Dermal expression of laminin-332 and type IV collagen in humans with severe sepsis.

BACKGROUND: An intact basement membrane at the dermal-epidermal junction is essential to the viability of the skin. The effect of sepsis on the basement membrane is unknown. METHODS: Skin biopsies were used to study basement membrane structure in severe sepsis (Day 1). Subsequent biopsies were taken on Day 8 and at 3 months in the survivors. Immunohistochemical staining was undertaken using laminin-223 and type IV collagen. Twenty patients with severe sepsis and four control subjects were included in the analysis. RESULTS: Intensive care unit mortality was 4/20, and total 30-day mortality was 5/20. Exactly, 7/17 of patients with severe sepsis exhibited weak or absent laminin-332 expression and 11/15 exhibited weak or absent type IV collagen expression compared with 0/4 of control subjects on Day 1 in intact skin. The proportion of sepsis patients with weak or absent laminin-332 expression was 5/11 on Day 8 and fell to 1/7 at 3 months. The proportion of sepsis patients with weak or absent type IV collagen expression was 10/11 on Day 8 and 4/7 at 3 months. CONCLUSION: These findings suggest that basement membrane formation may be compromised in patients with severe sepsis.

Precipitating factors of delirium: stress response to multiple triggers among patients with and without dementia.

BACKGROUND AND AIM: Delirium is common and serious acute syndrome among older people precipitated by multiple external factors such as acute illnesses, trauma, surgery, and drugs. The aim of this study was to find possible stressors and causative triggers for acute delirium and compare patients with or without dementia in this respect. METHODS: 193 delirious patients from two separate delirium studies including settings of nursing homes and geriatric wards were thoroughly assessed for precipitating factors of delirium. Patients with and without dementia were compared for their clinical status, symptoms and signs, prognosis, and the profile of precipitating factors of delirium. RESULTS: The patients with dementia (n=98) and without dementia (n=95) did not differ in their demographic factors, mean number of drugs, or their psychiatric symptoms. The patients with dementia had higher number of comorbidities, poorer cognition, and they were more often restrained than those without dementia. The mean number of precipitators for delirium was 2.6 among those without dementia and 2.0 among those with dementia (p=0.0019). Infections, metabolic conditions, trauma, and surgery were more common precipitating factors for delirium in those without than those with dementia. There was no difference in mortality between the groups. CONCLUSION: Most patients had multiple precipitating factors for delirium irrespective of prior dementia. Those with dementia and decreased cognitive reserves needed lower number of etiologies to develop delirium. The profile of causative agents differed among patients with and without dementia.

Secular trends in the use of vitamins, minerals and fish-oil products in two cohorts of community-dwelling older people in Helsinki--population-based surveys in 1999 and 2009.

OBJECTIVES: To examine and compare the prevalence of use of vitamins, minerals, and fish-oil products (VMFO) in Finnish community-dwelling older people at two time points over a decade, and to explore the associated factors with the VMFO use. METHODS: A postal survey was sent to people aged 75, 80, 85, 90, and 95 years living in Helsinki, Finland in 1999 (N=3219) and in 2009 (N=2247). The response rates were 78% (n=2511) and 73% (n=1637), respectively. The surveys included items on demographic and health related factors, used medication and self-reported supplemental use of vitamins or minerals, and natural products. RESULTS: The proportion of respondents using at least one VMFO was 49.8% in 1999 and 66.8% in 2009 (p<0.001). The proportion using vitamin D (RR 4.58, 95% CI 3.89 to 5.40; p<0.001), calcium (RR 2.47, 95% CI 2.18 to 2.80; p<0.001), magnesium (RR 1.47, 95% CI 1.17 to 1.85; p<0.001), and fish-oil/omega3 products (RR 3.66, 95% CI 2.41 to 5.55; <0.001) was higher in 2009 than in 1999, even when adjusted for age, gender, living conditions, education and comorbidities, whereas that of other vitamins and fish-liver-oil products was lower. At both time points the use of VMFO was associated with female gender and higher number of used medications. In 1999, higher education was associated with VMFO-use while age and comorbidities was not. In 2009 higher age and comorbidities was associated with VMFO-use. CONCLUSIONS: The use of VMFO is common among community-dwelling older people and it has significantly increased over ten years. The increase was mainly due to the use of vitamin D and calcium. The consumption of other vitamin supplements has decreased. Education was no longer associated with use of VFMO in 2009 where as age and comorbidities were.

