Validity testing of the EZ-SCREEN cannabinoid test

Recently, a number of "quick tests" became available for use in on-site drug testing. These tests offer advantages in simplicity, ease of performance, and rapid access to test results. However, there is a paucity of data on the validity of these tests for the detection of drugs of abuse. This report describes a validity study of the EZ-SCREEN cannabinoid test for the detection of cannabinoids in urine. Three healthy, male volunteers with a history of marijuana use participated in the study. Each subject smoked 1, 2, or 4 marijuana cigarettes (2.6% THC) on each test day. Urine samples were collected and incorporated into a specimen set consisting of 178 clinical urine samples, 72 urine samples containing known amounts of drug, and 50 drug-free urine samples. The specimen set was randomized and analyzed under blind conditions by the EZ-SCREEN test and by GC/MS for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH). Results were interpreted independently by three readers. Concordance analysis was performed by comparison of results of the EZ-SCREEN test with GC/MS. The EZ-SCREEN test was highly sensitive and produced positive results at a standard THCCOOH concentration of 5 ng/mL. While showing high sensitivity to THCCOOH, the assay demonstrated low cross-reactivity with delta 9-tetrahydrocannabinol (THC) and other cannabinoids. No false-positive results were recorded with 50 drug-free urine samples, but one reader recorded eight undecided results. Overall agreement between the three readers for the EZ-Screen results was approximately 80%. Delayed readings and photocopy readings tended to be less accurate than readings obtained at 3 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Augmented femoral venous return

We present a technique of femoral cardiopulmonary bypass that allows excellent venous drainage. This is accomplished by augmenting the venous return with a centrifugal pump.

Forensic drug testing for opiates. V. Urine testing for heroin, morphine, and codeine with commercial opiate immunoassays

Urine specimens collected after heroin, morphine, and codeine administration were tested by four commercial opiate immunoassays (TDx, CAC, ABUS, and EMIT) and GC/MS. Quantitative immunoassay results (morphine equivalents) were compared with results by GC/MS for total morphine, free morphine, or total codeine. Mean detection times for the broadly cross-reacting immunoassays (TDx, ABUS, and EMIT, 300 ng/mL cutoff) ranged from 15-44 hours following heroin and morphine administration and 33-54 hours following codeine administration. Detection times obtained with CAC (25 ng/mL cutoff) tended to be somewhat shorter as a result of the high selectivity of the antibody for free morphine. High correlations over a wide concentration range were obtained for TDx, CAC, and ABUS versus GC/MS, with specimens collected after heroin and morphine administration. EMIT showed a high correlation over a narrow concentration range (0-1000 ng/mL) with heroin and morphine specimens, but responses plateaued at higher concentrations. There was substantial variability in immunoassay responses with specimens collected after codeine administration. Generally, this study demonstrated that immunoassay responses for opiate urine testing can be used as a semi-quantitative guide for GC/MS confirmation; however, the presence of codeine increased variability and diminished the accuracy of the immunoassay response.

Thickness of tissues intervening between the transducer and fetus and models for fetal exposure calculations in transvaginal sonography

In transvaginal scanning the tissues intervening between the fetus and transducer are relatively thin. The average thickness in the first trimester is 25 mm and reduces to 15 mm by the third trimester; the minimum thicknesses are 14 and 8 mm, respectively. Two models are proposed for calculating exposure in transvaginal scanning. The models are considered in terms of the overlying tissues and the target tissues. A fixed path, constant attenuation of 0.3 dB/MHz describes the properties of the overlying tissues throughout pregnancy. In the model used in first-trimester scanning, the target tissues of the embryo/fetus are considered to have properties similar to those of soft tissues, and they attenuate the energy at the same rate as the overlying tissues. In the model used in second- and third-trimester scanning, the bony structures of the fetus are the target tissues. These reflect 30% of the incident energy and attenuate all of the transmitted energy at their surface.

Consequences of physicians' ownership of health care facilities--joint ventures in radiation therapy

BACKGROUND

Physicians are increasingly the owners of health care facilities to which they refer patients for services but at which they do not practice. We studied such ownership arrangements, known as "joint ventures," in the field of radiation therapy, examining their effects on access, use of services, costs, and quality.

