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Purpose: To evaluate the role of maintenance daily oral etoposide (VP-16) chemotherapy for germ cell patients who had a response to salvage therapy., Patients and Methods: Thirty-seven patients were entered onto this trial, and 34 were fully assessable. This was as heavily pretreated patient population, with a median of two prior salvage regimens. The salvage treatment that immediately preceded oral VP-16 consisted of autologous bone marrow transplantation in 14 patients (41%), surgery in 10 (29%), and standard-dose salvage chemotherapy in 10 (29%). Daily oral VP-16 was administered at a dose of 50 mg/m2 for 21 consecutive days every 4 weeks for three cycles., Results: The major toxicity with daily oral VP-16 was leukopenia. Three patients had grade III and two grade IV leukopenia. Two of these patients had granulocytopenic fever. Other grade III toxicities included thrombocytopenia (n = 1) and mucositis (n = 2). Twenty-three patients started daily oral VP-16 while in complete remission (CR) following salvage therapy. Seventeen (74%) remain continuously disease-free, with a median follow-up time of 36 months (range, 26 to 49) from initiation of daily oral VP-16. Eleven patients started daily oral VP-16 while in partial remission (PR) following salvage therapy. Three of these 11 patients converted to CR, but all three subsequently relapsed., Conclusion: Maintenance oral VP-16 was well tolerated in this heavily treated patient population. Results in this poor-risk population were encouraging.

In nephrotic syndrome, iron is presented to the tubule fluid in a nonreactive form in association with transferrin as a result of the glomerular protein leak. At an alkaline pH, iron remains bound to transferrin throughout the nephron and is excreted as such in the urine. As urine pH decreases below 6, iron is dissociated from transferrin. In the dissociated form, iron exists in the urine in a soluble, ultrafiltrable, and labile state. It is suggested that iron is maintained in this state by chelation to a relatively small organic compound, such as citrate. This non-transferrin-bound iron is capable of catalyzing bleomycin degradation of DNA, suggesting that this labile form of iron is able to catalyze free radical formation and cause tubule cell injury. Urine from proteinuric states represents one of the few, if not only, biologic fluids containing large amounts of reactive iron species. This may explain the mechanism by which proteinuric states cause tubulointerstitial disease and renal failure.

The etiology of testicular cancer is unknown. Familial testicular cancer is a rare entity that adds further information to research regarding the genetic influence on germ cell tumors. We report on 5 brothers, including 2 identical triplets and 1 fraternal brother, with testicular cancer and discuss the epidemiological factors. It appears that environmental and genetic factors must be considered.

We had the opportunity to study the clinical effects of granulocyte colony-stimulating factor in a heart transplant patient with a classic febrile neutropenic episode that was thought to be caused by immunosuppressive therapy. Administration of granulocyte colony-stimulating factor resulted in rapid recovery of his absolute neutrophil count, with resolution of fevers. Endomyocardial biopsy showed no pathologic evidence of worsened rejection. The use of hematopoietic cytokines after the organ allograft requires further study before it can be routinely advocated in this patient population.

A single 400-mg oral dose of sparfloxacin was given to each of six healthy male volunteers, and the concentrations of the drug were measured in plasma, cantharides-induced inflammatory fluid, and urine over the subsequent 52 h. The mean peak concentration in plasma of 1.6 micrograms/ml was attained at a mean time of 2.7 h postdose. The mean peak concentration in inflammatory fluid of 1.3 micrograms/ml was attained at a mean time of 5 h postdose. The mean elimination half-life in plasma was 17.6 h, and that in inflammatory fluid was 19.7 h. The overall penetration into inflammatory fluid was 117%. Urinary recovery within the first 52 h postdose was 8.8% of the administered dose. Our results indicate that a once-daily dosage of sparfloxacin should be adequate to treat systemic infections caused by most common bacterial pathogens.

