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Summary Sixty ASA 1 and 2 children aged between 2 and 16 years who required tracheal intubation as part of anaesthesia for elective surgery were studied. We evaluated intubating conditions, haemodynamic responses and duration of apnoea following propofol 4 mg.kg−1 combined with either remifentanil 1.25 μg.kg−1 (group R), or suxamethonium 1 mg.kg−1 (group S). Tracheal intubation was graded as excellent, good or poor according to ease of laryngoscopy, vocal cord position, coughing, and jaw relaxation and limb movement. Thirty of group S and 28 of group R children were successfully intubated on the first attempt. Overall, intubation conditions were excellent or good in 26/30 (87%) patients in group S and 20/30 (67%) in group R (p

A computer screen-based simulator has been developed to simulate the administration of intravenous and analgesic drugs. It merges on-line measurements (such as systolic arterial pressure (SAP) and heart rate (HR)) and nonnumerical clinical signs (such as sweating, lacrimation and pupil response), using anaesthetists' experience or self-organizing fuzzy logic control (SOFLC) algorithms to administer drugs into a patient. The hierarchical control architecture includes five parts, which are: monitoring depth of anaesthesia (DOA), drug controller, deciding the sensitivity of the patient, narcotic supplementation and recovery time. It has been developed to predict drug profiles, control the drug levels and assess recovery time during anaesthesia. Meanwhile, linguistic rules and fuzzy set theory have been used to model a patient's SAP and HR during induction and maintenance stages. Successful simulation results have given confidence to perform on-line clinical trials in operating theatre.

Propulsive movements of the caudal oscillating flukes produce large forces chat could induce equally large recoil forces at the cranial end of the animal, and, thus, affect stability. To examine these vertical oscillations, video analysis was used to measure the motions of the rostrum, pectoral flipper, caudal peduncle, and fluke tip for seven odonrocere cetaceans: Delphinapterus leucas, Globicepbala melaena, Lagenvrhyncbus obliquidens, O~cinus orra, Pseudorca crassidens, Stenella plagiodon, and TarJiops truncatus. Animals swam over a range of speeds of 1.4-7.3 mlsec. For each species, oscillatory frequency of the fluke tip increased linearly with swimming speed. Peak-to-peak amplitude at each body position remained constanc with respect ro swimming speed for all species. Mean peak-to-peak amplitude ranged from 0.02 to 0.06 body length at the rostrum and from 0.17 to 0.25 body length at the fluke tip. The phase relationships between the various body components remain constant with respect to swimming speed. Oscillations of the rostrum were nearly in phase with the fluke tip with phase differences out of -9.4"-33.0" of a cycle period of 360". Pectoral flipper oscillations trailed fluke oscillations by 60.9°-123.40. The lower range in amplitude at the rostrum compared co rhe fluke rip reflects increased resistance to vertical oscillation at the cranial end, which enhances the animal's stability. This resistance is likely due to both active and passive increased body stiffness, resistance on the flippers, phased movements of body components, and use of a lift-based propulsion. Collectively, these mechanisms srabilize the body of cetaceans during active swimming, which can reduce locomotor energy expenditure and reduce excessive motions of the head affecting sensory capabilities.

Postoperative analgesia in patients who receive regular oral opioids pre-operatively is frequently suboptimal. To improve management we introduced a regimen using subcutaneous diamorphine infusions with incremental doses. Infusion doses were calculated as half the daily pre-operative dose of oral morphine with the increments as one-sixth of the infusion dose. Results were recorded on the first two postoperative days before (n = 13) and after (n = 23) commencing the new regimen. The percentage of patients reporting severe pain at rest and on movement were significantly reduced by the new regimen (54% and 69% vs. 13% and 40%, respectively) since the opioid dose as a percentage of the pre-operative dose was significantly higher (160% vs. 352%). There were no instances of excessive sedation or slow respiratory rate in any patient. The use of the regimen has resulted in greater doses of opioids being administered with fewer patients in severe pain without significant complications.

A multi-sensor fusion system for monitoring and control of depth of anaesthesia in the operating theatre is described. Two types of anaesthesia measures are considered, the first being based on auditory evoked responses, while the second measure is based on cardiovascular system signals. The first measure is based on analysis of the signal using wavelets and a neuro-fuzzy system, while the second measure is based on analysis of the measurements using a rule-based fuzzy logic system. The two measures are combined to give a final level of depth of anaesthesia using another rule-based fuzzy logic system. The depth of anaesthesia level is fed back to a target controlled infusion system (TCI) to control the infusion of the drug propofol for maintaining a constant level of depth of anaesthesia.