METHODS

Because 44 percent of free-standing facilities providing radiation therapy in Florida in 1989 were joint ventures, as compared with 7 percent elsewhere (95 percent confidence interval, 3 to 10 percent), we compared data for Florida with comparable data for the remainder of the United States. We also compared radiation-therapy facilities in Florida that were established as joint ventures with those that were not. Since most data were derived from entire populations rather than from samples, any differences found were of necessity statistically significant.

RESULTS

No joint-venture facilities providing radiation therapy were located in inner-city neighborhoods or rural areas, but 11 percent of other free-standing facilities and hospital-based facilities were located in such areas. Among free-standing facilities, joint ventures received 39 percent of their revenues from patients with well-paying insurance coverage, as compared with 31 percent for facilities that were not joint ventures (P < 0.01). The frequency and costs of radiation-therapy treatments at free-standing centers were 40 to 60 percent higher in Florida than in the rest of the United States; there was no below-average use of radiation therapy at hospitals or higher cancer rates that explained the higher rates of use or higher costs in Florida. Radiation physicists at joint-venture facilities (the principal personnel involved in quality control other than physicians) spent 18 percent less time with each patient over the course of treatment than did their counterparts at free-standing facilities that were not joint ventures (P < 0.05). Mortality among patients with cancer in Florida was not lower than the U.S. average, even though joint ventures are much more common in that state.

CONCLUSIONS

Joint ventures in radiation therapy appear to have adverse effects on patients' access to care. They also appear to increase the use of services and costs substantially. Some indicators show that joint ventures cause either no improvement in quality or a decline. Our results add to the evidence indicating that physicians' self-referral generally has negative consequences. We recommend legislation to ban ownership of joint ventures by referring physicians. Such legislation needs to be carefully designed in order to achieve its objectives and forestall new, financially abusive arrangements.

New evidence of the prevalence and scope of physician joint ventures

Physician ownership of health care businesses (outside their own practice) to which they refer patients has attracted considerable attention in the medical literature, in the media, and from federal and state policymakers. Despite the concerns raised about these ownership arrangements, known as joint ventures, the prevalence and scope of joint ventures involving physicians is not well documented. This report examines the prevalence and scope of physician joint ventures in Florida based on data collected under a legislative mandate. Our results indicate that physician ownership of health care businesses providing diagnostic testing or other ancillary services is common in Florida. While this conclusion is based on our comprehensive survey of health care businesses in Florida, it is at least indicative that such arrangements are likely to occur elsewhere. We find that at least 40% of Florida physicians involved in direct patient care have an investment interest in a health care business to which they may refer their patients for services; over 91% of the physician owners are concentrated in specialties that may refer patients for services. About 40% of the physician investors have a financial interest in diagnostic imaging centers. The estimates reported here indicate that the proportion of referring physicians involved in direct patient care who participate in joint ventures is much higher than previous estimates suggest.

Inhibitory effect of topical application of a green tea polyphenol fraction on tumor initiation and promotion in mouse skin

A green tea polyphenol fraction was evaluated for its ability to inhibit tumor initiation by polycyclic aromatic hydrocarbons and tumor promotion by a phorbol ester in the skin of CD-1 mice. Topical application of the green tea polyphenol fraction inhibited benzo[a]pyrene- and 7,12-dimethylbenz[a]-anthracene-induced tumor initiation as well as 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced tumor promotion. Topical application of the green tea polyphenol fraction also inhibited TPA-induced inflammation, ornithine decarboxylase activity, hyperplasia and hydrogen peroxide formation. Studies with individual polyphenolic compounds in green tea indicated that topical application of (-)-epigallocatechin gallate, (-)-epigallocatechin and (-)-epicatechin gallate inhibited TPA-induced inflammation in mouse epidermis.

Forensic drug testing for opiates. IV. Analytical sensitivity, specificity, and accuracy of commercial urine opiate immunoassays

Four commercial immunoassays, TDx Opiates (TDx), Coat-A-Count Morphine in Urine (CAC), Abuscreen Radioimmunoassay for Morphine (ABUS) and Emit d.a.u. Opiate Assay (EMIT), were tested for sensitivity, specificity, and accuracy with urine specimens containing known amounts of opiates and opiate metabolites. The immunoassays were evaluated in a semiquantitative mode by comparison of morphine equivalents to GC/MS assay of free and total morphine and codeine or to target concentrations. In all cases, the apparent sensitivities of the assays were higher than those required for detection of morphine at cutoffs mandated by the Health and Human Services guidelines for testing of Federal workers. The apparent specificities of the immunoassays varied considerably. The CAC assay was found to be highly selective for free morphine, whereas TDx, ABUS, and EMIT demonstrated broad cross-reactivity with other opiates. Comparison of semiquantitative results from the immunoassays with GC/MS data indicated a high degree of accuracy for determination of morphine levels. Generally, the patterns of sensitivity and cross-reactivity were unique for each assay, indicating that a detailed knowledge of assay performance characteristics is necessary for accurate interpretation of forensic urine testing data.

