Neurotrophin-4 deficient mice have a loss of vagal intraganglionic mechanoreceptors from the small intestine and a disruption of short-term satiety

Intraganglionic laminar endings (IGLEs) and intramuscular arrays (IMAs) are the two putative mechanoreceptors that the vagus nerve supplies to gastrointestinal smooth muscle. To examine whether neurotrophin-4 (NT-4)-deficient mice, which have only 45% of the normal number of nodose ganglion neurons, exhibit selective losses of these endings and potentially provide a model for assessing their functional roles, we inventoried IGLEs and IMAs in the gut wall. Vagal afferents were labeled by nodose ganglion injections of wheat germ agglutinin-horseradish peroxidase, and a standardized sampling protocol was used to map the terminals in the stomach, duodenum, and ileum. NT-4 mutants had a substantial organ-specific reduction of IGLEs; whereas the morphologies and densities of both IGLEs and IMAs in the stomach were similar to wild-type patterns, IGLEs were largely absent in the small intestine (90 and 81% losses in duodenum and ileum, respectively). Meal pattern analyses revealed that NT-4 mutants had increased meal durations with solid food and increased meal sizes with liquid food. However, daily total food intake and body weight remained normal because of compensatory changes in other meal parameters. These findings indicate that NT-4 knock-out mice have a selective vagal afferent loss and suggest that intestinal IGLEs (1) may participate in short-term satiety, probably by conveying feedback about intestinal distension or transit to the brain, (2) are not essential for long-term control of feeding and body weight, and (3) play different roles in regulation of solid and liquid diet intake.

Early visual changes in reflected light on non-stained brain sections after focal ischemia mirror the area of ischemic damage

There is no reliable, simple method for delineation of ischemic regions at early time points after ischemia. We propose that at early times after stroke, ischemic regions can be visualized as a subtle change in reflected light directly in thaw-mounted, dried 20 microm brain sections. In 15 male Sprague-Dawley rats, anesthetized with isoflurane, middle cerebral artery transection and permanent bilateral common carotid artery occlusion was performed and brains were processed in five different ways. Areas of reflective change (RC) on non-stained sections were compared with areas on the adjacent sections delineated by microtubule associated protein 2 (MAP2) antibody, a reliable marker for early post-stroke, in five rats each at 1, 3, and 6 h after focal cerebral ischemia. A statistically significant correlation between ischemic areas (IA) measured on non-stained brain sections (IA(RC)) and adjacent sections immunostained (IM) with MAP2 Ab (IA(IM)) (IA(RC)=0.05+0.88.IA(IM); R2=0.8; n=15; P<0.01) and a small mean difference +/-2 S.D. (-0.9+/-6.0%) indicated that the area measured on non-stained sections reflects the IA measured on MAP2 -IM sections. At 1 and 3 h after ischemia, the ratio between ischemic regions measured on the non-stained sections and on the adjacent sections immunostained with MAP2 Ab were not different from 100% (97.6+/-1.7%, 100.9+/-6.0%). At 6 h post-stroke, the IA measured on the non-stained sections was larger than on the IM sections (109.8+/-2.7%, P<0.01, compared to 100% ratio). Our study demonstrated that this quick and simple method for detection of damaged brain permitted the use of brain tissue for other assays and could be very useful for neuroprotective evaluation and for directed micro-sampling of brain tissue at early times after ischemia.

Development of antibodies to topical bovine thrombin after abdominal hysterectomy. A case report

BACKGROUND

Topical thrombin spray is frequently used as a hemostatic agent in surgery, particularly following cardiovascular, orthopedic and neurologic surgery. Acquired coagulation factor inhibitors to thrombin and factor V may develop following gynecologic surgery with repeat topical thrombin use.

CASE

A 45-year-old woman underwent total abdominal hysterectomy/bilateral salpingo-oophorectomy. Her past medical history included idiopathic thrombocytopenic purpura and Marfan's syndrome and past surgery included splenectomy and aortic valve replacement with a three-vessel coronary artery bypass graft. She was converted from Coumadin (DuPont Pharmaceuticals, Wilmington, Delaware) to heparin preoperatively, and heparin was stopped six hours before surgery, with normalization of her prothrombin time (PT) and partial thromboplastin time (PTT). Topical bovine thrombin spray was applied to the surgical field in anticipation of early resumption of heparin anticoagulation. Seven days after surgery, after recovering from some acute bleeding problems, the patient began to have elevation of her PT in spite of being off Coumadin for 10 days. Her PT and international normalized ratio (INR) continued to rise, reaching peak values of 31.4 and 6.99, respectively. A mixing study did not correct the problem, confirming the presence of coagulation inhibitors. The patient was given intravenous immunoglobulins and corticosteroids, and her PT/PTT and INR values slowly normalized.

