New approaches to the management of poor prognosis non-seminomatous germ cell tumours. While most patients with disseminated non-seminomatous germ cell tumours (NSGCT) are cured by treatment with cisplatinum-based chemotherapy, a subset die from refractory or relapsing disease. Poor prognostic factors at diagnosis include bulky disease, visceral involvement, high serum marker levels and an inadequate rate of fall in these markers in response to treatment. There are a number of approaches to poorer risk patients. One is to use conventional induction chemotherapy followed by second-line salvage regimens in those who fail induction. Results with this approach have been disappointing. A second approach is to use more intensive induction regimens, in some cases with growth factor support; whether these are superior to standard treatment has yet to be established by randomised studies. A third approach, based on the chemotherapy-dose responsiveness of NSGCT, consists of the administration of very high dose chemotherapy followed by haematological rescue with autologous marrow to patients failing initial therapy. Review of autograft studies suggest that durable remissions can be obtained in most patients with responsive disease, but not if the disease is chemotherapy-refractory. A new approach may be elective early autografting in patients identified at diagnosis to have very poor prognosis disease.


The role of dipyridamole in addition to low dose aspirin in the prevention of occlusion of coronary artery bypass grafts. One hundred and one subjects were randomised to receive either aspirin 100 mg or aspirin 100 mg + dipyridamole 300 mg daily before undergoing coronary bypass surgery. The drugs were commenced at least 36 hours before operation and patients were followed for one year. There were three perioperative deaths and 37 withdrawals, of which 14 were drug related (aspirin four, aspirin + dipyridamole ten). Cineangiocardiograms at nine weeks and one year showed vein graft patency rates of 93% and 87% for subjects treated with aspirin alone; and 90% and 89% in those who received aspirin+dipyridamole. During the follow-up period 14% of 232 coronary lesions in the aspirin treated group advanced by more than two grades compared with 15% of 315 lesions in the aspirin+dipyridamole group. The study did not establish superiority of one regimen over another in terms of graft patency or progress of lesions in native vessels. However, low dose aspirin was better tolerated than combination therapy.


The structured interview as a tool for predicting premature withdrawal from medical school. A 1:1 matched case-control study was carried out to assess whether comments written about a candidate during a semi-structured interview can identify students likely to withdraw from a medical course better than global numerical scores. Fifty-nine students who withdrew from the undergraduate medical course at the University of Newcastle prior to completion were matched for sex, year and mode of entry into the course, prior academic qualifications and age at entry, with 59 students who had not discontinued or been excluded from the course. No significant differences were found between the numerical scores allocated for personal attributes to students who later withdrew from the course and those who continued. However, students who withdrew had statistically significantly more negative comments made about them at interview with respect to their supportive and encouraging behaviour (p = 0.04) and their motivation to become doctors (p = 0.05). Although no other comparisons reached statistical significance, students who withdrew consistently received more negative comments and fewer positive comments than their continuing peers. A stepwise logistic regression procedure identified the number of negative comments made by interviewers about a candidate on their supportive and encouraging behaviour as the only statistically significant predictor of later withdrawal (odds ratio 1.65 95% confidence interval 1.01-2.70).


The Australian and New Zealand Cardiothoracic Organ Transplant Registry: first report 1984-1992. This initial report of the Australian and New Zealand Cardiothoracic Organ Transplant Registry summarises the results of all cardiothoracic transplants performed between February 1984 and April 1992. A total of 549 first cardiothoracic transplant procedures and six cardiac retransplant operations were performed in five transplant units throughout Australia and New Zealand. There were 466 orthotopic cardiac transplants and one heterotopic transplant with overall survival 86% at one year and 80% at five years. Two of six patients who underwent cardiac retransplantation are alive. Fifty-three heart-lung transplants were performed with 72% one year and 42% five year survival. Twenty-nine single lung transplant procedures were undertaken, with actuarial survival 72% at 12 months. Factors influencing waiting period and post-transplant survival for each type of procedure are detailed. The relative lack of donors compared with recipient demand has produced increased waiting times for every type of cardiothoracic organ transplant.


[Homicide simulating electrocution suicide by spinal anesthesia]. A married woman was found dead with indications of suicide by electricity (household-voltage). On coroner's inquest (typical electric lesions at the wrist) and the result of police investigation, there was no indication of third party involvement. The cadaver war firstly released to burial, but on account of indication of conflicts between the married couple, a forensic autopsy was arranged. The most important pathological finding was a fresh puncture between L3/L4. On toxicological investigation, toxic concentrations of the local anaesthetic prilocaine were found in liquor and organs. Cause of death was central respiratory- and circulatory depression. The husband, an anaesthesist, blamed he was assisting the suicide of his wife at her request. He was found guilty by reasons of manslaughter but not for murder.


[Discrepant results with immunohistochemical detection TDx/ADx?]. In the last 2 years we had some problems to confirm the thin-layer results (amphetamines, opiates, benzodiazepines, barbiturates and cocaine) with the immunoassay system TDx/ADx. Between January 1989 and December 1990 we did 883 screenings in urine samples (pre- and postmortal) and had 157 discrepancies (20%). In regard of the high level of discrepancies, we had to test the compatibility of TDx and ADx, their detection limits and compared the results with a second method, thin-layer chromatography. Determining the correlation coefficients to prove our results statistically, we found that both systems, TDx and ADx, work reproducible.


[Significance of drug determination in pilocarpine sweat for detection of past drug abuse]. The presence of cocaine, morphine and methadone in sweat samples obtained after stimulation of the eccrine sweat glands, from drugs users after six drugs-free days, was investigated. The stimulation of the sweat elimination was proved using pilocarpine-iontophoresis every hour for 7 hours. The drugs concentrations were determined by radioimmunoassay. Consequently, the values measured represent the sum of the drug and its metabolites. Measurable levels of cocaine, morphine and methadone were obtained after the third stimulation of the glands.


[Detection of bromine uptake in cadavers from seawater]. Pieces of animal and human lungs were placed in seawater. The fluids pressed of it produced in X-ray fluorescence analysis bromine concentrations, which exceeded the physiological level. These experiments created the supposition to interpret correctly relevant findings in the victims of flight accidents.


[Matrix effects from the thanatochemical viewpoint]. The predominating hydrophilic physiological body constituents are not interfering severely during the toxicological analysis for organic poisons in biological matrices, whereas coextracted lipids are usually well distinguishable from xenobiotics. But interfering substances increase strongly with autolysis, and some of them behave like toxicologically relevant compounds to be detected by the respective analytical methods. Attempts are reaching from the STAS' isolation procedure through the ptomaines to our chromatographical epoche, to phenomenologically compensate the matrix effects--increasing in the course of putrefaction--by the determination and generalisation of according analytical signals. The paper outlines on the background of Systematic Toxicological Analysis how far a systematic thanatochemical concept should be considered more closely for the futural more effective analytical elimination of such matrix effects.


[Multifactorial studies of 154 fatalities of psychotropic drug poisoning]. The documents of 154 drug victims dissected in the Centre of Legal Medicine of the University of Frankfurt am Main in 1987 and 1988 were examined by computer. The average age i.e. was 26 years, the share of women 23 per cent. In 47 per cent the main cause of death was an overdoses of heroin and in 48 per cent heroin was the first drug that was taken. 58 per cent of the drug victims came from totally intact families.


[Strangulation fatalities in childhood]. The 12,000 obductions at the Institute for Forensic Medicine of the University of Hamburg from 1981 to 1990 included 30 cases of strangulation in children up to the age of 14 years (16 females, 14 males). 7 of these cases had been accidents (during infancy), 18 children had been murdered (all age groups), 4 children (elder ones) had committed suicide. In one case it could not be decided whether the reason of death had been suicide or an accident. Summarized data concerning epidemiological, phenomenological and morphological aspects are presented. Two case histories give some hints to special aspects of accidental strangulation and homicide among children.


[Sudden death after consumption of chloral hydrate]. Two cases of fatal chloral hydrate poisoning are reported. The young men were prisoners in jails of Vorarlberg. During their captivity the doctor prescribed them 4 g chloral hydrate per day because of insomnia. They accumulated some doses and consumed it all together. Causes of death were brain swelling with premature craniostenosis in one case and vomiting with aspiration of stomach content in the other. Morphological and toxicological findings are presented and juridical consequences are turned out.


[Quantitative measurements of hemagglutination using ultrasound scattering]. A new method of quantitative measurement of the strength and the progress of hemagglutination is being reported. A rapid investigation of antibody titres and receptor strength is possible.


[Blood group determination of a single hair]. Using the mixed cell agglutination reaction (MCAR) in a modification by Ishiyama and Okada (MCAR on adhesive tape) we examined single rootless hairs collected from 65 men, women and children (aged 6 months to 80 years). Correct results gave 57 probes (87%). False-positive and false-negative results mainly occurred at non-secretor donors. The modified method is quickly done, reproducible and does not alter the hair.


[The independence of the forensic physician as an expert witness]. Forensic physicians are often called upon by the courts and the public prosecutor's office to give expert opinions and carry out post-mortem examinations, e.g. to determine blood groups or cause of death. The expert is simply aiding the court within the framework of its function of hearing evidence. The court, after considering the evidence, must determine whether an allegation is true or false. Since, for example, the determination of cause of death demands qualified specialized knowledge and a high sense of responsibility, the expert should be both scientifically and personally autonomous in order to preclude wherever possible any conflict of interest. The not-too-distant past has demonstrated that justice, even here, can often be miscarried. This is why the autonomy of the expert is of prime importance. The readjustment to section 87, para. 2, clause 2, StPO may represent an infringement of the principle of autonomy, for in addition to calling on forensic physicians or the heads of forensic or pathology institutes to perform autopsies, as required before the 1975 amendment, these heads are now permitted to delegate their assignments to doctors in their own institutes. In compliance with the decisive trial commentary Loewe-Rosenberg, it should be pointed out that the presence of two pathologists is required by the law, one of whom must be a forensic physician or head of a forensic or pathology institute, and that the court presumes that the participation of delegated doctors will be the exception to the rule.(ABSTRACT TRUNCATED AT 250 WORDS)


[Acute fatal hemorrhage in craniocerebral trauma?]. At necropsy of fatal cases due to craniocerebral trauma it is highly recommended that the intraosseous course of the internal carotid arteries are dissected, as detected injuries of these vessels may allow improved conclusions concerning the course of death. Suitable preparation techniques are presented. On the basis of the anatomical and physiological situation as well as pathophysiological considerations the acute lethal outcome of traumatic rupture of the intraosseous part of these arteries is not to be interpreted as death by hemorrhagic/hypovolemic shock but rather as lethal cerebral hypoxia subsequent to a rapidly developing insufficiency of the brain circulation.