Physician self-referral: empirical evidence and policy implications

Ownership of health care businesses to which physicians refer patients but at which they do not directly provide services, has become commonplace in recent years. Perhaps these self-referral arrangements, known as "joint ventures," have proliferated because they are lucrative investments whereby physicians can earn legalized kickbacks for patient referrals. This article reviews existing empirical studies documenting the effects of physician self-referral arrangements. The general concensus of the empirical evidence on physician self-referral reveals that the financial incentives inherent in such arrangements are associated with increased utilization of services and higher costs to patients. None of the studies to date, however, has been able to determine whether the increased utilization that accompanies the practice of physician self-referral represents inappropriate or unwarranted services. Policy options which address the problem of physician self-referral are also discussed.

Forensic drug testing for opiates, III. Urinary excretion rates of morphine and codeine following codeine administration

The urinary excretion profile of free and conjugated codeine and morphine was determined by GC/MS for four healthy male subjects after intramuscular administration of 60- and 120-mg doses of codeine. Codeine and metabolites were rapidly excreted with the majority of drug appearing in the first 24 h. No dose-related differences in metabolism were observed. The initial ratio of total codeine to total morphine was substantially greater than 1.0 but declined over time. For two of the four subjects, the codeine-morphine ratio declined below 1.0 late in the elimination phase. With a 300-ng/mL cutoff, one subject tested positive on more than one occasion for total morphine and negative for codeine during the terminal elimination phase. The data indicate that urine codeine-morphine ratios are not reliable indices of the type of opiate exposure.

The golden hours of the myocardial infarction: nonthrombolytic interventions

Emergency care of patients with acute myocardial infarction requires active decision making to use agents that may improve morbidity and mortality. Thrombolysis remains the primary tool to accomplish this goal. Other pharmacologic agents, including lidocaine, nitrates, calcium channel blockers, beta-blockers, and aspirin, have been used acutely in myocardial infarction in the hopes of preventing death and salvaging myocardium. The decision to select one or all of these agents requires a knowledge of the clinical evidence of their efficacy and risk-to-benefit ratios. The clinical studies of the use of these agents acutely in the management of myocardial infarction are reviewed.

Work behavior after the onset of arthritis

Considerable evidence indicates that poor health has significant negative effects on labor force market activity. Nevertheless, because most of these analyses are based on cross-sectional data, their findings only indicate the relationship between poor health and work at a moment in time. This article uses a dynamic hazard model to examine how the onset of arthritis affects work behavior over the life cycle. The results indicate that the deterioration of health over time is the most significant determinant of why men with arthritis leave the labor force earlier than their otherwise healthy counterparts. These findings imply that the health-work relationship should be examined within the context of a life cycle framework to obtain a complete picture of the economic consequences of poor health.

Forensic drug testing for opiates. II. Metabolism and excretion rate of morphine in humans after morphine administration

Urine levels of free and total morphine were determined by GC/MS for four male subjects who received single doses of 20 mg of morphine sulfate intramuscularly. Peak concentrations were observed within 10 h for both conjugated and free morphine; thereafter, levels declined rapidly. Initially, free morphine represented from 25 to 34% of the total amount of morphine present, but this ratio declined after 12 h to an average of only 5.9% of total morphine. Free morphine accounted for an overall mean of 6.8% of the dose excreted in urine and conjugated morphine for 58.6%. The mean excretion half-life for free morphine was 6.6 h and for conjugated morphine was 8.2 h. The lower concentration and shorter half-life of free morphine resulted in a shorter detection time for free morphine versus total morphine at a 300-ng/mL cutoff. An equivalent detection time for free morphine was obtained when its cutoff was lowered to 25 ng/mL. The possibility that morphine is metabolized to codeine was unequivocally ruled out by the finding of an absence of codeine at or above the LOD of the GC/MS assay in all clinical specimens collected after morphine administration.

