A double-blind, placebo-controlled study of fluoxetine in patients with DSM-III-R obsessive-compulsive disorder. The Lilly European OCD Study Group

We have studied the effect of three fixed daily doses of fluoxetine in patients with obsessive-compulsive disorder (OCD) diagnosed according to DSM-III-R. Two hundred and fourteen patients were evaluated in an 8-week double blind, placebo-controlled study. A statistically significantly greater number of fluoxetine-treated patients achieved the prospectively defined criteria for clinical response when compared to placebo treatment. There was a statistically significant overall difference in the PGI rating of symptom change (P = 0.045) and a marginally significant difference (P = 0.089) in the CGI severity rating between groups. Pairwise comparison against placebo showed a marginally statistically significantly greater improvement (P = 0.059) in Y-BOCS-Total score for patients receiving fluoxetine 60 mg daily, and a significantly higher response rate in patients receiving fluoxetine 40 mg or 60 mg daily (P < 0.05). One hundred and sixty one patients continued to a 16-week extension evaluation. There was no significant difference in the rate of reporting of any individual adverse event between placebo and fluoxetine, and the rate of discontinuation due to adverse events was low (< 6% in each study phase). This study supports the growing evidence for the safety and efficacy of fluoxetine in the treatment of OCD.

Gallstone ileus complicating endoscopic sphincterotomy

A case of gallstone ileus is described complicating an endoscopic sphincterotomy. This rare cause of small bowel obstruction should be considered following endoscopic treatment of very large bile-duct calculi.

A consultative study as a catalyst for improving mental health services for rural children and adolescents

The consultative study is one model of academic involvement in public mental health services. However, the effects of consultation and how it acts as a catalyst for change have been poorly documented. The authors describe a consultative study in which a team from a academic training center examined the system of mental health and related human services for children and adolescents in a semirural county in western Pennsylvania. They also present results of a six-year follow-up survey assessing the study's effects. Improvement in the system of care during the follow-up period included creation and maintenance of a children's unit and a partial hospital program for adolescents at the country's community mental health center. The consultative study and the follow-up survey were instrumental in establishing a comprehensive range of services, including intensive case management for severely disturbed youngsters and a home-based mental health services program.

Butyrate production from dietary fibre and protection against large bowel cancer in a rat model

Butyrate slows the growth of cancer cells cultured in vitro. To determine the relevance of the fermentative production of butyrate in vivo, colonic butyrate concentrations were manipulated by feeding different dietary fibres and were related to tumour development in the rat dimethylhydrazine model of large bowel cancer. It has previously been shown that guar gum and oat bran, while highly fermentable, are associated with low butyrate levels in the distal colon, while wheat bran causes significantly higher concentrations. Diets containing these fibres (nominally 10% w:w) were administered for 3 weeks before, for 10 weeks during, and for 20 weeks after dimethylhydrazine administration, after which animals were killed and examined for tumours. Significantly fewer tumours were seen in the rats fed wheat bran compared with those fed guar or oat bran, and the total tumour mass was lowest in rats fed wheat bran. Rats on a 'no added fibre diet' had an intermediate tumour mass. Regression analysis, performed regardless of dietary group, showed that the concentration in stools of butyrate but not of acetate or stool volume, correlated significantly (and negatively) with tumour mass. These findings indicate that fibre which is associated with high butyrate concentrations in the distal large bowel is protective against large bowel cancer, while soluble fibres that do not raise distal butyrate concentrations, are not protective. Thus, butyrate production in vivo does bear a significant relationship to suppression of tumour formation.

Isolated hepatitis B core antibody--can response to hepatitis B vaccine help elucidate the cause?