[Detection of ischemic myocardial damage]. Cases of cardiac death (myocardial infarction, coronary artery thrombosis, coronary artery sclerosis) were investigated with histochemical and immunohistochemical methods. Histochemical staining methods (HE, LFB, CAB) were used, with immunohistochemical methods were detected the proteins Desmin, Myoglobin, Fibrinogen and Complement C5b-9. Macroscopically visible myocardial infarctions were detected with both methods clearly. The damage pattern was associated to the type of destruction. At myocardial infarction the changes were focal at the other groups more disseminated.


[Rectal temperature-time of death nomogram: dependence of corrective factors of body weight in significant thermal insulating conditions]. 98 test coolings were made under various cooling conditions (moving air, two types of both clothing and covering) on dummies of real masses of 1, 3.3, 9.9, 24.5 and 33.4 kg resp. which cool under standard conditions (unclothed, uncovered, still air) like human bodies of 14, 33, 41, 83 and 104 kg resp. The results provide evidence on a nonlinear dependence of corrective factors of body weight upon the body weight. The dynamics of the dependence increases with the thickness of thermic isolation. Transferred to the use of the nomogram method on bodies, cooling conditions requiring corrective factors known by experience between 0.75 (moving air) and 1.3 (rather thin clothing/covering) can be used as in the past independent on the body weight. Only in higher corrective factors for thicker clothing/covering according to experience the dependence of corrective factors on the body weight must be taken into account in bodies of a very high or low body weight. Beside a simplified table a formula for computing is also given for that purpose.


[Contact neck gunshot wound without weapon--suicide or homicide?]. To support police in reenacting criminal acts is one of the most important functions of forensic investigation. This case report deals with the discovery of the corpse of a 42-year old man at the bank of the river Inn. First of all the man was supposed to be drowned, but the autopsy showed a gunshot wound of the neck and a shot-through of the brain-stem. Intensive search for the weapon by the police and by divers was unsuccessful and therefore suspicion of homicide arose. The reconstruction of the act at the site of discovery of the corpse led to the discovery of the weapon and the case became clear to be a suicide.


[Ectotoxin-forming pyogenic Staphylococcus aureus (S. aureus) as a cause of toxic shock syndrome (TSS) in man]. Basing considerations on an extremely carefully examined case of toxic shock syndrome (TSS), an analysis of this phenomenon is presented from the clinical and forensic points of view. TSS is often associated with the term "tampon disease" but in the meantime it has turned out that it may also arise as a non-menstrual disorder, caused by local infections, for example after surgical interventions. The inevitable symptoms include: fever, exanthema, desquamation on the palms of the hands and soles of the feet as well as hypotension. The clinical symptoms would initially suggest a septic process, however bacteriological investigations (blood cultures) normally produce negative results. At the source, however, ectotoxin-producing staphylococci (S. aureus) are found. The present case which is described in detail involves a 17-year old woman who had contracted a crucial ligament injury at the knee of the right leg when playing football. She died a few days after the operation, her death being accompanied by high fever. In smears from the area of the operation it was possible to identify staphylococci (S. aureus) which by phagetyping determination were classified as belonging to lysogroup type II/71 and which produced ectotoxin B. It was not possible to culture bacteria from blood from the corpse. Criminal proceedings for involuntary manslaughter were in the end dismissed although the accused resident physician was sentenced to pay 30,000 DM damages to the parents of the young woman. He also had to pay the costs of the civil action incidental to the criminal proceedings.(ABSTRACT TRUNCATED AT 250 WORDS)


[Liver and splenic ruptures as a complication of heart pressure massage]. Injuries of the abdominal organs, especially liver and spleen, which were caused by resuscitative measures, can occasionally raise problems if an expert opinion on death is obtained particularly with regard to previous traumatization and if the question arises whether the trauma could have been avoided or not. These questions will be discussed from different points of view by means of ten cases. Even when lege-artis-cardiac massage is made, the above mentioned complications cannot always be avoided. In none of the ten cases the trauma caused by resuscitative measures was the cause of concomitant cause of fatal outcome.


[Unexpected fatalities in childhood caused by acute epiglottitis]. Report on two deaths from a natural internal cause in children beyond the first year of life. The children (a two-year and a three-year old boy), who seemed completely healthy, sudden suffered from acute inflammation of the upper respiratory tract with dyspnea, inspiratory stridor, fever, dysphagia, and flow of saliva. The disease took a fulminant course and the children died within a few hours showing symptoms of intense dyspnea and cyanosis. The above symptoms and progress were typical of acute epiglottitis. Autopsy revealed an intense inflammation and tumescence of the epiglottis in both cases. The diagnosis of epiglottitis was confirmed histologically and bacteriologically (Haemophilus influenzae).


[Injuries caused by automobile safety glass]. The report initially discuss the properties and application of tempered glass (TG) and laminated glass (LG) in motor vehicles. Although the trunk and extremities are injured these injuries are seldom life threatening. In contrast, head or neck injuries present a greater threat to life. Especially serious are TG injuries resulting in blindness. The resultant vehicle damage can appear not only as isolated glass cracking, which occurs regularly accompanying injuries without loss of consciousness, but as deformation of the vehicle interior adjacent to the windscreen. In the cases where more solid structures are impacted fatal injuries are possible. This report presents detail both of some real accident investigations and of 9 simulated oblique collisions using 9 post mortem human subjects (PMHS's). In these 9 simulations the head impacted during the primary impact phase against side windows constructed from TG. A modified tempered glass construction (two plates sandwiching a 3 mm air layer) was also tested. Impact angles were 35 to 45 degrees. The severity of facial laceration was dependent on collision severity, type of glass and glass damage resulting from head impact. Minor or severe cutting injuries of the face were caused. Only through the investigation of real accidents and accident simulations can occupant safety be improved.


[Body packing as a fatal risk--results of a questionnaire survey in Western Europe]. A questionnaire was sent to 138 institutes of Forensic Medicine in 18 countries of Western Europe to obtain information concerning bodypackers, who had died between 1980 and 1990. The total number of dead was 17 (4 own cases). 8 cases were reported from the Federal Republic of Germany, 4 from Italy, 2 from Great Britain and 1 from Austria, Spain and Norway each. In 15 cases some circumstances were told. Most of the bodypackers had transported heroin (10), in 2 cases cocaine and amphetamine were found and in 1 case marihuana inside of stomach and bowel. The related risk seems to be low in comparison to police authorities presuming that about 80% of drug-couriers move the stuff inside their body to and fro.


[Pilot study of dose dependence in glucuronidation of morphine to morphine-3- and morphine-5-glucuronide]. In the capacity of an initial study both, the half-lives of morphine and its metabolites morphine-3-glucuronide and morphine-6-glucuronide as well as the ratio of concentrations in the development of time using two different dosages were determined and shown by comparison. A bolus of 10 mg (10 micrograms) tritium-marked morphine was administered intravenously. Subsequently the half-lives of morphine, morphine-3-glucuronide and morphine-6-glucuronide in serum, saliva and urine were determined. To achieve this, morphine and its glucuronides were separated via HPLC and then quantified by measuring the radioactivity. In addition to the short half-lives of morphine and morphine-glucuronides long half-lives were found in the range of 12.6 to 20 hours in serum and urine. There was no positive evidence for glucuronides in saliva. In urine the morphine/glucuronide ratio showed a linear resp. exponential development dependent of dose.


[The value of breath alcohol determination in street traffic]. 436 cases were collected, in which both breath alcohol (AAK) as well as blood ethanol levels (BAK) were determined. We studied the correlation between AAK and BAK. Furthermore, the duration between event, breath alcohol analysis and the consecutive blood sampling was investigated.


[Spectrometry for determining hematoma duration in vivo]. Spectroreflectometric measurements in the range of 430 to 700 nm were carried out in order to check this new method with regard to its application to determine time of haematomas in living humans. For this purpose 52 cases with artificial superficial skin haematomas and 40 patients with pure "monocle-haematomas" were investigated. Wavelengths of 560 and 580 nm indicate the best results. There are significant differences in cases with "monocle-haematomas" if the age difference of the haematomas is more than two days.


[Postmortem endoscopic diagnosis].

[Postmortem endoscopic diagnosis]. The use of endoscopical methods augments the macroscopical diagnosis in autopsies. Cavities and sinuses which are hardly accessible may be inspected and photographically documented as well without damage of the anatomical context. In terms of forensic autopsies the endoscopical technique is mostly recommended for the inspection of the fundus of the eye, the external auditory meatus up to the tympanic membrane, the naso- and laryngopharynx. Pathological and traumatical changes can be valued at once in situ. Forensic evidence of postmortal endoscopical findings is exemplified.


[Fatal pleasure trip--the "covered wagon catastrophe"]. 17 rentiers from Hamburg took part in a trip with a covered wagon in the Siegerland. In a rugged field-path a screw in the bottom of the wagon, which was deficiently reconstructed, got loose. One of the benches tipped down so that the passengers who sat there fell backwards on the path and were covered by the rack, the lattice and the tilt. 6 persons in the age from 76 to 85 years died in the scene of accident. 3 others sustained contusions. The autopsy of the victims showed no signs of external violence, especially fractures of bones and no internal injuries. There were only found asphyctic petechial bleedings in the conjunctiva, partly in the mucous membrane of the mouth, in the facial region and the body. The internal findings corresponded to the age. The cause of death was an external, mechanical hindering of respiration because of the chest compression by the heavy wreckage.