Vibration perception threshold: influence of age, height, sex, and smoking, and calculation of accurate centile values

Vibration perception threshold (VPT) is increasingly used as a measure of large nerve fibre function in studies of patients with diabetes and in other disorders. In order to establish the influence of age, height, sex, and smoking on VPT values in the normal population and to allow the calculation of accurate age-related percentile charts, 1365 healthy volunteers were studied using a biothesiometer. Measurements were made bilaterally on thumbs, great toes, and over medial malleoli. Multivariate regression analysis confirmed age to be the major determinant of VPT levels at all sites (p less than 0.001). Height was a significant factor for toes and ankles (p less than 0.001) but not thumbs. Sex had no overall effect at toe or thumb but there were differences regarding ankle VPT (p less than 0.01). Log transformation of VPT data produced a linear relationship with age at all sites except at the thumbs in elderly females where there was significant deviation from this model (p less than 0.001) and inverse square root transformation was more appropriate. Smoking had no effect on VPT levels. Age-related centile charts were produced for each site and an easy-to-use computer program was developed to calculate centile values based on raw VPT data, age, height, and sex.

Continuous retrograde blood cardioplegia

We present a technique of myocardial protection using retrograde cold blood cardioplegia. This safe and simple method allows excellent continuous and homogeneous cooling of the heart during the ischemic period in all types of open heart operations.

Forensic drug testing for opiates: I. Detection of 6-acetylmorphine in urine as an indicator of recent heroin exposure; drug and assay considerations and detection times

The urinary excretion patterns of 6-acetylmorphine (6-AM), free morphine, and total morphine were determined by GC/MS assay for six human subjects who received single doses of 3.0 and 6.0 mg of heroin hydrochloride. Clinical specimens were collected and combined with standardized drug urines into a 400 specimen/standard set. The urines were coded, randomized, and analyzed under blind conditions. The GC/MS assay had a limit of sensitivity of 0.81 ng/mL for 6-AM and displayed a linear response across a concentration range of 1-100 ng/mL. Following heroin administration, 6-AM was excreted rapidly with an average half-life of 0.6 h. This resulted in a very short detection time for 6-AM with a range of 2-8 h at the most sensitive cutoff limit. This short detection time limits the usefulness of 6-AM as a marker for identification of heroin abusers to a period immediately after drug use. In contrast, free morphine and total morphine were detectable up to approximately 24 h after heroin administration. The average half-life for free morphine was 3.6 h and for total morphine was 7.9 h. After morphine and codeine administration, no 6-AM was detected by GC/MS above the 0.81-ng/mL detection limit of the assay. It is concluded that the presence of 6-AM in urine can be interpreted with confidence to mean that heroin, or 6-AM, was administered within 24 h of specimen collection and that the presence of 6-AM in urine is not caused by morphine or codeine administration.

Direct ultrasonographic measurement of fetal lung length in normal pregnancies and pregnancies complicated by prolonged rupture of membranes

Fetal lung length was measured directly with ultrasonography in 20 patients with prolonged rupture of membranes, commencing before 25 weeks' gestation. Measurements were made weekly and compared with data collected from 310 normal pregnancies. Measurement of fetal lung length by ultrasonography was a good predictor of pulmonary hypoplasia, predicting greater than 90% of cases. There was a good correlation between lung size assessed by the last ultrasonographic examination and lung weight postmortem (r = 0.783, p less than 0.05). Lung length measurements were superior to fetal chest circumference measurements in the identification of pulmonary hypoplasia. There was a significant negative association between the amount of amniotic fluid and pulmonary hypoplasia (p less than 0.05). There were fetuses with pulmonary hypoplasia that had respiratory movements seen at the majority of ultrasonographic examinations.

Gas chromatographic-electron-impact mass fragmentometric determination of lysergic acid diethylamide in urine

A sensitive method for the detection and quantitation of lysergic acid diethylamide (LSD) in urine was developed. After initial solvent extraction, the compound was further purified by liquid-liquid extraction or by solid-phase extraction. The trimethylsilyl derivative of LSD was detected by gas chromatography-mass spectrometry (GC-MS) operated in the electron-impact mode with selected-ion monitoring. The presence of LSD was confirmed by comparing retention times and relative abundances of ions of unknowns with that of a standard. The recovery of this procedure was greater than 89%. The intra-run and inter-run coefficients of variation were less than 5% and less than 7%, respectively. This procedure allows detection of LSD concentrations as low as 29 pg/ml. Quantitation of LSD was linear over the concentration range 50-2000 pg/ml.

