Retrotrapezoid nucleus muscarinic receptor subtypes localized by autoradiography

Microinjection of muscarinic receptor subtype antagonists into the region of the cat retrotrapezoid nucleus (RTN) decreases blood pressure (greatest efficacy; M2 subtype) and both baseline phrenic activity and CO2 sensitivity (greatest efficacy; M3/M1 subtype). Here we examine, in cat medullary sections at the level of the RTN, the effects of the same antagonists on binding of the high affinity muscarinic agonist quinuclidinyl benzilate (QNB). 3H-QNB binding was saturated and highly specific at 1 nM concentration and stable over 30 to 120 min (Kd, 0.49 nM; Bmax, 136 fm/mg protein). Studied biochemically, we found IC50 values for whole sections of 4.9 x 10(-6) M (M1 antagonist pirenzepine); 1.0 x 10(-6) M (M2 antagonist AFDX); and 0.64 x 10(-7) M (M3 antagonist DAMP; P < 0.03 vs PZ). Densitometric analysis of whole medullary cross section autoradiograms resulted in similar IC50 values as in the biochemical approach. Specific analysis of the RTN region demonstrated the presence of 3H-QNB binding and similar competition by the antagonists. Average IC50 values determined by densitometry were 14 x 10(-6) M (pirenzepine); 1.3 x 10(-6) M (AFDX; P < 0.01 vs PZ); and 0.53 x 10(-7) M (DAMP; P < 0.01 vs PZ). All three subtypes of muscarinic receptors identifiable via pharmacological antagonists appear to be present in the RTN region but we could not distinguish a subtype-specific pattern of receptor distribution.

A rapid screen test for in vitro susceptibility of clinical herpes simplex virus isolates

A rapid screening test for antiviral susceptibility to acyclovir and foscarnet was evaluated in 320 herpes simplex virus (HSV) isolates from 197 patients. Of the isolates tested (16% HSV-1, 84% HSV-2), 60% were resistant in vitro to acyclovir and 5% were resistant to foscarnet using the plaque reduction assay. The rapid screening test, requiring only 3 days to yield a preliminary susceptibility result, was highly associated with the results of the plaque reduction assay for acyclovir and foscarnet (P < or = .001 for each) and with the clinical response to antiviral therapy (P < .001, P = .001, respectively).

Prognosis in cystic fibrosis treated with continuous flucloxacillin from the neonatal period

All newborn infants in East Anglia are screened for cystic fibrosis by blood immunoreactive trypsin assay at 7 days. Thirty eight infants with cystic fibrosis were randomised to treatment with either continuous oral flucloxacillin 250 mg/day (group P, n = 18) or with episodic antimicrobials as clinically indicated (group E, n = 20). Their progress was monitored from diagnosis to 24 months by a nurse coordinator who visited all infants regularly, at home and in hospital, to collect anthropometric, dietary, clinical, and microbiological data. Mean (range) age of confirmation of diagnosis was 5.7 weeks (1-14 weeks). There was no significant difference in birth weight, genotype, immunoreactive trypsin concentration, neonatal history, symptoms at diagnosis, pancreatic enzyme supplementation, or parental smoking history between the groups. Infants in group E had more frequent cough and a greater number of Staphylococcus aureus isolates than infants in group P. More infants of group E were admitted to hospital, had higher admission rates during the second year (19 v 5), for longer periods (6.4 v 2.2 days), despite receiving more than double the number of courses of antibiotics than group P infants (in addition to flucloxacillin). Continuous prophylactic flucloxacillin from early diagnosis of cystic fibrosis is associated with improved clinical progress during the first two years of life.