Histological damage of colonic epithelium is associated with clinical severity and outcome in colectomized critically Ill patients.

BACKGROUND: Severe intestinal mucosal damage and organ failure has been associated in experimental models. Our purpose was to determine whether there is any association between histopathological findings and postoperative mortality among ICU patients undergoing emergency colectomies for various illnesses. METHODS: In a retrospective case control study, total colectomy specimens from 50 patients in a mixed ICU were analysed: 18 had sepsis, 11 vascular operations, and 21 Clostridium difficile colitis. Overall thickness, the width of epithelial defects, and presence of cryptal damage were assessed. Extent of necrosis and amount of neutrophils were separately evaluated in the layers of the colonic wall. Clinical features, including sequential organ failure assessment (SOFA) scores and survival, were registered. RESULTS: The histopathological findings for the three clinical entities were similar, except for the abundance of characteristic pseudomembranes in the Clostridium group. Mucosal height (maximum) showed a negative correlation with SOFA score on admission (ρ = -0.296, P = 0.037), and with preoperative blood lactate level (ρ = -0.316; P = 0.027). The nonsurvivors had wider enterocyte defects (60 vs. 40.8, P = 0.002) and more severe crypt damage (61 vs. 27 %; P = 0.024) than the survivors. CONCLUSIONS: The histopathological damage involves all layers of the colon wall among ICU patients being largely similar in sepsis, C. difficile infection, and ischemia after vascular operations. Mucosal epithelial damage is associated with clinical severity of the illness and mortality.

Serum markers of collagen synthesis and degradation in acute respiratory failure patients.

BACKGROUND: Procollagen-derived propeptides reflect the rate of collagen synthesis and type I cross-linked collagen telopeptides (ICTP) collagen I degradation. We studied the collagen metabolism to find out if changes seen in acute respiratory distress syndrome patients are observed in patients with acute respiratory failure (ARF), and whether multiple organ dysfunction (MOD) has impact on it. METHODS: ARF patients with prolonged hospitalisation at least 21 days were included to the study. Blood samples for serum procollagen aminoterminal propeptide I (PINP) and III (PIIINP), and ICTP measurements were collected at study admission (day 0) and on days 2, 7, and 21. RESULTS: The study population comprised 68 patients. Forty-three patients (63%) developed MOD during the first week. PIIINP levels increased in all patients over time. The increase was slightly more pronounced in patients with MOD. During the first week, the synthesis of PIIINP increased more than PINP, and PINP degradation exceeded its production. By day 21, the balance of collagen metabolites returned to baseline. CONCLUSION: The collagen metabolism was altered in ARF patients. The first week was dominated by degradation of type I collagen and production of type III collagen, but by day 21, the collagen composition returned to more stable form.

Anticholinergic drugs and their effects on delirium and mortality in the elderly.

AIM: To investigate the use of drugs with anticholinergic properties (DAPs) and their associations with delirium and mortality among elderly patients with comorbidities. METHODS: 425 patients (≥70 years of age) in geriatric wards and nursing homes were assessed. The use of DAPs was retrieved from their medical records. Delirium was diagnosed according to the DSM-IV criteria. RESULTS: Of the 341 patients (80.2%) treated with multiple DAPs (≥2), 92 patients (27.0%) suffered from delirium, whereas 14 of 84 patients (16.7%) without DAP treatment had delirium (p = 0.050). In a logistic regression analysis with age, gender, and Charlson Comorbidity Index as covariates, DAP treatment did not predict delirium (odds ratio 1.67, 95% confidence interval 0.87-3.21). The 2-year mortality was 49.3% (n = 168) in DAP users and 35.7% (n = 30) in non-users, respectively (p = 0.026). In the Cox proportional hazard model adjusted for age, gender, and comorbidity, DAPs did not predict mortality (hazard ratio 1.12, 95% confidence interval 0.75-1.68). CONCLUSION: The use of DAPs is very frequent among frail inpatients with comorbidities, but their use has no independent prognostic significance.