Mycotic processes occasionally complicate atherosclerotic aortic disease and usually require aggressive surgical therapy to control sepsis and prevent arterial rupture. Rarely, fungal organisms are responsible for primary infection of the abdominal aorta. We report the first case of Cryptococcal aortitis presenting as a ruptured abdominal aortic aneurysm. The surgical, pathologic, and microbiologic aspects of fungal aortitis are discussed. (J Vasc Surg 1999;30:189-92.)

This paper describes a self-organizing fuzzy model of patients undergoing surgery which was created from 10 clinical trials with off-line analysis during maintenance of anaesthesia using the drug propofol. The effects of patient sensitivity and surgical disturbances are also represented in this patient model. Hence, this model can be considered to be a qualitative pharmacologically related model for propofol during the anaesthetic maintenance stage. Furthermore, a closed-loop simulation has been designed to validate the patient model and compare the performance of a self-organizing fuzzy logic controller algorithm against a clinically derived linguistic controller. The successful results obtained provide proof-of-concept and encouragement to perform on-line clinical trials using fuzzy logic-based monitoring and control in operating theatre in the near future.

The predictive performance of a 'Diprifusor' target controlled infusion system for propofol was examined in 46 patients undergoing major surgery, divided into three age groups (18-40, 41-55 and 56-80 years). Measured arterial propofol concentrations were compared with values calculated (predicted) by the target controlled infusion system. Performance indices (median performance error and median absolute performance error) were similar in the three age groups, with study medians of 16.2% and 24.1%, respectively. Mean values for 'divergence' and 'wobble' were -7.6%.h-1 and 21.9%, respectively. Measured concentrations tended to be higher than calculated concentrations, particularly following induction or an increase in target concentration. The mean (SD) propofol target concentration of 3.5 (0.7) micrograms.ml-1 during maintenance was lower in older patients, compared with higher target concentrations of 4.2 (0.6) and 4.3 (0.7) micrograms.ml-1 in the two younger age groups, respectively. The control of depth of anaesthesia was good in all patients and the predictive performance of the 'Diprifusor' target controlled infusion system was considered acceptable for clinical purposes.

Depth of anaesthesia is hard to define and not readily measurable. Recently, attention has turned to evoked potentials (EPs) rather than the electroencephalogram (EEG) and they have been validated as a good measure of depth of anaesthesia. However, the amplitudes of the EPs vary from tenths of a microvolt to a few microvolts (/spl mu/V), and are embedded in the spontaneous EEG waveform whose amplitude is typically 10 to 30 /spl mu/V. An intelligent signal processing methodology for evoked potentials in anaesthesia monitoring and control is proposed in the paper. A model-based algorithm based upon autoregressive with exogenous input (ARX) models is used to improve the signal-to-noise ratio. Quantitative feature extraction is implemented to extract the factors describing the changes in amplitudes and latencies of the mid-latency auditory evoked response. In this way, three principal factors are obtained and then merged together using qualitative fuzzy logic to create a reliable index for monitoring depth of anaesthesia.

We report a prospective randomised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was designed to eliminate bias for or against either technique.Patients were randomised in the operating theatre and anaesthetic technique and pain-control methods were standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation.There was no significant difference between the groups for age, sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy (median 65 [range 27-140] min vs 40 [18-142] min, p0.001). The operating time included operative cholangiography which was attempted in all patients. We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3-0 [1-17] nights for laparoscopic vs 3-0 [1-14] nights for small-incision, p=0.74), time back to work for employed persons (median 5-0 weeks vs 4.0 weeks; p=0.39), and time to full activity (median 3-0 weeks vs 3.0 weeks; p=0.15).Laparoscopic cholecystectomy takes longer to do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery.

