Teaching medical students about epilepsy

A small study was designed to evaluate three seminars on epilepsy for junior medical students. A self-completion questionnaire on knowledge and attitudes was constructed and administered to case and control students and, as part of a parallel study, to senior medical students, general practitioners, and a sample of patients attending general practice. Students undertaking seminars on epilepsy showed significant improvement in overall knowledge, but not in attitudes. Many students had observed an epileptic seizure before entering medical school, but neither this, nor close acquaintance with persons with epilepsy, appeared to affect their responses. Age appeared to influence knowledge in the sample of general practice attenders, with those aged 30-59 scoring a significantly higher mean score than older and younger subgroups.

Women as mothers in northern Ireland and Jamaica: a critique of the transcultural nursing movement

Participant observation and structured interviews with selected groups of mothers in Northern Ireland and Jamaica revealed a variety of individual experiences that highlighted contrasts between the two cultures, and differences within each culture. The findings are used to illustrate the danger of cultural stereotyping, and the implications for the transcultural nursing movement are discussed.

Hereditary white sponge naevus

The authors report two cases of white sponge naevus in the same family, where the condition had clearly been inherited by the daughter from her mother. The positive family history aided correct diagnosis of this entirely benign lesion.

Effective reinduction therapy for childhood acute nonlymphoid leukemia using simultaneous continuous infusions of teniposide and amsacrine

The combination of teniposide (VM-26) and amsacrine (AMSA) was evaluated in a dose-finding and efficacy study in 58 patients with relapsed or refractory acute leukemia. Both agents were given as simultaneous continuous infusions for 72 h through separate i.v. lines. All patients were evaluable for toxicity and 57 were evaluable for response; only 2 of 20 with acute lymphoblastic leukemia (ALL), acute mixed-lineage leukemia, or chronic myelogenous leukemia in blast crisis achieved a complete remission (CR). More encouraging was a second-remission rate of 43% (13 complete and 3 partial) in the 37 patients with acute nonlymphoid leukemia (ANLL). Responses occurred only in patients who received VM-26 doses of greater than or equal to 200 mg/m2 per day and AMSA doses of greater than or equal to 100 mg/m2 per day. Thus, the CR rate for relapsed ANLL patients who received the higher doses of both agents was 40% (13 of 33). All responders had previously received epipodophyllotoxin therapy and 40% had also received AMSA. All but one patient had severe leukopenia (less than 2.0 x 10(9) leukocytes/l) and thrombocytopenia (less than 50.0 x 10(9) platelets/l) as a results of therapy. Severe mucositis (grade 3 or 4) was the dose-limiting toxicity. Our results indicate that VM-26 plus AMSA, given by continuous infusion, is effective in the treatment of ANLL. Further phase II studies should consider using VM-26 at 200 mg/m2 per day and AMSA at 100 mg/m2 per day, but the best administration schedule remains unclear.

Human lymphocyte proliferative response to a sporozoite T cell epitope correlates with resistance to falciparum malaria

To identify vaccine relevant T cell epitopes on the circumsporozoite (CS) protein of Plasmodium falciparum, the lymphocyte proliferative responses to 10 CS protein derived peptides were studied in 28 adult Kenyans, and correlated with resistance to malaria. Eight peptides, six of which were not overlapping, induced proliferation of lymphocytes from one to five volunteers, suggesting either genetic restriction of response to each of the T epitopes, or dominance of some T sites on the immunizing sporozoites. The 28 volunteers were radically cured of malaria and during the next 126 days 25 of the 28 were reinfected. Resistance to malaria was not correlated with antibodies to malaria Ag, but was significantly correlated with lymphocyte responses to CS protein residues 361-380 and 371-390. Among the 25 volunteers who became re-infected with malaria, lymphocytes from only two responded to a peptide including residues 361-380 of the P. falciparum CS protein, and only one to peptide 371-390. In contrast, lymphocytes from all three volunteers who did not become infected responded to peptide 361-380 (p = 0.003), and lymphocytes from two of the three responded to peptide 371-390 (p = 0.023). The significant correlation between proliferation to peptides 361-380 and 371-390 and resistance to malaria suggests that at least one epitope within these overlapping peptides is involved in a protective cellular immune response. The data support inclusion of these residues in future CS protein vaccines.

