Model-based evaluation of the Canberra Hospital Acute Care Surgical Unit : acute care surgery: a case of one size fits all?

PURPOSE: Surgical services in Australia are under sustained and growing pressure. The global implementation of acute care surgery services has been shown to facilitate the timeliness of acute surgery. The question is: Do acute care surgical units fit major regional centers like ours? The current study coincides with the introduction of a Surgical Assessment and Planning Unit (SAPU) at the Canberra Hospital and compares patient outcomes before vs. after the introduction of the SAPU, using acute appendicitis as the model illness. METHODS: We reviewed patients presenting to the Canberra Hospital Emergency Department with a preliminary diagnosis of acute appendicitis before vs. after the introduction of an acute care surgical unit. RESULTS: The subjects were 150 patients, ranging in age from 16 to 97 years. The mean time from presentation at casualty to surgical review and the surgical review itself was reduced by 19 and 26 %, respectively (p < 0.05). Time to the operating table and the percentage of after-hours operations were reduced by 8 and 40 %, respectively. There was a significant reduction in the utilization of abdominal ultrasonography after the implementation of the SAPU. CONCLUSIONS: The implementation of a SAPU has benefited the management of patients with acute surgical conditions. Ultimately, patient care is enhanced, with patients being reviewed, admitted, and treated earlier.

How to Reconstruct Middle Hepatic Vein Branches With Explanted Portal Vein and Inferior Mesenteric Vein Graft: A Case Report.

OBJECTIVE: The middle hepatic vein reconstruction is one of the crucial parts in adult living donor liver transplantation. Numerous techniques had been reported by using cadaveric iliac vessel or synthetic graft. The limitations of reported techniques are availability of the vessel and complication of synthetic graft. We report the technique of using explanted portal vein and inferior mesenteric vein graft in sequential fashion. PATIENTS AND METHODS: The recipient was a 54-year-old man with chronic hepatitis B cirrhosis and multiple hepatocellular carcinomas. He underwent living donor liver transplantation with modified right lobe graft from spouse. The venous drainages of segments 5 and 8 were reconstructed by explanted left portal vein and inferior mesenteric vein from the donor. The operative time was 9 hours 30 minutes. RESULTS: The postoperative course was uneventful. The recipient did not show any signs of small-for-size syndrome such as ascites or hyperbilirubinemia. He recovered well and showed no signs of recurrent disease 1 year after his transplantation. CONCLUSION: The explanted portal vein graft can be used with another autogenous vein graft such as inferior mesenteric vein for reconstruction of all middle hepatic vein branches.

Local superficial hyperthermia in combination with low-dose radiation therapy for palliation of locally recurrent breast carcinoma.

From September 1984 through March 1987, 30 patients with locally recurrent breast carcinoma who had been heavily pretreated with conventional modes of therapy (radiation, chemotherapy, and hormonal therapy) were entered into a phase II study of hyperthermia and low-dose irradiation. The purpose of the study was to determine the feasibility, effectiveness, and morbidity of this treatment combination. Radiation therapy was administered twice weekly, 4 Gy per fraction, to a total dose of 32 Gy, with 6 or 9 MeV electrons depending on the thickness of the lesions. Hyperthermia generated by microwave frequencies of 200 to 700 MHz was administered immediately after radiation therapy, with a time and temperature aim of 60 minutes at 43 degrees C. Complete response (CR) was achieved in 17 patients (57%), and partial response (PR) in 11 patients (36%). Response was positively correlated with tumor size; lesions less than 5 cm in diameter achieved CR significantly more frequently than lesions greater than or equal to 5 cm (P less than .001). Eighty percent of the complete responders continued to experience sustained control of the treated site from 6 to 32 months but showed evidence of progressive systemic disease or locoregional progression to the adjacent untreated sites, reflecting the natural history of this disease and extensive dermal lymphatic permeation. True recurrence within the treated volume occurred in three patients. Nonhealing ulceration developed in nine patients and seven of those were associated with persistent tumor. This study confirms the palliative value of hyperthermia in combination with radiotherapy for previously irradiated recurrent chest wall tumors and sets the scene for its comparative clinical evaluation against radiation therapy alone as first line therapy for locally recurrent breast carcinoma.

Measurement of blood flow using temperature decay: effect of thermal conduction.

