In vivo and vitro in diagnosis of latex allergy at Groote Schuur Hospital

OBJECTIVE: The aim of this study was to evaluate the diagnostic utility of skin-prick tests, radio-allergosorbent tests (CAP RASTs), basophil histamine release, sulphidoleukotriene release and Western blotting in the diagnosis of latex allergy at Groote Schuur Hospital. DESIGN: Patients with a history suggesting latex hypersensitivity were recruited via staff health and allergy clinics at Groote Schuur Hospital. A clinical assessment was followed by laboratory investigation and skin-prick testing. A control group consisted of laboratory and hospital staff who had regular latex exposure but were asymptomatic. SETTING: Hospital-based cohort at Groote Schuur Hospital. PARTICIPANTS: Twenty-three patients with suspected latex allergy; 10 control subjects exposed to, but not clinically sensitive to, latex. MAIN OUTCOME: Skin-prick testing was more sensitive than in vitro diagnostic tests for the diagnosis of latex allergy. RESULTS: Eighteen of 21 (85.7%) of the patients tested had a positive skin-prick test with a commercial latex solution (Allerbioprick) and 17/21 (80%) tested skin-prick-positive with an in-house glove extract. CAP RASTs were positive in 13/23 patients (56.5%), sulphidoleukotriene release was positive in 10/23 (43%), histamine release assay was positive in 10/23 (45%) and Western blots were positive in 8/23 (34.7%). All patients with only urticaria were Western blot-negative and CAP RAST-negative, suggesting that they have very little circulating latex-specific IgE. Although patients who were Western blot-positive tended to have multi-organ involvement, both patients with anaphylaxis were Western blot-negative. CONCLUSION: Latex allergy is a significant clinical problem at Groote Schuur Hospital. Titrated skin-prick testing performed in a controlled environment can safely and reliably confirm the diagnosis in patients who do not give a history of anaphylaxis. The CAP RAST was the most sensitive in vitro test for latex allergy locally available, but lacks sensitivity in patients presenting with urticaria only.     

Latex sensitization in general pediatric surgical patients: a call for increased screening of patients

BACKGROUND/PURPOSE: Latex sensitization is a well-documented occurrence in children with myelodysplastic and urologic anomalies. The incidence of latex allergy in general pediatric surgical patients, however, has not been previously addressed. The purpose of this study was to examine the risk of perioperative latex reactions in a general pediatric surgical practice over a 1-year period. METHODS: This study examined the occurrence of latex sensitization using two methods. First, the preoperative anesthesia records of patients that have undergone surgery from October 1995 through September 1996 at Mott Children's Hospital were reviewed retrospectively. Second, all patients who had intraoperative anaphylaxis attributable to latex sensitization, including those from three additional hospitals, were evaluated. RESULTS: During a 12-month period, 1,523 pediatric general surgical operations were performed at the C.S. Mott Children's Hospital. Of these, only 11 operations on five patients were performed under latex precautions. All of these patients had a preoperative diagnosis of latex sensitivity. During the same period, intraoperative anaphylactic reactions caused by latex allergy occurred in two of the general surgical patients (0.13%) at the C.S. Mott Hospital. Four additional cases are also reported from other study hospitals. None of these patients were suspected, based on current screening methods, of having a latex allergy before their surgery. CONCLUSIONS: Latex allergy is a potentially life-threatening condition in the pediatric general surgical population. Further study is needed to develop criteria to preoperatively identify patients at risk for latex sensitization.     

Radiation-induced cerebral meningiomas. Case reports

BACKGROUND: Because latex is a common allergen, the rate of latex sensitization may be high in the general population. A major issue would then be to determine whether a systematic preoperative screening in the general population should be recommended. OBJECTIVE: The purpose of the study was to evaluate the prevalence of latex sensitization in a sample of the general population and to assess the role of possible risk factors. METHODS: The subjects were 258 people, aged from 20 to 40 yr, visiting a health care centre for a check-up. The protocol included: a questionnaire (occupation, symptoms of atopy, use of latex goods and possible reactions, history of previous surgery), a skin-prick test, and a CAP RAST to latex. Atopy was evaluated by a skin-prick test to common allergens and a Phadiatop test. RESULTS: Some 6.6% of the study group had either a positive skin test or a positive RAST to latex. These subjects had a four-fold higher prevalence of symptoms when wearing gloves. The rate of latex sensitization was higher by fivefold in subjects with a history of reactions to latex goods and by fourfold in atopic subjects. CONCLUSIONS: Because the rate of latex sensitization is much higher than the anticipated rate of perioperative reactions due to latex allergy, a systematic preoperative screening for latex allergy should not be recommended for adults.     

