Variation in GH and IGF-I assays limits the applicability of international consensus criteria to local practice.

BACKGROUND: There is increasing reliance on consensus criteria for decision making. Recent criteria state that acromegaly is excluded by a nadir GH during an oral glucose tolerance test (OGTT) of < 1 microg/l and a normal level of IGF-I. OBJECTIVE: To study GH and IGF-I assay performance close to cut-off values for active acromegaly. DESIGN AND METHODS: Two serum samples known to give borderline results were sent to all centres participating in the UK National External Quality Assessment Service (NEQAS). Sample A was assigned to be a nadir during an OGTT and sent for GH assessment to 104 centres. Sample B, with a clinical scenario, was sent to 23 centres that measure IGF-I, and these centres were asked to measure IGF-I, interpret the result and provide the source of their reference ranges (RRs). RESULTS: For sample A, the median GH was 2.6 mU/l (range 1.04-3.5 mU/l). Applying a conversion factor (CF) of 2.0 (1 microg/l = 2 mU/l), the most negatively biased method classified 10% of the values consistent with acromegaly, while the most positively biased method classified all values as consistent with the diagnosis. Applying a CF of 3.0 (1 microg/l = 3 mU/l), only 11% of results were consistent with acromegaly. For sample B, the median IGF-I was 50.8 nmol/l (range 24.3-60.9 nmol/l). All centres used age-related RRs. There was a 50% variation in the upper limit of the RRs between centres. Overall, 30% of the IGF-I results were against the diagnosis. There was little agreement in the RRs quoted by centres using the same method. CONCLUSION: Variability in assay performance, coupled with use of inappropriate CFs and RRs, undermines the applicability of international consensus criteria to local practice.

Technology and the future of medical equipment maintenance.

Maintenance of medical equipment has been changing rapidly in the past few years. It is changing more rapidly in developed countries, but changes are also occurring in developing countries. Some of the changes may permit improved maintenance on the higher technology equipment in developing countries, since they do not require onsite expertise. Technology has had an increasing impact on the development of medical equipment with the increased use of microprocessors and computers. With miniaturization from space technology and electronic chip design, powerful microprocessors and computers have been built into medical equipment. The improvement in manufacturing technology has increased the quality of parts and therefore the medical equipment. This has resulted in increased mean time between failures and reduced maintenance needs. This has made equipment more reliable in remote areas and developing countries. The built-in computers and advances in software design have brought about self-diagnostics in medical equipment. The technicians now have a strong tool to be used in maintenance. One problem in this area is getting access to the self-diagnostics. Some manufacturers will not readily provide this access to the owner of the equipment. Advances in telecommunications in conjunction with self-diagnostics make available remote diagnosis and repair. Since components can no longer be repaired, a remote repair technician can instruct an operator or an on-site repairman on board replacement. In case of software problems, the remote repair technician may perform the repairs over the telephone. It is possible for the equipment to be monitored remotely by modern without interfering with the operation of the equipment. These changes in technology require the training of biomedical engineering technicians (BMETs) to change. They must have training in computers and telecommunications. Some of this training can be done with telecommunications and computers.

Profile of a BMET (biomedical equipment technician) in small hospitals.

A survey was done of biomedical engineering programs in hospitals of under 100 beds. A random sampling of 400 hospitals was selected from the American Hospital Association Guidebook. Questions were asked with regard to the size, educational background and experience of the biomedical engineering staff. The organizational location of the program was surveyed, and most programs were part of facility engineering. Programs are discussed as full-time, part-time and outside service contracts. An in-depth analysis of the educational and training background of BMETs has been done. This part of the study covered the type of training and what additional training they felt they required.

Production of extracellular enzymes and cytotoxicity by Vibrio vulnificus.

Thirty-three strains of Vibrio vulnificus of clinical and environmental origin were examined for production of 12 extracellular enzymes of potential importance to the virulence of this bacterium. Strains of Vibrio vulnificus were consistent in their production of protease, mucinase, lipase, chondroitinase, hyaluronidase, DNase, sulfatase, and hemolysin. No differences between clinical and environmental isolates were noted. Although none of the enzymes appeared to correlate with the ability of these strains to produce lethality in mice, the production of hemolysin and of a protease with activity against native serum albumin may be significant in the pathogenesis of the potentially fatal infections produced by this organism. The production of several of these exoenzymes also appeared to correlate with pathogenicity in the seven other Vibrio species examined. Culture filtrates of all virulent strains of Vibrio vulnificus were cytotoxic for Chinese hamster ovary cells, whereas those of the strains of Vibrio parahaemolyticus and Vibrio alginolyticus examined lacked this activity.

Veterans Administration BMET certification exam.

The Veterans Administration has developed a program to evaluate the level of competency of its medical equipment repairmen and to recognize those who surpass an established level of competency. This evaluation is carried out by means of testing. A passing score of 70% on all sections of the exam results in certification while failure results in enrollment in correspondence or short courses. Periodic evaluations of the exam are carried out to determine questions to be added or deleted and those which should be reworded. Since time limits are set for completing the exam, those time limits are also evaluated.

