Exploitation and inference: Mapping the damage from therapist-patient sexual involvement

A growing body of evidence documents a clinical pattern of harmful effects of therapist-patient sexual involvement. In addition, surveys suggest that 1 to 12% of all therapists may have engaged in this behavior at least once in their careers. In order to develop a more comprehensive research agenda, several of these studies are reviewed in terms of inferences that may or may not be drawn. Case studies and surveys may provide for inference of clinical harm and syndrome, but they are limited in terms of generalizations about incidence in the overall population. A population approach coupled with case sampling may provide a useful tool by which to approximate a minimum level of incidence and of effects.

Psychiatric consultation to a state board of medical examiners

This article describes the evolution of psychiatric consultation to the Oregon Board of Medical Examiners. The board is charged with the licensing and regulation of physicians in the state of Oregon in order to protect the public and uphold the standards of the medical profession. Psychiatric consultation has focused on the board's investigations of physicians with mental illness and/or substance abuse and physicians who inappropriately prescribe psychoactive drugs or sexually abuse patients. Each of these physician groups is described, and remedial programs for each group are discussed. The authors conclude that psychiatric consultation to medical boards is a feasible and productive activity that can make a positive contribution to the lives of a large number of physicians and patients.

In vitro and in vivo effects of a peptide mimetic (SC-47643) of RGD as an antiplatelet and antithrombotic agent

Platelet aggregation requires binding of fibrinogen (fgn) to activated platelets and inhibition of this binding blocks platelet aggregation. Synthetic peptides modeled after the platelet binding sequence on fgn block the platelet glycoprotein IIb/IIIa receptor and effectively inhibit aggregation. SC-47643 (SC) is a mimetic of the RGD-containing peptide sequence that is recognized by the platelet IIb/IIIa receptor. SC inhibited fgn binding to activated platelets (IC50: 1.0 x 10(-5) M) and prevented platelet aggregation in response to a variety of platelet agonists in both washed human platelets and platelet rich plasma (IC50's ranging from 4 x 10(-6) to 1 x 10(-5) M, respectively). SC inhibited collagen induced thrombocytopenia in the rat (ED50 0.07 mg/kg and t1/2 36 min). In dogs ex vivo collagen induced platelet aggregation was inhibited 50% after a bolus injection of 1.7 mg/kg. After a steady state infusion (2 hr), the ED50 was 0.03 mg/kg/min, with no effects on blood pressure, heart rate or platelet count. These data demonstrate that SC, a peptide mimetic of the natural fgn binding sequence, is capable of blocking platelet-fgn interactions and platelet aggregation.

Monitored conditional release of persons found not guilty by reason of insanity

This article reviews the recent literature documenting changes that have taken place in the management and treatment of insanity defense acquittees with the development of conditional release and monitored community treatment. The review demonstrates that conditional release is particularly important as a means of balancing the protection of society with the treatment of insanity defense acquittees in the least restrictive environment. The review also highlights the development of community programs based on treatment models for the chronically mentally ill. In addition, monitored community treatment programs appear cost-effective when compared with hospital-based programs. These factors point to the development in the 1990s of program standards for the release of insanity defense acquittees.

Relationship of coping style to affective state and perceived social support in asymptomatic and symptomatic HIV-infected persons: implications for clinical management

The authors describe the relationship of three coping styles to affective state (mood) and perceived social support in 29 human immunodeficiency virus (HIV)-infected homosexual/bisexual men between the ages of 18 and 45 years. Active-behavioral coping was significantly related to enhanced mood and greater perceived social support. Avoidance coping was significantly related to greater mood disturbance and lower social support. No relationships were found for active-cognitive coping. Recommendations for clinical management of HIV-infected persons and their traditional and/or nontraditional family follow from the findings.

Antiplatelet and antithrombotic effects of platelet glycoprotein IIb/IIIa (GPIIb/IIIa) inhibition by arginine-glycine-aspartic acid-serine (RGDS) and arginine-glycine-aspartic acid (RGD) (O-me)Y (SC-46749)