[Mass disasters in former East Germany--a forensic medicine retrospect]. The authors report the analysis of mass disasters, which had been dealt with by forensic experts, on the territory of the former GDR. The report comes on the initiative of the Society of Forensic Medicine and with the support of regional institutes. For the period 1960 to 1989, 20 events with 738 casualties were registered. The number of victims was particularly high in aviation and rail disasters as well as in the Zwickau mine disaster. The Forensic Institute of the Humboldt-University in Berlin was engaged in the investigation of the three airplane crashes on Berlin territory and near Berlin (Königs-Wusterhausen 1972, Berlin-Bohnsdorf 1986 and Berlin-Schönefeld 1989) as well as of the railway disaster near Lebus in 1977. As a result of the analysis, the experience gained in three decades regarding the planning, organization and realization of the identification of victims is dealt with in more detail. It emphasizes the significance of close cooperation with dentists and criminalists. Because of ethical, legal and criminalistic reasons the aim should always be a complete examination (including autopsy) of the victims as well as their identification.


[Disasters in former East Germany--experiences and problems of the Leipzig "Identification" Task Group]. Mass-disasters with high numbers of victims are a real challenge to the specialists. The role of forensic experts is generally emphasized. The missions of the Leipzig Taskgroup for identification and the experience gained during them confirm, that special training necessary staff members is. Compared with the general signs of identity, like clothing, jewelry and accessories, scars etc., the marks of ears and observations of forensic odonto-stomatology provide good chances for identification. For forensic odonto-stomatology, we developed computer programs.


[Salvaging a mass grave from 1945--Lieberose Labor Camp of the Sachsenhausen concentration camp]. It is reported about a recovering a common grave of 577 skeletons from 1945. Investigations of the age of the victims, the cause of death etc. were carried out. There were gunshot fractures at 541 skeletons. In 93.7% out of all cases there were gunshot fractures of the skull and the cervical vertebra. Difficulties arose from root interpretations in addition to intertwinings owing to the location of the skeletons. Indications to belonging to nationality of the victims are discussed by means the results from AB0-analysis and denture works.


[The external ear--a marker in identification]. The ear, well known anatomically in earlier investigations was only measured. We looked for 144 newborns and children (sex, age, morphology). We studied carefully and first of all systematically size, form and condition of the auricula. The form is genetically determined. Babies have a relative big ear between 9 and 15 months of age (accelerated?). In early time (20 century) this development only seen by children 3 years old. Eight specific characters changes with age (months). Outcome are proofed on 732 pupils. In forensic medicine a scientist should know this results before expertise of identification by mass disasters or unknown children.


[DNA of cadaver organs: comparison of two methods of extraction]. Genomic DNA was isolated from tissue specimen by two different methods. The rapid extraction according to Higuchi provided increased product yield of DNA in a better quality than the extraction with phenol/chloroform. Comparing the organ tissues according to quantity and quality of DNA it was found that best yield was recovered from brain tissue followed by lung and liver. DNA stability is directly influenced by postmortal age and age of the bodies.


[Puncture of central veins in homicide cases]. Puncture of a major cervical veins for insertion of a central venous catheter is a standard-method in resuscitation performed in emergency conditions. Even extensive lesion-marks due to punction are customarily seen by medico-legal practitioners, but in detail they may cause difficulties in differential diagnosis, when lesion marks caused by acts of violence directed straight against the neck are to be differentiated. Especially in the primary phase of inquiry about crimes of homicide these injuries due to punction are forensically important. Therefore frequency and methods of resuscitation efforts were evaluated in 453 crimes of homicide, committed in Göttingen and Berlin (subjects given by the Free University). Findings of the present study were that resuscitation measures were taken merely to a rate of 25%, and in proceeding a central venous catheter was not obligatorily inserted, moreover proceeding being regionally different. In Berlin a central venous catheter was inserted in 17 cases out of 77 resuscitated homicidal injuries, the rate being 24 cases out of 36 cases in Göttingen. In altogether 8 crimes of homicide committed by immediate attacks against the neck, a cervical vena was punctured, findings later being extensive effusions of blood marked around the tapped spot. The different ways to perform resuscitation may justify to point also at the forensic interest to discover the facts together with complete diagnosis in cases of crimes of homicide. That is why it may be vindicated to try to find out a proceeding, which does not lessen the effectiveness of resuscitative manoeuvres, yet by means of which forensical concerns are taken into consideration, too.(ABSTRACT TRUNCATED AT 250 WORDS)


[False positive radiographic findings in expert assessment of whiplash trauma of the cervical spine]. It is reported about a possible misdiagnosis after whiplash injuries. Calcifications of the nuchal ligament have been interpreted as fractures. The inappropriate radiological diagnosis has been corrected within the criminal procedure. Prolonged complaints as possible consequences of information about the false positive radiological diagnosis to the patient are discussed.


[Reliability of the Alco-Screen dip strips in evaluation of blood alcohol concentration for clinical or forensic studies]. We tested the accuracy of Alco-Screen dipsticks in comparison to the values of blood alcohol. The dipstick test is based on the reaction of alcohol-dehydrogenase, developing a green to blue color. Saliva as well as urine and liquor are easy to obtain at autopsies. We did not get any false-negative results. Interpretation of the change of color turned out to be a problem, because the tip appeared often to be inhomogenous. The dipstick could be used at autopsies and for emergency units, if a quick, semiquantitative result is required.


[Medical and technical aspects of weapon effects on man. Part 5--Common weapons]. "Weapons at hand" are tools of everyday life, which can be used as instruments for fighting. The investigation offers a survey concerning instruments, which were actually used for conflicting bodily injuries (cases selected from 1029 expertises) or for killing (cases selected from 474 autopsies). The findings are complemented by non-medical publications about self-defence. In the Austrian legal system the use of "weapons at hand" is interpreted like weapons in the technical sense.


[Use of "fuzzy logic" and fractal geometry in forensic medicine]. New developments of scientific basic research may be of theoretical as well as of practical significance for forensic medicine. This will be demonstrated for two examples: fuzzy logic and fractal geometry.


[Death caused by hypoglycemia after starvation--pathophysiology versus morphology]. We describe a 19-year-old mentally retarded man who after severe starvation (criminally induced by his parents) presented with hypoglycemic coma and eventually experienced death. Biochemical findings and pathophysiology of starvation are discussed. The cause of death was hypoglycemia in combination with terminal infection. The importance of structural-functional conclusions and considerations for determination of the manner and cause of death is demonstrated.


[Effect of environmental temperature on the course of spontaneous postmortem pupillary changes (studies of the rabbit eye)]. The diameter of the pupils was measured in the bodies of rabbits under different ambient temperatures (2-4 degrees C, 10-12 degrees C, 18-20 degrees C, 28-30 degrees C). It was found that the pupils changed in three phases: Initial miosis, which set in within minutes after death, was followed by a mydriatic phase, which lasted several hours and was approximately synchronous with the post-mortem rigidity of the skeletal muscles. In the third phase the pupils slowly contracted in the course of several days. The higher the ambient temperature, the more marked was the dilatation of the pupils in the second phase. In contrast to this the reaction of the pupils was characterized by less pronounced changes in size and a longer duration of secondary mydriasis, when temperatures were low.


[Epidemiology of fatalities in Alpine skiing--(1987-1990)]. At the Institute of Forensic Medicine, University Innsbruck, 78 cases of fatal accidents and of sudden death were examined which occurred during alpine skiing between 1987 und 1990. An increase of fatal accidents during skiing was observed in the past few years. This fact is related to the rising utilization of summer skiing areas. In about three quarters of the cases death as consequence of an accident was observed. One quarter died a sudden death. In this group myocardial infarction is dominant, which is an indication of an enhanced load of the cardiovascular system during skiing in higher altitudes. In the group with fatal accidents cranio-cerebral traumas including medulla injuries are dominant.


[Forensic medicine aspects of death caused by hypothermia in high altitude]. Macro- and micromorphological findings in cases of death from hypothermia are very questionable and unreliable diagnostical signs. We investigated 42 cases of death from hypothermia that occurred in mountain-ranges between 1974 and 1990. All cases showed erosions of the gastric mucosa ("Wischnewsky-spots"), in one case only we found bleedings in the ileopsoas muscles. In most cases hypothermia was based on natural disease or intoxication. Nine alcoholized persons showed a mean alcohol concentration in the blood of 1.07% and in accordance to a relatively long agonal period the alcohol concentration in urine was considerably higher.


[Suspected SIDS diagnosis--van Praagh I truncus communis as a nonfatal incidental finding]. Autopsy of a baby suspicious to SIDS. Most interesting postmortem finding was a congenital malformation of the great vessels, a truncus arteriosus communis typus van Praagh A I. That one is very rare with a clinically frequency of only 1.7%. The malformation was not cause of death and was statistically survived for 2 months. The baby died of aspiration resultant from an incarcerated inguinal hernia.


[Agonal dog bite injuries].

[Agonal dog bite injuries]. A 57-year-old woman, who was unconscious due to apoplectic cerebral haemorrhage, was injured on the right thigh by dog bites while still alive. In addition to a soft-tissue defect of 10 x 9 x 3 cm (gnawing effect) there were numerous small single lesions in the form of slit-shaped skin cuts. The area around the wounds was discoloured by haematomata. The bite wounds were caused by the mongrel dogs living in the same household (2 parent animals and 6 puppies). The pattern of the injuries corresponded well to the anatomy of a dog's set of teeth.


[Complete severance of the trunk in a pedestrian-automobile collision]. A 70-year-old pedestrian was hit by a passenger car, when she crossed a road outside built-up areas; at the time of the collision the car drove at a speed of about 100 km/h and did not brake. In this lateral accident the trunk of the pedestrian was completely severed near the upper brim of the pelvis. The upper part of the body was flown into the interior of the car through the windscreen; the lower half of the body was found between the place of collision and the place, where the car came to a standstill. The body was not severed at the front edge of the roof, but in the region of the front edge of the engine hood. The abdominal skin and the inguinal region were marked by numerous transverse distension tears; these were indirect injuries of the collision caused by tensile strain due to inertia.


[Comparative studies of bullet entrance holes in trunk and extremity bones of predominantly spongious structure]. The size relation between the bullet calibre and the minimum diameter of the entrance hole in extracranial bones of predominantly spongy structure was systematically investigated. Test shots (cartridges .22 lr, 7.65 mm Brown. and 9 mm Parabellum) on bone specimens covered with soft tissue (coxal end of the femoral bone, ala ossis ilii, corpus sterni) showed the following results: The entrance holes in bone produced by solid-lead projectiles of calibre .22 showed a tendency towards larger diameters compared with the bullet (deviations at the proximal femur up to about 20%); full-jacketed bullets of calibre 7.65 mm and 9 mm mostly produced entrance holes which were smaller than the cross-section of the projectile (deviations at the sternum and os ilium up to about 12%). For perpendicular hits it was possible within one test-firing region to assign the minimum diameters of entry to one of the three calibres without any overlapping in the borderline area. The measurement results classified according to calibre and area of entry are indicated in diagrams.


