Great expectations and the grapes of wrath: contamination of contact lenses

The results of an analysis of complications in contact lens wearers in The Netherlands indicate that there is an increased risk of keratitis associated with the extended wear of the lenses. This article discusses some of the underlying issues.

Inducible nitric oxide synthase is an endogenous neuroprotectant after traumatic brain injury in rats and mice

Nitric oxide (NO) derived from the inducible isoform of NO synthase (iNOS) is an inflammatory product implicated both in secondary damage and in recovery from brain injury. To address the role of iNOS in experimental traumatic brain injury (TBI), we used 2 paradigms in 2 species. In a model of controlled cortical impact (CCI) with secondary hypoxemia, rats were treated with vehicle or with 1 of 2 iNOS inhibitors (aminoguanidine and L-N-iminoethyl-lysine), administered by Alzet pump for 5 days and 1. 5 days after injury, respectively. In a model of CCI, knockout mice lacking the iNOS gene (iNOS(-/-)) were compared with wild-type (iNOS(+/+)) mice. Functional outcome (motor and cognitive) during the first 20 days after injury, and histopathology at 21 days, were assessed in both studies. Treatment of rats with either of the iNOS inhibitors after TBI significantly exacerbated deficits in cognitive performance, as assessed by Morris water maze (MWM) and increased neuron loss in vulnerable regions (CA3 and CA1) of hippocampus. Uninjured iNOS(+/+) and iNOS(-/-) mice performed equally well in both motor and cognitive tasks. However, after TBI, iNOS(-/-) mice showed markedly worse performance in the MWM task than iNOS(+/+) mice. A beneficial role for iNOS in TBI is supported.

Immune response to revaccination with meningococcal A and C polysaccharides in Gambian children following repeated immunisation during early childhood

Forty-two Gambian children randomised to receive two doses of meningococcal A/C polysaccharide vaccine (MPS) in infancy and either MPS (n = 15), meningococcal A/C conjugate (n = 13) or inactivated polio vaccine (IPV n = 14) at 2 years, were revaccinated with MPS at 5 years of age along with 39 matched control children. Meningococcal A and C polysaccharide antibodies were analysed by ELISA and bactericidal assay (SBA) in sera taken before and 10 days after revaccination. The geometric mean group SBA titre in the MPS group following revaccination was about half that of the unvaccinated controls (0.51 95%CI: 0.28, 0.90) for group A and less than half that of the controls for group C (0.41, 95%CI: 0.16, 1.03 P = 0.06). The group C SBA response in the conjugate group was 14-fold higher than in the MPS group (P < 0.001). Multiple doses of meningococcal polysaccharide in childhood may therefore attenuate the SBA response to both group A and group C polysaccharides. In contrast, vaccination with meningococcal A/C conjugate after MPS in infancy gives immunological memory to N. meningitidis group C.

The prevalence of dental erosion in the maxillary incisors of 14-year-old schoolchildren living in Tower Hamlets and Hackney, London, UK

The purpose of this study was to assess the prevalence of dental erosion in the maxillary incisors of a sample of 14-year-old schoolchildren and to explore the aetiological factors responsible for that erosion. The cross-sectionally design study took place in secondary schools in inner-city London, UK and involved 525, 14-year-old schoolchildren selected at random in a clinical examination and a self-completed questionnaire. The outcomes measures for dental erosion were; the prevalence, the area and depth of lesions and the risk factors. The prevalence of labial and palatal erosion was 16.9 per cent and 12 per cent respectively. Risk factors and behaviours including daily frequency of ingestion of acidic fruits and drinks, food vomiting, toothbrushing frequency, and swimming habits were not shown to have any relationship with the presence of erosion. It was concluded that the prevalence of erosion in the maxillary incisors of this sample was higher labially and lower palatally than in previously reported national figures. The risk factors which were investigated were not shown to have any relationship with the presence of erosion. Further investigations of these issues are necessary to establish whether or not dental erosion is a public health problem in the UK.

