Possible toxicity of herbal remedies

Herbal remedies are rapidly gaining popularity throughout the world as a result of dissatisfaction with conventional medicines. It is a widely held belief that herbal preparations are "natural" and are therefore intrinsically harmless. However, their effects can be very powerful and potentially lethal if used incorrectly and their use as a substitute for conventional medicines may be ineffective. Toxic effects have been attributed to several factors including hepatotoxicity of main constituents, contamination of preparations by heavy metals or microorganisms, and adverse reactions due to age, and genetic and concomitant disease characteristics of the user.

Altered expression of tropomodulin in cardiomyocytes disrupts the sarcomeric structure of myofibrils

Tropomodulin is a tropomyosin-binding protein that terminates "pointed-end" actin filament polymerization. To test the hypothesis that regulation of tropomodulin:actin filament stoichiometry is critical for maintenance of actin filament length, tropomodulin levels were altered in cells by infection with recombinant adenoviral expression vectors, which produce either sense or antisense tropomodulin mRNA. Neonatal rat cardiomyocytes were infected, and sarcomeric actin filament organization was examined. Confocal microscopy indicated that overexpression of tropomodulin protein shortened actin filaments and caused myofibril degeneration. In contrast, decreased tropomodulin content resulted in the formation of abnormally long actin filament bundles. Despite changes in myofibril structure caused by altered tropomodulin expression, total protein turnover of the cardiomyocytes was unaffected. Biochemical analyses of infected cardiomyocytes indicated that changes in actin distribution, rather than altered actin content, accounted for myofibril reorganization. Ultrastructural analysis showed thin-filament disarray and revealed the presence of leptomeres after tropomodulin overexpression. Tropomodulin-mediated effects constitute a novel mechanism to control actin filaments, and our findings demonstrate that regulated tropomodulin expression is necessary to maintain stabilized actin filament structures in cardiac muscle cells.

Cerebellar degeneration associated with human immunodeficiency virus infection

Cerebellar disorders associated with HIV infection are typically the result of discrete cerebellar lesions resulting from opportunistic infections such as toxoplasmosis and progressive multifocal leukoencephalopathy or primary CNS lymphoma. Clinical symptoms and pathologic abnormalities related to the cerebellum may also be observed with HIV dementia. A primary cerebellar degeneration with HIV has not previously been reported. Ten patients were identified over an 8-year period at five medical centers. All patients had clinical, laboratory, and radiologic evaluations, and three had neuropathologic examinations. Patients presented with progressively unsteady gait, slurred speech, and limb clumsiness. Examination revealed gait ataxia, impaired limb coordination, dysarthria, and abnormal eye movements. Cognition, strength, and sensory function remained normal. CD4 lymphocyte counts varied between 10 and 437 cells/mm3. Neuroimaging studies showed prominent cerebellar atrophy. Neuropathology showed focal degeneration of the cerebellar granular cell layer and unusual focal axonal swellings in the brainstem and spinal cord. Cultures, histopathology, and immunochemical studies showed no conclusive evidence of infection. We report a syndrome of unexplained degeneration of the cerebellum occurring in association with HIV infection.

Carbohydrate deficient transferrin in detecting relapse in alcohol dependence

Patients reports together with findings at clinical examination and information from an informant such as a relative were used to categorise patients as relapsed or not relapsed during a 6 month period of out-patient treatment at an alcohol problems clinic. At each fortnightly visit, blood was taken for measurement of serum gamma-glutamyl transferase and carbohydrate deficient transferrin (Pharmacia method). A total of 53 patients attended for at least one follow-up visit. Mean CDT differentiated relapsers from non-relapsers at seven of the 11 visits (P < 0.05), but at no visit did mean GGT differentiate. CDT tended to become elevated after a relapse more quickly than GGT. However, whether using upper limit of normal (ULN), or defining a 'positive test' as > last test and either > 20% above lowest previous test or > ULN, specificity (averaged over the 11 visits) was greater for GGT than CDT. Some of the false positive results for CDT were in patients who, shortly after having a positive test, relapsed, suggesting that a rising CDT can herald a relapse admitted by the patient. This could not be shown for false positive GGT results. Inspection of individual trajectories of alcohol consumption and blood test results shows that for some patients GGT is the more effective marker of relapse, whilst for others CDT operates better.

