A case-control study to detect modifiable risk factors for colonization with vancomycin-resistant enterococci

A case-control study was conducted to determine the modifiable risk factors associated with vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak. Cephalosporin use was identified as the only independent risk factor (odds ratio, 13.8; 95% confidence interval, 2.5-76.3; P = .01). Nursing work-load intensity was not associated with VRE colonization in this study.

Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities

BACKGROUND

Little is known about the risk factors, outcome, and impact of pneumonia and other lower respiratory tract infections (LRTIs) in residents of long-term care facilities.

OBJECTIVE

To determine the risk factors and the effect of these infections on functional status and clinical course.

METHODS

Active surveillance for these infections was conducted for 475 residents in 5 nursing homes from July 1, 1993, through June 30, 1996. Information regarding potential risk factors for these infections, functional status, transfers to hospital, and death was also obtained.

RESULTS

Two hundred seventy-two episodes of pneumonia and other LRTIs occurred in 170 residents during 228 757 days of surveillance for an incidence of 1.2 episodes per 1000 resident-days. Multivariable analysis revealed that older age (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.6 per 10-year interval; P = .01), male sex (OR, 1.9; 95% CI, 1.1-3.5; P = .03), swallowing difficulty (OR, 2.0; 95% CI, 1.2-3.3; P = .01), and the inability to take oral medications (OR, 8.3; 95% CI, 1.4-50.3; P = .02) were significant risk factors for pneumonia; receipt of influenza vaccine (OR, 0.4; 95% CI, 0.3-0.5; P = .01) was protective. Age (OR, 1.6 [95% CI, 1.0-2.5] per 10-year interval; P = .05) and immobility (OR, 2.6; 95% CI, 1.8-3.8; P = .01) were significant risk factors for other LRTIs, and influenza vaccination was protective (OR, 0.3; 95% CI, 0.2-0.4; P = .01). Residents with pneumonia (OR, 0.7; 95% CI, 0.3-1.4; P = .31) or with other LRTIs (OR, 0.5; 95% CI, 0.2-1.1; P = .43) were no more likely to have a deterioration in functional status than individuals in whom infection did not develop.

CONCLUSIONS

Swallowing difficulty and lack of influenza vaccination are important, modifiable risks for pneumonia and other LRTIs in elderly residents of long-term care facilities. Our findings challenge the commonly held belief that pneumonia leads to long-term decline in functional status in this population.

[Drug prescription to 4-year-old children in the county of Vestfold]

We carried out a study of four-year-old children's general health, diseases and use of medicines over a 12-month period in 1995-96. The study was based on a questionnaire administered in connection with the regular health controls. Questionnaires from 1,912 children were returned, representing 79% of children born during one year in the county. More than half the children had received medicine prescribed by a physician, corresponding to 557 preparations per 1,000 children. Some children had used several types of drugs, with a mean of 1.4 preparations per child. Antibiotics were prescribed to 63% of the children. Compared to what has been found in other studies, the use of prescribed medicine was moderate. More pharmacoepidemiological studies are needed to assess whether the use of medicine in children is at an acceptable level.

Two nursing home outbreaks of respiratory infection with Legionella sainthelensi

OBJECTIVE

To describe outbreaks of infection caused by Legionella sainthelensi occurring in older residents of two nursing homes and to determine risk factors for the development of infection.

DESIGN

Descriptive epidemiology and a case-control study.

SETTING

Two nursing homes (140 beds and 254 beds in nursing homes A and B, respectively) located in southern Ontario, Canada, experiencing outbreaks of respiratory tract infection in July and August 1994.

SUBJECTS

Case-residents of the two nursing homes who met clinical and laboratory criteria for Legionella infection. Control-residents were defined as those who were in the homes during the outbreaks and were asymptomatic.

MEASUREMENTS

Active surveillance was conducted in both nursing homes to identify symptomatic residents. Residents with fever or respiratory tract symptoms had nasopharyngeal swabs taken for viral antigen detection and culture, urine for Legionella antigen detection, and acute and convalescent serology for viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. Chest X-rays were performed, and an attempt was made to obtain blood and sputum cultures. Water samples from shower heads, faucets, and air conditioning units were collected for Legionella culture and polymerase chain reaction (PCR) assay. A case-control study was done to assess possible risk factors for legionellosis.

RESULTS

Twenty-nine cases -- 17 in nursing home A; 12 in nursing home B - were identified. Four (14%) case-residents had documented pneumonia and four case-residents died. Univariate analysis revealed that a history of stroke (odds ratio (OR) 2.3 (95% CI, 1.0-5.3)), eating pureed food (OR 4.6 (95% CI, 1.6-12.7)), and having fluids administered with medication (OR 2.5 (95% CI, 1.0-5.9)) were significant risk factors. Cases were less likely to wear dentures (OR .4 (95% CI, .2-.9)) or to eat solid food (OR .3, (95% CI, .1-.6)). Only eating pureed food remained significant in a multivariable analysis (OR 4.6 (95% CI, 1.6-13.0, P = .01)).

CONCLUSION

This report describes outbreaks of legionellosis in two nursing homes, representing the first reported outbreaks of infection caused by Legionella sainthelensi. The association with illness of dietary characteristics indicative of swallowing disorders suggests that aspiration was the most likely mode of infection. The diagnosis of legionellosis should be considered during outbreaks of respiratory infection in nursing homes.

The Norwegian naturalistic treatment study of depression in general practice (NORDEP)-I: randomised double blind study

OBJECTIVE

To evaluate the efficacy of emotional support and counselling combined with placebo or antidepressants with single or dual mechanism of action in the treatment of depression in primary care.

DESIGN

Randomised double blind study.

SETTING

Several locations in Norway.

SUBJECTS

372 patients with depression.

MAIN OUTCOME MEASURES

Improvement (clinical remission) reported both by the patient (Montgomery Asberg depression rating scale) and the physician (clinical global improvement and impression scales).

