CT scan does not predict optimal debulking in stage III-IV epithelial ovarian cancer: a multicentre validation study.

Our aim was to design and validate a model of CT findings that predict suboptimal cytoreduction in primary surgery (PS) for Stage III-IV epithelial ovarian cancer (EOC). We performed a retrospective review of preoperative CT scans of patients undergoing PS for EOC in a cancer centre in London, UK, between November 1995 and October 2003 (n = 91). Radiological features predictive of suboptimal cytoreduction were identified and the model tested in a second cohort undergoing PS in Manchester, June 2005 - March 2007 (n = 35). In the London cohort, liver surface disease and infrarenal para-aortic lymph node involvement predicted suboptimal cytoreduction with 80% accuracy. Accuracy of these predictors dropped to 63% when applied to the Manchester cohort. We concluded that CT prediction of suboptimal cytoreduction is unreliable and may not be reproducible. In the absence of favourable data from larger, prospective trials, it should not be used to guide management.

Body packers: a plea for conservative treatment.

BACKGROUND: The incidence of smuggling and transporting of illegal drugs by internal concealment, also known as body packing, is increasing in the Western world. The objective of this study was to determine the outcome of conservative and surgical approaches in body packers. MATERIALS AND METHODS: Clinical data on body packers admitted to our hospital from January 2004 until December 2009 were collected. The protocol for body packers required surgery when packets were present in the stomach for >48 h. Outcomes of the conservative and surgical group were assessed and analyzed. Morbidity and mortality were assessed in body packers with drug packets present in the stomach for <48 h and in those with gastric packets for >48 h. RESULTS: During the study period, more body packers were treated conservatively. Mortality was 2% in all patients and was due to intoxication. There were no significant differences of mortality, hospital admission time, and ICU admission time in the compared groups with drug packets in the stomach for less or >48 h. In 24% (4/17) of the patients with bad package material, a ruptured drug packet was found during surgery. This resulted in death in only one patient. CONCLUSION: Drug packets in the stomach for >48 h are not an indication for surgery. We recommend that surgery should only be performed in body packers with signs of intoxication or ileus and reserve conservative treatment for all other patients.

Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention.

OBJECTIVE: The long-term results and prognostic factors of radiofrequency ablation (RFA) for unresectable colorectal liver metastases (CRLM) in a single centre with >10 years of experience were retrospectively analysed. METHODS: A total of 100 patients with unresectable colorectal liver metastases (CRLM) (size 0.2-8.3 cm; mean 2.4 cm) underwent a total of 126 RFA sessions (237 lesions). The mean follow-up time was 29 months (range 6-93 months). Lesion characteristics (size, number and location), procedure characteristics (percutaneous or intra-operative approach) and major and minor complications were carefully noted. Local control, mean survival time and recurrence-free and overall survival were statistically analysed. RESULTS: No direct procedure-related deaths were observed. Major complications were present in eight patients. Local RFA site recurrence was 12.7% (n = 30/237); for tumour diameters of <3 cm, 3-5 cm and >5 cm, recurrence was 5.6% (n = 8/143), 19.5% (n = 15/77) and 41.2% (n = 7/17), respectively. Centrally located lesions recurred more often than peripheral ones, at 21.4% (n = 21/98) vs 6.5% (n = 9/139), respectively, p = 0.009. Including additional treatments for recurring lesions when feasible, lesion-based local control reached 93%. The mean survival time from RFA was 56 (95% confidence interval (CI) 45-67) months. Overall 1-, 3-, 5- and 8-year survival from RFA was 93%, 77%, 36% and 24%, respectively. CONCLUSIONS: RFA for unresectable CRLM is a safe, effective and potentially curative treatment option; the long-term results are comparable with those of previous investigations employing surgical resection. Factors determining success are lesion size, the number of lesions and location.

Cardiac disease in pregnancy: a 4-year audit at Pretoria Academic Hospital.

BACKGROUND: Pre-existing medical disease constitutes one of the five major causes of maternal death in South Africa. Increasing numbers of women with heart disease reach adulthood as a result of advances in diagnoses and treatment of heart disease in childhood. OBJECTIVE: To assess the profile of cardiac disease and the maternal and fetal outcome of pregnant patients at Pretoria Academic Hospital (PAH). METHODS: A retrospective analysis was carried out on 189 pregnant cardiac patients who delivered at PAH between January 2002 and December 2005. RESULTS: Nearly 1% of all mothers who delivered at PAH had underlying cardiac disease. Most cardiac lesions were valvular disease secondary to childhood rheumatic heart disease. Pulmonary oedema was associated with the greatest morbidity and mortality. The severe morbidity rate was 11.6% and the case fatality rate 3.3%. The mean gestational age at delivery was 35 weeks; 18 (9.7%) babies were born before 34 weeks. CONCLUSION: Cardiac disease in pregnancy is associated with high morbidity and mortality rates for mothers and their babies. Multidisciplinary evaluation with discussion of risk factors, appropriate family planning and optimising of the cardiac state before conception is advised.

