The Canadian Liver Foundation celebrates 50 years of commitment to hepatology.

Founded in 1969, the Canadian Liver Foundation (CLF) was the first foundation worldwide to support research and education relating specifically to the liver and liver diseases. This year marks its 50th anniversary. It has been highly effective in promoting hepatology in Canada.

Follow-up after anaesthetic anaphylaxis.

UNLABELLED: background: the anaesthetic allergy clinic has been established at our institution for 30 years. Our practice has been to give patients a letter detailing the results of their investigations to pass on to subsequent anaesthetists. Our aims were to assess the adequacy of this letter in ensuring this vital communication, and to quantify the effectiveness of our recommendations on the safety of future anaesthesia. METHODS: a project was undertaken to contact 606 previous clinic patients living in New South Wales by using last known addresses on our database, public telephone listing and local doctors. The review also involved collecting information, where available, about subsequent anaesthesia and the adequacy of information transfer about medications given safely or otherwise at this time. RESULTS: of 606 patients, 246 were contactable. Of these, 183 had been anaesthetised subsequently, all safely. It was found that in only 11 cases had the patient's clinic letter been updated with the information from subsequent anaesthesia. We updated the letters of 82 patients with new information to improve the safety of drug selection for future anaesthesia. CONCLUSIONS: although clinic testing allowed a high degree of safety in subsequent anaesthesia, it is evident that there is a need for systems to be implemented to improve the flow of patient anaesthetic allergy information after subsequent anaesthesia.

The investigation of bronchospasm during induction of anaesthesia.

BACKGROUND: The aim of this study was to ascertain whether anaesthetic induction-related anaphylactic bronchospasm could be distinguished from other types of bronchospasm by clinical features and response to treatment. Such features could then be used to identify a group of patients in whom skin testing is indicated. METHODS: We retrospectively studied data from 183 patients referred to an anaesthetic allergy clinic because of bronchospasm during induction. For the analysis, the patients were divided into two groups depending on whether there was evidence suggesting immunological anaphylaxis. RESULTS: When the patients in whom intradermal tests were positive were compared with those in whom intradermal tests were negative, the skin test-positive patients had significantly more severe reactions, and they were more commonly associated with other clinical signs. Mast cell tryptase (MCT) was an excellent discriminator between reactions likely to be allergic and those unlikely to be allergic. CONCLUSIONS: Anaphylactic bronchospasm related to induction of anaesthesia is more likely to be severe than bronchospasm due to non-immune causes. An allergic cause is more likely if there are associated features of anaphylaxis (skin changes, hypotension, angioedema) or elevated MCT. Patients with any of these features should undergo immuno-allergolical investigation.

On the origin and specificity of antibodies to neuromuscular blocking (muscle relaxant) drugs: an immunochemical perspective.

Following the demonstration 25 years ago that substituted ammonium groups on neuromuscular blocking drugs (NMBDs) are the main allergenic structures recognized by IgE antibodies in the sera of some patients who experience anaphylaxis during anaesthesia, immunoassays for these drugs were quickly applied to supplement skin tests in the diagnostic assessment of suspected adverse reactions to anaesthetic agents. Many subjects who react to an NMBD do so on first exposure and this led to the speculation that the origin of allergic sensitization is an environmental agent(s) or another drug containing an ammonium ion. Direct antibody binding and hapten inhibition studies revealed that morphine, which contains a tertiary amino group, was strongly recognized by IgE in sera from anaphylactic patients and a morphine-solid phase immunoassay was found to be superior to NMBD-based assays for the detection of NMBD-reactive IgE antibodies. Extensive inhibition experiments indicate the likelihood of antibody combining site heterogeneity with recognition at the fine structural level of features additional, and adjacent to, ammonium ions. Further quantitative investigations are needed to identify these neighbouring groups on different NMBDs. Recent work has implicated the morphine analogue pholcodine as the sensitizing agent in Norway where, unlike Sweden, anaphylactic reactions to NMBDs are not uncommon and the medicament is available over-the-counter. This has led to the suggestion that allergenic sensitization to the ammonium group of pholcodine may account for the different incidences of anaphylaxis during anaesthesia in the two countries. This work is subjected to critical review and some alternative speculations on the nature and origin of the sensitizing agent(s) are presented.

Radiography for the diagnosis of spirocercosis in apparently healthy dogs, St. Kitts, West Indies.

Fifty apparently healthy island dogs presenting to the Ross University School of Veterinary Medicine (RUSVM), St. Kitts, West Indies for neutering were used in this prospective study. Twelve of the dogs (24%) were diagnosed with spirocercosis based on a positive fecal analysis and characteristic lesions seen during esophagoscopy. Routine thoracic survey radiographs revealed changes previously reported with spirocercosis in 10/12 (sensitivity=83%) infected dogs, but in none of the uninfected dogs (38/38; specificity=100%). The most common radiographic changes were an increased fluid density within the caudal dorsal thorax on the lateral view and a widening and/or bulging of the caudal mediastinum on the dorsoventral view. After oral administration of barium sulfate, barium retention or a tortuous esophagus was visible in all infected dogs (12/12; sensitivity 100%) and in one uninfected dog (1/38; specificity 97%). The results show spirocercosis is common on St. Kitts and that radiographs are as dependable as fecal analysis and/or endoscopy in diagnosing the condition.

