Do chest physicians follow-up too many patients?

We have examined the pattern of attendance of 750 randomly selected regular attenders at a chest outpatient clinic and sought the patients' views on the frequency of their follow-up appointments and the possible consequences of discharge to the care of the general practitioners. In addition, the clinic doctors and the patients' general practitioners were asked about the appropriateness of the frequency of follow-up and whether the pattern of attendance should change or the patient be discharged. Patients were most commonly seen at three monthly intervals. Clinic doctors felt that 24% and general practitioners that 9% of patients attended too often while only 2% of patients felt that this was the case. Clinic doctors recommended discharge for 28% and general practitioners for 21% of patients. Sixty-nine per cent of patients felt that their condition would be unchanged or would improve if they were discharged to the care of their general practitioners. Our findings suggest that at least 20% of our patients should be discharged to the care of their general practitioners, and, if the patients are correct in their interpretation of the consequences of discharge, that as many as 70% could safely be discharged.

Epidemic of nosocomial Legionnaires' disease in renal transplant recipients: a case-control and environmental study

An outbreak of Legionella pneumophila pneumonia occurred in 6 of 49 new renal transplant recipients over the course of 13 months. We compared infected patients (cases) and uninfected patients (controls) with respect to potential risk factors. Corticosteroid use, need for hemodialysis and number of days of hemodialysis were significantly greater among the cases. Logistic regression analysis identified corticosteroid dosage and number of days of hemodialysis as independent risk factors. Lymphopenia and monocytopenia were correlated with the amount of corticosteroid administered and occurred to a greater degree in the cases. All clinical isolates were of L. pneumophila serogroup 1, subtype Philadelphia 1, which was also cultured from a recovery room sink outside the operating room where the transplants were done. Other areas of the hospital were colonized with other, heterogeneous strains of L. pneumophila. The organism was not eliminated from the hospital water supply despite shock chlorination and superheating of water tanks. The epidemic ended when new transplant recipients routinely received prophylactic trimethoprim-sulfamethoxazole (160-800 mg given orally once daily) while in hospital after transplantation. Corticosteroid-induced monocytopenia and lymphopenia and the complement activation and monocyte depletion effects of hemodialysis may combine to increase susceptibility to Legionnaires' disease.

Antigenic stimulation during ultraviolet therapy in man does not result in immunological tolerance

People receiving therapy with either 8-methoxypsoralen plus long wavelength ultraviolet radiation (PUVA) or medium wavelength ultraviolet radiation (UVB) have been studied to see whether their unresponsiveness to the contact sensitizer dinitrochlorobenzene (DNCB) is a form of immunological tolerance. It was confirmed that both PUVA and UVB therapy impair sensitization by DNCB:4/13 PUVA-treated and 9/29 UVB-treated psoriatic subjects became sensitized by a dose of DNCB which sensitizes 100% of untreated patients. Subjects unsuccessfully sensitized during PUVA therapy could subsequently be sensitized perfectly normally. Subjects unsuccessfully sensitized during UVB therapy showed slight impairment of subsequent sensitization which was not statistically significant, and which was probably a persistent effect of UVB exposure. In conclusion, the temporary unresponsiveness seen in human subjects exposed to antigens during PUVA or UVB therapy is not due to immunological tolerance.

Effects of maternal marijuana and cocaine use on fetal growth

To investigate the effects on infants of the use of marijuana and cocaine during pregnancy and to compare the importance of urine assays with that of interviews in ascertaining drug use, we prospectively studied 1226 mothers, recruited from a general prenatal clinic, and their infants. On the basis of either interviews or urine assays conducted prenatally or post partum, 27 percent of the subjects had used marijuana during pregnancy and 18 percent had used cocaine. When only positive urine assays were considered, the corresponding values were 16 percent and 9 percent, respectively. When potentially confounding variables were controlled for in the analysis, the infants whose mothers had positive urine assays for marijuana, as compared with the infants whose mothers were negative according to both interviews and urine assays, had a 79-g decrease in birth weight (P = 0.04) and a 0.5-cm decrement in length (P = 0.02). Women who had positive assays for cocaine, as compared with nonusers, had infants with a 93-g decrease in birth weight (P = 0.07), a 0.7-cm decrement in length (P = 0.01), and a 0.43-cm-smaller head circumference (P = 0.01). To compare our findings with those of other investigators who did not use urine assays, we repeated the analyses, considering only self-reported use of marijuana (23 percent) and cocaine (13 percent). There were no significant associations between such use as determined by interviews alone and any of the measures of outcome. We conclude that the use of marijuana or cocaine during pregnancy is associated with impaired fetal growth and that measuring a biologic marker of such use is important to demonstrate the association.