Manpower needs in academic emergency medicine

One of the value statements of the American College of Emergency Physicians states that, "Quality Emergency Medicine is best practiced by qualified, credentialed emergency physicians." To address this value ACEP has established the following goal: "The number of board-certified physicians will be sufficient to meet the manpower needs of the public." It is the position of ACEP that there is currently a severe shortage of appropriately trained and certified emergency physicians and, moreover, that the shortage will continue well into the next century. We discuss how ACEP arrived at this position and the role of academic emergency medicine in addressing this shortage. For many years, there has been a public debate as to whether there is a physician shortage or surplus. The Graduate Medical Education National Advisory Commission report of 1980 estimated that there would be 630,000 US physicians by 1990, with a surplus of 70,000. This report also identified emergency medicine as a shortage specialty, indicating there would be a need for 14,000 emergency physicians in 1990, with a supply of only 8,000. Schwartz included such factors as increased provision of administrative and research activity by physicians and concluded that there would be a shortage of 7,000 physicians by the year 2,000.

An ethics curriculum for teaching emergency medicine residents

Instruction in medical ethics has become standard in undergraduate medical education within the past decade; more recently, several specialty boards have formally endorsed ethics teaching and evaluation for residents as well. However, the current emergency medicine Core Content, representing emergency medicine's central body of knowledge, makes no specific mention of ethics. An ethics curriculum is proposed to remedy this gap in the emergency medicine residency curriculum. Issues frequently encountered in the emergency department are emphasized, and topics include moral foundations of clinical medicine, the unique ethical concerns of emergency medicine, patient competence, informed consent and refusal of treatment, truthfulness, confidentiality, foregoing life-sustaining treatment, duty to provide care, moral issues in disaster medicine, allocation of health care, and research and teaching involving human subjects. Educational objectives and readings for each of these topics are presented along with sample case scenarios to be used in a small group discussion format.

Thyroid disease in the emergency department. Thyroid function tests and hypothyroidism and myxedema coma

The recognition of hypothyroidism may not always be easy in the emergency department setting. Laboratory evaluations of thyroid function are not usually performed on a 24-hour basis, and therefore the emergency physician, although suspecting the presence of hypothyroidism, may be unable to confirm the diagnosis while the patient is in the Emergency Department. It is not always the responsibility of the emergency physician to diagnose hypothyroidism, but in some clinical settings it may be important to include thyroid function tests in laboratory evaluation of patients to ensure adequate patient care and followup. Careful attention to nonspecific complaints, myxedematous changes, and signs of dysfunction of any organ system, especially in older female patients, may lead to the ultimate correct diagnosis. Myxedema coma is potentially fatal and must be recognized and treated emergently, usually prior to laboratory confirmation. Ventilatory support and thyroid hormone replacement are the two most important therapeutic maneuvers in the treatment of myxedema coma.

The use of military antishock trousers in trauma--a reevaluation

The military antishock trousers (MAST) continue to be used widely. The physiologic mechanisms of action have been further elucidated. There are many potential complications associated with their use, some of which are serious. While most observations in the past were based on dog studies or human volunteers, clinical studies are now providing new information that questions the usefulness of the MAST.

Fetal liver length in normal and isoimmunized pregnancies

The length of the right lobe of the fetal liver was measured by means of ultrasound examined on 53 occasions in 21 isoimmunized pregnancies. Fetal blood samples were taken in all patients within 24 hours. Comparisons were made with 350 measurements of liver length in normal pregnancies. A good correlation was found between liver length and fetal hemoglobin level (r = 0.794, p less than 0.001) and between liver length and reticulocyte count (r = 0.721, p less than 0.001). At the time of first sample, all fetuses with a hemoglobin of less than 100 gm/L had a liver length that was greater than the ninetieth percentile. Liver length measurement seems to be a useful indicator of the degree of fetal anemia in isoimmunized pregnancies.

