Community-acquired Klebsiella pneumoniae liver abscess: an emerging infection in Ireland and Europe.

INTRODUCTION: Klebsiella pneumoniae has emerged as a predominant cause of community-acquired mono-microbial pyogenic liver abscess. This was first described in Taiwan and has been widely reported in Asia. This infectious entity has been described in Europe, with single case reports predominating. METHODS: We present three cases in one year from our institution in Ireland and review the European literature to date. RESULTS/CONCLUSION: Klebsiella pneumoniae invasive liver abscess syndrome is now emerging in Europe and notably is not restricted to individuals of Asian descent.

Double trouble--duplication of the gallbladder requiring repeat laparoscopic cholecystectomy.

Duplication of the gallbladder is a surprisingly common phenomenon. Clinically, these patients present with straightforward gallbladder pathologies. It is a challenging preoperative diagnosis on ultrasound, and most cases are diagnosed intra-operatively. We present a case of gallbladder duplication, where the patient presented with biliary colic, had a straightforward laparoscopic cholecystectomy, and then represented with biliary colic four years later.

Ultrasound-guided removal of Implanon devices.

Our study has shown that ultrasound-guided localisation and removal of Implanon rods is safe, practical and highly successful. Over a 4-year period, 119 patients had successful, uncomplicated removal of their subdermal devices.The technique is particularly useful for removal of the device when it is not palpable or when an attempt at removal of a palpable device has not been successful.

CT-guided bone biopsy: Initial experience with a commercially available hand held Black and Decker drill.

PURPOSE: To describe the use of a simple commercially available Black and Decker hand based drill in performing CT-guided bone biopsies. MATERIALS AND METHODS: Three international institutions were enrolled in the study. In each centre, a fellowship trained musculoskeletal radiologist directed the assessment of a hand based commercial drill for performing CT-guided bone biopsies. A specially designed component was engineered which allowed the connection of a standard bone biopsy set to a commercial drill. The component was distributed to the three centres involved. Over a 3-year period, data from all three institutions was collected. Information regarding technical success, diagnostic data and complication rates were all collated to assess the technical feasibility of this technique. RESULTS: In total 68 patients underwent bone biopsy using a hand held commercial drill. Technical success was achieved in 65 patients. Diagnostic material was obtained in 53 patients. Non-diagnostic material was obtained in 12 patients. Five out of the 12 patients with non-diagnostic material had repeat biopsies with diagnostic material obtained in 2 of these. No major complications occurred in any patient. CONCLUSION: CT-guided bone biopsy using a hand held commercial drill has a technically high success rate with minimal complications.

The effect of beam purity and scanner complexity on proton CT accuracy.

PURPOSE: To determine the dependence of the accuracy in reconstruction of relative stopping power (RSP) with proton computerized tomography (pCT) scans on the purity of the proton beam and the technological complexity of the pCT scanner using standard phantoms and a digital representation of a pediatric patient. METHODS: The Monte Carlo method was applied to simulate the pCT scanner, using both a pure proton beam (uniform 200 MeV mono-energetic, parallel beam) and the Northwestern Medicine Chicago Proton Center (NMCPC) clinical beam in uniform scanning mode. The accuracy of the simulation was validated with measurements performed at NMCPC including reconstructed RSP images obtained with a preclinical prototype pCT scanner. The pCT scanner energy detector was then simulated in three configurations of increasing complexity: an ideal totally absorbing detector, a single stage detector and a multi-stage detector. A set of 15 cm diameter water cylinders containing either water alone or inserts of different material, size, and position were simulated at 90 projection angles (4° steps) for the pure and clinical proton beams and the three pCT configurations. A pCT image of the head of a detailed digital pediatric phantom was also reconstructed from the simulated pCT scan with the prototype detector. RESULTS: The RSP error increased for all configurations for insert sizes under 7.5 mm in radius, with a sharp increase below 5 mm in radius, attributed to a limit in spatial resolution. The highest accuracy achievable using the current pCT calibration step phantom and reconstruction algorithm, calculated for the ideal case of a pure beam with totally absorbing energy detector, was 1.3% error in RSP for inserts of 5 mm radius or more, 0.7 mm in range for the 2.5 mm radius inserts, or better. When the highest complexity of the scanner geometry was introduced, some artifacts arose in the reconstructed images, particularly in the center of the phantom. Replacing the step phantom used for calibration with a wedge phantom led to RSP accuracy close to the ideal case, with no significant dependence of RSP error on insert location or material. The accuracy with the multi-stage detector and NMCPC beam for the cylindrical phantoms was 2.2% in RSP error for inserts of 5 mm radius or more, 0.7 mm in range for the 2.5 mm radius inserts, or better. The pCT scan of the pediatric phantom resulted in mean RSP values within 1.3% of the reference RSP, with a range error under 1 mm, except in exceptional situations of parallel incidence on a boundary between low and high density. CONCLUSIONS: The pCT imaging technique proved to be a precise and accurate imaging tool, rivaling the current x-rays based techniques, with the advantage of being directly sensitive to proton stopping power rather than photon interaction coefficients. Measured and simulated pCT images were obtained from a wobbled proton beam for the first time. Since the in-silico results are expected to accurately represent the prototype pCT, upcoming measurements using the wedge phantom for calibration are expected to show similar accuracy in the reconstructed RSP.

