fatal case of pulmonary toxoplasmosis in a BMT recipient. We have systematically reviewed the 110 published cases of toxoplasmosis following BMT. We analyzed the pre-transplant and clinical features of BMT recipients developing toxoplasmosis, together with the diagnostic procedures used and treatment given. By univariate and multivariate statistical analysis we analyzed the risk factors for diagnosis (during life vs post-mortem) and Toxoplasma-related mortality. Ante-mortem diagnosis was made in 47% of cases. Site of infection (P = 0.02; odds ratio 10.8), presence of symptoms at onset (P = 0.01) and conditioning regimen (P = 0.04) were factors influencing whether the diagnosis was made before or after death. Overall mortality rate was 80% and that attributed to toxoplasmosis was 66%. Variables influencing outcome were: site of infection (P = 0.02; odds ratio 5.28), day of onset (P = 0.04) and conditioning regimen (P = 0.04). Underlying disease (P = 0.02; odds ratio 9.45), among patients diagnosed before death, was the most significant factor influencing outcome.

Fatal invasive cerebral Absidia corymbifera infection following bone marrow transplantation.

A 56-year-old dairy farmer received a fully HLA matched unrelated donor marrow transplant for high risk CML in chronic phase. His early post-transplant course was complicated by a series of massive intracerebral bleeds and by sepsis related to a malignant otitis externa. The microbial pathogen isolated from ear swabs was found to be Absidia corymbifera, but CT scan at the time showed no intracerebral extension. Despite neutrophil engraftment and aggressive antifungal management he succumbed. Autopsy revealed invasion of Absidia into the brain from the ear. We speculate that colonisation by Absidia resulted from occupational exposure.

In situ hybridisation of albumin mRNA in normal liver and hepatocellular carcinoma with a digoxigenin labelled oligonucleotide probe.

AIMS: To study the localisation and distribution of albumin mRNA in normal liver and hepatocellular carcinoma by in situ hybridisation with an oligonucleotide probe. METHODS: A 51 base oligonucleotide was synthesised from a sequence at the 5' end of the human albumin gene and the probe was labelled at its 3' end with digoxigenin 11-dUTP. Formalin fixed, wax embedded sections of liver biopsy specimens were used to study the localisation and distribution of albumin mRNA. After in situ hybridisation the bound probe was visualised using a digoxigenin antibody conjugated with alkaline phosphatase. RESULTS: In normal liver albumin mRNA was detected in hepatocytes and no positive signal was observed in biliary epithelium, vascular endothelium, or Kupffer cells. In 75% (9/12) of the hepatocellular carcinomas studied a positive hybridisation signal was observed in tumour cells. CONCLUSIONS: Albumin mRNA can be detected in sections of formalin fixed, wax embedded liver, a digoxigenin labelled probe is ideally suited for in situ hybridisation of liver because there is no background from the detection system. The identification of albumin mRNA may be a useful marker of hepatocellular carcinoma, and the demonstration of albumin mRNA by in situ hybridisation overcomes the potential background problem associated with albumin immunohistochemistry.

Reduction in urinary oxalate values by allopurinol.

A variety of substances have been used to prevent recurrence of stone disease. Recently there has been considerable interest in the ability of allopurinol to prevent stone recurrence. This article discusses the effect of allopurinol on the urinary oxalate in a group of stone formers. A significant reduction was obtained especially in subjects in whom the blood urate levels exceeded 300 mumol./L. Possible mechanisms explaining the mode of action of the drug are discussed.

Whole body calcium deficit in cadmium-exposed workers with hypercalciuria.

Whole body elemental composition of 15 men occupationally exposed to cadmium was determined by total body in vivo neutron activation analysis and whole body counting. A significant deficit (P less than 0.01) in calcium was observed, compared with two groups of control subjects. The deficit increased with length of time exposed to cadmium.

Fertility and tubal morphology after microsurgical removal of segments of the porcine fallopian tube.

A controlled study was carried out in the pig to determine the effect on fertility of resecting either the ampullary-isthmic junction or the isthmus. In both treated groups, the nidation index was lower than that in the control animals. The index was not significantly lower in the isthmic resection group than in the ampullary-isthmic junction group. The implications of these findings in terms of fallopian tube physiology and human tubal reconstructive surgery are discussed.

Extra-anatomic urinary diversion.

In five patients with chronic intractable ureteral obstruction, a fine-bore nephrostomy tube was placed in a subcutaneous tunnel to drain the kidney without an external appliance. Good quality of life was achieved for 6 months to 2 years. When conventional intraluminal stents cannot be used, consideration should be given to subcutaneous diversion rather than long-term nephrostomy tubes.

Clear cell sarcoma of the kidney in an adult.

An adult case of clear cell sarcoma of the kidney is described. The clinical, histological, immunohistochemical and electron microscopical features of the tumour are described.

Distal blind-ending branch of Y ureteral duplication under surgical treatment.

A case of distal blind-ending branch of bifid ureter in a woman is presented. The complications caused by this anomaly have driven us to surgery, which was the only successful treatment for this patient.