Arginine-glycine-aspartic acid (RGD) is the minimal sequence in fibrinogen that leads to recognition and binding to the glycoprotein IIb/IIIa platelet receptor during aggregation. Analogs of tetrapeptides containing the RGD sequence have been previously shown to block fibrinogen binding to activated platelets in vitro. SC-46749 is an analog of arginine-glycine-aspartic acid-phenylalanine in which the phenylalanine is replaced by O-methyltyrosine. In this study the biological activities of SC-46749 were examined and its actions compared with the tetrapeptide arginine-glycine-aspartic acid-serine (RGDS), one of the natural sequences on the fibrinogen alpha chain that binds to platelets. In vitro, SC-46749 was more potent than RGDS in inhibiting fibrinogen binding (IC50: SC-46749, 27 microM; RGDS, 47 microM), in preventing ADP-induced aggregation in human platelet-rich plasma (IC50: SC-46749, 32 microM; RGDS, 95 microM) and in inhibiting thrombin-induced aggregation in washed human platelets (IC50: SC-46749, 23 microM; RGDS, 64 microM). In rats, SC-46749 prevented collagen-induced thrombocytopenia with an ED50 of 0.87 mg/kg whereas RGDS did not inhibit the response by 50% at doses up to 10 mg/kg. SC-46749 inhibited thrombus formation in an electrically damaged rat carotid artery in a dose-dependent fashion whereas the effects of RGDS were biphasic. RGDS appeared to delay thrombus formation at lower doses but had no effect at higher doses. When infused in dogs for 15 min, SC-46749 prevented ex vivo collagen-induced aggregation at 4 mg/kg/min. These data demonstrate that SC-46749 is a potent inhibitor of platelet aggregation and platelet-dependent thrombus formation.

High-dose intramuscular triamcinolone in severe, chronic, life-threatening asthma

BACKGROUND

Despite oral corticosteroid therapy, some patients with asthma have frequent exacerbations requiring emergency room visits, hospitalization, and occasionally, mechanical ventilation. We compared the effects of high-dose intramuscular triamcinolone with oral prednisone in patients with severe chronic asthma.

METHODS

In a double-blind, placebo-controlled, cross-over study that spanned all seasons, we treated 12 patients with high-dose intramuscular triamcinolone (360 mg over the first three days of the treatment period) or low-dose oral prednisone (median dose, 12.5 mg per day throughout the period; range 0 to 30). The two three-month treatment periods were separated by a three-month washout period. During all periods the patients were allowed to take additional doses of prednisone for acute exacerbations of asthma.

RESULTS

After receiving triamcinolone, the patients had significantly better peak expiratory flow rates than while receiving prednisone (the average [+/- SEM] weekly percent of the predicted value during the triamcinolone period was 91.5 +/- 6.9, as compared with 75.0 +/- 5.9 for the prednisone period; P less than 0.05). During the prednisone period there were 21 emergency room visits and 10 hospitalizations, but there were none during the triamcinolone period (P less than 0.05). There were two episodes of ventilatory failure during the prednisone period. Total steroid doses were significantly smaller during the triamcinolone period than during the prednisone period (P less than 0.04). Steroidal side effects were more pronounced after treatment with triamcinolone than after treatment with prednisone (P less than 0.1).

CONCLUSIONS

We conclude that high-dose intramuscular triamcinolone is more effective than low-dose prednisone in patients with severe, chronic, life-threatening asthma, but steroidal side effects are somewhat worse.

A biopsychosocial examination of symptomatic and asymptomatic HIV-infected patients

This study evaluated twenty-nine symptomatic and asymptomatic HIV-infected homosexual/bisexual men between eighteen and forty-five in the areas of psychiatric/psychosocial, neuropsychological, family, and immunological functioning. The subjects were referred by physicians, nurses, and mental health professionals from the Tulane/Louisiana State University AIDS Clinical Trials Unit and the C-100 outpatient Primary Care Clinic for HIV-infected patients served within the Charity Hospital of Louisiana at New Orleans. All subjects and their significant others were evaluated between November 1987 and October 1988 at the C-100 Clinic. The outcome measures were mood disturbance, psychological distress, and CD4 cell count. The most significant other family member, as selected by each subject, completed family measures. The subjects experienced psychological distress and neuropsychological problems. Active-behavioral coping appeared adaptive (related to enhanced mood) as did perceived social support (related to positive mood and lower psychological distress). Higher levels of neuropsychological functioning (verbal memory, visual memory, motor speed, and visual-motor sequencing) were associated with enhanced psychosocial functioning and/or immunological status. The findings from this study highlight the importance of conducting longitudinal studies using a multidimensional approach in which HIV-infected persons and their most significant other family members are evaluated within a biopsychosocial model.