The in-vitro activity of tosufloxacin (A-61827) was compared with that of temafloxacin, ciprofloxacin and selected members of other groups of antimicrobial agents, against 684 recent distinct clinical isolates and strains with known mechanisms of resistance. Against members of the Enterobacteriaceae, ciprofloxacin was slightly more active than tosufloxacin, which was more active than temafloxacin. The MIC90 of tosufloxacin for all species of Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter spp. was less than or equal to 1 mg/L. Tosufloxacin was slightly more active than temafloxacin, and four to eight fold more active than ciprofloxacin, against the Gram-positive species tested. The MIC90 of tosufloxacin for Staphylococcus aureus was 0.12 mg/L, and for Streptococcus pneumoniae was 0.5 mg/L. All strains of Neisseria spp., Haemophilus influenzae and Moraxella catarrhalis were inhibited by tosufloxacin at a concentration of less than or equal to 0.12 mg/L. Tosufloxacin was the most active quinolone against the anaerobic organisms tested. Cross resistance between quinolones was seen, but not between quinolones and other groups of antimicrobials. The protein binding of tosufloxacin across a range of concentrations averaged 60%. Human serum at a concentration of 70% decreased the bactericidal activity of tosufloxacin by about four-fold.

The in-vitro activity of PD 131628, the active metabolite of the prodrug PD 131112, was compared with that of ciprofloxacin and members of other groups of antimicrobial agents against 701 recent clinical isolates and strains with known mechanisms of resistance. The MIC90s of PD 131628 against the Enterobacteriaceae were between 0.008 and 0.5 mg/L; PD 131628 was one- to four-fold more active than ciprofloxacin against these strains and was four-fold more active than ciprofloxacin against Pseudomonas aeruginosa. Against the Gram-positive species tested, PD 131628 was two- to four-fold more active than ciprofloxacin, inhibiting all strains of Staphylococcus aureus and Streptococcus pneumoniae with 0.5 mg/L or less. PD 131628 was very active against Neisseria spp., Haemophilus influenzae and Moraxella catarrhalis, with MIC90s ranging from 0.004 to 0.008 mg/L. Organisms with decreased susceptibility to other quinolones had decreased susceptibility to PD 131628, but there was no cross-resistance between this class of antimicrobial and other classes. The protein binding of PD 131628 was at most 25% across a broad range of concentrations. The addition of 70% human serum had little effect on the MICs, but caused a two- to eight-fold increase in MBCs.

The kill kinetics of sparfloxacin and ciprofloxacin have been investigated under anaerobic conditions against Bacteroides fragilis and Escherichia coli. The results for E. coli were compared with those obtained under aerobic conditions. It was found that the quinolones were bactericidal under anaerobic conditions. This bactericidal activity is inhibited by the presence of chloramphenicol, a known protein synthesis inhibitor. Filamentation was seen with B. fragilis after 2 h exposure to either agent.

A modification of an immunofluorescence method previously used to study the in-vitro antimicrobial susceptibilities of Chlamydia trachomatis was used to investigate the activity of seven antimicrobials against a strain of C. pneumoniae. Our results differed from those obtained by other workers, so we modified our original method and repeated the study. Adding antimicrobial to pre-infected cells gave higher MICs and MLCs than when cells were infected in the presence of the antimicrobials, and this difference in methodology could account for the discrepancy between our results and those of others. Of the antimicrobials studied, clarithromycin and its 14-hydroxy metabolite were the most active agents; sparfloxacin was more active than ciprofloxacin, but no more active than more conventional antichlamydial agents.

The in-vitro activity of SR 44337 was compared with that of other broad-spectrum parenteral cephalosporins, plus imipenem and co-amoxiclav. SR 44337 showed good activity against the Enterobacteriaceae, with MIC90s of less than 0.5 mg/L against all species tested, with the exception of Citrobacter spp. (MIC90 2 mg/L) and Serratia spp. (MIC90 4 mg/L). Of the agents tested, only ceftriaxone showed consistently greater activity against this family of organisms. SR 44337 had higher activity than ceftriaxone against Acinetobacter spp. and Pseudomonas aeruginosa, and was the most active agent tested against Neisseria meningitidis (MIC90 0.004 mg/L). All strains of N. gonorrhoeae, Haemophilus influenzae and the streptococci (excluding the enterococci) were susceptible to less than or equal to 0.25 mg/L of SR 44337, which was also the most active cephalosporin tested against Staphylococcus aureus. SR 44337 was stable to hydrolysis by the TEM-1, SHV-1 and P99 beta-lactamases, and was more stable than ceftriaxone to the K-1 beta-lactamase.