The use of psychiatric services before imprisonment: a survey and case register linkage of sentenced prisoners in Melbourne

Information about contact with psychiatric services before imprisonment was obtained for a stratified random sample of sentenced prisoners, who were not receiving prison psychiatric care, in Melbourne's three metropolitan prisons. The sample of 158 men and 31 women was matched with the longitudinal person-linked records of state psychiatric service use in the Victorian Psychiatric Case Register (VPCR). Records of contact with the state services were found for 54 men (34%) and 19 women (61%), including records of in-patient treatment for 25 men (16%) and 15 women (48%). For 64% of individuals with a positive match, the case-note diagnoses were substance use disorders only. Diagnoses of psychotic disorders were recorded for four prisoners, and mood disorders for another six. In addition, clinicians conducted standardized diagnostic interviews and enquired about treatment and personal history. A further 24 prisoners reported specialist psychiatric treatment outside the state treatment sector. This study links the findings from an interview survey of psychiatric morbidity in prisoners with the records available in the VPCR, and emphasizes a number of matters important to the public health. The high rates of previous treatment for substance abuse disorders, the apparent pool of prisoners with largely untreated major depression, and the service needs of those with chronic psychotic disorders are discussed.

Pneumoperitoneum due to PCI in a patient with a strangulated femoral hernia

Although pneumatosis cystoides intestinalis (PCI) is a well-recognised condition, an individual surgeon is unlikely to encounter it often. The collected experience of two surgical units in Glasgow teaching hospitals over a 15-year period consisted of five patients. Surgical and radiological trainees may therefore have little or no exposure to the diagnostic difficulties this condition can cause. We report an illustrative case.

An audit of the obstetric outcome of 148 consecutive pregnancies from assisted conception: implications for neonatal services

OBJECTIVE

To assess the outcome of pregnancy following assisted conception.

DESIGN

Cohort descriptive study.

SETTING

Unit of Reproductive Medicine, Ninewells Hospital and Medical School.

SUBJECTS

One hundred and forty-eight consecutive assisted conceptions.

MAIN OUTCOME MEASURES

Patient characteristics and outcome of pregnancy.

RESULTS

Seventy-nine percent of mothers were aged between 26 and 35 years (mean 31.4). The main causes of infertility were tubal (48%), unexplained (35%), anovulatory (8%) and male factor (8%). Primary infertility accounted for 61% of cases and 82% of pregnancies occurred within 3 treatment cycles. Thirty-five (24%) pregnancies miscarried before 14 weeks and 7 (5%) between 15 and 24 weeks gestation. One hundred and three pregnancies resulted in 136 liveborn infants. There was one neonatal death. Thirty-five babies were admitted to SCBU. Antenatally, 13% of patients were admitted to hospital with hypertension and 8% with APH; 50% of multiple and 13% of singleton pregnancies were delivered prematurely, 68% following preterm labour. There were 28 sets of twins (four miscarried at less than 24 weeks) and four sets of triplets. Multiple pregnancy was not associated with cause of infertility, treatment, age or ovarian hyperstimulation syndrome. Seventy-eight per cent of singletons and 50% of multipara were delivered vaginally.

CONCLUSIONS

Our data confirm the high incidence of pregnancy loss and preterm delivery associated with assisted conception once allowing for the high rate of multiple pregnancies. The effect of assisted conception programme on health services is discussed.

Inhibition of platelet binding and aggregation by streptococcal exopolysaccharide

Streptococcal exopolysaccharides are major virulence factors in the pathogenesis of endocarditis. They promote bacterial adherence to valves and subsequent vegetation formation. Since platelet binding and aggregation by streptococci are postulated mechanisms for endocardial colonization and vegetation production, the effect of exopolysaccharide on binding and aggregation was evaluated by flow cytometry and aggregometry. Streptococcus salivarius D1, a minimal exopolysaccharide producer, bound human platelets extensively (86.8% of bacteria bound by 1 min). S. Salivarius M13 and M15 and Streptococcus mitis M4 produced larger amounts of exopolysaccharide and bound platelets significantly less (52.6%, 51.2%, 52.8%, respectively). Exopolysaccharide also inhibited platelet aggregation: Strains with minimal exopolysaccharide aggregated platelets maximally, while strains with extensive exopolysaccharide failed to induce aggregation. Removal of exopolysaccharide by shearing restored aggregation by these latter strains. Thus, exopolysaccharides can inhibit the binding and aggregation of platelets by streptococci. The virulence associated with exopolysaccharide may result from the inhibition of platelet-mediated interactions that limit disease progression.