The preoperative detection of risk of anaphylaxis during anaesthesia.

In 144 patients who were referred to an anaesthetic allergy clinic because of perceived risk of anaphylaxis during anaesthesia, the only 'at risk' group that could be identified was patients with a history of unexplained severe adverse reaction during previous anaesthesia. Twenty-two of 45 patients with such a history had positive skin tests to an anaesthetic drug. Twenty-one positive tests were to neuromuscular blocking drugs and one to an opiate. In 18 of these patients the medical records were available and an adverse event had been recorded consistent with anaphylaxis. On the contrary, investigation of patients without a previous adverse reaction did not appear to be of value. These findings suggest that those patients with a history of a severe undiagnosed adverse event during previous anaesthesia should be investigated with preoperative skin-testing before undergoing further elective surgery.

Magnesium-rich minerals in sediment and suspended particulates of South Florida water bodies: implications for turbidity.

Fine sediments in shallow water bodies such as Lake Okeechobee are prone to resuspension. Predominantly inorganic "mud" sediment that covers approximately 670 km2 of the lake has been recognized as a persistent source of turbidity. The objective of this study was to determine if mineral components of sediments in Lake Okeechobee and water conveyances of the northern Everglades also occur as suspended sediment and hence constitute a potential abiotic contributor to turbidity. Sediment samples were collected from nine stations within the lake and eight locations north of Water Conservation Area 2A in the Everglades. Water samples were also collected at selected locations. The silt and clay mineralogy of sediment and suspended particles was determined using X-ray diffraction, thermogravimetry, scanning-electron microscopy, energy-dispersive X-ray elemental microanalysis, and high-resolution transmission-electron microscopy. Clay fractions of the lake sediment contained the Mg silicate minerals sepiolite and palygorskite, along with smectite, dolomite, calcite, and kaolinite. Sediment silt fractions were dominated by carbonates and/or quartz, with smaller amounts of Ca phosphates and sepiolite. Mineralogy of the mud sediment was similar to that reported for geologic phosphate deposits. This suggests that the mud sediment might have accumulated by stream transport of minerals from these deposits. Suspended solids and mud-sediment mineralogy were similar, except that smectite was more abundant in suspended solids. Everglade samples also contained Mg-rich minerals. The small size, low density, and fibrous or platy nature of the prevalent mud sediment minerals make them an abiotic, hydrodynamically sensitive source of persistent turbidity in a shallow lake. Mitigation efforts focused exclusively on P-induced biogeochemical processes do not address the origin or effects of these minerals. Ecological management issues such as turbidity control, P retention, geologic P input, and suitability of dredging are related to mud-sediment properties and provenance.

Anaphylaxis during anaesthesia: diagnostic approach.

Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions.

Life-threatening pulmonary hypertension and right ventricular failure complicating calcium and phosphate replacement in the intensive care unit.

A 43-year-old man developed septic shock and acute lung injury after surgery to drain an ischiorectal abscess. In the intensive care unit he initially improved but developed severe hypoxaemia, right ventricular failure and pulmonary hypertension 90 min after receiving intravenous calcium gluconate and potassium phosphate, best explained by the formation of a calcium-phosphate precipitant that resulted in aggregate anaphylaxis. His rapid deterioration and lack of response to conventional therapies necessitated support with extracorporeal membrane oxygenation that was life saving. This adverse event has altered local practice regarding calcium and phosphate replacement and has implications for all intensive care units.

The effects of proprioceptive neuromuscular facilitation stretching on shoulder range of motion in overhand athletes.

AIM: The purpose of this study was to compare the effects of the contract-relax-contract (CRC) and hold-relax-contract (HRC) proprioceptive neuromuscular facilitation (PNF) stretching programs against a control, on external range of motion (ROM) of the shoulder in apparently healthy athletes. METHODS: The subjects were male and female adults between the ages of 25 to 50 years old. Subjects also had been involved in at least one overhand throwing sport (tennis, baseball, quarterback in football, etc.) in the past year. There were 30 participants whom were randomly assigned to 1 of 3 groups (CRC PNF, HRC PNF, control) with 10 subjects per group. Measurement of ROM for external rotation of the shoulder was performed prior to and after 6 weeks of training using a goniometer. The CRC and HRC PNF stretches were performed on subjects twice a week for 6 weeks. The statistical analysis conducted involved a 3x2 analysis of variance with the criteria for statistical significance set at p<0.05. Post hoc testing included paired t-tests and Tukey tests to pinpoint significant differences relative to the interaction between group and time. RESULTS: There was an increase in ROM from pretest to post-test for the HRC group (+13.50 degrees) and CRC group (+14.60 degrees), but not in the control group (+0.30 degrees). The improvement in ROM however, was similar between the HRC and CRC groups. CONCLUSIONS: The CRC and HRC PNF stretching techniques are effective at increasing external shoulder ROM when consistently performed 2 times a week for 6 weeks.