Endothelial keratoplasty: historical perspectives, current techniques, future directions

Endothelial keratoplasty (EK) has recently emerged as an alternative to penetrating keratoplasty (PK) for patients with endothelial diseases, including Fuchs' endothelial dystrophy, pseudophakic bullous keratopathy, and corneal graft failure. EK provides distinct advantages over PK, in that it is a less invasive procedure and leads to more rapid recovery of vision. Additionally, this procedure does not require long-term corneal sutures, eliminating problems with suture breakage, suture abscesses, astigmatism, and wound dehiscence. Disadvantages of EK include the need for specially prepared donor tissue and additional surgeon training or experience. In this review we discuss the history of EK, recent advances that have led to its widespread use, limits and complications of the procedure, and areas for future improvement.

Effects of prednisone on blood lactate concentrations in healthy dogs

BACKGROUND

Glucocorticoids affect carbohydrate and lactate metabolism.

HYPOTHESIS

Administration of prednisone to healthy dogs will result in clinically relevant hyperlactatemia.

ANIMALS

Twelve healthy adult Beagle dogs.

METHODS

Prospective, controlled experimental study. Twelve healthy adult Beagles were divided into 2 groups (3 of each sex per group). One group served as control. The other group received 2 treatments: low, 1 mg/kg prednisone PO q24h for 2 weeks; high, 4 mg/kg prednisone PO q24h for 2 weeks. A washout period of 6 weeks separated the treatments. Blood samples were drawn for whole blood lactate measurement on day (D) 0, D4, and D14 and measured in duplicate.

RESULTS

Compared with the control group, low and high groups had significantly higher blood lactate concentrations at D4 and D14. There was no difference at D0. There was no effect of time within the control group. In the low and high groups, blood lactate concentration was increased at D4 and D14 versus D0. Blood lactate concentration was greater in the high group than the low group at D14 only.

CONCLUSIONS AND CLINICAL IMPORTANCE

Dogs treated with prednisone experience statistically significant increases in blood lactate concentrations, which can result in type B hyperlactatemia. In such cases, improving tissue perfusion, treatment for the commonest form of hyperlactatemia (type A) would be unnecessary.

Efficacy of tadalafil once daily in men with diabetes mellitus and erectile dysfunction

AIMS

Erectile dysfunction (ED) is a common comorbidity in men with diabetes mellitus. Tadalafil 10 or 20 mg taken on demand is efficacious and safe for men with diabetes and ED. Recently, continuous treatment with tadalafil has been proposed, addressing ED management as any other chronic condition. This study examined whether once-daily tadalafil 2.5 and 5 mg is efficacious for men with diabetes and ED.

METHODS

This randomized, double-blind, placebo-controlled, multicentre, 12-week study enrolled 298 men with diabetes and ED to once-daily treatment with placebo, tadalafil 2.5 mg or tadalafil 5 mg. Primary efficacy measures were International Index of Erectile Function Erectile Function (IIEF EF) Domain score, and patient success rates for vaginal penetration and completion of intercourse. Patient satisfaction, endothelial function biomarkers, and safety were also assessed.

RESULTS

Patients receiving either dose of tadalafil had clinically and statistically significant improvements in IIEF EF and statistically significant improvements in mean success rates for vaginal penetration, completion of intercourse, and overall treatment satisfaction (P < or = 0.005 tadalafil vs. placebo, all measures). Endothelial dysfunction biomarkers were unchanged. The most common adverse events were headache, back pain and dyspepsia.

CONCLUSIONS

In this first study of men with diabetes and ED, once-daily tadalafil 2.5 and 5 mg was efficacious and well tolerated, suggesting this may be an alternative to on-demand treatment for some men, eliminating the need to plan sex within a limited timeframe.

Assessment of Eye Bank–Prepared Posterior Lamellar Corneal Tissue for Endothelial Keratoplasty

OBJECTIVE

To evaluate eye bank-prepared tissue for Descemet's stripping automated endothelial keratoplasty (DSAEK).

DESIGN

Experimental study and retrospective case series.

PARTICIPANTS

Seventeen human donor corneas and 4 recipient patients undergoing DSAEK surgery.

METHODS

Corneal-scleral discs were obtained. Specular microscopy and pachymetry were performed. A designated Tissue Banks International technician used a microkeratome to prepare a flap. Posterior bed thickness was measured. The sectioned tissue was stored, and at 24 and 48 hours, pachymetry was repeated. At 48 hours, specular microscopy was repeated, and endothelial cell viability was assessed with trypan blue. Descemet's stripping automated endothelial keratoplasty was performed in 4 patients using eye bank-prepared posterior lamellar tissue.

MAIN OUTCOME MEASURES

Corneal tissue was assessed with the following parameters: corneal thickness measured with ultrasonic pachymetry, cell density counts measured with a keratoanalyzer, and cell viability as observed with trypan blue exclusion. Patient outcomes were measured by changes in visual acuity (VA) and the presence of a clear graft.

RESULTS

Donor corneal pachymetry before sectioning averaged 599+/-52 microm. Immediately after sectioning with a microkeratome set at a depth of 300 microm, mean posterior bed thickness was 328+/-95 microm. Thus, the mean cutting depth achieved by the microkeratome when set at 300 micrometers averaged 271+/-83 microm. After storage for 24 hours, the posterior beds measured 352 microm, an average swelling of 24 (7%) microm (P = 0.14). After 48 hours, the posterior beds measured 382 microm, an average swelling of 54 (16%) microm (P = 0.02). Cell counts 48 hours after sectioning decreased by an average of 11% (P = 0.10). Endothelial cell staining confirmed improvement in postsectioning morphology and survival with increased technician experience. All 4 patients receiving eye bank-prepared DSAEK tissue showed uncomplicated postoperative results, with improvement in VA.

CONCLUSIONS

The microkeratome cutting depth was moderately accurate. Pachymetry, cell density, and cell viability of sectioned tissue after 48 hours in storage were encouraging overall. Initial clinical results of eye bank-prepared DSAEK tissue showed uncomplicated postoperative courses and improved VA. Additional studies are needed to follow the long-term outcomes in the recipients of these tissues.