The features of hepatic congestion on computed tomography, ultrasound and nuclear medicine sulphur colloid scans have been reviewed. Hepatic congestion may not be appreciated clinically, especially in the elderly, but the features described should be sufficiently characteristic to establish the diagnosis. The CT appearance may be confused with neoplastic infiltration, so that recognition of the condition may avoid further unnecessary investigations.

The in-vitro activity of sparfloxacin (AT-4140), a new difluorinated quinolone, was compared with those of ciprofloxacin, temafloxacin and selected members of other groups of antimicrobial agents, against 651 recent distinct clinical isolates and strains with known mechanisms of resistance. Three strains of Chlamydia trachomatis were also studied. The MICs for 90% of the Enterobacteriaceae were between 0.06 and 1 mg/l; for Pseudomonas aeruginosa the MIC90 was 2 mg/l. Sparfloxacin was 16-fold more active against Acinetobacter spp. than ciprofloxacin. For Staphylococcus spp., Streptococcus, spp. and Enterococcus faecalis the MIC90 was between 0.25 and 1 mg/l; sparfloxacin was four-fold more active against Str. pneumoniae than ciprofloxacin. Ninety percent of strains of Haemophilus influenzae, Branhamella catarrhalis and Neisseria spp. were inhibited by less than 0.03 mg/l; for Bacteroides fragilis the MIC90 was 1 mg/l. The three strains of Chl. trachomatis were susceptible to 0.06-0.12 mg/l sparfloxacin, which was 16-fold more active than ciprofloxacin. There was cross resistance among the quinolones, but not between the quinolones and other groups of antimicrobials. The protein binding of sparfloxacin was 40% and serum had little effect on its activity.

The pharmacokinetics of azithromycin were determined during a 24 h period following oral administration of a single 500-mg dose to each of six male volunteers. Concentrations in serum, urine and cantharides-induced inflammatory fluid were determined by microbiological assay. The mean peak serum concentration of 0.45 mg/l was obtained at a mean time of 2.6 h post-administration. The elimination half-life from serum was seen to increase with time post-dose; the mean elimination half-life at 16 h post-dose was 9.6 h. Inflammatory fluid was penetrated rapidly, with the mean peak concentration of 0.13 mg/l achieved at a mean time of 3.25 h post-dose. After this peak, levels initially decreased, but after 8 h from drug administration until the end of the trial period, inflammatory fluid concentrations remained relatively constant. The mean inflammatory fluid penetration up to the end of the study period was 74%. The mean urinary recovery of azithromycin, during the initial 24 h post-dose, was 6%.

The technique of immediate exposed skin grafting following early tangential excision of burns in children overcomes the difficulties of applying dressings with the attendant risk of graft loss from shearing forces. We report on 36 patients treated by this method. Wound healing was achieved in all patients without the need for further surgery.

The post-antibiotic effect (PAE) of teicoplanin was compared with that of vancomycin for five selected Gram-positive cocci. Two concentrations of each antibiotic were investigated, with the test organisms being exposed to each for both 1 and 2 h. At a concentration of 25 mg/l, teicoplanin had a greater PAE than vancomycin for the methicillin resistant staphylococci and Enterococcus faecalis strains tested. At a concentration of 5 mg/l, teicoplanin gave equal effects to those of vancomycin except for the strain of methicillin-resistant Staphylococcus aureus (MRSA) tested. The variation in the antibiotic exposure time gave only small changes in the PAE, except for the MRSA tested.

The technique of the multiple Y-V plasty is described. The records of all 129 patients who underwent surgery to release burn scar contractures over a 5-year period are reviewed. Halfway through this study period the multiple Y-V plasty was introduced, resulting in a marked reduction in the number of Z-plasty and skin grafting procedures carried out. There was an associated fall in the number of wound complications seen and the length of hospital stay required.

Eight stress-susceptible and eight normal pigs were used in the first portion of the study. Urine samples were collected for 24 hr over 4 consecutive days while the pigs were kept in metabolism cages. Each 24-hr sample was assayed for epinephrine, norepinephrine and dopamine. Urinary levels of dopamine were lower (P < .01) in the stress-susceptible pigs. No significant differences in urinary epinephrine or norepinephrine were observed. The second portion of the study evaluated the catecholamines in the caudate nucleus of the brain. Six stress-susceptible and six control pigs were examined. Immediately after exsanguination, caudate nuclei were excised and frozen in liquid nitrogen. The caudate nuclei were assayed for catecholamines within 2 to 3 days of freezing. Caudate nuclei dopamine levels were lower (P < .01) in stress-susceptible pigs (5,961 ng/g) than in control pigs (10,878 ng/g). No significant differences in norepinephrine levels of the caudate nuclei were observed between the two groups.