Human lymphocyte proliferative response to a sporozoite T cell epitope correlates with resistance to falciparum malaria

To identify vaccine relevant T cell epitopes on the circumsporozoite (CS) protein of Plasmodium falciparum, the lymphocyte proliferative responses to 10 CS protein derived peptides were studied in 28 adult Kenyans, and correlated with resistance to malaria. Eight peptides, six of which were not overlapping, induced proliferation of lymphocytes from one to five volunteers, suggesting either genetic restriction of response to each of the T epitopes, or dominance of some T sites on the immunizing sporozoites. The 28 volunteers were radically cured of malaria and during the next 126 days 25 of the 28 were reinfected. Resistance to malaria was not correlated with antibodies to malaria Ag, but was significantly correlated with lymphocyte responses to CS protein residues 361-380 and 371-390. Among the 25 volunteers who became re-infected with malaria, lymphocytes from only two responded to a peptide including residues 361-380 of the P. falciparum CS protein, and only one to peptide 371-390. In contrast, lymphocytes from all three volunteers who did not become infected responded to peptide 361-380 (p = 0.003), and lymphocytes from two of the three responded to peptide 371-390 (p = 0.023). The significant correlation between proliferation to peptides 361-380 and 371-390 and resistance to malaria suggests that at least one epitope within these overlapping peptides is involved in a protective cellular immune response. The data support inclusion of these residues in future CS protein vaccines.

Early intensification of chemotherapy for childhood acute nonlymphoblastic leukemia: improved remission induction with a five-drug regimen including etoposide

We tested the value of early intensification of chemotherapy in 68 consecutive children with acute nonlymphocytic leukemia (ANLL) who were admitted to St. Jude Children's Research Hospital from November 1983 through March 1987. Fifty-eight patients (85%) entered complete remission after treatment with etoposide (VP-16)/cytarabine (ara-C) (A), followed by daunorubicin (Dauno)/ara-C/thioguanine (6-TG) (B) and then VP-16/azacytidine (5-AZ) (C). Thirty percent of the complete responders, mainly those with an M4 or M5 leukemia subtype, attained M1 marrow status after component A, 60% after A + B, and 10% after A + B + C. Induction failures resulted primarily from absolute or relative drug resistance; there was only one death during this phase of therapy. Postremission treatment consisted of three pairs of drugs (vincristine [VCR]/amsacrine [m-AMSA], or doxorubicin [Doxo]/6-TG/ara-C, and VP-16/cyclophosphamide [CTX]) administered sequentially in 6-week cycles for 22 months. Despite the high rate of remission induction, only 33% +/- 7% SE of the patients are expected to be failure-free survivors at 2 years. Remission durations were not significantly affected by the majority of factors examined in this study, with the exception of marrow cellularity after VP-16/ara-C induction therapy. Patients with less than or equal to 5% leukemic cells survived relapse-free for a median of 36.1 months, compared with 11.3 months for the group with a larger infiltrate (P = .01). Although postremission therapy did not improve the percentage of long-term failure-free survivors, the induction regimen we used appears highly effective, and its components should be considered for inclusion in other treatment programs.

[Local immune reaction in human intestinal spirochetosis]

The pathogenetic and clinical importance of intestinal spirochaetes in man is still unresolved. In 12 patients mainly presenting with mild diarrhoea, light and electron microscopy demonstrated massive spirochaetal infestation of the colonic mucosa (spirochaetosis). There were several hitherto unreported features: spirochaetes adhered not only to the surface epithelium of the intestine but were also present within epithelial cells and subepithelial macrophages; many partially degranulated mast cells were noted within the epithelium; there was a marked increase of IgE plasma cells within the lamina propria. In control biopsies intraepithelial mast cells were absent and IgE cells occurred only sporadically. Penetration of the microorganisms into the intestinal mucosa may be responsible for this unusual immune response. Spirochaetes, symptoms and findings disappeared after antibiotic therapy. The authors therefore suggest that intestinal spirochaetosis can cause clinical symptoms in man, and that spirochaetes should not invariably be considered harmless commensals.

Growth cone morphology varies with position in the developing mouse visual pathway from retina to first targets

We have labeled the growth cones of retinal ganglion cell axons with HRP in intact mouse embryos. This has allowed us to visualize growth cone morphology during outgrowth along an entire CNS pathway from origin to target; to ask whether growth cone forms, and thus behaviors, differ at various points along the pathway; and to study the relationships of growth cones with the cellular environment. During the major period of axon outgrowth between embryonic day (E) 12 and 15, growth cones in the optic nerve are highly elongated (up to 40 microns) and have lamellopodial expansions, but the majority lack the microspikes or filopodia characteristic of many growth cones. Within the optic chiasm (E13-15), most growth cones shorten and spread, and project several short filopodia. In the optic tract, growth cones become more slender and again lack filopodia, resembling sleeker versions of optic nerve growth cones. Near the first target region (lateral geniculate nucleus), growth cones with filopodia arise from individual axon lengths and turn medially toward the target. Within target regions, the branches of immature axon arbors are tipped by minute swellings rather than by the enlarged growth cones prevalent during outgrowth toward targets. Electron-microscopic analysis of identified labeled growth cones in the optic nerve reveal intimate interactions between growth cones and glia or other growth cones in the form of invaginating contacts. In the optic nerve, growth cones contact immature glial (neuroepithelial) cells somewhere along their length, and also envelop bundles of neurites. In the chiasm, single growth cones simultaneously relate to many different profiles. These results demonstrate that in this single pathway from origin to targets, growth cone morphology varies systematically with position along the visual pathway. During outgrowth, simple growth cones are prominent when axons follow well-defined common pathways, and more elaborate filopodial forms appear when growth cones diverge, as they turn or come to decision regions. Together with observations in vitro and in nonmammalian nervous systems in situ, these data serve as reference points for testing to what extent growth cone form reflects intrinsic factors and interactions with the environment.

