Educating rural allied health professionals: an interdisciplinary effort

This article describes the process and outcome of an innovative, interdisciplinary educational effort which was initiated in rural Maine. Within the context of a comprehensive, statewide interdisciplinary rural health care training project that was federally funded through the Interdisciplinary Training for Health Care for Rural Areas (ITHCRA) grant program, a primary strategy for recruiting and training rural allied health practitioners was the development and implementation of a year long interdisciplinary graduate course sequence. The results of the evaluation suggested that interdisciplinary education is not only useful in learning the roles and functions of allied health professions, but is valuable tool in promoting the development of skills necessary for competent and relevant rural allied health practice.

Epidemic Bacillus endophthalmitis after cataract surgery I: acute presentation and outcome

OBJECTIVE

The purpose of the study is to report the clinical outcome of acute Bacillus endophthalmitis after cataract surgery.

DESIGN

The study design is a cohort study.

PARTICIPANTS

Fourteen eyes of 14 patients with epidemic acute postoperative inflammation after exposure to bacteria-contaminated viscoelastic material were studied.

INTERVENTION

Three patients with milder clinical presentations were treated without vitrectomy or antibiotics. Eleven patients with more severe infection were treated with vitrectomy as well as intravitreous and topical fortified antibiotics.

MAIN OUTCOME MEASURES

Final visual acuities were obtained in all 14 study patients. Results of microbiologic studies of aqueous and vitreous specimens from 11 vitrectomized eyes also were analyzed.

RESULTS

One patient with late presentation had severe inflammation and had phthisis bulbi develop with no light perception. The remaining 13 patients had successful resolution of inflammation after treatment by 1 month of follow-up. Twelve of these 13 patients, including 1 nonvitrectomized patient, had final visual acuities of 20/100 or better at 6 months' follow-up. Six patients, including two patients with nonvitrectomized eyes, had outcomes of 20/40 or better visual acuity. Bacillus species were grown from all 11 (100%) vitreous and 7 (88%) of 8 aqueous specimens obtained from vitrectomized patients, as well as from the contaminated viscoelastic material remaining in the operating room.

CONCLUSIONS

Postoperative Bacillus endophthalmitis need not result in poor outcome. Results depend on factors including bacterial load, specific bacterial species, timing of treatment, and immune status of the patient.

[Pulmonary mycobacteriosis--diagnostic problem and prevalence in Poland (a retrospective study)]

The diagnosis of pulmonary mycobacteriosis was verified in 267 patients in Poland, classified in the years 1991-1995 to group VI M. Among 267 patients, 213 were men in age 28-83 years (median 43 years) and 54 women in age 24-81 years (median 50 years). The verification of the diagnosis was based on the authors own criteria of pulmonary mycobacteriosis and colonisation. These criteria included at least two positive sputum cultures and presence or absence of the respiratory tract inflammation. Pulmonary mycobacteriosis was recognised in 199 patients (168 men and 31 women). Colonisation was diagnosed in 41 patients (23 men and 18 women). Non-tuberculous mycobacteria most often responsible for pulmonary mycobacteriosis were identified as M. kansasii, M. avium--intracellulare and M. xenopi. Majority of patients with pulmonary mycobacteriosis or with colonisation had pulmonary lesions caused by tuberculosis in the past or suffered from chronic obstructive pulmonary disease. In 63 cases, data concerning previous diseases of the respiratory tract were not available.

Myeloproliferative disease and myelodysplastic syndrome induced by transplantation of bone marrow cells expressing mutant p53

p53 mutations are the most common genetic alterations observed in human cancers including lymphomas and leukemias. We have previously shown that transduction of normal murine hematopoietic cells with mutant p53 alone in vitro results in an enhanced proliferative capacity and modified differentiation potential of transduced cells. In order to investigate further the role of mutant p53 in hematopoietic cell transformation, mutant p53-transduced bone marrow cells were used to reconstitute the hematopoietic system of lethally irradiated mice. The results show that overexpression of mutant p53 can initiate the transformation of immature murine hematopoietic cells in vivo and induce two types of hematopoietic disorders, myeloproliferative disease and myelodysplastic syndrome.

Multiple metabolic abnormalities in normal glucose tolerant relatives of NIDDM families

Non-diabetic first degree relatives of non-insulin-dependent diabetic (NIDDM) families are at increased risk of developing diabetes mellitus, and have been studied to identify early metabolic abnormalities. Hormone concentrations measured by specific enzyme immunoassays were assessed in non-diabetic relatives of North European extraction, and control subjects with no family history of diabetes were matched for age, sex and ethnicity. A 75-g oral glucose tolerance test was conducted and those with newly diagnosed NIDDM were excluded. Basal insulin resistance was determined by homeostasis model assessment (HOMA), and hepatic insulin clearance by C-peptide:insulin molar ratio. Relatives (n = 150) were heavier (BMI: p < 0.0001) than the control subjects (n = 152), and had an increased prevalence of impaired glucose tolerance (15 vs 3%, p < 0.01). The relatives had increased fasting proinsulin levels and decreased C-peptide levels following the glucose load, while insulin levels were increased at all time points. To examine whether the differences in hormone levels were secondary to the differences in glucose tolerance and adiposity, we studied 100 normal glucose tolerant relatives and control subjects pair-matched for age, sex, waist-hip ratio and BMI. The differences in proinsulin levels were no longer apparent. However, the relatives remained more insulin resistant, and had decreased C-peptide levels and C-peptide:insulin ratios at all time points. In conclusion, we have identified several metabolic abnormalities in the normal glucose tolerant relatives, and propose that the decreased hepatic insulin clearance helps to maintain normoglycaemia in the face of combined insulin resistance and decreased insulin secretion.