Reliability of a nutrition screening tool for use in elderly day hospitals.

BACKGROUND: There are a plethora of nutrition screening tools (NSTs) in use in a variety of clinical settings that are either unvalidated and/ or not client specific. There is a need for an NST for all elderly patients attending community day hospitals. At present such a validated tool is unavailable. AIMS: To assess the reliability and reproducibility of a developed NST; and to identify elderly patients attending day hospitals who have, or are at risk of, poor nutritional status. METHODS: Three day hospitals were selected and 70 admissions were prospectively assessed by Nursing staff and independently by a State Registered Dietitian (SRD) The patients' nutritional status was anthropometrically assessed using the NST. RESULTS: The level of agreement between the nurse and the dietitian for each of the levels of the NST and the overall score was either 'good agreement' or 'very good agreement' as defined by Cohen's Kappa. Spearman's Rank Correlation between objective markers of assessment and the Nurse or Dietitian score from the NST were all statistically significant (P = 0.42). As an identifier of risk, the NST has low levels of sensitivity, but high levels of specificity. CONCLUSION: The Ayrshire NST is a reliable and valid tool which can be used by qualified Nursing staff to assist in screening elderly patients at high risk of poor nutritional status.

Never again joy without sorrow: the effect on parents of a child with ataxia-telangiectasia.

The purpose of this study was to explore the impact of having a child with ataxia-telangiectasia (A-T) as well as to assess parental understanding of the genetics of A-T and attitudes toward carrier testing. Sixty-eight parents of individuals with A-T were interviewed. Ninety percent of the parents correctly believed if there is a child with A-T, both are obligate heterozygotes. Only 9% knew each well sib had a two-thirds chance of being a carrier. Eighty-four percent would have their unaffected child tested for carrier status prior to age 18 years. Eighty-two percent believed heterozygosity is associated with increased health risks. We offer the following recommendations. 1) Physicians must realize that communicating the possibility of early death is difficult; parents need guidelines so they know what to expect, but diagnosis should not be a death sentence. Clinicians should stress individual variations in expression of the disorder and offer hope for future progress in treatment. 2) Parents underestimated carrier risks for the well sib and the frequency of carrier status in the general population. Although these distortions are self-protective, they interfere with transmission of accurate genetic information to their children. Parents should be referred to genetic counseling. 3) Psychological counseling should be offered to families at the time of diagnosis so parents can support each other, the affected, and unaffected offspring.

Respiratory disease in thoroughbred horses in training: the relationships between disease and viruses, bacteria and environment.

A longitudinal study of respiratory disease in racehorses was carried out to assess its relative associations with different infectious agents and to examine any role that the environmental conditions might play. The relationships between coughing, nasal discharge, pyrexia and lower respiratory tract disease were also examined to provide information for improving clinical diagnosis, particularly of disease of the lower respiratory tract. Lower airway disease was closely associated with infection with Streptococcus zooepidemicus. It was also found that equine herpesvirus seroconversions and S pneumoniae infections were independently associated with the development of nasal discharge. Coughing was a specific, but insensitive measure of lower respiratory tract disease (specificity 84 per cent, sensitivity 38 per cent). However, horses that coughed were very likely to have had lower airway disease for more than one month. Horses housed on straw in loose boxes were twice as likely to suffer from lower airway disease as those kept on shredded paper in American barns. The study was not large enough to assess the significance of rarer infections but it did improve the definition of the problem of respiratory disease in racehorses and revealed some of the trends in the associations between viruses, bacteria and the environment in respiratory disease.

The microflora of the lower respiratory tract of the horse: an autopsy study.