Water absorption of methacrylate soft lining materials

The water absorption of soft methacrylate prosthetic materials is very high compared with rigid methacrylates and is not at an equilibrium value even after 6 yr. This very high and prolonged uptake can be explained qualitatively in terms of the presence of water soluble impurities which form sites for the formation of water droplets. These droplets grow until the osmotic and elastic forces balance; this mechanism can be accompanied by creep or even rupture under the osmotic pressure. Desorption on the other hand, is rapid and obeys diffusion laws, giving diffusion coefficients of 5-7 X 10(-8) cm2 s-1.

Gelatin embedding and diagnostic ultrasound in the examination of the fetal and neonatal brain

We describe a new method for the post-mortem examination of the fetal central nervous system. The brain is immobilized in gelatin prior to ultrasonic examination. Correlation with prenatal ultrasound is excellent and subsequent pathological examination is enhanced and facilitated.

Double jeopardy: the impact of poverty on early child development

This article reviews the extent to which a child is placed at risk because of poverty. It looks especially at behavioral and developmental outcomes that are affected by poverty and suggests interventions to overcome any adverse effects.

Work of a rehabilitation medicine service

The results of the work of the Edinburgh Rehabilitation Medicine Service in one year were evaluated. Over 1400 new patients were seen, of whom 525 were in hospital at the time. Patients most often referred were those who had had cardiovascular accidents, back pain, lower limb amputations, and head injuries and those convalescing after heart surgery. Most patients had several problems. Many were referred so that they could obtain wheelchairs or other appliances, or for assessment of their ability to drive. Only 3% of the referrals were considered inappropriate. Of the inpatients, 455 (87%) returned home after treatment, but 13 (2%) did not respond satisfactorily to rehabilitation. Twelve per cent (18% of the inpatients) were referred from other health boards, suggesting a need for similar facilities elsewhere.

Left ventricular wall motion abnormalities in subarachnoid hemorrhage: an echocardiographic study

Although electrocardiographic (ECG) abnormalities and autopsy evidence of myocardial necrosis are associated with subarachnoid hemorrhage, their relation to in vivo measures of left ventricular function in this condition has not been established. Thirteen patients with subarachnoid hemorrhage and no prior history of heart disease were studied by two-dimensional echocardiography, performed initially 10 to 48 h (mean 18) after admission and serially for less than or equal to 14 days. Serum creatine kinase (total and myocardial isoenzyme) was determined 5 times over the first 48 h; ECGs were performed daily. Neurologic state was assessed with the use of a standard grading system. Four patients (Group I) exhibited left ventricular wall motion abnormalities in one to eight segments. In two of these patients there was also left ventricular apical mural thrombus that embolized in one patient, leading to further neurologic deterioration. The initial creatine kinase myocardial isoenzyme was higher in Group I than in Group II (patients without wall motion abnormalities) (10.3 versus 2.1 U/liter, p less than 0.001), initial heart rate was higher (91 versus 61 beats/min, p less than 0.01), neurologic grade was higher (2.5 to 4.5 versus 1 to 2, p less than 0.001) and inverted T waves were more common (4 of 4 versus 1 of 9). Three of the four patients in Group I died; two of the three underwent autopsy and were found to have no significant coronary artery disease. No other patients died.(ABSTRACT TRUNCATED AT 250 WORDS)

How hospital ward members treat learner nurses: an investigation of learners' perceptions in a British hospital

Twenty-five learner nurses who had just completed their first two wards were questionned about the behaviour of other ward members towards them. Although many ward sisters' and charge nurses' behaviour was positive towards learners, just under 50% of learners' responses indicated that the ward sister/charge nurse was sometimes rude and did not make them feel 'at home'. The ward sister/charge nurse's behaviour was, on average, more negative than another liked qualified staff, whose behaviour was more negative than a more experienced student on the ward. The ward sister/charge nurse's behaviour was the major determinant of ward preference by the learner. However, the behaviour of ward members tended to correlate, providing evidence of a 'ward atmosphere'. There is a need for leadership and educational training for ward sisters and charge nurses.

Effect of inhaled methacholine on gas mixing efficiency

1. Pulmonary function tests, including alveolar mixing efficiency by the single-breath and multi-breath methods, and ventilation scans were performed on 16 volunteer subjects. The tests were repeated after the inhalation of a methacholine aerosol in sufficient dosage to increase airways resistance. 2. After inhalation of methacholine there was a significant fall in mean series dead space of 31 ml (P less than 0.05), and mean multi-breath alveolar mixing efficiency fell from 68% to 36% (P less than 0.001), a fall occurring in all subjects. Mean single-breath alveolar mixing efficiency measured on the first breath of the nitrogen washout fell from 76% to 70%, but this change did not reach statistical significance (0.1 greater than P greater than 0.05). 3. In eight of the subjects, technically adequate lung scans and pulmonary function tests were obtained both before and not more than 30 min after methacholine inhalation. In seven there were obvious visible defects on the ventilation scans, and in five of these the computer-calculated underventilation score became abnormal. 4. Thus inhalation of methacholine causes maldistribution of ventilation, a fall in alveolar mixing efficiency and a fall in series dead space, presumably brought about by bronchoconstriction. The parallel component of this maldistribution of ventilation, as judged by 81mKr ventilation scanning, does not of itself seem to be sufficient to explain the fall in alveolar mixing efficiency, and therefore a degree of diffusion limitation is probably involved as well.