Asthma: the pulse is not the paradox

Some interesting, unusual features of asthma are discussed: that patients may be better able to evaluate the severity of their asthma than physicians; that expiratory obstruction indirectly increases the work of inspiration; that 1 of the responses to airflow obstruction is hyperventilation; that localized areas of airflow obstruction may cause increased ventilation/perfusion ratios by decreasing perfusion more than ventilation; that increasing tidal volume may cause a reduction in alveolar ventilation; and, finally, that there is evidence that asthma has worsened in recent years, despite advances in the understanding and treatment of this disease.

The pregnant psychiatric inpatient: a missed opportunity

The authors describe a group of pregnant psychiatric patients admitted to a psychiatric service in an urban hospital. A high rate of involuntary admission (44%), homelessness (36%), and substance abuse (64%) was noted. In this group of high-risk obstetric patients, we identified risk factors associated with noncompliance with ongoing prenatal care. Brief psychiatric hospitalization can be an important aspect in improving obstetric outcome by providing an opportunity to collect obstetric information and promote ongoing prenatal care.

The self-help movement in head injury

The purpose of the research project reported in this article was to describe head injury support groups and compare them to other types of self-help groups. A 21-item questionnaire inquired about the impact, benefits, and description of the support group selected for study. Seventy-seven members of four randomly selected state chapters of the National Head Injury Foundation (NHIF) answered the survey. Eighty-two percent of the members felt that their membership was helpful in their adjustment. The perceived benefits of the groups were (a) to obtain information on head injury; (b) to be with others who were experiencing the same ordeal; (c) to increase awareness about head injury; and (d) to learn about available resources.

Effect of inosine supplementation on 3-mile treadmill run performance and VO2 peak

The purpose of this study was to investigate the ergogenic effect of oral inosine (IN) supplementation (6,000 mg.d-1 for 2 d) upon 3-mile run time (3MTIME) and VO2 peak. Nine highly trained endurance runners participated in a double-blind, placebo (PL), crossover study. Each subject undertook an IN or PL trial, consisting of three exercise tests: a submaximal warm-up run (SUBRUN), a competitive 3-mile treadmill run (3MRUN), and a maximal treadmill run (MAXRUN) to determine VO2 peak and time to exhaustion (MAXTIME). Additional measurements during the 3MRUN and MAXRUN included oxygen uptake (VO2), ventilation (VE), respiratory exchange ratio (R), and ratings of perceived exertion (RPE); blood samples were also taken prior (PRERUN) to the SUBRUN test and following the SUBRUN, 3MRUN, and MAXRUN tests in order to assess glucose, pyruvate, lactate, phosphorus, 2,3-DPG, hemoglobin, and uric acid. Analyses of the data revealed no significant effect of oral IN supplementation either upon 3MTIME (IN = 18.31 +/- 1.21; PL = 18.33 +/- 1.15 min) or VO2 peak (IN = 58.6 +/- 5.1; PL = 60.7 +/- 4.5 ml O2.kg-1.min-1) or upon other dependent variables. MAXTIME was significantly longer during the PL trial (P less than 0.05), suggestive of a possible impairment effect of oral IN supplementation. Based upon our data, we conclude that IN is not an effective ergogenic aid to enhance athletic performance of an aerobic nature.

Effects of phosphate loading on oxygen uptake, ventilatory anaerobic threshold, and run performance

Seven male competitive runners (VO2max 73.9 +/- 6.3 ml.kg-1.min-1) participated in a two-session, placebo, double-blind study to determine the effects of phosphate loading on oxygen uptake, ventilatory anaerobic threshold, and 5-mile run performance. Subjects ingested 1000 mg of tribasic sodium phosphate or a placebo four times daily for 6 d. A maximal running stress test or a 5-mile performance run was performed randomly on either the 3rd or the 6th d. Test sessions were separated by a 2-wk washout period and repeated with alternating phosphate and placebo regimens. Venous blood samples were collected prior to and following each max and run session. Results revealed that placebo resting serum phosphate levels were mildly elevated and that phosphate loading significantly increased resting and post-exercise serum phosphate values. Resting and post-exercise 2,3-diphosphoglycerate values were decreased while hemoglobin values were elevated with phosphate ingestion. Phosphate loading significantly increased maximal oxygen uptake from 4.77 +/- 0.29 to 5.18 +/- 0.25 l.min-1 and ventilatory anaerobic threshold from 3.74 +/- 0.28 to 4.18 +/- 0.14 l.min-1. Five-mile run times were nonsignificantly different between placebo and phosphate sessions. However, mean performance run oxygen uptake was significantly lower (3.87 +/- 0.3 to 3.80 +/- 0.3 l.min-1) with phosphate ingestion. Data demonstrate that maximal and run performance were influenced by elevations in serum phosphate eliciting an increased maximal oxygen uptake, ventilatory anaerobic threshold, and variable effects on 5-mile run performance. These adaptations occurred without observable increases in red cell 2,3-diphosphoglycerate.