CONCLUSION

Acquired coagulation factor may develop following gynecologic surgery with topical thrombin use. This potential complication should be strongly considered in any patient prior to using topical bovine thrombin, especially those with a prior exposure or history of surgical procedures in which bovine thrombin is commonly used.

The interleukin 1 receptor antagonist gene allele 2 as a predictor of pouchitis following colectomy and IPAA in ulcerative colitis

BACKGROUND & AIMS

The interleukin 1 receptor antagonist gene allele 2 has been suggested as a determinant of both disease susceptibility and extent in ulcerative colitis. The aim of this study was to assess the allele as a predictor of both the indication for colectomy and the occurrence of pouchitis after ileal pouch-anal anastomosis formation.

METHODS

Genotyping for the +2018 single nucleotide polymorphism in the interleukin 1 receptor antagonist gene was performed in 109 patients who had undergone colectomy, including 82 patients who had been followed prospectively after ileal pouch-anal anastomosis formation.

RESULTS

Patients with pouchitis had a higher allele 2 carriage rate compared with those without pouchitis (72% vs. 45%) and Kaplan-Meier survival analysis showed that allele 2 carriers had a significantly increased incidence of pouchitis compared with noncarriers (log-rank test, 6.5). After adjustment for confounding covariates in a Cox proportional hazards model, the relative hazard was 3.1 (95% confidence interval [CI], 1.2-7.8; P = 0.02). Although there was a higher allele 2 carriage rate in patients with chronic refractory compared with acute severe ulcerative colitis (63% vs. 48%), this difference was not significant (odds ratio, 1.9; 95% CI, 0.9-4.1; P = 0.1).

CONCLUSIONS

The interleukin 1 receptor antagonist gene allele 2 predicts pouchitis after ileal pouch-anal anastomosis in ulcerative colitis.

Fulminant leptospirosis in a patient with human immunodeficiency virus infection: case report and review of the literature

We report a case of fulminant leptospirosis that was acquired in New York City by a patient with underlying infection with human immunodeficiency virus (HIV). Review of the literature on leptospirosis in HIV-infected persons showed that all patients were severely ill but responded well to treatment, which highlights the importance of recognizing this potentially life-threatening illness, especially in unusual settings.

Binding of transcriptional activators to sigma 54 in the presence of the transition state analog ADP-aluminum fluoride: insights into activator mechanochemical action

Conformational changes in sigma 54 (sigma(54)) and sigma(54)-holoenzyme depend on nucleotide hydrolysis by an activator. We now show that sigma(54) and its holoenzyme bind to the central ATP-hydrolyzing domains of the transcriptional activators PspF and NifA in the presence of ADP-aluminum fluoride, an analog of ATP in the transition state for hydrolysis. Direct binding of sigma(54) Region I to activator in the presence of ADP-aluminum fluoride was shown and inferred from in vivo suppression genetics. Energy transduction appears to occur through activator contacts to sigma(54) Region I. ADP-aluminum fluoride-dependent interactions and consideration of other AAA+ proteins provide insight into activator mechanochemical action.

The caregiver's careshop. A renewal experience for nursing staff

What are some creative methodologies that staff development educators can use to nurture nursing staff while promoting caring and compassionate behaviors? The authors describe an innovative process used during a 1-day workshop designed to convey caring to nursing staff through a variety of experiences. The overall goal of the session is to provide caregivers with a variety of new "tools" to care for themselves as they deal with multiple stressors in their personal and professional lives.

Similarities and differences in eyewitness testimonies of children who directly versus vicariously experience stress

This study tested questions of ecological validity by comparing the eyewitness testimonies of children directly experiencing a painful inoculation experience those of children in a yoked-control group who vicariously experienced the inoculation onwith videotape. The study involved 86 5-year-olds, divided between 2 groups: the experiential and yoked control. The experiential group was followed through a health department with a video camera as they received diphtheria, pertussis, tetanus (DPT), and oral polio inoculations. They were tested immediately, 20 min later, and 1 month later. Each child in the yoked-control group merely watched the videotape of his or her counterpart in the experiential group, made similar ratings of pain, and was given the same tests and suggestions. Stress and personal experience affected items congruent with the stressor to produce flashbulb-like memories, with slower rates of forgetting for some items, such as nurse identifications, and greater suggestibility for other items, such as estimates of needle size. These and the apparently conflicting results in the literature were said to make sense when personally experienced stress was viewed from S.-A. Christianson's (1992) interactive perspective rather than as a single ubiquitous variable.

Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical Course

BACKGROUND

Medical students receive increasing amounts of their clinical education in a primary care setting. The educational possibilities of such attachments are still being explored.

AIM

To report the evaluation of a small, radical innovation to provide students with a long-term community attachment which integrated with hospital-based education.

METHOD

Between 1993 and 1998, 13 medical students completed 15-month attachments with a single general practice in England. The course offered them experience in the major clinical specialties throughout this period. Students were exposed to specialist as well as generalist education in the context of patients with whom they could establish a continuing relationship. The innovation was evaluated by its feasibility, by students' examination results, by analysis of clinical experience, through formal student feedback and by cost.

RESULTS

The course was practicable in a particular setting with academic leadership. The students all passed their exams. They had wide, appropriate clinical experience even though the attachment was to a single practice. When they returned to the hospital environment, students did not feel themselves at a disadvantage compared with traditional students. The costs of the course are controversial: placement costs were higher than in the hospital, but those for facilities were lower.

CONCLUSION

It is possible to run a course like this successfully. It remains the most radical attempt to share clinical education in the UK between primary and secondary/tertiary care. Further research is required into providing long-term clinical attachments in NHS primary care settings.

HOPE for patients with Type 2 diabetes: an application of the findings of the MICRO-HOPE substudy in a British hospital diabetes clinic

AIMS

The MICRO-HOPE substudy demonstrated that when ramipril treatment was added to people with Type 2 diabetes and additional cardiovascular risk factors cardiovascular events were reduced by 25% in 4.5 years. We wished to determine the proportion of people with Type 2 diabetes and additional cardiovascular risk factors registered with a hospital diabetes service.

METHODS

Non-proteinuric people (n = 1370) with Type 2 diabetes identified on our diabetes register were subject to analysis. Anticipated reductions in cardiovascular events due to ramipril treatment were based on reductions observed in the MICRO-HOPE substudy.

RESULTS

Non-proteinuric people (n = 1075 (78%)) with Type 2 diabetes had at least one additional cardiovascular risk factor. Twenty-nine percent were already taking an angiotensin-converting enzyme inhibitor. The remaining 764 patients were similar to ramipril-treated participants in the MICRO-HOPE substudy. Treatment with ramipril for 4.5 years would be anticipated to reduce cardiovascular deaths by 26, revascularization procedures by 19 and admissions for myocardial infarction and stroke by 18 and 26, respectively.

CONCLUSIONS

Of non-proteinuric people with Type 2 diabetes, 78% have additional cardiovascular risk factors. Only a small proportion currently receive treatment with an angiotensin-converting enzyme inhibitor. The incidence of cardiovascular events could be reduced if more patients were treated with ramipril and other cardiovascular risk factors were addressed.

Gastrointestinal projection maps of the vagus nerve are specified permanently in the perinatal period

The vagal innervation of the proximal gastrointestinal (GI) tract is lateralized. To determine whether this pattern is specified as early as the perinatal period, neonatal rat pups were given unilateral cervical vagotomies. Separate groups received (1) transections below the left nodose ganglion, (2) left cervical resections that included removal of the nodose ganglion, or (3) sham surgeries. At 4 months of age, each animal's vagal afferent projections from the unoperated side were mapped by injecting the nodose with WGA-HRP, preparing the stomach as wholemounts, and processing the tissue with tetramethyl benzidine. The two types of vagal afferent endings in GI smooth muscle, namely intraganglionic laminar endings and intramuscular arrays, were surveyed separately, and their regional distributions were mapped. Changes in the nucleus of the solitary tract (NST) and dorsal motor nucleus of the vagus (DMNX) were assessed with cell counts and area measurements. Neonatal loss of the vagus innervating one side of the GI tract, with or without ganglionectomy, did not cause the unoperated vagus to sprout to the denervated side. In addition, removal of the projections to the one side of the target organ did not produce a reorganization of the projection maps of the unoperated vagus within its normal or ipsilateral wall of the GI tract. Although the regional patterns of the unoperated ipsilateral vagus were not affected, the packing densities of both types of afferents supplied by this trunk were moderately reduced. The DMNX of the vagotomized side displayed extensive (approximately 83%) neuronal loss; the DMNX on the unoperated side as well as the NST on both sides exhibited limited (approximately 20--25%) losses. The lack of a peripheral projection field reorganization -- except for a moderate down-regulation -- after complete unilateral denervation suggests that both the laterality and the afferent terminal phenotypes (or target tissues) of the vagus in the proximal GI tract are specified by postnatal day one in the rat. The present results, taken together with other observations, also suggest that three different combinations of signals orchestrate the commitments of vagal afferents respectively to (1) the side of the organ, (2) the region within the organ wall, and (3) the accessory and innervated tissues that complex with the fully differentiated ending.

