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Notes: Objective To compare a one-step (rapid) application of negative pressure (vacuum) with conventional stepwise application for ventouse extraction following a prolonged second stage of labour.Design Randomised controlled study.Setting Teaching Hospital.Participants Forty-seven women were randomised to the rapid vacuum group and 47 to the stepwise group.Main outcome measures Duration of ventouse procedure, effectiveness of methods of application, morbidity of mother and infant.Results There was no significant difference in frequency of detachment of the cup after rapid or stepwise application of vacuum. A reduction in mean duration of the ventouse procedure of 6 min was realised without significant difference in maternal or neonatal morbidity.Conclusion Rapid application of vacuum significantly reduces the duration of a ventouse extraction procedure without compromise to efficiency and safety.

Notes: Background/aims: Large-scale comparative screening of der-matological and cosmetic products require non-invasive bioengineering methods which give reproducible results that can be statistically analyzed. To determine the most suitable test region for testing irritating substances, the response of the skin to the weak irritant sodium lauryl sulphate (SLS) was measured on standardized locations on the forearm and back. Furthermore, using 3 bioengineering methods, we aimed to establish the most sensitive method to measure skin response to SLS.Methods: The baseline measurements of transepidermal water loss (TEWL), cutaneous blood flow (CBF) and skin colour a*-value were performed at 6 standardized locations on the volar forearms and at 12 locations on the back on 2 consecutive days, day 1 and 2, in 9 healthy volunteers. On day 2, 9 out of the 18 sites were exposed to 0.5% SLS by occlusive 24-h patches and the skin response was evaluated on days 3 and 4.Results: For TEWL, CBF and a*-value, no significant regional variations were found within individuals at any time on the arm locations and on the back locations. However, significant inter-individual variation was found. At the back on day 4, a slightly higher skin response to SLS was found compared to that found on the forearms as measured by TEWL and the a*-value. Of the 3 bioengineering methods used, TEWL was the most sensitive method to detect cutaneous response to the weak irritant used. TEWL measurements on days 1 and 2 performed at the 6 standardized locations on the volar forearms inside and outside a specially constructed air convection protection box, showed no relevant differences in measured TEWL values.Conclusion: Both the forearms and the back were found to be suitable sites for irritancy testing. Since considerable differences in mean reactivity between subjects have been observed the use of large numbers of subjects in predictive irritant patch testing is required.

Notes: The efficacy of specific histopathological features for diagnosing dysplastic naevi was established by comparing their frequency in 62 dysplastic naevi, from 36 patients with the dysplastic naevus syndrome, with those in 326 ostensibly benign naevocellular naevi derived from a group of 67 autopsy cases. Individual diagnostic features had a low sensitivity, a low specificity or low predictive values. Discriminant analysis showed that the presence of dust-like melanin, irregular naevoid nests, markedly increased junctional activity and melanocytic nuclei equal or larger in size than overlying keratinocyte nuclei were the most discriminating features. Using two or more of these criteria plus a lymphocytic infiltrate as an obligatory diagnostic criterion, a reasonable efficacy could be reached for dysplastic naevi. Based on these combinations of criteria the prevalence of histologically proven dysplastic naevi in the autopsy group would be 10%. Lesions with all these four discriminating features were found in half of the patients from the dysplastic naevus syndrome group, but were absent in the autopsy group. We suggest that such severely atypical dysplastic naevi may be indicative of patients at high risk for developing malignant melanoma.

Notes: The anatomy and pathology of the splenic red pulp was studied in three-dimensional reconstructions of methylmethacrylate embedded blocks of tissue obtained after splenectomy, as well as by morphometrical analysis of a large number of specimens. The sinuses of the spleen form a plexus of anastomosing vessels with remarkable buds. Capillaries end as sheathed capillaries in the cord tissue, the ‘filtering’ area, but a large proportion of the red pulp cords appear to be ‘non-filtering’. These might form part of the lymphatic compartment, which is separate from the white pulp and its extension along the capillaries. This area has not yet been described in man. The change in the volume and structure of the various components of the red pulp were studied in 60 controls and in cases of traumatic rupture, idiopathic thrombocytopenic purpura, aplastic anaemia, autoimmune haemolytic anaemia, congenital spherocytosis, splenic congestion, and Hodgkin's disease. Significant differences were found in the volume of filtering and non-filtering areas, the size of the sinus compartment, and the degree of vascularization; these differences were only partially expected, for instance in disorders with excessive erythrocyte sequestration. A decrease of the ‘non-filtering’ area in Hodgkin's disease might indicate an unknown aspect of this disease. In agreement with our previous paper on the amount of white pulp, spleens removed because of traumatic rupture and those incidentally removed during abdominal surgery may not be combined as a single control group, because of significant and probably functional differences in the composition also of the red pulp.

