Geriatric-patient flow-rate modelling

We consider the application of a three-compartment mathematical model using difference equations in discrete time to model the flow of patients through departments of geriatric medicine. It has been shown empirically that the time spent in hospital since admission may be described by a two-term mixed-exponential distribution. Previous work has explained this empirical finding in terms of a two-compartment model of geriatric in-patient behaviour where the two compartments are acute/rehabilitative and long-stay care. Our model extends this approach by considering patients released from geriatric departments and their subsequent length of stay in the community. We have therefore, two states of patient behaviour while in hospital: (i) patients can be admitted to the acute-rehabilitative state, from which they may die or be released back into the community; (ii) patients can be admitted to the long-stay state, from which they eventually die. The community state currently has only one state, from which patients may be readmitted back into the geriatric department or they may die. The model may then be used to estimate the average numbers and lengths of stay for short-term and long-term patients and the average number and length of stay in the community for released patients, allowing for a significant improvement in the forecasting of future bed requirements to aid the planning of geriatric departments.

Aging-associated endothelial dysfunction in humans is reversed by L-arginine

OBJECTIVES

This study investigated the hypothesis that aging selectively impairs endothelium-dependent function, which may be reversible by administration of L-arginine.

BACKGROUND

An impaired response to acetylcholine with aging has been demonstrated in humans. However, the mechanisms underlying this impaired response of the coronary microvasculature remain to be determined.

METHODS

We infused the endothelium-independent vasodilators papaverine and glyceryl trinitrate (GTN) and the endothelium-dependent vasodilator acetylcholine (1,3,10 and 30 micrograms/min) into the left coronary artery of 34 patients (27 to 73 years old) with atypical chest pain, negative exercise test results, completely normal findings on coronary angiography and no coronary risk factors. Coronary blood flow was measured with an intracoronary Doppler catheter. The papaverine and acetylcholine infusions were repeated in 14 patients (27 to 73 years old) after an intracoronary infusion of L-arginine (160 mumol/min for 20 min).

RESULTS

There was a significant negative correlation between aging and the peak coronary blood flow response evoked by acetylcholine (r = -0.73, p < 0.0001). However, there was no correlation to papaverine (r = -0.04, p = 0.82) and GTN (r = -0.24, p = 0.17). The peak coronary blood flow response evoked by acetylcholine correlated significantly with aging before L-arginine infusion (r = -0.87, p < 0.0001), but this negative correlation was lost after L-arginine infusion (r = -0.37, p = 0.19).

CONCLUSIONS

The results suggest that aging selectively impairs endothelium-dependent coronary microvascular function and that this impairment can be restored by administration of L-arginine, a precursor of nitric oxide.

Sialidases: structures, biological significance and therapeutic potential

The structure-based design of a potent inhibitor of the influenza-virus neuraminidase (sialidase) is one of the outstanding successes of rational drug design. Recent clinical trials of the drug have stimulated many companies to seek a share of the potentially huge flu market. Sialidases, however, are involved in the pathogenesis of a whole range of other diseases, so perhaps the knowledge and expertise gained from the influenza story can be used in the design of other drugs, given that they all share certain structural features.

Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study

The 20-item Toronto Alexithymia Scale (TAS-20) has been shown in previous research to measure a general dimension of alexithymia with three intercorrelated factors. This study evaluated the reliability and factorial validity of an Italian translation of the TAS-20 in a group of normal adults (N = 206) and in a mixed group of medical and psychiatric outpatients (N = 642). Using confirmatory factor analyses, the previously established three-factor model of the TAS-20 was found to be replicable in both groups. In addition, the Italian TAS-20 demonstrated adequate estimates of internal reliability and test-retest reliability. Although evaluation of the convergent, discriminant, and concurrent validity of the TAS-20 is required in Italian populations, the present results support the use of the Italian translation of the scale for clinical and research purposes.

Subgrouping of bovine respiratory syncytial virus strains detected in lung tissue

Bovine respiratory syncytial virus is an important respiratory pathogen in cattle. Recently, subgroups of BRSV have been identified, based on antigenic differences. However, little is known about subgroups of BRSV that circulate in the cattle population. Therefore, we determined the reactivity of monoclonal antibodies (mAbs), directed against the G, F, or P protein of BRSV, with lung tissue from 47 calves, that suffered from severe respiratory disease. Fourteen animals (30%) proved to be infected with BRSV, because they all reacted with mAbs against the P or F protein, as detected by fluorescent antibody tests. Monoclonal antibodies against the G protein were able to discriminate between the BRSV-positive specimens: 7 strains were identified as subgroup A strains, and 5 strains as subgroup AB, which is introduced as BRSV subgroup in this paper. Two strains could not be identified unambiguously. It is concluded that BRSV subgroup A and AB were associated with severe respiratory disease, and that strains belonging to either subgroup circulated concurrently in the cattle population in the Netherlands.