A series of 31 thoroughbreds and 18 non-thoroughbreds was examined post mortem to assess what bacteria might be present in the lower respiratory tract, and to assess their significance by correlating the bacteriological findings with histological changes in the lung. The distal trachea and seven representative lung sites were swabbed in each case. Sixty-six per cent of the sites were sterile with remaining sites producing scanty growths of mainly coagulase negative Staphylococcus spp., E. coli, Bacillus spp. and Pseudomonas spp. Anaerobes, mainly Clostridium perfringens, Bacteroides fragilis and Bacteroides oralis, were only recovered on enrichment media and were isolated more frequently from the right lung than the left. More bacterial species were isolated from thoroughbreds than non-thoroughbreds. Significant inflammation was absent in the majority of lungs examined and this correlated well with the large percentage of sterile sites and low number of potential pathogens. The results indicate that the lower respiratory tract of horses is normally sterile or may contain small numbers of bacteria of low pathogenicity. Chlamydia and respiratory viruses were not isolated from any horse.

Role of anaerobic bacteria in equine endometritis.

This study, performed over 3 breeding seasons, surveyed anaerobic and aerobic bacterial isolates from 362 clitoral and endometrial swabs and uterine washes from 263 Thoroughbred maiden, foaling, foal heat and barren mares, and from 113 urethral, urethral fossa, preputial and pre-ejaculatory fluid swabs from 29 Thoroughbred stallions. The significance of isolates was determined by their association with acute endometritis, as determined by concurrent endometrial smear results and by consideration of age and reproductive status before and after the survey. The results suggest that the horse uterus may harbour obligate anaerobes as surface commensals. These organisms normally inhabit the external genital surfaces of mares and stallions and are periodically introduced into the uterus at coitus or in association with genital pathology, e.g. pneumovagina or vagino/cervical injury. They may act as opportunist pathogens when there is epithelial damage, e.g. during the post-partum involutionary period. Synergism with aerobic bacteria may result in mixed infection and active endometritis. In the mare, the predominant uterine anaerobic species is Bacteroides fragilis. This species is predominantly penicillin- and aminoglycoside-resistant, a feature which is pertinent when intrauterine antimicrobial therapy for endometritis is considered. Detailed anaerobic diagnoses are unavoidably time consuming and as mixed infections are common, nitrofurantoin or metronidazole should be included in antibiotic mixtures. Failure to do this may account for some cases of aerobe-negative persistent endometritis.

Isolation of Streptococcus pneumoniae from the respiratory tract of horses.

Streptococcus pneumoniae was isolated from nasopharyngeal swabs and tracheal washings taken from Thoroughbred horses in training at three of four separate stables that were sampled during investigations into respiratory disease. The growth of Strep pneumoniae in culture was enhanced by an environment enriched with carbon dioxide. In one stable, five of 15 horses that were sampled repeatedly were found to carry the organism for at least four months. There was an apparent association between lower respiratory tract inflammatory disease and heavy growths (10(6) to 10(8) colony forming units/ml) predominantly of Strep pneumoniae or of that organism together with large numbers of Strep zooepidemicus obtained from tracheal washings. Twelve strains of Strep pneumoniae isolated from three stables were all of capsule Type 3. Only one strain, which was of capsule Type 9, was isolated from nose and throat swabs taken from 32 staff working in one of the stables and suggested an absence of cross infection between horses and their handlers in this instance.

A double blind trial of nitroglycerin vasodilator ointment in patients undergoing cytotoxic chemotherapy.

A randomized double blind controlled trial has shown that topical, nitroglycerin vasodilator cream applied to the intended injection site in patients undergoing cytotoxic chemotherapy for various malignancies, produced detectable vasodilation and a decrease in minor aids to venepuncture compared to placebo. It did not decrease the number of attempts at cannulation needed nor the overall cannulation failure rate and cannot be recommended for general use in cytotoxic chemotherapy clinics.

Observations on vaccine and post-infection immunity in contagious equine metritis.

The vaccination of four ponies on two occasions with a formolised culture of Haemophilus equigenitalis produced a high circulating antibody titre to the organism in each pony. Three out of four vaccinated and all of three unvaccinated ponies developed typical symptoms of contagious equine metritis (CEM) when subsequently challenged with a vaginal exudate containing H equigenitalis. Similarly, three ponies which had previously been infected with H equigenitalis and which had recovered spontaneously also developed contagious equine metritis when rechallenged with the organism. The clinical and bacteriological symptoms in the vaccinated ponies and in the rechallenged ponies were less severe than those observed in the unvaccinated ponies but H equigenitalis was still recovered 17 days after challenge from the three vaccinated ponies which had developed CEM. The vaccinated pony which remained free from infection did not exhibit the highest circulating antibody titre of the vaccinates before challenge.