A hierarchical structure, based on fuzzy modelling, which can monitor depth of anaesthesia (DOA) from many clinical signs in the operating theatre, is described. The first level uses numerical clinical signs, such as systolic arterial pressure (SAP) and heart rate (HR), via a rule-base from anaesthetists' experience or a self-organizing learning algorithm to interpret primary depth of anaesthesia (PDOA). The second level is focused on non-numerical clinical signs, such as sweating (SW), lacrimation (LA) and pupil response (PR), which can be merged with the first level of PDOA to decide DOA with more confidence. Furthermore, linguistic rules and a simple fuzzy modelling concept have been used to model a patient during induction and maintenance stages. Not only can this model simulate new ideas and monitoring methods, but it can also be used clinically on-line to give an estimate of the adequacy of DOA. Successful results have given confidence to perform on-line clinical trials in the operating theatre. Two configurations of fuzzy modelling to determine the rule-base are described in this paper. Firstly, a self-organizing fuzzy modelling approach has the ability to generate rules on-line from input and output data. Secondly, if there is no direct measurement for the system output or it is very difficult to interpret, a self-organizing learning system which can learn rules from off-line input and output data can be utilized for modelling such systems.

Changes in-intra-ocular pressure during spontaneous ventilation with a laryngeal mask were compared with controlled ventilation using a tracheal tube in 40 patients undergoing intra-ocular surgery under general anaesthesia. Intra-ocular pressure was measured before induction, after establishing the airway, at the end of the operation and after removal of the airway device. Anaesthesia was induced with propofol and maintained with enflurane and nitrous oxide in oxygen. Mean end-tidal carbon dioxide tension was significantly higher during spontaneous ventilation than during controlled ventilation 5 min after establishing the airway (5.7 versus 4.5) and at the end of surgery (6.1 versus 4.2) (p < 0.001). Despite this, intra-ocular pressures were lower than baseline and similar in the two groups throughout anaesthesia. At the end of surgery, intra-ocular pressure (mmHg) was 11.2 and 8.6 during spontaneous or controlled ventilation respectively. One min after removal of the device, mean intra-ocular pressure (mmHg) in the tracheal tube group (16.0) was slightly higher than baseline (15.3) and was significantly higher than the laryngeal mask group (10.9) (p < 0.01). Spontaneous ventilation with a laryngeal mask is an acceptable alternative to controlled ventilation with tracheal intubation in elective intra-ocular surgery.

A 65-year-old man developed massive hemoperitoneum secondary to spontaneous splenic rupture. Histopathological analysis of the spleen demonstrated necrotizing granulomas. Results of serological tests indicated infection with a species of Bartonella, and immunohistochemical staining established Bartonella henselae as the cause of splenitis. To our knowledge, this represents the first reported case of spontaneous splenic rupture caused by infection with a species of Bartonella.

Summary A new system for sampling from arterial cannulae has been designed which avoids the need to aspirate flushing solution before taking a sample and limits blood loss. The new system was compared with a standard sampling system and direct arterial sampling using in vitro models. A series of haemoglobin concentrations wen- prepared and sampled using the three sampling methods. There were no clinically significant differences in the values obtained with the different sampling techniques.

Isolated pulmonary cryptococcosis (IPC) is an infrequently diagnosed infection, the management of which is not well defined. In past years, IPC traditionally has not been treated in the immunocompetent host, given its perceived benign and self-limited course and the toxicity associated with amphotericin B. However, some patients manifest prominent and disabling symptoms, and infection occasionally may disseminate. Fluconazole is active against Cryptococcus neoformans, is easily administered, and has an excellent safety profile. We present four healthy hosts with IPC who were treated with oral fluconazole for 6 to 8 weeks. A review of the literature was conducted to identify other cases of IPC in healthy hosts who were also treated with fluconazole. Our results and the limited experience reported in the literature suggest that fluconazole may be an appropriate choice for the treatment of IPC in the immunocompetent host. Indications for treatment are not defined, but symptomatic patients, those with multiple nodules or extensive infiltrates on chest radiographs, and/or those testing positive for serum cryptococcal antigen might be potential candidates for therapy.

Chronic pain is common among hospital inpatients. Patients with chronic pain have low expectations of pain relief. The patient's need for information is frequently not met.