Critical care nursing education and practice in Canada and Australia: a comparative review

Critical care nursing is an area of policy concern with respect to staffing projections, skill mix and educational preparation in both Canada and Australia. Despite many similarities between the health systems of these two countries, differences exist in both undergraduate and graduate specialty nursing education. In Australia, specialist education is primarily delivered via the tertiary sector as a formalised qualification, whereas the current Canadian model displays significant variation in duration, content, and mode of delivery. This paper provides a comparative perspective on the educational preparation of critical care nurses in these two countries. Consideration of alternative models of specialty nursing education may provide a method to improve recruitment and retention of staff while maintaining quality of care.

Dermatological toxicities of panitumumab in the treatment of patients with metastatic colorectal cancer (mCRC) from three clinical studies

14551

Introduction: Epidermal growth factor receptor (EGFr) expression in CRC is associated with metastatic potential and poor prognosis. Panitumumab, a fully human monoclonal antibody against EGFr, was approved for the treatment of patients with refractory mCRC. The main side effects of panitumumab include dermatological manifestations that have been termed “rash”. However, classification of the dermatological manifestations has not been clearly described. Methods: We summarized the dermatological manifestations of 19 patients from 3 clinical studies investigating the the safety and efficacy of panitumumab monotherapy in mCRC in a single institution. Two of these studies were open lable, phase 2 in design which enrolled patients with documented disease progression (PD) during or after adequate doses of fluoropyrimidine, irinotecan, and oxaliplatin chemotherapy. In the other panitumumab was given in combination with irinotecan or oxaliplatin with bevacuzumab, 5FU, and leucovorin. Pts received panitumumab at 6mg/kg Q2W until PD or intolerability. Skin assessments were made q2w. Results: Five patients were men (26%) and 14 (73%) women; 12 were Caucasian (63%) and 7 (36%) African American. The median age was 53 (Range 38–80). Tumor response, disease control, and skin manifestations did not correlate with tumor EGFr levels as assessed by immunohisxtochemistry (Dako EGFR pharmDxtm). No enhancement of skin toxicity was observed when panitumumab was combined with chemotherapy. The median number of cycles received was 11 (Range 3–20). All pts experienced erythema; 17 macular/papular; 13 pustular; 18 acneiform rash; 15 pruritis; 3 honey crusting; 15 dry/flaking; 11 paronychia; 9 hirsuitism; 9 trichomegaly; and all 7 African American patients had significant hyperpigmentation. Photograph illustrations of each category and severity will be presented. Conclusion: Rash associated with panitumumab is common and can be classified according to the clinical dermatological manifestations; specific treatment strategies should be developed and evaluated accordingly. This is the first report of hirsuitism in women and hyperpigmentation in African Americans.

[Table: see text]

Phase I study of topotecan (T) with weekly 5-fluorouracil (5FU)/leucorin (LV) in patients with advanced malignancies

13018

Background: Topotecan (T) is a semi-synthetic camptothecin analog with a broad spectrum of activity targeting the nuclear enzyme topoisomerase I. Daily iv schedules (up to 5) can result in dose limiting neutropenia. Reported synergy in vitro between topoisomerase I inhibitor and 5 FU/LV led us to explore a weekly schedule of 5FU, LV, and T in refractory tumors. Methods: Entry criteria: metastatic or locally advanced solid tumors; up to two prior chemotherapy regimens; prior adjuvant regimen admissible; no chemotherapy or radiation therapy within 4 weeks; adequate hepatic, hematologic, renal function. Exclusion: active second malignancy; CNS metastases; prior topotecan; allergy to related agents; active uncontrolled infection or conditions that would interfere with the study. Treatment was administered days 1, 8, 15, 22 of a 42 day cycle as LV 20 mg/meter (m)2 over 15 minutes intravenously (iv), 5 FU 400mg/m2 bolus, iv, and T at the specified dose (1.5mg/m2, 1.75, 2.0, up to 4 mg) over 30 minutes iv. Cohorts were advanced after at least three pts had completed 42 d. Study is reported through cohort 9: 5 FU 400/m2, LV 20/m2, topotecan 4 mg/m2. Results: Pt characteristics: 19 F, 25 M; ages 29–80, median 62. Tumor types: Pancreas (9), colorectal (6), lung (6), liver (3), salivary gland (5), sinus (2), nasopharynx (2) esophagus (2), and tongue, larynx, ovary granulosa cell tumor (gct), endometrium, mixed mullerian, mesothelioma, sarcoma, gastric (1 each). Related toxicities: gr 3/4 neutropenia 9%/2%, Hb 11%/0, platelets 4.5%/0, fatigue 4.5%/0. Stable disease of ≥ 4 cycles was observed in 18%: pancreas (2), ovarian (1), endometrium (1), salivary gland (3) (2 adenoid cystic, 1 adenocarcinoma). Conclusions: 5 FU, LV and T is well tolerated as a weekly out patient schedule (4 of 6 wks). It achieved minor response in one patient with gct for 8+ cycles and stable disease for ≥ 4 cycles in 6 pts. It is worthy of further exploration for gynecologic, salivary gland and pancreatic cancers.

No significant financial relationships to disclose.

Update in computer-driven weaning from mechanical ventilation

Weaning from mechanical ventilation is a complex process requiring assessment and interpretation of both objective and subjective clinical parameters. For many years, automated computerised systems for various medical processes, including respiratory management, have been proposed to optimise decision-making and reduce variation amongst clinicians. SmartCare/PS, available since 2003 as a software application for the EvitaXL ventilator (Dräger Medical AG & Co. KG, Lübeck, Germany), is one of the first such ventilator systems to be made commercially available. SmartCare/PS can be described as a knowledge-based weaning system, which adjusts pressure support based on measurement of the patient's respiratory status, specifically the spontaneous respiratory rate, tidal volume and end-tidal carbon dioxide with the aim of optimising the weaning process. The primary proposed advantage of this system is an ability to provide management of ventilatory weaning through continuous physiological monitoring and real-time interventions. The relatively small number of available clinical studies indicate the system is able to deliver appropriate ventilation during pressure support weaning from both short-term and prolonged ventilation. Of potential clinical note, a recent study suggested that use of SmartCare/PS might be associated with useful reductions in the duration of weaning compared to existing clinical practice using weaning protocols. One recently published randomised trial supports this conclusion. However, given the known large variation in international critical care ventilatory practices further randomised trials are desirable.

