Need For Strict Adherence Research Articles

Endometrial papillary serous carcinoma: patterns of spread and treatment.

Uterine papillary serous carcinoma exemplifies the potential for Müllerian epithelium at any site to differentiate along histologic patterns that replicate Müllerian epithelium at other sites, especially when neoplastic. Papillary serous differentiation is most commonly associated with epithelial ovarian carcinoma. Papillary serous differentiation of endometrial malignancy is associated with a poor prognosis wrought mainly through the tendency to present as late- stage disease. There is a considerable discrepancy between clinical and surgical staging. Because surgical stage is the single most important prognostic factor, the need for standardized, accurate, and comprehensive staging is highlighted, particularly where experimental protocols are being evaluated. Similarly, there is a need for strict adherence to standardized histologic criteria and reporting, particularly in making the often subtle distinction between papillary endometrioid adenocarcinoma and UPSC. Because even the earliest stage of disease is associated with a poor prognosis, a case can be made for offering adjuvant therapy to all patients diagnosed with UPSC. No single adjuvant modality has emerged as preeminent. There is comparable response to both radiotherapy and chemotherapy regimens, suggesting a need to compare these regimens in a multicenter, randomized trial. Because UPSC constitutes up to 10% of all endometrial carcinomas, there should be no difficulty accruing sufficient numbers for meaningful analysis. Although such a study may provide clues to optimizing available adjuvant strategies, further improvement in treatment regimens is required to effectively alter the poor prognosis associated with this condition.

Infection Control Precautions and Anesthesia

In Response: We appreciate the comments by Dr. Arron regarding our survey [1]. Dr. Arron suggests that Question 27 of our survey may have resulted in an underreporting of the degree to which anesthesiologists clean laryngoscope blades appropriately. His point is well taken in that we did not distinguish between high and low levels of disinfection as recommended by the Centers for Disease Control (CDC). As Dr. Arron suggests, this may have resulted in an underreporting of compliance with respect to the practice of cleaning laryngoscope blades. However, if indeed this was true, then it further highlights the need for stricter adherence to the CDC's guidelines. Although we concur that this particular question may not have been definitive, we disagree with Dr. Arron's suggestion that the questionnaire as a whole was therefore misleading. Dr. Arron makes some important points with respect to the expectation of anesthesiologists to meet at least the minimum standards of care regarding perioperative control of infection. In a previous report which represented the first phase of this study, 88% of anesthesiologists reported that they always complied with the CDC guidelines for the prevention of occupational transmission of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) when presented with a known HIV- or HBV-infected patient, but only 24.7% adhered to the guidelines when the patient was considered low risk [2]. Despite the fact that there is no convincing evidence to support a direct cause and effect relationship between anesthesia practice and infection, anesthesiologists can ill afford to become complacent and, as Dr. Arron points out, we should strive to adhere to the recommended guidelines until we can be persuaded that less stringent measures can be adopted safely. Alan R. Tait, PhD Department of Anesthesiology University of Michigan Medical Center Ann Arbor, MI 48109 Dale B. Tuttle, MBA Department of Management Michigan State University East Lansing, MI 48824

Infection Control Precautions and Anesthesia

In Response: We appreciate the comments by Dr. Arron regarding our survey [1]. Dr. Arron suggests that Question 27 of our survey may have resulted in an underreporting of the degree to which anesthesiologists clean laryngoscope blades appropriately. His point is well taken in that we did not distinguish between high and low levels of disinfection as recommended by the Centers for Disease Control (CDC). As Dr. Arron suggests, this may have resulted in an underreporting of compliance with respect to the practice of cleaning laryngoscope blades. However, if indeed this was true, then it further highlights the need for stricter adherence to the CDC's guidelines. Although we concur that this particular question may not have been definitive, we disagree with Dr. Arron's suggestion that the questionnaire as a whole was therefore misleading. Dr. Arron makes some important points with respect to the expectation of anesthesiologists to meet at least the minimum standards of care regarding perioperative control of infection. In a previous report which represented the first phase of this study, 88% of anesthesiologists reported that they always complied with the CDC guidelines for the prevention of occupational transmission of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) when presented with a known HIV- or HBV-infected patient, but only 24.7% adhered to the guidelines when the patient was considered low risk [2]. Despite the fact that there is no convincing evidence to support a direct cause and effect relationship between anesthesia practice and infection, anesthesiologists can ill afford to become complacent and, as Dr. Arron points out, we should strive to adhere to the recommended guidelines until we can be persuaded that less stringent measures can be adopted safely. Alan R. Tait, PhD Department of Anesthesiology University of Michigan Medical Center Ann Arbor, MI 48109 Dale B. Tuttle, MBA Department of Management Michigan State University East Lansing, MI 48824