Surgical treatment of syringomyelia associated with spinal dysraphism

Clinical and radiological features of syringomyelia in 15 patients with spinal dysraphism are reported. There were 8 patients with occult spinal dysraphism (lumbosacral lipoma) and 7 with spina bifida aperta (meningomyelocele). Syringomyelia with spinal dysraphism can be radiologically divided into two types according to the dysraphic state. The syrinx in the patients with occult spinal dysraphism occurred immediately rostral to the lipoma and was localized to the lower thoracic to lumbar levels, while in the meningomyelocele patients the syrinx extended from the cervical to the thoracic level. Large syrinx formation was recognized in 1 of the 7 occult spinal dysraphism cases and 3 of the 8 meningomyelocele cases. For syringomyelia with occult spinal dysraphism, 4 patients underwent syringo-subarachnoid shunting (S-S shunt, 2 cases) or syringostomy (2 cases) during an untethering operation. In the case of meningomyelocele, S-S shunts were placed in 2 patients. Collapse of the syrinx was achieved in all 6 patients who underwent S-S shunting or syringostomy. Decreased size of the syrinx was also noted in 3 occult spinal dysraphism patients who underwent untethering operations alone. In conclusion, a large syrinx in the case of spinal dysraphism should be surgically treated. S-S shunting is effective in both types of syringomyelia. Foramen magnum decompression may be an alternative method of surgical treatment for syringomyelia in patients with meningomyelocele.     

Familial predisposition for degenerative disc disease. A case-control study

STUDY DESIGN: This case-control study was undertaken to determine if relatives of patients who had been admitted for surgery for degenerative disc disease-related problems were at increased risk for lower back pain or sciatica. OBJECTIVES: To determine if familial factors play a role in placing a person at risk for development of degenerative disc disease of the lumbar spine. SUMMARY OF BACKGROUND DATA: It is known that smoking and various occupational factors can place a person at risk for degenerative disc disease problems. It is not known if a familial predisposition may also exist. METHODS: The family members and relatives of 65 patients who had undergone surgery for lumbar degenerative disc disease were interviewed with a standardized questionnaire and compared with a control group of 67 patients who had been admitted to hospital for non-spine-related orthopedic procedures. The same interview and standardized questionnaire was used for both groups by a single observer. RESULTS: In the study group of 65 patients who had undergone surgery for degenerative disc disease, 44.6% were noted to have a positive family history, whereas 25.4% of the patients in the control group had a positive family history. Eighteen and one-half percent of relatives in the study group had a history of having spinal surgery, compared with only 4.5% of the control group. CONCLUSIONS: The results indicate that a familial predisposition to degenerative disc disease can exist along with other risk factors.     

Effects of clozapine and haloperidol on baseline levels of vacuous jaw movements in aged rats

BACKGROUND: IgE-mediated hypersensitivity to latex proteins has become a significant clinical problem over the last decade. Nursing and medical staff are at risk because of their occupational exposure to latex. AIMS: To determine the prevalence of type I hypersensitivity to latex allergens in the nursing staff of an Australian hospital. METHODS: A questionnaire which asked about symptoms associated with the use of latex gloves was completed by 140 nurses working in the Alfred Hospital (72 in general medical wards, 68 in intensive care units). Skin prick tests with eluates of five different types of latex glove as well as common aeroallergens (rye pollen and house dust mite) and banana extract were performed. RESULTS: Thirty-one nurses (22%) were skin prick test positive to at least one of the five latex glove eluates. All of these nurses were atopic, having positive skin prick tests to rye pollen or house dust mite. Symptoms of local dryness, itch and erythema associated with glove use were reported by more than half the study group, but not more frequently by those who were skin prick test positive to latex. Urticaria associated with glove use was reported more frequently by those with positive latex skin prick tests (13% vs 4%, p = 0.05). Eighty-seven per cent of the nurses who were latex skin test positive were also positive to banana extract. CONCLUSIONS: IgE-mediated hypersensitivity to latex is common in nurses working in an Australian hospital. Glove associated symptoms were frequently reported, but in most cases the symptoms were more typical of irritant or contact dermatitis rather than type I hypersensitivity reactions. However, the extent of subclinical sensitisation to latex found in this study suggests that symptomatic latex allergy is likely to emerge as an increasing problem for nursing staff in this country.     