African American Couples Merging Strengths to Successfully Cope With Breast Cancer

PURPOSE/OBJECTIVES

To explore the process of coping with breast cancer among African American women and their spouses.

DESIGN

Exploratory, qualitative study using grounded theory methods.

SETTING

Large metropolitan area in the mid-Atlantic United States.

SAMPLE

12 African American couples (N = 24).

METHODS

African American women and their spouses were asked to complete a background data sheet and participate in a face-to-face semistructured interview. Qualitative data were audiotaped and transcribed verbatim. Themes were identified using the constant comparative method. Quantitative data were analyzed with descriptive statistics.

MAIN RESEARCH VARIABLES

The process of coping with breast cancer among African American couples.

FINDINGS

The basic social concern was living through and beyond a breast cancer diagnosis. The core variable was merging strengths to cope with and survive a breast cancer diagnosis. Six main categories emerged to describe how African American couples actively worked together to cope with a breast cancer diagnosis: walking together, praying together, seeking together, trusting together, adjusting together, and being together.

CONCLUSIONS

African American couples described the importance of combining their strengths and working together as a couple to cope with a breast cancer diagnosis.

IMPLICATIONS FOR NURSING

Nurses must understand the importance of developing culturally sensitive and culturally relevant interventions to assist African American couples with effectively coping with a breast cancer diagnosis. When providing care to African American couples, nurses should incorporate the six categories of walking, praying, seeking, trusting, adjusting, and being together to help couples cope with the various phases of the breast cancer experience.

The role of intra-luteal factors in the control of the porcine corpus luteum

In this paper we review three intra-luteal factors and their roles in the corpus luteum (CL). Insulin-like growth factor (IGF)-I, together with its receptor and IGF-binding proteins (IGFBPs), represent an important control system in the CL. IGF-I is a product of small luteal cells and has steroidogenic (i.e. luteotrophic) actions on large luteal cells via the type I receptor, while IGFBPs (e.g. BP-2 and 3; small cells) generally inhibit IGF-Is actions. IGF-I is particularly important in early CL development (up to day 7 of the oestrous cycle) in the pig. Tumour necrosis factor (TNF)-alpha is a product of luteal macrophages that infiltrate CLs in increasing numbers as the cycle progresses. TNF-alpha has been shown to play an important role in luteolysis, but we hypothesise that in the pig, this factor plays an additional role during the mid-luteal phase (days 7-13) in promoting the acquisition of luteal sensitivity to the luteolytic actions of prostaglandin (PG)F2alpha (= luteolytic sensitivity; LS). Endothelin (ET)-1 is a product of (luteal) endothelial cells, and along with its receptors (ETA and ETB) and endothelin-converting enzyme (ECE)-1, represent an intra-luteal system that also plays a role in luteolysis, in association with PGF2alpha. Since TNF-alpha induces endothelial cells to secrete ET-1, we hypothesise that ET-1 mediates the sensitising effects of TNF-alpha on the porcine CL during the mid-luteal phase (days 7-13). Finally, we hypothesise that TNF-alpha and/or ET-1 act to up-regulate luteal protein kinase C (e.g. isoforms betaII and epsilon) activity and thereby sensitises luteal cells to PGF2alpha.

Effects of stressful life events in young black men with high blood pressure

OBJECTIVES

1) To describe stressful life events as experienced by a sample of young Black men with high blood pressure (HBP) living in inner-city Baltimore, Maryland; and 2) to examine the effect of cumulative stressful life events on substance use, depression, and quality of life.

METHODS

Data were obtained over 48 months by interview from 210 men in an HBP management study.

RESULTS

Stressors repeatedly occurring over time included death of family member or close friend (65.2%), having a new family member (32.9%), change in residence (31.4%), difficulty finding a job (24.3%), and fired or laid off from work (17.6%). Involvement with crime or legal matters was reported at least twice during the 48 months by 33.3% of men. When a cumulative stressful life events score was calculated by summing the number of events experienced at 6-month points over 48 months and tested for its relationship with the health outcomes, the findings of multivariate analyses revealed significant associations between cumulative life stressors and depression and quality of life. No significant relationship was found between stressful life events and substance use.

CONCLUSIONS

The results suggest that cumulative stressful life events have a negative effect on mental health and quality of life in young Black men with HBP. Future study should focus on developing interventions to assist individuals in managing distress related to stressful events with necessary community resources.

Effects of mental illness on family quality of life

Worldwide, at least 25% of persons and their families are affected by mental illness resulting in significant stress and burden; yet little is known about how the illness affects quality of family life. In this paper, we report a secondary analysis of a grounded theory study that identified the process by which 17 families managed mental illness over time. Families were characterized as Hanging On, Being Stable, or Doing Well based on their responses to caring for relatives with mental illness. Most of the families perceived themselves as Being Stable or Doing Well and four families perceived themselves as Hanging On. In this paper, these descriptors of family quality of life, interpreted within the context of family development and illness trajectories, are presented as a focus of professional support and intervention.

Antiglaucoma eye drop pulses--increased interleukin-6 secretion by Tenon's capsule fibroblast cultures

PURPOSE

Long-term antiglaucoma eye drop therapy prior to trabeculectomy is a risk factor for surgical failure resulting from Tenon's capsule fibrosis at the fistula site. The study tested the hypothesis that secretion of the proinflammatory cytokine interleukin (IL)-6 by wounded Tenon's capsule-fibroblasts is elevated by prior long-term antiglaucoma eye drop treatment.