Treatment of stage D hormone-resistant carcinoma of the prostate with estramustine phosphate.

We report on 51 patients with hormone-resistant, stage D prostatic carcinoma who were treated with estramustine phosphate and followed for at least 6 months. Of the 51 patients 5 (10 per cent) had a partial objective response, 30 (59 per cent) remained stable and 16 (31 per cent) had progression of the disease. All of those patients who had a partial response or remained stable also experienced subjective improvement as judged by relief of pain and performance status. Approximately 8 per cent of the patients will be unable to take estramustine phosphate because of intolerable gastrointestinal side effects.

Biofeedback in urology using urodynamics: preliminary observations.

Biofeedback training aided by urodynamic instrumentation produced significant clinical improvement in 4 of 8 urological patients. The display of electromyographic activity of the periurethral striated muscles was facilitated by the use of a new intraurethral catheter with 5 surface mounted electrodes. This modality of treatment seems worth considering for selected patients with urinary retention or urinary incontinence.

A new approach to the treatment of priapism.

A 26-year-old man with post-traumatic priapism was treated successfully by occlusion of the left internal pudendal artery with an autologous clot. The recovery was marked by the return of entirely normal sexual function. This excellent result suggests that autologous clot injection of the internal pudental artery should be considered as an appropriate form of therapy for the treatment of selected patients with priapism.

Concentrating ability after antireflux operation.

Children undergoing surgical correction of reflux require short-term and long-term assessment of the functional, bacteriological and radiologic results. In short-term assessment concentrating ability may be a more sensitive indicator of benefit or harm than creatinine clearance. There were no cases of persistent reflux and a 7 per cent obstruction rate in 59 ureteral reimplantations in 36 children.

Vesicocolonic fistulas in diverticulitis.

Diverticulitis is a disease affecting patients in the fifth to sixth decades. The charts of 12 patients with cesicocolonic fistulas secondary to diverticulitis were reviewed. Their presentation was primarily urological with pneumaturia present in 10 of 12 patients and fecaluria present in 5 of 12. The process of fistulization occurs in stages. If the incipient stage can be identified early fistulization can be prevented and the morbidity and mortality rates will be reduced significantly. In older patients with bladder irritation (with or without positive urine cultures) a high degree of suspicion for diverticular disease will ensure an accurate diagnosis earlier. Patients with penumaturia or fecaluria present less of a diagnostic challenge. Cystoscopy is a reliable procedure and we recommend its use in discovering a vesicocolonic fistula. Surgical therapy should be individualized for each patient and good results were obtained with primary resection as well as staged repair.

Familial Kallmann syndrome with unilateral renal aplasia.

On the basis of studies in two brothers and their double first cousin, the Kallmann syndrome (KS) is discussed as an X-linked syndrome of anosmic hypogonadotropic hypogonadism. The anosmia is thought to represent agenesis or hypoplasia of the olfactory lobes, the mildest form of the alobar holoprosencephaly developmental field defect; this is supported by the finding of hypotelorism in two of the patients and their mother. The endocrine defect is thought to represent a hypothalamic abnormality of the luteinizing hormone releasing hormone; borderline normal intelligence may represent another pleio-tropic CNS manifestation of the KS gene. All three affected males had unilateral renal aplasia, associated in one with ipsilateral absence of the testis. The presence of at least two developmental field defects (involving the CNS and urogenital system) makes it likely that the KS is a true multiple congenital anomaly syndrome; this is supported by the finding of additional, mostly minor, anomalies reported by other investigators. Heterozygous females may also show manifestations of anosmia, hypogonadism, possibly even internal genital malformation; however, genetic heterogeneity of anosmic hypogonadism is possible, and for the time being it is probably better to designate sporadic female cases of anosmic hypogonadism as examples of the olfacto-genital syndrome of DeMorsier. Linkage studies are urgently needed to clear up the question of genetic heterogeneity and to help develop empiric recurrence risk figures in anosmic hypogonadism.

Effect of fluorocarbon emulsions on the mechanical fragility of normal and sickle cells: in vitro studies.

Mechanical fragility measurements have been made in vitro on fluorocarbon emulsions mixed with normal and sickle cells in plasma to determine the effect of fluorocarbon. Emulsions of FC-80 with Pluronic F-68 were added to give final solutions of 0, 1, 5, 10, and 20% fluorocarbon emulsion. The effect of the fluorocarbon emulsion was observed in the presence and absence of oxygen. In the presence of oxygen, there was no effect of the fluorocarbon emulsion on the mechanical fragility of normal or sickle cells. In deoxygenated systems, however, there was significantly less hemoglobin in the plasma during the mechanical fragility test with fluorocarbon emulsion added to sickle cell blood. The normal blood was not affected by the fluorocarbon emulsion in the deoxygenated system. Five percent of fluorocarbon emulsion was required for a significant effect on the deoxygenated sickle cells. Since the effect of the fluorocarbon emulsion was in a deoxygenated condition, the effect is due to the presence of the fluorocarbon emulsion and not its oxygen carrying capability.