Respiratory health and immunological profile of poultry workers

OBJECTIVES: To examine work-related respiratory symptoms in poultry workers, and to test for immunologically mediated responses to poultry-related agents. DESIGN: A cross-sectional survey of differentially exposed poultry workers and unexposed blue-collar workers. SETTING: Three poultry farms and a poultry plant in Gauteng (exposed workers) and a municipal workers' clinic in Johannesburg (controls). PARTICIPANTS: 134 poultry workers (85.4% of all eligible workers) and 122 controls (> 95% response rate). OUTCOME MEASURES: Respiratory symptoms plus allergy and hypersensitivity to poultry agents identified by skin-prick tests, and by the presence of specific IgE and IgG enzyme-linked immunoflow assay and nonspecific (radial immunodiffusion) antibodies. RESULTS: Smoking habits and atopic status were similar in the poultry workers and the controls. Symptoms were very common in poultry workers, for example work-related cough in 32% and work-related wheeze in 23% of highly exposed workers. Significantly more poultry workers than controls complained of chest symptoms (increasing with increasing exposure), and of eye, skin and nose irritation at work. More poultry workers than controls had symptoms consistent with asthma (e.g. 3%, 4%, 13% and 11% in controls and subjects with low, medium and high exposure, respectively), and symptom complexes associated with organic dust exposure. Five poultry workers had positive skin-prick test reactions to poultry-specific antigens, but none of the unexposed controls reacted. More poultry workers than controls had positive immunodiffusion test reactions to chicken feed, feathers and serum, and IgE to chicken faeces. There was no association between immunological status and respiratory symptoms. CONCLUSION: We found a very high prevalence of exposure-related symptoms in poultry workers; improved hazard control is strongly indicated. Tests of allergy and hypersensitivity were associated with exposure, but not with disease. The possibility of useful tests of sensitisation has not been excluded; a prospective study design is likely to be more rewarding than cross-sectional approaches such as in this study.     

Understanding latex allergy

Latex allergy is an increasingly important problem in both health-care workers and patients. Predisposing factors to development of latex allergies include a history of atopy or allergy and frequent exposure to latex products. Identified allergens include latex proteins from the rubber tree that remain in manufactured products, as well as smaller molecules that remain from the latex purification and manufacturing process. Latex proteins absorbed to powder in latex surgical and examination gloves may be aerosolized and inhaled. Powder-absorbed latex proteins are thought to be important in triggering of sensitization in susceptible individuals, as well as in elicitation of symptoms in previously sensitized patients. Allergic reactions to latex can include local dermal reactions or generalized immediate hypersensitivity (anaphylactic) reactions. Pathophysiology, signs and symptoms, and treatment of each type of reaction are discussed. Measures to address latex allergy, however, must include measures to decrease exposure to latex antigens both in latex-allergic subjects, to prevent symptoms, and in naive subjects, to prevent sensitization. These measures may include finding, acceptable substitutes for latex in many products.     

Clinical management of latex-allergic children

Latex allergy in children with myelodysplasia and urological anomalies is well recognized. We anesthetized 162 children with latex allergy who underwent 267 anesthetics according to a latex-safe protocol. Medication for allergy prophylaxis was not administered. Our patients were 11.6 +/- 5.8 yr old (range 1-31 yr). Primary diagnoses were myelodysplasia, extrophy of the bladder, and cloacal extrophy. These children had many allergies to medications and foods as well as environmental sensitivities. One patient of 162 (1 procedure of 267) had an allergic reaction after injection of an epidural catheter with bupivacaine and fentanyl. No other patient manifested allergy signs or symptoms. Latex-allergic children can be safely anesthetized using a latex-safe protocol without allergy chemoprophylaxis. These patients require avoidance of latex products or the use of latex products that have been thoroughly washed. IMPLICATIONS: This audit of the medical histories and treatment of 162 children with latex allergy who underwent 267 anesthetics indicates that latex-allergic children can be safely anesthetized if exposure to latex in the medical environment is avoided, and that administration of prophylactic medications to decrease the allergic response is unnecessary.     