Within the framework of the bioheat equation, we studied the effect of conduction on the thermal washout curve for a model tissue configuration subjected to a thermal perturbation such as hyperthermia treatment. In particular, we studied the implications of the assumption made by many investigators to neglect the effect of thermal conduction while analyzing the temperature decay curve for measuring blood perfusion. The present analysis suggests that during the localized hyperthermia treatments, this assumption can lead to inaccurate values for the blood perfusion parameter. This is particularly so under non-steady state conditions when the temperature distribution is changing. In addition to the value of blood flow, the shape of the temperature decay curve depends on the temperature distribution at the start of temperature decay.

Practical thermal dosimetry.

A relatively simple means of thermal dose documentation is presented. It has the advantage of greatly condensing the vast amount of data collected during a course of hyperthermia treatments. The formulation incorporates both temporal and spatial temperature transients and is applicable when comparing hyperthermia devices and in quality control for prospective hyperthermia treatment protocols.

Fractionated half-body irradiation (HBI) for the rapid palliation of widespread, symptomatic, metastatic bone disease: a randomized Phase III trial of the International Atomic Energy Agency (IAEA).

PURPOSE: To find the fastest and most effective/efficient method to economically deliver fractionated half-body irradiation (HBI) for widespread (WS), symptomatic, metastatic bone cancer. METHODS AND MATERIALS: A Phase III trial with 3 HBI arms: (Arm A) Control (15 Gy/5 fractions/5 days); (Arm B) Hyperfractionation (HF) (8 Gy/2 fractions/1 day); (Arm C) Accelerated HF (12 Gy/4 fractions/2 days). Six countries randomized 156 patients (all with WS bone metastases): 51, 56, and 49 patients to Arms A, B, and C, respectively. There were 72 (46%) breast, 50 (32%) prostate, 9 (6%) lung, and 25 (16%) miscellaneous primary tumors. Initial performance status (PS) was 1-2 in 101 (65%) and PS 3-4 in 55 (35%). The lower, upper, and middle halves of the body were treated 79, 68, and 9 times. RESULTS: Pain relief was seen in 91% of patients (45% complete [CR] and 46% partial [PR]) within 3-8 days. Overall (OS), median (MST), and pain-free (PFS) survival was 174, 150, and 122 days. Breast tumors had a higher OS (279 days) than that of other primary tumors, but when analyzed by treatment, was not significantly different than prostate tumors in Arm A. No survival differences were found in patients with PS 1-2 vs. 3-4, CR vs. PR, bone with/without visceral metastases, or by the number of metastases (< or > 15 bone lesions). Quality of life (QOL) assessed by the percent of the remaining life free of pain was 71%; furthermore significant improvements in PS, pain, and narcotic scores were seen after HBI. Toxicity was very acceptable (41% none, 50% mild/moderate, 12% severe but transitory); more was seen with upper HBI. CONCLUSION: In terms of response, time to response, OS, MST, PFS, QOL, and toxicity, schedules for Arms A and C were similar for all but prostate primaries. Schedule for Arm B, which delivered the lowest biologic dose in the shortest time, had significantly worse results in pain relief, OS, MST, PFS, and QOL. Results indicate that, for most primary tumor types (except prostate), delivering two HBI daily doses of 3 Gy in 2 consecutive days is as effective as delivering a daily dose of 3 Gy for 5 consecutive days. Thus, this is a faster and much more convenient HBI schedule for the palliation of pain in widespread cancer.

Immunization of White Pekin ducklings against Pasteurella anatipestifer infection.

Since Pasteurella anatipestifer (PA) serotypes 1, 2, and 5 gave no significant protection against heterologous serotype challenge, a trivalent formalin-inactivated bacterin containing all these serotype cells was developed and tested in the laboratory. Two inoculations of bacterin in White Pekin ducklings at 10 and 17 days of age gave highly significant protection against challenge with virulent organisms. The protection lasted only 2 weeks after the second inoculation. A third bacterin inoculation given at 31 days or exposure to an active field infection during the period of protection extended protection to market age (7 wk). Aluminum-hydroxide-gel-adsorbed bacterin gave no better protection than bacterin without adjuvant. One inoculation of multiple oil-emulsion (MOE) bacterin gave absolute protection up to market age: unfortunately, it produced noticeable tissue reactions at the site of inoculation. Day-old ducklings were also responsive to PA bacterin, and developed significant immunity against experimental challenge.

Fecal streptococcal infection of commercial white pekin ducklings.