METHODS

Fibroblast cultures were established from Tenon's capsule biopsies during trabeculectomy. Twice daily and for four and a half days, confluent secondary (2-4 passages) cultures were treated (30 minutes at 37 degrees C) with the following drugs (diluted at 1:400-1:100): 0.2% brimonidine-tartrate (Alphagan), 2.0% dorzolamide-HCl (Trusopt), 0.5% timolol-maleate (Timoptic), 2.0% dorzolamide-HCl/0.5% timolol-maleate (Cosopt), 2 and 4% pilocarpine-HCl (Akarpine and Pilocar), 0.005% latanoprost (Xalatan), placebos for Trusopt and Timoptic, and 0.01% benzalkonium chloride. Subsequently, cultures were wounded by removing cells grown on half of each culture dishes along with the medium and conditioned for 20 hours in serum-free growth medium, which was then collected for ELISA for IL-6 (and TNF-alpha and IL-1 beta). Cultures were grown for four additional days to show the maintenance of culture sterility.

RESULTS

Latanoprost, pilocarpine-HCl, and timolol-maleate increased IL-6 levels in the conditioned medium in a dilution factor-dependent manner (P < 0.05, ANOVA). IL-6 concentrations were increased most significantly by latanoprost and were (pg/ml; mean +/- SEM; N = 3 cultures) 186 +/- 37, 187 +/- 33, 295 +/- 46 and 336 +/- 76 in cultures treated at 1:400, 1:250, 1:150, and 1:100 dilutions, respectively, whereas those of six control cultures averaged 80 +/- 9. Benzalkonium chloride, brimonidine-tartrate, dorzolamide-HCl, Cosopt placebo, Timoptic placebo, and dorzolamide-HCl/timolol-maleate did not significantly elevate IL-6 concentrations. IL-1 beta and TNF-alpha were not detected in the medium of control cultures and those treated with pilocarpine (1:200).

CONCLUSIONS

The present study demonstrated for the first time that the level of IL-6 secretion by wounded Tenon's capsule fibroblast cell cultures was increased by repeat pulsing of these cultures with some, but not all, antiglaucoma eye drops prior to wounding.

Interleukin-17 family and IL-17 receptors

Interleukin-17 (IL-17) is a pro-inflammatory cytokine secreted by activated T-cells. Recently discovered related molecules are forming a family of cytokines, the IL-17 family. The prototype member of the family has been designated IL-17A. Due to recent advances in the human genome sequencing and proteomics five additional members have been identified and cloned: IL-17B, IL-17C, IL-17D, IL-17E and IL-17F. The cognate receptors for the IL-17 family identified thus far are: IL-17R, IL-17RH1, IL-17RL (receptor like), IL-17RD and IL-17RE. However, the ligand specificities of many of these receptors have not been established. The IL-17 signaling system is operative in disparate tissues such as articular cartilage, bone, meniscus, brain, hematopoietic tissue, kidney, lung, skin and intestine. Thus, the evolving IL-17 family of ligands and receptors may play an important role in the homeostasis of tissues in health and disease beyond the immune system. This survey reviews the biological actions of IL-17 signaling in cancers, musculoskeletal tissues, the immune system and other tissues.

Depression, substance use, adherence behaviors, and blood pressure in urban hypertensive black men

Relationships between depression, alcohol and illicit drug use, adherence behaviors, and blood pressure (BP) were examined in 190 urban hypertensive Black men enrolled in an ongoing hypertension control clinical trial. More than one fourth (27.4%) of the sample scored greater than 16 on the Center for Epidemiological Studies-Depression Scale (CES-D), indicating a high risk of clinical depression. Depression was significantly associated with an increased likelihood of meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for alcohol abuse or dependence (odds ratio = 5.2; 95% confidence interval = 1.897-14.214). The level of depression was significantly correlated with poor medication (r =.301) and poor dietary compliance (r =.164). Both alcohol intake and illicit drug use were significantly correlated with poor dietary compliance (r =.195 and.185, respectively) and smoking (r =.190 and.269, respectively). Although no direct relationship between depression and the level of BP was substantiated by multivariate analysis, findings of descriptive analyses revealed statistically significant associations among depression, substance use, poor adherence, and poor BP outcomes. Given the harsh environment in which a large number of young urban Black men live, the high prevalence of substance abuse might be an attempt to fight off depression. Further in-depth investigation is needed to identify the role of depression and BP control in urban young Blacks in order to construct effective interventions that address their unique needs.

Interleukin-17 family and IL-17 receptors

Interleukin-17 (IL-17) is a pro-inflammatory cytokine secreted by activated T-cells. Recently discovered related molecules are forming a family of cytokines, the IL-17 family. The prototype member of the family has been designated IL-17A. Due to recent advances in the human genome sequencing and proteomics five additional members have been identified and cloned: IL-17B, IL-17C, IL-17D, IL-17E and IL-17F. The cognate receptors for the IL-17 family identified thus far are: IL-17R, IL-17RH1, IL-17RL (receptor like), IL-17RD and IL-17RE. However, the ligand specificities of many of these receptors have not been established. The IL-17 signaling system is operative in disparate tissues such as articular cartilage, bone, meniscus, brain, hematopoietic tissue, kidney, lung, skin and intestine. Thus, the evolving IL-17 family of ligands and receptors may play an important role in the homeostasis of tissues in health and disease beyond the immune system. This survey reviews the biological actions of IL-17 signaling in cancers, musculoskeletal tissues, the immune system and other tissues.

Clinicopathologic effects of mutant GUCY2D in Leber congenital amaurosis

PURPOSE

To study the retinal degeneration in an 11 -year-old patient with Leber congenital amaurosis (LCA) caused by mutation in GUCY2D.

STUDY DESIGN

Comparative human tissue study.

PARTICIPANTS

Two subjects with LCA; postmortem eye from one LCA patient and three normal donors.

METHODS

Clinical and visual function studies were performed between the ages of 6 and 10 years in the LCA eye donor and at age 6 in an affected sibling. Genomic DNA was screened for mutations in known LCA genes. The retina of the 11 -year-old subject with LCA was compared with normal retinas from donors age 3 days, 18 years, and 53 years. The tissues were processed for histopathologic studies and immunofluorescence with retinal cell-specific antibodies.

RESULTS

Vision in both siblings at the ages examined was limited to severely impaired cone function. Mutation in the GUCY2D gene was identified in both siblings. Histopathologic study revealed rods and cones without outer segments in the macula and far periphery. The cones formed a monolayer of cell bodies, but the rods were clustered and had sprouted neurites in the periphery. Rods and cones were not identified in the midperipheral retina. The inner nuclear layer appeared normal in thickness throughout the retina, but ganglion cells were reduced in number.