The case of a patient who sustained horrific injuries resulting in the loss of his left leg and hemipelvis and damage to the right sacroiliac joint and leg is discussed. The remaining leg was paralyzed as a result of damage to the sacral plexus. As a salvage procedure, a right above-knee amputation was performed, preserving a large composite flap from the distal part of the limb. This flap, consisting of most of the skin and soft tissue of the lower leg, contained within it a 10 cm segment of tibia and fibula. By islanding the flap on a pedicle composed of the femoral vessels, saphenous, and sciatic nerves, it was possible to mobilize it sufficiently far proximally to reconstruct the bone and soft-tissue defect of the contralateral hemipelvis. Seven years after this appalling injury, the patient has achieved a remarkable psychological and functional rehabilitation. He is independent and is successfully pursuing a professional career. This case report is a dramatic illustration of what can be achieved in reconstruction following trauma using salvage techniques.

The pathophysiology, types, and treatment of electrical and lightning injuries are discussed in detail. Cases of electrical injury almost always eventually involve litigation. Therefore, careful charting of history and physical findings may save the physician court time later. Care of lightning injuries is very different from that of high voltage injuries.

Therapeutic methods that use facilitation and inhibition to alter dysfunctional patterns of movement were implemented in children with multiple handicaps within educational settings. Desired movement patterns such as reach and manipulation skills were performed by students throughout the classroom day and across a variety of contextual uses. Data collected on several students indicated that more normal patterns of movement were attained at more rapid rates where students were provided the opportunity to practice the desired movement more frequently. Successful contextual programming depends on accurate and consistent implementation of therapeutic methods by all individuals who come in contact with a student. The therapist must identify the targeted movement pattern, determine appropriate intervention procedures, and train others to implement the procedures accurately. While such an approach shows promise as a means of developing function movement patterns with severely handicapped children, the increased opportunities to practice appropriate movement enhance the effectiveness of direct therapy but do not necessarily replace required individual intervention.

A chi-square analysis of 66 cases, including the author's eight cases and 58 from the literature, was undertaken to determine prognostic signs for death in patients seriously injured by lightning. A review of the injuries and of the physics and pathophysiology of lightning is presented. Prognosis was poor for those victims suffering leg burns (mortality 30%), cranial burns (37%), or cardiopulmonary arrest (76%). Death occurred in 30% of the cases studied. Permanent sequelae were found in 74% of the survivors. Nonsignificant factors were age, sex, and trunk and arm burns. Resuscitation of victims exhibiting loss of consciousness should begin immediately, as these are the most likely to die.

Lightning victims who survive the initial insult can usually be treated conservatively, supportively, and expectantly.

Ten trauma patients and 13 burns patients were studied intensively for the first 36 h and subsequent 6 days post injury in order to investigate the mechanism of trauma and burn associated proteinuria. Burns patient's initial maximum proteinuria occurred between 4 and 8 h post injury, whilst trauma patients showed greatest proteinuria within 4 h. In both groups coexisting myoglobinuria or marked elevation of serum renin activity was not found during the first 36 h. Following admission serum lipid peroxides rose in burns patients reaching a maximum between 2 and 8 h following injury, after which levels fell rapidly; in contrast trauma patient's values were initially within normal limits, but rose sharply after 12 h with peaks occurring between 16 h and 7 days post injury. Some patients within both groups showed a recurrent protein leak 2 to 5 days post injury. The data suggest that myoglobinuria or raised renin levels do not play an important role in trauma associated proteinuria.

