Gown-glove interface: a possible solution to the danger zone.

The gown-glove interface is the weakest point in the present barrier system of gown and glove protection for the surgeon and other healthcare professionals who come into direct contact with body liquids. Try it yourself: put on a fluid-resistant gown and surgical gloves. See that the glove cuff is well proximal to the stockinette. Hold your wrist and forearm for a moment under running water. Wait a minute to see if your forearm is wet. A wet forearm during surgery would be a blooded one. We propose a gown redesign that creates a dart at the terminal forearm, sealed by a liquid-proof method, and then similarly sealing the proximal end of the glove to the sleeve.

Selective amplification of simian immunodeficiency virus genotypes after intrarectal inoculation of rhesus monkeys.

Animal models for sexual transmission of human immunodeficiency virus can define the influences of virus type, dose, and route of inoculation on infection and clinical outcome. We used an uncloned simian immunodeficiency virus stock (SIVmac) to inoculate cells in vitro and to inoculate rhesus monkeys by intravenous and intrarectal routes. The distribution of virus genotypes present in each of these infection examples was characterized by DNA sequence analysis of viral long terminal repeats (LTRs). Our analysis of LTR sequences from in vitro and in vivo infections revealed three main genotypes: one genotype was observed only for in vitro infection, and two other genotypes were recovered only from infected animals. By comparing animals inoculated with high intrarectal doses of SIVmac and those inoculated with low doses, we demonstrated that unique subsets of the stock were selected after intrarectal infection. Our findings indicate that minor genotypes present in the stock cross the rectal mucosa and are amplified selectively to become prominent in peripheral blood mononuclear cells from acutely infected animals. Studies with a molecular recombinant of SIV and human immunodeficiency virus type 1 sequences, SHIV, showed that viral LTR sequences do not undergo especially rapid sequence variation or rearrangement after intrarectal inoculation. The mucosal barrier exerts a significant influence on infection and disease progression by reducing the efficiency of SIVmac infection and by permitting distinct, pathogenic genotypes to become established in the host.

Multiple mesenteric aneurysms complicating subacute bacterial endocarditis.

Multiple visceral aneurysms complicating periarteritis nodosa are considered characteristic, though not pathognomonic, on arteriography. This arteriographic pattern has been described with hairy-cell leukemia, collagen vascular disorders, and atrial myxoma, but, to our knowledge, has not been previously reported with subacute bacterial endocarditis. A patient with enterococcal endocarditis sustained separate intra-abdominal hemorrhages, 24 hours apart, from aneurysms of the middle colic and left colic arteries. Sterile vessel cultures with inflammatory infiltrates, decreased complement levels, positive rheumatoid factor, and arteriographic evidence of multiple visceral aneurysms suggest the vasculitis was immunologically mediated and not mycotic. Antibiotic therapy after control of hemorrhage controlled abdominal symptoms.

Psoas abscess complicating Crohn's disease.

Psoas abscess classically was described as secondary to tubercular spondylitis but now more frequently is a complication of an intraabdominal process such as Crohn's disease. Less well recognized is that the fever, flexion contracture of the hip, and weight loss characterizing psoas abscess may be the first indications of Crohn's disease; in fact, gastrointestinal symptoms may be completely absent. Psoas abscess was the first sign of Crohn's disease in 11 of 46 reported patients. We present three additional patients; two were asymptomatic before psoas abscess formation. Only seven of 26 patients whose sole surgical procedure was drainage had subsequent resolution of the abscess. When drainage was combined with bowel resection, 14 of 18 patients (77.8%) were cured by the initial procedure. Thromboembolic complications occurred in four patients (8.3%). Effective therapy when psoas abscess complicates Crohn's disease, includes appropriate antibiotics, drainage, resection of fistulous intestine, and antithrombotic prophylaxis.

Recurrent pseudocysts and pancreatitis after trauma: a complication of pancreas divisum.

Two patients are described who developed pancreatitis and recurrent pseudocysts after minimal trauma. Both had the congenital anomaly of pancreas divisum, and neither responded to surgical therapy appropriate to patients with normal anatomy. Both patients eventually required excision of the entire dorsal portion of the pancreas for relief. Patients with pancreatitis and pseudocysts should undergo endoscopic pancreatography immediately before surgery to aid in the definition of appropriate surgical therapy.

Mastectomy performed by Lawrence Heister in the eighteenth century.

In 1720, Heister successfully removed a massive tumor of the breast. The lesion was probably a massive cystosarcoma phylloides rather than infiltrating carcinoma of the duct. His thorough description reveals that patients and surgeons have changed little in two and one-half centuries.

Measurement of ferritin-bearing peripheral mononuclear blood cells in cancer patients by radioimmunoassay.