Hospital and long-term outcomes of ICU-treated severe community- and hospital-acquired, and ventilator-associated pneumonia patients.

BACKGROUND: Our purpose was to analyse the association of pneumonia types with hospital and long-term outcomes of intensive care unit (ICU)-treated pneumonia patients. METHODS: The occurrence of pneumonia was retrospectively evaluated among prospectively registered patients admitted into a mixed university-level ICU during a 14-month period. Their age, severity of underlying disease, malignancy, immunosuppressive therapy and organ dysfunctions were recorded, as well as the length of hospital stay and short- and long-term mortalities. RESULTS: There were 117 severe community-acquired pneumonia (SCAP), 66 hospital-acquired pneumonia (HAP) and 25 ventilator-associated pneumonia (VAP) cases among the 817 patients admitted. ICU and hospital mortality did not differ between pneumonia groups. VAP and HAP patients had more malignant underlying diseases than SCAP patients (P < 0.001). HAP patients were older than SCAP and VAP patients (P = 0.023). The admission Acute Physiology and Chronic Health Evaluation II scores did not differ between the groups (P > 0.90). The patients with VAP had higher Sequential Organ Failure Assessment maximum scores compared with patients with SCAP and HAP (P < 0.001). In an adjusted multivariate logistic regression model, there were no significant differences in odds ratios for hospital mortality between the three pneumonia types. Mortality among the hospital survivors during the 12-month follow-up period was 18% (16/89) in the SCAP group, 35% (18/51) in the HAP group and 41% (7/17) in the VAP group (P = 0.023). CONCLUSION: The type of pneumonia (i.e. SCAP, HAP or VAP) had no significant association with hospital mortality, whereas the SCAP patients had the lowest 1-year mortality.

A new endotoxin adsorber in septic shock: observational case series.

AIMS: Effects of a new endotoxin adsorber on the length of noradrenaline (NA) treatment, LPS (lipopolysaccharide) levels and SOFA (sequential organ failure assessment) scores in septic shock were evaluated. METHODS: Two-hour hemoperfusion with LPS adsorber was initiated in patients with septic shock and endotoxemia. Controls were matched for age, focus and severity of illness. RESULTS: Adsorption treatment (n = 9) exhibited a significant decrease in EAA (endotoxin activity assay) activity (0.55 [0.44-0.68] vs. 0.25 [0.13-0.41], p = 0.019) and NA infusion rate (0.217 µg/kg/min [0.119-0.0508] vs. 0 µg/kg/min [0-0.09], p = 0.026) from pretreatment to 24 h post-treatment. The median decrease in SOFA scores from pretreatment to 24 h was 3.0 points (1.5-4.5), p = 0.002. Duration of NA infusion was significantly shorter compared to controls (39 h [31-48] vs. 54 h [43-151], p = 0.03). CONCLUSIONS: LPS adsorber treatment was associated with a decrease in NA dose, decrease in SOFA scores and LPS concentrations.

Involvement of the first transmembrane segment of human α(2) -adrenoceptors in the subtype-selective binding of chlorpromazine, spiperone and spiroxatrine.

