A rare case of ischaemic pneumatosis intestinalis and hepatic portal venous gas in an elderly patient with good outcome following conservative management.

INTRODUCTION: Pneumatosis intestinalis (PI) and hepatic portal venous gas (HPVG) are typically associated and are likely to represent a spectrum of the same disease. The causes of both entities range from benign to life-threatening conditions. Ischaemic causes are known to be fatal without emergency surgical intervention. PRESENTATION OF CASE: In this case a 93year old male experienced acute abdominal pain radiating to his back, with nausea and vomiting and a 2-week history of altered bowel habit. Examination revealed abdominal tenderness and distension. He had deranged white cell count (WCC) and renal function. Computed tomography (CT) revealed PI with associated HPVG. The cause was due to ischaemic pathology. The patient was managed conservatively with antibiotics and was discharged 7days later with resolution of his abdominal pain and WCC. DISCUSSION: The pathogenesis of HPVG secondary to PI is poorly understood but usually indicates intestinal ischaemia, thought to carry a mortality of around 75%. HPVG in the older patient usually necessitates emergency surgery however this is not always in the patient's best interest. CONCLUSION: There are few reported cases of patient survival following conservative management of PI and HPVG secondary to ischaemic pathology. This case demonstrates the possibility of managing this condition without aggressive surgical intervention especially when surgery would likely result in mortality due to frailty and morbidity. Further work is required to identify suitable patients.

Early decrease in surface expression of HLA-DQ predicts the development of infection in trauma patients.

The behaviour of human leucocyte antigen-DR (HLA-DR) following injury has been extensively studied. However, the behaviour of other class II antigens following trauma has not been characterized as well, despite evidence that HLA-DQ genotype influences the response to several bacterial antigens. Our study attempts to characterize and analyse the behaviour of HLA-DQ after trauma in patients with and without infection. Twenty-five patients were studied following major injury. Fifteen of the 25 patients developed infection (men = 11, women = 4); 10 patients developed no infection (men = 9, women = 1). The mean age was 34 +/- 12 years for patients with no infection and 52 +/- 20 years for those with infection. Monocyte HLA-DQ surface expression was determined using FITC-labelled antibodies and flow cytometry. Expression was compared with a control population of 11 healthy volunteers. The percentage of monocytes expressing HLA-DQ following trauma was reduced in patients with infection and in those without infection, but returned to normal (days 8-14) only in those patients who did not develop infection. Monocyte HLA-DQ mean channel fluorescence was reduced on day 1, but quickly returned to normal in those patients who subsequently developed infection. Stimulated with lipopolysaccharide, the initial samples of 13 patients who developed infection showed that surface expression on these monocytes could be elevated into the normal range. We conclude that HLA-DQ is an additional early marker of outcome that may not function merely as an immune suppressor. The maintained ability of HLA-DQ to present self-antigens may be important in the initial stages of the host response to injury.

Unusual infant death: dog attack or postmortem mutilation after child abuse?

An unusual form of fatal child abuse is reported in which investigations by the police and the medical examiner were able to distinguish blunt force head trauma followed by postmortem dismemberment from a fatal dog attack. A discussion of the approaches used to ascertain the correct diagnosis is presented, as well as an overview of dog attacks on humans.

Differences between bacterial species shown by simultaneous assessment of neutrophil phagocytosis and generation of reactive oxygen intermediates in trauma patients.

HYPOTHESIS: Previous studies on alterations in phagocytosis and bacterial killing after trauma have yielded conflicting results. We hypothesize that these changes are variable, depending on the species of bacteria used to assay these variables. DESIGN: Blood samples from patients were assayed by means of flow cytometry for phagocytosis and reactive oxygen intermediate generation. Several common clinical pathogens were used: Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus. Results were compared with those from controls. SETTING: Regional level I trauma center. PATIENTS: Ten consecutive patients were studied with E. coli and K. pneumoniae. Five of these were also studied with S. aureus. Patients were 18 years of age or older, with an Injury Severity Score of 16 or more. Patients who were taking corticosteroids before hospital admission or who were administered corticosteroids before blood was drawn were not studied. Isolated head injuries or limb fractures were also excluded. Controls consisted of healthy volunteers. MAIN OUTCOME MEASURES: The ingestion of bacteria by neutrophils and the generation of reactive oxygen intermediates. RESULTS: After trauma, phagocytosis of E. coli was enhanced, whereas ingestion of K. pneumoniae was depressed. Ingestion of S aureus remained unchanged. The generation of reactive oxygen intermediates was depressed after incubation with E. coli and unchanged with K. pneumoniae, but enhanced with S. aureus. CONCLUSIONS: Neutrophil response to trauma is dependent on which bacterial species the cell is attempting to kill. This may, in part, explain why only a limited number of bacterial species cause a significant proportion of early infections after trauma.

