Safety guideline: skin antisepsis for central neuraxial blockade.

Concise guidelines are presented that recommend the method of choice for skin antisepsis before central neuraxial blockade. The Working Party specifically considered the concentration of antiseptic agent to use and its method of application. The advice presented is based on previously published guidelines, laboratory and clinical studies, case reports, and on the known properties of antiseptic agents.

Enhanced trabeculectomy in a UK district general hospital setting: is selective use of 5-fluorouracil all that is required?

To determine whether primary trabeculectomies performed in a UK district general hospital, specifically without making use of mitomycin-C augmentation but with selective use of the low potency anti-metabolite 5-fluorouracil, produce an acceptable long-term intraocular pressure (IOP)-lowering effect for an unselected patient group. Retrospective analysis of the outcomes of all the trabeculectomies (53 eyes) performed by a single surgeon in a UK district hospital with or without 5-fluorouracil enhancement. The mean follow-up period was 5.04 years. Mean IOP preoperatively was 26.4 mm Hg while postoperatively the mean was ≤14.9 at all the time periods examined. Intraoperative complications occurred in two eyes (3.8 %) including one suprachoroidal haemorrhage and one hyphema. Postoperative complications that occurred during the follow-up period included choroidal effusions in seven patients (13 %), early postoperative bleb leak in four patients (8 %) and immediate postoperative hypotony not requiring intervention in 18 patients (34 %). Five patients (9 %) developed postoperative hyphema (all <30 % anterior chamber height) and one patient (1.9 %) developed blebitis and endophthalmitis. None of our patients developed hypotony maculopathy. When trabeculectomy is performed on unselected patients attending a UK district general hospital, selective 5-fluorouracil augmentation is probably all that is required to obtain acceptable surgical outcomes.

Requirement for CD8-major histocompatibility complex class I interaction in positive and negative selection of developing T cells.

The interaction of the T cell surface glycoprotein CD8 with major histocompatibility complex (MHC) class I molecules on target cells is required for effective T cell activation. Mutations in the alpha 3 domain of the MHC class I molecule can disrupt binding to CD8, yet leave antigen presentation unaffected. Here we show that such a mutation can interfere with positive and negative selection of T cells bearing T cell receptors (TCRs) that interact specifically with the mutant class I molecule. Autoreactive T cells in male mice expressing a transgenic TCR specific for the male antigen H-Y and H-2Db were not deleted in the context of a transgenic Db molecule bearing a mutation at residue 227. Similarly, CD8+ cells were not positively selected in female mice expressing both the TCR and mutant class I transgenes. Endogenous MHC class I molecules were competent to bind CD8, but were unable to rescue the defect, indicating a requirement for coordinate recognition of antigen/MHC by a complex of the TCR and CD8 coreceptor for both positive and negative selection of thymocytes.

Antibodies to peptides detect new hepatitis B antigen: serological correlation with hepatocellular carcinoma.

The expression of a previously unidentified gene product, encoded by the hepatitis B virus (HBV) genome, has been achieved with a recombinant SV40 expression vector. Antibodies against synthetic peptides representing defined regions of this protein were used to screen cells infected with recombinant virus as well as tissues naturally infected with HBV. A 24,000-dalton protein (p24) was detected in cells infected with recombinant virus and a 28,000-dalton protein (p28) was detected in tissues infected with HBV. The peptides or recombinant-derived protein were used as antigens to screen sera from individuals infected with HBV. Specific antibodies were detected predominantly in sera from patients with hepatocellular carcinoma. The presence of p28 in tissues infected with HBV and the appearance of specific antibodies in infectious sera establish the existence of an additional marker for HBV infection.

Antibodies against CD14 protect primates from endotoxin-induced shock.