RESULTS

Intention to treat analyses showed 47% remission in patients randomised to placebo compared with 61% remission in patients randomised to sertraline (odds ratio 0.56, 95% confidence interval 0.33 to 0.96) and 54% in patients randomised to mianserin (0.75, 0.44 to 1.27). Women responded better than men (1.86, 1.17 to 2.96). Subgroup analyses showed that subjects with recurrent depression (n=273) responded more frequently to sertraline than to placebo (0.43, 0.23 to 0.82) than those having their first episode of depression (1.18, 0.39 to 3.61). Statistically significant interactions between type of drug treatment and history of depression were not shown by logistic regression.

CONCLUSION

The combination of active drug and simple psychological treatment (counselling, emotional support, and close follow up over a 24 week period) was more effective than simple psychological treatment alone, in particular for those with recurrent depression. Overall, women may benefit more than men. If confirmed in future studies, the findings should lead to more differentiated treatment guidelines for depression in primary care.

Seven-year clinical follow-up after lumbar disc surgery: results and predictors of outcome

This study evaluates the 7-year outcome of lumbar disc surgery and the predictive value of pre- and perioperative risk factors. The 7-year follow-up rate of a sample of 122 patients was 93% (n = 114). Six per cent of the patients had undergone repeat surgery. Approximately 90% reported that they were satisfied with having undergone surgery. The clinical outcome was evaluated in 96 patients (54 men and 42 women) by means of patient-scores (VAS) of low back and leg pain, and a Clinical Overall Score (COS). In multivariate regression analyses, women were shown to have poorer outcome than men. Preoperative psychological distress and impaired fibrinolytic activity were predictors of poor 7-year outcome. Age, weight, smoking habits and physical fitness had no statistically significant prognostic value. Whether the patients were operated for one or two herniated discs, or whether surgery involved a full or partial laminectomy, did not influence the outcome significantly.

Cutaneous malignant melanoma in Norway: experiences from the Norwegian Melanoma Project

The Norwegian Melanoma Project was conducted during 1989-1993 as a co-operative study by the dermatological, surgical, oncological and pathological departments of the five university hospitals in Norway. We present the results from the patients diagnosed and treated in our dermatological department at Ullevaal Hospital. During the study period 4582 patients received a clinical evaluation of pigmented lesions and 1347 patients were included in follow-up analyses, which consisted of a complete anamnestical evaluation and a clinical and pathological investigation of excised pigmented lesions. In all, 66 cutaneous malignant melanomas, 50 superficial spreading melanomas, seven lentigo maligna melanomas, eight nodular melanomas and one acral lentiginous melanoma were diagnosed. Correlation of the clinical and anamnestical information demonstrated an increased risk of developing malignant melanoma in persons with red hair and skin type I/II. When the histological thickness of superficial spreading melanomas diagnosed before the start of the project was compared with that of those treated during the project, there was a significant decrease in thickness in the project period.

Clinical overall score: outcome evaluation after lumbar disc surgery, assessments of reliability and validity

In previous studies assessing prognostic factors for the outcome of lumbar disc surgery, a Clinical Overall Score (COS) based on four subsets-pain intensity (VAS), physical signs, functional status (Oswestry) and analgesics--was used as the main outcome criterion. Both the patient's and the examiner's opinions of outcome and return to work were registered. In this paper, assessments are made of reliability and validity regarding the COS. The COS was found sensitive to changes, and internal consistency, assessed using Cronbach's alpha, Pearson's correlation analyses and factor analysis, was good. An interrater reliability study of the assessments of the physical signs, using weighted Kappa statistics, demonstrated fair to good levels of agreement for most of the signs. The concurrent validity of the COS was satisfactory; COS compared favourably with the patient's and with the examiner's opinion of outcome and return to work.

Background variables (medical history, anthropometric and biological factors) in relation to the outcome of lumbar disc surgery

In a prospective cohort study 122 patients with herniated intervertebral lumbar disc and no previous low back surgery preoperatively were assessed regarding medical history, anthropometric and biological background variables. The outcome of surgery (traditional methods) was evaluated one year postoperatively, mainly using a composite Clinical Overall Score (COS), including pain intensity, physical signs, functional capacity and analgesics. Return to work was also assessed. In regression analyses, low body height, high values of weight and body mass index, as well as long duration of sickness absence were shown to be significantly related to a poor outcome, as evaluated by the COS. However, after controlling for modifying effects of previously determined predictive fibrinolytic and psychological variables, the background variables lost their significance. Female sex, low stature, long duration of sickness absence and physically strenuous work activities were statistically significantly related to lower frequencies of return to work.

Lack of correlation between vacuolating cytotoxin activity, cagA gene in Helicobacter pylori, and peptic ulcer disease in children

To determine the prevalence of the cagA gene and vacuolating cytotoxin in Helicobacter pylori isolates obtained from children and to characterize the relationship between cagA, cytotoxin production, and ulcerogenesis, pediatric Helicobacter pylori isolates were tested for cagA by the polymerase chain reaction and for vacuolating cytotoxin by a cell culture assay. Helicobacter pylori isolates were obtained from 33 children referred for upper gastrointestinal endoscopy. Twenty-six of these isolates were tested for cagA by the polymerase chain reaction; all 26 (100%) were positive. Of the 26 children from whom these isolates were obtained, 26 (100%) had chronic gastritis and 12 (46%) had duodenal ulcers. Nine (30%) of 30 isolates tested showed expression of vacuolating cytotoxin, only three of which came from patients with duodenal ulceration (odds ratio 0.81, 95% confidence interval 0.1-5.3). Of the 23 cagA-positive isolates tested for cytotoxin, only nine (39%) were positive. There was no association between vacuolating cytotoxin and clinical symptoms, nor was cytotoxicity associated with ulcerogenesis. In summary, the findings suggest that cagA is not a marker of duodenal ulceration or of vacuolating cytotoxin production in children referred for endoscopy.