Anti-tuberculous therapy and acute liver failure

The incidence of tuberculosis has been increasing since 1987, exposing a greater number of patients to the risks of three potentially hepatotoxic drugs, isoniazid, rifampicin, and pyrazinamide. Awareness of potentially severe drug hepatotoxic reactions is vital because fulminant hepatic failure is a devastating and often fatal condition without liver transplantation. We report four cases of fulminant hepatic failure caused by rifampicin, isoniazid, or both. These cases highlight the need for stricter adherence to and review of current guidelines on liver function tests after starting anti-tuberculous therapies.

Prevalence of human immunodeficiency virus, hepatitis B virus and hepatitis C virus among dialysis patients. The Italian Multicentric Study on Nosocomial and Occupational Risk of Blood-Borne Infections in Dialysis.

In April 1991, a cross-sectional study of HIV, HBV and HCV markers among dialysis patients was carried out in 19 Italian units in order to evaluate the spread of these bloodborne infections among patients and to evaluate the potential risk for staff who care for them. A total of 2,180 patients were eligible and all consented to be tested. Of the 1,347 patients who had not been given hepatitis B vaccine, 67.9% had at least one marker of HBV infection; of these 9.2% were HBsAg carriers; conversely, the rates were 7.6 and 0.4%, respectively, among the 833 vaccinated patients. Antibodies against HCV were found in 501 patients (23%) by EIA C100-3; of these, 270 were tested by RIBA-100: 246 (91%) were reactive and 11 (4.1%) indeterminate. Five patients resulted anti-HIV positive [0.22%, 95% CI (Poisson distribution): 0.07-0.53] by EIA and Western blot techniques. Length of time on dialysis seems to correlate with higher prevalence of HBV and HCV infection markers, but (not) HIV. Overall, 608 (28%) patients were a potential source of infections for other patients and staff. This emphasizes the need for stricter adherence to infection control, barrier precautions and preventive behaviours with all patients.

Ocular disease from wearing contact lenses. A potentially devastating complication.

Because of the continued popularity of contact lenses in the United States, ocular inflammatory diseases are being encountered with increasing frequency by both ophthalmologists and primary care physicians. Distinction between minor noninfectious inflammation and serious, sight-threatening infection is crucial to the proper management of these patients. Symptoms of infectious keratitis are pain and loss of vision. Signs include infiltration or loss of clarity of the cornea, eyelid swelling, and purulent discharge. If an infectious process is suspected, the patient should be referred to an ophthalmologist immediately. If this is not possible, the contact lens should be removed and a culture performed, if possible. Aminoglycoside antibiotic drops should be applied frequently until ophthalmologic consultation is obtained. Patients should be reminded of the need for strict adherence to disinfection techniques and avoidance of homemade saline preparations. They should also be told to discontinue use of contact lenses at the first sign of ocular irritation or inflammation and to report to their physician if inflammation persists.

Home Parenteral Nutrition for the Child with Cancer

Compliance with treatment is greatly increased when the caregiver(s) understand the treatment, the need for the treatment, and the need for strict adherence to sterile technique. When the caregiver is not ready to handle home care of the child, compliance is less than optimal and may be a threat to the child. Parenteral nutrition support can be both safe and effective in children with cancer when the family and health-care team work together. Nutrition support facilitates treatment of the whole child and can help improve his or her quality of life.

Implication of translocated fishes in the apparent extinction in the wild of the Lake Eacham rainbowfish, Melanotaenia eachamensis

The Lake Eacham rainbowfish, M. eachamensis, has been recorded from only Lake Eacham, a small crater lake in northern Queensland. Colonisation by four Australian fishes not native to the lake and the concomitant decline of the rainbowfish prompted a detailed survey in 1987. Intensive sampling failed to reveal any rainbowfish. It appears that the Lake Eacham rainbowfish no longer exists in its natural habitat. Although the cause of the demise of the Lake Eacham rainbowfish cannot be proven, temporal and trophic evidence implicated the translocated species. Aquarium stocks are being maintained to make feasible the consideration of a restocking programme in the future. This case study indicates the need for strict adherence to scientifically responsible policies on fish translocation programmes.