Identification of potential CTL epitopes of bovine RSV using allele-specific peptide motifs from bovine MHC class I molecules

Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infection in young infants and housed calves. Depletion of CD8+ lymphocytes from calves inhibited their ability to clear the virus from the nasopharynx and lungs. To study these cells further, a cytotoxic T lymphocyte (CTL) assay was established. CTL could be demonstrated in the peripheral blood of gnotobiotic calves 7-10 days post infection (p.i.) with RSV and in lungs 10 days p.i. This response was both MHC-restricted and virus-specific. Following separation of the lung lymphocytes by magnetic activated cell sorting, it was shown that the cytolytic activity was mediated by cells of the CD8+ phenotype. To identify epitopes recognised by bovine CTL, the consensus motifs from MHC class I alleles found in the herd at Compton were identified. cDNA libraries were constructed and screened for full length class I sequences. The isolated cDNA clones were then transfected into mouse P815 cells and the expressed product immunoprecipitated and matched with a serological specificity. The bovine MHC class I molecules were isolated from lysed transfected cells by affinity chromatography, using a monoclonal antibody specific for bovine MHC class I, and bound peptides were separated by reverse-phase HPLC. Analysis of the protein sequences of bovine RSV for the defined motifs has identified potential CTL epitopes.

Incidence of tissue coring with the 25-gauge Quincke and Whitacre spinal needles

BACKGROUND AND OBJECTIVES

Tissue cores, implanted into the subarachnoid space during subarachnoid injections, can develop into intraspinal lumbar epidermoid tumors. The availability of smaller needles has made spinal anesthesia more popular. Therefore, this prospective, randomized, blinded study was undertaken to determine whether tissue coring occurs with two of the currently used 25-gauge spinal needles.

METHODS

Fifteen 25-gauge Quincke and seventeen 25-gauge Whitacre spinal needles, in which cerebrospinal fluid (CSF) was not identified and the local anesthetic solution not injected, were obtained from adult male patients undergoing spinal anesthesia. The needles were then evaluated by a pathologist following randomization with similar sterile, unused spinal needles. Twenty additional needles, ten of each type, in which CSF was identified and through which local anesthetic was injected, were also randomized with similar sterile, unused spinal needles and examined.

RESULTS

Tissue cores were identified in 12 of the 15 Quincke and 7 of the 17 Whitacre spinal needles in which CSF was not identified (P < .05). Of the 20 needles in which CSF was identified and local anesthetic injected, no tissue cores were identified in the 10 Whitacre needles and only one small tissue core was identified in the 10 Quincke needles. All the tissue cores were identified as fat tissue.

CONCLUSIONS

The 25-gauge Quincke and 25-gauge Whitacre spinal needles currently used in anesthesia can produce tissue coring.

Colour Doppler ultrasound in renal artery stenosis: intrarenal waveform analysis

Renal artery stenosis (RAS) is the commonest secondary cause of hypertension and may result in renal ischaemia with resultant renal failure. Recent studies hve suggested that colour Doppler ultrasound, with spectral analysis of the intrarenal waveforms, can identify those patients with a significant RAS. A prospective study was performed in which colour Doppler ultrasound was compared with angiography in 73 patients (143 kidneys) presenting for renal angiography. Colour Doppler ultrasound was unsuccessful in 16% of kidneys due to a combination of technical failures and small kidney size. Accessory renal vessels were present in 14% of kidneys on angiography but none was detected by ultrasound. Of the 120 kidneys that had both examinations, no significant difference in intrarenal pulsatility or resistive index was noted between the angiographically stenosed and normal arteries. There were significant differences for intrarenal peak and end diastolic velocities, and acceleration time and index. Of these measurements, acceleration time was the best indicator of RAS. The probability of detecting a high grade RAS in an individual patient did not reach 90% until the acceleration time was prolonged to more than 0.12 s. Intrarenal colour Doppler ultrasound is not a general screening test for RAS and it should be reserved for selected patient groups where the incidence of disease is high. Patients with prolonged acceleration times of more than 0.12 s have a high likelihood of at least 70% RAS and should proceed directly to angiography.