A radioimmunoassay has been developed to measure ferritin bound to the surface of isolated human peripheral blood mononuclear white blood cells (PBMs) in order to investigate the possible relationship of this phenomenon to breast and other forms of cancer. The assay measures the specific binding (%SP) of affinity-purified 125I-labeled rabbit anti-Hodgkin's spleen ferritin antibody to isolated patient PBMs. A preliminary prospective, preclinical trial on 300 patients was run which included: (a) normals, benign breast disease, and medical/surgical patients as non-cancer controls; (b) postoperative primary cancer and advanced cancer in clinical remission as post cancer controls; and (c) both early preoperative breast cancer patients and cancer patients with localized recurrences or active disseminated disease as test groups. The mean %SP for the non-cancer control groups was in the range of 4.3 to 5.1 (n = 187), which was identical to that for inactive cancer or postoperative cancer, which was no evidence of recurrence. Using a %SP normal cutoff level of 6.5, which resulted in a false-positive rate of approximately 10% for both non-cancer and post-cancer control groups, only 27% of early preoperative cancers (n = 22) gave elevated %SP values. These results suggest that measurement of ferritin-PBM is inappropriate for early disease diagnosis. In contrast, 91% of patients with advanced active breast cancer and 73% of those patients with other types of advanced cancers, including tumors of ovarian, lung, colon or esophageal origin, showed elevated %SP values more than double those of post-cancer controls. The mean %SP value in active advanced cancer was 10.8 for breast (n = 12) and 10.6 for all other solid tumors investigated (n = 34). Paired patient comparisons of ferritin-PBM and plasma carcinoembryonic antigen in breast cancer showed elevations in 91% of the patients for ferritin-PBM and 67% for carcinoembryonic antigen. Overall, these results suggest that patients with advanced cancer display elevated levels of ferritin on the surface of their PBMs and that this measurement may be a useful adjunct in monitoring and evaluating the clinical status of cancer patients.

Increased risk of malignancy and uterine disease following perimenarchal hospitalization: an estrogen window effect.

The estrogen window hypothesis postulates that tumor induction by environmental carcinogens is facilitated by the endocrine effects of incomplete ovarian maturation at menarche. To determine if illness and operation at or near menarche might modify ovarian maturation and thus increase cancer risk, we studied the subsequent reproductive, surgical, and malignancy history of 125 women who were aged 10 to 15 years when admitted for possible appendicitis during 1945 to 1951. Total operative experience and cholecystectomy rates were within expectation, but excess rates for dilatation and curettage (98 versus 57 expected, P less than 0.001) and hysterectomy (41 versus 23 expected, P less than 0.0006) suggest disturbed endocrine maturation. In addition, one patient developed Cushing's syndrome and five patients developed rheumatoid arthritis. Eight malignancies were observed (twice the expected rate of 3.4, P = 0.047); six occurred before age 40 years (versus 1.54 expected, P = 0.001). Tumors and age at diagnosis were: lymphoma (20), ovarian (28), breast (32), thyroid (34), lung (36), cervix (39), endometrium (48), and colon (50). Compared with standard rates, the peak incidence in those who were menarchal at hospitalization was 20 times the expected incidence; in those who were premenarchal the rate was five times the expected incidence, and in those who were postmenarchal the rate was as expected. The results of this study support the validity of the estrogen window hypothesis and indicate the serious consequences of perimenarchal illness. Enteric disease requiring hospitalization at or near menarche appears to define a group of women at risk for gynecologic disease and malignancy; further study is needed to determine if there is an appropriate prophylactic therapy to reduce that risk.

Diagnostic error in breast disease.

Fifty-six breast biopsies, incorrectly assessed by preoperative clinical or mammographic examination, were reviewed to define the characteristics in the tumor or patient that caused the clinician and mammographer to be diagnostically inaccurate. The most important patient characteristic associated with error was the use of hormones. Failure to recognize that oral contraceptive use significantly reduces the incidience of benign breast disease contributed to the frequent misdiagnosis of lesions in those patients. Twelve of 16 masses in oral contraceptive users were malignant. In seven, their resemblance to cysts or fibroadenomas resulted in treatment delay of two weeks or 18 months. Because benign disease is uncommon in women who have used contraceptives two or more years, all new lesions in those women should be studied by biopsy promptly. Neither clinical nor mammographic evaluation of lesions in postmenopausal women who used estrogens was accurate. Twelve postmenopausal patients with carcinoma had used estrogens. Three of these lesions were considered benign clinically and four, by mammogram. In one, treatment was delayed four years. In women over 50 not using hormones, clinical diagnosis of malignancy was accurate. Ten carcinomas in those women were missed by mammogram. Eight had negative nodes; thus a negative mamogram when the clinical diagnosis is correct may be an effective guide in predicting the status of axillary nodes. Paget's disease was not recognized clinically in two of eight patients with that disease, and an additional two were not recognized on mammography. The initial examiner did not identify three of six inflammatory carcinomas. Ten percent of benign lesions were intraductal hyperplasia or papillomatosis with atypia and were the benign lesions most often misdiagnosed clinically and by mammogram. No microscopic lesions were noted on mammography without an associated palpable mass. Twenty-five per cent of the lesions in women aged 40-49 were incorrectly assessed by mammography or clinical examination. Four (15%) of the 27 carcinomas in this age group were not recognized by either modality. Mammography helped delineate the characteristics of masses in premenopausal women. With recognition that any mass that appears in a woman using oral contraceptives must be studied by biopsy, combined clinical and mammographic study in primenopausal women should minimize diagnostic error. Unfortunately, neither clinical nor mammographic evaluation of the women with irregular periods approaching menopause or within three years past menopause is accurate. It is in that age group that new diagnostic modalities are needed and when reported their efficacy in that age group should be stressed.