Lipopolysaccharide (LPS), residing in the outer membrane of all gram-negative bacteria, is considered a major initiating factor of the gram-negative septic shock syndrome in humans. LPS forms a complex with the LPS binding protein (LBP) in plasma, and LPS-LBP complexes engage a specific receptor, CD14, on the surface of myeloid cells, leading to the production of potent proinflammatory cytokines. The major goal of this study was to test the importance of the CD14 pathway in vivo in a primate model that is similar to human septic shock. Primates were pretreated with one of two different inhibitory anti-CD14 mAbs, then challenged with intravenous endotoxin (375 microg/kg/h) for 8 h. The anti-CD14 treatment regimens were successful in preventing profound hypotension, reducing plasma cytokine levels (TNF-alpha, IL-1beta, IL-6, and IL-8), and inhibiting the alteration in lung epithelial permeability that occurred in animals treated with LPS and an isotype-matched control antibody. These results demonstrate for the first time the importance of the CD14 pathway in a primate model that is similar to human septic shock. Inhibition of the CD14 pathway represents a novel therapeutic approach to treating this life-threatening condition.

Lipopolysaccharide binding protein enhances the responsiveness of alveolar macrophages to bacterial lipopolysaccharide. Implications for cytokine production in normal and injured lungs.

A plasma lipopolysaccharide (LPS)-binding protein (LBP) has been shown to regulate the response of rabbit peritoneal macrophages and human blood monocytes to endotoxin (LPS). We investigated whether LBP is present in lung fluids and the effects of LBP on the response of lung macrophages to LPS. Immunoreactive LBP was detectable in the lavage fluids of patients with the adult respiratory distress syndrome by immunoprecipitation followed by Western blotting, and also by specific immunoassay. In rabbits, the LBP appeared to originate outside of the lungs, inasmuch as mRNA transcripts for LBP were identified in total cellular RNA from liver, but not from lung homogenates or alveolar macrophages. Purified LBP enhanced the response of human and rabbit alveolar macrophages to both smooth form LPS (Escherichia coli O111B:4) and rough form LPS (Salmonella minnesota Re595). In the presence of LBP and LPS, the onset of tumor necrosis factor-alpha (TNF alpha) production occurred earlier and at an LPS threshold dose that was as much as 1,000-fold lower for both types of LPS. In rabbit alveolar macrophages treated with LBP and LPS, TNF alpha mRNA appeared earlier, reached higher levels, and had a prolonged half-life as compared with LPS treatment alone. Neither LPS nor LPS and LBP affected pHi or [Cai++] in alveolar macrophages. Specific monoclonal antibodies to CD14, a receptor that binds LPS/LBP complexes, inhibited TNF alpha production by human alveolar macrophages stimulated with LPS alone or with LPS/LBP complexes, indicating the importance of CD14 in mediating the effects of LPS on alveolar macrophages. Thus, immunoreactive LBP accumulates in lung lavage fluids in patients with lung injury and enhances LPS-stimulated TNF alpha gene expression in alveolar macrophages by a pathway that depends on the CD14 receptor. LBP may play an important role in augmenting TNF alpha expression by alveolar macrophages within the lungs.

Targeted deletion of the tub mouse obesity gene reveals that tubby is a loss-of-function mutation.

The mouse tubby phenotype is characterized by maturity-onset obesity accompanied by retinal and cochlear degeneration. A positional cloning effort to find the gene responsible for this phenotype led to the identification of tub, a member of a novel gene family of unknown function. A splice defect mutation in the 3' end of the tub gene, predicted to disrupt the C terminus of the Tub protein, has been implicated in the genesis of the tubby phenotype. It is not clear, however, whether the Tub mutant protein retains any biological activity, or perhaps has some dominant function, nor is it established that the tubby mutation is itself responsible for all of the observed tubby phenotypes. To address these questions, we generated tub-deficient mice and compared their phenotype to that of tubby mice. Our results demonstrate that tubby is a loss-of-function mutation of the tub gene and that loss of the tub gene is sufficient to give rise to the full spectrum of tubby phenotypes. We also demonstrate that loss of photoreceptors in the retina of tubby and tub-deficient mice occurs by apoptosis. In addition, we show that Tub protein expression is not significantly altered in the ob, db, or melanocortin 4 receptor-deficient mouse model of obesity.

The Role of Cognitive Factors in Predicting Balance and Fall Risk in a Neuro-Rehabilitation Setting.

