Should the degree of peritoneal soiling and duration of perforation influence surgical strategy in perforated peptic ulcer?

A prospective study was undertaken in patients with perforated peptic ulcer to ascertain which organisms were encountered and to assess what role the duration of peritoneal soiling plays in the flora encountered and whether the degree of peritoneal soiling, as judged by the surgeon, correlates with bacterial contamination. After assessing the degree of soiling, pus swabs were taken and aerobic and anaerobic cultures and antibiotic sensitivity tests were performed. The most common organisms encountered were Gram-positive cocci (47%) followed by Gram-negative organisms (33%). There was no statistically significant increased bacterial growth time elapsed up to 48 hours. Severe peritoneal soiling, as judged by the surgeon, did not imply greater contamination.

Evidence that tolerance to cultured thyroid allografts is an active immunological process. Protection of third-party grafts bearing new antigens when associated with tolerogenic antigens.

We studied the tolerance phenomenon that develops in long-term recipients of cultured thyroid allografts. Allogeneic mouse thyroids were cultured under hyperbaric oxygen or acidic conditions and then transplanted beneath the kidney capsule of C57BL/6 recipients. Donors differed from the recipients in minor antigens alone, major histocompatibility complex antigens alone, or both. At 35-77 weeks after the first cultured graft, recipients received two more cultured grafts under the capsule of the opposite kidney and were immunized with donor spleen cells (SC). At 5 weeks after the second transplantation, we observed that whereas second grafts carrying new antigens alone were rejected, second grafts carrying new antigens in association with antigens in the first graft were significantly protected. In another set of experiments, normal mice became tolerant to cultured allografts after 2 weeks in parabiosis with tolerant individuals. Tolerant mice showed reduced specific in vivo and in vitro cytotoxic T lymphocyte responses. However, the frequency of CTL precursors of tolerant mice was the same as in normal mice. The reduced in vitro CTL responses were restored to normal levels by the addition of a lymphokine rich medium. Also, we observed that the injection of specifically activated immune SC caused the rejection of cultured allografts in normal but not in tolerant recipients. We conclude that the tolerance that develops in recipients of cultured allografts is an active immunological process that affects the activation and effector function of CTL.

Early benefits of improved burn-care capability at Kalafong Hospital.

The creation of an improved burn-care capability was a long-awaited dream at Kalafong Hospital, one of the two academic (tertiary referral) hospitals of the University of Pretoria. When this recently became a reality, a prospective analysis of cost-effective burn care was initiated. For patients with burns of less than 10% body surface area (BSA), hospital stay (healing time) was shortened from a mean of 4.1 d/% BSA burnt to 2.7 d/% BSA burnt (34% reduction; P = 0.01). For patients with burns greater than 10% BSA, hospital stay (healing time) decreased from 2.3 d/% BSA burnt to 1.4 d/% BSA burnt (39% reduction; P = 0.0095). The overall mortality rate declined from 16.2% to 11.2% over the 24-month period. Patients with the largest deep dermal burn injury to survive in our hospital improved from 35% BSA to 60%. It is concluded that the creation of better burn care facilities at our hospital has shortened the hospital stay of survivors by a mean of 35% and decreased the mortality rate by 30%. Hospital authorities should take note of the fact that better facilities not only improve cost-effective patient care but also survival figures.

Pneumatosis cystoides intestinalis with pneumoperitoneum in renal transplant patients on cyclosporine and prednisone.

Pneumatosis cystoides intestinalis has been detected in 3/103 kidney transplant patients (3%) treated with CsA and prednisone, in contrast to less than 1% of kidney transplant patients treated with Aza and prednisone. In these three patients, the diagnosis of PCI was made by plain x-rays, 10 to 25 days after transplantation. PCI may be more likely to occur in patients with CsA trough blood levels above the recommended therapeutic range. There was associated pneumoperitoneum in all three patients, but none were subjected to exploratory laparotomy. PCI and associated pneumoperitoneum were not associated with adverse effects in any of our three patients. Antibiotics and exploratory laparotomy appear to be unnecessary.

Desferrioxamine treatment prevents chronic islet allograft damage.

BALB/cByJ islet allografts are acutely rejected when transplanted into allogeneic mice (CBA/J). Culture of the tissue for 7 days in 95% O2 before grafting is a suboptimal treatment for the reduction of immunogenicity in this strain combination. Approximately half the animals reject these transplants in a chronic fashion. Chronic islet rejection differs from acute rejection of uncultured allogeneic islets. During chronic rejection, beta cells within the transplanted tissue degranulate but remain intact when the animal returns to the diabetic condition. Acute islet rejection is characterized by the destruction of beta cells that remain heavily granulated as long as they remain intact. We examined the effect of the iron chelating agent, desferrioxamine, on chronic islet allograft damage. Desferrioxamine inhibited chronic islet allograft damage but did not influence the process of rejection of uncultured islet tissue. This effect of desferrioxamine could not be attributed to a direct immunosuppressive effect of this agent.

Legionella lung abscess after renal transplantation.

Although Legionella infections have been widely reported, the clinical importance of Legionella lung abscess has not been sufficiently emphasised. A renal transplant recipient with a pulmonary abscess due to Legionella pneumophila is presented and 21 other cases from the literature are reviewed. Seven abscesses arose in renal transplant patients. Even though an abscess may develop during treatment, superimposed infection with other micro-organisms appears to be uncommon, and an abscess may be expected to resolve with prolonged appropriate antimicrobial therapy alone. Recognition of lung abscess as a complication of legionella infection will therefore prevent unnecessary operations.