BACKGROUND AND PURPOSE: Some large antagonist ligands (ARC239, chlorpromazine, prazosin, spiperone, spiroxatrine) bind to the human α(2A) -adrenoceptor with 10- to 100-fold lower affinity than to the α(2B)- and α(2C)-adrenoceptor subtypes. Previous mutagenesis studies have not explained this subtype selectivity. EXPERIMENTAL APPROACH: The possible involvement of the extracellular amino terminus and transmembrane domain 1 (TM1) in subtype selectivity was elucidated with eight chimaeric receptors: six where TM1 and the N-terminus were exchanged between the α(2)-adrenoceptor subtypes and two where only TM1 was exchanged. Receptors were expressed in CHO cells and tested for ligand binding with nine chemically diverse antagonist ligands. For purposes of interpretation, molecular models of the three human α(2)-adrenoceptors were constructed based on the ß(2)-adrenoceptor crystal structure. KEY RESULTS: The affinities of three antagonists (spiperone, spiroxatrine and chlorpromazine) were significantly improved by TM1 substitutions of the α(2A)-adrenoceptor, but reciprocal effects were not seen for chimaeric receptors based on α(2B)- and α(2C)-adrenoceptors. Molecular docking of these ligands suggested that binding occurs in the orthosteric ligand binding pocket. CONCLUSIONS AND IMPLICATIONS: TM1 is involved in determining the low affinity of some antagonist ligands at the human α(2A)-adrenoceptor. The exact mechanism is not known, but the position of TM1 at a large distance from the binding pocket indicates that TM1 does not participate in specific side-chain interactions with amino acids within the binding pocket of the receptor or with ligands bound therein. Instead, molecular models suggest that TM1 has indirect conformational effects related to the charge distribution or overall shape of the binding pocket.

Improved outcome after trauma care in university-level intensive care units.

BACKGROUND: Centralized trauma care has been shown to be associated with improved patient outcome. We compared the outcomes of trauma patients in relation to the size of the intensive care unit (ICU) using a large Finnish database. METHODS: A national prospectively collected ICU data registry was used for analysis. All adult trauma admissions excluding isolated head trauma and burns registered from July 1999 to December 2006 were analyzed. Data from 22 ICUs were available. The non-university-affiliated units were categorized according to the number of beds and referral population as small, mid size and large. Acute physiology and chronic health evaluation (APACHE II)- and sequential organ failure assessment (SOFA)-adjusted mortalities were compared between the units. RESULTS: There were 2067 trauma admissions that fulfilled the inclusion criteria; 38% were treated in the university hospitals, 26% in large non-teaching ICUs, 20% in mid size ICUs and 15% in small ICUs. The crude hospital mortality was 5.6%, being 4.7% in university ICU and 6.6% in mid size ICU. In two subgroup analyses of severely ill trauma patients with APACHE II points >25 or SOFA score >8 points, respectively, hospital mortality was significantly lower in university ICUs. CONCLUSIONS: University-level hospitals were associated with better outcomes with critically ill trauma patients. These results can be used in planning future organization of trauma patient care in Finland.

Multi-detector computed tomography in critically ill patients.

BACKGROUND: There is a lack of studies showing the overall impact of multi-detector computed tomography (MDCT) on the treatment of critically ill patients in a general intensive care unit (ICU) setting. METHODS: A prospective observational study on the effects of MDCT on the treatment of patients in a 12-bed medical-surgical ICU in a university hospital providing tertiary care. RESULTS: During the 9-month study period, there were 343 admissions with ICU length of stay longer than 48 h. Of these patients, 64 (19%) had had inconclusive findings with other modalities of radiological imaging, and they underwent altogether 82 MDCT examinations. Fifty examinations (61%) resulted in a change of treatment. The changes included 22 surgical interventions, 16 percutaneous or paranasal interventions, 15 changes of antimicrobial therapy, three withdrawals of active treatment, and four other changes of treatment. Eight patients underwent two and one patient underwent three changes of treatment. Twenty examinations (24%) were regarded as otherwise necessary for clinical decision-making, although no change in the treatment was indicated. Twelve examinations (15%) failed to provide any additional information relevant to the patient's treatment. CONCLUSION: Sixty-one percent of the MDCT examinations led to a change of treatment, and 24% of them otherwise contributed to or supported clinical decision-making, suggesting that MDCT examination is helpful in the case of general ICU patients, with inconclusive findings with other imaging modalities.

The second extracellular loop of alpha2A-adrenoceptors contributes to the binding of yohimbine analogues.