[Discovery of human bones at the Prägratkees (Tyrol) 1953 and 1990]. At the Prägratkees (Granatspitz, Tyrol) human bones, pieces of equipment and garment were found at the same site in 1953 and 1990. According to the forensic investigations, the bones were attached to a 37 year-old mountain climber, who has been missed since 1936. Because of the fact that between both discoveries an interval of 37 years elapsed, it is doubtful whether the bones are from one person. The forensic conclusion, that the bones are attached to one person could be supported by the glaciological situation of this glacier.


[Alcohol intoxicated bicyclists in Düsseldorf 1986-1990]. Although traffic participation of bicycle riders is steadily increasing only few investigations concerning "riding while intoxicated" are available. This study examines the blood sample records of all blood samples submitted to the Duesseldorfer Institute of Forensic Medicine for blood alcohol analysis from 1986 to 1990 with respect to the participation of bicycle riders. As to the most important epidemiologic data: The proportion of samples from bicyclists increased from 2.6% in 1986 to 4.8% in 1990. Women account for 6.5%. 36.8% are younger than 30 years. Most bicycle riders were apprehended during the months of summer, on the days of the weekend and in the hours around midnight. 67.3% displayed a BAC above the legal limit for bicycle riders of 1.7 g/l. In comparison only 34.5% were judged highly drunken on medical examination. Regarding the group with a BAC above 2.5 g/l expected to be highly intoxicated 37.7% only appeared slightly or moderately impaired rising the suspicion of high alcohol tolerance.


[Alcohol drinking behavior in a sample of students]. In 1988 we interviewed approximately a quarter (n = 395) of the female students enrolled at Ulm/D. University in order to get knowledge of their alcohol-drinking habits. There was no selection of whom we asked. The results encourage us to the conclusion that we might have got a representative survey. Of the students inquired about 11% lived abstinently, less than 2% consumed alcohol daily, most of all took alcohol repeatedly per month. The predominant part of the students questioned, stated an intake of less than 40 g alcohol per day. The average quantity of alcohol consumed per month was smaller than with a group of female students interviewed in Spain as well as with a group of young women comparable in age in Northern Germany.


[Acute and chronic effect of alcohol--a long-term problem in forensic medicine autopsies]. Influence of the acute and chronic alcohol influence in connection with the sudden unexpected death is very high. Between 1986 and 1990 in 949 death cases out of 2402 autopsies carried out in the Institute for Forensic Medicine in Essen the death could be related either to chronic alcohol abuses or to an acute alcoholisation. The influence of alcohol in the various kinds of death is described.


[Effect of ethanol on plasma amino acid concentration in man]. Human blood plasma amino acids and urea levels after repeated ethanol administration were investigated. Under ethanol an increase of several amino acids and urea levels were observed.


[Toxic alcohol dysmyelopoiesis--bone marrow histology studies of a forensic medicine autopsy sample]. Histological evaluation of bone marrow in 30 autopsy cases with a history of chronic alcohol consumption revealed characteristic changes concerning the medullary iron distribution and, first and foremost, the erythropoiesis, which was found to be macroblastic. These autoptic findings reflected the pattern of alcoholic dyshematopoiesis resulting from a toxic effect of alcohol on the bone marrow, well-known from biopsies and aspirates of alcohol-dependent patients and combined with hemochromatosis-associated plasma cell iron in the marrow and elevation of median corpuscular volume of erythrocytes in the peripheral blood. Therefore, this stereotyped morphological findings in the bone marrow of autopsy cases extend the well-known scope of alcohol-induced pathological organ changes.


[Bolus death and drowning--expression of central nervous system dysregulation?]. According to the author's own investigations and to findings reported in the literature, almost all bolus deaths and highly numerous accidental deaths by drowning occur to adults and adolescents under the impact of alcohol. An attempt was made to elucidate the mechanism by which alcohol actually play its role in bolus or drowning death. These two causes of death have in common complete or partial obstruction of respiratory tract. Yet, safety against that life-threatening condition were devised by evolution very early in phylogenesis (respiratory block, cough reflex, circulatory centralisation). They are reflex-triggered for immediate effect and take that effect through the vegetative nervous system. These findings have been secured by animal experiments. However, on account of considerable interference of alcohol with vegetative activity, via action on transmitter metabolism (transmitter synthesis, storage, release, rebonding and bonding by means of products of alcohol metabolism), symptoms of extreme vagotomia may develop, such as bradycardia with circulatory centralisation and apnoea of alcohol-related irreversibility, finally resulting in cardiac arrest. The "reflex-related" process of bolus death has often been described, with reference being regulatory made to individuals staying in water and drowning without any self-rescue attempt.


[A screening method for rapid detection of barbiturates in serum using tandem mass spectrometry]. A mass spectrometric screening method for the detection of barbiturates in serum will be presented. Fragmentation of barbiturates under EI conditions leads to a loss of HNCO. Therefore, "neutral loss scans" of 43 u allow the indication of possibly existing representatives of this class of compounds. Identification can be achieved by "daughter" or "parent ion scans". Thus, 10 micrograms/ml apro-, pento- and phenobarbital could be detected in serum.


How strictly do dialysis patients want their advance directives followed? The Cruzan case and the Patient Self-Determination Act will encourage patients to specify in advance which life-sustaining treatments they would want if they become mentally incompetent. However, strictly following such advance directives may not always be in a patient's best interests. We sought to determine whether patients differ in how strictly they want advance directives followed. Interview study. Seven outpatient chronic dialysis centers. One hundred fifty mentally competent dialysis patients. Using a structured questionnaire, we asked the subjects whether they would want dialysis continued or stopped if they developed advanced Alzheimer's disease. We then asked how much leeway their physician and surrogate should have to override that advance directive if overriding were in their best interests. Subjects granting leeway were also asked what factors should be considered in making decisions for them. Subjects varied greatly in how much leeway they would give surrogates to override their advance directives: "no leeway" (39%), "a little leeway" (19%), "a lot of leeway" (11%), and "complete leeway" (31%). Subjects also varied in how much they wanted various factors considered in making decisions, such as pain or suffering, quality of life, possibility of a new treatment, indignity caused by continued treatment, financial impact of treatment on family members, and religious beliefs. Strictly following all advance directives may not truly reflect patients' preferences. To improve advance directives, we recommend that physicians explicitly ask patients how strictly they want their advance directives followed and what factors they want considered in making decisions.


Rotator cuff disease: assessment with MR arthrography versus standard MR imaging in 36 patients with arthroscopic confirmation. Standard proton-density- and T2-weighted magnetic resonance (MR) imaging and MR arthrography were used to depict rotator cuff disease in 36 shoulders in 36 patients; the findings were compared with arthroscopic findings in every patient. In 19 rotator cuffs normal at arthroscopy, MR arthrography revealed no tear in 16 patients, a partial tear in one patient, and a full-thickness tear in two patients. Standard proton-density- and T2-weighted images were normal in 15 of these patients and revealed a partial tear in two patients and a full-thickness tear in two patients. In 13 partial tears found at arthroscopy, MR arthrography showed a partial tear in six patients, no tear in five patients, and a full-thickness tear in two patients; standard MR imaging revealed a partial tear in one patient, no tear in 10 patients, and a full-thickness tear in two patients. All four full-thickness tears proved with arthroscopy were correctly diagnosed with both MR imaging methods. The main advantage of MR arthrography was better depiction of partial tears in the articular surface.


A human immunodeficiency virus-resistant airway for cardiopulmonary resuscitation. Due to fear of transmitted disease, mouth-to-mouth cardiopulmonary resuscitation (CPR) is now rare, even though early CPR is associated with a fivefold to 30-fold increase in survival. The authors have devised a one-piece silicone mask (Kiss of Life [KOL], Brunswick Biomedical Technologies, Inc, Warehom, MA) with a one-way valve and circular recess to form a no-contact lip seal, enabling mouth-to-mouth CPR to be given. The ventilatory volume during mannequin CPR using the KOL mask was 0.75 +/- 0.235 L. This volume was significantly (P less than .05) greater than that generated by alternate widely used airways (range, 0.195 +/- 0.147 to 0.617 +/- 0.208 L). To assess mask performance in vivo, the authors measured exhaled volumes in 10 apneic anesthetized patients under three conditions: with the KOL mask, a standard anesthetic mask and bag, and an anesthetic mask with an endotracheal tube. The results were: anesthetic mask and tube, 1.5 L (range, 1.2 to 1.7 L); KOL mask, 1.1 L (range, 1.0 to 1.3 L); anesthetic mask alone, 0.7 L (range, 0.5 to 0.8 L). To test permeability, we exposed two KOL masks to a high titer of human immunodeficiency virus (HIV)-1 soup (10(6) culture infection doses/mL) for 10 and eight masks for 60 minutes, respectively, and cultured swabs of the interior of the valve for 1 month. There was no growth in any culture. These data suggest that the KOL mask has excellent ventilating characteristics, is practical (pocket-portable, disposable), experimentally impermeable to HIV-1, and inexpensive.(ABSTRACT TRUNCATED AT 250 WORDS)


Evaluation of the Alvarado score in acute appendicitis. Use of the Alvarado scoring system was assessed prospectively in a consecutive series of 215 patients with suspected appendicitis over a 12 month period at the University Hospital of Wales, Cardiff. In comparison the high negative appendicectomy rate during the year prior to the study was reduced considerably with the scoring system without increasing morbidity or mortality.


Esophageal perforation: a continuing challenge. Perforation of the esophagus remains a diagnostic and therapeutic challenge. Currently, the most common cause of perforation is instrumentation of the esophagus, and the incidence of esophageal perforations has increased as the use of endoscopic procedures has become more frequent. Diagnosis depends on a high degree of suspicion and recognition of clinical features, and is confirmed by contrast esophagography or endoscopy. Outcome after esophageal perforation is dependent on the cause and location of the injury, the presence of underlying esophageal disease, and the interval between injury and initiation of treatment. Reinforced primary repair of the perforation is the most frequently employed and preferable approach to the surgical management of esophageal perforations. Nonoperative management consisting of antibiotics and parenteral nutrition is particularly successful for limited esophageal injuries meeting proper selection criteria.


