Pneumoperitoneum in perforated peptic ulcer; factors in roentgenographic demonstration

Evidence compiled in review of data on 324 cases of perforated gastric or duodenal ulcer indicated that pneumoperitoneum is more likely to be demonstrated in roentgen films made within six hours after perforation than in films made after a longer interval. In several cases films made early did not show intraperitoneal gas and later films did. There appeared to be no constant relationship between the size of the perforation and the incidence of demonstrable pneumoperitoneum. Pneumoperitoneum was less often demonstrated in cases of posterior perforation than it was when the lesion was at an anterior site. In many cases roentgen examination was performed with the patient in both the erect and the left lateral decubitus positions. These two roentgenographic views were equally reliable and there was agreement between them in 94 per cent of the cases. Clinical factors, however, may influence decision as to which position should be used in each case. Occasionally when intraperitoneal gas is not demonstrated in one view, it may be observed in films made with the patient in the other position.     

PNEUMOPERITONEUM IN PERFORATED PEPTIC ULCER—Factors in Roentgenographic Demonstration

Evidence compiled in review of data on 324 cases of perforated gastric or duodenal ulcer indicated that pneumoperitoneum is more likely to be demonstrated in roentgen films made within six hours after perforation than in films made after a longer interval. In several cases films made early did not show intraperitoneal gas and later films did. There appeared to be no constant relationship between the size of the perforation and the incidence of demonstrable pneumoperitoneum. Pneumoperitoneum was less often demonstrated in cases of posterior perforation than it was when the lesion was at an anterior site.In many cases roentgen examination was performed with the patient in both the erect and the left lateral decubitus positions. These two roentgenographic views were equally reliable and there was agreement between them in 94 per cent of the cases. Clinical factors, however, may influence decision as to which position should be used in each case. Occasionally when intraperitoneal gas is not demonstrated in one view, it may be observed in films made with the patient in the other position.     

Genital oedema in patients treated by continuous ambulatory peritoneal dialysis: an unusual presentation of inguinal hernia.

Four patients receiving continuous ambulatory peritoneal dialysis presented with scrotal or labial oedema but no detectable cough impulse. Two of the patients later developed clinical evidence of inguinal hernia, and in the other two inguinal hernias were found at operation. These cases suggest that genital oedema occurring in a patient receiving continuous ambulatory peritoneal dialysis is a sign of a small inguinal hernia which may not be detectable clinically.     

Down's syndrome in brother and sister without evident trisomy 21

Summary In the present report two siblings with the typical Down's phenotype but without evident full or partial 21 trisomy are described. The finding of a regular 21 trisomy in a minority of the cells in the elder patient favors the hypothesis that both present a hardly demonstrable normal/trisomy 21 mosaicism and may be examples of a constitutional familial tendency to nondisjunction in man.     

Significance of microhaematuria in young adults.

The medical records of 1000 asymptomatic male air force personnel were examined retrospectively for the results of 15 yearly examinations of urinary sediment. The study covered the period 1968-82, beginning with the subjects aged 18-33 years. The cumulative incidence of two to four or more red blood cells per high power field found at one or more examinations was 38.7% after an average of 12.2 yearly examinations per person. In 161 subjects two to four or more red blood cells per high power field were found at two or more yearly examinations within a five year period. Intravenous pyelography in 58 cases disclosed asymptomatic nephrolithiasis in six. Cystoscopy performed in 11 cases identified one patient with urethritis, one with a vesical calculus, and one with transitional cell carcinoma of the bladder. Two years before diagnosis the patient with carcinoma had had a single transient finding of 10-12 red blood cells per high power field which was not investigated further. Cystoscopy was performed after an episode of macroscopic haematuria. Renal biopsy in one subject with recurrent microhaematuria and trace proteinuria disclosed focal glomerulonephritis. None of the remaining subjects with microhaematuria developed hypertension or proteinuria, and at the end of the study period all were active and free of urinary symptoms. The observed cumulative incidence of urological neoplasms at 15 years (0.1%) was consistent with that expected in Israeli men aged 18-40 (0.09%). Hence microhaematuria detected during a screening examination probably should not be regarded as a specific sign of a significant lesion and does not of itself warrant urological investigation in adults aged 40 or less.     

A migration inhibition-factor assay for tumor immunity in man

A migration inhibition factor (MIF) assay to detect cellular immunity to tumor antigens in man is described. This assay utilizes a 48-hr incubation period of lymphocytes with the tissue homogenate and subsequent assay of the supernate for inhibition of the migration of guinea pig peritoneal macrophages. With this method MIF is not demonstrable in the supernate of lymphocytes cultured with histoincompatible tissue homogenates and the assay can be applied to homologous as well as autologous tumor homogenates. It can thus be used to detect tumor immunity in patients and their healthy relatives or contacts.     