An acute septicemic disease was reported in 1-to-2-week-old white pekin ducklings on eight Long Island duck farms. Gross lesions were primarily hepatomegaly and enlarged necrotic spleens. Fibrinous pericarditis, perihepatitis, and airsacculitis were observed in some birds. Mortality ranged from 0.5 to 5%. Streptococcus faecium was isolated from heart blood, livers, lungs, and spleens of sick or dead ducklings. Serologically, all isolates belonged to Lancefield Serogroup D. The disease was reproduced in 8-day-old susceptible ducklings by parenteral infection. The lesions were indistinguishable from those observed in field outbreaks. Novobiocin at 350 g per ton of feed was effective in controlling mortality in the field.

Laboratory and field trials with formalin-inactivated Escherichia coli (O78)-Pasteurella anatipestifer bacterin in white pekin ducks.

A combination Escherichia coli serotype O78 and Pasteurella anatipestifer bacterin was developed and tested in white pekin ducks in laboratory and field trials. Inoculations with bacterin at 2 and 3 weeks of age provided significant protection against challenge with virulent E. coli O78 and Pasteurella anatipestifer serotypes 1, 2, and 5. No significant cross-protection was observed against heterologous E. coli serotypes, although there was a slight reduction in mortality in ducklings challenged with E. coli serotypes O2a and O119. In field trials, the E. coli-P. anatipestifer bacterin produced significant reduction of mortality in commercial white pekin ducks compared with P. anatipestifer bacterin.

Protection of ducklings with a broth-grown Pasteurella anatipestifer bacterin.

Pasteurella anatipestifer (PA) serotypes 1, 2, and 5 grew to high densities in tryptic soy broth and tryptose broth (TB) when the media were continuously shaken or aerated. Growth in 100 ml to 15 liters of TB exceeded an absorbance of 1.0 at a wavelength of 525 nm (about 0.7 for a 1/3 dilution) and contained more than 10(10) colony-forming units per ml. A bacterin was prepared from the three serotypes of PA grown in aerated TB. Two subcutaneous injections of this bacterin protected 70% to 85% of ducklings against experimental challenge with each of the three PA serotypes, which killed 90% to 100% of unimmunized controls. The bacterin could be diluted 1/5 without decreasing protection below 80%. Field studies on Long Island duck farms in 1980 and 1981 demonstrated significant reductions in mortality with the use of the broth-grown PA bacterin.

Inactivated vaccine for protection against duck virus enteritis.

Immunogenicity of inactivated tissue-culture-derived duck enteritis virus (DEV) vaccines was evaluated in white Pekin and mallard ducks. DEV from a Lake Andes outbreak was propagated in chicken embryo fibroblast cells, inactivated with beta-propiolactone, and emulsified with Freund's adjuvant (FA), multiple-oil emulsion (MOE), or Squalane-pluronic L121 (L121). White Pekin and mallard ducklings were vaccinated at 2 or 3 wk of age, respectively. Challenge at 2 wk postvaccination with a virulent DEV isolated from a Long Island outbreak indicated that inactivated Lake Andes (ILA) vaccine mixed with any of the above adjuvants conferred protection, even with a single-dose inoculation. Antibody responses to vaccination, as determined by indirect enzyme-linked immunosorbent assay, showed that ILA virus with FA induced an early production of antibodies similar to that induced by commercially available modified live virus (MLV) vaccine. However, the mean anti-duck virus enteritis (DVE) IgG titers determined by multiple samplings during the first 35 days postvaccination showed titers from ILA virus with FA to be at least 10 times higher than those induced by MLV vaccine. The highest antibody titers were induced by ILA mixed with FA followed by ILA mixed with the MOE and L121. The results of this study indicated that inactivated vaccine is as efficacious as modified live vaccine in enhancing protection against virulent DEV in waterfowl.

Serotypes of Pasteurella anatipestifer isolated from commercial White Pekin ducks in the United States.

Pasteurella anatipestifer isolates from commercially raised, clinically diseased White Pekin ducks were serotyped by agglutination and agar-gel precipitin methods. Plate agglutination was found to be the most suitable test for preliminary classification. Based on National Animal Disease Center (Ames, Iowa) nomenclature, six serotypes were classified as types 1, 2, 3, 5, 7, and 8. These were compared with strains held by Houghton Poultry Research Station (Houghton, Huntingdon, England), at present constituting 15 serotypes (A to O), isolated in England and other countries. Serotype 1 was found to be identical to serotype A, the strain most commonly associated with outbreaks of the disease in England. Serotype 3 was found to be identical to serotype L, which was isolated from an outbreak of the disease in swans in Tasmania. Types 5, 7, and 8 did not react with any of the typing sera available, but serotype 7 was found to be identical to a strain (type N) isolated subsequently in England. More than 95% of field isolations made from 1975 to 1979 belonged to serotypes 1, 2, and 5.