CONCLUSIONS

An 11-year-old subject with LCA caused by mutant GUCY2D had only light perception but retained substantial numbers of cones and rods in the macula and far periphery. The finding of numerous photoreceptors at this age may portend well for therapies designed to restore vision at the photoreceptor level.

[Comparison between line immunoassay (LIA) and enzyme-linked immunosorbent assay (ELISA) for the determination of antibodies to extractable nuclear antigenes (ENA) with reference to other laboratory results and clinical features]

INTRODUCTION

The line immunoassay (LIA) for the determination of antibodies to individual extractable antinuclear antigens (ENA) is a development of the enzyme-linked immunosorbent assay (ELISA) in which the antigens to be tested are adsorbed onto a nylon test strip. In addition, the antigen subspecificities B/B' and D in the case of Sm, the 70 kD, A and C components in the case of U1-snRNP and the Ro52 and Ro60 components in the case of SSA/Ro are present separately on the strips. The aim of the study was to determine whether the line immunoassay is suitable for routine laboratory use by means of a comparison with the ELISA.

METHODS

Sera from 92 patients stored in our serum bank with known ENA profile as determined by ELISA and with at least one antibody to ENA were tested again with LIA. The clinical features and other available laboratory data taken from the patient records were used to classify the disease according to the relevant diagnostic criteria. In discrepant cases, antibodies to ENA were also determined by Western blot. These data were used to determine which of the two methods gave the more plausible results and to calculate the sensitivity and specificity for each autoantibody.

RESULTS

There was good correlation between the two methods, especially for anti-CENP-B (centromere protein B) and anti-Jo1 (histidyl-tRNA transferase) antibodies. For anti-Sm, there was a trend toward higher specificity with the LIA in patients with systemic lupus erythematosus (SLE) if antibodies to Sm D were detected. The LIA was significantly more specific for the detection of antibodies to ribonucleoprotein (RNP) in mixed connective tissue disease and, if antibodies to the 70 kD component were present, also in SLE, although the sensitivity was significantly lower in this case. For anti-SSA/Ro, the specificity of the LIA was significantly higher than ELISA if anti-Ro60 was detected. In the case of anti-SS-B/La, anti-Scl70 (topoisomerase I), anti-CENP-B (centromere protein B) und anti-Jo-1 (histidyl-tRNA transferase), the sensitivity and specificity of the two methods were not significantly different. The LIA was significantly more specific but less sensitive for the detection of anti histone antibodies.

CONCLUSION

The suitability of the LIA for routine laboratory determinations was confirmed.

A grounded theory of families responding to mental illness

Despite decades of research documenting family burden related to mental illness of a relative, little is known about families' responses over time. A grounded theory study was designed to describe families' responses to these severe mental illnesses. Twenty-nine participants representing 17 families were interviewed 3 times over 2 years. Interviews were analyzed using constant comparison. Living with ambiguity of mental illness was the central concern. The basic social process was pursuing normalcy and included confronting the ambiguity of mental illness, seeking to control impact of the illness, and seeing possibilities for the future. Goals were managing crises, containing and controlling symptoms, and crafting a notion of "normal." Strategies were being vigilant, setting limits on patients, invoking logic, dealing with sense of loss, seeing patients' strengths, and taking on roles. The study revealed that families were profoundly affected by the social contexts of mental illnesses.

The nuclear receptor NR2E3 plays a role in human retinal photoreceptor differentiation and degeneration

Normal human retinal development involves orderly generation of rods and cones by complex mechanisms. Cell-fate specification involves progenitor cell lineage and external signals such as soluble factors and cell-cell interactions. In most inherited human retinal degenerations, including retinitis pigmentosa, a mutant gene causes loss of visual function, death of mature rods, and eventually death of all cone subtypes. Only one inherited retinal disorder, the enhanced S cone syndrome (ESCS), shows increased visual function, involving the minority S (blue) cones, and decreased rod and L/M (red/green) cone function. This autosomal recessive disease is caused by mutations in NR2E3, a photoreceptor nuclear receptor transcription factor, and may result from abnormal cell-fate determination, leading to excess S cones at the expense of other photoreceptor subtypes. In 16 ESCS patients with the most common NR2E3 mutation, R311Q, we documented an abnormal ratio of S to L/M cone function and progressive retinal degeneration. We studied the postmortem retina of an ESCS patient homozygous for NR2E3 R311Q. No rods were identified, but cones were increased approximately 2-fold, and 92% were S cones. Only 15% of the cones expressed L/M cone opsin, and some coexpressed S cone opsin. The retina was disorganized, with densely packed cones intermixed with inner retinal neurons. The retina was also degenerate, retaining photoreceptors in only the central and far peripheral regions. These observations suggest a key role for NR2E3 in regulation of human photoreceptor development. Degeneration of the NR2E3 retina may result from defective development, known S cone fragility, or abnormal maintenance of mature photoreceptors.

["Freud and fetichism": previously unpublished minutes of the Vienna Psychoanalytic Society]

On the occasion of this session held by the Viennese Psychoanalytic Society on the 24th of February 1909, Freud made a presentation on fetchism that was the point of departure for a reflection that led him to the theorization of the article of 1927. Being careful to differentiate his position from that of other authors having shown an interest for the subject, he clearly stressed the role of infantile sexuality as an etiological factor, and in particular the link between fetichism and repression. The discussion that followed the presentation shows that Freud and Adler's positions were beginning to diverge, the latter replacing the notion of instincts that Freud held to be involved in the mechanism of repression, by that of "fear of degradation" and of "sensitivity". These Minutes that had been thought to have disappeared are studied within the more general framework of the meetings of the Viennese Psychoanalytic Society.

Endurance, pain and resumption in fully flexed postures

In this study effects of low loads in fully flexed postures were investigated. Thirteen men who were unused to the postures participated. Thirteen professional construction workers with long experience of suchlike postures were also studied. Pain reactions during and after loading were observed, as well as endurance time and the recovery process, here by studying the resumption time. Endurance and resumption times differed little from those given by models used for more common postures. Pain from the legs and not from the back limited the working ability in 86% of the endurance tests. Thirdly, the construction workers had significantly longer endurance time and shorter resumption time.