Prediction of the spread of repeated spinal anaesthesia with bupivacaine. We have studied in 56 patients the predictability of spread of repeated spinal anaesthesia in the same patient on the basis of a previous block. With plain 0.5% bupivacaine, prediction of the second block was accurate. A significantly higher or lower spread of analgesia than in the previous block was achieved when plain 0.5% bupivacaine was administered using a modified technique--sitting position or lower interspace, respectively. When hyperbaric 0.5% bupivacaine was injected instead of plain solution for the second block using a similar technique, no baricity-related correlation was found between the first and second blocks. Change in technique did not reduce interindividual variation in the spread of analgesia. We conclude that individual anatomical properties may play a more important role than, for example, baricity in subarachnoid distribution of a local anaesthetic solution.


The Roux stasis syndrome. Treatment by pacing and prevention by use of an 'uncut' Roux limb. Ectopic pacemakers in the Roux limb are associated with delayed gastric emptying after Roux gastrectomy. The aim herein was to suppress the ectopic pacemakers by electrical pacing or to prevent them by maintaining enteric myoneural continuity with an "uncut" Roux limb, and so improve the delayed emptying. Among eight dogs with truncal vagotomy and Roux hemigastrectomy, four dogs had a pacing electrode applied to the proximal end of the Roux limb. The other four dogs had a gastrojejunostomy to an uncut Roux limb. In them, the afferent jejunal limb was occluded by staples but not divided, and a diverting jejuno-jejunostomy was performed. Roux pacing and the uncut Roux operation abolished ectopic pacemakers in the Roux limb and speeded the slow gastric emptying present in unpaced control tests. At autopsy, however, dehiscences were found in the staple line in the dogs with the uncut Roux procedures. In conclusion, electrical pacing and the uncut Roux limb show promise as techniques to prevent ectopic jejunal pacemakers and gastric stasis after Roux gastrectomy. Both must be improved before they can be used in patients.


Thrombosis in antithrombin-III-deficient persons. Report of a large kindred and literature review. To estimate the prevalence of objectively proven thrombotic complications in antithrombin-III-deficient persons. Cross-sectional study and a critical review of the literature. The prevalence of thrombosis in antithrombin III-deficient and -nondeficient family members of a large kindred was estimated by history, review of diagnostic tests, and examination for venous reflux by Doppler ultrasonography, as an indicator of previous venous thrombosis. A MEDLINE search and literature review of the published English- and French-language literature from 1966 to 1990 that described antithrombin-III-deficient families was done, and the following information was obtained: the prevalence of thrombosis in deficient and nondeficient family members, the presence or absence of risk factors for thrombosis (surgery, pregnancy, the postpartum state, use of oral contraceptives, immobilization, metastatic cancer, major trauma) at the time of the thrombotic event, and age of onset of the first episode of thrombosis. The validity of the studies was assessed according to predetermined criteria. Sixty-seven research subjects were evaluated. Six of 31 (19.4%) antithrombin-III-deficient subjects compared with none of 36 (0%) nondeficient subjects had had one or more thrombotic events. The initial episode in five of six subjects had occurred in association with risk factors for thrombosis. The literature search indicated that the pooled prevalence of symptomatic venous thrombosis among the deficient subjects was 51%, but objective testing was done in only 17% of these subjects at the time of presentation. Based on the data from this antithrombin-III-deficient kindred, lifelong anticoagulant prophylaxis does not appear to be warranted in asymptomatic carriers, and prophylaxis could be limited to periods of high risk for thrombosis.


Papillary cystic neoplasm of the pancreas: presentation and natural history in two cases. Two young women, one white and one Chinese, with the rare but increasingly recognised papillary and cystic neoplasm of the pancreas are reported. The initial symptom in both was non-specific abdominal pain which, after investigation, was found to be caused by a pancreatic tumour. One patient did not come to surgery until five years after the initial diagnosis when she developed jaundice. In the five year interval between diagnosis and the development of jaundice computed tomography showed no change in the size (20 cm) of the pancreatic mass. Histology after resection, however, showed signs of lymphatic invasion. Cystic neoplasm of the pancreas can thus be regarded as an indolent, very slow growing tumour with potential for local invasion and hence metastatic spread.


Bending and fracture of the femoral component in cemented total hip replacement. A computer method was used to make 41 measurements on the geometry of insertion of the femoral component in 200 Charnley total hip replacements. Surgery had been performed at least 12 years before, giving results which were classified as: success (90); fracture (56); or loose (54), according to rigid selection criteria. Fracture was associated with heavier patients in which there was poor proximal fixation of the femoral component but adequate distal fixation. Stems with a medial disposition proximally were more common in the fracture group than in the successful or loose groups. Sequential measurements of bending and subsequent fracture were made on the follow-up radiographs of 24 of the 200 cases (6 fracture and 18 successful). These measurements allowed bending to be detected at an earlier stage than by simple inspection of the radiographs.


Interferon alfa-2a therapy for life-threatening hemangiomas of infancy. Most hemangiomas are small, harmless birthmarks that appear soon after birth, proliferate for 8 to 18 months, and then slowly regress over the next 5 to 8 years, leaving normal or slightly blemished skin. In rare cases, hemangiomas can endanger vital structures, with a mortality of up to 60 percent. About a third of these life-threatening hemangiomas respond to treatment with corticosteroids, but for the others there is no safe and effective treatment. We evaluated the effects of daily subcutaneous injections of interferon alfa-2a (up to 3 million units per square meter of body-surface area) in 20 neonates and infants with life-threatening or vision-threatening hemangiomas that failed to respond to corticosteroid therapy. In 18 of the 20 patients the hemangiomas regressed by 50 percent or more after an average of 7.8 months of treatment (range, 2 to 13). One infant died of refractory proliferation of a lesion and consumptive coagulopathy. The condition of three other patients who had large hemangiomas associated with consumptive coagulopathies that were unresponsive to conventional therapies stabilized after seven days of treatment with interferon alfa-2a alone. Transient side effects of treatment with interferon alfa-2a included fever, neutropenia (one patient), and skin necrosis (one patient). No long-term toxicity has been observed after a mean follow-up of 16 months. Interferon alfa-2a appears to induce the early regression of life-threatening corticosteroid-resistant hemangiomas of infancy.


Preoperative laboratory assessment of hemostasis for orthognathic surgery. Platelet count, prothrombin time, and activated partial thromboplastin time provide a baseline to evaluate patients with known coagulopathy, as well as present an opportunity to diagnose disease in previously symptom free patients. Current hematologic management of patients with Von Willebrand's disease uses heated Factor VIII that allows patients to undergo orthognathic surgery without significant risk of disease transmission from banked blood products.


Historical changes in serum PCB and DDT levels in an environmentally-exposed cohort. A previously characterized cohort of 115 Great Lakes fisheaters and 95 non-fisheating controls was re-examined in 1989 to evaluate changes that had occurred in serum PCB and DDT levels since the 1982 study. Substantial and significant decreases in mean serum DDT levels had occurred in both fisheaters (25.8 ppb vs 15.6 ppb) and controls (9.6 ppb vs 6.8 ppb) over this time period. In contrast, only a slight decrease in serum PCB levels was observed, and in fisheaters only. No association between individual changes in serum PCB or DDT levels and self-reported changes in Great Lakes fish consumption was observed. The findings from this longitudinal examination of serum PCB and DDT levels confirm earlier cross-sectional surveys of western populations, and demonstrate that the prohibition of DDT has been successful in reducing the level of DDT contamination in human populations.


Occurrence of ophthalmopathy after treatment for Graves' hyperthyroidism. The Thyroid Study Group. Ophthalmopathy caused by Graves' disease may first appear or worsen during or after treatment for hyperthyroidism. It is not known, however, whether choosing to treat hyperthyroidism with antithyroid drugs, iodine-131, or surgery affects the development or aggravation of Graves' ophthalmopathy. We studied 168 patients with hyperthyroidism caused by Graves' disease, stratified into two age groups--20 to 34 years (54 patients, group 1) and 35 to 55 years (114 patients, group 2). The patients in group 1 were randomly assigned to treatment with methimazole for 18 months or subtotal thyroidectomy, and those in group 2 to either of these two treatments or to iodine-131 therapy. All the patients received thyroxine to avert hypothyroidism, except those treated with iodine-131, who received thyroxine only if hypothyroidism developed. The duration of follow-up was at least 24 months. Twenty-two patients (13 percent) had infiltrative Graves' ophthalmopathy at randomization. During follow-up, ophthalmopathy developed for the first time in 22 patients (13 percent) and worsened in 8 patients (5 percent). The frequency of the development or worsening of ophthalmopathy was similar among the patients in group 1 (medical therapy, 4 of 27 patients [15 percent]; and surgery, 3 of 27 patients [11 percent]). In group 2, ophthalmopathy developed or worsened in 4 of the 38 patients (10 percent) treated medically, 6 of the 37 patients (16 percent) treated surgically, and 13 of the 39 patients (33 percent) given iodine-131 (P = 0.02 for the comparison between the iodine-131 subgroup and the others combined). The risk of the development or worsening of ophthalmopathy increased as pretreatment serum triiodothyronine concentrations increased. As compared with other forms of antithyroid therapy, iodine-131 is more likely to be followed by the development or exacerbation of Graves' ophthalmopathy.


Effective audit: reporting to the National Confidential Enquiry into Perioperative Deaths. To investigate the effectiveness of computer based and manual district and unit information systems for identifying hospital deaths eligible for reporting to the National Confidential Enquiry into Perioperative Deaths (NCEPOD). Prospective six to 10 week study of hospital (death register, immediate coding of medical records) and district information systems followed by six month assessment after modification to entry of data. Acute units within Lewisham and North Southwark Health District. All 290 patients dying in hospital during the six weeks, for whom the medical records were obtainable in 231. Sensitivity and specificity of the information systems in ascertaining eligible surgical deaths (patients dying in hospital who had during 30 days previously had a surgical procedure while under the care of a consultant in a surgical specialty) tested against validated list of screened medical records. Of 231 medical records, 30 (12 from Lewisham, 18 from North Southwark) met the national inquiry's criteria. The computer based systems of both units detected less than 60% of eligible deaths (sensitivity 53%, specificity 83%); the death register detected about 60% (sensitivity 61%, specificity 89%); manual systems detected all eligible deaths. Subsequent modification to ensure immediate coding of records into the computerised systems during follow up failed to show any improvement. Routine hospital information systems may miss up to half the deaths eligible for NCEPOD.