Villous adenoma of the distal appendix.

Villous adenoma confined to the distal appendix has not been previously reported in conjunction with acute apendicitis. The presence of an adenoma indicates a need for further investigation due to an association with neoplasia elsewhere.

Response of immunoregulatory lymphocyte subsets to methotrexate in rheumatoid arthritis.

In an attempt to define the immunoregulatory mechanisms operating in rheumatoid arthritis, the authors examined peripheral blood functional lymphocyte subsets in 15 patients with active rheumatoid arthritis who were not receiving remittive therapy, as well as 33 healthy controls. The percentage and absolute numbers of total T cells (CD3), T-helper/inducer cells (CD4), and T-suppressor/cytotoxic cells (CD8) did not differ among the groups, nor did the CD4:CD8 ratio or the numbers of T cells coexpressing CD4 and the activation markers Ia or IL-2R. However, rheumatoid arthritis patients did have reduced percentages and numbers of CD4+ cells coexpressing the 2H4 antigen (CD45R-naive T cells) (P less than .0003) and CD8+ cells coexpressing the Leu-15 (CD11b) marker (suppressor/effectors) (P less than .0005). Twelve patients then received oral methotrexate, 7.5 mg weekly. Most showed clinical improvement by 4 weeks and all did by 8 weeks. Although changes in the T-cell subsets were not statistically significant, several tended toward normalization. These findings may help explain the immunoregulatory defect in rheumatoid arthritis and the effectiveness of methotrexate in modifying disease activity.

Metropolitan Forensic Anthropology Team (MFAT) case studies in identification: 2. Identification of a Vietnamese trophy skull.

A Vietnamese trophy skull, apparently a victim of the Vietnam war, was recently received for analysis in a New York State homicide case. The skull, which is well preserved except for the missing mandible and maxillary dentition, is compared to trophy skulls of Japanese military personnel, also brought back to the United States by American soldiers following wartime duty in Asia.

Discriminant function analysis of the central portion of the innominate.

Terry Collection innominates of 260 American whites and blacks (65 males and 65 females of each race) were analyzed by discriminant function analysis for sex assessment, race known, and for simultaneous race and sex assessment. Measurements from the preservationally favored central portion of the innominate were chosen for their potential usefulness in forensic casework and to objectify long-recognized "formal" differences between the sexes in the greater sciatic notch. These included acetabular diameter, greater sciatic notch height, and position of greatest notch depth. Accuracy of sex prediction when race is known is roughly 90% in both the base sample of 260 and a test sample of 200 (50 additional individuals for each group). For simultaneous race and sex assessment, accuracy of prediction is roughly 60% for each group in both samples. This represents about a 45% reduction in error over random assignment by race and sex.

Metropolitan Forensic Anthropology Team (MFAT) studies in identification: 1. Race and sex assessment by discriminant function analysis of the postcranial skeleton.

A case study is presented to demonstrate the utility of the team approach to the identification of human remains, and to illustrate a methodological innovation developed by MFAT. Case 1 represents the first of several planned case studies, each designed to present new methodological solutions to standard problems in identification. The present case describes a test, by application, of race and sex assessment of the postcranial skeleton by discriminant function analysis.

Multiple discriminant function analysis of sex and race in the postcranial skeleton.

Terry Collection femora and innominates of 260 American Whites and Blacks (65 males and 65 females of each race) were analyzed by multiple discriminant function analysis. A stepwise procedure produced three optimal discriminant functions using 15 of our 32 measurements. These functions correctly identified 95% of the sample. The first two-one for sex and one for race-are statistically and biologically significant and form the basis of our analysis. The sexing function manifested both size and shape elements. Prominent among the former was joint size--acetabular diameter and epicondylar diameter of the femur. The shape elements included form of the greater sciatic notch and of the inferomedial aspect of the pubic body. The racing function highlighted a pattern of greater innominate dimensions, exclusive of the acetabular joint, in Whites. This was in contrast to the greater length of the Black femur. Overall, the function seems to express the established differences between the races in the ratio of lower limb length to torso length. While these functions have been applied successfully to forensic cases with confirmed identifications, questions regarding the breadth of applicability of discriminant functions make it desirable to validate our results on new material from the Terry and other collections.

Classification and misclassification in sexing the Black femur by discriminant function analysis.