The effect of hormone replacement therapy on cardiovascular risk factors in type 2 diabetes: a randomized controlled trial

BACKGROUND

Postmenopausal women with diabetes are at high risk for cardiovascular disease, compared with their nondiabetic counterparts. Combined continuous hormone replacement therapy (HRT) is associated with improvements in serum lipoprotein levels in nondiabetic women; however, the effect in women with diabetes has not been determined. We evaluated the effect of combined continuous HRT on lipoprotein and coagulation factor concentrations and glycemic control in postmenopausal women with type 2 diabetes mellitus.

METHODS

In a randomized controlled crossover study, 61 subjects received combined continuous HRT or placebo. Each treatment phase was of 6 months' duration, with an 8-week washout phase between treatment phases.

RESULTS

Total cholesterol concentration decreased by 7% (95% confidence interval [CI], 4%-11%) during HRT. For low-density lipoprotein concentration, the mean decrease with HRT was 12% (95% CI, 6%-17%). Apolipoprotein B levels decreased in keeping with the reduction in low-density lipoprotein cholesterol concentrations. There were no significant changes in concentrations of high-density lipoprotein, its subfractions, or triglycerides. Lipoprotein(a) and fibrinogen concentrations were reduced by 21% (95% CI, 10%-31%) and 8% (95% CI, 2%-13%), respectively, with HRT. Fructosamine concentrations declined by 5% (95% CI, 2%-9%) during HRT.

CONCLUSIONS

In postmenopausal women with type 2 diabetes mellitus, combined continuous HRT has beneficial effects on lipoprotein concentrations and improves some markers of coagulation and glycemic control.

Undergraduate community health nursing education in a neighborhood settlement house

Undergraduate community health nursing faculty are continually challenged to find appropriate clinical placements. Prior to using an inner-city neighborhood settlement house as a clinical site, traditional public health and home-care agencies provided clinical placements for senior baccalaureate nursing students. The settlement house had several programs but did not have a traditional nursing department. A 14-item questionnaire was developed to examine student (N = 30) perceptions of the opportunities for course objectives to be met and student attitudes and beliefs regarding the settlement-house placement. The majority of the students agreed that the learning experiences at the settlement house provided opportunities to meet course objectives. Findings indicated that students who considered the neighborhood safe are more apt to recommend the clinical placement to other students (p < .01). Those students who believe that professional nursing services can help improve the health of people who live in the inner city are more apt to say, "This experience changed my beliefs regarding people who live in an inner-city neighborhood" (p < .01).

Impact of genotypic resistance testing on physician selection of antiretroviral therapy

OBJECTIVES

To determine the impact of genotypic resistance testing on physician selection of antiretroviral therapy.

STUDY DESIGN/METHODS

This was a prospective, observational study. A single genotypic resistance test was done when patients failed highly active antiretroviral therapy. The antiretroviral regimen predicted at the time the genotypic resistance assay was done was compared with the regimen that was ultimately selected after review of resistance testing results.

RESULTS

In the vast majority of cases (83%), the regimen that the physician selected after resistance testing was different from the predicted regimen. In 54% of cases, these changes involved changing more than two antiretroviral agents, and in 22%, one agent was changed. In 1% of cases, all medications were discontinued, and in 6%, the physician ultimately decided not to change the baseline regimen. Although patients were screened for nonadherence to their medication regimen, 11% had no detectable resistance mutations.

CONCLUSIONS

Access to genotypic resistance testing has a significant impact on physician selection of antiretroviral therapy.

Tension-free vaginal tape and percutaneous vaginal tape sling procedures

PURPOSE

Midurethral synthetic sling procedures for treatment of stress urinary incontinence (SUI) are gaining increased attention from surgeons specializing in female pelvic reconstructive techniques seeking successful patient outcomes through reproducible simplicity. This report describes the procedural steps and methods used to maximize the potential for successful outcomes using techniques of midurethral synthetic sling placement. Reported complications and surgical outcomes are reviewed with respect to patient selection and minimizing the potential for morbidity and mortality as long-term clinical experience is accumulated.