Natural killer cytotoxicity and antibody-dependent cellular cytotoxicity of human immunodeficiency virus-infected cells by leukocytes from human neonates and adults

In infants born to mothers infected with the human immunodeficiency virus (HIV), antibody-dependent cellular cytotoxicity (ADCC) or natural killer cytotoxicity (NKC) may either eliminate infection or ameliorate its course. We developed and standardized an assay for cytotoxicity of HIV-infected cells and studied the capacity of leukocytes from healthy neonates and adults to lyse HIV-infected cells by ADCC and NKC. The chosen target cell line, a T cell line infected with the HXB-2 clone of human T-cell lymphotrophic virus-IIIB, displayed stable surface expression of viral antigens over months of continuous culture and allowed simultaneous assessment of NKC and ADCC of effector cell populations. Conditions for optimal ADCC lysis of target cells were defined for unpurified peripheral blood mononuclear cells and purified lymphocytes and monocytes. Polymorphonuclear neutrophils from healthy adults and neonates exhibited low activity in ADCC of HIV-infected targets. Lymphocytes and monocytes from adults were found to differ in antibody dependence, kinetics, and sensitivity to latex inhibition for ADCC-mediated lysis of HIV-infected targets. Peripheral blood mononuclear cells of healthy neonates and adults displayed equivalent capacity to mediate NKC of HIV-infected targets. However, neonates' peripheral blood mononuclear cells were found to be significantly less active than adults' in ADCC lysis of HIV-infected cells. This pattern of diminished ADCC cytotoxicity with intact NKC is the opposite of that seen in HIV-infected adults. Our findings suggest that therapies designed to enhance ADCC effector cell function in the neonate may help interrupt vertical transmission of HIV.

Screening for inhibitors of HIV gp120-CD4 binding using an enzyme-linked immunoabsorbent assay

Binding of the HIV-1 major viral surface glycoprotein, gp120, to the major cell receptor, CD4, is essential for HIV infection of the target cell and syncytium formation. An enzyme-linked immunoassay using solid phase CD4 was used to quantitate the binding of HIV-1 gp120 to CD4, and to assess the activity and mechanism of action of putative inhibitors of that reaction. Monoclonal antibodies to the gp120 binding site on CD4 (e.g., Leu3a) blocked gp120 binding, while monoclonal antibodies to other portions of CD4 (e.g. OKT4) did not. Both aurintricarboxylic acid and sulfonated polysaccharides (e.g., dextran sulfate) blocked CD4-gp120 interactions by binding to the CD4 component. Human polyclonal antibodies to gp120 also blocked gp120-CD4 binding, but none of the monoclonal antibodies tested (including several with neutralizing activity) were effective. In contrast, several lectins (including mannose binding protein) bound to gp120 and blocked CD4-gp120 interactions. Enzymatic deglycosylation of gp120 only minimally affected its CD4 binding capacity, while non-glycosylated gp120 (produced in Escherichia coli)-bound CD4 about 10-fold less well than fully-glycosylated material. The results demonstrate that this assay system can be used to measure the activity of inhibitors of CD4-gp120 binding, and to determine the mechanism of action of those inhibitors.

HIV-related respiratory disease

The lungs are a primary target for the opportunistic infections and malignancies affecting those with HIV infection. In the patient whose HIV infection is undiagnosed, PCP is the commonest clue to its presence. Early diagnosis prevents morbidity and mortality. Less commonly, interstitial lung disease and tuberculosis, often "primary" or clinically atypical, will be the clue to underlying HIV infection. Other pulmonary complications are usually a late manifestation of HIV infection, which has usually (but not always) already been diagnosed.

Autonomous staff selection teams

Although some other organizations encourage staff input into employee selection, the advanced care department at Bellin Hospital in Green Bay, Wisconsin has taken this concept to a new level by implementing an autonomous interview team. This team is empowered to make hiring decisions for all positions within the department without management influence or interference.