Multiple peptide synthesis using a single support (MPS3)

An automated multiple peptide synthesis method to synthesize, cleave, and purify several peptides simultaneously in a single batch has been developed. The technique is based on the synthesis of multiple peptides on a single solid phase support and is easily adapted to manual or to automated methods. The approach relies on coupling of amino acid mixtures to the resin and it has been found that DCC/HOBt gives the best coupling performance. Fast Atom Bombardment Mass Spectrometry (FAB-MS) was used to rapidly and efficiently identify the peptides in each synthetic mixture which significantly assisted the purification process by HPLC. The method has been successfully applied to the synthesis of magainin 2 and angiotensinogen peptides.

The malpractice claims experience of physicians investigated for inappropriate prescribing

Inappropriate prescribing of controlled substances, primarily opiates and benzodiazepines, is the most common complaint brought before the Oregon Board of Medical Examiners. We describe the malpractice claims experience of 120 physicians previously investigated by the Oregon board for inappropriate prescribing. These physicians were matched with a comparison group by age, specialty, and practice location. We found that a mean of one malpractice claim had been filed against each physician in our study, with the specialties of obstetrics and gynecology, neurosurgery, and orthopedics having the most claims. A significantly higher mean number of malpractice claims had been filed against 31 physicians disciplined by the board. Our study suggests a role for state regulatory boards in the malpractice area. We propose that such bodies do practice reviews based on the convergence of two events, a disciplinary action such as those described in this article and the filing of more than one malpractice claim against a physician. Further research is needed on inappropriate prescribing by physicians and its possible association with malpractice.

Radiographic measurement of total lung capacity in acute asthma

The thoracic cage appears to be large during attacks of asthma. Lung volume measurements by body plethysmography and helium dilution have suggested that total lung capacity may be increased during an acute attack of asthma, but doubt has been cast on the accuracy of these measurements in the presence of airflow obstruction. The change in total lung capacity has therefore been investigated during and after an acute attack of severe asthma in 32 patients by a radiographic technique. There was a small decrease (0.29 l) in mean total lung capacity between admission and follow up, though a quarter of the subjects showed a slight increase. There was no correlation between change in total lung capacity and change in expiratory flow rates, arterial carbon dioxide tension on admission, body mass index, and length of stay in hospital. Our findings agree with previous reports of a decrease in total lung capacity with improving airway obstruction, but the changes were small and inconsistent.

Physicians investigated for inappropriate prescribing by the Oregon Board of Medical Examiners

We retrospectively reviewed all allegations of inappropriate prescribing investigated by the Oregon Board of Medical Examiners from 1981 through 1986. Inappropriate prescription writing accounted for 51% of all investigations during this period, with controlled drugs, primarily opiates and benzodiazepines, accounting for most complaints. Of 130 physicians investigated, more than half had previous complaints; 50 were ultimately restricted or disciplined by the board. Inappropriate prescribing of controlled drugs is probably underdetected and frequently repeated. Available literature suggests that inappropriate prescribing of other drugs, especially antibiotics, is extremely common, but such problems were rarely identified by the current discovery and review processes of the Oregon board. Inappropriate prescribing will require increased attention from physician educators and licensing boards.

Sportsmedicine forum

A Forum For Our Readers Sportsmedicine Forum is intended to provide a sounding board for our readers. Perhaps you have a special way to treat a common medical problem, or you may want to air your views on a controversial topic. You may object to an article that we have published, or you may want to support one. You may have a new trend to report, identified through an interesting case or a series of patients. Whatever your ideas, we invite you to send them to us. Illustrative figures are welcomed. Address correspondence to Sportsmedicine Forum, The Physician and Sportsmedicine, 4530 W 77th St, Minneapolis, MN 55435.

Mental health services research with forensic populations

Research on the management and treatment of insanity acquittees and the right to refuse treatment illustrates the need for empirical analysis in the overlapping areas of law, mental health services, and public policy issues.

Streptokinase in a loculated pleural effusion. Effectiveness determined by site of instillation

A patient with a large loculated pleural effusion had streptokinase instilled into the loculation, and this was ineffective; however, when the same amount of streptokinase was instilled into the space around the loculation, there was rapid lysis of the loculation, resulting in the drainage of purulent fluid through the chest tube.