Bags of toys: the demise of PVC

Poly(vinyl chloride) (PVC) is a widely used commodity plastic that has many applications in medical devices. Recent concerns over the oestrogenic activity of some of the phthalate plasticizers used in PVC, and the hazards associated with dioxin that may be produced during the incineration of PVC waste have initiated an assessment of the future role of this material. This article addresses some of the underlying toxicological and risk assessment issues.

An overview of proteinase inhibitors

Proteinase inhibitors are proteins in the body that regulate the catalytic activity of proteinases. They are important in a large variety of physiologic processes including coagulation, digestion, tumor metastasis and immunity. Proteinase inhibitors are categorized as either nonspecific proteinase inhibitors or class-specific proteinase inhibitors. Nonspecific proteinase inhibitors are comprised soley of the alpha macroglobulins, most notably alpha2-macroglobulin. Class-specific proteinase inhibitors are subcategorized as serine proteinase inhibitors, aspartic proteinase inhibitors, metalloproteinase inhibitors, and cysteine proteinase inhibitors. Each subcategory is made up of numerous inhibitors. As the roles of individual proteinase inhibitors are determined, the therapeutic use of natural and synthetic proteinase inhibitors is also being investigated. The purpose of this article is to review the history and classification of proteinase inhibitors and their relevance to veterinary medicine.

Characteristics of depression as assessed by the Diagnostic Assessment for the Severely Handicapped-II (DASH-II)

Fifty-seven individuals with severe and profound mental retardation (18 with a DSM-IV diagnosis of depression, 19 with a Diagnostic Statistical Manual, 4th edition diagnosis of autism, and 20 who meet no criteria for an emotional disorder) were studied. The validity of the Diagnostic Assessment for the Severely Handicapped II depression subscale was evaluated to determine its value in categorizing individuals in these two groups. Suggestions were made for diagnosing depression in persons with severe and profound mental retardation. In a second study the above individuals were compared on symptomology to assess comorbidity with related symptoms. These "core," peripheral, or associated features of depression were identified. Implications of the findings for describing and defining depression in these persons are discussed.

Intraoperative acetazolamide in the prevention of intraocular pressure rise after pars plana vitrectomy with fluid-gas exchange

PURPOSE

To assess the effect of intraoperative acetazolamide (Diamox) on postoperative intraocular pressure (IOP) in gas-filled, vitrectomized eyes.

METHODS

We conducted a prospective randomized clinical trial of 63 consecutive patients undergoing pars plana vitrectomy with total fluid-gas exchange and long-acting intraocular gas tamponade. Patients were randomized by a blind draw to receive either intravenous 500 mg acetazolamide (Diamox) (Group 1) or no treatment (Group 2) at the conclusion of the operative procedure. Intraocular pressures at the conclusion of surgery (IOP-1), 4-8 hours following surgery (IOP-2), and on the first postoperative day (IOP-3) were measured using an Oculab Tono-Pen.

RESULTS

Patients in Groups 1 and 2 showed similar mean IOP on postoperative day 1 (20.48+/-7.84 mmHg versus 19.89+/-7.89 mmHg). A similar incidence of IOP-2 greater than 30 mmHg (1 versus 3 patients with high IOP) and IOP-3 greater than 30 mmHg (4 versus 3 patients with high IOP) was seen. Patients in Group 1 had a lower mean IOP at 4-8 hours postoperatively (16.25+/-6.47 mmHg) than those in Group 2 (20.13+/-6.33 mmHg). No correlation could be demonstrated between IOP-1 and subsequent IOP. However, IOP on the first postoperative day (IOP-3) was strongly correlated with IOP 4-8 hours after surgery (IOP-2) (P = 0.0001). No protective effect of Diamox could be demonstrated on either IOP-2 or IOP-3.