Safety and bactericidal activity of rifalazil in patients with pulmonary tuberculosis

Rifalazil, also known as KRM-1648 or benzoxazinorifamycin, is a new semisynthetic rifamycin with a long half-life of approximately 60 h. Rifalazil has potent bactericidal activity against Mycobacterium tuberculosis in vitro and in animal models of tuberculosis (TB). Prior studies in healthy volunteers showed that once-weekly doses of 25 to 50 mg of rifalazil were well tolerated. In this randomized, open-label, active-controlled phase II clinical trial, 65 subjects with sputum smear-positive pulmonary TB received one of the following regimens for the first 2 weeks of therapy: 16 subjects received isoniazid (INH) (5 mg/kg of body weight) daily; 16 received INH (5 mg/kg) and rifampin (10 mg/kg) daily; 17 received INH (5 mg/kg) daily plus 10 mg of rifalazil once weekly; and 16 received INH (5 mg/kg) daily and 25 mg of rifalazil once weekly. All subjects were then put on 6 months of standard TB therapy. Pretreatment and day 15 sputum CFU of M. tuberculosis were measured to assess the bactericidal activity of each regimen. The number of drug-related adverse experiences was low and not significantly different among treatment arms. A transient decrease in absolute neutrophil count to less than 2,000 cells/mm(3) was detected in 10 to 20% of patients in the rifalazil- and rifampin-containing treatment arms without clinical consequences. Decreases in CFU counts were comparable among the four treatment arms; however, the CFU results were statistically inconclusive due to the variability in the control arms. Acquired drug resistance did not occur in any patient. Studies focused on determining a maximum tolerated dose will help elucidate the full anti-TB effect of rifalazil.

Inhibition of isoniazid-induced expression of Mycobacterium tuberculosis antigen 85 in sputum: potential surrogate marker in tuberculosis chemotherapy trials

Mycobacterium tuberculosis antigen 85 is induced in vitro by isoniazid (INH); its sustained induction in sputum during tuberculosis (TB) therapy predicts relapse. In this trial, rifampin or rifalazil inhibited the induction of sputum antigen 85 by INH in a dose-dependent fashion. This approach may facilitate the evaluation of new TB drugs.

Cardiac rehabilitation in the United Kingdom. How complete is the provision?

PURPOSE

To bring up-to-date information about all the cardiac rehabilitation (CR) units in the UK, including their staffing and the services they offer, and to determine the numbers and diagnoses of the patients they treat.

METHODS

Questionnaire survey to establish the continued functioning of the centers, the disciplines of their staff, the number of patients treated, their diagnoses, and the outcomes measured.

RESULTS

286 centers were identified. Of the 236 who returned their questionnaires, 171 (72%) gave figures of the numbers and diagnoses of their patients. The median number treated in the different programs was 150, with a total of 32,499 patients. Of those, 63% were recovering from myocardial infarction, 25% from coronary artery bypass graft (CABG), and 4% from percutaneous transluminal coronary angioplasty (PTCA). Twenty-four percent of patients were female, 87% were between the ages of 40 and 74, and 10% were older than 75. Of the responders, 80 (34%) performed an exercise test both before and after the course. Of the 171 who gave figures, 113 (66%) measured outcomes.

CONCLUSIONS

In the UK, between 14% and 23% of infarct patients, between 33% and 56% of CABG patients, and between 6% and 10% of PTCA patients are enrolled into CR programs.

Factors associated with successful answering of clinical questions using an information retrieval system

OBJECTIVES

Despite the growing use of online databases by clinicians, there has been very little research documenting how effectively they are used. This study assessed the ability of medical and nurse-practitioner students to answer clinical questions using an information retrieval system. It also attempted to identify the demographic, experience, cognitive, personality, search mechanics, and user-satisfaction factors associated with successful use of a retrieval system.

METHODS

Twenty-nine students completed questionnaires of clinical and computer experience as well as tests of cognitive abilities and personality type. They were then administered three clinical questions to answer in a medical library setting using the MEDLINE database and electronic and print full-text resources.

RESULTS

Medical students were able to answer more questions correctly than nurse-practitioner students before and after searching, but both had comparable improvements in the number of correct questions before and after searching. Successful ability to answer questions was also associated with having experience in literature searching and higher standardized test-score percentiles.

CONCLUSIONS

Medical and nurse-practitioner students obtained comparable benefits in the ability to answer clinical questions from use of the information retrieval system. Future research must examine strategies that improve successful search and retrieval of clinical questions posed by clinicians in practice.

Endurance time, pain and resumption in passive loading of the elbow joint

This study investigated reactions in passively loaded, fully extended elbow joints in 13 men. Pain reactions during and after loading were studied, as were endurance time, T(end), and resumption time, Tr. The loading moment on the elbow joint, Mn, varied between 7 and 100% of maximum elbow moment. Discomfort/ pain was estimated with Borg's CR-10 scale. T(end) decreased with increasing load level. The opposite was found for the resumption time: the higher the load, held until T(end), the shorter the Tr. The pain limiting the working capability originated mainly from muscle tissue and not from the joint itself. It is concluded that the relation between load and endurance time for passively loaded, fully extended elbow joints resembles that for muscular loading in more 'normal' postures. Equations for estimation of endurance and resumption times (in minutes) for fully extended joints are proposed: T(end) = 20.6e(-6.04Mn) and Tr = 0.0167e(8.84/(1.46+0.346Mn)), respectively.

Caring for patients who experience chemotherapy-induced side effects: the meaning for oncology nurses

PURPOSE/OBJECTIVES

To explore the meaning for oncology nurses of caring for patients with cancer who experience chemotherapy-induced side effects.

DESIGN

Descriptive phenomenology.

SETTING

Participant's work setting (n = 2), home setting (n = 1), and social setting (n = 2).