Adult spinal deformity and respiratory failure. Surgical results in 35 patients

STUDY DESIGN: Retrospective chart and complementary study review. OBJECTIVES: To describe the features of adult patients with spinal deformity and respiratory failure and to analyze the results of surgical treatment. SUMMARY OF BACKGROUND DATA: Many authors have studied the relation between spinal deformities and cardiorespiratory failure, but there exists little information about the benefits of reconstructive surgery in severely compromised patients. METHODS: The charts and complementary studies of 35 adult patients surgically treated between January 1, 1978, and December 31, 1994, were reviewed. The patients were 18 years old or older (average age, 36 years). They had spinal deformity of any etiology with respiratory insufficiency as evidenced by vital capacity of less than 60% of predictive normal, PaO2 less than 80 mm Hg, or PaCO2 more than 45 mm Hg. All had reconstructive spinal surgery in an attempt to improve their respiratory problem. RESULTS: Seven patients died within the first postoperative year, and one patient was lost to follow-up at 6 months. The other 27 patients had a mean follow-up time of 72 months. The 34 patients were divided into three groups: good, fair, and poor evolution. The patients in the good evolution group had a better preoperative general condition, had more correction of their deformities, had more improvement in their respiratory function, and had fewer complications than those in the other groups. The patients in the poor evolution group were older, had more cardiac problems, and had less correction at surgery. CONCLUSION: The results of surgery varied from extremely good to extremely bad. The seven patients who died within the first year had no benefit, but the 27 others did very well, usually gaining significant improvement of their respiratory function. Because the alternative to surgical correction is death, this study shows that, under the right circumstances, correction of spinal deformity and, therefore, correction of respiratory function can be life-saving.     

Ophthalmic complications after spinal surgery

STUDY DESIGN: A retrospective review of 3450 spinal surgeries was performed. OBJECTIVES: To review ophthalmic complications and their etiologies, as well as treatments and outcomes, in patients who have undergone spinal surgery. SUMMARY OF BACKGROUND DATA: Ophthalmic complications after major spinal reconstructive surgery are rare and have not been adequately addressed in the orthopedic literature. METHODS: In a series of 3450 spinal surgeries at three institutions, the authors identified seven patients (incidence = 0.20%) whose postoperative course was complicated by loss of visual acuity. These perioperative ophthalmic complications included posterior optic nerve ischemia, occipital lobe infarcts, and central retinal vein thrombosis. Operative time, estimated blood loss, and medical history of peripheral vascular, cardiovascular, or ophthalmic disease were obtained from the charts, as were follow-up data. RESULTS: Three patients recovered completely, and one had partial return of visual function. In the remaining three patients, significant visual loss persisted. CONCLUSIONS: The risk of ophthalmic complications with spinal surgery has not been fully appreciated. Because ophthalmic complications in spinal surgery may be reversed with prompt recognition and intervention, it is important for clinicians to be aware of their possible occurrence.     

Does CTAP prior to hepatic resection improve patient survival rates?

The purpose of our study was to compare survival rates of colon carcinoma patients who had undergone attempted curative hepatic resection based on liver staging by computed tomographic angiography (CTA) or portography (CTAP) with previously reported survival rates of patients who underwent similar surgery without preoperative CTAP evaluations. A total of 404 CTAP studies performed at three institutions were reviewed. Of this group, 197 had colon carcinoma. Sixty-nine of the colon patients went to surgery. Actuarial adjusted yearly survival rates were calculated for the prior CTAP colon group and compared to historical controls. The control survival data were taken from reports published prior to the CTAP era. Our study demonstrated no difference in the 1-year survival data between the groups. However, the CTAP patients had greater survival in years 2-4. This greater survival may be multifactorial but in part due to better surgical selection caused by CTAP.     

Alteration of activities of hepatic antioxidant defence enzymes in developing chick embryos after glucocorticoid administration--a factor to produce some adverse effects?