Influence of fibrinolytic factors on scar formation after lumbar discectomy. A magnetic resonance imaging follow-up study with clinical correlation performed 7 years after surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To assess the amount of scar tissue by viewing magnetic resonance images, and to evaluate the correlation between the amount of scar tissue and clinical outcome, surgical technique, and fibrinolytic factors.

SUMMARY OF BACKGROUND DATA

The influence of fibrinolytic factors on magnetic resonance images has not been investigated previously. The relation between clinical outcome and findings on magnetic resonance imaging remains uncertain.

METHODS

Magnetic resonance imaging at 0.5 Tesla was performed to produce sagittal and axial spin-echo T1-weighted images before and after contrast enhancement on 78 patients 7 years after traditional lumbar discectomy with partial or full laminectomy. Before surgery all patients had been tested for fibrinolytic factors.

RESULTS

The overall clinical success rate of the surgery was 73%. No evidence of scar formation was seen in 19 patients, a small amount was seen in 36 patients, a moderate amount in 17 patients, and a large amount was observed in 6 patients. Ten patients who had undergone surgery at two disc levels and 18 who had been treated with full laminectomy exhibited more scar tissue than those patients who had undergone surgery on a single level (P = 0.033) and those who had undergone a partial laminectomy, respectively (P = 0.017). The amount of scar formation also was associated with a poor outcome (P = 0.017) and with low preoperative values of tissue plasminogen activator antigen (P = 0.003) and tissue plasminogen activity (P = 0.048) in samples collected after venous occlusion. The intensity of contrast enhancement, however, was not influenced by these or any other parameters.

CONCLUSION

The amount of scar formation after lumbar discectomy seems to be related to the clinical outcome, the size of the surgical exposure, and some fibrinolytic factors.

[Prevention and early diagnosis of malignant melanoma]

A Norwegian melanoma project was carried out in 1989-1993 as a joint study by the dermatological, surgical, oncological, and pathological departments at the five university hospitals in Norway, Of 4,582 patients (2,894 women, 1,688 men) diagnosed and treated at the Department of Dermatology, Ullevål Hospital, 1,347 patients (833 women, 514 men) were included in the analysis, which consisted of a clinical evaluation and pathological investigation of their excised pigmented lesions. In all, 66 malignant melanomas were diagnosed, including 50 superficial spreading melanomas, seven lentigo maligna melanomas, eight nodular melanomas, and one acral lentiginous melanoma. Persons with red hair and skin type I/II were at increased risk of developing malignant melanoma. Superficial spreading melanomas excised during the study period had a significant lower histological thickness compared with those lesions excised before the study period.

Immunocytochemical localization of testis ecdysiotropin in the pupa of the gypsy moth, Lymantria dispar (L.) (Lepidoptera: Lymantriidae)

Antiserum against testis ecdysiotropin isolated from the gypsy moth, Lymantria dispar, reacted with neurons in the protocerebrum, optic and antennal lobes, subesophageal, thoracic and abdominal ganglia, as well as in nerve tracts extending through the optic lobes, tritocerebrum, and interganglionic connectives of the pupal stage of these insects. Testis ecdysiotropin is a peptide required by immature moths to initiate production of testes ecdysteroid, which is necessary for the development of the male reproductive system and initiation of spermatogenesis. Antiserum against testis ecdysiotropin also detected an accumulation of testis ecdysiotripic-like material between the inner and outer testis sheaths of pupae. The localization of this peptide in the imaginal disks of the last larval stage, cells and nerve fibers in the optic and antennal lobes of the pupa of both sexes, as well as in the testes during development of the adult reproductive system indicates that testis ecdysiotropin has a much larger impact on adult metamorphosis than development of the reproductive system and initiation of gametogenesis. Although this peptide may have a modulatory role in the central nervous system (CNS), it may also initiate a cascade of activity required for the development of the adult nervous system, in addition to its role in reproduction.

Functional role of M2 and M3 muscarinic receptors in the urinary bladder of rats in vitro and in vivo

1. Urinary bladder smooth muscle is enriched with muscarinic receptors, the majority of which are of the M2 subtype whereas the remaining minority belong to the M3 subtype. The objective of the present study was to assess the functional role of M2 and M3 receptors in the urinary bladder of rat in vitro and in vivo by use of key discriminatory antagonists. 2. In the isolated bladder of rat, (+)-cis-dioxolane produced concentration-dependent contractions (pEC50 = 6.3) which were unaffected by tetrodotoxin (0.1 microM). These contractions were antagonized by muscarinic antagonists with the following rank order of affinity (pA2) estimates: atropine (9.1) > 4-diphenyl acetoxy-methyl piperidine methiodide (4-DAMP) (8.9) > darifenacin (8.5) > para fluoro hexahydrosiladifenidol (p-F-HHSiD) (7.4) > pirenzepine (6.8) > methoctramine (5.9). These pA2 estimates correlated most favourably (r = 0.99, P < 0.001) with the binding affinity (pKi) estimates of these compounds at human recombinant muscarinic m3 receptors expressed in Chinese hamster ovary cells, suggesting that the receptor mediating the direct contractile responses to (+)-cis-dioxolane equates with the pharmacologically defined M3 receptor. 3. As M2 receptors in smooth muscle are negatively coupled to adenylyl cyclase, we sought to determine whether a functional role of M2 receptors could be unmasked under conditions of elevated adenylyl cyclase activity (i.e., isoprenaline-induced relaxation of KCl pre-contracted tissues). Muscarinic M3 receptors were preferentially alkylated by exposing tissues to 4-DAMP mustard (40 nM, 1 h) in the presence of methoctramine (0.3 microM) to protect M2 receptors. Under these conditions, (+)-cis-dioxolane produced concentration-dependent reversal (re-contraction) of isoprenaline-induced relaxation (pEC50 = 5.8) but had marginal effects on pinacidil-induced, adenosine 3':5'-cyclic monophosphate (cyclic AMP)-independent, relaxation. The re-contractions were antagonized by methoctramine and darifenacin, yielding pA2 estimates of 6.8 and 7.6, respectively. These values are intermediate between those expected for these compounds at M2 and M3 receptors and were consistent with the involvement of both of these subtypes. 4. In urethane-anaesthetized rats, the cholinergic component (approximately 55%) of volume-induced bladder contractions was inhibited by muscarinic antagonists with the following rank order of potency (ID35%inh, nmol kg-1, i.v.): 4-DAMP (8.1) > atropine (20.7) > methoctramine (119.9) > darifenacin (283.3) > pirenzepine (369.1) > p-F-HHSiD (1053.8). These potency estimates correlated most favourably (r = 0.89, P = 0.04) with the pKi estimates of these compounds at human recombinant muscarinic m2 receptors. This is consistent with a major contribution of M2 receptors in the generation of volume-induced bladder contractions, although the modest potency of darifenacin does not exclude a role of M3 receptors. Pretreatment with propranolol (1 mg kg-1, i.v.) increased the ID35%inh of methoctramine significantly from 95.9 to 404.5 nmol kg-1 but had no significant effects on the inhibitory responses to darifenacin. These data suggest an obligatory role of beta-adrenoceptors in M2 receptor-mediated bladder contractions in vivo. 5. The findings of the present study suggest that both M2 and M3 receptors can cause contraction of the rat bladder in vitro and may also mediate reflex bladder contractions in vivo. It is proposed that muscarinic M3 receptor activation primarily causes direct contraction of the detrusor whereas M2 receptor activation can contract the bladder indirectly by reversing sympathetically (i.e. beta-adrenoceptor)-mediated relaxation. This dual mechanism may allow the parasympathetic nervous system, which is activated during voiding, to cause more efficient and complete emptying of the bladder.