Crystal-associated cholangiohepatopathy and photosensitisation in lambs.

Four outbreaks of hepatogenous photosensitisation occurred in weaned lambs in north eastern Victoria during the summers of 1985 and 1986. Attack rates varied between 7% and 43% and case fatality rates between 60% and 71%. Clinical signs included photosensitisation and jaundice. Serum biochemistry suggested hepatobiliary and hepatoparenchymal damage with impaired renal function. At necropsy livers were an ochre colour and kidneys a mottled brown to khaki. Histopathologically, needle-shaped to lenticular clefts were observed in and around bile ducts and in hepatocytes, hepatic sinusoidal macrophages and renal tubules. Optically active rhomboidal crystals were present in bile sediments. Panicum schinzii was identified as a possible cause in 2 of the 4 outbreaks. The clinical disease was reproduced in 2 of 6 lambs grazed on a toxic paddock. The disease was indistinguishable from geeldikkop except for the fact that Tribulus terrestris was not present on any of the 4 farms.

Factors influencing the success of microsurgical tuboplasty for sterilization reversal.

A series of microsurgical sterilization reversal procedures has been analysed. It demonstrates that better pregnancy rates are achieved where mechanical sterilization techniques have resulted in only short lengths of tubal destruction. Isthmo-isthmic anastomoses have the most favourable outcome.

PIP: This study analyzed a series of 147 microsurgical tuboplasties performed for purposes of sterilization reversal. 87 (59%) of the women achieved at least 1 viable uterine pregnancy, 5 (3%) experienced an ectopic pregnancy, and 6 (4%) had a spontaneous abortion. Over 75% of the successful pregnancies in the series were conceived within 1 year of sterilization reversal. Sterilization techniques represented in this series included Pomeroy (71 cases), diathermy (44), ring (18), clip (7), and fimbriectomy (7). The highest success rates were associated with techniques involving the Hulka clip (86%) or the Fallope ring (78%). Reversals from the Pomeroy (56%) and tubal diathermy (59%) techniques less frequently resulted in viable pregnancies. Previous fimbriectomy procedures were successfully reversed in only 1 case (14%). Isthmo-isthmic anastomosis resulted in a viable pregnancy in 83% of cases compared to 57% for amp-isthmic and 55% for amp-cornual anastomoses. 102 (69%) of the tuboplasties were bilateral, and 66 (65%) of these procedures were successful compared to 47% of the unilateral procedures. Tube lengths of less than 4 cm were associated with somewhat depressed pregnancy rates. These results highlight the significance for the type of sterilization procedure on the prospects for pregnancy following reversal sutgery. Mechanical procedures that produce minimal damage to the isthmus of the tube are the most favorable.

ABH secretor status in patients with bladder tumours.

The ABO blood groups and secretor status of a group of patients with bladder tumours were investigated and compared with those of a group of patients of a similar age suffering from a variety of genito-urinary diseases. Some of the control patients were known to have been exposed to potential carcinogens, and the findings in this group were analysed separately. No significant differences were found when comparisons of these three groups of patients were made.

Tubal sterilization--its aftermath.

A review of the long-term sequelae of female sterilization has been made. There is little support for the belief that the procedure leads to an increased incidence of menstrual problems, psychological difficulties, or subsequent surgery. All presently available techniques occasionally fail. The rate is not significantly greater when mechanical methods are employed. The proportion that are ectopic, however, is greatly increased following tubal diathermy. Reversal requests per 1,000 women sterilized are numerically higher than failure rates. Success rates following reversal are far higher when mechanical techniques have been used.

Indications for the treatment of tubal infertility patients by microsurgery or in vitro fertilization.

Pregnancy rates following the treatment of tubal infertility patients by microsurgery or in vitro fertilization (IVF) have been analysed. The results indicate that microsurgery should be the primary treatment for the following: (a) Sterilization reversal (except fimbriectomies or tubes of less than 3cm length); (b) Incomplete lateral tubal occlusion; (c) Medial tubal occlusion; (d) Peritubal or periovarian adhesions. IVF is indicated as the primary treatment for tubal infertility patients when investigation demonstrates (a) Total lateral tubal occlusion; (b) Previous fimbriectomy sterilizations; (c) Reconstructable tubal length of less than 3cm.

Quality of life after a Marshall-Marchetti-Krantz procedure for stress urinary incontinence.

PURPOSE: We assessed the long-term results of the Marshall-Marchetti-Krantz procedure. MATERIALS AND METHODS: A total of 151 case records was reviewed and a questionnaire was mailed to patients to estimate the success rate and patient satisfaction. RESULTS: The response rate was 67.3% (101 replies). The overall success rate was 72.8% (mean followup 51.5 months). The success rates in patients with irritative symptoms and pure stress incontinence were 65% and 82.6%, respectively. The procedure was equally effective for recurrent stress incontinence. CONCLUSIONS: The procedure is characterized by a high success rate 5 years postoperatively. The method of review, based on a mailed questionnaire, appears to be more objective than conventional reviews but further improvements may increase the accuracy.