Influence of selective T-lymphocyte depletion on the lung pathology of gnotobiotic calves and the distribution of different T-lymphocyte subsets following challenge with bovine respiratory syncytial virus

The depletion of CD8+ T-lymphocytes with a murine monoclonal antibody (mAb) specific for the CD8 molecule delayed the ability of three gnotobiotic calves to clear bovine respiratory syncytial virus (BRSV) from their lungs within 10 days after an experimental challenge with the virus. This protracted infection was associated with an enhanced pneumonic consolidation score (21.6 per cent) compared with seven control calves (7.4 per cent) and a histological lesion of active respiratory epithelial hypertrophy. Three gnotobiotic calves depleted of the CD4+ subpopulation with the appropriate mAb also had enhanced macroscopic lesions (16.6 per cent) but the histological lesion was less active. The depletion of the gamma/delta TCR+ WC1+ subpopulation had no apparent effect on the macroscopic or microscopic pulmonary lesions. Although the depletion of the CD8+ or the CD4+ subpopulations enhanced the pulmonary lesions, no clinical signs of respiratory disease were detected. Immunoperoxidase labelling and image analysis of the lymphocyte subpopulations in lung tissue revealed an increase in the number of CD8+ T cells after the infection of non-depleted, control calves, especially in the lamina propria of the large bronchioles. Calves depleted of individual lymphocyte subsets and infected with BRSV showed no compensatory increase in the remaining subpopulations and no lymphoreticular hyperplasia.

Primary cytotoxic T-cell responses to bovine respiratory syncytial virus in calves

Bovine respiratory syncytial virus (RSV) is a major cause of respiratory disease in young calves. Recent studies in calves, in which different T-cell subsets were depleted, have shown that CD8+ T cells play a central role in recovery from RSV infection. The present study demonstrates that RSV-specific, major histocompatibility complex-restricted cytotoxic T cells appear in the peripheral blood of gnotobiotic calves 7-10 days after infection with bovine RSV and were also detected in the lungs 10 days after infection. The cytotoxic T lymphocytes (CTL) recognized antigenically distinct strains of bovine RSV. There was no correlation between either the level of CTL activity in the lung or the development of CTL in the peripheral blood and the extent of pneumonic consolidation. The demonstration of CD8+ CTL in the lungs at a time when bovine RSV has been cleared confirms the importance of these cells in recovery from infection.

Cardioesophageal reflex: a mechanism for "linked angina" in patients with angiographically proven coronary artery disease

OBJECTIVES

The purpose of this study was to investigate the presence of a cardioesophageal reflex in patients with coronary artery disease that may explain the mechanism of "linked angina."

BACKGROUND

It has been previously shown that esophageal acid stimulation can reduce coronary blood flow in patients with syndrome X, suggesting the presence of a cardioesophageal reflex in humans.

METHODS

We studied the effect of esophageal acid stimulation on coronary blood flow in 14 patients with angiographically documented significant coronary artery disease and in 18 heart transplant recipients. Hydrochloric acid (0.1 mol/liter) and 0.9% saline solution were infused in random, double-blind manner (60 ml over 5 min) through a fine-bore tube positioned in the patient's distal esophagus, and coronary blood flow measurements were obtained after each infusion by use of a 3.6F intracoronary Doppler catheter positioned in the proximal left anterior descending coronary artery.

RESULTS

Coronary blood flow was reduced significantly by esophageal acid stimulation in the coronary artery disease group (before acid 70.4 +/- 14.3 ml/min, after acid stimulation 46.4 +/- 19.1 ml/min [mean +/- SD], p < 0.01). However, there was no significant difference in coronary blood flow during saline infusion (73.5 +/- 15.3 vs. 72.5 +/- 14 ml/min). Coronary blood flow in the heart transplant group was not affected by acid or saline infusion.

CONCLUSIONS

Esophageal acid stimulation can cause animal attacks and significantly reduce coronary blood flow in patients with coronary artery disease. The lack of any significant effect in heart transplant recipients with heart denervation suggests a neural reflex.

Mutant forms of the F protein of human respiratory syncytial (RS) virus induce a cytotoxic T lymphocyte response but not a neutralizing antibody response and only transient resistance to RS virus infection

Vaccinia virus (vv) recombinants expressing either wild-type (VA-F) or mutant forms (VA-FT, VA-FR47, VA-FS1 to VA-FS6) of the fusion (F) protein of respiratory syncytial (RS) virus were examined for their ability to elicit antibody, cytotoxic T lymphocytes (CTL) and protection against RS virus infection in BALB/c mice. Cells infected with the VA-F and VA-FT recombinants expressed the F protein on their surface and mice vaccinated with these recombinants developed RS virus neutralizing antibodies. The VA-FR47 recombinant expressed a mutant form of the F protein (with six amino acid changes from the wild-type) in which both proteolytic processing of the F0 precursor and its transport to the cell surface were inhibited. These mutants induced transient protection against RS virus infection although they did not induce RS virus neutralizing antibodies, or antibodies detectable by ELISA. All the vv recombinants were able to induce an RS virus-specific, MHC class I restricted CTL response. Vaccination of mice with a second set of vv recombinants expressing mutant forms of the F protein showed that the replacement Phe to Ser at amino acid 237 either alone or in combination with others abolished the neutralizing antibody response but did not affect priming of CTLs. These results demonstrate that long-term protection against RS virus infection in mice vaccinated with recombinant vv expressing the F protein is more dependent upon the induction of an antibody rather than a CTL response.