The finding of a positive hepatitis B core antibody (anti-HBc) in the absence of hepatitis B surface antigen (HBsAg) or hepatitis B surface antibody (anti-HBs) is relatively uncommon. This finding is known to occur during the 'window period' of acute hepatitis B between loss of HBsAg and the appearance of anti-HBs. It may also occur with active infection or following resolution. The aim of this study was to determine if response to hepatitis B vaccination would allow the separation of these subgroups of patients with isolated anti-HBc. Seventeen patients with persistent isolated core antibody were vaccinated and serum obtained at 2, 4 and 8 weeks. Results were compared with a seronegative control group. Six subjects (35%) but no control patients (p = 0.016) responded with a titre of greater than 50mIU/mL at two weeks, suggesting an anamnestic response due to prior infection and immunity. A further seven subjects (41%) finally seroconverted (anti-HBs titre greater than 10mIU/mL) thus excluding chronic infection and suggesting initial false positive results. Only two subjects did not respond to a full course of vaccination, but neither they nor any other subjects were positive for HBV DNA. These results indicate that hepatitis B vaccination and subsequent measurement of anti-HBs will identify evidence of past infection in the form of an anamnestic response in up to one third of the patients and will also exclude chronic infection on the grounds of a normal vaccine response in a majority of the remainder.

Different fibers have different regional effects on luminal contents of rat colon

The purpose of this study was to compare the effects of two highly fermentable fibers (oat brain and guar gum) with those of a less fermentable fiber (wheat bran) on the luminal environment of the large bowel. Rats were fed one of four diets containing either low fiber (2%), a highly fermented fiber (guar, 10%, or oat bran, 10%), or a medium fermented fiber (wheat bran, 10%). Short-chain fatty acids and pH showed a falling gradient along the large bowel with the low fiber, guar, and oat bran diets. However, wheat bran maintained total short-chain fatty acid levels in fresh feces at three times the levels seen with the other diets; both fecal butyrate concentrations and pH were maintained at cecal values in the distal large bowel. Thus, dietary fibers have differing effects on different regions of the luminal environment depending on their fermentability; it appears that slowly fermented fibers have a greater influence on the distal environment. Because butyrate is implicated as having an antitumor action, the variable effects of dietary fiber on tumorigenesis might be accounted for by its ability to influence distal large bowel butyrate concentrations.

Precessional Forcing of Nutricline Dynamics in the Equatorial Atlantic

Climate control of nutricline depth in the equatorial Atlantic can be monitored by variations in the abundance of the phytoplankton species Florisphaera profunda. A conceptual model, based on in situ evidence, associates high abundances of F. profunda with a deep nutricline and low abundances with a shallow nutricline. A 200,000-year record of F. profunda relative abundances, obtained from a deep-sea core sited beneath the region of maximum equatorial divergence at 10 degrees W, has 52 percent of its variance centered on the 23,000-year precessional band. Cross-spectral analysis between the signals of F. profunda and sea-surface temperature, independently derived from zooplankton species, shows their 23,000-year cycles to be coherent and nearly in phase. Abundance minima of F. profunda coincide with times of December perihelion, whereas abundance maxima coincide with June perihelion. These relations indicate that nutricline dynamics in the divergence region of the equatorial Atlantic are controlled by variations in the tropical easterlies, forced by the precessional component of orbital insolation, on time scales greater than 10,000 years.

Spontaneous intramural rupture of the oesophagus

The clinical, endoscopic, and radiological features of seven patients with an uncommon oesophageal injury characterised by long lacerations of the oesophageal mucosa with haematoma formation but without perforation are reported. The injuries were not related to forceful vomiting or any other definable cause but were similar to those previously described as intramural oesophageal rupture. Upper gastrointestinal endoscopy undertaken to identify the cause of haematemesis in six patients proved safe and useful. When dysphagia and odynophagia occurred early in the clinical course to alert the clinician to possible oesophageal injury, radiological contrast studies were used to exclude perforation. One patient in this study had oesophageal cavernocapillary haemangiomatosis which may have caused intramural oesophageal bleeding and submucosal dissection but in the remainder the aetiology of intramural oesophageal rupture remains uncertain. Conservative management was successful in all patients.

Hypovolaemia can potentiate hypoglycaemic stress-induced adrenaline release in the anaesthetized rat

The interaction between hypoglycaemic stress and hypovolaemic stress in promoting adrenaline secretion from the adrenal medulla has been studied in anaesthetised and conscious rats. In anaesthetized rats, insulin (1 IU/kg, i.v.) markedly increased plasma adrenaline concentrations whereas blood sampling alone did not. The hypoglycaemic response to insulin was greatly reduced if donor blood was used instead of saline to replace the withdrawn blood. The hypoglycaemic response was abolished by captopril or saralasin. The results suggest that adrenaline secretion in response to hypoglycaemic stress in anaesthetized rats is potentiated by hypovolaemic activation of the renin-angiotensin system. In contrast, in fully conscious rats, the response to hypoglycaemia was not abolished by captopril, indicating that in the absence of barbiturate anaesthesia, the hypoglycaemic release of catecholamines is not potentiated by the renin-angiotensin system.

