Candida endophthalmitis: A critical diagnosis in the critically ill.

Three cases of candida endophthalmitis complicating critical illness in young adult surgical patients with implications for safer practice are presented. We highlight how early ophthalmological examination can aid in the management of such critically ill patients. Clinicians need to be vigilant for the early diagnosis and aggressive treatment of hospital acquired opportunistic candida infection in at risk patients. Time may be of the essence as sight and life are at risk.

The distribution of oxidatively-modified lysine in the human vasculature.

Fifty-seven sections of human vessels, collected in the Pathobiological Determinants of Atherosclerosis in Youth study from individuals aged 25-34, were stained with two monoclonal antibodies to oxidatively-modified lysine. Intensity and extent of immunoreactivity were graded by three pathologists. Aorta from a Watanabe heritable hyperlipidemic (WHHL) rabbit was stained as a positive control. Intimal immunoreactivity in the rabbit was predominantly localized to lesions. Although immunoreactivity in humans was somewhat more intense in atherosclerotic plaques, substantial staining was present in intima with diffuse intimal thickening and coronary veins. Localization of oxidatively-modified lysine in humans did not correlate with localization or severity of atherosclerosis. Localization of immunoreactivity for oxidatively-modified lysine to intimal lesions in the WHHL rabbit may be due to absence of diffuse intimal thickening, which prevents retention of epitopes throughout the intima.

Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies.

BACKGROUND: The use of methotrexate for the treatment of women with tubal ectopic pregnancies is now common practice. However, the clinical and hormonal determinants of the success of this treatment are not known. METHODS: We studied 350 women with tubal ectopic pregnancies who were treated with methotrexate intramuscularly according to a single-dose protocol. Pretreatment serum concentrations of human chorionic gonadotropin and progesterone, the size and volume of the gestational mass, fetal cardiac activity, and the presence of fluid (presumably blood) in the peritoneal cavity were correlated with the efficacy of therapy, as defined by resolution of the ectopic pregnancy without the need for surgical intervention. RESULTS: There was no relation between the women's age or parity, the size or volume of the conceptus, or the presence of fluid in the peritoneal cavity and the efficacy of treatment. Among the 320 women in whom treatment was successful (91 percent), the mean (+/-SD) serum chorionic gonadotropin and progesterone concentrations were 4019+/-6362 mIU per milliliter and 6.9+/-6.7 ng per milliliter (21.9+/-21.3 nmol per liter), respectively, as compared with 13,420+/-16,590 mIU per milliliter and 10.2+/-5.5 ng per milliliter (32.4+/-17.5 nmol per liter) (P<0.001 and P=0.02) in the 30 women in whom treatment was not successful. Fetal cardiac activity was present in 12 percent of the successfully treated cases and 30 percent of those in which treatment was not successful (P=0.01). Regression analysis revealed the pretreatment serum chorionic gonadotropin concentration to be the only factor that contributed to the failure rate. CONCLUSIONS: Among women with tubal ectopic pregnancies, a high serum chorionic gonadotropin concentration is the most important factor associated with failure of treatment with a single-dose methotrexate protocol.

Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy.

OBJECTIVE: To evaluate the conservative management of pain after systemic methotrexate therapy for ectopic pregnancy; identify prognostic factors for success; and compare hCG resolution time for patients with and without pain. METHODS: A retrospective review of patients with ectopic pregnancy requiring evaluation for pain after receiving single-dose methotrexate therapy is performed. Results of hematocrits, ultrasound findings, hCG levels, time for hCG levels to reach less than 15 mIU/mL, and outcome were noted. RESULTS: Fifty-three patients with 64 episodes of pain were identified. Seven hospitalized patients required surgery during admission. Two previously hospitalized and one outpatient also ultimately underwent surgery. For hospitalized patients, there were no statistical differences between patients who did or did not undergo surgery during admission for any variable studied, including the presence of free peritoneal blood or rebound tenderness. However, comparison of hospitalized and nonhospitalized patients showed those with rebound tenderness were more likely to be admitted. Hospitalized patients not requiring surgery had shorter resolution time than nonhospitalized patients. For hospitalized and nonhospitalized patients, the median time from treatment to presentation for pain was 8 days. CONCLUSION: The occurrence of pain following methotrexate therapy for ectopic pregnancy should not be the sole indication for surgical intervention. The majority of stable patients with pain after methotrexate therapy, even with rebound or free peritoneal fluid, can be treated successfully without surgery, either in hospital with close observation for severe pain or as outpatients for patients with less severe pain.