Expression of the junD proto-oncogene in the rat spinal cord and skin following noxious cutaneous ultraviolet irradiation. Noxious peripheral stimulation induces the expression of various proto-oncogenes in rat spinal neurons. However, proto-oncogene expression seems to differ depending on the mode of the stimulus. Here, we report that noxious cutaneous ultraviolet (UV) irradiation results in a nearly 8-fold increase in junD mRNA levels in the rat lumbar spinal cord. RNA slot-blotting and hybridization techniques revealed a transcriptional activation of the junD proto-oncogene after 6 h, but not 1 h following UV exposure. These results suggest that low-frequency ongoing afferent impulse discharge is reflected by an accumulation in junD transcripts.


Computer-assisted tracking simulation (CATS). The tracking technique involves a sender reading consecutive segments from a story and a receiver attempting to repeat each segment verbatim. The reliability and validity of the tracking procedure have been criticized based upon uncontrolled variables such as sender, receiver, and text characteristics. To address these problems, a computer-assisted interactive tracking simulation (CATS) system has been developed in which story segments are presented to the receiver via a video laser disc system and repair strategies are implemented through a computer program.


Back injuries among nursing personnel: the relationship of personal characteristics, risk factors, and nursing practices. Reducing the total number of work related back injuries among nurses is important, but reducing those injuries that are severe enough to result in lost time and/or disability is critical. Results of this study indicate that female nurses in the early phases of assignment on long term care units are at greatest risk for back injury, but risk factors that relate significantly to the severity of the injury are tour of duty (evening) and weight of the nurse (200 + pounds). Recommendations suggested by this study include: evaluation of lifting techniques and practices; orientation whenever assignments are changed; accurate assessment of nurse, client, and situation; and the regular use of an assessment tool which incorporates all of these factors.


Hepatitis B vaccination: a survey of health care workers' knowledge and acceptance. The purpose of this survey was to determine methods to improve compliance and knowledge related to Hepatitis B vaccination. A self administered questionnaire was distributed to employees of a large metropolitan hospital. The survey asked for information about the health care workers' acceptance of Hepatitis B vaccination and knowledge of appropriate follow up after a significant blood exposure occurs. According to the results, 45% of employees at risk for contracting HBV have not received the vaccination. Findings related to the methods of follow up used by employees after a blood exposure indicate a lack of knowledge about HBV. The results of this survey support the need for further education about the risk of occupationally acquired HBV.


Role function and job satisfaction: a study of nurse graduates of educational resource center programs employed by the health care industry. This study analyzed the roles, functions, and job satisfaction of 65 master's prepared occupational health nurses employed within the health care industry to compare nurses who function as internal consultants with those who function as external consultants. The only significant difference between groups was that external consultants were more involved in marketing and management functions, whereas internal consultants were more involved in direct care. The study hypothesis that occupational health nurses performing more management functions would report greater job satisfaction was not supported by the data. Study findings did support a theoretical model by Hardy, revealing that greater role certainty and more role adapting behaviors were significantly associated with job satisfaction.


General nursing and occupational health nursing: a comparison of scientific progress. Education, research, theory development, and scientific knowledge development are indices that can be used to measure scientific progress. The progress of occupational health nursing science has followed the progress of general nursing science by a period of 20 years. A critical mass of doctorally prepared occupational health nurses is necessary for the scientific development of the profession. Federal funding of doctoral programs in occupational health is needed to increase these numbers. Occupational health nursing has established research priorities. Acting on these priorities will help develop scientifically based nursing practice.


Occupational health nursing: a theoretical model. Predictability must exist in occupational health nursing theory, as it does in other theory. Occupational health nursing can be examined within a simple, dynamic model, from which theory can be developed. Predictions of output can be derived from knowledge of input. Occupational health nursing is a vital component of the occupational health and safety team, the members of which collaborate to provide occupational health services to the aggregate of workers in the workplace. Delivery of occupational health services to workers is provided within a dynamic environment which can be analyzed as both internal and external. The elements of these environments determine the composition and characteristics of the occupational health services.


Designing a respirator fit testing program. The requirements for adequate respiratory protection for the employees of this agency vary. Therefore, accurate, updated job descriptions are a critical piece of information. Although the agency has made an effort to establish a respiratory protection program, a number of limitations exist when compared to the program components defined in ANSI, NIOSH, and OSHA guidance documents. In response to a request from the agency, the nurse consultant evaluated the existing respiratory protection program and made specific recommendations for improvement. At this time, the agency has signed a formal agreement with the Division of Federal Occupational Health to request continued assistance with "overhauling" their program. Top management has begun assigning responsibilities for the program to specific individuals, and a centralized database is being set up. The agency has implemented two new DFOH developed forms to improve the testing process, and the nurse consultant has revised the educational/training session to more adequately meet the needs of the work force. The Agency and DFOH are collaborating on reassessment of employees to correctly assign them to appropriate respiratory risk categories. This will, in turn, affect the medical monitoring needs as well as the educational needs of each individual.


Suppression of development of diabetes in NOD mice by lactate dehydrogenase virus infection. It has been reported that lactate dehydrogenase virus (LDV) selectively infects a subpopulation of macrophages, thereby affecting the immune system. We studied the effects of LDV infection on the development of diabetes in non-obese diabetic (NOD) mice. Five-week-old female NOD mice were infected with LDV (10(8) ID50/mouse) and observed until 23 weeks of age. None of the 21-LDV-infected mice developed diabetes, whereas 10/14 (71.4%) uninfected mice did. Although the subpopulations of T cells and the percentage of Mac1-positive cells in the NOD murine spleen and the number of harvested peritoneal macrophages were unaffected by LDV infection, the proportions of Ia-positive peritoneal macrophages were significantly decreased in LDV-infected compared with uninfected mice (1.1 +/- 0.2%, 6.5 +/- 2.9%; P < 0.01). In LDV-infected NOD mice, insulitis of the same grade as that seen in uninfected NOD mice was observed. In another experiment, 3, 5, 10 or 16-week-old female NOD mice were infected with LDV. None of the mice infected with LDV at 3, 5 or 10 weeks of age developed diabetes and only one of six infected at 16 weeks of age did. These findings indicate that LDV infection suppresses the development of diabetes in female NOD mice by reducing the capacity of Ia-positive macrophages, and suggest that the development of human type 1 diabetes may be suppressed by certain viral infections.


Bacterial agents protect against autoimmune disease. I. Mice pre-exposed to Bordetella pertussis or Mycobacterium tuberculosis are highly refractory to induction of experimental autoimmune encephalomyelitis. Infectious agents have often been implicated in the etiology of autoimmune diseases. Here we show that bacteria may also play a role in resistance to autoimmune diseases. SJL/J and (SJL/J x BALB/c)F1 mice are genetically susceptible to induction of experimental autoimmune encephalomyelitis (EAE), a murine model for human demyelinating autoimmune diseases such as multiple sclerosis. We studied the effect of several bacteria on the development of EAE and found that exposure of SJL/J or (SJL/J x BALB/c)F1 mice to Mycobacterium tuberculosis or Bordetella pertussis consistently rendered mice highly refractory to subsequent induction of the disease. Other bacteria such as Escherichia coli, Shigella and Staphylococcus aureus were found to be less effective, or were protective only if specific immunization procedures were used. Furthermore, M. tuberculosis and B. pertussis were protective irrespective of the route of administration and minute amounts (as low as 0.5 micrograms) of M. tuberculosis were sufficient to protect EAE-susceptible mice against induction of the disease. Interestingly, these bacteria, which are commonly used to promote development of EAE, conferred the highest degree of protection against the disease. The M. tuberculosis-induced protection was found to be associated with active suppression mechanisms mediated by T lymphocytes capable of transferring protection to naive syngeneic mice. These findings indicate that certain bacteria may protect against the development of autoimmune diseases. These results also suggest the potential use for still-unidentified bacterial agents in the manipulation of certain autoimmune diseases.


T-lymphocyte reactivity to the recombinant mycobacterial 65- and 70-kDa heat shock proteins in multiple sclerosis. Owing to their conservation and immunogenicity, heat shock proteins (hsps) represent a class of potential autoantigens. Moreover, they could be targets for gamma delta T lymphocytes, which are prominent in various immune disorders. We studied the T cell proliferative primary responses to recombinant M. bovis 65 kDa hsp (hsp65) and M. tuberculosis 70 kDa hsp (hsp70) in 31 patients with multiple sclerosis (MS), 19 patients with other neurological diseases (OND) and 19 healthy individuals. Positive responses to hsp70, but not to hsp65 were significantly more frequent in patients with MS than in patients with OND or in healthy individuals. In order to verify and refine these results and to characterize the hsp reactive T lymphocytes, we screened 147 PPD-specific long-term T cell lines (76 from 10 patients with MS and 71 from 12 healthy donors) for their proliferative response to hsp65 and hsp70. hsp70-reactive T lines were significantly more common in patients with MS than in healthy controls. The number of T lines responding to hsp65 increased in the MS group only slightly. In 19 T lymphocyte lines from patients with MS and healthy donors, a cytofluorometric analysis was performed with special attention paid to distinct T cell receptor gamma delta determinants. With one exception, in each line the population of gamma delta T cells remained a minority. We conclude that an increased T cell response to mycobacterial hsp70 may be present in patients with multiple sclerosis.


Enhancement of S-antigen and its mRNA in the irides of uveitic patients. S-antigen (S-Ag) and its mRNA were analysed by immunohistochemistry and in situ hybridization in 32 iridectomy specimens from 29 uveitic patients and 10 non-uveitic patients. S-Ag was detected in one iris and its mRNA was detected in 12 uveitic patients. Neither S-Ag nor its mRNA was found in the controls (P < 0.003). Ten of the 12 patients who had detectable S-Ag mRNA, while only four of the 17 patients who did not, had received corticosteroids for more than 3 years (P = 0.006). We also demonstrated S-Ag and its mRNA in bovine iris by immunoprecipitation and polymerase chain reaction. These results indicate that S-Ag and its mRNA accumulate in the irides of some uveitic patients. This accumulation may be the result of local immunoregulatory factors and an effect of corticosteroid treatment, and may modulate ocular inflammation.


