Injectional anthrax at a Scottish district general hospital.

This retrospective, descriptive case-series reviews the clinical presentations and significant laboratory findings of patients diagnosed with and treated for injectional anthrax (IA) since December 2009 at Monklands Hospital in Central Scotland and represents the largest series of IA cases to be described from a single location. Twenty-one patients who fulfilled National Anthrax Control Team standardized case definitions of confirmed, probable or possible IA are reported. All cases survived and none required limb amputation in contrast to an overall mortality of 28% being experienced for this condition in Scotland. We document the spectrum of presentations of soft tissue infection ranging from mild cases which were managed predominantly with oral antibiotics to severe cases with significant oedema, organ failure and coagulopathy. We describe the surgical management, intensive care management and antibiotic management including the first description of daptomycin being used to treat human anthrax. It is noted that some people who had injected heroin infected with Bacillus anthracis did not develop evidence of IA. Also highlighted are biochemical and haematological parameters which proved useful in identifying deteriorating patients who required greater levels of support and surgical debridement.

Laparotomy for a patient with warfarin-induced large bowel obstruction.

Many commonly prescribed drugs can interact with warfarin and prolong bleeding time beyond therapeutic limits. We report a patient who developed a rectus sheath haematoma following inadvertent over anticoagulation. Despite conservative management, the patient went on to develop large bowel obstruction from the expanding haematoma and operative intervention became necessary.

A novel method of myeloablation to enhance engraftment of adult bone marrow cells in newborn mice.

This report describes the successful development of a transplantation model in which we engrafted adult murine bone marrow hematopoietic cells in congenic day-old murine pups. Newborn animals conditioned with high doses (> or = 7.0 Gy) of total-body irradiation (TBI) demonstrated severe growth retardation and untoward effects on the developing central nervous system. Newborn pups conditioned with a sublethal dose (5.0 Gy) of TBI, however, achieved normal growth and development up to 6 months posttransplantation, and donor type hematopoietic cell reconstitution exceeded 50% in these animals. A second conditioning regimen, comprising one or two doses of busulfan (15 mg/kg) administered intrapartum, resulted in significant myelosuppression in untransplanted newborn pups. This second regimen was associated, however, with engraftment and full multilineage reconstitution of the conditioned newborn recipient animals with adult bone marrow cells, and the engrafted pups grew and developed without apparent defect. A third conditioning regimen combining a single dose of busulfan with sublethal TBI also permitted engraftment and full multilineage reconstitution of the recipient animals. Thus, successful transplantation of hematopoietic cells into newborn recipient mice may be achieved without significant morbidity if a specific conditioning regimen is employed.

Further experience in the healing rate of lower limb amputations.

Results of lower limb amputation in the Tayside Region in the years 1981-1985 have been analysed. Three-hundred and twenty-four amputations were performed on three-hundred and eight patients. Two-hundred and thirty-six amputations were attempted at the below-knee level. Only 19 required proximal revision. Prior to amputation, all patients should have a detailed vascular assessment, and the operation should be performed by experienced amputation surgeons using meticulous technique.

Fate of the vascular patient after below-knee amputation.

50 below-knee amputations were carried out in 45 patients (25 men and 20 women), mean (SD) age 73 (10.5) years. The mean survival time was 22(16) months after the operation. In each patient the healing potential of a below-knee amputation was determined preoperatively by segmental pressure studies and thermographic delineation of skin perfusion. 33 of the stumps healed by first intention, in 14 healing was delayed but occurred without the need for further surgery, and 3 stumps healed after local wedge excision. The initial mobilisation rate was 90%. Thus, there are no grounds for carrying out an initial above-knee amputation to save the patient a further operation.

Subcutaneous calcium heparin versus intravenous sodium heparin in treatment of established acute deep vein thrombosis of the legs: a multicentre prospective randomised trial.

One hundred patients with phlebographically proved acute deep vein thrombosis of the legs were prospectively randomised into two treatment groups to compare the safety and efficacy of subcutaneous calcium heparin versus intravenous sodium heparin administered by constant infusion pump. The dose of heparin was determined by daily measurement of the kaolin cephalin clotting time. Treatment was maintained for up to 14 days, after which phlebography was repeated. Of 49 patients who received subcutaneous calcium heparin, two showed an increase in thrombus size, while eight showed complete lysis. In the 47 patients who received intravenous sodium heparin thrombus increased in size in 13 while only one showed evidence of complete lysis. These differences were significant. There were no significant differences between the two groups in the incidence of serious complications, although almost half of those receiving intravenous heparin had some minor problem with the constant infusion pump and just over half of those receiving subcutaneous heparin had some bruising at the injection site. This study showed that subcutaneous calcium heparin was more effective in helping lyse existing thrombus and preventing its propagation than intravenous sodium heparin.

Diagnosis of exocrine pancreatic insufficiency in cystic fibrosis by use of fluorescein dilaurate test.

In the fluorescein dilaurate test fluorescein dilaurate is cleaved by the pancreas specific cholesterol ester hydrolase activity and the liberated fluorescein is absorbed and excreted in the urine. Fluorescein recovery is a reflection of exocrine pancreatic function. The test was evaluated in 14 patients with cystic fibrosis and 16 healthy volunteers. The test was well tolerated by patients, was easy to perform, and gave significantly lower values in the patients suffering from cystic fibrosis. The result of the pancreolauryl test was also correlated with the result of the faecal chymotrypsin test in 11 of the patients suffering from cystic fibrosis. A positive correlation was found between the two test results. The test is a practical and reliable index of pancreatic exocrine function and may have a useful role as a screening procedure.

Subtotal pancreatectomy in the male Wistar rat.

Subtotal pancreatectomy was performed in the male Wistar rat in order to obtain a model for the study of pancreatic regeneration. Adherence to previously published techniques caused an unacceptably high operative mortality due to duodenal necrosis. The operation was modified after a detailed study of the duodenal vasculature was performed and this modification together with meticulous haemostasis enabled the procedure to be performed with an acceptable operative mortality. The procedure ensured that between 73 and 83% of the total pancreatic mass was removed.

Evidence for sphincter dysfunction in patients with gallstone associated pancreatitis: effect of ceruletide in patients undergoing cholecystectomy for gallbladder disease and gallstone associated pancreatitis.

The functional activity of the sphincter of Oddi complex has been examined by ceruletide manometry in patients undergoing cholecystectomy with a normal peroperative cholangiogram. In Group I (n = 14), which included patients with previous acute cholecystitis/biliary colic, the sphincter activity appeared to be normal and responded to intravenous ceruletide by a marked relaxation with a significant fall in both the infusion and postinfusion pressures. In patients undergoing cholecystectomy for gallstone-associated pancreatitis (n = 8), the sphincter exhibited manometric features of hypotonia with low infusion and postinfusion pressures which were not significantly altered by intravenous ceruletide.

Prospective comparison of the fluorescein-dilaurate test with the secretin-cholecystokinin test for pancreatic exocrine function.

In a prospective study of 60 patients undergoing investigation for possible exocrine pancreatic disease the fluorescein-dilaurate test was compared with the secretin-cholecystokinin (CCK) test. Forty one patients had a normal response to secretin-CCK, 14 patients had abnormal responses and in five patients the results were equivocal. Taking the secretin-CCK test as the diagnostic criterion, the fluorescein-dilaurate test had a sensitivity of 100% and a negative predictive value of 100%. There was a 54% false-positive rate. The fluorescein-dilaurate test is easy to perform and is a useful screening test for pancreatic exocrine insufficiency.