The effect of meditation on shooting performance

OBJECTIVE

To study effects of meditation on the shooting performance.

METHODS

25 elite shooters were investigated in an independent groups design. The results in standardised test shootings indoors and in ordinary competitions outdoors were assessed before and after regular meditation training for the experimental group. The experience of tension during the test shootings was self recorded on a visual analogue scale (VAS).

RESULTS

The competition results in the outdoor season (1993), just after the meditation training period, compared with the results the previous season (1992), were better in the meditation group (P < 0.05). No significant difference between the groups was observed in the test shootings before and after the relaxation intervention. A significant association was shown between low tension and the results in the test shootings (correlation r = 0.42, P < 0.0001; Wilcoxon rank sum test, z = -3.36, P < 0.001); 18% (= r2) of the variance in performance was explained by tension.

CONCLUSIONS

Meditation may enhance competitive shooting performance.

Is the outcome of traditional lumbar disc surgery related to the size of the exposure?

The purpose of this study was to evaluate whether wide surgical exposures result in poorer outcome of lumbar disc surgery compared to smaller traditional exposures. The aim was also to assess if a dural tear has any impact on the postoperative clinical outcome. One hundred and twenty-two patients (56 women and 66 men, mean age 40.8 years) with herniated intervertebral lumbar disc and no previous back surgery, were included. Postoperatively they were grouped according to surgery as follows: surgery on one vs. two herniated discs (106 vs. 16 patients), partial vs. full laminectomy (93 vs. 29 patients), and the occurrence or not of a dural rent (8 vs. 114 patients). The outcome of surgery was evaluated one years postoperatively mainly by a composite clinical overall score (COS) and by its separate elements, which were: pain intensity in the lower-back or leg (VAS), neurological and clinical examination, functional capacity (Oswestry), and the need for analgesics. The results of the statistical regression analyses did not reveal significant differences in the postoperative outcome scores in the various groups of patients. The groups were comparable; no significant differences were seen in the pre-operative clinical overall scores.

In vitro differentiation of isolated stem cells from the midgut of Manduca sexta larvae

Isolated spherical stem cells from midguts of pharate fourth-instar larvae of Manduca sexta proliferated in vitro in the presence of 1 ng ml-1 20-hydroxyecdysone and co-cultured fat body tissue or cell-free fat body extract from M. sexta, Lymantria dispar or Heliothis virescens. In this environment, the stem cells were able to undergo mitosis and increase in number. However, stem cells were only able to differentiate to mature goblet and columnar cells when cell-free conditioned medium, taken from midgut cell cultures containing mature cells as well as stem cells and differentiating forms, was introduced into the culture medium. The presence of early and mature goblet cells, lying randomly on their sides, suggested that cell polarity developed in vitro as an intrinsic property of individual cells rather than with reference to an external inductive material. The differentiation factor (or factors) from the conditioned medium appears to include a heat-stable, peptide-like molecule of 10 kDa or less.

Pharmacological evaluation of 1229U91, a novel high-affinity and selective neuropeptide Y-Y1 receptor antagonist

The physiological role of neuropeptide Y (NPY), peptide YY (PYY) and their receptors (Y1 and Y2) has been difficult to elucidate mainly due to the lack of selective and high-affinity antagonists. Recently, Burroughs Wellcome disclosed a series of cyclic peptides, including the compound 1229U91, which were reported to be selective NPY receptor antagonists (PCT Publication No. WO 94/00486). The objective of this study was to evaluate the pharmacological properties of 1229U91. In radioligand binding studies, 1229U91 displaced specifically bound [125I]PYY from SK-N-MC cells (Y1 receptors) and SK-N-BE(2) cells (Y2 receptors) yielding pKi +/- S.E.M. estimates of 10.9 +/- 0.2 and 7.9 +/- 0.2, respectively. In the isolated perfused kidney of rat (Y1 receptor assay), NPY (10-1000 ng, bolus injection) evoked concentration-dependent increases in perfusion pressure (EC50 = 54.5 ng). In this assay, 1229U91 (1, 10 and 100 nM) produced concentration-dependent dextral displacement of the concentration-effect curve to NPY. The antagonism was surmountable at 1 nM 1229U91 (apparent pA2 estimate +/- S.E.M. = 9.3 +/- 0.4). At concentrations of 10 and 100 nM, 1229U91 produced significant depression of the maximum response to NPY (36 and 67%, respectively). In the vas deferens of rat (Y2 receptor assay), 1229U91 (3 microM) had no effect on NPY-induced inhibition of electrically evoked twitch response. In pithed rats, 1229U91 (0.3, 1 and 3 micrograms/kg/min i.v.) produced dose-dependent dextral displacement of the pressor dose-response curve to NPY yielding dose-ratio estimates of 2.4, 25.4 and 57.5, respectively. 1229U91 (3 micrograms/kg/min i.v.) had no effect on the pressor responses to norepinephrine or angiotensin II.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment with letrazuril of refractory cryptosporidial diarrhea complicating AIDS