Computerized psychological testing: Overview and critique.

We present an overview and a eritique of computerized psychologies! testing and assessment. Emphasis is placed on describing computer testing systems currently in place, discussing considerations (factors) in developing a computerized psychological testing system, examining the research on potential benefits and problems associated with computerized psychological testing, and discussing Ihe need for the adoption of a set of guidelines, both scientific and ethical, for computerized psychological testing. We conclude that computerized psychological testing systems have the potential of being practical, cost-effective, and psychometrically sound means of assessing individuals. The potential of computerized psychological testing can be realized if proper considerations are made in designing, developing, and implementing these testing systems, and if professional standards (guidelines) are adhered to by computer test service providers and users. Before the adoption of computerized psychological testing becomes widespread, a number of serious issues deserve the attention of professionals. Over the past two decades, the use of computers in psychological assessment has steadily increased. During this time, computers have assisted in administering and scoring tests as well as in providing interpretive reports. Some of the early work related to the use of computers in psychological assessment, for a variety of different purposes, was reported by Gedye (1968), KJeinmuntz and McLean (1968), Lang (1969), and Stillman, Roth, Colby, and Rosenbaum (1969). Sampson (1983) reported that the use of computers in the testing field began when large time-sharing computers were used to optically scan, score, and profile standardized tests. This was followed by the addition of interpretive narrative reports to these systems. More recently, tests have been administered via computer terminals. Systems for administering tests via computer terminals also incorporate test scoring and interpretation components. A number of different types of computer systems for administering, scoring, and interpreting tests are commercially available. Our purpose is to provide an overview of existing computerized psychological testing systems, to describe some of the considerations in developing and implementing a computer testing system, to discuss the potential benefits and problems associated with computerized psychological testing, and to discuss the need for strict adherence to a set of standards for the administration and interpretation of computerized psychological tests.

HTLV-III/LAV Seroconversion Following a Deep Intramuscular Needlestick Injury

The authors report a case of human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) seroconversion after an occupational injury. The subject a female health care worker in the US received a deep intramuscular needlestick injury with a large-bore unit that was visibly contaminated with blood from a patient with acquired immunodeficiency syndrome (AIDS). 14 days after injury fever chills myalgias and arthralgias developed. Examination revealed an enlarged right axillary lymph node. On day 17 an erythematous macular rash appeared on the abdomen and lasted 5 days. The health care worker continued to have cramps diarrhea and weight loss. A diagnosis of Clostridium difficile colitis was made and oral vancomycin therapy was followed by a complete resolution of symptoms. Since then the health worker has had intermittent oral candidiasis a persistent postcervical lymph node and transient enlargement of suboccipital and inguinal lymph nodes. Serum collected 9 days after the injury was negative for HTLV-III/LAV antibody but samples collected on days 184 and 239 were positive. The health workers husband was seronegative when tested 239 days after injury. The results of virus culture for HTLV-III/LAV performed on blood from both the health care worker and her husband were negative at 239 days. The only 2 documented cases of HTLV-III/LAV antibody seroconversion in health care workers have occurred after highly unusual parenteral exposure to blood. In the other case blood from an AIDS patient may have been injected into a health care workers finger. These 2 cases emphasize the need for strict adherence to recommended infection control precautions especially those regarding the handling of needles and other sharp objects.

Surgical judgment in the management of abdominal stab wounds. Utilizing clinical criteria from a 10-year experience.

A 10-year retrospective study of patients with stab wounds to the abdomen managed under a protocol of selective management has been performed. Patients were assessed on the basis of clinical presentation and physical examination, with minimal diagnostic studies. Peritoneal lavage was not utilized in the evaluation of the patients. Two hundred and nineteen such patients were identified. One hundred and eleven of these patients were treated nonoperatively. Ninety patients were treated by immediate laparotomy. Eighteen patients, initially observed, underwent delayed laparotomy. One patient, not explored despite clear-cut indications for laparotomy, died of sepsis, emphasizing the need for strict adherence to the stated protocol. The negative or unnecessary laparotomy rate was 7.8%. The false-negative examination rate was 5.5%. Overall mortality rate was 2.3%. The accuracy of careful clinical evaluation and observation is comparable to, or better than, any other method currently available to identify intra-abdominal injuries in patients with abdominal stab wounds. The study suggests that selective management of stab wounds of the abdomen may be safely practiced in a smaller community hospital.