Nickel is a strong biological sensitizer and consequently may induce a delayed hypersensitivity reaction (type IV immune response). Because nickel is a component of the majority of the orthodontic alloys, the objectives of this cross-sectional study were to determine the prevalence of nickel hypersensitivity reaction before, during, and after orthodontic therapy with conventional stainless steel brackets and wires; to evidence the induction of this reaction by the orthodontic appliances; and to characterize the nickel hypersensitive persons. Nickel patch tests and a questionnaire were used to evaluate the hypersensitivity to this metal. The total sample consisted of 170 patients, 105 females and 65 males, from the orthodontic department at Bauru Dental School, University of S?o Paulo. They were divided into three groups as follows: A (n = 60), patients before the beginning of orthodontic therapy; B (n = 66), patients currently undergoing orthodontic treatment, and C (n = 44), patients who had undergone orthodontic treatment previously. The chi-square test (chi2) showed an allergic reaction in 28.3% of the total sample with 23% female and 5.3% male. This indicated a gender difference (chi2 = 10.75, p < 0.001). There was a positive association between nickel hypersensitivity and previous personal allergic history to metals (chi2 = 34.88, p < 0.0001) as well as with the daily use of metal objects (chi2 = 11.95, p < 0.0005). There was no statistically significant difference in the prevalence of contact dermatitis among the three groups (chi2 = 0.39, p = 0.848). This suggests that orthodontic therapy with conventional stainless steel appliances does not initiate or aggravate a nickel hypersensitivity reaction.     

Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis

STUDY DESIGN: A retrospective clinical and radiographic review. OBJECTIVES: To provide current data on the results and complications of patients who have undergone spinal fusion for neuromuscular scoliosis at a center with physicians experienced in these types of cases. SUMMARY OF BACKGROUND DATA: The reported complication rate in the management of neuromuscular scoliosis ranges from 44% to 62% in the recent literature. This literature is that of 1991 or earlier reflecting operative techniques of the mid-1980s, and it has been used to argue against the efficacy of neuromuscular spinal fusions. METHODS: A retrospective chart and radiographic review of 50 consecutive spinal fusions for neuromuscular scoliosis was performed at Connecticut Children's Medical Center between January 1990 and January 1994. The three most common diagnoses were spastic quadriplegic cerebral palsy (20 patients), myelomeningocele (13 patients), and muscle disease (8 patients). There were 38 posterior spinal fusions including two kyphectomies and 12 anteroposterior spinal fusions. The Luque-Galveston technique was used in 39 of 50 patients. The average age at surgery was 13 years and 6 months, with an average follow-up of 40 months (minimum, 24 months). RESULTS: Before surgery, the mean major scoliosis measured 72 degrees, with mean best bend or traction view of 35 degrees. At most recent follow-up, the mean scoliosis magnitude was 25 degrees (mean correction, 65%). There were 17 minor complications in 14 patients and three major complications (deep wound infections) in three myelomeningocele patients. Rod breakage was noted in two patients, one of whom had an asymptomatic pseudarthrosis. There were no neurologic complications or deaths, and none of the complications affected the final results. CONCLUSIONS: The data in the current study support the authors' belief that with current surgical techniques and perioperative management in an experienced center, the results for patients undergoing spinal fusion for neuromuscular scoliosis have been improved, and major complications have been minimized.     

Prospective study of risk factors in natural rubber latex hypersensitivity

Five hundred sixty-nine subjects routinely underwent skin prick tests for latent sensitization to latex. The study of risk factors included skin tests to inhalant allergens, to diagnose atopy, and a questionnaire aimed at revealing frequent exposure to latex such as the wearing of gloves, multiple surgical procedures, or urinary catheterization. The subjects were categorized into five groups: group I, subjects with no risk factor (n = 272); group II, nonatopic subjects exposed to latex (n = 73); group III, atopic subjects not exposed (n = 180); group IV, exposed atopic subjects (n = 44); and group V, subjects with a history of intraoperative anaphylactic shock caused by latex (n = 13). Twenty-five subjects had spina bifida and were in either group II (14 subjects) or group IV (11 subjects). The questionnaire identified a probable allergy to latex in 18 subjects: 16 cases were confirmed by skin test, but responses were not informative in 23 patients who were sensitive to latex. Positive prick tests to latex were obtained in 0.37% of group I, 6.85% of group II, 9.44% of group III, and 36.36% of group IV. Of the children with spina bifida, 32% had positive skin test results. As risk factors, atopy and exposure were synergistic. We recommend predictive prick tests not only in children with spina bifida but also in any atopic subject or in any patient with a history of frequent exposure to latex. Latex could be considered a habitual allergen. The use of latex urinary catheters should be avoided in patients who are catheterized on a daily basis.     