The usefulness of CT guided drainage of abscesses caused by retained appendicoliths.

OBJECTIVES: To determine the utility of percutaneous computed tomography (CT) guided drainage of abscesses formed secondary to retained appendicoliths. MATERIALS AND METHODS: A retrospective review was conducted over a 5-year period to identify patients who underwent CT guided drainage of abscesses related to retained appendicoliths. Inclusion criteria were a history of prior proven appendicitis treated by laparoscopic appendicectomy, identification of a post-operative abscess related to a visualised retained appendicolith and initial treatment by CT guided drainage. Data regarding initial technical success as well as long-term outcome was recorded in each case. RESULTS: In total, five patients were identified who underwent CT guided abscess drainage related to retained appendicoliths. There were three males and two females (age range 12-54 years). Initial drainage under CT guidance was technically successful in all cases with successful catheter placement and resolution of the abscess cavity. In all five cases however, there was recurrence of abscess formation following catheter removal. In one case, a second attempt with CT guided drainage was performed. Again this was initially successful with abscess recurrence following catheter removal. In all five cases, formal surgical drainage with removal of retained appendicolith resulted in a successful outcome. CONCLUSION: CT guided percutaneous drainage of intra abdominal abscess secondary to retained appendicoliths is only successful in the short term. Formal surgical drainage and removal of the appendicolith is required for long-term success.

Valsalva and gravitational variability of the internal jugular vein and common femoral vein: ultrasound assessment.

PURPOSE: Central venous cannulation via the common femoral vein is an important starting point for many interventions. The purpose of this study was to determine the optimum conditions for cannulation of the femoral vein and to compare these with the relative changes in the internal jugular vein. METHODS: High-resolution 2D ultrasound was utilised to determine variability of the calibre of the femoral and internal jugular veins in 10 healthy subjects. Venous diameter was assessed during the Valsalva manoeuvre and in different degrees of the Trendelenburg position. RESULTS: The Valsalva manoeuvre significantly increased the size of the femoral and internal jugular veins. There was a relatively greater increase in femoral vein diameter when compared with the internal jugular vein of 40 and 29%, respectively. Changes in body inclination (Trendelenburg position) did not significantly alter the luminal diameter of the femoral vein. However, it significantly increased internal jugular vein diameter. CONCLUSIONS: Femoral vein cannulation is augmented by the Valsalva manoeuvre but not significantly altered by the gravitational position of the subject.

Operation of the Preclinical Head Scanner for Proton CT.

We report on the operation and performance tests of a preclinical head scanner developed for proton computed tomography (pCT). After extensive preclinical testing, pCT is intended to be employed in support of proton therapy treatment planning and pre-treatment verification in patients undergoing particle-beam therapy. In order to assess the performance of the scanner, we have performed CT scans with 200 MeV protons from both the synchrotron of the Loma Linda University Medical Center (LLUMC) and the cyclotron of the Northwestern Medicine Chicago Proton Center (NMCPC). The very high sustained rate of data acquisition, exceeding one million protons per second, allowed a full 360° scan to be completed in less than 7 minutes. The reconstruction of various phantoms verified accurate reconstruction of the proton relative stopping power (RSP) and the spatial resolution in a variety of materials. The dose for an image with better than 1% uncertainty in the RSP is found to be close to 1 mGy.