The purpose of this article is to review the potential role of nuclear medicine scanning, especially with 67Ga, in the presumptive diagnosis and clinical management of patients with renal parenchymal malacoplakia (RPMP), a rare disease associated with coliform bacterial infection of the kidney and characterized by chronic unresolving inflammatory infiltrates containing von Hansemann macrophages in the renal parenchyma.Published cases of RPMP were collected from the archival literature by searching the MEDLINE database and by reviewing bibliographic references contained in articles on malacoplakia. Data on the clinical features and radiographic evaluation of patients with RPMP were extracted from the clinical case reports.Forty-three cases of RPMP published over the past 20 yr were identified. Ten of the 43 patients (23%) had 67Ga scanning as a component of their diagnostic evaluation. In all 10 patients, renal uptake of 67Ga was classified as intense. Two of those 10 patients had serial 67Ga scanning performed to assess response to antibiotic treatment; both patients exhibited decreased uptake or complete resolution of abnormal renal uptake over time, a finding also exhibited by our patient.Intense renal uptake of 67Ga, typically in the clinical setting of fever, progressive renal failure and nephromegaly, strongly supports a diagnosis of RPMP. In those patients receiving prolonged antimicrobial therapy for RPMP, resolution of abnormal 67Ga uptake over time may provide an objective endpoint for treatment.

The predictive performance of a 'Diprifusor' target controlled infusion system for propofol was examined in 46 patients undergoing major surgery, divided into three age groups (18-40, 41-55 and 56-80 years). Measured arterial propofol concentrations were compared with values calculated (predicted) by the target controlled infusion system. Performance indices (median performance error and median absolute performance error) were similar in the three age groups, with study medians of 16.2% and 24.1%, respectively. Mean values for 'divergence' and 'wobble' were -7.6%.h-1 and 21.9%, respectively. Measured concentrations tended to be higher than calculated concentrations, particularly following induction or an increase in target concentration. The mean (SD) propofol target concentration of 3.5 (0.7) micrograms.ml-1 during maintenance was lower in older patients, compared with higher target concentrations of 4.2 (0.6) and 4.3 (0.7) micrograms.ml-1 in the two younger age groups, respectively. The control of depth of anaesthesia was good in all patients and the predictive performance of the 'Diprifusor' target controlled infusion system was considered acceptable for clinical purposes.

To evaluate the morbidity and mortality of Candida fungemia and to assess the efficacy of low- vs high-dose amphotericin B and fluconazole vs amphotericin B in patients with candidemia.Multicenter, prospective, observational study of 427 consecutive patients with candidemia.The mortality rate for patients with candidemia was 34%. The mortality rate for patients with catheter-related candidemia in whom the catheters were retained was significantly higher than that of patients in whom the catheters were removed (41% vs 21%, P.001). We found no overall difference in mortality in patients treated with low-dose (total amphotericin B dose ofor = 500 mg) (13%) vs high-dose amphotericin B (total amphotericin B dose of500 mg) (15%), but the group treated with a low dose had fewer side effects (40%) than those treated with a high dose (55%) (P = .03). Fluconazole was as efficacious as amphotericin B in the therapy of candidemia, even when stratified by risk factors for mortality. Fewer side effects were seen with fluconazole (12%) compared with amphotericin B (44%) (P.001).In selected patients with candidemia, low-dose amphotericin B was as efficacious as high-dose amphotericin B. Based on other studies and ours, fluconazole seems to be an alternative therapeutic option to amphotericin B in selected patients.

The objective of this study was to report the occurrence of reactivation ocular toxoplasmosis in bone marrow transplant (BMT) recipients and to propose guidelines for identification and chemoprophylaxis of high-risk patients. The study design was a series of cases from the tertiary care university hospital which has an active BMT program. The patients were two recipients of autologous BMTs with past histories of toxoplasma retinochoroiditis who developed symptomatic reactivation of ocular toxoplasmosis as documented by formal opthalmologic examination in the early post-transplant period. Opthalmoscopic examinations in the two patients with non-Hodgkin's lymphoma who received autologous transplants and then developed decreased visual acuity in the first week after transplant revealed recurrent retinochoroiditis adjacent to old toxoplasma lesions. Pre-transplant eye examinations in both patients had demonstrated only inactive chorioretinal scars. Therapy with sulfadiazine, pyrimethamine and prednisone ultimately led to resolution of retinitis in both patients. BMT recipients who are seropositive for antibody to T. gondii and have findings consistent with previous toxoplasma retinochoroiditis on pre-transplant ophthalmologic examination appear to be at risk for reactivation of ocular toxoplasmosis in the early post-transplant period and may warrant preventive chemoprophylaxis for toxoplasmosis.