Notes: Background Corticosteroid therapy has become the mainstay in the treatment of asthma. However, the risk-benefit balance in the patient calls for assessment of the state of inflammation in the airways. In this respect serum eosinophil cationic protein (ECP) might be a marker, which can easily be measured in a clinical setting. Studies have indicated a relation between level of serum ECP and activity and severity in asthma.Objective To investigate the feasibility to guide steroid therapy on the basis of the level of serum ECP in patients with chronic asthma.Methods Twenty adult patients on maintenance inhaled steroid therapy visited the chest clinic once every 2 months over a 12-month period. At each visit a short history, blood sample for ECP and number of eosinophils, baseline spirometry, and histamine inhalation provocation test (PC20) were obtained. On the basis of level of ECP, adjustments in daily dose of steroids were considered. Data were compared with those of a previous 6-month ECP evaluation study in these same patients.Results In 10 patients mean dose of inhaled steroids was decreased 〈inlineGraphic alt="geqslant R: gt-or-equal, slanted" extraInfo="nonStandardEntity" href="urn:x-wiley:09547894:CEA519:ges" location="ges.gif"/〉 25%. ECP rose slightly (antilogged mean from 9.06 to 11.8μg/L) and lung function decreased slightly (mean FEV1%predicted from 85.5 to 81.6). In seven patients mean dose of inhaled or oral (n= 2) steroids was increased 〈inlineGraphic alt="geqslant R: gt-or-equal, slanted" extraInfo="nonStandardEntity" href="urn:x-wiley:09547894:CEA519:ges" location="ges.gif"/〉 25%. In this group ECP decreased but remained elevated at 〈inlineGraphic alt="geqslant R: gt-or-equal, slanted" extraInfo="nonStandardEntity" href="urn:x-wiley:09547894:CEA519:ges" location="ges.gif"/〉20μg/L (antilogged mean from 30.5 to 25.6μg/L) and lung function improved (mean FEV1%predicted from 67.2 to 74.5). In both groups patients' scores of asthmatic well-being increased significantly, and PC20 did not show a trend. Exacerbation rate remained the same in the decreased and the no change group (n= 3, in which no substantial change in steroid dose occurred), but was reduced by about 50% in the increased group.Conclusion From this observational study it is concluded that adjusting steroid therapy guided by serum ECP-level may be helpful in tailoring asthma treatment.

Notes: Duplex sonography was used to determine the changes in mesenteric arterial blood flow occurring in patients undergoing aortic surgery, anaesthetised either by total intravenous anaesthesia with propofol and sufentanil (group A) or inhalational anaesthesia with isoflurane and nitrous oxide (group B). Sixteen patients were studied. Measurements were performed immediately before and 15 min after induction of anaesthesia, before surgery. There was a 38% decrease (p = 0.015) in the superior mesenteric artery end diastolic velocity in group A and a 23% decrease (p = 0.033) in the superior mesenteric artery peak systolic velocity in group B. There were no changes in any of the other sonography parameters in either group. We conclude that neither total intravenous anaesthesia with propofol and sufentanil nor inhalational anaesthesia with isoflurane and nitrous oxide have any clinically significant influence on mesenteric blood flow in the absence of surgical stimulation.

Notes: We present a novel approach for improving the management of patients with pigmented neoplasms including malignant melanomas and dysplastic nevi. A cohort of 215 dysplastic nevi and malignant melanomas was studied by cyanoacrylate skin surface stripping (CSSS) and conventional histology. Presence of atypical melanocytes was found in the stratum corneum in more than 95% of malignant melanomas and was always absent in dysplastic nevi. We conclude that this non-invasive technique is rapid, easy to perform, and inexpensive. Its specificity and sensitivity are high enough to be considered by clinicians as an aid for distinguishing dysplastic nevi from malignant melanomas. We recommend this ancillary technique as a screening procedure though not as a substitute for conservative excisional biopsy, when doubt persists in the diagnosis of atypical pigmented neoplasms.

Notes: The variation between three pathologists examining histological features seen in non-neoplastic colonic mucosa from 40 biopsies was analysed. Several procedures to express observer variation were used and compared, with emphasis on kappa statistics. Only five features, the presence of ulceration, villous surface, epithelioid granulomas, severe mucus depletion and crypt abscesses were sufficiently reproducible by the three pairs of pathologists. These findings suggest that other criteria used for the classification of inflammatory bowel disease are potentially unsatisfactory. When results from different studies on biopsies are being compared, influence of observer variation should be identified. Comparison of statistical techniques showed overall variation to be less useful than other statistical procedures. There was little difference between results from kappa statistics and other measures of agreement (overall agreement excluded).

Notes: BACKGROUND: Continuous therapy with low-dose ranitidine (150 mg b.d.) is known to be effective for the prevention of recurrent nonsteroidal anti-inflammatory drug (NSAID)-associated duodenal ulcer but not for gastric ulcer. AIM: To investigate, in a double-blind placebo- controlled study, the preventive effect of a high dose of ranitidine (300 mg b.d.) on the recurrence of both duodenal ulcers and gastric ulcers in rheumatoid arthritis patients with a continuous need for NSAIDs. METHODS: Rheumatoid arthritis patients with a history of peptic ulcer disease were randomized to receive either ranitidine 300 mg b.d. or placebo for 12 months. Endoscopy was performed at study entry and after 6 and 12 months. End-point was the recurrence of gastric or duodenal ulcers. RESULTS: The study was stopped after a blinded interim analysis; at that time 10 of the 15 included patients in each treatment group were evaluable. Recurrent duodenal ulcers had occurred in four patients treated with placebo and none of the patients treated with ranitidine (Fisher's exact one-tailed P = 0.04; 95% CI, - 0.70 to - 0.10). Recurrent gastric ulcers had occurred in six patients in the placebo group and three patients in the ranitidine group (Fisher's exact one-tailed P = 0.18; 95% CI, -0.72 to 0.12). Two patients in the placebo group had developed both duodenal ulcers and gastric ulcers. No adverse events were observed. CONCLUSIONS: High dose ranitidine is effective for the prevention of recurrent duodenal ulcer but not for recurrent gastric ulcer in rheumatoid arthritis patients taking NSAIDs.