CONCLUSIONS

No protective effect against pressure rise could be demonstrated for intraoperative acetazolamide (Diamox) in the prophylaxis of IOP rise following pars plana vitrectomy and total fluid-gas exchange with long-acting intraocular gas.

rhBMP-collagen sponges as osteoinductive devices: effects of in vitro sponge characteristics and protein pI on in vivo rhBMP pharmacokinetics

Osteoinductive devices, comprised of biodegradable collagen scaffolds and recombinant human Bone Morphogenetic Proteins (rhBMPs), are being currently pursued for local bone induction. To better understand the biological performance of such devices, we have carried out a series of studies to investigate the effects of sponge properties and protein structural features on the pharmacokinetics of implanted rhBMPs. The results indicated little dependence of the rhBMP-2 pharmacokinetics on the in vitro determined sponge properties. The protein isoelectric point (pI), on the other hand, was found to significantly affect the initial implant retention of rhBMPs, but not the subsequent pharmacokinetics. A 100-fold difference in the implant-retained dose could be observed depending on the type of rhBMP implanted. We conclude that protein structural features are important variables controlling in vivo pharmacokinetics of rhBMPs, and possibly the osteoinductive potency of the devices.

Accessing data from external centralized sources to enhance analysis of a completed clinical trial

After the data collection phase of a clinical trial has been completed, new hypotheses may surface which require additional data before they can be tested. In the Veterans Affairs Cooperative Study on Single Drug Therapy of Hypertension, we investigated the relationship between location of the participating center, race and ability to control blood pressure. The analysis indicated poorer blood pressure control among sites located in the "stroke belt" (southeastern United States), especially among African-Americans. We sought to determine whether the effect was attributable to socioeconomic patterns; however, income data were not collected as part of the original study. Therefore, we accessed centralized data bases to obtain zipcode-level income information for the randomized study patients. This approach yielded estimates of income data for 94.3% of the patients and compared favorably to data acquisition rates for variables which were collected prospectively in the study.

Preventive care in Canterbury general practice

AIMS

To describe the preventive care attitudes, beliefs, priorities and systems of Canterbury general practitioners, to compare their beliefs about appropriate care with evidence-based guidelines and to investigate possible associations between preventive care beliefs and attitudes, and selected practitioner variables.

METHOD

A questionnaire was mailed to all 375 general practitioners in Canterbury, with a response rate of 70%.

RESULTS

Respondents expressed positive attitudes to preventive care, their views about appropriate care corresponding well to United States Preventive Services Task Force recommendations. The responses of practitioners who had qualified more recently were closer to the recommendations, with these practitioners more likely to want to carry out more preventive care. Membership of an independent practice association or the Royal New Zealand College of General Practitioners was associated with more positive attitudes to preventive care and with believing more interventions to be appropriate. Relatively few preventive interventions appeared to be offered to patients in a systematic way.

CONCLUSIONS

Canterbury general practitioners were well-informed about, and interested in carrying out, more preventive care. Preventive care delivery could be enhanced in many practices by the adoption of a more systematic approach.

Neisseria meningitidis serogroup B outer membrane vesicle vaccine in adults with occupational risk for meningococcal disease

Vaccination provides a safe and effective means of reducing the risk of laboratory-acquired infection due to some Neisseria meningitidis serogroups. However, there is currently no serogroup B meningococcal vaccine licensed for use in the US. We used an investigational N. meningitidis serogroup B outer membrane vesicle (B:15:P1.7,16) vaccine produced by the National Institute of Public Health (NIPH) in Norway to immunize 20 researchers with occupational risk for disease. Three doses of vaccine were administered via intramuscular injection at 8-week intervals. The vaccine produced moderate or severe pain with 19 (33%) of the 58 doses administered. Reactions were similar following first, second and third doses. The number and severity of reactions peaked at 24 h postvaccination and then gradually waned. Of 16 vaccinees with results available from all blood draws, 12 (75%) showed a fourfold or greater rise in serum bactericidal activity (SBA) against the vaccine type-strain following two doses of vaccine, and 15 (94%) responded after three doses. Geometric mean titers increased by more than sixfold following two doses of vaccine when compared with prevaccination levels, and by more than 11-fold following a third dose. There was no significant difference between SBA measured using the vaccinee's own complement versus a donor complement source. The NIPH vaccine elicited an excellent bactericidal response against the vaccine type-strain in researchers with an occupational risk for disease. It may be useful for other laboratory personnel who routinely work with meningococcal strains containing similar outer membrane antigens. These findings reconfirm that the NIPH vaccine is immunogenic in adults and support the validity of using properly screened human donor complement in serum bactericidal assays against serogroup B meningococci.