Anaesthesia was induced in 30 ASA I patients by propofol titrated at 100 mg min-1 to loss of verbal contact, and maintained by infusion of propofol at 10 mg kg-1 h-1 with 100% oxygen. According to randomization, either alfentanil 30 micrograms kg-1 ketamine 1.5 mg kg-1, or 0.9% sodium chloride was injected over 20 s, followed 1 min later by vecuronium 0.08 mg kg-1. Mean arterial pressure and heart rate were measured before and after induction, and 1 and 2 min after analgesic or saline. Onset of neuromuscular block was measured by the evoked hypothenar electromyographic response to train-of-four supra-maximal stimuli at 0.1 Hz. There were significant haemodynamic differences between groups, but mean (SD) times to reduction of T1/control ratios below 95% were 114 (28.0), 106 (19.0) and 128 (34.3) s (P = 0.2, ANOVA). Supplementation of propofol anaesthesia with alfentanil or ketamine does not appear to influence the onset time of vecuronium.

Intraocular infection caused by Candida species can have devastating visual consequences. With the emergence of Candida as a major nosocomial pathogen, the authors investigated the prevalence of ocular lesions in patients with candidemia and evaluated risk factors for eye involvement.This study is a prospective, multicentered, observational design. One hundred eighteen patients with candidemia were evaluated by the infectious disease service and received indirect ophthalmologic examination within 72 hours of a reported positive blood culture. Ocular findings were classified on the basis of objective, pre-determined criteria. Candida chorioretinitis was defined as the presence of focal, white, infiltrative chorioretinal lesions without vitreal involvement. Candida endophthalmitis was defined as chorioretinitis with extension into the vitreous or intravitreal "fluff balls."In contrast to previous studies of patients with candidemia citing prevalence rates of endophthalmitis approaching 40%, no patients were shown to have endophthalmitis. Candida chorioretinitis was seen in 9% of the patients, all of whom received antifungal agents. The observation that chorioretinitis never progressed to endophthalmitis suggests that systemic antifungal agents provided adequate ocular therapy. Risk factors for Candida chorioretinitis include fungemia with Candida albicans (versus nonalbicans species), multiple positive blood cultures, visual symptoms, and immunosuppression. Twenty percent of patients had nonspecific ocular lesions not directly related to infection.Patients with candidemia who have the risk factors noted above warrant formal ophthalmologic examination.

A machine-learning rule-based fuzzy logic controller for depth of anaesthesia which is similar to the way an anaesthetist works is presented in this paper. The results of discussions with anaesthetists to obtain a rule base and the application of fuzzy logic to predict the primary depth of anaesthesia (PDOA) and to control drug administration are very promising. By using simple rules from machine learning trials, similar results for the prediction of PDOA were obtained and can be used to design a drug infusion controller. The robustness of the self-organising fuzzy logic control (SOFLC) algorithm is good and can supplement the anaesthetist's experience for administering drug to patients when the system is dynamic and time-varying. Using these results, the design of a hierarchical architecture for the determination of the level of depth of anaesthesia is being investigated, which will include the use of clinical signs and refinements in the control of drug administered to patients.< >

Summary A double-blind trial of the effect of droperidol on the incidence of nausea and vomiting in patients using patient-controlled analgesia was carried out in 60 healthy women undergoing abdominal hysterectomy. After a standard anaesthetic including droperidol 2.5 mg as a prophylactic antiemetic, patients were randomly allocated to receive postoperative patient-controlled analgesia with either morphine alone (2mg.ml−1) or morphine (2mg.ml−1) with droperidol (0.2 mg.ml−1) added to the syringe. Verbal scores and visual analogue scores for nausea, vomiting, pain and sedation were made at 4, 12 and 24 h postoperatively, and any requirement for intramuscular prochlorperazine noted. There was no difference between the groups at any time in the amount of morphine consumed or in pain scores. At 12 h, patients receiving droperidol experienced significantly less nausea, and over the first 24 h, 31% required prochlorperazine compared with 59.3% of patients not receiving droperidol. The number of patients with sedation at 24 h was significantly greater in the droperidol group. We conclude that the addition of droperidol to morphine both reduces nausea and the need for further antiemetic treatment.