Evidence of a novel association of unsaturated fatty acids with Gc (vitamin D-binding protein)

The strong sequence homology described recently between Gc (Vitamin D-binding protein) and albumin, and the ability of the latter, to bind 2-p-toluidinylnaphthylene sulfonate (TNS) promoted similar binding studies with Gc. TNS bound to native Gc as demonstrated by fluorescence, but chloroform:methanol extraction of Gc and gas chromatography revealed that large amounts of unsaturated fatty acids - 16:1, 18:1, 18:2 and 20:4 were also associated with Gc. In addition, TNS fluorescence was abolished by delipidation of Gc, and restored upon subsequent reconstitution with fatty acid. Finally, 70-80% of [3H]-arachidonic acid added to whole serum bound to Gc. These results demonstrated that TNS fluorescence of the native molecule reflects associated lipid, and suggest a novel role for Gc as a reservoir for a circulating pool of unsaturated fatty acids.

Role of group-specific component (vitamin D binding protein) in clearance of actin from the circulation in the rabbit

The possible role of group specific component (Gc) (vitamin D-binding protein) in the clearance of cellular actin entering the circulation was examined with 125I-labeled Gc and actin injected into a rabbit model. Although filamentous F-actin is depolymerized primarily by plasma gelsolin, greater than or equal to 90% 125I-actin injected in either monomeric G- or F-form became complexed eventually with Gc (1:1 molar ratio). Clearance of Gc complexes was much faster (greater than 90% within 5 h) than that of native Gc (t1/2 = 17.2 h). Nephrectomy did not significantly alter the clearance of either Gc or actin. Since Gc complexes are dramatically increased in situations of tissue necrosis such as in fulminant hepatic failure, the current results suggest a crucial role for Gc in sequestration and clearance of released cellular actin.

Design and application of an expert system for mobile phase optimisation in reversed-phase liquid chromatography

The selection of the optimum composition for the mobile phase in reversed-phase high-performance liquid chromatography (HPLC) is a complex task; conventional approaches require the expenditure of significant amounts of time by the analyst, particularly for complex mixtures of solutes of biological origin. Some of the existing strategies for the automated optimisation of mobile phase composition (e.g. Simplex), may fail if the elution order of the components changes; or they may require that standards be chromatographed in order to establish the retention behaviour of each component in a mixture (e.g. resolution mapping). These problems may be overcome if the retention behaviour of each individual solute can be established from the chromatogram of the mixture. In this regard, components can be tracked by exploiting the spectral information generated by a rapid scanning photodiode array detector. Unfortunately this information is often insufficiently detailed to allow an unambiguous model of retention behaviour to be constructed. The system developed by the Authors uses these spectral data as a basis for constructing one or more hypothetical retention models, each of which is refined or rejected as further information is obtained during the progress of the experiment. To improve the reliability of the retention models proposed by the system, the spectral data are utilised in a number of tests designed to assess the purity of each chromatographic peak. The information so generated may be used in conjunction with any previously acquired spectral data both to select an appropriate method for extracting spectra for each component from the matrix of (A, lambda, t) data and to establish reliability parameters for the resultant spectra. The development and philosophy of the expert system developed for eluent optimisation in reversed-phase HPLC is discussed.

Lack of effect of hydration on sputum production in chronic bronchitis

Patients with chronic lung disease productive of sputum are generally encouraged to drink a large amount of fluid to facilitate sputum production. This clinical practice has not been tested systematically. Twelve outpatients with chronic obstructive pulmonary disease in clinically stable condition who had daily sputum production were asked in random sequence: 1) to drink one glass of fluid every waking hour after supper and upon waking the next morning (hydration), 2) to drink no fluid after supper and upon waking the next morning (dry), and 3) to drink fluid ad lib (ad lib). Each morning sputum collection was started upon waking and continued for four hours. The differences in volume, elasticity of sputum, respiratory symptoms, and ease of expectoration were not significant. We conclude that moderate hydration and dehydration have no effect on volume expectorated, the elasticity of sputum, respiratory symptoms or forced expiratory volume in one second.