Limiting dilution analysis of autoreactive T cells in patients affected by hydatid disease. We evaluated the peripheral autoreactive response in patients with Echinococcus granulosus compared with healthy individuals. A limiting dilution analysis (LDA) was performed to estimate frequency of auto-reactive T cells and to detect the complex mechanism that often underlies the autoreactive response. Different LDA curves were seen in healthy controls and patients. The control group provided a straight line passing through the origin ('single hit' kinetics), indicating that only peripheral autoreactive T cells are limiting. On the other hand, autoreactive T cell titration in hydatid patients did not follow 'single hit' kinetics, suggesting that two or more cell types are titrated. More interestingly, we observed a very high frequency of autoreactive T cells in hydatid patients (1/1,000 to 1/2,500) compared with healthy controls (1/5,000 to 1/35,000). These data suggest that chronic infection may provide adequate stimuli for the induction of autoimmune disorders and increase in autoreactive T cells.


A 64 kDa antigen/glutamic acid decarboxylase (GAD) in fetal pig pro-islets: co-precipitation with a 38 kDa protein and recognition by T cells in humans at risk for insulin-dependent diabetes. The development of insulin-dependent diabetes mellitus (IDDM) is associated with circulating antibodies to a pancreatic islet protein of MW 64,000 (64 kDa), reported to be glutamic acid decarboxylase (GAD). To investigate the antigenic properties of the 64 kDa antigen/GAD in IDDM we employed fetal pig pro-islets, a convenient source of islet antigens and an alternative to adult human islets for transplantation. Pro-islets contained a 64 kDa protein precipitated by antibodies in the sera of 9/14 (64%) at-risk IDDM, 12/33 (36%) recent-onset IDDM and 4/12 (33%) established IDDM patients and in 1/18 (5%) healthy control subjects. In addition, a 38 kDa protein was co-precipitated with the 64 kDa protein by 6/14 (43%) at-risk IDDM, 5/33 (12%) recent-onset IDDM, 1/12 (8%) established IDDM patient sera and 1/18 (5%) control subject serum. Both 64 kDa and 38 kDa antigens were specific to pro-islets; neither was detected in fetal pig thyrocytes, hepatocytes or splenocytes. The majority of the 64 kDa protein was co-precipitated with GAD enzymatic activity from pro-islets by either IDDM sera or a sheep anti-GAD serum. Previously, we showed that peripheral blood mononuclear cells (PBMC) from over half the subjects defined as being at risk for IDDM proliferate in response to fetal pig pro-islets. Proliferative responses of PBMC from pre-diabetic subjects to a crude extract of pro-islets were therefore measured before and after depletion of GAD by adsorption of the extract against GAD-1 monoclonal antibody. In 5/10 at-risk subjects, T cell stimulation indices were greater than the control mean + 2 SD and decreased in four by > 50% after depletion of GAD. In summary, a 64 kDa protein with the properties of GAD is present in fetal pig pro-islets and is recognized by both antibodies and T cells in a significant proportion of subjects at risk for early IDDM. Some subjects with anti-64 kDa antibodies also have antibodies that co-precipitate a 38 kDa pro-islet protein. Prospective studies of T cell reactivity in at-risk IDDM subjects are required to delineate the role of GAD and other candidate autoantigens in the initiation and progression of beta cell destruction.


Characterization of human-human hybridoma monoclonal anti-Ro(SS-A) autoantibodies derived from normal tonsil lymphoid cells. Human-human hybridomas obtained from the separate fusion of tonsillar lymphoid cells from three different normal individuals to the lymphoblastoid cell line GM 4672 were screened by ELISA for the presence of autoantibody to Ro(SS-A). Those anti-Ro(SS-A) reactive hybridomas were then cloned by limiting dilution. Nineteen monoclonal IgM anti-Ro(SS-A) antibodies were obtained, which showed specificity to Ro(SS-A) by ELISA and Western blotting (60 kDa). Some of these monoclonal anti-Ro(SS-A) antibodies showed reactivity to DNA (2/19), cardiolipin (9/19), Sm/RNP (15/19) by ELISA, and to IgG (12/19) and La(SS-B) (19/19) by ELISA and Western blotting. None showed reactivity to the unrelated proteins casein and BSA, nor to RNA. Inhibition studies revealed that the binding to Ro(SS-A) of both IgM hybridoma monoclonal and SLE serum polyclonal IgM anti-Ro(SS-A) antibodies was inhibited with Ro(SS-A), La(SS-B) and Sm/RNP but not with IgG, DNA, RNA and BSA. These data indicate that (1) normal humans have the genetic potential to express antibodies to Ro(SS-A) and (2) the normally derived monoclonal and SLE serum IgM anti-Ro(SS-A) antibodies share similar antigen binding properties and therefore may possibly originate from a common pool of precursor B cells.


Phospholipid specificity and requirement of beta 2-glycoprotein-I for reactivity of antibodies from patients with primary antiphospholipid syndrome. Some disease manifestations are associated with serum antiphospholipid antibodies (aPL) in patients with systemic lupus erythematosus (SLE) in what has been termed antiphospholipid syndrome (aPLS). There are patients with aPLS who do not have SLE or any other illness who have been grouped under the term primary antiphospholipid syndrome (PAPS). However, patients with diverse infections, notably syphilis, may have aPL but do not develop the associated clinical manifestations. This has been attributed, at least in part, to the immunochemical features of their aPL, including the requirement for beta 2-glycoprotein-I (beta 2GP-I) for binding of aPL to phospholipids, but these have not been studied in sera from patients with PAPS. By ELISA we studied 95 sera from 17 patients with PAPS and 100 sera from clinically normal individuals for IgG and IgM antibodies to the main anionic and zwitterionic phospholipids and their related compounds, phosphatidic acid (PA) and synthetic phosphorylcholine (PRC). beta 2GP-I was present, either in newborn calf serum (NBCS) or purified, to block wells and to dilute samples, or was substituted by 0.3% gelatin. Inhibition studies with phospholipid micelles were used to confirm reactivities with the corresponding phospholipids. All 17 patients had IgG and 11 had IgM antibodies to cardiolipin. Antibodies to anionic phospholipids were primarily IgG whereas those to zwitterionic phospholipids were mainly, and often exclusively, IgM. We found a statistically significant difference in the mean levels of antibodies to all anionic phospholipids except aPTS, and to the haptene PA (P < 0.001) between patients and controls. The difference between levels of IgM antibodies to zwitterionic phospholipids was statistically significant with sphingomyelin (P < 0.001) and the haptene (P < 0.001). Levels of most IgG and most IgM aPL correlated significantly among them. The pattern and titers of reactivity are variable between patients, but stable within each patient. Requirement of beta 2GP-I for this reactivity was not an all-or-nothing phenomenon in individual sera. In general, as in lupus sera, antibodies to anionic phospholipids require that this cofactor be present coating the ELISA plates, whereas those to zwitterionic phospholipids do not. It would appear that patients with PAPS have polyclonal mixtures of antibodies that react with various phospholipids and have different requirements for beta 2GP-I for such reactivity.


Surface expression of heat shock protein 90 by blood mononuclear cells from patients with systemic lupus erythematosus. Previous studies have indicated that blood mononuclear cells from 15-20% of patients with systemic lupus erythematosus (SLE) carry elevated levels of hsp90, a heat shock protein associated with steroid receptors in cells. We analysed surface expression of hsp90 on mononuclear cells (lymphocytes and monocytes) from patients with SLE by monoclonal antibody AC88 and flow cytometry. Whilst all blood mononuclear cells have intracellular hsp90, a significant proportion of patients with SLE expressed hsp90 on lymphocyte and monocyte surfaces. This was significantly higher on SLE lymphocytes than in laboratory controls and was positively correlated with disease activity. Comparison of total hsp90 with surface hsp90 in the same SLE patients' blood mononuclear samples indicated a correlation with a subgroup of patients. There was no correlation with expression of surface hsp90 by lymphocytes and activation markers. Patients with Sjögren's syndrome, rheumatoid arthritis, dermatomyositis and scleroderma were studied as disease controls and increased levels of shsp90 were detected in only three of the 53 patients studied. It is concluded that surface hsp90 expression is a feature of about 20% of patients with SLE and is correlated with high disease activity. The exposure of this hsp on the surface of some lymphocytes suggests that it is a candidate autoantigen in SLE.


The effect of tolbutamide on burn hypermetabolism. The effect of tolbutamide on improving burn hypermetabolism was studied prospectively in 31 burn adults with total body surface area burned > 40 per cent and 18 burned rabbits immediately after burn injury to postburn day 10. The results showed that burn hypermetabolism could be reduced using tolbutamide, which may be the result of the correction of relative insulin insufficiency, tissue insulin resistance and improving glucose utilization.


Bacterial flora of burn wounds in Lagos, Nigeria: a prospective study. A prospective study of burn wound sepsis was carried out on 31 consecutive patients with fresh burns. Wound swab cultures were assessed at weekly intervals for 5 weeks. The study revealed that while 96.7 per cent of burn wounds were sterile on admission, bacterial colonization reached 80.6 per cent within the first week after admission. Although the Gram-negative organisms, as a group, were more predominant, Staph. aureus (38.2 per cent) was the most prevalent organism in the first week. It was however surpassed by Pseud. aeruginosa from the second week onwards. Anaerobes were conspicuous by their absence. Similarly, beta-haemolytic streptococcus was not isolated from any patient. Proteus mirabilis was unusually preponderant, forming 19.4 per cent of all isolates. The antibiotic sensitivity pattern showed resistance of most of the organisms to ampicillin. Only 15 per cent of staphylococci were sensitive to cloxacillin. Most of the organisms cultured (93.5 per cent) were sensitive to ceftazidime.