Thirty-five AIDS patients (mean CD4 count 44 x 10(6)/L) with chronic cryptosporidiosis were treated with letrazuril at an initial oral daily dose of 50 mg in an open-label Phase I prospective trial. Treatment was continued for > or = 10 days and for as long as there was a response. The majority of subjects (91%), had previously failed paromomycin treatment. At baseline, 74% of patients had moderate (five to nine bowel movements per day) to severe (> 10 bowel movements per day) diarrhea. Twenty-three subjects (66%) had a clinical response within a mean of 1.7 weeks of treatment initiation. Twenty-two patients had a partial response (> 50% reduction in bowel movements per day for > or = 1 week), one patient had a complete response (two or fewer bowel movements per day). Of the responders, 15 (65%) had a clinical relapse with worsening diarrhea at an average of 1.2 months following initiation of letrazuril. The other eight (35%) had had symptom control for an average of 2.9 months from initiation of letrazuril to the latest follow-up. Microbiologic eradication was demonstrated in 10 (40%) of 25 patients with follow-up stool examinations. Seven patients (20%) experienced a rash, all within 1 week of starting the drug, and resolved in all patients when the drug was discontinued. In conclusion, severely immunocompromised AIDS patients with refractory cryptosporidiosis may show a modest, short-lived response to letrazuril. Microbiologic response is variable and relapse high. Rash is a major limiting side effect of the drug.

Effects of an acidic beverage (Coca-Cola) on absorption of ketoconazole

Absorption of ketoconazole is impaired in patients with achlorhydria. The purpose of this study was to determine the effectiveness of a palatable acidic beverage (Coca-Cola Classic, pH 2.5) in improving the absorption of ketoconazole in the presence of drug-induced achlorhydria. A prospective, randomized, three-way crossover design with a 1-week wash-out period between each treatment was employed. Nine healthy nonsmoking, nonobese volunteers between 22 and 41 years old were studied. Each subject was randomized to receive three treatments: (A) ketoconazole 200-mg tablet with water (control), (B) omeprazole (60 mg) followed by ketoconazole (200 mg) taken with water, and (C) omeprazole (60 mg) followed by ketoconazole (200 mg) taken with 240 ml of Coca-Cola Classic. The pH values of gastric aspirates were checked after omeprazole was administered to confirm attainment of a pH of > 6. Multiple serum samples were obtained for measurements of ketoconazole concentrations by high-pressure liquid chromatography. The mean area under the ketoconazole concentration-time curve from zero to infinity for the control treatment (17.9 +/- 13.1 mg.h/liter) was significantly greater than that for treatment B (3.5 +/- 5.1 mg.h/liter; 16.6% +/- 15.0% of control). The mean peak concentration was highest for the control treatment (4.1 +/- 1.9 micrograms/ml), for which the mean peak concentration showed a significant increase over that for treatment B. The absorption of ketoconazole was reduced in the presence of omeprazole-induced achlorhydria. However, drug absorption was significantly increased, to approximately 65% of the mean for the control treatment, when the drug was taken with an acidic beverage, such as Coca-Cola.

5-HT4 receptor mediated stimulation of gastric emptying in rats

It is well documented that certain substituted benzamides, such as cisapride, and benzimidazolones, such as BIMU 8, enhance gastric emptying in rats. As these compounds possess 5-HT3 antagonistic and 5-HT4 agonistic properties, the precise mechanisms (5-HT3 or 5-HT4) underlying their gastroprokinetic effects is still unclear. In the present study, we used SC 49518 (a benzamide and selective 5-HT4 receptor agonist) and two selective 5-HT4 receptor antagonists (RS 23597-190 and SB 204070) to elucidate the role of 5-HT4 receptors in gastroprokinesis. SC 49518 (1-316 micrograms/kg; ip) produced significant and dose-dependent stimulation of gastric emptying in rats (ED50 = 2.3 micrograms/kg; ip). SC 49518 also produced dose-dependent inhibition of bradycardia induced by 2-methyl 5-HT (von Bezold-Jarisch reflex) but with a 156 fold lower potency (ID50 = 0.36 mg/kg; ip). The gastroprokinetic effects of SC 49518 (3-316 micrograms/kg; ip) were significantly antagonized by the selective 5-HT4 receptor antagonist RS 23597-190 (0.1 mg/kg/min; iv). SB 204070 (0.003-1 mg/kg; ip), another selective 5-HT4 receptor antagonist, produced dose-dependent inhibition of the gastroprokinetic effects of SC 49518 (10 micrograms/kg; ip), the inhibition attaining statistical significance at the dose of 0.1 mg/kg; ip. RS 23597-190 had no effects on gastric emptying per se whereas SB 204070 significantly increased gastric emptying by itself at 1 mg/kg; ip but not at 0.1 mg/kg; ip. These findings show, for the first time, that SC 49518, a selective 5-HT4 receptor agonist, produces potent stimulation of gastric emptying in rats via a mechanism involving activation of 5-HT4 receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Can psychological traits predict the outcome of lumbar disc surgery when anamnestic and physiological risk factors are controlled for? Results of a prospective cohort study