Anesthesia type does not influence early graft patency or limb salvage rates of lower extremity arterial bypass

PURPOSE: The effect of anesthesia type on 30-day graft patency and limb salvage rates was evaluated in patients who underwent femoral to distal artery bypass. METHODS: Of 423 patients randomly assigned to receive general, spinal, or epidural anesthetic, 76 did not meet protocol standards and 32 had inadequate anesthesia. A chart review of the remaining 315 patients was undertaken to obtain surgical information not recorded in the original study. All patients were monitored with radial and pulmonary artery catheters. After surgery, patients were in a monitored setting for 48 to 72 hours and had graft function assessments hourly during the first 24 hours and then every 8 hours until discharge. RESULTS: Fifty-one patients were lost to follow-up (15 general, 22 spinal, 14 epidural). Baseline clinical characteristics were similar for the three groups except prior carotid artery surgery, which was more common in the spinal group. Indications for surgery were also similar except for a higher incidence of nonhealing ulcer in the epidural group. There were no differences among groups for 30-day graft patency with or without reoperation, 30-day graft occlusion, death, amputation, or length of hospital stay. CONCLUSION: These results suggest that the type of anesthetic given for femoral to distal artery bypass does not significantly affect 30-day occlusion rate, limb salvage rate, or hospital length of stay.     

5-year reoperation rates after different types of lumbar spine surgery

STUDY DESIGN: Population-based cohort study of Washington State patients who underwent lumbar spine surgery for degenerative conditions in 1988. OBJECTIVES: To compare complications and reoperation rates during the 5-year period after surgery between patients who have undergone lumbar spine fusion surgery and those who have undergone laminectomy or discectomy alone. SUMMARY OF BACKGROUND DATA: Spinal fusion is associated with wider surgical exposure, more extensive dissection, and longer operative times than lumbar surgery without fusion, and previous studies have shown higher complication rates and hospital charges associated with these more complex procedures. In elderly patients, spinal fusion operations were associated with higher mortality rates than laminectomy or discectomy alone, and reoperation rates were not lower. In the current study, reoperations, mortality, and complications following lumbar spine surgery were examined for the general population. METHODS: A statewide hospital discharge database was used to identify all Washington patients who underwent spine surgery in 1988 and to determine the rate of reoperation during the subsequent 5 years. Administrative records also were used to identify complications, mortality, and hospital charges associated with the operations. Unadjusted complication and reoperation rates for the groups were compared using chi-square statistics. Adjusted rates were compared using logistic regression and proportional hazards (Cox) regression after controlling for age, gender, prior spine surgery, diagnosis, comorbidity, type of surgery, and coverage by Workers' Compensation. RESULTS: Of 6376 patients who underwent lumbar surgery for degenerative conditions in Washington in 1988, 1041 (16%) had operations involving spine fusion. Diagnoses of degenerative disc disease or possible instability were more frequent among patients undergoing fusion surgery, whereas herniated discs were more frequent among those undergoing discectomy or laminectomy alone. Complications were recorded in 18% of fusion patients and 7% of nonfusion patients (P < 0.01), but mortality rates did not differ. Unadjusted reoperation rates over the 5-year period were greater for patients who underwent fusion than for patients who underwent nonfusion surgery (18% vs. 15%, respectively), but after adjustment for baseline characteristics, fusion patients had only a slightly greater (and nonsignificant) risk of reoperation (relative risk 1.1, confidence interval .9-1.3). CONCLUSION: As in previous studies, complications in the current study occurred more frequently among patients who underwent lumbar spine fusion than among those who underwent laminectomy or discectomy alone. Reoperations were at least as frequent after fusion, but the authors could not assess treatment efficacy in terms of pain relief or improved function. Although the characteristics of patients undergoing fusion differed from those undergoing a laminectomy or discectomy alone, there appeared to be sufficient overlap in the clinical populations to warrant closer scrutiny of the safety, efficacy, and indications for spinal fusions, preferably in randomized trials.     