BACKGROUND AND PURPOSE: Rodent alpha(2A)-adrenoceptors bind the classical alpha(2)-antagonists yohimbine and rauwolscine with lower affinity than the human alpha(2A)-adrenoceptor. A serine-cysteine difference in the fifth transmembrane helix (TM; position 5.43) partially explains this, but all determinants of the interspecies binding selectivity are not known. Molecular models of alpha(2A)-adrenoceptors suggest that the second extracellular loop (XL2) folds above the binding cavity and may participate in antagonist binding. EXPERIMENTAL APPROACH: Amino acids facing the binding cavity were identified using molecular models: side chains of residues 5.43 in TM5 and xl2.49 and xl2.51 in XL2 differ between the mouse and human receptors. Reciprocal mutations were made in mouse and human alpha(2A)-adrenoceptors at positions 5.43, xl2.49 and xl2.51, and tested with a set of thirteen chemically diverse ligands in competition binding assays. KEY RESULTS: Reciprocal effects on the binding of yohimbine and rauwolscine in human and mouse alpha(2A)-adrenoceptors were observed for mutations at 5.43, xl2.49 and xl2.51. The binding profile of RS-79948-197 was reversed only by the XL2 substitutions. CONCLUSIONS AND IMPLICATIONS: Positions 5.43, xl2.49 and xl2.51 are major determinants of the species preference for yohimbine and rauwolscine of the human versus mouse alpha(2A)-adrenoceptors. Residues at positions xl2.49 and xl2.51 determine the binding preference of RS-79948-197 for the human alpha(2A)-adrenoceptor. Thus, XL2 is involved in determining the species preferences of alpha(2A)-adrenoceptors of human and mouse for some antagonists.

Continuous retention suture for the management of open abdomen: a high rate of delayed fascial closure.

BACKGROUND AND AIMS: Open abdomen is most often a consequence of damage control surgery, abdominal decompression or intra-abdominal infections. Ventral hernia after unsuccessful closure of open abdomen causes marked disability to the patient. Several methods for delayed fascial closure have been developed. Patients treated with continuous retention suture were evaluated to find out how often fascial closure was achieved, and what complications were related to the technique. METHOD: A retrospective analysis of 16 open abdomen patients treated with continuous retention suture. RESULTS: The most common cause of open abdomen was abdominal infection. Complete fascial closure was achieved in nine of the eleven surviving patients. Closure failed in one patient. Partial closure was also achieved in one patient. The median time between leaving the abdomen open and starting the process of closure was twelve days. The longest period of open abdomen before successful fascial closure was 29 days. Five patients died before the process of closure was complete. CONCLUSION: Delayed fascial closure can be accomplished by using the retention suture method described here.

Incidence of infections in patients with status epilepticus requiring intensive care and effect on resource utilization.

Data from a six-year period were retrospectively retrieved from medical records and an intensive care unit data management system to study the impact of infections on patients with status epilepticus. Out of 161 admitted patients, 33 had a community-acquired infection and 35 acquired an infection during their hospital stay, 10 while in a ward before admission to the intensive care unit and 25 while in an intensive care unit, giving an infection rate of 42% of all admissions (68 patients). The patients with intensive care unit-acquired infection had three times longer stays in the intensive care unit than those without any infection (P<0.001), and they utilized almost four times more nursing resources than those without infections (P<0.001). Furthermore, they were more often sedated with thiopentone infusion, either alone or in combination with other drugs, than the non-infectious patients (80% vs 20%, P <0.001). Both community- and hospital-acquired infections were related to longer intensive care unit stays (P<0.001). The hospital stay of patients with hospital-acquired infection was threefold compared to that of patients without infection (P<0.001), and these patients utilized almost three times more nursing resources than those without any infection (P<0.001). Patients with infections consumed 65.5% of the intensive care unit nursing resources of status epilepticus patients. In conclusion, the infection rate of status epilepticus patients was high and nosocomial infections were associated with more severe illness, treatment escalation, prolonged hospital stay and enhanced resource utilization.

Epidemiology of intensive care unit (ICU)-acquired infections in a 14-month prospective cohort study in a single mixed Scandinavian university hospital ICU.