Aspiration and microscopy in the diagnosis of ectopic pregnancy.

OBJECTIVE: To compare Karman cannula aspiration followed by dissecting microscopy with suction curettage and permanent histology in obtaining and identifying chorionic villi. METHODS: Karman cannula aspiration was performed before standard curettage for failed intrauterine pregnancies (N=22) or possible ectopic gestation (N=24). Dissection microscopy for chorionic villi was performed on aspirates before submission for permanent histology. Sensitivity, specificity, positive and negative predictive value of each method in obtaining and identifying villi was determined. RESULTS: Overall, all methods were only moderately sensitive in detecting chorionic villi (50-76%). If failed intrauterine pregnancies were excluded, all methods had poor sensitivity (25-64%). However, if villi were detected, the positive predictive value of all methods was high (> 80%). CONCLUSIONS: Karman cannula aspiration followed by dissecting microscope examination or permanent histology may offer an alternative to traditional curettage in the diagnosis of ectopic gestations. A larger trial to validate these findings seems justified.

Role of acid and salivary epidermal growth factor in gastric mucosal adaptation to naproxen in man.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) frequently damage the gastrointestinal tract, but with continued administration this usually resolves by a process of adaptation. There is evidence that the acute injury can be reduced by acid suppression, and animal models have shown that salivary epidermal growth factor (EGF) is an important factor in gastric mucosal adaptation. We therefore wanted to assess the effect of acid suppression and salivary EGF output during naproxen-induced acute gastric injury and subsequent adaptation. METHODS: Healthy subjects were given a 14-day course of naproxen with different regimens of ranitidine and placebo. Before and on three occasions during treatment subjects provided a salivary sample for EGF and underwent gastroscopy to assess gastric damage. RESULTS: Similar gastric damage occurred after 24 h in all groups and resolved in most subjects. Base-line salivary EGF output was similar in all groups but increased in the placebo/ranitidine group on day 3 and in the ranitidine group on day 9. CONCLUSIONS: Acid suppression with ranitidine did not prevent acute gastric injury. Adaptation may be associated with an increase in salivary EGF output.

Gastrointestinal tolerability of meloxicam and piroxicam: a double-blind placebo-controlled study.

AIMS: The aim of the study was to compare the effects of meloxicam and piroxicam on the gastroduodenal mucosa in healthy adults. METHODS: Forty-four healthy volunteers were given a 28 day course of either meloxicam 15 mg, piroxicam 20 mg or placebo. Damage to the oesophageal, gastric and duodenal mucosa was assessed, mucosal blood flow (MBF) measured at endoscopy and biopsies taken for prostaglandin content and microscopic assessment of damage before NSAID administration and during days 1, 7 and 28 of continued intake. RESULTS: Maximal macroscopic gastric mucosal damage (median grade+IQR) occurred within 24 h of piroxicam administration, the damage score increasing from 0 to 2.5 (0-3) (P=0.02) at day 1 before falling to 2.0 (0-2) at day 7 and 0 (0-1) at day 28 with resolution of damage observed in six out of the seven subjects who sustained acute injury. No significant macroscopic gastric damage occurred in either of the two other groups although some minor damage was observed in seven subjects taking placebo and five taking meloxicam. There was a trend towards piroxicam causing more acute gastric damage than meloxicam (P=0.06). Baseline antral, body and duodenal MBF were similar in all three groups. No significant changes occurred in any of the groups on any of the visits. There were also no changes in gastric mucosal prostaglandin content in any group. CONCLUSIONS: These observations suggest that meloxicam causes little acute damage to the upper gastrointestinal tract and piroxicam causes some acute gastric injury but such damage resolves in most subjects by 28 days.

