Characterisation of bacteria in ascites--reporting the potential of culture-independent, molecular analysis.

Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease. A significant proportion of patients have culture-negative ascites, despite having similar signs, symptoms and mortality to those with SBP. Therefore, empirical antibiotic treatment for infection is often started without knowledge of the causative organisms. Here, we investigated the potential of molecular techniques to provide rapid and accurate characterisation of the bacteria present in ascitic fluid. Ascites samples were obtained from 29 cirrhotic patients undergoing clinically indicated therapeutic paracentesis. Bacterial content was determined by terminal restriction fragment length polymorphism (T-RFLP) analysis, quantitative polymerase chain reaction (PCR) and 16S ribosomal clone sequence analysis. Bacterial signal was detected in all samples, compared to three out of ten using standard methods. Bacterial loads ranged from 5.5 x 10(2) to 5.4 x 10(7) cfu/ml, with a mean value of 1.9 x 10(6) cfu/ml (standard deviation +/- 9.6 x 10(6) cfu/ml). In all but one instance, bacterial species identified by culture were also confirmed by molecular analyses. Preliminary data presented here suggests that culture-independent, molecular analyses could provide rapid characterisation of the bacterial content of ascites fluid, providing a basis for the investigation of SBP development and allowing early and targeted antibiotic intervention.

Presentation of thyroid carcinoma as a thrombosed external jugular vein, with intraluminal tumour thrombus in the great veins.

Carcinoma of the thyroid most commonly presents as an asymptomatic thyroid nodule. Some types of thyroid carcinoma show vascular invasion, but this is usually microscopic.(1,2)It is rare for such invasion to involve the great veins and be macroscopic. There are 18 such reports in the literature to date.(3-12)We report a case of a carcinoma of the thyroid that presented due to the presence of tumour thrombus within the external jugular vein, where thrombus was also seen within the great veins.

The small bowel barium follow-through enhanced with an oral effervescent agent.

A method is described for consistently improving the quality of the small bowel barium follow-through by enhancement with an oral effervescent agent. With this method, although satisfactory double-contrast views of the whole small bowel were obtained in less than half the patients, satisfactory distension of the small-bowel loops was achieved in 96% of examinations.

Clinical assessment and radiograph following blunt chest trauma.

This study was undertaken to assess the accuracy of clinical examination in predicting significant injury following blunt chest trauma and to determine whether more selective use of frontal chest radiography could be achieved.

Intravenous remifentanil: placental transfer, maternal and neonatal effects.

BACKGROUND: Remifentanil has not been studied in obstetric patients. This study evaluates the placental transfer of remifentanil and the neonatal effects when administered as an intravenous infusion. METHODS: Nineteen parturients underwent nonemergent cesarean section with epidural anesthesia and received 0.1 microg kg(-1) x min(-1) remifentanil intravenously, which was continued until skin closure. Maternal arterial (MA), umbilical arterial (UA), and umbilical venous (UV) blood samples were obtained at delivery for analysis of drug concentrations of remifentanil, its metabolite, and blood gases. Maternal vital signs were monitored continuously, and pain and sedation levels were assessed intermittently. Apgar scores were obtained at 1, 5, 10, and 20 min, and Neonatal and Adaptive Capacity Scores were noted 30 and 60 min after delivery. Parturients and newborns were observed for at least 24 h after surgery for side effects. RESULTS: The means and SDs of UV:MA and UA:UV ratios for remifentanil were 0.88+/-0.78 and 0.29+/-0.07, respectively. Mean clearance was 93 ml x min(-1) kg(-1). The mean UV:MA and UA:MV ratios for remifentanil acid were 0.56+/-0.29 and 1.23+/-0.89, respectively. The mean MA (remifentanil acid):MA (remifentanil) ratio was 2.92+/-3.65. There were no adverse effects on the neonates, but there was a sedative effect and respiratory depressant effect on the mothers. CONCLUSIONS: Remifentanil crosses the placenta but appears to be rapidly metabolized, redistributed, or both. Maternal sedation and respiratory changes occur, but without adverse neonatal or maternal effects.

Long-term efficacy of fenfluramine in treatment of obesity.

42 obese women who lost at least 6 kg after 26 weeks on fenfluramine tablets had their treatment changed to either an equivalent dose of a sustained-release preparation of fenfluramine or matching placebo in double-blind fashion. Of the 21 given placebo all but 2 regained weight over the following year. Of the 21 crossed over to fenfluramine, 8 maintained their weight loss, 7 regained weight, and 6 had to be withdrawn for reasons other than weight gain. Plasma concentrations of fenfluramine and norfenfluramine taken before and 4 weeks after the crossover were similar in both responders and non-responders, but non-responders did not maintain their drug levels for as long as did the responders. Longer controlled administration of fenfluramine will prevent weight regain in some obese women but the hazards of prolonged use remain to be evaluated.

pH-adjusted 2-chloroprocaine for epidural anesthesia in patients undergoing postpartum tubal ligation.

PIP: The effect of added sodium bicarbonate on 2-chloroprocaine epidural anesthesia in women having postpartum tubal ligation was compared to the commercial product in a double-blind, randomized study. The rationale for the comparison was the reported hastened onset of anesthesia when the pH of bupivacaine and lidocaine are raised. Anesthetic solutions were prepared no more than 20 minutes before use by adding 1 ml sterile 8.4% sodium bicarbonate or 1 ml sterile saline to 27 ml commercial product (3% solution). The pH of the commercial solution was 3.82; that of the saline diluted drug was 3.74; and the pH of the bicarbonate diluted drug was 7.08. Groups of 15 subjects received 23 ml of either diluted anesthesia by a standardized protocol. There were no differences in the matched groups in age, height, weight, or postpartum interval. There were no differences in anesthetic variables, i.e., time of onset of anesthesia, time to T4 level, time to maximum level, or duration of anesthesia, between the groups.^ieng