BCG-induced murine effector cells. II. Characterization of natural killer cells in peritoneal exudates.

The cytotoxic activity in peritoneal exudates harvested from C57BL/6 mice 4 to 6 days after they had received viable Bacillus Calmette-Guérin (BCG) organisms i.p. was associatee with a nonadherent, nonphagocytic cell. The cytotoxic cell lacked demonstrable surface immunoglobulin and Thy 1 antigen and bore no readily detectable Fc receptors. Lytic activity was labile at 37 degrees C and was diminished after trypsinization of the effector cells. Preincubating effector cells with immune complexes was without effect on lytic expression. These features make it likely that the cytolytic activity was associated with "natural killer" (NK) cells, previously described in unimmunized mouse spleens and mesenteric lymph nodes. Whether BCG induced "activation" of resident NK cells, the de novo production of NK cells, or "homing" into the peritoneum of cells normally resident in other lymphoid tissue is not known.     

Drying Dynamics of Solution‐Processed Perovskite Thin‐Film Photovoltaics: In Situ Characterization,Modeling, and Process Control

A key challenge for the commercialization of perovskite photovoltaics is the transfer of high‐quality spin coated perovskite thin‐films toward applying industry‐scale thin‐film deposition techniques, such as slot‐die coating, spray coating, screen printing, or inkjet printing. Due to the complexity of the formation of polycrystalline perovskite thin‐films from the precursor solution, efficient strategies for process transfer require advancing the understanding of the involved dynamic processes. This work investigates the fundamental interrelation between the drying dynamics of the precursor solution thin‐film and the quality of the blade coated polycrystalline perovskite thin‐films. Precisely defined drying conditions are established using a temperature‐stabilized drying channel purged with a laminar flow of dry air. The dedicated channel is equipped with laser reflectometry at multiple probing positions, allowing for in situ monitoring of the perovskite solution thin‐film thickness during the drying process. Based on the drying dynamics as measured at varying drying parameters, namely at varying temperature and laminar air flow velocity, a quantitative model on the drying of perovskite thin‐films is derived. This model enables process transfer to industry‐scale deposition systems beyond brute force optimization. Via this approach, homogeneous and pinhole‐free blade coated perovskite thin‐films are fabricated, demonstrating high power conversion efficiencies of up to 19.5% (17.3% stabilized) in perovskite solar cells.     

Peritonitis prevented in continuous ambulatory peritoneal dialysis by using the Hong Kong connection.

Based on the hypothesis that air contamination is an important cause of peritonitis in continuous ambulatory peritoneal dialysis, a simple and cheap connection system was developed whereby a clear polyethylene bag containing an antiseptic gauze was used as a sterilising chamber, effectively enclosing the connection procedure. Seven modifications to the connection technique were introduced over 32 months in 28 patients during 27.9 patient years of experience. The overall rate of peritonitis was 0.6 episode/patient year, but after a final modification at the beginning of the third year the rate fell to 0.17, without a single case of peritonitis occurring attributable to a connection failure in 11.5 patient years. These findings show that in patients receiving continuous ambulatory peritoneal dialysis peritonitis may be prevented by enclosing the connection process and sterilising the introduced air and tubing ends.     

Inapparent primary hypothyroidism

Some 12 years ago a 56-year-old man was observed for Epipharyngitis. All the tests, including cytology of the epipharynx, were normal. Thyroid tests, including free thyroxine and triiodthyronine, were normal, only the hypophysial thyroid stimulating hormone was elevated. In a second IGR TSH test it was again elevated. The patient was seen again: he was adynamic. Thyroxine was prescribed in a small initial dose of 25 mgr. daily and after several weeks he was consuming 125 mgr thyroxine daily. TSH was normalised. This inapparent expression of primary hypothyreosis with elevated TSH only was the trigger for many cases of hyporthyreosis without laboratory or clinical signs of thyroid hypofunction. In this paper 27 cases are presented with the sign of elevated TSH only.     

Supine position decreases the ability of the nose to warm and humidify air.

We tested the hypothesis that decreasing nasal air volume (i.e., increasing nasal turbinate blood volume) improves nasal air conditioning. We performed a randomized, two-way crossover study on the conditioning capacity of the nose in six healthy subjects in the supine and upright position. Cold, dry air (CDA) was delivered to the nose via a nasal mask, and the temperature and humidity of air were measured before it entered and after it exited the nasal cavity. The total water gradient (TWG) across the nose was calculated and represents the nasal conditioning capacity. Nasal volume decreased significantly from baseline without changing the mucosal temperature when subjects were placed in the supine position (P < 0.01). TWG in supine position was significantly lower than that in upright position (P < 0.001). In the supine position, nasal mucosal temperature after CDA exposure was significantly lower than that in upright position (P < 0.01). Our data show that placing subjects in the supine position decreased the ability of the nose to condition CDA compared with the upright position, in contrast to our hypothesis.     