A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates.

OBJECTIVE: To compare intraoperative and postoperative outcomes between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy among patients who are not eligible for vaginal hysterectomy. METHODS: Study subjects were randomly assigned to undergo laparoscopically assisted vaginal hysterectomy or standard abdominal hysterectomy. Intraoperative and postoperative management was similar for each group. Surgical characteristics, complications, length of hospital stay, charges, and convalescence were analyzed. RESULTS: Sixty-five women at three institutions underwent laparoscopically assisted vaginal hysterectomy (n = 34) or abdominal hysterectomy (n = 31). Three patients in the laparoscopic group required conversion to abdominal hysterectomy. Mean operating time was significantly longer for laparoscopically assisted vaginal hysterectomy (179.8 versus 146.0 minutes). There were no differences in blood loss or incidence of intraoperative complications. There was a higher incidence of wound complications in the abdominal hysterectomy group, but no significant difference in the frequency of postoperative complications. Laparoscopically assisted vaginal hysterectomy required a significantly shorter mean hospital stay (2.1 days) and convalescence (28.0 days) than abdominal hysterectomy (4.1 days and 38.0 days, respectively). There were no significant differences in mean hospital charges between the study groups (laparoscopic $8161, abdominal $6974). CONCLUSION: Except for operating time, there are no differences between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy regarding intraoperative characteristics among abdominal hysterectomy candidates. Postoperatively, laparoscopically assisted vaginal hysterectomy requires a shorter hospital stay and convalescence. Hospital charges are similar between the procedures. A larger number of cases will help determine the indications for laparoscopically assisted vaginal hysterectomy.

Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate.

OBJECTIVES: The objective of this study was to review the largest single series of ectopic pregnancies treated with single-dose methotrexate reported to date. STUDY DESIGN: A review of 315 patients with unruptured ectopic pregnancies treated with single-dose methotrexate 50 mg/m2 from March 21, 1990, to March 1, 1997, was performed. RESULTS: Overall 287 patients were successfully treated with methotrexate for a success rate of 90.1%. Six patients electively withdrew and requested surgery within 1 week of starting therapy. Excluding withdrawals the overall success rate was 92.9%. Ten patients with an ectopic pregnancy > 3.5 cm but < or = 4 cm in size were treated for a 90% success rate. Forty-four patients with positive ectopic cardiac activity were treated with an 87.5% success rate. CONCLUSIONS: This large series indicates that single-dose intramuscular methotrexate for treatment of ectopic pregnancy is associated with an excellent overall success rate.

The influence of age, gender, Helicobacter pylori and smoking on gastric mucosal adaptation to non-steroidal anti-inflammatory drugs.