Stepwise discriminant function analysis for sex assessment was applied to 130 North American Black femora. The measurements included femoral length and three midshaft dimensions likely to be preserved in archaeologically-derived and forensic remains. The method correctly assigned sex for 76.4% of the sample (range 70.8-81.5%). This compares favorably with results achieved with other skeletal parts; it also compares favorably with results using the femur in sexing other racial groups. Among our other conclusions are: (1) a "general size factor" is one of major significance in correct classification and in misclassification of sex, and most misclassified individuals are anomalous for this factor; (2) the inconsistency in the relation between circumference and femoral length, which characterizes the remaining misclassified individuals, suggests that anomalous functional demands of body weight/musculature are at fault, and affect circumference more than length; and (3) discriminant function analysis of the same variables in Whites produced similar results, suggesting that sex overrides race in sex assessment; this was confirmed by cross-validating the predictive accuracy of Black discriminant function coefficients on White data, and vice versa.

Determination of sex of white femora by discriminant function analysis: forensic science applications.

Stepwise multiple discriminant function analysis is used to establish classification functions for sex assessment of North American white femora. The functions correctly assign sex for 82% of a sample consisting of 85 femora of verified age, sex, and race, and for a similarly verified test sample of 30. The objectives are to provide criteria for sexing poorly preserved and fragmentary unknown specimens and a statement of the probable accuracy of such assessments in individual cases. The application of the method to forensic casework is illustrated by a sample case.

Cranial capacity/cranial base relationships and prediction of vault form: a canonical correlation analysis.

Canonical correlation analysis was used to test an hypothesized morphological relationship between vault form and cranial capacity relative to length of the chondrocranium. Ninety-five adult male Czech skulls were measured for vault form expressed as length, width and height of the brain case; the chondrocranium was represented by nasion-basion and basion-opisthion lengths. In terms of explained variation, the first and most important dimension of covariation between vault and chondrocranial variables was size. The second most significant dimension of covariation expressed the hypothesized shape relationships--i.e., overall size being equal, the shorter the chondrocranial base relative to cranial capacity, the shorter and wider the vault. Furthermore, the competing hypothesis that vault form is determined by facial length proved untenable since facial length was predictive of vault shape only when measured as prosthion-basion, a measure that incorporates basal length. When corrected for basal length, facial length is unrelated to vault form. The results are consistent with the assumption that phylogenetic and microevolutionary trends toward brachycephaly in man stem from changes in the relationship between two components of skull growth, the chondrocranial base and the brain.

Sex assessment of the femur: a test of a new method.

Simple and multiple discriminant functions using mid-shaft femoral circumference for the determination of sex were used to test a sexing method recently proposed by Black. The method was able to correctly assign sex for 82% of the sample, which consisted of 115 North American White femora of verified age and sex. Circumference proved as accurate as any other criteria that have been used in sexing the femur. This suggests a usefulness beyond the limited archaelogical scope originally proposed by Black.

Pharmacology of some acetylcholine homologues.

1. The acetates of several long chain (3 to 12 methylene groups) analogues of choline have been prepared and their pharmacological properties studied.2. None of the compounds had a high level of activity at the post-ganglionic parasympathetic acetylcholine receptors. The lower members of the series showed weak agonist activity and the homologues with 8 to 10 methylene groups had very weak anticholinergic activity.3. All the compounds had a depolarizing action at the acetylcholine receptors of the neuromuscular junction and of sympathetic ganglia. At the neuromuscular junction there were two peaks of stimulant activity, one with the hexamethylene and one with the dodecamethylene homologue, whereas at the ganglion there was only one peak, with the hexamethylene homologue.4. The ganglion-stimulant activity of the higher members of the series was blocked by pretreatment with the anticholinesterase drug dyflos, whereas the activity of lower members was either unaffected by such treatment or slightly potentiated.5. The results are discussed in terms of possible spatial arrangements of acetylcholine receptor units in the neuromuscular junction and the ganglion.

The synthesis and pharmacology of some 1,4,5,6-tetrahydropyrimidines.

1. Several 1- and 2-substituted, and 1,2-disubstituted, 1,4,5,6-tetrahydropyrimidines have been prepared and their toxicological and pharmacological properties have been investigated.2. In general the compounds were neuromuscular blocking agents with the monosubstituted members of the series showing a depolarizing type of activity and the disubstituted compounds a non-depolarizing type.3. The toxicity to mice of some of the monosubstituted compounds was increased by pretreatment of the animals with SKF 525A, but the toxicity of the disubstituted compounds was unaffected.4. The results obtained with these compounds are not at variance with a suggestion made previously that nicotinic action at the neuromuscular junction can result from an interaction between drug and receptor at two points separated by about 4 A.