The value of using a combined infusion of morphine with a variable dose of ketamine for postoperative analgesia following upper abdominal surgery was assessed in a double-blind randomised study of 40 elderly patients. Four groups of 10 patients received an infusion of morphine at 1 mg.h-1, either alone, or combined with ketamine at a rate of 5, 10 or 20 mg.h-1. The addition of ketamine to a continuous infusion of morphine did not significantly improve either analgesia or postoperative lung function. Increasing the dose of ketamine resulted in an increased incidence of postoperative dreaming (p < 0.01).

In this 3-year study of suppressive acyclovir for recurrent genital herpes, patients with more than six recurrences per year were randomized initially to 400 mg of acyclovir or placebo orally two times per day, with recurrences treated with 200 mg of acyclovir five times per day for 5 days. In the second year of the study, all patients received acyclovir as a daily suppressive or intermittent acute therapy; in the third year, all received daily acyclovir. Among 525 patients completing 3 study years, 289 received 3 years of suppressive therapy and 236 received 1 year of acute therapy followed by 2 years of suppressive therapy. Of those who completed the third year, 61% were recurrence free that year; 25% of the suppressive therapy-only group were recurrence free for all 3 years. The annual recurrence rate dropped from more than 12 recurrences per year at baseline to 1.0 (suppressive therapy) and 1.4 (acute and suppressive therapy) recurrences during the third year. No significant toxic effects were detected. Daily suppressive acyclovir therapy was effective and well tolerated.

Persistent neutrophilic meningitis is an unusual but distinct clinical variant of chronic meningitis characterized by CSF neutrophilia with hypoglycorrhachia which persists for more than 1 week on serial CSF studies. Documented etiologies include selected bacteria and higher bacteria such as Brucella, Nocardia and Actinomyces as well as "opportunistic" fungi such as Candida, Aspergillus, the Zygomycetes, and Pseudallescheria. Recognition of the syndrome is important, as empiric therapy (e.g., cotrimoxazole and amphotericin B) may differ significantly from that used for classic chronic meningitis.

The Ohmeda 9000 syringe pump was developed in response to the need for an infusion apparatus to administer intravenous anaesthetic agents. It incorporates a bolus facility for the rapid, controlled delivery of loading infusions, or incremental dosing over a background maintenance infusion, and may be interfaced with a controller for computer-driven infusions. The Ohmeda 9000 pump has undergone bench testing and detailed evaluation in clinical practice using a variety of syringe sizes and makes. It is capable of accurate delivery over a range of infusion rates provided the recommended manufacturers' syringes are used with the appropriate pump setting. The pump was easy to use and reliable in clinical research and routine clinical practice. It should find its niche as the first genuinely 'anaesthetist-friendly' infusion pump.

EDITOR,—D W Ryan1 and J Bion,2 in discussing the provision of intensive care beds, suggest that there should be more high dependency beds, although information on their effectiveness seems to be lacking. At the Royal Hallamshire Hospital we opened a two bedded, five day high dependency unit in 1992. The primary reason for this was to counter the recurrent cancellation of elective major surgery when an intensive care bed …

Dental disorders have been recognized as major sources of infection in patients with hematologic malignancies (HM). Management of severe dental infections usually includes dental extractions (DE), but the safety of extractions in patients with HM who are at risk for bleeding, sepsis, and poor wound healing has not been well established. In conjunction with an aggressive program of dental care, 142 DE were performed in 26 patients with acute leukemia, myelodysplastic syndromes, and myeloproliferative disorders. Granulocytopenia (less than 1,000 granulocytes/microL) was present during or within ten days following surgery in 14 patients. In these 14 patients (101 DE), the mean granulocyte count was less than 450/microL, with a median duration of granulocytopenia following surgery of 32 days (range, four to 169 days). Thrombocytopenia (less than 100,000 platelets/microL) occurred during or within two days following surgery in 13 patients (80 DE), with a mean platelet count of 63,500/microL. Transfusions were given for platelet counts less than 50,000/microL. All DE were performed without significant complications. Bleeding was minor to moderate and easily controlled with local measures; no patient required transfusion due to hemorrhage. Average maximum temperature 24 hours after DE was 37.7 degrees C. No episodes of bacteremia were documented within ten days of DE. Minor delay in wound healing was observed in two patients. We conclude that DE can be safely performed in patients with HM in combination with aggressive supportive care.