INTRODUCTION: Oral NSAIDs cause acute gastric injury that resolves, despite continued administration, by a process known as adaptation. Little is known about the factors that influence this process. METHODS: Sixty-two healthy volunteers were given a 28-day course of either etodolac 300 mg b.d. (13 subjects), naproxen 500 mg b.d. (23), enteric-coated diclofenac (10) or effervescent diclofenac 50 mg b.d. (16). All subjects were gastroscoped before and on days 1, 7 and 28 during drug administration, to assess gastric mucosal damage using a modified Lanza scale. Subjects were then divided into three categories: those who adapted completely, those who adapted incompletely and those who showed no adaptation. The proportion of subjects in each group was compared with respect to age, gender, smoking, the presence of Helicobacter pylori, and the NSAID prescribed. RESULTS: Fifty-nine subjects (median age 25.0 years, range 18-70) developed initial gastric injury to NSAIDs of whom 42 adapted completely, 13 adapted incompletely and four showed no evidence of adaptation. The mean age of subjects was lower in those who adapted (26.8 +/- 9.8 years) than those who adapted incompletely (32.5 +/- 10.3 years) and those who did not adapt (42.0 +/- 15.7 years, P = 0.01). There was no evidence of gender influencing adaptation. Of 17 H. pylori-positive subjects, a higher proportion had incomplete adaptation, with only nine subjects adapting completely (53% vs. 81%, P = 0.04). Sixteen subjects were smokers, of whom a greater proportion showed no evidence of adaptation (19% vs. 2%, P = 0.03). A smaller proportion of those who took naproxen (48%) adapted completely than those who took enteric-coated diclofenac (89%), effervescent diclofenac (75%) or etodolac (91%, P = 0.03). CONCLUSION: Some adaptation occurred in over 90% of subjects after 4 weeks dosing with an NSAID, but adaptation was less frequent in older subjects and in smokers. Complete adaptation occurred less frequently in H. pylori-positive subjects and in those who were given naproxen.

The use of percutaneous endoscopic gastrostomy (PEG) feeding tubes in patients with neurological disease.

Percutaneous endoscopic gastrostomy (PEG) is being used increasingly in the treatment of patients with neurogenic dysphagia to improve nutrition and prevent choking and aspiration pneumonia. PEG is used in a wide range of general medical conditions, but its role in clinical neurology is sometimes controversial. This paper reviews the place of PEG in the management of 32 patients with a variety of chronic and progressive neurological disorders. All the patients found it to be an effective and acceptable method of feeding that prevented weight loss, reduced chest infections, facilitated nursing care and improved their quality of life. PEG has an important role in neurological rehabilitation.

A prospective study of abdominal computerized tomography and colonoscopy in the diagnosis of colonic disease in an elderly population.

OBJECTIVE: The aim of this prospective study was to compare the accuracy of abdominal computed tomography (CT) and colonoscopy in diagnosing colonic pathology in an elderly population. METHODS: Patients over the age of 70 for whom an outpatient diagnostic colonoscopy had been requested, were invited to attend for a CT scan of the abdomen following oral colonic preparation. CT was carried out within 1 month of the colonoscopy and all images were evaluated by a single consultant radiologist with no prior knowledge of the colonoscopy result. RESULTS: Of 72 patients who fulfilled entry criteria and attended for colonoscopy, 55 (29 female) had abdominal CT of the abdomen (mean age 76.6 years, range 70-92). Colonoscopy was successful in 67% of cases and the following colonoscopic diagnoses were made: diverticular disease (26), normal (14), colonic carcinoma (6), polyps (9) colitis (2) and angiodysplasia (1). There was agreement between colonoscopic and CT diagnoses in 38 patients (69%) including all those with carcinoma of the colon. There was disagreement in 12 patients with diverticular disease, CT missed three polyps in three patients and angiodysplasia in one patient. CT provided additional important information in 9 patients: gastric leiomyosarcoma (1), aortic aneurysm (1), absence of metastases (3), liver metastases (2), cirrhosis and portal hypertension (1) and a large pleural effusion (1). One patient thought to have a carcinoma of the colon by both techniques was subsequently found to have a diverticular mass at laparotomy. Two patients undergoing colonoscopy had colonic perforations and one of these died. CONCLUSION: CT may provide an alternative to colonoscopy in diagnosis of colonic disease in the elderly population.

Influence of Helicobacter pylori on gastric mucosal adaptation to naproxen in man.