Bone metabolism following bladder substitution with the ileal urethral Kock reservoir

OBJECTIVES: To assess bone metabolism following bladder substitution with the ileal Kock reservoir. PATIENTS, SUBJECTS AND METHODS: The investigation comprised two separate studies, one with baseline measurements before and after surgery, and the second after surgery only, of bone mass, made using single-photon absorptiometry and dual-energy X-ray absorptiometry, biochemical variables of bone turnover, plasma analyses and measurements of renal calcium and phosphate excretion. After inclusion, both groups of patients were observed longitudinally for 2 years. The post-surgery study included 25 patients who had undergone bladder substitution (median age 67 years, range 44-75), with a median post-operative follow-up of 1.0 year (range 0.3-3.7), and 16 control subjects (either healthy or with other minor urological complaints; median age 62 years, range 34-80), and the pre-surgery study comprised seven patients who had undergone bladder substitution (median age 57 years, range 42-68). RESULTS: Total body, forearm and spinal bone mineral contents were similar in patients with an ileal bladder substitute measured 1 year after surgery and in control subjects. There were equivalent significant changes in both the patients and control subjects during the 2-year observation period, with a 2-3% decrease in total body and forearm bone mineral content. The values were similar in patients with and without a mild metabolic acidosis. Plasma calcium, phosphate, total alkaline phosphatase, intact parathyroid hormone, vitamin D and osteocalcin were normal in both patients and control subjects. Renal excretion of calcium and phosphate was also similar in patients and in control subjects. CONCLUSIONS: Ileal urethral Kock bladder substitution does not lead to accelerated bone mineral loss in elderly men, despite a mild metabolic acidosis in half of the patients.     

Functional results following the antegrade continence enema procedure

BACKGROUND: Forty children who underwent the antegrade continence enema (ACE) procedure for faecal soiling were studied to determine factors predictive of outcome. METHODS: There were four patient groups: (1) ambulant with spinal dysraphism (n = 13), (2) wheelchair bound with spinal dysraphism (n = 14), (3) ambulant with miscellaneous disorders (n = 11) and (4) wheelchair bound with miscellaneous disorders (n = 2). Effectiveness of the procedure was assessed using technical evaluation and quality-of-life improvement (QOLI) scores (0-5). Objective assessment included colonic transit time (CTT) and anorectal manometry. Median follow-up was 21 (range 5-37) months. RESULTS: Some 28 of 40 children achieved continence. The procedure was reversed in four of 40 children. Of the other 36 children with a functioning ACE stoma, all reported improvement in quality of life (mean QOLI score 3.5). There were no significant differences in technical evaluation score, QOLI score, CTT, manometry findings or continence between ambulant groups and the wheelchair-bound group with miscellaneous disorders. QOLI score, anorectal squeeze pressure and continence were significantly poorer in those who were wheelchair bound with spinal dysraphism. Absent squeeze pressure was associated with poor outcome. CONCLUSION: Wheelchair-bound children with spinal neuropathy have a poorer outcome following the ACE procedure. Although ACE is an effective method of promoting faecal continence, it is essential to determine the aetiology of incontinence and sphincter function before operation.     

Latex allergy: allergen identification in Hevea braziliensis fractions by immunoblotting

BACKGROUND: Latex is the cause of several clinical symptoms of allergy, but the identification of allergens is not completely known. OBJECTIVE: The aim of this report was to study the immunoreactivity of purified stable latex fractions from Hevea braziliensis. METHODS: We purified the cytoplasm of Hevea braziliensis and obtained three fractions: latex particles (LP), lutoids (L) and cytosolic serum (CS). Using Western blot, specific IgE directed to latex allergens was found in 80 patients with latex allergy. RESULTS: Five major groups of allergens migrating as 14, 25, 29, 37-45 and 50 kDa were recognized. They were unequally distributed with the latex fractions: 37-45 kDa proteins were essentially recognized in CS and LP, whereas 14 and 29 kDa proteins were mainly labelled in the L fraction. As a control, aqueous glove extracts exhibited a more restricted pattern of reactivity, because only 14 and 29 kDa proteins were recognized by patient sera. The pattern of reactivity was not correlated specifically with IgE levels, but sera from patients suffering from spina bifida reacted specifically with the minor protein of 25 kDa located in LP. CONCLUSIONS: The present results show that latex allergic patients recognize several allergens which are differently distributed in subcellular fractions extracted from H. braziliensis and aqueous GE. The L fraction and GE were enriched in low molecular weight proteins and apparently contained the same allergens.