Screening for drugs of abuse (II): Cannabinoids, lysergic acid diethylamide, buprenorphine, methadone, barbiturates, benzodiazepines and other drugs

Requirements for the provision of an efficient and reliable service for drugs of abuse screening in urine have been summarized in Part I of this review. The requirements included rapid turn-around times, good communications between requesting clinicians and the laboratory, and participation in quality assessment schemes. In addition, the need for checking/confirmation of positive results obtained for preliminary screening methods was stressed. This aspect of the service has assumed even greater importance with widespread use of dip-stick technology and the increasing number of reasons for which drug screening is performed. Many of these additional uses of drug screening have possible serious legal implications, for example, screening school pupils, professional footballers, parents involved in child custody cases, persons applying for renewal of a driving licence after disqualification for a drug-related offence, doctors seeking re-registration after removal for drug abuse, and checking for compliance with terms of probation orders; as well as pre-employment screening and work-place testing. In many cases these requests will be received from a general practitioner or drug clinic with no indication of the reason for which testing has been requested. This also raises the serious problems of a chain of custody, provision of two samples, stability of samples, and secure and lengthy storage of samples in the laboratory-samples may be requested by legal authorities several months after the initial testing. The need for confirmation of positive results is now widely accepted but it may be equally important to confirm unexpected negative results. Failure to detect the presence of maintenance drugs may lead to the patient being discharged from a drug treatment clinic and, if attendance at the clinic is one of the terms of continued employment, to dismissal. It seems likely that increasing abuse of drugs and the efforts of regulatory authorities to control this, will lead to the manufacture of more designer drugs. Production of substituted phenethylamines was facilitated by the drug makers' cook book, 'PIHKAL' (Phenethylamines I Have Known And Loved) by Dr Alexander Shulgin and Ann Shulgin, and production of substituted tryptamines is promised in their next book, TIHKAL. Looking to the future, laboratories will need to ensure that they can detect and quantitate an ever-increasing number of drugs and related substances. The question of confidence in results of drugs of abuse testing raised in 1993 by Watson has assumed even greater importance as a result of attention focused on the OJ Simpson trial in Los Angeles. Toxicological investigations are likely to be challenged more frequently in the future. Even if analyses have been performed by GC-MS, there is a need to establish the level of match between the spectrum of the unknown substance and a library spectrum which is considered acceptable for legal purposes. It will also be essential to ensure that computer libraries contain spectra for all substances likely to be encountered in drugs of abuse screening.

Genomic sequence analysis of a key residue (Arg183) in human G alpha q in invasive non-functional pituitary adenomas

OBJECTIVE

With isolated exceptions the only oncogene significantly associated with pituitary tumours is a constitutively active Gs protein (G alpha s). The recent cloning of the cDNA of human G alpha q has facilitated the study of this activator of the phospholipase C beta/Ca2+/ protein kinase C pathway. Since, with isolated exceptions, non-functional tumours are responsive in vitro to TRH and GnRH which activate Gq, we have investigated the genomic sequence of G alpha q, in non-functional (NF) invasive pituitary adenomas, at a residue corresponding to the one most frequently mutated in G alpha s.

PATIENTS AND MEASUREMENTS

We studied 27 invasive NF pituitary tumours by direct sequencing of DNA derived from archival slide extracted tumour cells. Primers were designed to encompass Arg183 (corresponding to Arg201 of G alpha s) which when mutated has been shown to have oncogenic potential when transfected into cultural rat fibroblasts. In a previous study we have described allelic loss at tumour suppressor gene loci (TSG) in 7 of these 27 tumours.

RESULTS

We successfully amplified genomic DNA with primers designed from the cDNA sequence of G alpha q with specific exclusion of a processed pseudogene. No mutations were found at Arg183, in either the tumours showing allelic losses at specific TSG loci, or in the 20 remaining tumours in which we found no losses at the TSG loci investigated.

CONCLUSIONS

Mutations at this key residue in G alpha q occur infrequently, if at all, in invasive non-functional pituitary tumours. However we cannot exclude the possibility of mutation(s) at the other key residue of G alpha q, Gin209, implicated in GTP hydrolysis, or in other components of this pathway.