INTRODUCTION: There is a consistent body of evidence supporting the role of cognitive functions, particularly executive function, in the elderly and in neurological conditions which become more frequent with ageing. The aim of our study was to assess the role of different domains of cognitive functions to predict balance and fall risk in a sample of adults with various neurological conditions in a rehabilitation setting. METHODS: This was a prospective, cohort study conducted in a single centre in the UK. 114 participants consecutively admitted to a Neuro-Rehabilitation Unit were prospectively assessed for fall accidents. Baseline assessment included a measure of balance (Berg Balance Scale) and a battery of standard cognitive tests measuring executive function, speed of information processing, verbal and visual memory, visual perception and intellectual function. The outcomes of interest were the risk of becoming a faller, balance and fall rate. RESULTS: Two tests of executive function were significantly associated with fall risk, the Stroop Colour Word Test (IRR 1.01, 95% CI 1.00-1.03) and the number of errors on part B of the Trail Making Test (IRR 1.23, 95% CI 1.03-1.49). Composite scores of executive function, speed of information processing and visual memory domains resulted in 2 to 3 times increased likelihood of having better balance (OR 2.74 95% CI 1.08 to 6.94, OR 2.72 95% CI 1.16 to 6.36 and OR 2.44 95% CI 1.11 to 5.35 respectively). CONCLUSIONS: Our results show that specific subcomponents of executive functions are able to predict fall risk, while a more global cognitive dysfunction is associated with poorer balance.

Etiology of pure tricuspid regurgitation based on anular circumference and leaflet area: analysis of 45 necropsy patients with clinical and morphologic evidence of pure tricuspid regurgitation.

Despite recent renewed interest in the detection of tricuspid valve regurgitation by echocardiographic and Doppler techniques, little morphologic information is available on dysfunctioning tricuspid valves. This report describes 45 necropsy patients with clinical and morphologic evidence of pure (no element of stenosis) tricuspid regurgitation and provides morphometric observations (anular circumference, leaflet area) of the tricuspid valve useful in determining the etiology of pure tricuspid regurgitation. Of 45 patients, 24 (53%) had pure tricuspid regurgitation resulting from an anatomically abnormal valve (prolapse in 7, papillary muscle dysfunction in 6, rheumatic disease in 5, Ebstein's anomaly in 3, infective endocarditis in 2, carcinoid tumor in 1), and 21 (47%) had an anatomically normal valve with systolic pulmonary artery hypertension (cor pulmonale in 12, mitral stenosis in 9). Anular circumference was dilated (greater than 12 cm) in patients with various causes of pulmonary hypertension, floppy valve and Ebstein's tricuspid anomaly. Leaflet area was increased in floppy valve and Ebstein's anomaly. Of the 45 patients, 24 had pulmonary systolic artery pressure measurements available for correlation with tricuspid valve morphology. Pulmonary artery pressures accurately predicted morphologically normal from abnormal valves in 16 patients (89%). Morphologic overlap occurred in six patients with pulmonary pressures of 41 to 54 mm Hg. Of these six, the additional knowledge of normal or dilated anular circumference correctly separated valves with normal and abnormal leaflets.

The CD14 differentiation antigen mediates the development of endotoxin responsiveness during differentiation of mononuclear phagocytes.

The CD14 antigen was originally described as a differentiation antigen on mononuclear cells. The purpose of this study was to investigate the relationship between the appearance of surface CD14 and the acquisition of lipopolysaccharide (LPS) responsiveness during maturation of mononuclear phagocytes. Immature THP-1 cells responded poorly to LPS in the absence or presence of serum. Treatment with the maturational agent calcitriol caused a dose- and time-dependent increase in CD14 mRNA and surface CD14 and enhanced the responsiveness of THP-1 cells to smooth and rough form LPS, complexes of LPS and lipopolysaccharide-binding protein (LBP), and LPS in low concentrations of serum. Monoclonal antibodies to CD14 blocked the responses of THP-1 to LPS, LPS-LBP complexes and LPS in serum. Immunodepletion of LBP from serum also inhibited the effect of LPS in serum. The data show that maturation of the response of THP-1 cells to LPS and LPS-LBP complexes depends on the appearance of CD14 on the cell surface. Maturation of the response to LPS in serum depends in large part on the appearance of CD14 on the cell surface and the presence of LBP in serum.