Human immunodeficiency virus-infected monocyte-derived macrophages express surface gp120 and fuse with CD4 lymphoid cells in vitro: a possible mechanism of T lymphocyte depletion in vivo

Monocyte-derived macrophages (MDM) infected in vitro with a macrophage-tropic strain of human immunodeficiency virus (HIV) fused with uninfected, CD4-expressing T lymphoblastoid cells, but not with a subclone of these cells lacking surface CD4. Infected MDM also fused with uninfected autologous and heterologous MDM. Recombinant soluble CD4 protein (rsCD4) (10 micrograms/ml) and full-length recombinant glycosylated gp120 (20 micrograms/ml) each inhibited fusion by 94-99%; the inhibition was dose-dependent. The N-terminal portion of gp120 did not inhibit syncytium formation. Fusion was also inhibited by a monoclonal antibody to an epitope which binds gp120 (S3.5), but not by antibody to an epitope not involved in gp120 binding (OKT4). HIV-infected MDM specifically bound fluorescein-conjugated rsCD4, and virus could be visualized budding from the surface of these cells. HIV-infected MDM express viral gp120 on their surface and fuse with CD4-bearing cells in a fashion similar to lymphoid cells. Macrophages may contribute to CD4 lymphocyte depletion in vivo by this fusion mechanism.

Comparison of the Western immunoblot assay and a glycoprotein G enzyme immunoassay for detection of serum antibodies to herpes simplex virus type 2 in patients with AIDS

Herpes simplex virus type 2 (HSV-2) seroprevalence in 68 patients with AIDS was 77% by Western blot (immunoblot) and 44% by glycoprotein G-2 immunoassay. Each of 16 patients with culture-proven HSV-2 infection was positive by Western blot versus 8 by glycoprotein G-2 immunoassay. No differences in age, race, duration of AIDS, acyclovir usage, or HSV-1 seroprevalence were found to explain differences in sensitivity.

The money laundering control act and proposed amendments: Its impact on the casino industry

In their efforts to track unreported income, Congress passed the Money Laundering Control Act in 1985. Because they are often involved in large cash transactions, casinos were required to report on cash transactions in amounts of $10,000 or more in much the same manner as banks and other financial institutions. However, because of the unique nature of cash and chip transactions within modern casinos, the Act, or state variants of it, have created significant compliance costs for casinos. This analysis examines the implications of the Act for the casino gaming industry, and evaluates some of the recent suggested Amendments to the Act.

Lack of evidence of occult human immunodeficiency virus in seronegative individuals at very high risk of infection

Reports of human immunodeficiency virus (HIV) infection in seronegative individuals prompted the authors to investigate subjects who are at very high risk of acquisition of HIV in San Francisco. Nine HIV seronegative subjects were evaluated extensively, eight of whom were drawn from a well-characterized cohort of seropositive and seronegative homosexual men who have been followed prospectively since 1983-1984. These men have calculated probabilities of infection based on a fitted model of between 0.22 and 0.94. One additional subject is an intravenous drug user who has shared needles with HIV-infected individuals extensively. Peripheral blood lymphocytes and monocytes were separately cultured from each subject and evidence of HIV infection was sought by a reverse transcriptase assay, enzyme immunoassay, and immunocytofluorographic analysis for HIV antigens, in situ hybridization, RNA slot blot analysis, and polymerase chain reaction amplification of HIV cDNA. Uncultured monocytes and lymphocytes from each donor were also examined by these techniques. Evidence of HIV infection was not found in the peripheral blood mononuclear cells of these high risk individuals.

Toxoplasma serology, parasitemia and antigenemia in patients at risk for toxoplasmic encephalitis

In order to further characterize the pathogenesis of Toxoplasma gondii infection in patients with AIDS and AIDS-related complex (ARC), a cohort of HIV- and Toxoplasma-infected individuals were identified and prospectively followed. Four hundred and 10 HIV-infected individuals followed in the San Francisco General Hospital AIDS Clinic were screened for antibodies to Toxoplasma between November 1986 and November 1988. Of the 67 (16%) individuals seropositive for Toxoplasma antibodies, 33 (49%) were followed monthly for a mean duration of 7.5 months. One hundred and 11 follow-up blood samples were obtained in order to determine Toxoplasma serology and the incidence of parasitemia. In general, Toxoplasma immunoglobulin (Ig) G antibodies remained stable over time. Detection of Toxoplasma antigenemia and parasitemia was uniformly negative, including those specimens obtained from two individuals within 45 days of their developing toxoplasmic encephalitis.