BACKGROUND: Our aim was to evaluate the epidemiology of intensive care unit (ICU)-acquired infections in a prospective cohort study. METHODS: Patients with longer than a 48-h stay in an adult mixed medical-surgical ICU in a tertiary level teaching hospital were included. The incidence (per cent) and incidence density (per 1000 patient days) of ICU-acquired infections and the device-associated infection rates per 1000 device days were analysed prospectively in a 14-month study. RESULTS: Eighty (23.9%) of 335 patients, whose ICU stay was longer than 48 h, acquired a total of 107 infections (1.3 per patient) during their ICU stay, with an infection rate of 48 per 1000 patient days. The most common infections were ventilator-associated pneumonia (VAP) [33.8% (18.8 per 1000 respiratory days)], other lower respiratory tract infections (LRTIs) (20%) and sinusitis (13.8%). The rate of central catheter-related (CRI) or primary bloodstream infections was 6.3% (2.2 per 1000 central venous catheter days), and the rate of urinary tract infections was 1.3% (0.5 per 1000 urinary catheter days). The first ICU infection was observed in 58.8% (47/80) of cases within 6 days after admission. The median time from admission to the diagnosis of an ICU-acquired infection was 4 days (25th-75th percentiles, 4.0-6.0) for VAP, 6.0 days (4.5-7.0) for LRTIs and 9.5 days (6.5-13.0) for CRIs. CONCLUSIONS: The rates of urinary tract infections and bloodstream infections were lower than reported previously, differentiating our results from the classic pattern of ICU-acquired infections, with the exception of the predominance of VAP.

Development of renal failure during the initial 24 h of intensive care unit stay correlates with hospital mortality in trauma patients.

BACKGROUND: Although multiple organ failure is the leading late cause of death, there is controversy about the impact of acute organ dysfunction and failure on trauma survival. METHODS: Consecutive adult trauma admissions between January 2000 and June 2003, excluding isolated head traumas and burns, were analysed for parameters of organ function during the first 24 h following intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) scoring system. A national prospectively collected ICU data registry was used for analysis, including data from 22 ICUs in university and central hospitals in Finland. RESULTS: The study population consisted of 1044 eligible trauma admissions; 32% of the cases were treated at university hospital level, the rest being secondary referral central hospital admissions. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15 (SD8), ICU mortality was 5.6% and a further 1.6% of patients died during their post-ICU hospital stay. Forty-five per cent of the patients were categorized as having multiple traumas. In univariate analysis, APACHE II > or = 25 [odds ratio (OR), 35; 95% confidence interval (CI), 18-66] and renal failure (OR, 29.5; 95% CI, 14-63) produced the highest ORs for ICU mortality. In the APACHE II-, sex- and age-adjusted logistic regression model, renal failure was a significant risk factor for both ICU and hospital mortality (OR, 11.8; 95% CI, 3.9-35.4; OR, 8.2; 95% CI, 2.9-23.2, respectively). CONCLUSION: The development of renal failure during the initial 24 h of ICU stay remained an independent risk factor for mortality in trauma patients requiring intensive care treatment even after adjusting for the APACHE II score, age and sex.

Organ system dysfunction following open cholecystectomy for acute acalculous cholecystitis in critically ill patients.

BACKGROUND: Acute acalculous cholecystitis (AAC) refers to cholecystitis without gallstones and is a serious complication of critical illness. We describe the time course of organ system dysfunction associated with cholecystectomy in critically ill patients with AAC. METHODS: The data of all intensive care unit (ICU) patients who had operatively confirmed AAC during their ICU stay between 2003 and 2004 were analyzed. Patients who also had other intra-abdominal pathologies were excluded. The Sequential Organ Failure Assessment (SOFA) scores were recorded 3 days before, on the day of operation and on the first, second, third and seventh post-operative day after cholecystectomy. The impact of open cholecystectomy on organ dysfunction was evaluated on the basis of the change in the total and individual organ SOFA scores. RESULTS: Twenty-four patients underwent open cholecystectomy for AAC with no other intra-abdominal pathology. Sepsis was the most common admission diagnosis, followed by cardiovascular surgery. The mean (standard deviation, SD) Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS) II and SOFA scores on admission were 24.7 (5.8), 44.3 (12.3) and 9.4 (3.2), respectively. The median (25th, 75th percentiles) total SOFA score 3 days before cholecystectomy was 7.5 (1.3, 8.0), which increased to 10.5 (8.3, 13.0) (P < 0.0001) by the day of cholecystectomy, indicating developing multiorgan dysfunction. After the operation, the score decreased to 5.5 (3.3, 10.8) (P = 0.004) by the seventh post-operative day. The change was most obvious in cardiovascular and respiratory SOFA scores. CONCLUSIONS: AAC is associated with multiorgan dysfunction in critically ill patients. Open cholecystectomy seems to alter the course of multiorgan dysfunction in these patients.