Our objective was to determine whether H. pylori influences gastric mucosal injury and adaptation caused by naproxen. Twenty-four healthy volunteers, 12 H. pylori-positive and 12 H. pylori-negative, were given a 28-day course of naproxen 500 mg twice a day. They were each gastroscoped to assess gastric mucosal damage and mucosal blood flow before and at 1, 7, and 28 days during treatment. Maximal gastric mucosal damage (median grade + IQR) occurred during the first 24 hr in both groups and was of similar magnitude (H. pylori-positive: 2.5, 2.0-3.0 P < 0.01; H. pylori-negative: 2.0, 1.0-3.0 P < 0.01). This damage was associated with a fall in antral but not corpus mucosal blood flow. With continued NSAID administration, gastric damage resolved confirming adaptation (H. pylori-positive 1.0, 0-2.0, H. pylori-negative: 1.0, 0-1.0) and antral mucosal blood flow returned to baseline in both groups by day 28. These observations suggest that initial gastric mucosal injury is not influenced by H. pylori colonization and adaptation occurs regardless of its presence.

Gastric mucosal injury and adaptation to oral and rectal administration of naproxen.

INTRODUCTION: Oral nonsteroidal anti-inflammatory drugs (NSAIDs) cause acute gastric mucosal injury but the relative importance of systemic and topical effect of NSAIDs to overall gastric damage remains uncertain. METHODS: Twenty-four healthy volunteers were allocated either oral or rectal naproxen 500 mg b.d. and gastroscoped before and during days 1, 7 and 28 of dosing. Macroscopic gastric damage was assessed using a modified Lanza score, mucosal blood flow recorded using laser Doppler flowmetry and prostaglandin E2 (PGE2) measured in antral mucosal biopsies. RESULTS: Maximal gastric damage occurred during the first 24 h in the oral naproxen group and was associated with a fall in antral mucosal blood flow (mean +/- S.E.M.) from 58.2 +/- 3.3 to 46.6 +/- 4.1 arbitrary units (a.u.) (P < 0.05). With continued administration of oral naproxen, gastric damage resolved and antral mucosal blood flow returned to baseline (54.2 +/- 3.7 a.u.). No macroscopic damage or significant changes in mucosal blood flow were observed during rectal administration. There was no significant difference between mucosal PGE2 concentrations in those receiving oral or rectal naproxen, falling from an initial level of 335 +/- 29 to 155 +/- 49 pg/mg at day 1 (P = 0.06) in those receiving oral naproxen and from 235 +/- 55 to 107 +/- 31 pg/mg at day 1 (P = 0.1) in those receiving rectal naproxen, and remaining suppressed throughout the study in both groups. CONCLUSIONS: These observations suggest that acute mucosal damage and changes in mucosal blood flow are caused by the topical rather than systemic actions of naproxen.

Methotrexate therapy for ectopic pregnancy in adolescents.

STUDY OBJECTIVE: To determine the suitability and efficacy of methotrexate (MTX) therapy for adolescent patients with ectopic pregnancy. MATERIALS: Patients with ectopic pregnancy were treated with methotrexate, 50 mg/m2 intramuscularly. Follow-up determinations of quantitative beta hCG levels were done on days 1, 4, and 7. They were then seen weekly until beta hCG levels were less than 15 mIU/ml. PARTICIPANTS: Adolescents with ectopic pregnancy (55 patients) received MTX therapy and comprised the study group. They were compared with 186 adults similarly treated. The groups were compared for treatment outcome and for compliance with the rigid protocol requirements. MAIN OUTCOME MEASURES: Treatment success was defined as a patient who required no surgical intervention and whose beta hCG levels declined to < 15 mIU/ml. RESULTS: 85% of patients required no surgical intervention following MTX injection. Surgical intervention rates were slightly higher and success rates slightly lower for adolescent patients, but these differences were not statistically significant (p = .71). Although adult patients were more likely to have a perfect compliance rating, comparison of all compliance categories showed no significant differences (p = .17). CONCLUSIONS: MTX therapy is satisfactory for adolescent patients. It is effective, and adolescent patients are able to comply with the requirements of a rigid protocol.

A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting.

OBJECTIVE: To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance. DESIGN: A retrospective review of charges. SETTING: The Regional Medical Center, Memphis, Tennessee. PATIENTS: Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization. MEASUREMENTS AND MAIN RESULTS: Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment. CONCLUSION: Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.