Small bowel obstruction secondary to a giant enterolith complicating Crohn's disease.

BACKGROUND: Enterolith formation associated with Crohn's disease is a very uncommon clinical entity. AIM: To describe a case of sub-acute small bowel obstruction secondary to a giant enterolith in a patient with Crohn's disease. RESULTS: A 54-year-old male with a history of Crohn's disease presented with sub-acute small bowel obstruction secondary to a giant enterolith. The diagnosis was confirmed utilising plain film radiography and computed tomography CONCLUSION: Plain film radiography and computed tomography play a central role in establishing the diagnosis of this rare complication of Crohn's disease and assist in planning surgical intervention.

Plasma exchange in acute renal allograft rejection. A controlled trial.

A controlled trial was carried out to assess the value of intensive plasma exchange in 27 renal transplant recipients with clinical and histological evidence of acute vascular rejection. In addition to standard immunosuppression, 13 patients received plasma exchange on six consecutive days at a mean exchange volume of 40.6 ml/kg of body weight each day using an intermittent cell separator. A further 14 patients received standard immunosuppression only. In addition, 10 patients exchanged prior to the controlled trial have been studied. Analysis of short-term benefit, as evidenced by a reduction in serum creatinine, and by subsequent graft survival revealed no significant difference in these parameters between the two groups in the controlled trial. This regimen of plasma exchange has not, therefore, been shown to modify acute renal allograft rejection.

Expression of prostaglandin receptors EP4 and FP in human lens epithelial cells.

PURPOSE: To examine the expression of prostaglandin (PG) receptors EP2, EP4, and FP in a human lens epithelial cell line (HLE-B3) at molecular and pharmacologic levels. METHODS: Reverse transcription-polymerase chain reactions (RT-PCR) were performed with total RNA preparations from HLE-B3 cells using sense and antisense primers for each of the three prostaglandin receptors. The PCR products were hybridized with specific 32P-labeled probes and, for further confirmation, digested with appropriate restriction enzymes. At the pharmacologic level, the expression of EP4 receptors was determined by measuring intracellular cyclic adenosine monophosphate (cAMP) formation in response to PGE2 (EP1, EP2, EP3, and EP4 agonist) and the EP4 receptor-selective antagonist AH23848. The expression of FP receptors in HLE-B3 cells was explored by measuring intracellular [Ca2+]i mobilization. RESULTS: RT-PCR generated DNA products of predicted sizes corresponding to the EP2, EP4, and FP receptors. Hybridization of the PCR products with specific 32P-labeled probes and restriction digestion of the PCR products further confirmed that they were generated from the respective EP2, EP4, and FP mRNAs. The EP receptor agonist PGE2 significantly increased the cAMP level in HLE-B3 cells. The formation of cAMP by PGE2 was concentration-dependently inhibited by the EP4 receptor-selective antagonist AH23848. Stimulation of HLE-B3 cells by the FP receptor agonist fluprostenol increased [Ca2+]i in a time-dependent manner. CONCLUSIONS: The results of the molecular biologic and pharmacologic experiments showed conclusively the presence of EP4 and FP receptor messenger RNAs and proteins, respectively, in HLE-B3 cells.

Transforming growth factor alpha and its receptor in neural retina.

Transforming growth factor alpha (TGF-alpha) stimulates mitosis of many ectodermal cells but has not previously been studied for its role in neural tissues such as retina. We examined bovine retina for the presence of TGF-alpha mRNA, TGF-alpha protein and for the presence and location of the TGF-alpha/EGF receptor. Biochemical studies demonstrated a high level (770 fmol/mg protein) of specific, high affinity (Kd = 2 nM) TGF-alpha/EGF receptors in membrane homogenates of neural retina, but undetectable binding to homogenates of retinal pigment epithelium. Light microscopic autoradiograms of sections of neural retinal tissue incubated with 125I-EGF indicated that specific TGF-alpha/EGF receptors were present on one or more cell types of the retina with the exception of the outer segments of the photoreceptor cells. In addition, retinal cells appear to synthesize TGF-alpha since both mRNA for TGF-alpha and TGF-alpha protein (4.2 ng/mg protein) were detected in retinal extracts using cDNA hybridization and TGF-alpha RIA techniques. The role(s) of TGF-alpha and its receptor in retina is unknown, but it is possible that they interact via an autocrine/paracrine mechanism to influence retinal regeneration, proliferative retinopathies or neural transmission.