The erect abdominal radiograph in the acute abdomen: should its routine use be abandoned?

The value of erect and supine abdominal radiographs and erect chest radiographs was analysed prospectively in 102 consecutive patients admitted to hospital with acute abdominal symptoms. The radiographs were reported on initially by junior surgeons of the admitting team, special note being made of the value of the erect abdominal radiograph over the combination of the supine abdominal radiograph and erect chest radiograph. On the basis of information obtained from the erect abdominal radiograph alone no changes in patient management were recorded. A consultant radiologist reported on the same radiographs at a later date. In five cases the erect abdominal radiograph was thought to have contributed useful or additional information, although in four of these cases abnormal features were visible in the supine film. In three of the five cases important but subtle information was missed by junior surgeons. In five of the 102 patients information obtained from the erect abdominal radiograph was potentially misleading. The small yield of positive information, potentially misleading features, and lack of effect on surgical management suggest that the routine use of the erect abdominal radiograph in the acute abdomen should be abandoned.     

Immunologically demonstrable hormones and hormone-like molecules in rat white blood cells and mast cells

The presence or absence of four biologically active hormone or hormone-like molecules was studied in rat immune cells using specific antibodies with flow cytometry and confocal microscopy. Epidermal growth factor (EGF) was not demonstrable at all, digoxin was present only in blood lymphocytes, and insulin was found in the monocyte-macrophage-granulocyte group in peritoneal fluid and thymic lymphocytes. Immunologically demonstrable triiodothyronine (T3) was present in all cells studied (lymphocytes, mast cells and monocyte-macrophage-granulocytes in peritoneal fluid and blood, and thymic lymphocytes). While there is no explanation of the presence of digoxin and insulin, it is assumed that T3 is an extrathyroidal source of the hormone that is needed for maintaining cell proliferation and normal status in the immune system, particularly as it is absent in the case of transitional or durable thyroid deficiency.     

Efficiency of palpation in clinical detection of breast cancer.

An annual clinical screening test for breast cancer must be simple, brief and efficient. The traditional physical examination of the breast is time-consuming, mainly because of the complicated maneuvers necessary to inspect for retraction. Palpation with the patient supine, however, can be performed quickly. Of 286 primary breast cancers 96% (275) were palpable as a lump, and this was the only clinical sign in 55%. Retraction was the sole clinical sign in only 1%. The combination of retraction and a solid lump is a very specific but not very sensitive test for breast cancer. Retraction in this series was not related to the size of the primary tumour but among the women with a cancerous breast lump was significantly more likely to be found in those over 44 years of age, being present in 52% of these women but only 10% of the younger women. Inspection of the breast can therefore safely be detected from screening breast examinations, whether performed by the physician or the patient.     

Liposome supported peritoneal dialysis in rat amitriptyline exposure with and without intravenous lipid emulsion

Liposome supported peritoneal dialysis is a recently described technique which may eventually be applicable in the clinical scenario of the intoxicated patient. We evaluated the hypothesis that intravenous injection of lipid emulsion (ILE) would augment acidic pH gradient liposome supported peritoneal dialysis (LSPD). Orogastrically amitriptyline dosed rats were treated with either Sodium bicarbonate (NaHCO3) intravenously and standard intraperitoneal dialysate (Group A); NaHCO3 intravenously and LSPD (Group B); or ILE and LSPD (Group C). The primary endpoint was dialysate amitriptyline concentration after a 60?min dwell. Secondary analysis included an estimate of extraction ratio for peritoneal blood flow (ERs). There were significantly higher intraperitoneal concentrations of amitriptyline and ERs in the two groups treated with LSPD (Group B, p?=?0.02, Group C, p?<?0.01 vs. Group A). There was no observed effect for ILE on intraperitoneal amitriptyline concentration or ERs (p?>?0.20). LSPD increased the amitriptyline concentration in peritoneal dialysate. No further increase was demonstrated with ILE. This may be either because such an effect is absent, or type II error. Exploratory analysis suggests LSPD may be driven by total rather than free drug concentrations.     

Postural effects on peritoneal transport and systemic uptake of radiolabeled monoclonal antibodies