Histopathology of acute acalculous cholecystitis in critically ill patients.

AIMS: To illustrate the histopathological features of acute acalculous cholecystitis (AAC) of critically ill patients and to compare them with those of acute calculous cholecystitis (ACC) and normal gallbladders. METHODS AND RESULTS: We studied 34 gallbladders with AAC and compared them with 28 cases of ACC and 14 normal gallbladders. Histological features were systematically evaluated. Typical features in AAC were bile infiltration, leucocyte margination of blood vessels and lymphatic dilation. Bile infiltration in the gallbladder wall was more common and extended wider and deeper into the muscle layer in AAC compared with ACC. Epithelial degeneration and defects and widespread occurrence of inflammatory cells were typical features in ACC. Necrosis in the muscle layer was also more common and extended wider and deeper in ACC. There were no differences in the occurrence of capillary thromboses, lymphatic follicles or Rokitansky-Aschoff sinuses between the AAC and ACC samples. CONCLUSIONS: There are characteristic differences in histopathology between AAC and ACC, although due to overlap, none appeared to be specific as such for either condition. These results suggest that AAC is largely a manifestation of systemic critical illness, whereas ACC is a local disease of the gallbladder.

Cardiac tamponade and septic shock caused by viral infection in a previously healthy woman.

A previously healthy woman was admitted to hospital after 'flu-like' symptoms for 5 days followed by acute intense abdominal and lower back pain. On admission she was found to be in severe shock and was transferred to the ICU. Echocardiography revealed cardiac tamponade, and pericardiocentesis was performed immediately. Thereafter her cardiovascular state improved, but she developed hypotension with low systemic vascular resistance and required vasoactive treatment for 4 days. Nine days after admission the patient was transferred to the ward, after which she recovered rapidly and completely. The cause of her illness was extensively screened. No underlying disease was found, and all bacterial cultures remained negative. Acute virus infection was confirmed by diagnostic elevations of antibody titers to Influenza A and adenovirus. Adenovirus was also isolated from her bronchoalveolar lavage fluid.

Glycoalkaloid aglycone accumulations associated with infection by Clavibacter michiganensis ssp. sepedonicus in potato species Solanum acaule and Solanum tuberosum and their interspecific somatic hybrids.

Solanum acaule Bitt., a wild potato species, is closely related to cultivated potato (Solanum. tuberosum L.). Incorporation of desirable traits from allotetraploid [2n=4x=48, 2 endosperm balance number (EBN)] S. acaule (acl) into autotetraploid (2n=4x=48, 4EBN) S. tuberosum (tbr) is difficult due to incongruity boundaries. In this study, three hybrid combinations, each with a specific genome constitution, were produced through protoplast fusion: (1) hexaploid 2x acl (+) 4x tbr, (2) tetraploid 2x acl (+) 2x tbr, and (3) hexaploid 4x acl (+) 2x tbr hybrids. In terms of glycoalkaloid aglycones, the hybrids produced demissidine, tomatidine and solanidine, similarly to the S. acaule parental species, but S. tuberosum synthesised only solanidine. Inoculations with Clavibacter michiganensis ssp. sepedonicus (Cms), which is the causal agent of bacterial ring rot in potato, yielded significantly lower total glycoalkaloid aglycone accumulation both in S. acaule plants and in interspecific hybrids in comparison with the corresponding mock-inoculated plants. However, in S. tuberosum the aglycone levels were either higher or unchanged as a result of infection by Cms. To incorporate the desirable traits of the interspecific somatic hybrids into 4EBN S. tuberosum, sexual backcrosses were carried out. The hexaploid 4x acl (+) 2x tbr hybrids with the hypothetical 4EBN showed the greatest capacity to undergo backcrosses with S. tuberosum.