SAMPLE

Five female oncology nurses (four Caucasian and one African American), age range 31-62 years, with an average of 13.3 years in oncology nursing from a variety of settings (e.g., private medical practice, ambulatory infusion centers, university-based bone marrow/peripheral blood stem cell transplantation unit) with present or recent experience administering chemotherapy.

METHODS

Open-ended, audiotaped interviews were conducted. The text was transcribed verbatim and was analyzed using Colaizzi's phenomenologic analysis technique.

MAIN RESEARCH VARIABLE

Meaning for oncology nurses of providing care to patients with cancer experiencing chemotherapy-induced side effects.

FINDINGS

Six main themes and four subthemes emerged from the data analysis. The main themes were Being Drawn Into Patients' Experiences of Suffering. Being Challenged by Personal and Professional Imperatives to Act, Defining Treatment Purpose for Self and Patient, Reconsidering the Meaning of "Sick" and "Well," Being Changed by Ties of Shared Experience, and Advocacy for Self and Patient.

CONCLUSIONS

The fundamental meaning to oncology nurses of providing care to patients with cancer experiencing chemotherapy-induced side effects is their empathetic use of self as an oncology nurse/friend to alleviate the suffering related to these side effects.

IMPLICATIONS FOR NURSING PRACTICE

Providing nursing care to patients who experience chemotherapy-induced side effects is both rewarding and stressful. Sharing these research results may help other oncology nurses discover and experience deeper meaning in their own practice.

Sleep alterations in cancer patients

This multi-institutional sleep study involved two phases aimed at investigating sleep alterations in patients with any stage of breast and lung cancer. The first phase of this study used an 82-item, 20-minute telephone survey to elicit information regarding the impact of sleep disturbances on a convenience sample of 150 patients. Of these patients, 44% reported a sleep problem during the month before the interview. Significant relations included these: report of sleep problems prediagnosis over the past month (x = 5.82; p = 0.02), duration of sleep medication use and frequency of sleep problem (r = 0.58; p = 0.05), age and severity of sleep problems (r = 0.38; p = 0.05), and frequency and severity of the sleep problem over the past month (r = 0.21; p < 0.10). Communication with health care providers occurred in 16.6% of patients reporting a sleep disturbance. The second phase of this study explored the type, frequency, and severity of sleep problems and perceptions of causation, support, and methods of coping with the sleep problem. A qualitative approach to the problem was used in this phase. A one-time telephone interview of 42 patients, derived from a convenience sample, revealed a 45% prevalence of sleep problems a month before the interview. A qualitative analysis of the responses suggested that sleep problems are related to experiences of other symptoms and perceptions of cancer and treatment. Content analysis of the responses identified the following categories: figuring out the reason, seeking help, seeking support and relation to the overall cancer experience.

Distress, symptom distress, and immune function in women with suspected breast cancer

PURPOSE/OBJECTIVES

To investigate distress and its association with immune function among women with suspected breast cancer.

DESIGN

Prospective, descriptive, correlational study.

SETTING

An outpatient breast clinic at a tertiary urban hospital.

SAMPLE

A convenience sample of women who had either a fine needle aspiration or open breast biopsy for a suspicion of breast cancer. Thirty-five women comprised the study sample, 6 with malignant and 29 with benign tumors.

METHODS

Data were collected at three points in time. The first time (T1) was after the physician visit when the need for breast biopsy was ascertained. The second time (T2) was 7-10 days postbiopsy, and the third time (T3) was 7-10 days after T2. At T1, T2, and T3, participants filled out the Brief Symptom Inventory (a measure of psychological distress) and the Adapted Symptom Distress Scale (a measure of symptom distress) and provided a blood sample. Demographic data also were collected at T1. Immune function was measured by serum cytokine levels of transforming growth factor beta (TGF beta) and tumor necrosis factor alpha (TNF alpha).

MAIN RESEARCH VARIABLES

Psychological distress, symptom distress, and immune function.

FINDINGS

Psychological distress scores were moderate to high. Symptom distress was either nonexistent or slight. Significant correlations between psychological distress and symptom distress were found at T2 and T3. At T2, significant relationships between psychological distress and TNF alpha and between symptom occurrence and TNF alpha were found. Psychological and symptom distress scores were significantly different between women with malignant versus benign tumors at all three times. No differences in cytokine levels were found between the groups.

CONCLUSIONS

These results suggest the strong effect that the diagnostic process has on psychological distress and its potential effects on immune functioning. Distress was significantly greater for women with malignant disease; however, women with benign disease continued to have elevated levels of distress.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should be aware of the extremely stressful nature of the diagnostic phase and should continue to provide support, knowing that this distress continues throughout this phase, particularly for women diagnosed with malignancy.

The fatigue experience: persons with HIV infection

Fatigue is a frequently reported symptom by persons with HIV infection and one that has an adverse impact on activities of daily living and overall quality of life. Although the concept of fatigue has been studied extensively and discussed in the literature, little is known about the experience of fatigue by persons with HIV infection. A hermeneutic phenomenological study was conducted to investigate the subjective experience of HIV-associated fatigue and to describe the management of fatigue in the context of daily life. In-depth interviews were done with 10 adult patients of an outpatient HIV/AIDS clinic. Thematic analysis identified three concerns that represented the meaning of fatigue for the participants. The first concern was 'Fatigue as a signal of AIDS'. A second concern was 'The mind, the body, the social experience of fatigue'. The third concern was 'Choosing ways to live with fatigue and addiction'. The findings provide insights for nursing practice regarding the subjective meaning of fatigue for patients with HIV and the need for nurses to explore this topic with patients.

Immediate loading of root-form implants: two case reports 3 years after loading

This study examines a protocol for achieving successful osseointegration in immediately loaded implants. With an atraumatic surgical technique and an acceptable biomaterial for implant placement, in certain cases adequate splinting of implants may sufficiently shield the bone-implant interface from functional overload and prevent micromovement from exceeding the allowable limits for successful osseointegration. Two successful cases are presented in which titanium root-form implants were immediately loaded for the support of fixed restorations in the maxilla and the mandible. The authors conclude that for a distinct patient population, immediate loading of multiple, splinted implants may prove to be a valuable adjunct to therapy.