Pharmacokinetics of N-acetylcysteine are altered in patients with chronic liver disease

BACKGROUND

The threshold plasma paracetamol concentration at which N-acetylcysteine (NAC) treatment is recommended to treat paracetamol poisoning in a patient with induced liver enzymes (for example, with chronic liver disease or taking anticonvulsant drugs) is 50% lower than in a patient without induced liver enzymes. More patients with chronic liver disease might therefore be expected to be exposed to NAC treatment than previously. In addition, there is increasing use of NAC in patients with chronic liver disease for multiorgan failure or hepatorenal syndrome. Little is known of NAC's pharmacokinetic properties in patients with cirrhosis.

AIM

The aim was to determine if the pharmacokinetics of NAC are altered by chronic liver disease.

SUBJECTS AND METHODS

NAC was given intravenously in a dose of 600 mg over 3 min to nine patients with biopsy-proven cirrhosis (Child's grade; 1 A, 4 B, 4 C: aetiology: 7 alcohol-related, 1 primary biliary cirrhosis, 1 secondary biliary stenosis) and six healthy matched controls. Venous blood was taken at 20, 40, 60 and 90 min then at 2, 3, 4, 6, 8 and 10 h after NAC administration. Serum NAC was estimated by HPLC. The data were normalized to a standard body weight of 70 kg.

RESULTS

The area under the serum concentration-time curve was increased (152.34 mg/L.h +/- 50.38 s.d.) in cirrhotics compared with normal controls (93.86 mg/L.h +/- 9.60 s.d.) (P < 0.05). The clearance of NAC was reduced in patients with chronic liver disease (4.52 L/h +/- 1.87 s.d.) compared with controls (6.47 L/h +/- 0.78: P < 0.01).

CONCLUSIONS

Increased vigilance for untoward anaphylactoid reactions is necessary in cirrhotics as they may have higher plasma NAC concentrations. Further studies to determine the optimum dosage regimen in such patients are required.

Paré as a neurosurgeon

The Cowlishaw Collection gives a splendid representation of the works of a Ambroise Paré (1510-1590). His Complete Works, in the great French edition edited by J.F. Malgaigne, are essential in any study of Paré's achievement, but the 1649 English edition provides a good basis for consideration of Paré's practice in what would now be termed neurosurgery. Paré had a large clinical experience in head injury management. His patients included Henri II King of France, who died from a penetrating orbital wound, and be described a number of other craniofacial wounds sustained in war or in warlike sports. His surgical instruments and operative techniques do not appear very innovative, but were doubtless good in their day; his methods of trephination compare favourably with those of the English surgeon John Woodall, his younger contemporary. He operated on head injuries and cranial infection, but had no capacity to treat intradural conditions, such as cerebral abscesses and tumours: his technical limitations are obvious, and the physicians on whom he had to rely could give him no guidance in neurological diagnosis. He was keenly interested in developmental malformations, and described several conditions that would now be referred to a paediatric neurosurgeon. Paré is of great historical importance as an outstanding Renaissance surgeon, whose influence extended throughout the literate world, and as far as Japan. With him, France replaced Italy and Spain in leadership in European surgical progress, a position that France retained at least until the age of Hunter.

Defining and evaluating quality for ambulatory care educational programs

As the training of medical students and residents increasingly moves to ambulatory care settings, clerkship and program directors must find a way to use their limited resources to guide the development and evaluation of the quality of these ambulatory-based learning experiences. To evaluate quality, directors must first define, in operational and measurable terms, what is meant by the term "quality" as it is applied to ambulatory-based education. Using educational theories and the definition of quality used by health care systems, the authors propose an operational definition of quality for guiding the planning, implementation, and evaluation of ambulatory care educational programs. They assert that quality is achieved through the interaction of an optimal learning environment, defined educational goals and positive outcomes, participant satisfaction, and cost-effectiveness. By describing the components of quality along with examples of measurable indicators, the authors provide a foundation for the evaluation and improvement of instructional innovations in ambulatory care education for the benefit of teachers, learners, and patients.