Immunologic monitoring of the cardiac transplant patient.

Peripheral blood lymphocyte morphology and cell surface markers were repeatedly evaluated in 49 orthotopic cardiac transplant patients over a period of three years to determine the utility of these parameters in predicting an episode of acute cardiac rejection. Lymphocytes were measured with a calibrated microscope and termed "activated" if greater than 10 mu in diameter. If a patient demonstrated greater than 30 activated lymphocytes/cu mm, the same lymphocytes were stained with monoclonal antibodies directed to T-cell subsets and B cells. These findings were retrospectively correlated with endomyocardial biopsy results. Absolute numbers of T-cell subsets and B cells were analyzed via Student's t test to identify significant differences during acute cardiac rejection. Of 347 biopsy specimens, 47 demonstrated histologic features of acute cardiac rejection. Simultaneous immune activation of lymphocytes occurred with 33 of 47 samples, while another 51 episodes of lymphocyte activation were detected without acute rejection. No statistically significant differences in absolute numbers of T-lymphocyte subsets were noted at the time of acute rejection.

Severe corneoscleral infection. A complication of beta irradiation scleral necrosis following pterygium excision.

OBJECTIVE: To assess the precipitating factors, clinical course, and treatment of 11 cases of severe intraocular infections of radionecrosis after pterygium excision in an attempt to minimize the devastating ocular sequelae. DESIGN AND SETTING: From the database of cases of radionecrosis at Royal Perth (Australia) Hospital and Lions Eye Institute, Perth, we identified 11 cases of severe intraocular infection complicating radionecrosis. We reviewed the case notes and the available radiotherapy records (n = 8). PATIENTS: Eleven patients admitted during an 8-year period. RESULTS: Mean (+/- SD) dose of radiotherapy was 22.7 +/- 1.0 Gy and mean latency period, 14.45 +/- 2.5 years. Among the six proven bacterial cases, Pseudomonas was identified in four, Staphylococcus aureus in one, and Streptococcus pneumoniae was involved in one bilateral case. Among the four fungal cases, Petriellidium boydii was indicated in two, and Fusarium and Scedosporium inflatum in one each. The condition may remain undiagnosed for some time and mimic a posterior scleritis, serous retinal detachment, or pseudotumor. INTERVENTIONS: Early débridement and culture; close microbiological assistance; and systemic antimicrobials for a prolonged period. Perforation or incipient perforation necessitated penetrating keratoplasties in seven patients and repeated keratoplasties in three. MAIN OUTCOME MEASURES: The use of radiotherapy following pterygium excision should be limited and only low doses used. Ulcer beds and calcific plaques at sites of radionecrosis should not be directly covered without first performing adequate sterilization. Removal of plaques may precipitate sepsis; ulcer beds and plaques harbor infective agents. CONCLUSION: Severe radionecrosis may expose a patient to a lifelong risk of intraocular sepsis and profound visual morbidity. Conjunctival autografting is a safer method to reduce recurrence rate after pterygium excision.

Studies of the blood-aqueous barrier in diabetes mellitus.

We measured the breakdown of the blood-aqueous barrier in 63 patients with diabetes (126 eyes) by using a laser flare meter. Of 126 eyes, 40 had no retinopathy, 34 had proliferative retinopathy, 24 had regressed proliferative retinopathy, 14 had background retinopathy, and 14 had maculopathy. Eyes were classified into one category only. Mean flare was greater for proliferative retinopathy compared to background retinopathy (P = .0065), no retinopathy (P = .0001), and maculopathy (P = .0189). Flare values were greater for regressed proliferative retinopathy compared to no retinopathy (P = .0118) (paired Student's t-test). Diabetic eyes without demonstrable retinopathy still had higher flare values than control eyes without diabetes. The length of diabetes was greater for those eyes with proliferative diabetic retinopathy (P = .0195), regressed proliferative diabetic retinopathy (P = .0625), and background diabetic retinopathy (P = .006) compared to those with no retinopathy. No significant difference was noted in duration of diabetes for eyes with diabetic maculopathy when compared to those with no retinopathy (P = .5788). Breakdown of the blood-aqueous barrier precedes the development of retinopathy, and the more severe proliferative forms have greater blood-aqueous barrier dysfunction.