Pasteurella anatipestifer-like bacteria associated with respiratory disease in pigeons.

Two cases of respiratory disease in pigeons are described. The first case involved pneumonia and tracheitis, and the second case involved tracheitis. In both cases, unusual gram-negative, non-fermenting, short rod-shaped bacteria were recovered along with other microorganisms. The bacteria produced small, glistening, gray colonies on blood agar, did not grow on MacConkey agar, were unreactive on several biochemical tests, and resembled Pasteurella anatipestifer. Neither pigeon isolate was distinguished from P. anatipestifer by biochemical tests. However, there were morphologic and growth differences between the pigeon isolates and P. anatipestifer. Furthermore, unlike P. anatipestifer, both pigeon isolates were sensitive to aminoglycoside antibiotics and to polymyxin B. Finally, neither isolate was agglutinated by antisera to 15 serotypes of P. anatipestifer. Diagnosticians, especially those who seldom encounter P. anatipestifer, might have difficulty distinguishing the pigeon isolates from P. anatipestifer because of their close resemblance.

Pathologic and serologic characterization of a variant of duck hepatitis type I virus.

A duck hepatitis virus (DHV), isolated from ducks on a farm in Virginia in 1963, was shown to be only partially related to DHV type I (DHV-I) in cross-neutralization and in cross-protection tests. The virus, named DHV-Ia, apparently is a serologic variant of DHV-I; both viruses are serologically distinct from DHV type III. Pathologic responses to DHV-Ia were similar to those described for DHV-I infection.

Pathogenicity of a low-virulence duck virus enteritis isolate with apparent immunosuppressive ability.

Duck enteritis virus (DEV) was isolated from commercial 2-to-6-wk-old white Pekin ducks experiencing 25%-30% mortality and high morbidity. Secondary infections with Pasteurella multocida, Riemerella anatipestifer, and Escherichia coli were frequently seen in affected ducks. The isolated virus was identical to the prototype DEV by virus neutralization test but differed from the classic DEV by causing lymphoid organ atrophy and inconsistent hemorrhagic lesions in the intestinal annular bands. Attempts to reproduce the disease in white Pekin ducks were unsuccessful until the virulence of the virus was increased by three passages in Muscovy ducklings. Significant thymic atrophy (P < or = 0.001) was detected during the first 10 days postinfection (DPI), but thymus size returned to normal by 17-24 DPI. However, bursal atrophy increased significantly (P < or = 0.001) from 4 DPI until the end of the experiment (39 DPI). Reduction in body weight was significant (P < or = 0.05) between 4 and 6 DPI. There was massive depletion of thymic and bursal lymphocytes with lymphoid necrosis in the thymus, bursa, spleen, and Harderian gland. Eosinophilic intranuclear inclusions were observed in thymus, bursa, spleen, esophagus, cloaca, liver, conjunctiva, and Harderian gland. Occasional intracytoplasmic inclusions were also found scattered in the epithelial cells of conjunctiva, esophagus, bursa of Fabricius, and cloaca. Virus was recovered from experimentally infected ducks from thymus, bursa, spleen, liver, kidneys, trigeminal ganglion, and cloaca during the first 10 days of infection. These findings suggest that a low-virulent DEV can cause a massive lymphoid atrophy and can sustain immunosuppression as noted by the secondary bacterial infection.

Results of a phase I/II clinical trial of fractionated hyperthermia in combination with low dose ionizing radiation.

This paper addresses, in part, the current status of hyperthermia as a new clinical modality and reports the results of a large, prospective clinical trial employing microwave hyperthermia in combination with low doses of ionizing radiation. In the protocol employed, each treated area received 8 hyperthermia treatments of 1.5 hour combined with 1600 rad over a total period of 5 weeks. Patients were heated with microwaves of 915 or 300 MHz employing external applicators or internal intracavitary antennas. The results of this fractionation scheme are encouraging since in 121 fields that were treated completely according to protocol and were available for follow-up for at least 2 months, complete responses were observed in 65% of all cases, partial response in 30% and no response in only 5%. It is also important to note that toxicity was minimal throughout the study.