Three percent to 30% of the episodes of peritonitis occurring in patients undergoing chronic peritoneal dialysis are culture-negative or aseptic. The etiology of these episodes remains poorly defined, though endotoxin-contaminated dialysates and fastidious anaerobic organisms occasionally have been implicated. We treated a patient who had fever, epigastric pain, and peritoneal fluid neutrophilic leukocytosis while undergoing chronic peritoneal dialysis. Despite multiple negative pretherapy aerobic, anaerobic, fungal, and mycobacterial cultures, bacterial peritonitis was the presumptive diagnosis. At postmortem examination, there were no findings to suggest infectious peritonitis; however, myocardial infarction with pericarditis was noted. We conclude that myocardial infarction should be included in the differential diagnosis of aseptic peritonitis in the patient undergoing peritoneal dialysis.

Noncholera vibrios can cause soft tissue infections as well as diarrheal disease. A history of exposure to marine water or shellfish aids in the presumptive diagnosis of these atypical infections. The treatment of choice for Vibrio wound infections is tetracycline, since these organisms often are resistant to penicillins, cephalosporins and some aminoglycosides.

Summary In clinical trials, the diagnostic utility of a radioimmunoassay (RIA) to detect Aspergillus antigen was demonstrated in sera obtained from patients with invasive pulmonary, endothelial, and disseminated aspergillosis, in cerebrospinal fluids from patients with Aspergillus meningoencephalitis, and in bronchoalveolar lavage fluids from patients with invasive pulmonary aspergillosis. The RIA was further evaluated in three blinded, controlled clinical trials. In one, sera were collected prospectively from patients with acute leukemia. Antigenemia was detected in four patients with invasive pulmonary aspergillosis (IPA) due to A. flavus , appeared early in the course of infection of three patients concurrent with the onset and evolution of lung infiltrates, and remitted with antifungal chemotherapy. Antigenemia was not detected in three patients before the onset of IPA, in eight leukemic controls, or in the 24 normals. In contrast, seven bronchoscopies were performed in five patients with IPA; fungi were not isolated in three. In a second study, antigenemia was found in coded sera from two patients with invasive aspergillosis but not in eight controls. In the third controlled study, 616 sera from 79 hematology patients admitted on 152 occasions were analyzed for circulating fungal antigen. The diagnostic utility of the RIA was confirmed and levels of antigenemia correlated with the patients' clinical course. These studies demonstrate the utility of the Aspergillus antigen RIA for diagnosis of invasive aspergillosis in hospitalized high risk patients.

A 57 year old white man with aortic insufficiency and previously undiagnosed ankylosing spondylitis, who developed subacute bacterial endocarditis (SBE), is described. Emergency aortic valve replacement was necessary, and the aortic valve pathology showed diffusely fibrosed and thickened valve leaflets with bacterial vegetations. This is the first recorded case of SBE in ankylosing spondylitis.

There are few data in the literature that describe the use of remifentanil when administered as a component of an inhalation or total i.v. anaesthetic (TIVA) technique. We studied 251 male and female patients, aged 18-75 years, ASA I-II, undergoing inguinal hernia repair, arthroscopic knee surgery or varicose vein surgery of at least 30 min duration without premedication. Patients were randomized to receive a remifentanil loading dose of 1.0 microgram kg-1 followed by a continuous infusion of 0.5 microgram kg-1 min-1 in combination with isoflurane (end-tidal concentration 0.6%), (Group I, n = 115) or propofol (initial infusion rate 9 mg kg-1 h-1 reduced to 6 mg kg-1 h-1 after 10 min), (Group P, n = 118). The remifentanil infusion rate was reduced by 50%, 5 min after tracheal intubation. Intraoperative stresses were treated with a remifentanil bolus (1 microgram kg-1) followed by an increase in the remifentanil infusion rate. At the insertion of the last suture, the remifentanil infusion and concomitant anaesthetic were switched off simultaneously. Times to spontaneous respiration, adequate respiration and tracheal extubation were significantly shorter in group I compared with group P (6.4 min vs 7.6 min, P < 0.01; 7.6 min vs 9.3, P < 0.003; 7.8 min vs 9.5 min, P < 0.015). Overall mean systolic blood pressures during surgery were greater in group P compared with group I (P < 0.05) but the absolute differences were clinically insignificant (4-5 mm Hg).