Spirochaetosis of the human rectum associated with an intraepithelial mast cell and IgE plasma cell response

In two patients presenting with mild intestinal symptoms, rectal spirochaetosis was the only morphological abnormality diagnosed by light microscopy. A re-evaluation of the morphological changes using electron microscopy and immunohistochemistry showed certain unusual features: the microorganisms were observed within epithelial cells and in subepithelial macrophages; there were numerous partially degranulated intraepithelial mast cells; and there was a marked increase in the proportion of IgE plasma cells within the lamina propria. Mucosal penetration by the organisms may be responsible for the unusual immune response. In one patient, treatment with antibiotics eliminated the spirochaetes and resulted in a clinical improvement. Spirochaetes should not always be considered as harmless commensals in the colon.

Changing effects on erythrocyte sodium and potassium during the development of chronic renal failure with anaemia in rats

Rats were studied 7 days and 17 days after the onset of renal failure which was induced by a surgical technique. Plasma urea, creatinine (PCr) and potassium had increased after 7 days; plasma potassium increased much more after 17 days but PCr was slightly lower. Renal failure caused resetting of erythropoietic control to a lower level of packed cell volume (PCV). After 7 days renal failure some rats had a low PCV, whereas others still had a normal PCV apparently due to slower erythrocyte destruction of pre-renal failure cells. After 7 days renal failure, rats with a normal PCV had an increased erythrocyte membrane leak to potassium that resulted in a low erythrocyte potassium [K+]RBC. This was accompanied by an increase in active sodium pump units [increased ouabain sensitive sodium flux (Fo) and its rate constant (ko)] that caused erythrocyte sodium ([Na+]RBC) to fall. The increased active pump units retarded the fall in [K+]RBC and may have extended the life of the normal erythrocytes in the renal failure environment. The PCV was below normal in all rats after 17 days renal failure. [K+]RBC was increased and since ko was normal there appeared to be compensation to produce erythrocytes with reduced membrane leak to potassium with longer standing renal failure. PCr was only related to PCV after 17 days renal failure and not in the earlier phase of erythrocyte destruction. The changes in erythrocyte membrane permeability were very significantly related to PCV after 17 days.

The psychosexual histories of young women with bulimia

While it is known that anorexia nervosa patients show a wide range of sexual knowledge, attitudes and practices, the psychosexual histories of bulimia patients have not been studied. In this paper the psychosexual histories of 20 bulimic patients and 20 matched control subjects are presented. Bulimic patients were more likely to experience orgasm with masturbation, were more likely to have experimented with anal intercourse, and were more likely to describe their libido as 'above average.' Control subjects were more likely to experience orgasm during sexual intercourse. Bulimic patients associated high body weights with unattractiveness, and tended to withdraw from social and sexual activity at high weights. In other aspects of their sexual behaviour, and in their attitudes to sexual matters, the two groups were similar.

The production and effects of uncertainty with special reference to diabetes mellitus

Ninety-one patients of one consultant physician were followed up for 1 year. All were newly diagnosed as suffering from diabetes mellitus. Patients were found to be distressed by continuing uncertainties about the nature of the disease from which they suffered and about important aspects of self-management required of them. The 'doctor-centered' style of communication adopted by health professionals was not conducive to the resolution of these uncertainties.

Seizures in childhood lymphoblastic leukaemia patients

Features of seizures in children with acute lymphoblastic leukaemia were examined in relation to the type of treatment received for central nervous system prophylaxis. Of the 1289 patients in the study, 132 (10%) had experienced one or more seizures. In 96 the seizures had not been associated with any recognisable aetiology and, with 3 exceptions, had been generalised or focal motor in type. Status epilepticus had occurred in one-third of the group with seizures. Initial seizure rates among patients in continuous complete remission were significantly related to the method of central nervous system prophylaxis. Those who had received intrathecal methotrexate repeatedly with or without moderate doses of methotrexate intravenously or prior prophylactic cranial irradiation had a 20-fold higher seizure risk during remission induction, and a 37-fold higher risk during the 6th to 12th month of therapy, than did those who had received irradiation and only five intrathecal injections of methotrexate early in the course of treatment. Other clinical factors associated with an increased frequency of seizures were escalation of intravenous methotrexate dosage following cranial irradiation and treatment of meningeal leukaemia with intrathecal methotrexate. Parenterally administered methotrexate thus seems to increase susceptibility to seizure development in childhood leukaemia patients.