Extracellular antigens of Moraxella bovis.

The extracellular antigens of 2 isolates of Moraxella bovis were isolated by ammonium sulfate precipitation of cell-free culture filtrate, purified by filtration and differentiated by immunodiffusion and immunoelectrophoretic techniques. The extracellular filtrate from rough types had 2 specific extracellular antigens in addition to those in the culture filtrate of smooth-type cells of the same isolate. The extracellular antigens produced by smooth-type cells were identical in all isolates of Moraxella bovis. The serotype-specific extracellular antigens of 2 isolates were serologically identical but were different from those of a 3rd isolate. The possibility of serotyping M bovis isolates, on the basis of their extracellular rough-type antigens, was suggested. Although both serotype-specific antigens were destroyed by trypsin treatment, 1 antigen was also heat-labile and partially destroyed by formalin treatment.

Production and characterization of Moraxella bovis hemolysin.

Moraxella bovis hemolysin was produced in trypticase soy broth and maximum hemolytic activity of the culture was observed during the logarithmic phase of growth. The hemolysin was filterable through a 0.22-micrometer (APD) membrane filter, heat labile, and destroyed by treatment with formalin or trypsin. There was no difference in the amount of hemolysin production by rough or smooth colony types of an isolate, although differences were observed between 2 different isolates. Partial requirement of a sulfhydryl group and divalent cations were suggestive of an enzymatic nature of M bovis hemolysin.

Effect of chemotherapeutic agents on Pasteurella anatipestifer infection in White Pekin ducklings.

In a series of experiments, various chemotherapeutic agents administered in feed were evaluated for their efficacy against experimental Pasteurella anatipestifer (PA) infection in White Pekin ducklings. The feeding of medicated diets was started 3 days prior to challenge and continued throughout each experiment. Novobiocin and lincomycin, when fed at adequate concentrations, were the most effective medicaments tested. Mortality in treated groups was 0-18% compared with 45-92% mortality in controls. Sulfadimethoxine-ormetoprim, sulfaquinoxaline, and lincomycin-spectinomycin were moderately effective. Drugs that were not effective included chlortetracycline, tylosin-sulfamethazine, fosfomycin, furazolidone, nihydrazone, penicillin, bacitracin, and erythromycin. Six antibiotics were tested parenterally against experimental PA infection in another series of experiments. A single dose of an antibiotic was injected subcutaneously 5 to 6 hr after infection except in one experiment in which treatment was delayed until 24 hr after infection. When given 5 to 6 hr after infection, lincomycin-spectinomycin, penicillin-streptomycin, penicillin, oxytetracycline, and spectinomycin significantly reduced mortality. Gentamicin tested under the same conditions was ineffective. Drugs injected 24 hr after infection were not effective.

The frequency of salmonellae on duck eggs.

Total plate counts on washed duck eggs from a breeder farm on Long Island were less than 30/shell during the winter (January to February) of 1982. Clean unwashed eggs had counts less than 9 X 10(1)/shell, whereas dirty unwashed eggs had counts as high as 9 X 10(5)/shell. Our results showed that washing with a chlorine sanitizer (under commercial conditions) was highly effective in reducing surface bacterial counts on egg shells. Prolonged storage reduced bacterial counts on clean eggs, but it did not significantly affect loads on dirty eggs. No salmonellae could be detected on shells or in the magma of all eggs examined. In a second trial (March 1982) bacterial loads on washed and clean duck eggs from six different breeder farms were low, ranging from too few to count to 10(2)/shell. A higher proportion of dirty eggs were heavily contaminated with counts ranging from 10(5) to 10(6)/shell, but no salmonellae were detected either on shells or in magma. In the third trial (May 1982) bacterial determinations on eggs from breeder ducks that were not confined followed the pattern of the second trial. However, in this trial Salmonella enteritidis was detected on dirty egg shells in four of six farms. In a fourth trial (May 1983), bacterial loads on washed and nest-clean eggs from the same breeder farms (not confined) ranged between 10(2) to 10(3)/shell and 10(2) to 10(4)/shell, respectively. S. enteritidis and S. badar were recovered from washed, nest clean, and dirty eggs in two of six farms. We conclude that proper egg washing and confinement of duck breeders should minimize the problem of salmonellosis in ducklings.