Fine-needle biopsy techniques of aspiration versus capillary in head and neck masses.

Fine-needle aspiration and fine-needle capillary biopsy techniques were compared, and the number of samples necessary to assure a diagnostic specimen was determined. In this study, each mass served as its own control, since both aspiration and capillary fine-needle biopsy were performed randomly on each mass. The study found the number of "superior" slides to be evenly distributed between the two biopsy techniques, but a different preference, based on tumor type, was noted for one or the other technique. The "best" slides were obtained from one of the first four samples 92% of the time. The authors concluded that both fine-needle aspiration and capillary biopsy should be used and that three to four samples should be obtained to increase the likelihood of a diagnostic biopsy.

Air-borne laser induced fluorescence system for measuring OH and other trace gases in the parts-per-quadrillion to parts-per-trillion range.

Described in detail is a laser induced fluorescence system which has been successfully interfaced with two aircraft sampling platforms (i.e., Sabreliner jet and an L-188C Electra). This system, which has been under development for four years, presently consists of the following major components: (1) a Nd-Yag laser driven oscillator-amplifier dye laser; (2) a sampling manifold with associated fluorescence detection optics; (3) an OH calibration chamber; (4) a laser beam steering assembly; and (5) sampling electronics and data processing hardware. During the last three years, this system has been flown some 50 000 air miles making tropospheric OH radical measurements over the latitude range of 70 degrees N to 57 degrees S. OH concentrations measured during these flights have ranged from 30 parts-per-quadrillion (3.7x10(5) molecules/cm(3)) at altitudes of 6 km to 0.8 parts-per-trillion (2.0x10(7) molecules/cm(3)) at 0.5 km. Computations have been completed which indicate that the existing aircraft system with modest modifications should also be capable of detecting natural tropospheric levels of NO, SO(2), CH(2)O, NO(2), HNO(2), NO(3), H(2)O(2), and CS(2) by using both conventional laser-induced fluorescence methodology and multiphoton techniques.

Localized primary amyloid tumor associated with osseous metaplasia presenting as bilateral breast masses: cytologic and radiologic features.

This report details the cytologic features of primary localized amyloid tumor of the breast presenting as bilateral breast masses in a 72-yr-old woman. Clinically and radiographically, the masses simulated metastatic or multifocal carcinoma. Fine-needle aspiration revealed irregular globules of acellular amorphous material and numerous multinucleated giant cells resembling granulomatous inflammation. Histology confirmed amyloid tumors with a foreign-body giant cell reaction in response to amyloid and foci of osseous metaplasia. Subsequent clinical workup included a serum electrophoresis and immunofixation which showed a small IgG kappa monoclonal protein. Urine immunofixation was negative for Bence Jones protein. Bone marrow examination revealed no evidence of a plasma cell dyscrasia. To date the patient has not developed clinical or laboratory evidence of systemic amyloidosis or multiple myeloma. Amyloidosis involving the breast and specifically localized primary amyloid tumors of the breast are rare and infrequently reported entities. To our knowledge, osseous metaplasia within isolated primary amyloid tumors of the breast has not been reported. We present this unusual case to illustrate the intratumoral calcification patterns mimicking carcinoma and to characterize the cytologic features. Emphasis is placed on the inclusion of amyloidosis in the differential diagnosis of breast masses.

Molluscum contagiosum presenting as cellulitis in an AIDS patient: cytologic and ultrastructural features.