Immunosuppressive therapy for ulcerative colitis: results of a nation-wide survey among consultant physician members of the British Society of Gastroenterology

BACKGROUND

The role of immunosuppressive therapy in ulcerative colitis remains controversial. There is little information available on how frequently immunosuppressives are used, the circumstances, dose and duration of use and perceived benefit.

METHODS

A postal survey was sent to consultant gastroenterologist members of the British Society of Gastroenterology.

RESULTS

Questionnaires were returned by 81% of the 496 UK consultants approached. Azathioprine use was frequent, with 93% reporting previous use and 86% use within the past year. Although 95% usually prescribed a < or =2 mg/kg dose, only 39% were prepared to prescribe higher doses. There was marked variation in duration of use, with 46% using azathioprine for <2 years and 17% continuing it for 4 years or longer. Consultants with more experience of azathioprine in ulcerative colitis used it at higher maintenance doses for longer periods, and in patients with less extensive disease. Cyclosporin use was reported by 47% of those caring for ulcerative colitis patients, with 36% having used it at least once in the past year. However, 65% of users estimated that fewer than 50% of patients subsequently avoided colectomy. On stopping cyclosporin only 21% always introduced an alternative immunosuppressive, while 23% never did so. Potentially serious side-effects attributable to azathioprine and cyclosporin were reported by 36% and 45% of users of each drug, respectively.

CONCLUSIONS

This survey reveals considerable variation in the amount and pattern of immunosuppressive use in ulcerative colitis, with serious side-effects commonly seen. There is a pressing need for further randomized controlled trials to provide reliable evidence as to how immunosuppressive therapy should be used in ulcerative colitis.

The parting of the ways? How biomaterials may differ from advanced materials in the next century

A recent symposium on the future role of materials science in some critical industries suggests that the historical reliance of the medical device industry on the advances made in conventional materials development may not be sustained in the next few decades.

Immunogenicity of 2 serogroup B outer-membrane protein meningococcal vaccines: a randomized controlled trial in Chile

CONTEXT

Meningococcal disease occurs worldwide, and serogroup B disease accounts for a large proportion of cases. Although persons younger than 4 years are at greatest risk for serogroup B meningococcal disease, vaccine efficacy has not been demonstrated in this age group.

OBJECTIVE

To evaluate serum bactericidal activity (SBA) against homologous vaccine type strains and a heterologous Chilean epidemic strain of Neisseria meningitidis as a potential correlate for vaccine efficacy.

DESIGN

Double-blind, randomized controlled trial conducted between March 14 and July 20, 1994. All blood samples were taken by December 1994.

SETTING

Santiago, Chile, where a clonal serogroup B meningococcal disease epidemic began in 1993.

PARTICIPANTS

Infants younger than 1 year (n = 187), children aged 2 to 4 years (n = 183), and adults aged 17 to 30 years (n = 173).

INTERVENTION

Participants received 3 doses of outer-membrane protein (OMP) meningococcal vaccine developed in either Cuba or Norway or a control vaccine, with each dose given 2 months apart. Blood samples were obtained at baseline, prior to dose 3, and at 4 to 6 weeks after dose 3.

MAIN OUTCOME MEASURE

Immune response, defined as a 4-fold or greater rise in SBA titer 4 to 6 weeks after dose 3 compared with prevaccination titer.