Invasive Cancer Following Conservative Therapy for Previous Cervical Intraepithelial Neoplasia

From January 1983 to December 1984, 205 cases of invasive cervical cancer were seen in the Gynecologic Oncology Clinic at the Royal Brisbane Hospital. Eleven of these women had been previously treated for cervical intraepithelial neoplasia (CIN); 7 by cone biopsy and 4 by electrocoagulation diathermy. Failure to adhere to the recommended triage protocol emerged as the major factor in allowing malignant progression. Common errors included the use of blind biopsies, reliance on a single biopsy, concurrent therapy at the time of diagnosis, and the use of conservative therapy despite positive endocervical curettage or colposcopically suspect atypical vessels. Finally, 4 of 7 women who developed invasive cancer after an interval of more than 2 years had been lost to follow-up. Colposcopic triage of abnormal Papanicolaou smears is increasingly undertaken by gynecologists with only modest colposcopic experience. Leaders in this area must stress the need for strict adherence to protocol, lest more women die of cervical cancer through errors of diagnosis, treatment or follow-up.

Cellular immunity in children with coeliac disease.

The experimental evidence implicating defective cell-mediated immunity in coeliac disease, a condition where symptomatology is believed to be due to immunological reaction to wheat gluten, is often inconsistent and sometimes controversial. Studies of certain parameters of cellular immunity in four groups of pediatric patients were performed: coeliac patients on normal diet; coeliac patients consuming gluten-free diet; children with cow's milk sensitivity. In all these assays no significant differences were found between treated or untreated coeliac children, infants with milk allergy or the gastro-intestinal control groups. On the basis of this study we could find no evidence of impairment of cell-mediated immunity in coeliac children. This conclusion is compatible with the hypothesis that intestinal damage may be due to a subpopulation of lymphocytes sensitive to gluten in persons with normal immune systems. In adults where abnormalities of cell-mediated immunity have sometimes been noted, the reason could be a loss of lymphocytes from the damaged mucosa of the gastrointestinal tract following prolonged antigenic stimulation. This indicated the need for strict adherence to a gluten-free-diet.

Data on the chromosome examinations of workers exposed to pesticides

Cytogenetic data for workers exposed to pesticides in Be´ke´s County, Hungary, are reported. The aim of these investigations was the evaluation of some pathognomonic phenomena in man as being probable consequences of the microtoxicological long-term effects of pesticides. Chromosome preparation was carried out according to the modified method of P.S. Moorhead, P. C. Nowell, W. J. Mellman, D. M. Battips, and D. A. Hungerford (1960, Exp. Cell Res. 20, 613–616). The chromosomes were evaluated according to the Edinburgh classification after using the ASG band technique. Some of the data from the chromosome examinations do not exclude a probable mutagenic effect and call attention to the need for strict adherence to labor (labor hygienic) health and accident-prevention regulations

The meaning and structure of species as applied to mycobacteria

In an attempt to determine the nature of species amongst mycobacteria analyses at both interspecific and intraspecific levels have been performed. Over 1000 strains were examined in immunodiffusion analysis, and the majority were allotted to 20 named species on the basis of from two to eight species specific (group iv) antigens. In no case were any of these antigens shared by other species. The genus could be divided into two subgenera, one containing the slow-growing species and the other the fast-growing species, on the basis of two other groups (ii and iii) of antigens. Twenty eight strains of Mycobacterium fortuitum (ranae) were analysed by a multiplicity of methods to determine the extent of naturally occurring variation within this species. By picking off single colonies, certain variants could be selected from other variants indicating that genetically more complete strains throw off deleted mutants which may be most successful in surroundings different from those favouring the parent strain. Another mechanism of intraspecific variation, lysogeny with mycobacteriophage, was also demonstrated. The nature of species as determined by the two methods of approach are discussed, and the need for strict adherence to the rules of taxonomic nomenclature explained.