Substantial work disability and earnings losses in individuals less than age 65 with osteoarthritis: comparisons with rheumatoid arthritis

Substantial earnings losses and work disability were seen in individuals less than age 65 with asymmetric oligoarthritis, a surrogate for osteoarthritis, almost as great as those seen with symmetric polyarthritis, a surrogate for rheumatoid arthritis. The proportions of individuals who were working was 66.7% for men and 35.5% for women with asymmetric oligoarthritis, compared to 56.1% and 31.0% of those with symmetric polyarthritis, and 89.4 and 61.6% of those with no arthritis. Rates of work disability in individuals with asymmetric oligoarthritis involving one knee or one hip were in the same range as those in individuals with symmetric polyarthritis involving two knees or two hips. The earnings of women and men with asymmetric oligoarthritis were only 30 and 63% respectively of the earnings of persons with no arthritis. However, less than one-third of these earnings losses were explained by the presence of arthritis, with further explanation from higher age, lower formal education levels, and comorbidity in individuals with asymmetric oligoarthritis. These results suggest that greater attention to demographic and comorbidity variables may be indicated in efforts to control economic losses associated with arthritis.

Gas chromatography/electron impact mass fragmentometric determination of urinary 6-acetylmorphine, a metabolite of heroin

A procedure for detection and quantification of urinary 6-acetylmorphine (6-AM), a metabolite of heroin, is described. After initial solvent extraction from urine, the 6-AM was purified either by acid-base liquid-liquid extraction or by solid-phase extraction techniques. The 6-AM was then derivatized to its propionyl ester, which was characterized by gas chromatography/mass spectrometry in the electron impact mode. Confirmation of 6-AM was accomplished by comparing retention times and relative abundances of selected ions with that of a standard. Quantification was based on 6-[2H3]acetyl-N-[2H3]methylnormophine (6-[2H6]AM) as internal standard. Excellent linearity was obtained in the concentration range 1-100 ng/mL. The overall yield after solvent extraction and acid-base purification ranged from 79 to 82%; for solvent extraction and solid-phase purification, it was 92 to 95%. The limit of detection was 810 pg/mL. Within-run and between-run CVs for 6-AM at concentrations in the range 1-100 ng/mL were generally less than 5% and less than 10%, respectively.

GC/MS analysis of phencyclidine acid metabolite in human urine

Available methods for determining PCP use are based on the presence of the parent drug in urine. PCP, however, is very potent and is extensively metabolized; it is therefore present in urine in only small quantities. This work was undertaken to determine whether an amino acid metabolite of PCP, 5-(N-(1'-phenylcyclohexyl)amino)pentanoic acid, can be used to determine PCP use. A solid phase adsorption technique was developed to extract the amino acid metabolite from urine. Recovery averaged 93%, and subsequent GC/MS analysis was free from interference. Analysis of 67 urine samples demonstrated that the amino acid metabolite exists in human urine in significant quantities.

The importance of age, education, and comorbidity in the substantial earnings losses of individuals with symmetric polyarthritis

A population-based survey designed to be representative of the entire US population of working age (18-64 years) includes data on pain and swelling of specific joints in each subject. We analyzed these data to estimate work status and disability status, as well as earnings losses, associated with Symmetric Polyarthritis. Subjects identified in the survey as having Symmetric Polyarthritis were similar in age, race, sex, and marital status to rheumatoid arthritis patients seen in clinical settings. Overall, 51% of women with Symmetric Polyarthritis and 47% of men with Symmetric Polyarthritis were severely disabled, compared with 4.5% of women and 3.7% of men with no arthritis. Earnings of women and men with Symmetric Polyarthritis were only 27% and 48%, respectively, of earnings of individuals without arthritis. The total earnings gap between the 2 groups was +17.6 billion (1986 dollars). Econometric regression analyses indicated that about one-third of this earnings gap was explained by the presence of Symmetric Polyarthritis. The remaining two-thirds was explained by differences in age, education, and comorbidity between individuals with Symmetric Polyarthritis and those without arthritis. The earnings of individuals with Symmetric Polyarthritis, therefore, would be expected to be considerably lower than those of the general population, even if these individuals were not affected by arthritis. Nonetheless, earnings losses of at least +6.5 billion annually are explained by Symmetric Polyarthritis.