In a prospective study 122 patients with herniated lumbar disc pre-operatively completed psychological questionnaires. Surgical outcome was evaluated 12 months post-operatively mainly by a composite clinical overall score (COS), and by its separate elements. Anxiety (HAD-A scale) and psychosomatic symptoms (MSPQ) had predictive value: fewer symptoms favoured a satisfactory overall outcome, and vice versa. The HAD-A Scale had a predictive power of poor (ppp) and satisfactory (pps) outcome of 28 and 81%, respectively. Correspondingly, for the MSPQ, the ppp and pps were 42 and 85%. Anamnestic and biological variables (including fibrinolytic variables: ECLT and PAI-1) predicted 20% of the outcome. By adding all psychological variables the prediction increased only to 24%, but the HAD-A Scale and the MSPQ were still significant. The results suggest that in order to further improve prediction of outcome, future studies should combine biological variables sensitive to the mental state of the patient, with psychometric assessments.

Evidence for the involvement of 5-hydroxytryptamine 4 receptors in 5-hydroxytryptophan-induced diarrhea in mice

The objective of this study was to characterize the receptor(s) to 5-HT mediating 5-HTP-induced diarrhea in mice. The severity of diarrhea in mice was assessed using an arbitary scoring scale ranging from 0 (normal stools) to 3 (watery diarrhea). Administration of 5-HTP (1-30 mg/kg i.p.) produced a dose-dependent increase in diarrhea score (ED50, 1.47 mg/kg i.p.). 5-HTP (10 mg/kg i.p.)-induced diarrhea was unaffected by atropine (3 mg/kg i.p.) but was completely abolished by the aromatic L-amino acid decarboxylase inhibitor benserazide (10 mg/kg i.p.). Pretreatment (5 min before 5-HTP) with DAU 6285, a marginally selective 5-HT4 receptor antagonist, significantly inhibited 5-HTP-induced diarrhea (ID50, 0.58 mg/kg i.p.). Pretreatment (5 min before 5-HTP) with GR 113808 or SB 204070, two highly selective 5-HT4 antagonists, significantly inhibited 5-HTP-induced diarrhea with ID50 estimates of 0.31 and 0.003 mg/kg i.p., respectively. The maximal inhibition produced by DAU 6285, GR 113808 and SB 204070 was 63%, 68% and 36%, respectively. Neither GR 113808 (1 and 3 mg/kg i.p.) nor SB 204070 (0.1 and 1 mg/kg i.p.) had any effect on 16,16-dimethyl prostaglandin E2 (30 micrograms/kg i.p.)-induced diarrhea in mice. DAU 6285 significantly inhibited 16,16-dimethyl prostaglandin E2-induced diarrhea at the highest dose (3 mg/kg i.p.). Pretreatment (30 min before 5-HTP) with methysergide (0.1-3 mg/kg i.p.), metergoline (0.01-0.1 mg/kg i.p.), ketanserin (0.01-1 mg/kg i.p.), YM 060 (0.01-0.1 mg/kg i.p.) or ondansetron (0.01-3 mg/kg i.p.) had no significant effects on 5-HTP-induced diarrhea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Vegetarians and vitamin B12. A controlled trial of vitamin B12 status in 63 lactovegetarians]

In this study vitamin B12 status was assessed in 63 adult long-term lactovegetarians and 63 controls. No significant difference in mean plasma levels of vitamin B12 was found between the two groups. In contrast to what might have been expected, the vegetarians showed a slight increase in the vitamin B12 levels with increasing number of years as vegetarians. There was a significant (r = 0.34, p = 0.01) correlation between oral intake of vitamin B12 in the lactovegetarians and the plasma levels of the vitamin. Folate in plasma and whole blood were significantly higher (p < 0.001) in the vegetarian group than in the control group. The findings do not indicate that lactovegetarians risk developing dietary-induced vitamin B12 deficiency.

Rheumatoid arthritis and vertebral artery occlusion: a case report with angiographic and magnetic resonance demonstration

A 40-year-old woman with rheumatoid arthritis (RA) who presented with vertigo and nausea, was found to have left vertebral artery occlusion on angiography. There was minimal atlantoaxial subluxation and no odontoid herniation. Magnetic resonance imaging (MRI) was suggestive of a left vertebral artery dissection. This is the first report of MRI of vertebral artery occlusion in RA. It will be important to accumulate MR images of this complication in future cases.

Fibrinolytic activity as a predictor of the outcome of prolapsed intervertebral lumbar disc surgery with reference to background variables: results of a prospective cohort study

In a prospective study 122 patients with a slipped lumbar disc and no previous surgery were preoperatively examined for fibrinolytic activity. Surgical results for these patients were evaluated 12 months postoperatively by clinical overall assessment. In a multiple linear regression analysis fibrinolytic variables, euglobulin clot lysis time and plasminogen activator inhibitor 1, were shown to have predictive value regarding outcome of surgery; that is, normal fibrinolytic activity favors a satisfactory outcome and vice versa. Background variables and lipid profile were also recorded preoperatively. Body mass index, gamma-glutamyl transpeptidase, triglycerides and smoking were of statistical significance in relation to euglobulin clot lysis time and plasminogen activator inhibitor 1. Postoperative fibrinolytic re-examination of 20 patients seem to confirm that patients at risk of surgical failure have a prolonged depression of fibrinolytic activity.

Postoperative radiotherapy in breast cancer--long-term results from the Oslo study

The long-term results of a randomized clinical trial evaluating the effect of postoperative radiotherapy as an adjuvant to radical mastectomy are presented. There were 1115 patients including 27 protocol deviants. The follow-up time is 11-20 years. In the first part a conventional roentgen unit was used, and in the second part a 60Co unit, with considerably increased dosage and altered treatment plan. Both types of radiation techniques lowered the incidence of loco-regional recurrences significantly, but had no significant influence on the overall survival. The relapse-free survival was significantly improved by 60Co radiation in Stage II patients, but was unaffected by radiation in the other subgroups. Regarding survival, Stage II patients with medially located tumors seemed to benefit more from 60Co radiation than those with lateral tumors. A significant increase in the number of deaths caused by myocardial infarction was observed in Stage I patients having 60Co radiation, indicating that the radiation dose to the heart is of significance.