Strategies for efficient and effective teaching in the ambulatory care setting

Medical education in the ambulatory care setting is characterized in part by the question of how to ensure educational effectiveness while simultaneously providing high-quality, cost-effective patient care. The constraints associated with managed care have only served to escalate the intensity of this dilemma. However, in spite of the difficulties faced by ambulatory care preceptors, there are educationally sound and time-efficient strategies clinical teachers may employ to improve ambulatory care education. Emphasizing the basic three-step process of planning, teaching, and reflection, the authors describe five such strategies: "wave" scheduling, orienting learners to patients, having learners do their case presentations in the examination room, employing the microskills of the "one-minute preceptor," and effectively reflecting on one's teaching in order to develop effective teaching scripts. Research in ambulatory care learning has indicated that learners must be given significant roles in patient care and that preceptors must observe trainees as they care for patients so that they can provide trainees with helpful feedback. Employing these strategies in the ambulatory care setting will help educators to accomplish these two objectives while minimizing disruption to cost-effective, high-quality clinical practice.

Future faculty development in family medicine

BACKGROUND AND OBJECTIVES

Several recurring conclusions about the changed conditions and future needs of faculty emerged from the articles in this dedicated issue. Faculty work is becoming more differentiated; time is increasingly constrained; and faculty are working in more diverse settings. Faculty reward structures and career ladders are changing, and acquiring additional competencies in new areas is essential. Although less then anticipated, there is some research to guide the development of programs to prepare faculty for these changes. Based on these conclusions, it is expected that in the future, faculty and program chairs will seek a tight match between what a faculty development effort addresses and the responsibilities of faculty participants and/or the goals of the department or program. The following trends are expected: 1) Regional/national comprehensive programs will often be the best choice for new faculty since many departments and residencies will not have sufficient resources to support their own faculty development programs. 2) Research-oriented faculty will be expected to devote 2 years or more to formal training. 3) Experienced faculty and department/program leaders, many of whom are graduates of our faculty development programs, will need advanced training in targeted areas, through on-site, contextualized education or through individualized programs--perhaps electronic. 4) Organizational development will be needed to help departments and programs make changes in missions and processes and to maintain a sense of community. At the same time that new models must be created to meet these future faculty development needs, support for such programs has decreased. Both local and national sources must be recommitted to support faculty development programs and research so we may advance our understanding of cost-effective approaches to faculty development. Funding agencies need to change their guidelines to match the current needs for development and limit funding to programs designed on evidence.

Atresia of the external acoustic meatus in a dog

A 3 year old, female great Dane with atresia of the right external ear canal had recurrent episodes of ear pain. Radiography revealed absence of air in the right external acoustic meatus, thickened bone of the right tympanic bulla and increased radiodensity of the chamber of the bulla. Total ear canal ablation and lateral bulla osteotomy were performed. The superficial portion of the external ear canal was absent and the deeper segment of the vertical ear canal began as a blunt ended cartilage tube. A patent lumen in the existent portion of the external ear canal and the tympanic bulla contained wax, hair and exfoliated squames. The tympanic membrane was not intact. No bacteria were cultured from the contents of the external and middle ear. The dog responded well to surgery and was free of pain 11 months later. Failure to surgically correct atresia of the ear canal in young dogs may allow the accumulation of cellular and sebaceous debris with subsequent involvement of the middle ear in an inflammatory response.

Tumour suppressor genes in the pathogenesis of human pituitary tumours

Abnormal cell proliferation is controlled by opposing actions of oncogene products (stimulatory) and tumour suppressor gene (TSG) products (inhibitory). The former are dominantly acting, i.e. only one copy needed for tumorigenesis, whilst for TSG both copies of the gene must be inactivated so these are recessive at a cellular level. For anterior pituitary tumours only one oncogene (Gsp) has been identified in a variable proportion (4-40%) of a single tumour subtype (somatotrophinomas). Contrariwise, allelic deletion studies, using a PCR-based microsatellite polymorphism analysis of DNA extracted from archival specimens, have shown significant loss of heterozygosity in 20-40% of all tumour subtypes at the locus of the putative MEN-1 gene (chr. 11q13); the retinoblastoma gene (chr. 13q 12-14), and 10q26. Moreover, these DNA microdeletions were concentrated in radiologically invasive tumours compared to noninvasive tumours (modified Hardy gdes 3 and 4 vs. 1 + 2). In addition, 50% of Cushing's adenomas showed presence of p53 immunopositivity, though no point mutations in exons 4-9 were found, by SSCP analysis, to account for this. These studies show that analysis of TSGs in pituitary adenomas may provide clues to their pathogenesis, and more importantly relate to clinical behaviour of the tumour, and hence aid decisions regarding management.