Professional training in the practice of hypnosis--the Australian experience

Increasingly around the world as clinicians and researchers alike become more sophisticated in their understanding of the hypnotic process, there is developing a conviction that the hypnotic state or process itself poses no inherent dangers for patients but that its inexpert use may. The solution to prevent potential patient harm is to ensure that all clinicians of whatever discipline have adequate and appropriate clinical training prior to being allowed to practice. Since 1985, in all the Australian states, the appropriate disciplines, already licensed to practice their profession, have completed 2 years part-time academic and clinical training in the nature and nuances of hypnosis (30 hours), practical experience of direct and indirect approaches, and supervised clinical case management (50 hours). At the end of the training they complete a 3 part examination of competence (clinical cases reports, written examination, and oral examination) in order to be accepted as members of the Australian Society of Hypnosis. Only by completing this training and peer reviewed assessment are clinicians able to receive the backing of the Society and recommendation to patients of their competence as clinicians using hypnosis. Recently in the states of Victoria and South Australia (and soon in the state of Queensland), the training program of the Australian Society of Hypnosis has been incorporated into a university diploma course, giving formal academic recognition to the approach to training. The University of Melbourne diploma course will be discussed with a view to illustrating these recent developments.

Benefits and limitations of professional-family interactions: the family perspective

Families of persons with severe mental illness often experience burden and stress related to the caregiving role. There is a paucity of research describing effective interventions for relieving this burden. This article reports the findings of a study that elicited families' perceptions of professional interventions. Two focus groups were conducted with relatives of persons with schizophrenia or bipolar disorder. Participants described their experiences of the illness, current concerns, and coping strategies. A major focus of the study was the families' evaluations of past and future interventions from health professionals. Content analysis of the data identified critical elements of supportive and nonsupportive behaviors from professionals. Recommendations for future interventions were identified.

Crosstalk between the phosphatidylinositol cycle and MAP kinase signaling pathways in Xenopus mesoderm induction

Recent studies have established a role for the phosphoinositide (PI) cycle in the early patterning of Xenopus mesoderm. In explants, stimulation of this pathway in the absence of growth factors does not induce mesoderm, but when accompanied by growth factor treatment, simultaneous PI cycle stimulation results in profound morphological and molecular changes in the mesoderm induced by the growth factor. This suggests the possibility that the PI cycle exerts its influence via crosstalk, by modulating some primary mesoderm-inducing pathway. Given recent identification of mitogen-activated protein kinase (MAPK) as an intracellular mediator of some mesoderm-inducing signals, the present study explores MAPK as a potential site of PI cycle-mediated crosstalk. We report that MAPK activity, like PI cycle activity, increases in intact embryos during mesoderm induction. Phosphoinositide cycle stimulation during treatment of explants with basic fibroblast growth factor (bFGF) synergistically increases late-phase MAPK activity and potentiates bFGF-induced expression of Xbra, a MAPK-dependent mesodermal marker.

Cytoskeletal actin reorganization in neutrophils from patients with localized juvenile periodontitis

Localized juvenile periodontitis (LJP) is an early-onset periodontal disease associated with a polymorphonuclear neutrophil (PMN) defective migratory response. Kinetics of actin polymerization-depolymerization determine the shape changes occurring in the plasma membrane-associated cytoskeleton and provide the driving force for directed cell migration (chemotaxis). Therefore, we investigated the relation between an abnormality in LJP PMN chemotaxis and an altered reorganization of the actin filament network. PMNs isolated from peripheral blood of LJP patients (n=14) and matching control subjects (n=12) were evaluated for random and directed migration in a Boyden chamber assay, and the kinetics of actin polymerization were studied by flow cytometry. Three groups of LJP patients could be distinguished on the basis of their PMN-chemotactic response compared to their matched control: depressed (n=6), normal (n=4), and elevated (n=4). The abnormal (depressed or elevated) chemotaxis was generally not related to abnormal random migratory response, except for two patients. Since the kinetics of formyl-methionyl-leucyl-phenylalanine-induced F-actin response were highly variable from one subject to another, means were calculated at each timepoint with the values obtained from each group of subjects and compared by a general factorial design analysis. No statistically significant differences were detected between the control group and the LJP patient group. Furthermore, the data did not show a correlation between the kinetics of actin polymerization-depolymerization and the abnormal chemotactic response observed in LJP PMNs. Hence, the chemotaxis defect in LJP PMN appears to be mediated by signaling events that carry their effect independently of an intact cytoskeleton.

One-step surgical placement of Brånemark implants: a prospective multicenter clinical study

This prospective longitudinal multicenter study evaluated the clinical outcomes after placement and restoration of one-step Brånemark implants into the maxillae and mandibles of completely and partially edentulous patients. Six surgical treatment centers participated in this study, in which 135 implants were placed into 63 adult patients. All implants were stable after placement. The majority of implants were placed into type B bone with minimal jaw resorption and type 2 bone quality. After implant placement, standard transmucosal healing abutments were firmly placed. The average amount of time between implant placement and prosthetic abutment connection was 170 days in the maxillae and 147 days in the mandibles. To evaluate crestal bone changes caused by implant placement, a periodontal probe was used to measure midbuccally from the top of the implant cylinder to the alveolar crest; in 29 patients, 54 midbuccal bone crest sites were remeasured following prosthetic abutment connection. Crestal bone changes in mandibles and maxillae were statistically and clinically insignificant. Six implants were lost prior to loading and one implant has not been restored. No implants or restorations were lost after loading. At 1 year, the implant success rate was 95.6%. Mesiodistal radiographic measurements from 34 patients were averaged, and changes from prosthetic abutment connection to, on average, 12 months follow-up were compared. The radiographs, which were digitalized, measured from the bottom of the implant cylinder to the most coronal bone in contact with implant thread. For mandibular implants, the mean radiographic bone level at prosthetic abutment connection was 1.07 mm; after loading, it was 1.35 mm. For maxillary implants, the mean radiographic bone height at prosthetic abutment connection was 1.16 mm; after loading, it was 1.36 mm. These changes were not statistically significant. The 1-year outcomes from this patient series indicate that one-step Brånemark implants provide excellent clinical results when placed in patients with good bone quality and quantity.