Doxifluridine (5'-dFUrd) in patients with advanced colorectal carcinoma. A phase II study

Infusion of 5'-dFUrd (2.0-3.0 g/m2 over 1 h on days 1-5 every 3rd week) resulted in one partial response in 21 patients with advanced and progressing colorectal cancer. No patient had received chemotherapy before the 5'-dFUrd trial. Hematological and gastrointestinal toxicity were generally mild. In 4 patients peripheral neurotoxicity was diagnosed during treatment, whereas transient cerebellopathy was observed in one. Cardiac side effects (repeated angina pectoris following 5'-dFUrd infusion) led to discontinuation of treatment after two courses in one patient. It is concluded that 5'-dFUrd at the above doses is not superior to conventional 5-FU treatment in colorectal cancer. Neurological and cardiac side effects are rare but may be a problem in individual patients.

Post-treatment fertility in patients with testicular cancer. I. Influence of retroperitoneal lymph node dissection on ejaculatory potency

"Dry ejaculation" occurred in none of 15 patients with testicular cancer treated by right-sided retroperitoneal lymph node dissection (RLND). After left-sided and bilateral RLND, "dry ejaculation" was observed in 7/21 and 51/61 men respectively. Twelve of 21 patients with "dry ejaculation" or small volumes of seminal fluid had true retrograde ejaculation. In 7 of 10 men the ejaculatory volume increased significantly after treatment with imipramine chloride. Four men impregnated their wives during treatment with the drug. Without impairing the results of therapy it is possible to spare fibres from the sympathetic chains and pre-sacral plexus during RLND due to testicular cancer, thus preserving fertility in at least 40% of patients.

Post-treatment fertility in patients with testicular cancer. II. Influence of cis-platin-based combination chemotherapy and of retroperitoneal surgery on hormone and sperm cell production

Active sperm production was observed in 20 of 35 patients with testicular cancer 1 year after discontinuation of all treatment (retroperitoneal surgery only: 13; cis-platin-based chemotherapy (CVB) +/- other treatment: 22). The percentage of patients who regained spermatogenesis increased slightly after a further 1 to 2 years. Fourteen patients (of 121 under observation) impregnated their wives (after retroperitoneal surgery: 9; after CVB +/- other therapy: 5). The individual serum FSH values correlated significantly with the results of sperm analysis: an FSH value greater than or equal to 20 iu/l indicated azoospermia in 8 of 12 patients, whereas only 5 of 30 patients with FSH levels less than or equal to 12 iu/l were azoospermic. Serum testosterone and pituitary serum LH were virtually unaffected by the treatment. In conclusion, 1 to 3 years after cis-platin-based multi-modality treatment for testicular cancer, 50 to 60% of patients have active spermatogenesis and fatherhood can be achieved by a significant number of them.

Prediction of tumour progression in superficial bladder carcinoma

In a retrospective study, prognostic factors have been analyzed in 45 patients with superficial bladder carcinoma (Tis, Ta, T1) with subsequent progression to invasive (T2, T3, T4) and/or metastatic (M+) disease. The findings are compared with those from a control group of 17 patients with no subsequent invasive or metastatic disease. In a single-parameter analysis the following parameters were significantly associated with a high risk of developing invasive disease: tumour multiplicity; tumour invasion of blood and/or lymph vessels; increasing histological grade, and the history of previous surgical treatment. In a multivariate analysis, multifocality, small vessel infiltration and previous treatment per time (TPT factor) were significantly related to the risk of subsequent progression. An arbitrary score system revealed that progression could be predicted significantly in patients with a high score.

Isolation of crustacean erythrophore concentrating hormone from nerve tissue of Homarus americanus

Crustacean erythrophore concentrating hormone (CECH) was isolated from lobster (Homarus americanus) eyestalks by reverse phase high-performance liquid chromatography (rp-hplc). Putative lobster CECH fractions co-chromatographed with commercially available pure CECH on two independent rp-hplc systems, and were positive for activity by bioassay. CECH was detected in eyestalk, but not brain homogenates.

Do pili play a role in pathogenicity of Haemophilus influenzae type B?

Surface components of Haemophilus influenzae type b (Hib) responsible for mucosal adherence were identified through assay of in-vitro attachment to human buccal epithelial cells (EC). Among many Hib strains from cerebrospinal fluid, blood, or the nasopharynx (NP), two isolates from NP were found to be exceptionally adherent. Adherence correlated with agglutination of human red blood cells (RBC). The adherent strains displayed pili, not previously described for Hib or other encapsulated H. influenzae. Moreover, highly adherent, piliated subpopulations of bacteria could be selected from any strain, but were lost upon subculture. Thus, the potential to express pili may be general for Hib and may aid the NP colonisation which precedes systemic invasion by this organism. Piliation was correlated with the amount of an outer membrane protein with a molecular weight of about 20,000 daltons, which had proved to be immunogenic in an 8-month-old child.

Nonanatomic prognostic factors in carcinoma of the lung: a multivariate analysis

Existing records of 651 patients with bronchogenic carcinoma registered at the Kingston Clinic of the Ontario Cancer Treatment and Research Foundation during the period between 1965-1974 were examined in order to determine the relationship to survival of the following four "nonanatomic" prognostic factors: symptomatic history, performance status, weight loss, and age. Even when stage, histologic factors, and treatment were taken into account, it was found that weight loss and performance status significantly affected survival. Age, however, was related to survival only when the treatment given to the patient was not considered. Symptomatic history was important in so far as it related to weight loss and performance status. These results are compared to those obtained in other series and the implications discussed.