Altered conformation of Gc (vitamin D-binding protein) upon complexing with cellular actin

Complexing of serum Gc (Vitamin D-binding protein) with cellular actin can occur in the extracellular space as a result of cell turnover, and particularly cell necrosis. The clearance of such complexes is significantly more rapid than that of Gc alone, and several tissues are involved in their uptake, but the mechanisms involved are unknown. We present evidence here that interaction with actin results in alteration of certain physicochemical properties of Gc. Fluorescence of the hydrophobic probe 2-p-toluidinylnaphthylene-6-sulfonate was abolished by complex formation with actin. In addition, isoelectric focusing of complexes between Gc, and actin from different tissues, revealed that complexes were generally more acidic than either protein individually. These findings indicate that complexing of Gc with actin results in altered conformation.

Cough and wheezing from beclomethasone dipropionate aerosol are absent after triamcinolone acetonide

STUDY OBJECTIVE

To test the hypothesis that patients with asthma who develop cough and wheezing after the use of beclomethasone aerosol would have a better tolerance for triamcinolone aerosol.

DESIGN

Randomized, double-blinded, crossover trial.

SETTING

Pulmonary function laboratory.

PATIENTS

Volunteer sample of 24 patients attending an asthma clinic who had developed cough, with or without wheezing, after inhaling beclomethasone aerosol. All patients completed the study.

INTERVENTIONS

Aerosols were used in habitual manufacturers' preparations and canisters, but both were administered in three puffs through the delivery system used for triamcinolone. The preparations differed in drug (beclomethasone dipropionate or triamcinolone acetonide), propellant (trichloromonofluoromethane and dichlorodifluoromethane, or dichlorodifluoromethane alone, respectively) and dispersant (oleic acid or dehydrated alcohol, respectively). PATIENTS inhaled three puffs of one aerosol on one day and three of the other on the next.

MEASUREMENTS AND MAIN RESULTS

Forced expiratory volume in one second (FEV1) was measured before and after each aerosol application. The FEV1 decreased a mean of 17.7% from baseline after inhalation of beclomethasone, and 0.8% after triamcinolone (difference, 16.9; 95% confidence limits, 12.36 to 21.34; p less than 0.001). Coughs were counted after each puff. The mean number of coughs after beclomethasone aerosol inhalation was 35.8, and after triamcinolone, 0.5 (difference, 35.3; 95% confidence limits, 22.62 to 47.98, p less than 0.001).

CONCLUSIONS

Asthmatic patients who are unable to inhale beclomethasone aerosol due to cough or wheezing can inhale triamcinolone aerosol without difficulty. Our investigation does not determine the exact cause of the coughing and wheezing with the beclomethasone aerosol, but we suspect the dispersant as the source.

Cough and wheezing from beclomethasone aerosol

Cough and wheezing are frequent side effects of inhaling beclomethasone dipropionate aerosol (BA) in patients with asthma. Twenty percent of our outpatient asthmatic subjects are unable to take BA due to these side effects. Twelve patients with history of severe cough and wheezing after inhaling BA were tested. Three puffs of either BA or placebo (Plc) were administered from a metered dose inhaler (MDI) in a double-blind crossover design. They coughed a mean of 31 times after BA and 19 times after Plc. Forced expiratory volume in one sec (FEV1) declined a mean of 22.6 percent after BA and 22.0 percent after Plc. Pretreatment with albuterol attenuated both the cough and the drop in FEV1. Follow-up study showed that regular pretreatment with bronchodilator enabled seven of 12 patients to tolerate BA therapy. The remaining five required a short course of increased dose oral steroid therapy. Cough and wheezing are frequent side effects of BA therapy that interfere with regular compliance. Pretreatment with a bronchodilator is effective in attenuating these side effects in some patients; in others, a short course of oral steroid therapy may be necessary.

Positional effects on distribution of ventilation in chronic obstructive pulmonary disease

Ventilation is distributed predominantly to the dependent lung in normal persons in the decubitus position. We evaluated the distribution of ventilation in four patients with mild-to-moderate chronic obstructive pulmonary disease using 81mKr gas. Patients were tested in the sitting and right and left decubitus positions with and without the application of positive end expiratory pressure (PEEP). In contrast to findings in controls, ventilation was predominantly distributed to the nondependent lung in patients in the decubitus position. Mean ventilation in the right lung decreased from 51% of the total in the sitting position to 31% in the right decubitus position; it increased with the application of 10 cm PEEP. Reduced ventilation in the dependent lung most likely is caused by closure of the airways after a decrease in volume. Application of PEEP resulted in increased lung volume and preferential distribution of ventilation to the dependent lung.