This report describes the cytologic features of molluscum contagiosum presenting clinically as a left thigh abscess in a 29-yr-old male with AIDS. The fine-needle aspiration findings are correlated with the histologic and ultrastructural findings. Molluscum contagiosum's clinical presentation, natural course, and induction of host immune responses in immunocompetent and immunosuppressed individuals as identified by light microscopy, immunocytochemically and ultrastructurally are reviewed. Molluscum contagiosum presenting clinically and cytologically as an abscess is unusual. In this report, we emphasize the inclusion of molluscum contagiosum in a differential diagnosis of an abscess, particularly in immunosuppressed patients, and discuss the cytologic differential diagnoses.

Cytologic criteria for subclassification of Hodgkin's disease using fine-needle aspiration.

Hodgkin's disease (HD) is increasingly being evaluated by fine-needle aspiration (FNA); however, criteria to subclassify HD into its four subtypes--nodular sclerosis (NS), mixed-cellularity (MC), lymphocyte-depleted (LD), and lymphocyte-predominant (LP)--has not been established. In order to evaluate criteria for subclassification, all FNA cases of HD obtained over a 5-yr period at Indiana University Medical Center that had confirmatory surgical biopsies were reviewed. The number of Reed-Sternberg (RS) cells was quantitated in each cytologic case and statistically analyzed by subgroup, using analysis of variance (ANOVA). LD had the highest mean (means) number of RS cells (means = 51) with NS and MC having similar means (means = 7 and 6, respectively). Only one case of LP was identified and therefore could not be analyzed statistically. Fibrosis and the presence of RS variants were qualitatively assessed and were not helpful in distinguishing the subtypes of HD. Although the quantitation of RS cells may be used to identify LD types of Hodgkin's disease, MC and NS cannot be separated reliably on this criterion alone. Although FNA can be used to diagnose HD, stage a patient, or assess efficacy of chemotherapy, subtyping of HD should still be done on histologic sections of excised lymph nodes.

Fine-needle aspiration of metastatic atrial myxoma.

Atrial myxoma is the most common primary neoplasm of the heart, but "metastatic" or embolic phenomena are rare. The first reported case of "metastatic" atrial myxoma diagnosed by fine-needle aspiration biopsy is presented. It occurred in a 54-yr-old woman with multiple metastatic lesions. The cytologic and histologic findings of the fine-needle aspiration biopsy and subsequent surgical excision are presented as is a discussion of the incidence, origin, and clinical findings of atrial myxoma and the characteristics of its emboli.

Immunophenotyping of cytologic specimens by flow cytometry.

Immunophenotyping by flow cytometry is well established as an ancillary technique in the diagnosis of hematopoietic neoplasms. However, flow cytometry is rarely performed on cytologic specimens because most cytologist are more comfortable with direct microscopy and believe that there is inadequate cellularity for analysis. Paradoxically, cytologic material is usually cell suspensions making it ideal for flow cytometry. In order to evaluate the usefulness of immunophenotyping cytologic specimens by flow cytometry, we retrospectively reviewed all cytologic specimens submitted to our flow cytometry unit from 1988 to 1991. Thirty-one cerebrospinal fluid specimens were analyzed. There were inadequate cells for analysis in 15 cases. Five showed a monoclonal proliferation; 11 were nondiagnostic. A range (r) of one to six cell surface markers were performed. Thirty-two body cavity fluids were analyzed: 7 peritoneal, 19 pleural, 2 pericardial, and 4 bronchoalveolar lavage. There were cells to analyze in all cases. Seven had a monoclonal proliferation; 25 were nondiagnostic (r = 4-21 markers performed). One hundred eighteen fine needle aspirates (FNA) were reviewed; 58 FNA were radiologically guided, 60 were superficial lesions. There were inadequate cells for analysis in two cases. Sixty-one demonstrated a monoclonal proliferation; 55 were nondiagnostic (r = 1-22 markers performed). We conclude that immunophenotyping by flow cytometry is of limited value for cerebrospinal fluid analysis and that knowledge of previous immunophenotyping studies is essential for correct analysis; analysis of body cavity fluids is easily performed but less often demonstrates a monoclonal proliferation. Immunophenotyping by flow cytometry is a valuable adjunctive technique for FNA and yields adequate cells for analysis.