Cytoreductive surgery and systemic bacillus Calmette-Guerin therapy in metastatic renal cancer: a phase II trial

A phase II trial has been conducted to determine the effect upon survival of cytoreductive surgery (nephrectomy) and adjuvant active immunotherapy (bacillus Calmette-Guerin) in patients with stage IV renal cancer. A total of 20 patients underwent removal of the primary tumor and received bacillus Calmette-Guerin therapy (adjuvant group). The results were compared to those obtained in 20 historical controls treated with conventional methods (hormones, chemotherapy and radiotherapy with or without nephrectomy) and 16 concurrent controls. All patients in the historical control group were dead within 4 years after the diagnosis of metastases. Seven patients (35 per cent) in the adjuvant group were alive 2 to 5 years after documentation of metastatic disease and onset of therapy. The ratio of observed to expected deaths in the adjuvant group was 0.59 compared to 1.6 in the historical controls. This superior survival was statistically significant (p less than 0.01). A difference in survival between the adjuvant group and concurrent controls also was present but was not statistically significant (0.10 less than p less than 0.20). Other factors suspected to influence survival were investigated. We found that in addition to bacillus Calmette-Guerin therapy a prolonged interval free of disease and better performance status had a better prognosis. Location of metastases, nephrectomy, age and sex are of no significant prognostic value. Definitive answers on the therapeutic value of bacillus Calmette-Guerin and the influence on survival of various biological factors can only be provided by large, controlled, randomized and stratified (phase III) trials.

Annoyance by aircraft noise and fear of overflying aircraft in relation to attitudes toward the environment and community

If, as has been suggested, expressions of annoyance attributable to aircraft noise may reflect, in part, fear of aircraft overflights and possible crashes, then residents of areas where crashes have occurred should express more annoyance. To test this hypothesis, 50 residents of an Albany, New York area where an aircraft crash producing fatalities recently occurred, and 50 residents of a comparable nearby area without such a history, were asked to respond to a "Quality of Life" questionnaire. Among the items were some designed to test annoyance by noise and fear of aircraft overflights. It was predicted that those in the crash area would express more fear and would more often identify aircraft as a noise source. Factor analysis and discriminant analysis results sustained these hypotheses. A near-replication was carried out in Louisville, Kentucky; results were much the same. For the crash-area groups there was association of aircraft fear and noise annoyance responses; this was true to an apparently lesser extent for non-crash-area groups. The greater annoyance of crash groups by aircraft community noise apparently does not carry over to assessment of aircraft noise in the laboratory.

Survival after recurrence of breast cancer

A series of 456 patients with cancer of the breast that was first diagnosed between 1961 and 1970 were studied to determine the effect of certain prognostic factors on survival after recurrence. The prognostic factors studied included those recorded at the time of initial diagnosis and at the time of recurrence. Life-table and log-rank methods were used to analyse the influence of individual prognostic factors, and the simultaneous effects of multiple factors were assessed with Cox's proportional hazards model. The analysis indicated that, in addition to the strong effect of the length of the free interval and the nature and number of sites of recurrence, variables assessed at the time of initial diagnosis -- stage and histologic subtypes of the tumour -- also influenced survival after recurrence. This supports the contention that the presenting characteristics of breast cancer reflect the underlying biologic aggressiveness of the tumour as much as the length of time the tumour has been present.

The present state of research on the effects of noise: are we asking the right questions?

A review is presented, with a bibliography of 68 items, of some effects and aftereffects of noise on other senses and on intelligence, on performance on multiple tasks, memory, computation, vigilance, signal detection, reaction time, and on industrial performance. Throughout this literature contradictions abound. Mechanisms reviewed include distraction, arousal, stress, concentration, masking of task-produced feedback, erasure of auditory store, and interference with or inhibition of articulation and rehearsal. It was concluded that it is necessary to consider complex interactions of the effects of noise with task difficulty and task proficiency of the subject, personality of the subject, time of day, food and drug ingestion, and the meaning of the noise and the previous exposure of the subject to it, whether it represents a threat or interference with work or reaction, or is in fact interesting and enjoyable. Such information must be available before generalizing.

America in the 1980s: 10 major changes ahead

At least 10 major developments will substantially change our country, our lives, our livelihoods, and our families in the 1980s. Despite all of our immediate and visible problems, if we Americans follow sensible policies of government deregulation, of capital formation, of energy conservation, and energy development, then the economic, the political, and the social future of the United States in the revolutionary 1980s is absolutely dazzling.

Influence of noise characteristics on behavioral aftereffects

Two experiments were performed which were designed to replicate and extend the findings of Glass and Singer and others on the aftereffects of noise on performance. In the first, subjects were exposed to 24 min of 95 dBA fixed schedule (FS) or random schedule (RS) intermittent conglomerate noise or to 46 dBA background control (C) noise. After exposure. persistence on insoluble puzzles was least in the RS noise condition and greatest in the C noise condition. In the second experiment. subjects were exposed to 95-dBA intermittent white noise. Recorded nonnal aircraft flyovers, recorded combinations of aircraft noise peaks (AC), and Glass and Singer (GS) conglomerate noise or to 48-dBA background control noise. Following exposure, the GS and AC groups persisted less on the puzzles than the other three groups. In neither experiment was there an effect of noise on routine tasks performed during exposure or on a proofreading task following exposure. Also, there were no significant correlations between subjective ratings of the noise and the performance aftereffects. The significance of these findings is considered ill terms of existing theories.

Effects of intense continuous- and impact-type noise on pupil size and visual acuity

The data obtained from these studies suggest that continuous noise at high levels will produce an increase in arousal, as indicated by pupil size, and that there is a tendency toward adaptation. At lower noise levels the effect is, at most, transitory. This papillary change does not appear to mediate a change in visual acuity. Impact noise such as that used here does not appear to produce reproducible changes in pupil size or visual acuity. For the noise conditions used here, concern for nonauditory sensory effects seems to be unwarranted.