Rate of improvement of pulmonary function in sarcoidosis during treatment with corticosteroids

Serial measurements of vital capacity were obtained in 11 patients with impaired pulmonary function due to sarcoidosis during 12 courses of corticosteroid treatment. Vital capacity improved promptly and approached a maximum value in about three weeks. A three week trial is probably sufficient to show whether or not corticosteroids are effective in a patient with sarcoidosis.

Bullous pulmonary damage in users of intravenous drugs

Among a large group of users of illicit intravenous drugs, the incidence of bullous pulmonary damage was noted to be 2 percent (6/387). Bullous damage was significantly different in the drug users than in those who did not use drugs. The drug users were significantly younger than the nonusers, their bullae were large and confined to the upper lobes, and alpha 1-antitrypsin deficiency was very unlikely. These features strongly implicate intravenous drug abuse in the pathogenesis of these patients' bullous pulmonary damage.

Effect of odors in asthma

Many patients complain that some odors worsen their asthma. Perfume and cologne are two of the most frequently mentioned offenders. Four patients with a history of worsening of asthma on exposure to cologne underwent challenge with a cologne, and their pulmonary function was tested before, during, and after the exposure. Forced expiratory volume in one second declined 18 to 58 percent below the baseline period during the 10-minute exposure and gradually increased in the next 20 minutes. Saline placebo pretreatment did not affect the response to subsequent challenge. Single-blind pretreatment with metaproterenol and atropine prevented decline in one-second forced expiratory volume in three of four patients and blunted the response in the other. Cromolyn sodium prevented decline in one of four, and occlusion of nostrils prevented decline in one of three. A survey of 60 asthmatic patients revealed a history of respiratory symptoms in 57 on exposure to one or more common odors. Odors are an important cause of worsening of asthma.

Aerosol beclomethasone in patients with steroid-responsive chronic obstructive pulmonary disease

Some patients with chronic obstructive pulmonary disease have favorable responses to treatment with oral corticosteroids with increase in one-second forced expiratory volume of 30 percent or more above the baseline. The benefit of long-term steroid therapy may be outweighed by the side effects. Twelve patients who had previously demonstrated a response to oral corticosteroids were studied in a double-blind randomized crossover trial comparing prednisone (30 mg daily) with beclomethasone (metered-dose inhaler, 16 puffs daily) for two weeks each with a two-week washout period between the two regimens. Those who were taking prednisone tapered the dose to 5 mg daily and those taking beclomethasone discontinued it for two weeks before the beginning of the study. History, physical examination, and pulmonary function were monitored. The mean one-second forced expiratory volume increased from 0.65 to 1.00 liter after prednisone therapy and it increased from 0.63 to 0.81 liter after aerosol beclomethasone (difference significant, p less than 0.01 by paired t test). Only five of 12 patients had an increase in one-second forced expiratory volume with steroid aerosol, an increase that was at least 50 percent that achieved by prednisone. In most patients with steroid-responsive chronic obstructive pulmonary disease, aerosol beclomethasone is not an adequate substitute for oral steroids.

Arteriovenous malformations: complications of surgical intervention and implications for nursing

Arteriovenous malformations occur in approximately 4 percent of the population and are frequently seen in young adulthood. Controversy exists in the neurosurgical community as to the management of arteriovenous malformations; the four most common methods are medical management, radiation, embolization, and surgical intervention. Complications occur frequently regardless of the treatment selected. These complications are discussed using a selected patient population and case studies. Nursing diagnosis is used and a plan of care formulated for each problem. A one-year follow-up status will also be given for the selected patient population.

Vitamin and mineral supplements to athletes: do they help?

Although the general implications of this review would be that vitamin and mineral supplements are ineffective as ergogenic aids when added to the diet of an athlete who is well-nourished, there may be certain instances in which supplementation is warranted. For example, wrestlers on low calorie diets and high levels of energy expenditure may not be receiving a balanced intake of nutrients. Young male athletes and female athletes of all ages should be aware of iron-rich foods and include them in the daily diet. The female athlete who experiences a heavy menstrual flow may consider commercial iron preparations; hemoglobin and other hemotologic variables may be evaluated in order to determine the need for supplementation. More research is needed, particularly with large doses of the vitamin B-complex and vitamin C. Although some of the studies cited herein have used large doses, some athletes have been reported to consume massive dosages, for example, 10,000 mg of vitamin C daily. Unfortunately, there may be some adverse side effects of such massive doses, and it may not be ethical to conduct research with humans at those high intake levels. Do these massive dosages elicit a pharmacodynamic effect on some metabolic reactions that are favorable to physical performance? More research with vitamin E at altitude also appears to be warranted, as does iron supplementation to iron-deficient, but not anemic, athletes. As noted earlier, the current data base suggests that vitamin and mineral supplements are unnecessary for the athlete receiving a balanced diet. However, only with additional controlled research may we expand that data base to help answer some of the questions that still remain relative to nutrition and athletic performance. There are still a large number of athletes who believe that the "racers edge" may be found in a tablet.