The ventilatory status of patients within the first few hours following head injury has not been well established. We prospectively studied 63 patients who presented to an urban trauma center with varying severity of head injury to determine whether any trend toward hypo- or hyperventilation existed within the first two hours following injury. Arterial blood gas analysis done on emergency presentation showed that 14 patients with severe head injury (Glasgow coma scale less than or equal to 4) had mean pH values of 7.29 and mean PaCO2 of 41.86 torr. Twenty patients categorized as moderate head injury (GCS = 5-11) had mean pH values of 7.38 with a mean PaCO2 of 34.1 torr. Twenty-nine patients with GCS greater than or equal to 12 had mean pH and PaCO2 values of 7.4 and 31.8 torr, respectively. These differences in pH and PaCO2 were statistically significant between the GCS groups with mild and severe head injury (P less than or equal to .01 pH), (P = .05 PCO2), and could not be explained on the basis of hypoxemia, blood alcohol level, hypotension, or associated chest injury. It is concluded that patients with severe craniocerebral trauma show an early trend toward hypercapnea and acidosis. Immediate control of airway and assisted ventilation is necessary in order to reduce PaCO2 to optimal levels in patients with severe head injury.

Sharing techniques using the upper eyelid to reconstruct the lower one have been criticised for causing distortion of the normal upper lid leading to corneal exposure and possible visual disturbance, and for creating second-rate lids. A modification of previously described tarsoconjunctival flap techniques is described which minimises the known complications of earlier methods. A flap of conjunctiva alone is mobilised from the upper eyelid and covered with a full thickness skin graft. A second minor procedure to divide the flap from its donor site is necessary 2 weeks later. Forty-three patients over a 25-year period have undergone total lower eyelid reconstruction with this modified technique and are reviewed with some illustrative cases. Total or subtotal lower eyelid reconstruction is most commonly performed following tumour resection and only occasionally to correct congenital or traumatic defects. The surgical techniques available still cause controversy (Byrd, 1983). An upper lid sharing technique has been criticised for possibly causing a shortened or distorted normal lid (Mustardé, 1981). A modification of this method is described which has been used for over 25 years and has reduced the morbidity of the procedure, leading to acceptable cosmetic and functional long-term results.

A patient with hysterical, "artificial" or factitious oedema of the hand caused by the application of a tourniquet is reported. A high index of suspicion is needed in diagnosing this condition in which surgery should be avoided. Psychotherapy is the ultimate treatment but a pneumatic compression bag was found to be of use and helped confirm the diagnosis.

Twenty pairs of acute and convalescent sera were tested for antibody to the coxsackie B viruses types 1-5 by neutralization and fluorescent-antibody techniques. Results by fluorescence were difficult to read and sensitivity was therefore reduced. Rises by neutralization were type specific in the majority of cases, while those by fluorescence were always against more than one viral type.

Educators often find themselves confronted with the need to address health-related problems of chronically impaired students. Specific needs often are demonstrated by chronically impaired individuals. The roles and responsibilities of the classroom teacher with respect to meeting these needs are discussed. In addition, suggestions about how these concerns can be addressed through existing classroom health instruction are offered. Teachers can use the health curriculum to compliment the efforts of parents and health-care providers in informing, supplementing, and reinforcing disabled students' knowledge, attitudes, and skills. In this way, chronically impaired children can be assisted to meet present and future health needs in a manner conducive to optimal growth and development.

We present an outline of how to conduct a financial feasibility study for an emergency transport helicoptor service as well as an example of one hospital's successful experience. Data regarding types of patients transported and guidelines for setting up such a program also are discussed.

Carbon monoxide (CO) is the leading toxic cause of death in the United States today. Unsuspected exposure to this gas will sometimes result in clinically significant, but undiagnosed, toxicity. A high incidence of such unsuspected exposures would make screening for these worthwhile among high-risk populations. We conducted a two-part study to determine the value of screening for unsuspected CO exposure in a population of patients presenting to an emergency department. The first part of our study involved the prospective screening of ED patients using CO breath analysis, regardless of their chief complaint. In the second part, COHGB levels of all patients who underwent arterial blood gas analysis during the study period were reviewed retrospectively. Of 1,038 patients screened by this combined approach, only 29 (2.8%) had abnormal CO breath readings and/or COHGB levels. Of a condensed subgroup of 152 patients defined retrospectively by chief complaint, eight (5.3%) had abnormal values. We conclude that routine screening of ED patients for unsuspected CO exposure is not practical. Although yield increases when patients are screened in a more selective manner on the basis of chief complaint, such an increase still does not appear to justify the screening process.