Roles of thromboxane and prostacyclin in the pathogenesis of acute respiratory failure in burn patients combined with inhalation injury. Forty-one severely burned patients were divided into inhalation injury and non-inhalation injury groups. It was found that in the inhalation injury group, TXB2 level and TXB2/6-keto-PGF1 alpha ratio in both plasma and lung tissues were significantly elevated, circulatory platelet aggregate ratio markedly decreased, and blood viscosity greatly increased. Histopathologically, congestion, oedema, haemorrhage and thrombosis were observed in lung tissues taken from patients succumbing to respiratory failure. The changes in TXB2 and TXB2/6 keto-PGF1 alpha ratio accorded with the clinical course of the development of respiratory failure in burn patients with inhalation injury. It is proposed that the imbalance of TXA2/PGI2 plays an important role in the pathogenesis of respiratory failure in severely burnt patients complicated with inhalation injury.


Effect of cerium nitrate-silver sulphadiazine on deep dermal burns: a histological hypothesis. Although there are excellent clinical results from using cerium nitrate plus silver sulphadiazine in the treatment of deep dermal burns in our burn centre, its mechanism of action remains unexplained. We set up a prospective study to establish a hypothesis which could explain the formation of the typical leathery crust. Burns treated with cerium nitrate plus silver sulphadiazine and silver sulphadiazine alone were compared histologically and metallurgically. Application of cerium nitrate plus silver sulphadiazine on deep dermal burns caused superficial connective tissue calcification with few deep dermal changes. Cerium penetration was low and silver was never detected intradermally. The precipitation of cerium and pyrophosphate destroys the calcification inhibitory function of the latter, creates multiple calcification nuclei and leads to superficial dermal calcification. No calcium was detectable in biopsies from silver sulphadiazine-treated wounds. No major toxicological side-effects were seen during this study. The clinical results were favourable, as have been reported previously.


Effect of heta-starch colloidal solutions on reticuloendothelial phagocytic system (RES) function in burned and infected rats. The biodistribution of the plasma expander colloidal solution, heta-starch (HES), has been examined in rats, subjected to thermal injury or sepsis. The ability of these solutions to alter RES phagocytic function of [99mTc]-sulphur colloid ([99mTc]SC) uptake in vivo has been examined. The biodistribution of radiolabelled HES has been determined in normal rats. The HES colloidal solution has no deleterious effect upon RES function in vivo in the thermally injured animals or the septic animals as compared to sham controls. In addition, the HES colloidal solution seemed to be distributed primarily within the liver, spleen and kidney, with a small amount residing in the lung. Thermal injury did not increase the uptake of this material by the lung. These results suggest that the use of HES in thermally injured and septic individuals has no deleterious effects on RES function, nor does it accumulate in the lungs, and hence, should be advocated for use in these situations.


Burn wound healing: James Ellsworth Laing memorial essay for 1991. This essay has concentrated on the basic processes, clinical techniques involved in burn wound healing and how the two relate to each other. The achievement of early, sound, durable burn wound healing is one of the fundamental aims of burn care in order to minimize subsequent morbidity and mortality. It must be remembered that all patients with burns are individuals. There is no standard way to treat a burn and treatment must be tailored to suit the needs and requirements of both the patient and the burn wound. Burn wound healing is not the specific domain of any one specialist. It requires input from all disciplines and can be best achieved by the burn team approach.


Cytotoxicity evaluation of antiseptics and antibiotics on cultured human fibroblasts and keratinocytes. Infection is the greatest problem in burn patients and topical antimicrobial agents must be chosen with great care, especially when cultured skin is grafted. We examined the cytotoxic effect of six antiseptics and six antibiotics commonly used on cultured human fibroblasts and keratinocytes. Cultured cells were exposed for 15 min to Hibitane (chlorhexidine), Biseptine (chlorhexidine+benzalkonium chloride+benzylic alcohol), Benzalkonium Chloride, Yellow Betadine (polyvidone-iodine+nonoxinol), Betadine Scrub (polyvidone-iodine+quaternary ammonium) and Green Betadine (polyvidone-iodine) and viability was determined using the MTT test. At therapeutic concentrations all the antiseptics are cytotoxic for fibroblasts and keratinocytes. Additionally the cells were exposed for 48 h to vancomycin, colistin, amikacin, imipeneme, pefloxaxin, piperacillin and cell viability was determined using the MTT test. The concentrations of antibiotics corresponding to the plasma peak obtained after therapeutic application were not cytotoxic to the tested cells. The CD50 was much higher than the MIC (from 125 to 875 times for keratinocytes and from 1400 to 5900 times for fibroblasts). These data suggest that commonly applied antiseptics must not be used before grafting cultured skin grafts. After grafting any infection can be controlled with topical applications of appropriate antibiotics.


Are plasma endotoxin levels related to burn size and prognosis? Plasma endotoxin concentrations were determined in 42 patients with burns covering more than 20 per cent of the body surface area, using the endotoxin-specific Endospecy assay and treatment of plasma by a new method developed by ourselves. The normal endotoxin level was 9.8 pg/ml or less. In the early period after injury when no infection was present, very few patients had an endotoxin level above 9.8 pg/ml and endotoxin levels did not correlate with the area of the burns or with prognosis. However, later in the clinical course, endotoxin levels were correlated significantly with the burned area and with the prognosis.


A quantitative assessment of blood loss in burn wound excision and grafting. A prospective study was performed that allowed a quantitative estimation of blood loss in excision and grafting of adult burn injuries. The average value for blood loss was 9.2 per cent of the patient's estimated blood volume or 387 ml per 1 per cent burn excised and grafted. There was no exponential increase in blood loss as the percentage excised and grafted increased apart from proportionality and there was no statistical difference between males and females for burns excised and grafted days 1-14 after injury or greater than 14 days after injury. It was therefore concluded that a useful working figure is 400 ml whole blood or 10 per cent of patient blood volume is lost per 1 per cent full thickness burn excised and grafted for an adult. These values do not apply to the very young, the very old and those patients who have bleeding disorders, and when using various methods to limit blood loss. This figure allows adequate cross-matched whole blood to be available preoperatively.


Porcine dermal collagen as a wound dressing for skin donor sites and deep partial skin thickness burns. Collagen was extracted by pepsin digestion from porcine skin, and collagen membrane was prepared by salt precipitation. The porcine collagen membrane was evaluated as a burn wound dressing in deep partial skin thickness burn wounds in rats. Burn wounds, 4 x 4 cm, were inflicted by exposure of skin to 75 degrees C for 15 s followed by de-epithelialization. Wound healing was assessed by planimetry of epithelialization on day 10 after injury. Open wounds exhibited 24 per cent of wound area re-epithelialized. Collagen membrane dressing significantly improved the healing to 69 per cent of wound area (P < 0.0001). In a completely separate experiment, the porcine collagen membrane was applied as a wound dressing to the donor sites of burn patients, and its effect on wound healing was compared with that of a petroleum jelly gauze dressing. The donor sites covered with petroleum jelly gauze had re-epithelialized by an average of 14.5 days (ranging from 13 to 16 days) after wounding. The wounds dressed with collagen membrane demonstrated a significant increase in the healing rate. Complete re-epithelialization was observed by 10.3 days (ranging from 10 to 12 days) after wounding (P < 0.0001).


Electrical burns in Kuwait: a review and analysis of 64 cases. Sixty-four patients with electrical burns were admitted to the Department of Plastic Surgery, Ibn Sina Hospital, Kuwait during the past 6 years. There were 1202 admissions during this period, the incidence of electrical burns being 5.3 per cent. Sixty-nine per cent of the patients sustained injury from direct contact with live electrical wire, the remaining 31 per cent sustained flash burns. The incidence of low voltage injury was much higher as compared to high voltage. Forty-four per cent of these injuries were not work related. Less than 10 per cent of the body surface area was involved in about 80 per cent of the patients. A total of 65 operations was carried out in 39 patients. Twenty of these patients had repeated debridements until the wound was ready for coverage. All 64 patients survived.


Updated evaluation of the activity of antibiotics in a burn centre. The results of microbiological tests performed in a burns unit between January 1989 and December 1990 have been analysed. Burn wound swabs and biopsies, blood cultures, central venous and urinary catheters, bronchial aspirates, pharyngeal swabs and faecal cultures for a total of 7950 examinations were considered. Staph. aureus was the most frequently isolated bacterium, followed by Staph. epidermidis, Pseud. aeruginosa and E. coli. The antibiograms have shown a low efficacy rate of cephalosporins, even of the latest generation, while with Gram-positive isolates the highest rates of activity were recorded by vancomycin and teicoplanin (100 per cent sensitivity). The situation seems better with Gram-negative organisms since they appear to be sensitive to a larger number of antimicrobial agents.


Reconstruction of postburn breast deformities. Postburn breast deformity is a sequela of severe scar contraction of the burned chest. During the past 3 years, 24 female patients with such deformities required reconstruction, the surgery was performed in our department. These patients, the types of the deformities and the techniques used for reconstruction have been reviewed. For mild deformities (10 patients) reconstructions with skin grafts and local skin flaps were found to be satisfactory. For deformities which affected the mammary development (14 patients), mammary prostheses directly or under the soft tissue obtained by skin expansion or musculocutaneous flaps were used. In three of our patients, reduction mammaplasty or mastopexy was needed to symmetrize the breasts.


Reconstruction of exposed sternum following electrical burns using a superior transverse rectus abdominis musculocutaneous flap. An unusual case of a patient with electrical burns with exposed sternum was reconstructed using a superior transverse rectus abdominis flap (also known as 'epigastric rectus flap'). The clinical rarity of the condition and the innovation of the reconstructive method is discussed.


Toxicology of quinone-thioethers.

Toxicology of quinone-thioethers. Cytotoxicity associated with exposure to quinones has generally been attributed to either redox cycling, and the subsequent development of "oxidative stress," and/or to their interaction with cellular nucleophiles, such as protein and non-protein sulfhydryls. Glutathione (GSH) is the major non-protein sulfhydryl present in cells, and conjugation of potentially toxic electrophiles with GSH is usually associated with detoxication and excretion. However, this review discusses the biological (re)activity of quinone-thioethers. For example, quinone-thioethers are (1) capable of redox cycling (2) substrates for, and inhibitors of, a variety of enzymes (3) methemoglobinemic (4) potent nephrotoxicants (5) DNA reactive and (6) may contribute to quinone-mediated carcinogenicity and neurotoxicity. The ubiquitous nature of quinones, and the high intracellular concentrations of GSH, ensures that cells and tissues will be exposed to quinone-thioethers. The toxicological importance of quinone-thioethers in quinone-mediated toxicities therefore deserves further attention.