Effect of bronchodilator therapy administered by canister versus jet nebulizer

Bronchodilator efficacy of metaproterenol sulfate aerosol therapy delivered either by canister or jet nebulizer was compared in 25 patients, 13 with severe asthma and 12 with COPD. Treatment was carried out in double-blind crossover fashion on 2 days and consisted of either metaproterenol sulfate solution 15 mg in 2.3 ml administered from a jet nebulizer or three puffs of metered-dose metaproterenol sulfate (total 1.95 mg) inhaled sequentially. FVC and FEV1 were monitored before and after therapy for 2 hr. In 13 asthmatic patients, FEV1 increased from a baseline mean of 0.83 L to 1.57 L at 2 hr after jet nebulizer therapy and increased from 0.84 L to 1.52 L after canister therapy. In 12 patients with COPD, FEV1 increased from 0.58 L to 0.78 L after jet nebulizer therapy and from 0.57 L to 0.76 L after canister therapy. FVC also increased similarly after each form of therapy. The two types of aerosol therapy were equally effective and were without side effects. Canister therapy has the advantage over jet nebulizer therapy by being convenient and cheaper.

Lactic acidosis in severe asthma

Twelve patients with severe asthma in whom lactic acidosis developed are presented. All had an arterial blood pH level lower than that expected for the measured partial pressure of arterial carbon dioxide, all had an abnormally large anion gap, and the blood lactate level exceeded 2.8 mmol/liter. Respiratory acidosis subsequently developed in eight patients, and six required intubation. Lactic acidosis can develop in patients with severe asthma. Such patients are in danger of the development of respiratory failure and must be treated vigorously and observed closely.

Bronchodilator response to oral aminophylline and terbutaline versus aerosol albuterol in patients with chronic obstructive pulmonary disease

Bronchodilator efficacy of oral administration of aminophylline (400 mg) and terbutaline sulfate (5 mg) was compared with inhalation of three puffs of albuterol sulfate in 17 patients with stable chronic obstructive pulmonary disease in a double-blind crossover study. Two hours after either form of therapy, the patients were treated again with three puffs of albuterol. Forced expiratory volume in one second (FEV1) increased significantly more from the baseline value after albuterol aerosol than after oral medication at 30, 60, and 120 minutes (paired t test, p less than 0.01). After three puffs of albuterol at 120 minutes, FEV1 increased to similar values an hour later on both days in 14 of 17 patients. Thirteen patients complained of side effects during oral therapy and none during aerosol therapy. Maximum bronchodilatation was achieved by albuterol aerosol in 14 of 17 patients, and addition of oral therapy produced no further increase of flow rate in these patients. Bronchodilator aerosol is the logical choice for treatment of chronic obstructive pulmonary disease because it is more effective than oral therapy and because it is free from side effects.

Relationship of wheezing to the severity of obstruction in asthma

Ninety-three asthmatic patients were examined on 320 occasions for wheezing and peak expiratory flow rate (PEFR). The presence of a wheeze (either reported by the patient or found on examination) was associated with a significantly lower PEFR. Expiratory wheezing was usually accompanied by inspiratory wheezing; this biphasic wheezing was associated with a lower PEFR than only expiratory wheezing. Loudness and the high pitch of wheezing were associated with more severe obstruction. Most expiratory wheezing lasted throughout the entire expiration. Expiratory or inspiratory wheezing of high pitch, moderate to severe intensity, and spanning the entire phase of the breath was associated with a lower PEFR than wheezing without these characteristics. Although characterization of wheezing has a general relationship to the severity of airway obstruction, an objective measurement of expiratory flow rate is necessary for the evaluation of each patient's condition.

Evidence for an alternative route from sterol to sapogenin in suspension cultures from Trigonella foenumgraecum

Incorporation of [4-(14)C]cholesterol, [26-(14)C]-cholesterol, [4-(14)C]sitosterol and [22,23-(3)H]-sitosterol into sapogenin in suspension cultures from Trigonella foenumgraecum differed when substrates were added at subculture and 10 d after subculture, suggesting alternative biosynthetic routes were in operation.