Detection of EP2, EP4, and FP receptors in human ciliary epithelial and ciliary muscle cells.

We have examined the expression of three prostaglandin (PG) receptors, EP2, EP4, and FP, in a nonpigmented ciliary epithelial cell line (ODMCl-2) and in human ciliary muscle (HCM) cells. Total RNA preparations from either ODMCl-2 or HCM cells were subjected to reverse transcription-polymerase chain reaction (RT-PCR) with sense and antisense primers for each of the three PG receptors. The RT-PCR generated DNA products of predicted sizes corresponding to the EP2, EP4, and FP receptors in both ODMCl-2 and HCM cells. PCR products corresponding to each receptor were hybridized with specific 32P-labeled probes and, for further confirmation, digested with appropriate restriction enzymes. Pharmacological studies with the EP2 receptor-selective agonist butaprost resulted in a significant increase in the cyclic AMP level in ODMCl-2 cells. The stimulation of cyclic AMP in ODMCl-2 cells by PGE2 and 11-deoxy PGE1, the respective EP1/EP2/EP3/EP4 and EP2/EP3/EP4 receptor agonists, was concentration-dependently inhibited by the EP4 receptor-selective antagonist AH23848. These results conclusively demonstrate the presence of both mRNA and protein for EP2, EP4, and FP receptors in ODMCl-2 and HCM cells.

Transcriptional regulation of decreased protein synthesis during skeletal muscle unloading.

Muscle atrophy resulting from disuse is associated with marked decrements in protein synthesis. The objective of the present investigation was to determine levels of total muscle RNA and the content and composition of the mRNA fraction as a qualitative assessment of the potential regulatory role of transcriptional alterations in unloaded skeletal muscles. Hindlimb muscle unloading was produced by whole-body suspension of rats for up to 7 days. The soleus, gastrocnemius, and extensor digitorum longus (EDL) were excised from 1-, 3-, and 7-day suspended and pair-fed controls, and RNA was extracted by homogenization in 5 M guanidinium thiocyanate. Total RNA and mRNA contents were lower in soleus and gastrocnemius after 7 days of suspension compared with pair-fed controls, but total RNA and mRNA concentrations (per g muscle and per microgram total RNA, respectively) were unaltered. alpha-Actin mRNA, assessed by dot blot hybridization, was significantly reduced in soleus after 1 (37%), 3 (28%), and 7 (59%) days of suspension and in gastrocnemius after 3 (44%) and 7 (41%) days. However, alpha-actin mRNA was unchanged in the EDL after suspension. Protein synthesis directed by RNA extracted from soleus and EDL indicated marked (30-400%) alterations in mRNAs coding for several small (15- to 25-kDa) proteins. The results of this study suggest that altered transcription and availability of specific mRNAs could contribute significantly to the regulation of protein synthesis during unloading of skeletal muscle.

Age effects on rat hindlimb muscle atrophy during suspension unloading.

Disuse can induce numerous adaptive alterations in skeletal muscle. In the present study the effects of hindlimb unloading on muscle mass and biochemical responses were examined and compared in adult (450 g) and juvenile (200 g) rats after 1, 7, or 14 days of whole body suspension. Quantitatively and qualitatively the soleus (S), gastrocnemius (G), plantaris (P), and extensor digitorum longus (EDL) muscles of the hindlimb exhibited a differential sensitivity to suspension and weightlessness unloading in both adults and juveniles. The red slow-twitch soleus exhibited the most pronounced atrophy under both conditions, with juvenile responses being greater than adult. In contrast, the fast-twitch EDL hypertrophied during suspension and atrophied during weightlessness, with no significant difference between adults and juveniles. Determination of biochemical parameters (total protein, RNA, and DNA) indicated a less rapid rate of response in adult muscles. This was corroborated by assessment of muscle alpha-actin mRNA levels, which indicated a rapid (within 1 day) and significant (P less than 0.05) effect in juveniles but not in adults. The results of this investigation indicate 1) a qualitatively similar differential effect of unloading on muscles of adults and juveniles, 2) a quantitatively reduced and less rapid effect of suspension on adult muscles, and 3) a close similarity of adult and juvenile muscle responses during suspension and spaceflight, suggesting that this ground-based model simulates many of the unloading effects of weightlessness.