MATERIALS AND METHODS

Tension-free vaginal or transvaginal tape (TVT) and the recently introduced percutaneous vaginal tape (PVT) are two new procedural choices for placement of synthetic sling material at the midurethra. Both procedures use sling material composed of polypropylene mesh, a nonabsorbable synthetic material, placed at the level of the midurethra via an antegrade (PVT, using a percutaneous ligature carrier) suprapubic approach or retrograde (TVT, using vaginal trocars) vaginal approach. Patient selection, procedural techniques, and methods described are based on observations obtained or reported from clinical experience. Outcomes and complications for TVT are derived from a literature review of all published articles in Index Medicus from 1996 to 2000.

RESULTS

The experience with TVT for the last 5 years is encouraging. At 3-year follow-up for TVT, reported cure rates for SUI range from 80% to 95%. A multitude of worldwide reports on PVT with shorter follow-up support the findings of the TVT experience. Reproducible findings with midurethral synthetic slings are the short operative times recorded for the sling procedure, ease of technical performance, minimal patient discomfort, and a high rate of early return of normal voiding function. The rate of complications such as obstructive voiding or de novo instability (0-15%) and urinary retention necessitating a secondary procedure (2-4%) appear to be equal to the rates of contemporary competing technologies and procedures for treatment of SUI.

CONCLUSIONS

Preliminary reports and the experience at our institution suggest that the techniques of midurethral synthetic sling placement of TVT and PVT are reproducible, easy to master, and minimally invasive with respect to tissue handling. Although complications with all anti-incontinence procedures exist, understanding the anatomical considerations and methodology of these unique procedures should minimize patient morbidity, avoid patient mortality, and produce a high rate of durable success.

Infection control programs at children's hospitals: a description of structures and processes

BACKGROUND

Infection control (IC) structures and processes determine the effectiveness of surveillance efforts to prevent infections in health care settings.

METHODS

A survey was sent to 56 children's hospitals collaborating in the Pediatric Prevention Network (PPN).

RESULTS

Completed surveys were returned from 48 hospitals. Responsibility for the IC program resided with the medical director (21%); vice president for patient care (18%); quality improvement director (17%); other senior hospital administrator (15%); or other hospital personnel (18%). Forty-two hospitals had an IC committee; 32 had antimicrobial restriction/control policies; and 21 had an antimicrobial restriction/control task force or committee. Components of antimicrobial restriction programs included infectious disease specialist approval, restricted formularies, selective susceptibility test reporting, and staff education programs. Many methods were used to detect infections, including microbiology laboratory reports (100%); record reviews (98%); informal reports from providers (90%); and readmission reviews (77%).

CONCLUSIONS

Children's hospitals vary widely in how they design and implement their IC functions. These variations influence adverse event detection and nosocomial infection rate calculations. If medical errors, including nosocomial infections, are to be detected and hospital rates compared, standardized methods to collect, analyze, and report data are needed. The PPN has initiated activities to standardize surveillance and IC practices in participating hospitals.

Il-6 and its soluble receptor orchestrate a temporal switch in the pattern of leukocyte recruitment seen during acute inflammation

During acute inflammation, leukocyte recruitment is characterized by an initial infiltration of neutrophils, which are later replaced by a more sustained population of mononuclear cells. Based on both clinical and experimental evidence, we present a role for IL-6 and its soluble receptor (sIL-6R) in controlling this pattern of leukocyte recruitment during peritoneal inflammation. Liberation of sIL-6R from the initial neutrophil infiltrate acts as a regulator of CXC and CC chemokine expression, which contributes to a suppression of neutrophil recruitment and the concurrent attraction of mononuclear leukocytes. Soluble IL-6R-mediated signaling is therefore an important intermediary in the resolution of inflammation and supports transition between the early predominantly neutrophilic stage of an infection and the more sustained mononuclear cell influx.

Identification and characterization of segments 3 and 4 of the ISAV genome

Infectious Salmon Anaemia is a serious disease of farmed Atlantic Salmon on three continents. The disease causes severe anaemia and haemorrphagic liver necrosis, and carries major economic consequences for affected areas. Nevertheless, the causative agent, a novel orthomyxo-like Virus (Infectious Salmon Anaemia Virus - ISAV), is only partially characterized at the molecular level. We report the isolation and characterization of two novel ISAV segments at the genomic and proteomic levels. These segments are the third and fourth largest of the (ISAV) genome and may code for a nucleocapsid protein (NP) and a polymerase (PA). Western blot analysis using an ISAV polyclonal antibody identified one of these novel proteins as being the major tissue antigen. We discuss the implications of our findings for vaccine development and surveillance of Infectious Salmon Anaemia.