The nurse manager as mentor

Mentoring staff is an essential role of the nurse manager. Developing a workable system and investing the time to carry it through has many positive outcomes for both the manager and the nursing staff. Staff nurses are able to function independently and make decisions concerning their practice as well as their work environment, leaving the nurse manager free to assume a true leadership role.

Clinical and serologic features of herpes simplex virus infection in patients with AIDS

We studied the natural history of herpes simplex virus (HSV) infection and its association with specific serum antibody in a sample of 68 HIV-infected patients with a first episode of Pneumocystis carinii pneumonia at San Francisco General Hospital in 1986. Seroprevalence was 66 and 77% for HSV-1 and HSV-2 antibody, respectively, by immunoblot assay. Twenty-seven patients had 45 HSV outbreaks diagnosed during 739 patient-months of follow-up. Median frequency of recurrence resulting in a medical visit was once every 6.5 months, and median duration of treated outbreak was 10 days. Fourteen of 48 evaluable patients seropositive for HSV-2 had no outbreak of HSV during a median follow-up of 7.5 months. Our data suggests that neither frequency nor severity of HSV were substantially increased in this group of patients, despite severe immunosuppression caused by HIV. However, validation of these results by a prospective study is required.

A controlled trial comparing foscarnet with vidarabine for acyclovir-resistant mucocutaneous herpes simplex in the acquired immunodeficiency syndrome. The AIDS Clinical Trials Group

BACKGROUND AND METHODS

Most strains of herpes simplex virus that are resistant to acyclovir are susceptible in vitro to both foscarnet and vidarabine. We conducted a randomized trial to compare foscarnet with vidarabine in 14 patients with the acquired immunodeficiency syndrome (AIDS) and mucocutaneous herpetic lesions that had been unresponsive to intravenous therapy with acyclovir for a minimum of 10 days. The patients were randomly assigned to receive either foscarnet (40 mg per kilogram of body weight intravenously every 8 hours) or vidarabine (15 mg per kilogram per day intravenously) for 10 to 42 days. In the isolates of herpes simplex virus we documented in vitro resistance to acyclovir and susceptibility to foscarnet and vidarabine.

RESULTS

The lesions in all eight patients assigned to foscarnet healed completely after 10 to 24 days of therapy. In contrast, vidarabine was discontinued because of failure in all six patients assigned to receive it. The time to complete healing (P = 0.01), time to 50 percent reductions in the size of the lesions (P = 0.01) and the pain score (P = 0.004), and time to the end of viral shedding (P = 0.006) were all significantly shorter in the patients assigned to foscarnet. Three patients had new neurologic abnormalities while receiving vidarabine. No patient discontinued foscarnet because of toxicity. Although initial recurrences of herpes simplex infection after the index lesion had healed tended to be susceptible to acyclovir, acyclovir-resistant infection eventually recurred in every healed patient, a median of 42.5 days (range, 14 to 191) after foscarnet was discontinued.

CONCLUSIONS

For the treatment of acyclovir-resistant herpes simplex infection in patients with AIDS, foscarnet has superior efficacy and less frequent serious toxicity than vidarabine. Once the treatment is stopped, however; there is a high frequency of relapse.

Morbidity and mortality of patients with AIDS and first-episode Pneumocystis carinii pneumonia unaffected by concomitant pulmonary cytomegalovirus infection

To determine the significance of cytomegalovirus (CMV) pulmonary coinfection with Pneumocystis carinii pneumonia in AIDS, we examined the association of long- and short-term survival and morbidity (as defined by length of hospital stay) with recovery of CMV from bronchoscopy specimens and an indirect measure of virus titer in bronchoalveolar lavage fluid (the time to develop CMV cytopathology in culture) in 111 patients diagnosed with a first episode of P. carinii pneumonia. Compared with 57 individuals from whom CMV was not isolated, the 54 individuals from whom CMV were isolated did not differ in baseline characteristics, long-term survival (213 versus 275 days, p = 0.97), acute death rate (19% in both, p = 1.0), or length of hospital stay (19.7 versus 21.1 days, p = 0.68). Also, the time to develop CMV cytopathology in culture did not correlate with acute or long-term survival. Our observations thus do not support the use of CMV-specific antiviral therapy in AIDS patients with P. carinii pneumonia who also have evidence of pulmonary CMV infection.