Young injectors: a comparative analysis of risk behaviour.

This study compares the injecting and sexual risk-behaviour of young injectors, with injectors over the age of 25. All respondents presented for the first time at the Merchants' Quay Health Promotion Unit between May 1st 1997 and February 28th 1998. Analysis revealed that the young injectors were significantly more likely to report recently borrowing and lending used injecting equipment, and injecting paraphernalia. Regarding sexual risk behaviour, younger respondents were proportionately more likely to report being sexually active, having multiple sexual partners, and having a regular partner who is an injecting drug user. However, they were significantly more likely than older clients to report condom use. The suggestion is that the harm minimisation message, which reached its zenith in the early 1990s, has now been somewhat de-emphasised in both policy and practice. Consequently, it is not reaching the young injectors who have recently initiated intravenous drug use. Additional strategies are needed this group of drug users, in order to promote positive behaviour changes.

Air travel in pregnancy: the 'air-born' study.

An increasingly common question posed by patients antenatally is whether air travel can be considered safe in pregnancy. The aim of this study was to assess whether any agreed standards or policies exist between airlines with respect to flying in pregnancy. Sixty-eight international airlines were surveyed, of whom seventeen (25%) replied. Three of seventeen (17.5%) airlines applied no restrictions at all to pregnant passengers; the remainder applied restrictions to air travel with varying gestations (28 to 36 weeks). A full delivery kit was carried by 5/17 airlines (29%), and some form of training in the management of a delivery was provided to the cabin crew in 12/17 airlines (70%). Experience of in-flight obstetric emergencies was reported by 11/17 airlines (65%). This study highlights a lack of consensus regarding restrictions on air travel in pregnancy. The low response rate also suggests an unwillingness on the part of the airline industry to openly declare their policy on this issue.

Syringe exchanges: a public health response to problem drug use.

This paper presents the findings of the first ever Irish follow-up study to establish the effectiveness of syringe exchanges as a harm reduction strategy in the context of public health. The study was conducted in collaboration with 370 injecting drug users who attended the Merchant's Quay Project's Health Promotion Unit between May 1st 1997 and October 31st 1998. Data was collected from respondents by means of a structured interview at first visit and three-months after initial contact. Evidence from the study demonstrates that syringe exchanges play an important contributing role in significantly reducing the numbers reporting both the use of heroin as a primary drug (n=41; McNemar x2=10.1;p<0.01), and its frequency of use (n=70; McNemar x2=4.13;p<0.05) at follow-up. Moreover, there were significant reductions in the reported borrowing (n=60; McNemar x2=10.1;p<0.01) and lending (n=42: McNemar x2=7.9;p<0.01) of used injecting equipment. There was however no significant change in the reported sharing of injecting paraphernalia or in levels of reported condom use. The results of this study illustrate that low threshold services such as the Health Promotion Unit have the ability to attract injecting drug users not in contact with other drug treatment services. Furthermore, this type of service has been shown to be effective in maintaining contact with injecting drug users and promoting safer drug use among attendees. Even though the distribution of sterile injecting equipment reduces the situational sharing, this is hampered by the limited availability of sterile injecting equipment in Dublin. There is a need to continue to develop strategies to prevent HIV and hepatitis C transmission. One such approach would be to develop effective outreach as a means of reaching greater numbers of drug users earlier in their injecting histories. Other areas for future HIV and HCV prevention include discouraging the transition from smoking to injecting, and among those who inject, encouraging further reductions in sharing, sustaining risk reduction over time, and encouraging the adoption of safer sexual behaviour.