RESULTS

Children and adult recipients of either meningococcal vaccine were more likely than controls to develop an immune response to the heterologous epidemic strain. After 3 doses of vaccine, 31% to 35% of children responded to the vaccine vs 5% to placebo; 37% to 60% of adults responded to vaccine vs 4% to placebo (P<.05 vs control for all). Infants, however, did not respond. In contrast, against homologous vaccine type strains, the response rate was 67% or higher among children and adults and 90% or higher among infants (P<.001 vs control for all). Subsequent SBA against 7 isogenic homologous target strains identified class 1 OMP as the immunodominant antigen.

CONCLUSIONS

These data suggest that neither serogroup B OMP meningococcal vaccine would confer protection during a heterologous epidemic. However, epidemic strain-specific vaccines homologous for class 1 OMP are promising candidates for the control of epidemic serogroup B meningococcal disease.

Small is beautiful: microparticle and nanoparticle technology in medical devices

An increasing number of technologies require the production of ultra-small spherical particles, often described as micro-spheres or nano-spheres. They may be used for a variety of medical applications from cell encapsulation to serological diagnostic procedures. This article discusses some of the principles of this technology.

Levels of high energy phosphate in the dorsal skin of the foot in normal and diabetic adults: the role of 31P magnetic resonance spectroscopy and direct quantification with high pressure liquid chromatography

Determining viability of tissues and wound-healing potential in diabetic patients remains a significant challenge. Current methods for preoperative assessment of wound-healing potential (pressures in the ankle, temperature of tissues, transcutaneous measurements of oxygen, and systemic nutritional status) are indirect, in that they characterize the delivery of oxygen or other nutrients to the cells. A noninvasive means to measure adenosine triphosphate (ATP) and phosphocreatine (PCr), the fundamental high energy phosphate substrates of oxidative energy-metabolism in the skin, has been devised by using magnetic resonance spectroscopy (MRS). The signal-to-noise ratio of bioenergetic metabolites in the skin was 86% lower in five patients with diabetes who had ischemia of the lower extremity compared with five control subjects (P < 0.0001), suggesting that the concentration of high energy metabolites in diabetic patients was reduced. The ratio of ATP/phosphocreatine (PCr) in patients with diabetes was also significantly lower than in controls (P < 0.01). Chewing a single piece of nicotine gum reduced the measured concentrations of ATP and PCr in control subjects by an average of 18% and by an average of 75% in subjects with diabetes. To verify these results in a second experiment, skin was harvested from the surgical wound sites in eight patients with diabetes undergoing elective amputation, eight patients with diabetes undergoing elective foot surgery, and ten age-matched control (nondiabetic) patients undergoing elective foot surgery. Analysis of ATP and PCr using high pressure liquid chromatography corroborated MRS findings, showing a significant reduction in ATP and PCr in diabetic skin. Depression of metabolites was more severe in the patients with diabetes undergoing amputation than in the ones undergoing elective surgery. Results demonstrate depression of metabolites in the skin of patients with diabetes and suggest that MRS with 31p may be useful in characterizing metabolites in the skin.

The collaboration process in HIV prevention and evaluation in an urban American Indian clinic for women

Collaboration between providers and researchers can be key to doing women's HIV prevention that is holistic, gender sensitive, and responsive to communities. This report centers on providers' and evaluators' experiences in developing and implementing a project promoting "healthy relationships" with low-income women from different ethnicities at an urban American Indian clinic. During planning, decisions on the health problems to be targeted, division of labor, program goals, resource allocation, evaluation design, and outcome measures were jointly made. Other factors were the input of participants and the influence of American Indian values at the clinic. The implementation process was fully collaborative. There are implications for creating conditions for successful collaborations in health education.

A stain on the stainless? The role of steels in the new age

Some recent events have suggested that the best days of steels have gone and that disposable plastics would be better for many applications. Although it cannot be denied that plastics have taken over many of the roles of steel during the last few decades and will, quite rightly, continue to do so in certain areas, this article argues the case for proper consideration for steels in other areas, where their properties are still of the greatest relevance.