Chorioretinal scarring following the Faden operation. A retrospective study of 100 procedures

Following reports of a high incidence of chorioretinal scarring related to the Faden Procedure, a retrospective study was carried out at Moorfields Eye Hospital. One hundred unselected Faden procedures were followed up with orthoptic and fundoscopic examination. Our indications and technique for performing this operation are described. A 7% incidence of chorioretinal scarring was noted; this compares well with previously published figures for conventional squint surgery and this operation should therefore be considered safe.

Effect of codeine and loperamide on upper intestinal transit and absorption in normal subjects and patients with postvagotomy diarrhoea

Patients with chronic severe diarrhoea after truncal vagotomy and pyloroplasty are often difficult to treat using conventional antidiarrhoeal drugs and remain severely disabled. We examined the effect of two drugs, codeine phosphate and loperamide, on upper intestinal transit and carbohydrate absorption, measured non-invasively by serial exhaled breath hydrogen monitoring, in patients with postvagotomy diarrhoea who had previously failed to gain relief from drug therapy. Orocaecal transit was consistently faster in these patients than a group of controls and was associated with malabsorption of glucose. Codeine phosphate 60 mg significantly delayed transit in patients and controls and was associated with a reduction in glucose malabsorption and improvement in symptoms. Loperamide also delayed transit and improved symptoms, but the doses required for this effect (12-24 mg) were higher than usually considered necessary in secretory diarrhoea. These studies indicate that rapid intestinal nutrient transit and associated malabsorption is a factor in the development of diarrhoea postvagotomy and that symptomatic relief can be achieved in most patients by more rational use of existing drugs.

Oceanic Mechanisms for Amplification of the 23,000-Year Ice-Volume Cycle

Situated adjacent to the largest Northern Hemispher ice sheets of the ice ages, the mid-latitude North Atlantic Ocean has an important role in the earth's climate history. It provides a significant local source of moisture for the atmosphere and adjacent continents, forms a corridor that guides moisture-bearing storms northward from low latitudes, and at times makes direct contact along its shorelines with continental ice masses. Evidence of major ice-ocean-air interactions involving the North Atlantic during the last 250,000 years is summarized. Outflow of icebergs and meltwater initially driven by summer insolation over the ice sheets affects midlatitude ocean temperatures, summer heat storage, winter sea-ice extent, and global sea level. These oceanic responses in turn influence the winter moisture flux back to the ice sheets, as well as ablation of land ice by calving. Spectral data indicate that the oceanic moisture and sea-level feedbacks, in part controlled by glacial melt products, amplify Milankovitch (insolation) forcing of the volumetrically dominant mid-latitude ice sheets at the 23,000-year precessional cycle.

Warmth of the Subpolar North Atlantic Ocean During Northern Hemisphere Ice-Sheet Growth

Two 10,000-year periods of Northern Hemisphere continental ice-sheet growth stand out prominently within the last full interglacial-to-glacial cycle. During the first half of each rapid ice-growth phase, the subpolar North Atlantic from 40 degrees N to 60 degrees N maintained warm sea-surface temperatures comparable to those of today's ocean. The juxtaposition at latitudes 50 degrees N to 60 degrees N of an "interglacial" ocean along-side a "glacial" land mass, particularly along eastern North America, is regarded as an optimal configuration for delivering moisture to the growing ice sheets.

Coccoliths as Paleoclimatic Indicators of Pleistocene Glaciation

Selected species of Coccolithophoridae from recent sediments and mid-Wisconsin glacial sediments of the North Atlantic were examined in an attempt to determine cooling effects. All species showed a definite shift southward during the glacial period. The average shift in this planktonic population was 15 degrees of latitude, with the greatest change in the eastern Atlantic. A paleoisotherm map can be drawn on the basis of the temperature boundaries of coccolithophorids. The species boundaries indicate a possible shift in position of the subtropical gyral to a glacial position roughly parallel to the 33-degree line of latitude.