 To optimize the regional delivery advantage with i. p. administration of monoclonal antibody (mAb) for radioimmunotherapy, it may be possible to delay the rate and extent of mAb absorption from the peritoneal cavity by simply altering the position of a patient after radioantibody administration. It has been shown that the hydrostatic pressure against the diaphragm plays a major role in the rate of egress of radioantibodies from the peritoneal cavity and that fluid removal from the peritoneal cavity can be altered by posture. The current study examined postural effects in normal rats following the i. p. injection of ¹²⁵I-5G6.4 murine IgG2a anticarcinoma antibody (45 μCi). A 10-ml injection volume of the radioantibody solution was administered to rats restrained in either a supine or inclined (reverse Trendelenburg; feet down at a 45° angle) position. Pharmacokinetic analysis confirmed that the appearance of the radioantibody into the systemic circulation was delayed in the inclined group. The time to peak blood concentration was prolonged from 14.7 (supine) to 19.2 (inclined) hours (P = 0.005). All other pharmacokinetic parameters were equivalent across the treatment groups. The mean half-life of 166 h, mean blood clearance of 9 ml/min, and mean steady-state volume of distribution of 36 ml were consistent with previous experience with this radioantibody in the rat. The intrinsic absorption profile indicated that the mean percentage absorption from the peritoneal cavity to the blood stream was greater in the supine animals from 4 h after i. p. injection until absorption was complete. By 10 h after injection, absorption from the peritoneal cavity was essentially complete in the supine-dosed animals, while those restrained in an inclined position had cleared only 50% of the total absorbed dose. Hence, the regional delivery advantage afforded by intraperitoneal administration of the radioantibody may be further exploited by maintaining an inclined position throughout the absorption phase, a strategy that may be applicable to radioimmunotherapy of patients. Received: 26 July 1996 / Accepted: 27 January 1997     

Locomotion of T cells from patients with cutaneous T-cell lymphoma (Sezary syndrome and mycosis fungoides)

Peripheral blood T cells from eight patients with cutaneous lymphoma (four each with Sezary syndrome or mycosis fungoides) and T cells from skin tumor of one patient each with Sezary syndrome or mycosis fungoides were studied for their locomotor responses to the chemoattractant, casein. Nonmalignant peripheral blood T cells from each patient with mycosis fungoides moved normally. Malignant T cells from skin tumor of patients with mycosis fungoides or Sezary syndrome did not move in the presence of casein. Peripheral blood malignant T cells (Sezary cells) from three of four patients with Sezary syndrome either moved very poorly or did not move at all. The circulating Sezary cells from the fourth patient with Sezary syndrome responded moderately to the chemoattractant, casein. Two of three patients with Sezary syndrome with poor or no locomotor response of T cells underwent therapeutic leukopheresis without any demonstrable effect on their skin infiltration. The patient whose malignant T cells demonstrated moderate locomotor response to casein had a leukemic blast crisis and at that time her skin became free of malignant cells. A repeat study of her circulating T cells at that time demonstrated almost normal locomotor response to casein. These results demonstrate that the locomotor properties of malignant T cells in patients with Sezary syndrome may have prognostic significance.     

In vitro studies on transplantation immunity. II. The migration inhibition in homograft reactions in guinea pigs

The migration of peritoneal exudate cells from guinea pigs exhibiting transplantation immunity is inhibited in the presence of donor antigens. This inhibition of migration is demonstrable whether the donor transplantation antigens are presented in the form of viable cells (peritoneal exudate cells) or as particulate subcellular antigens (spleen microsomes). A greater degree of inhibition was observed when transplantation immunity was induced with lymphoid cells in Freud's adjuvant compared to sensitization with orthotopic skin grafts. There was no inhibition of migration in mixtures of normal allogeneic cells or when peritoneal cells from guinea pigs exhibiting tuberculin hypersensitivity were mixed with similar cells from normal animals. Finally, supernatants from cultures of sensitive lymphocytes plus donor antigens inhibited the migration of normal peritoneal cells indicating the presence of migration inhibitory factor (MIF) activity.     

Influence of head position on thermal stress in newborns: simulation using a thermal mannequin.

The influence of head position on thermal stress was assessed by using a heavily clothed thermal mannequin in three different body positions [supine, face straight up (FSU); supine, face to the side (FTS); prone, FTS] and with or without the head covered by a bonnet. The mannequin was exposed to air temperatures of 29, 32, 34, and 36 degrees C. When the head is uncovered, body or head position has no impact on heat loss. When the head is covered, dry heat loss from the mannequin as a whole (and that from the head in particular) is lower (-0.35 to -0.40 W) in the FTS position than in the FSU position as a result of decreased heat loss from the surface area of the face in contact with the mattress. In the FTS position and with the head covered, there was no difference in heat loss between the prone and supine positions. The results suggest that in heavily clothed newborns whose head is covered by a bonnet, thermal stress depends on the head position.     

Rupture of the gastrointestinal tract; dealing with lesions caused by non-penetrating trauma

The possibility of rupture of the gastrointestinal tract should be considered in every case of abdominal trauma, and the patient should be carefully observed for a period of 12 to 48 hours. There are many factors that may confuse diagnosis, but in the presence of persistent pain and tenderness, persistent or recurring shock, fever, leukocytosis, roentgen demonstration of free intra-abdominal air, or of other signs of peritonitis, operation should be carried out. The mortality rate is much higher when definitive treatment is delayed more than 12 hours.