Pulmonary first-pass and steady-state metabolism of phenols

PURPOSE

To study (A) the effect of the administration route (i.v. and i.t.) on pre- and post-absorptive metabolism of phenol and 1-naphthol by the lung and (B) pulmonary extraction of phenol at steady-state.

METHODS

Phenols were administered intra-arterially, intravenously and intratracheally and the pre- and post-absorptive metabolism assessed by comparing the AUCs in arterial blood. Phenol was infused to steady-state and the pulmonary extraction assessed by measuring jugular vein and carotid artery blood concentrations.

RESULTS

In contrast to previously published data (e.g., Mistry and Houston, Drug Metab.Dispos.l3:740-745 (1985)) we could not detect pulmonary first-pass metabolism of the phenols; reasons for this disparity are discussed. An apparent negative pulmonary extraction of phenol at steady-state was observed, probably as a consequence of extraction by organs which are in series, and not parallel, with the lungs (e.g. liver, kidneys and GIT).

CONCLUSIONS

(A) Phenol and 1-naphthol do not undergo pulmonary first-pass metabolism. (B) Traditional methods of assessing organ extraction and clearance at steady-state cannot be utilised when metabolising organs are in series.

Male reproductive systems under chronic fluoxetine or trimipramine treatment

Adult male Long-Evans rats (n = 9 per group) received daily exposure for 4 weeks to fluoxetine (0.75 mg FLUOX/kg body weight) or trimipramine (1.6 mg TRIMI/kg body weight). Separate tests of copulation, sexual motivation, and intermale aggressive behaviors were used to evaluate functional changes during chronic exposure to either typical or atypical antidepressant drugs with more or less serotonin specificity. Circulating hormones, primary and secondary sex structures, and concentrations of dopamine (DA) and serotonin (5-HT) from mesolimbic tissue were assessed at necropsy. Results of tests with estrous females and untreated males revealed progressive disruption to sexual performance and aggressive responsiveness over time of treatment with TRIMI and, to a lesser extent, with FLUOX. By contrast, motivation, testosterone, and all measures of reproductive physiology were indistinguishable from controls. Ratios of transmitter metabolites relative to the parent compounds indicated similar reductions of 5-HT turnover with FLUOX and TRIMI. However, influences on DA turnover were significantly less with FLUOX than with TRIMI. Conclusions are that long-term intervention with antidepressant drugs may disrupt sociosexual exchanges without compromising male rats' interest in sexual contact or integrity of their reproductive physiology. Lessened disruption of sociosexual behaviors with this regimen of chronic FLUOX treatment may be related to the greater selectivity on serotonin relative to dopamine turnover.

High activated and memory cytotoxic T-cell responses to HTLV-1 in healthy carriers and patients with tropical spastic paraparesis

The cytotoxic T-lymphocyte (CTL) response to HTLV-1 is directed mainly against the Tax protein. Circulating, activated Tax-specific CTL can be found in a majority of healthy carriers and patients with the HTLV-1-associated disease tropical spastic paraparesis (HAM/TSP). In this study we present data on the Tax-specific CTL response of 26 HTLV-1 carriers, including 10 newly recruited subjects. Rex-specific CTL were not found in any subjects investigated. Activated and memory CTL responses were determined separately in 4 healthy carriers, 3 HAM/TSP patients, and 1 "seronegative HAM/TSP." In all subjects, the mean frequency of peptide-specific memory cells per epitope (1/1307) was high. There was no significant difference in mean memory CTL frequency per epitope or in the proportion of subjects with activated CTL between healthy carriers and HAM/TSP patients. One individual with HAM/TSP had an unusually high frequency response to two peptides, suggesting immunodominance of epitope recognition in this individual. We conclude that the magnitude and components of the HLTV-1-specific CTL response do not differ between healthy carriers and HAM/TSP patients. These data do not support a specific CTL-mediated component in the pathogenesis of HAM/TSP.

Promoting compliance with tuberculosis drug therapy

The recent increase in the notifications of tuberculosis infections has focused the attention of healthcare professionals on reasons for the disease's resurgence. This article describes how directly observed therapy and an enlightened approach to health promotion for groups of people perceived as being at risk, could prevent further increases in incidence.