All primary tumours from the upper respiratory tract and ear submitted for a histological diagnosis in Iceland during the 20 years, 1955-1974, were reviewed and typed according to the World Health Organization Classification published in 1978. The series included 83 benign and 114 malignant tumours from the upper respiratory tract. The nasal cavity was the commonest site for benign tumours in both sexes, most being squamous cell and transitional papillomas. The larynx was the commonest site for malignant tumours in males, all being squamous cell carcinomas, and the paranasal sinuses and the nasopharynx in females, squamous cell carcinoma forming the largest group in the sinuses and undifferentiated carcinoma in the nasopharynx. The distribution of tumours in the nasal cavity and sinuses differed much between the two sites and between the sexes, which emphasizes that these two sites should be separated and not combined as they have been until recently in epidemiological reports and cancer registries. A relatively high incidence of nasopharyngeal carcinoma in Iceland may be due to a high consumption of salted food. A rising incidence of laryngeal carcinoma is believed to be related to the use of tobacco and alcohol and is of special concern owing to its marked rise in young females.

There is often misunderstanding and conflict between the emergency physician and paramedic team, particularly as a new system is being implemented. This paper outlines a four-pronged approach to reduce this conflict: 1) community physician involvement in protocol development by means of a Paramedic Policy and Procedures Committee; 2) clinical training of paramedics in community hospitals; 3) involvement of community physicians in primary training and by riding rescue squads; and 4) formulation of a base station physician course to familiarize physicians with radio technique, system operation, and paramedic field work. An outline of the base station physician course is given and discussed. The reactions and outcome of the course and the positive changes it made in both physician and paramedic attitudes are discussed.

When evaluating an individual planning to scuba-dive, search for conditions that increase the risk of a diving accident. These risks can be categorized as absolute, relative or temporary. An understanding of barotrauma and decompression sickness is essential. The psychologic examination is as important as the determination of physical fitness.

Neuropathic foot ulceration can lead to long periods of in-patient treatment, and healing time is related to the size of the skin defect. We report a case where most of the skin was lost from the plantar surface of the foot, and healing was dramatically assisted by the application of split-skin grafts, a technique seldom considered for the treatment of diabetic foot lesions.

The changes in the economy and in tax rules have caused hospitals to assess the financial viability of different areas within their institutions. While emergency departments generally have become recognized as a cost-effective portal of entry for patients, trauma centers, particularly those located in the inner city, usually are seen as areas of large investment and small financial return. This study looks at a large, inner-city trauma service and the charges, collections, and demographics of the trauma population it serves. For patients admitted to the trauma service, total collections were 77% of charges. There was no difference in collections between those patients with blunt injuries and those with penetrating injuries; violent vs nonviolent injuries; patients transferred in vs primary receivals; or patients transferred out after stabilization vs those retained at the trauma center.

We conducted a study to determine the type, incidence, and timing of complications that occur in patients who have a carbon monoxide (CO) exposure serious enough to require hyperbaric oxygen therapy (HBOT). Complication data were retrospectively collected from a ten-year period for 297 consecutive CO-poisoned emergency department patients who received HBOT. HBOT was indicated for 41% of the patients because of an elevated carboxyhemoglobin (COHb) level alone. Central nervous system dysfunction, including loss of consciousness, and/or cardiovascular dysfunction, was the criteria for HBOT in 59% of patients, regardless of their COHb level. The mean peak COHb level was 38 mg%, with 88% of patients having a peak COHb level greater than 25 mg%. The mortality rate was 6% in this case series. Cardiac arrest occurred in 8% of patients; all experienced their first arrest prior to HBOT. The 3% of patients who sustained an isolated respiratory arrest and those who had a myocardial infarction did so prior to HBOT. Several complications, however, occurred for the first time or as a recurrent event during HBOT. These included emesis (6%), seizures (5%), agitation requiring restraints or sedation (2%), cardiac dysrhythmias or arrests (2%), and arterial hypotension (2%). No patient's level of consciousness deteriorated subsequent to the initial resuscitation except for those who later had a generalized seizure. The most significant complication attributable to HBOT was tension pneumothorax, noted in three patients (1%).(ABSTRACT TRUNCATED AT 250 WORDS)