Detection and quantitation of urinary 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid, a metabolite of tetrahydrocannabinol, by capillary gas chromatography and electron impact mass fragmentography

A procedure for detection and quantitation of 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid, a major metabolite of delta-9-tetrahydrocannabinol in urine, has been described. Since the metabolite is present in both conjugated and unconjugated forms, hydrolysis of urine was carried out to increase the sensitivity of detection. The acidic metabolite was isolated by strongly basic anion exchange resin, and subsequently derivatized to methyl 1-dehydroxy-1-methoxy-11-nor-delta-9-tetrahydrocannabinol-9-carbox ylate (1a) by methyliodide in the presence of tetramethylammonium hydroxide. The derivatized product was separated in a capillary column gas chromatograph, and finally detected by a mass spectrometer under electron impact mode. Confirmation of the product was carried out by monitoring three ions that represent the major portions of the molecule and comparing their relative abundances to that of a standard. Quantitation was based on 5'-2H3-11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid as internal standard. Excellent linearity was obtained over the range of 2 to 1000 ng/mL. The overall yield of extraction using the anion exchange resin was 50 to 60%. This extraction process is rapid and suitable for a large number of sample analyses. The methylated product (1a) is stable for at least 72 hr at room temperature.

Cardiopulmonary arrest secondary to lightning injury in a pregnant woman

A young woman who was seven months pregnant was struck by lightning, resulting in cardiopulmonary arrest. Bystander CPR was begun at the scene. Vital signs were restored by the time the rescue squad arrived. The patient was comatose on arrival in the emergency department and fetal death was apparent. The patient's neurological status improved markedly, with a small residual motor deficit.

Effects of arthritis on wage earnings

Arthritis is the most frequently reported health condition in the working-age population, reported by nearly one quarter of the age 45 to 64 population in the 1978 Social Security Survey of disability and work. An economic model of earnings, which controls for differences in socioeconomic characteristics and other health conditions, indicates that arthritis is responsible for an annual loss of approximately $17 billion in wage earnings in the United States.

Arthritis and the earnings of men. An analysis incorporating selection bias

Arthritis is a chronic and crippling disease which affects the work effort and earnings of more than 14 million working-age victims. This paper examines the effects of arthritis on the earnings of men aged 18 to 64. Arthritis has large and significant effects on earnings. Most models incorporating selection bias have examined groups with lower labor force participation rates than prime-age males, but significant selection bias is found here. When selection bias is considered, the estimated absolute effects of arthritis are increased and the percentage of the gap between arthritic and non arthritic males explained by arthritis, as opposed to other factors, increases. This study is unusual in identifying the effects of a single disease on earnings.

Simultaneous identification and quantitation of codeine and morphine in urine by capillary gas chromatography and mass spectroscopy

An analytical procedure for simultaneous determination of codeine and morphine in urine is described. The detection of codeine and morphine is based on liquid-liquid extraction and derivatization to the acetylated compounds. The acetylated codeine and morphine are separated by capillary gas chromatography and identified mass spectrometrically by selected ion monitoring (SIM). Quantitative determination was carried out by SIM using nalorphine as internal standard. Excellent linearity was obtained over a concentration range of 25 to 800 ng/mL. The overall recovery for codeine and morphine in the extraction was found to be 58% and 40%, respectively. The on-column sensitivity for both compounds was 2 ng at a peak-to-noise ratio of 5:1. The derivatives, acetylcodeine, diacetylmorphine, and diacetylnalorphine were stable at room temperature for 72 hr.

Pacemaker therapy in the seventies: interaction of patient age, time of implant, and indications for pacing

In the 1970s, 707 patients received a primary pacemaker implant in our hospital. An analysis of the indications for pacemaker therapy revealed that one-third had third degree heart block, one-third had sick sinus syndrome and one-third had other indications. The distribution of indications was identical in all age groups. Furthermore, this distribution did not change from the first half of the decade to the second.

Periodic alternating skew deviation

A 78-year-old hypertensive woman suddenly developed blurred vision, followed shortly by dizziness, difficulty walking with a tendency to veer to the left, and vertical diplopia. Examination 3 weeks later revealed a unique neuro-ophthalmologic motility pattern, which may be described as periodic alternating skew deviation. This previously unreported motility disturbance was associated with downbeat nystagmus in our patient, and a focal lesion at the level of the interstitial nucleus of Cajal was demonstrated on computed tomography. The spectrum of physiologically related motility patterns--including periodic alternating nystagmus, cyclic oculomotor paralysis, see-saw nystagmus, periodic alternating gaze deviation, "ping-pong" gaze, and intermittent aperiodic alternating skew deviation--has been considered and is helpful in topical neuro-ophthalmologic diagnosis.