Transfection of mammalian cells with plasmid DNA by scrape loading and sonication loading

Scrape loading and sonication loading are two recently described methods of introducing macromolecules into living cells. We have tested the efficacy of these methods for transfection of mammalian cells with exogenous DNA, using selection systems based either on resistance to the drug G418 (Geneticin) or on acquisition of the ability to utilize the salvage pathway of pyrimidine biosynthesis. These loading methods can be employed to generate cell lines that express the gene product of the transfected DNA molecules both transiently and stably. Optimal transfection is observed when the DNA is added to cells in physiological saline lacking divalent cations and containing K+ in place of Na+. DNA molecules 7.1 to 30 kilobases long have been introduced by the scrape loading procedure. In addition, the scrape loading procedure has been employed for cotransfection and subsequent expression of nonselectable genes encoded on DNA molecules added in a mixture with DNA molecules whose expression is selected. Cell lines expressing oncogenes or proteins that are important for regulation of cell growth and division have been obtained by this procedure. The scrape loading procedure is also useful for studies of the cellular changes that occur upon expression of an exogenous gene. As many as 80% of cells scrape loaded with the plasmid pC6, which encodes the simian virus 40 large tumor antigen, contained this protein in the nucleus between 1 and 5 days after transfection. Thus, scrape loading and sonication loading are simple, economical, and reproducible methods for introduction of DNA molecules into adherent and nonadherent cells, and these methods may be useful in the future for experimentation at both fundamental and applied levels.

Effect of PUVA on plasma and skin immunoreactive alpha-melanocyte stimulating hormone concentrations

Plasma alpha-melanocyte stimulating hormone (alpha-MSH) concentrations were measured in patients receiving PUVA therapy as treatment for mycosis fungoides, and PUVA or UVB as treatment for psoriasis. Skin immunoreactive alpha-MSH was also measured in those patients who received PUVA. The mean plasma and skin alpha-MSH concentrations after 2-3 weeks of PUVA were not significantly different from pre-treatment values and showed no relationship either to skin type or to the degree of tanning that occurred in response to PUVA. Plasma alpha-MSH concentrations were also unchanged after UVB. There was also no short term change in plasma alpha-MSH concentrations in patients after receiving their first treatment with PUVA. It would appear that circulating and skin alpha-MSH levels are unaffected by UV and show no causal relationship to PUVA induced pigmentation.

Synthesis and characterization of O6-(2-chloroethyl)guanine: a putative intermediate in the cytotoxic reaction of chloroethylnitrosoureas with DNA

The chloroethylnitrosoureas are useful antitumor agents which evidently exert a significant part of their cytotoxic action through the formation of a unique 1-(3-deoxycytidyl), 2-(1-deoxyguanosinyl)ethane cross-link in DNA. It has been suggested that this cross-link is formed from O6-(2-chloro-ethyl)guanine, an initial product of DNA alkylation by the chloroethylnitrosoureas; however, O6-(2-chloroethyl)guanine has never been described. We have synthesized this derivative from the reaction of thionyl chloride with O6-(2-hydroxyethyl)guanine, and have found that it decomposes to 1-(2-hydroxyethyl)guanine through an intermediate, presumably 1,O6-ethanoguanine. Its half life at 37 degrees and pH 7.4 is 17.8 min.

Evidence for the involvement of calmodulin in natural cytotoxicity using a range of calmodulin antagonists of varying potency and improved specificity

The calmodulin antagonist W7 and 4 of its analogues were examined for their ability to inhibit human NK cell mediated cytotoxicity. With the exception of one of these compounds, which is extremely hydrophobic, there was a good correlation between the ability of drugs to inhibit human NK antitumour cytotoxicity and calmodulin-dependent phosphodiesterase activity in vitro. The most potent of the compounds, 5-iodo-1-C8, an analogue of W7, has an IC50 of 3 microM upon biological and biochemical assay. This particular compound is both more potent and specific than the parent compound W7, is non-toxic to cells over the range used and is also capable of inhibiting the biological activity of NK cells upon pre-treatment of the effector cells, inferring the mechanism of NK cytotoxicity to be calmodulin dependent.