A model for erythropoiesis in experimental chronic renal failure

Chronic renal failure (CRF) in rats was induced by various subtotal nephrectomy procedures. Plasma creatinine concentrations ([Creat]p) were consistently elevated in partially nephrectomized (PNX) rats (P less than 0.001) and renal function ([Creat]p-1) was correlated with the amount of intact renal tissue (r = 0.624, P less than 0.001). Red blood cell (RBC) production in uraemic and non-uraemic rats was assessed using the recovery of packed cell volume (PCV) and the production of reticulocytes in response to acute blood loss (5, 10, 15 and 20 ml kg-1 body wt). PCV recovery was significantly delayed and failed to reach pre-bleed values for up to 28 d in PNX rats compared with full recovery within 8 d in controls. Linear relationships between the index of reticulocyte production (RP1) and blood loss induced falls in PCV were found in PNX (r = -0.679, P less than 0.001) and control rats (r = -0.696, P less than 0.001). The index of RBC production was lower in PNX rats compared with controls. This was attributed to a reduced erythropoietin (Ep) mediated reticulocyte response to acute blood loss in PNX rats. PNX rats developed a normocytic, normochromic form of anaemia in which the red blood cell volume (RBCV) and plasma volume (PV) were both appropriate for measured PCVs. The reduced RBC production response in experimental CRF may explain the development of anaemia in PNX rats, even though steady state erythropoiesis may eventually be established at a reduced level of PCV. Furthermore, the quantitative evaluation of RBC production in response to acute blood loss provides a further model for the assessment of agents which may stimulate erythropoiesis in CRF.

Current opinion concerning the treatment of heart disease. Report of a postal survey among Tayside general practitioners

Using a postal questionnaire method of investigation, the views of Tayside general practitioners were examined with respect to the management of three hypothetical patients with ischaemic heart disease. In the case of a man showing symptoms suggestive of infarction, hospital care was preferred by the majority of doctors. Of three categories of employment, the person in a manual occupation would be advised by most doctors to change his job after a second serious infarction. The advice given to patients was orientated towards the risk factors associated with ischaemic heart disease. Such advice was general rather than specific and emphasized restriction of activities rather than return to normal life. Commonly held social stereotypes appeared to affect the advice which practitioners said they would offer. The implications of these findings are discussed.

Abstracts of state legislated hospital cost-containment programs

This report summarizes State legislated efforts to control rising hospital costs and the status of these efforts in May 1982. The abstract for each of 17 State programs summarizes key legislative features and operating aspects. The States included in this report are: Arizona, California, Connecticut, Florida, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Virginia, Washington, West Virginia, and Wisconsin, The abstracts focus on programs requiring the disclosure, review, or legislation of hospital rates and budgets.

Cytokinetically based induction chemotherapy and splenectomy for childhood acute nonlymphocytic leukemia

A four-drug regimen, based on cell kinetic principles, induced complete remissions in 68 of 95 children (72%) with acute nonlymphocytic leukemia (ANLL). Patients entered remission after 2-5 weekly cycles of vincristine-daunorubicin (day 1) followed by sequential cytosine arabinoside and 6-azauridine (days 4-7). With continuation therapy of monthly vincristine-doxorubicin-cyclophosphamide, weekly cytosine arabinoside, and daily 6-mercaptopurine, the median duration of complete remission was 10 mo and the median survival time 21 mo. Portal triaditis, evident in 11 of 23 patients with liver biopsies, was associated with long remissions. A larger spleen size (greater than 5 cm) and a higher myeloblast labeling index (greater than 10%) at diagnosis were clearly related to shorter durations of remission. Splenectomy within 1 mo of remission had no statistically significant effect on the frequency of relapse or length of remission. Patients without central nervous system (CNS) leukemia at diagnosis, all treated prophylactically with intrathecal methotrexate, had a low frequency of initial CNS relapse (3/56, 5%). The 2-yr disease-free survival rate is 29% (20 of 68 patients attaining complete remission). fifteen patients have completed 2.5 yr of therapy, and each remains in continuous complete remission, off treatment, for 1+ -36+ mo. This induction chemotherapy was as effective as more intensive regimens, with the advantage of less toxicity and shorter periods of hospitalization.