Induction of renal cancers in rats by intrarenal injection of nickel subsulfide

The carcinogenicity of nickel subsulfide (alpha Ni3S2) was studied following intrarenal (i.r.) injection in rats. Within 100 weeks after i.r. injection of 5 mg of alpha Ni3S2, renal cancers were found in 64 percent of Wistar-Lewis rats, 50 percent of NIH Black rats, 28 percent of Fischer rats and 0 percent of Long-Evans rats. These findings demonstrate significant differences in susceptibilities of the four rat strains to alpha Ni3S2-induction of renal cancers. No renal cancers were found in male Fischer rats that received i.r. injection of alpha Ni3S2 in dosages of 0.6, 1.2 or 2.5 mg. In male Fischer rats that received i.r. injection of alpha Ni3S2 in dosages of 5 or 10 mg, the incidences of renal cancers were 28 percent and 75 percent, respectively. These findings demonstrate a dose response relationship for alpha Ni3S2-induction of renal cancers. In male Fischer rats that received i.r. injection of 10 mg of alpha Ni3S2 combined with 6.9 mg of Mn dust, the incidence of renal cancers was 32 percent, which differed significantly from the corresponding incidences of 75 percent and 0 percent in rats that received i.r. injections of only alpha Ni3S2 (10 mg) or Mn dust (6.9 mg). These findings demonstrate that alpha Ni3S2-induction of renal cancers is inhibited by simultaneous administration of manganese dust. The 54 renal tumors that were found in this study were all malignant, and distant metastases were present in 69 percent of tumor-bearing rats. The histogenesis of alpha Ni3S2-induced renal tumors from epithelial or mesenchymal progenitor cells could not be definitely established.

Eye malformations in rats: induction by prenatal exposure to nickel carbonyl

Exposure of pregnant rats to inhalation of nickel carbonyl on days 7 or 8 of gestation frequently causes the progeny to develop ocular anomalies, including anophthalmia and microphthalmia. The incidence of extraocular anomalies is very low. The specificity of nickel carbonyl for induction of ocular anomalies in rats appears to be unique among known teratogenic agents.

Serum ceruloplasmin concentrations in rats with primary and transplanted sarcomas induced by nickel subsulfide

Ceruloplasmin (CPN) concentrations were measured by p-phenylenediamine oxidase assay in serums from (a) 30 control Fischer rats; (b) 5 rats with primary sarcomas induced by i.m. injection of nickel subsulfide (alpha Ni3S2), and (c) 12 rats at intervals up to six weeks after s.c. transplantation of four alpha Ni3S2-induced sarcomas. Serum CPN concentrations were not significantly increased in rats with primary sarcomas (mean = 0.38 g per liter) (S.D. +/- 0.05), versus 0.35 g per liter (S.D. +/- 0.04) in controls. In contrast, serum CPN concentrations were increased within 11 to 21 days in all rats with transplanted sarcomas. Maximum concentrations of serum CPN occurred at 31 to 34 days after tumor transplantation, (mean = 0.56 +/- 0.05 g per liter), equivalent to 1.6 +/- 0.2 times the initial CPN concentrations in serums obtained prior to treatment (P less than 0.001). The development of hyperceruloplasminemia in rats with transplanted sarcomas and not in rats with primary sarcomas is attributed to greatly enhanced growth-rates of the transplanted neoplasms.

Effects of nickel chloride and nickel carbonyl upon glucose metabolism in rats

Hyperglycemia, hyperglucagonemia and hyperinsulinemia were observed in fasting rats at 0.5 hr after ip injection of NiCl2 (68 mumole per kg). Infusion of somatostatin iv (0.5 mg per rat) did not prevent Ni(II)-mediated hyperglycemia, hyperglucagonemia or hyperinsulinemia. Exposure of rats to inhalation of Ni(CO)4 (1.2 to 6.4 mumole per liter of air per 15 min) caused acute hyperglycemia, similar to that observed after ip injection of NiCl2. Hyperglycemia induced by NiCl2 and Ni(CO)4 was not associated with inhibition of erythrocyte glycolysis measured in vitro by erythrocyte uptake of 1-14C-glucose and release of 14CO2. These findings indicate that Ni-induced hyperglycemia may be mediated by increased pancreatic release of glucagon, but that Ni stimulation of glucagon release differs from stimulation of glucagon release by arginine or epinephrine, since the Ni effect is not antagonized by somatostatin.