Expression and characterization of bryodin 1 and a bryodin 1-based single-chain immunotoxin from tobacco cell culture

Bryodin 1 (BD1) is a potent ribosome-inactivating protein (RIP) isolated from the plant Bryonia dioica. It is relatively nontoxic in rodents (LD50 > 40 mg/kg) and represents a potential improvement over other RIPs and bacterial toxins that have been used in immunotoxins. Recombinant BD1, expressed in Escherichia coli, localizes to insoluble inclusion bodies necessitating denaturation and refolding steps to generate active protein. In this report, BD1 was expressed as a soluble recombinant protein in tobacco cell culture (ntBD1) and purified to near homogeneity with yields of up to 30 mg/(L of culture). The protein synthesis inhibition activity of ntBD1 was identical to that of both native BD1 isolated from the roots of B. dioica and recombinant BD1 expressed in E. coli. Toxicology analysis showed that ntBD1 was well tolerated in rats at doses that cannot be achieved with most other toxin components of immunotoxins. Additionally, a single-chain immunotoxin composed of BD1 fused to the single-chain Fv region of the anti-CD40 antibody G28-5 (ntBD1-G28-5 sFv) was expressed in tobacco tissue culture as a soluble protein and was specifically cytotoxic toward CD40 expressing non-Hodgkin's lymphoma cells in vitro. These data indicate that tobacco tissue culture is a viable system for soluble expression of BD1 and BD1-containing immunotoxins.

Rapid recovery of octogenarians following coronary artery bypass grafting

BACKGROUND

Rapid recovery protocols for coronary artery bypass grafting (CABG) have resulted in major decreases in postoperative hospital length of stay (LOS) when applied to younger patients undergoing elective procedures. However, the effectiveness of rapid recovery protocols when applied to octogenarians has not been thoroughly studied.

METHODS

Thirty-seven consecutive octogenarians underwent isolated CABG utilizing cardiopulmonary bypass (CPB). A protocol emphasizing preoperative placement of the intra-aortic balloon pump, reduced CPB time, early extubation, perioperative steroids, thyroid hormone, and aggressive postoperative diuresis was used.

RESULTS

The 30-day operative mortality for the entire series was 5.4%. Twenty-five patients (71%, group I) were discharged in < 10 days postoperatively (average LOS of 6.3 +/- 1.6 days), while ten patients (29%, group II) were discharged at 10 or more days postoperatively (average LOS of 20.3 +/- 8.0, p < 0.001). Patients in group II were found to have a higher incidence of obesity (50% vs 4%, p < 0.01), symptomatic peripheral vascular disease (60% vs 8%, p < 0.01), and preoperative ambulatory difficulties (50% vs 0%, p < 0.01). The incidence of complications was 31% for the entire series, with no differences between the groups.

CONCLUSION

Octogenarians performed well under a rapid recovery protocol, with 71% being discharged in < 10 days postoperatively, while patients with obesity, symptomatic peripheral vascular disease, and ambulatory difficulties rehabilitated more slowly.

Local cerebral metabolic effects of the novel cocaine analog, WF-31: comparisons to fluoxetine

The effects of the acute administration of the selective serotonin uptake inhibitor, fluoxetine, on rates of local cerebral glucose utilization in rats were compared to those of the novel cocaine analog, [2beta-propanoyl-3beta-(4-isopropylphenyl)-tropane, WF-31, which has greater affinity for serotonin than dopamine transporters, using the quantitative autoradiographic 2-[14C]deoxyglucose method. Locomotor activity was assessed simultaneously. Fluoxetine administration resulted in dose-dependent decreases in locomotor behavior, as well as widespread reductions in rates of metabolic activity in brain areas including raphe nuclei, dorsal and ventral striatum, amygdala, hippocampus, limbic cortex, and thalamus. These effects were largely concentrated in brain regions containing high densities of serotonin transporters as revealed by in vitro autoradiography. In contrast, the acute administration of WF-31 produced more discrete changes in metabolic activity that were localized within the raphe nuclei and in portions of the hippocampal formation. Blockade of WF-31's dopaminergic effects by pretreatment with the antagonist, alpha-flupenthixol, resulted in a pattern of metabolic changes that closely resembled that observed with fluoxetine. These data suggest that the alterations in functional activity produced by both fluoxetine and WF-31 are largely the result of actions on serotonergic systems.

Statistical methods in computational anatomy

This paper reviews recent developments by the Washington/Brown groups for the study of anatomical shape in the emerging new discipline of computational anatomy. Parametric representations of anatomical variation for computational anatomy are reviewed, restricted to the assumption of small deformations. The generation of covariance operators for probabilistic measures of anatomical variation on coordinatized submanifolds is formulated as an empirical procedure. Populations of brains are mapped to common coordinate systems, from which template coordinate systems are constructed which are closest to the population of anatomies in a minimum distance sense. Variation of several one-, two- and three-dimensional manifolds, i.e. sulci, surfaces and brain volumes are examined via Gaussian measures with mean and covariances estimated directly from maps of templates to targets. Methods are presented for estimating the covariances of vector fields from a family of empirically generated maps, posed as generalized spectrum estimation indexed over the submanifolds. Covariance estimation is made parametric, analogous to autoregressive modelling, by introducing small deformation linear operators for constraining the spectrum of the fields.

Structural Analysis of Photosystem II: Comparative Study of Cyanobacterial and Higher Plant Photosystem II Complexes

Oxygen evolving photosystem II (PSII-OEC) complexes and PSII core complexes were isolated from spinach and the thermophilic cyanobacterium Synechococcus sp. OD24 and characterized by gel electrophoresis, immunoblotting, and absorbance spectroscopy. The mass of the core complexes was determined by scanning transmission electron microscopy (STEM) and found to be 281 &plusmn; 65 kDa for spinach and 313 &plusmn; 52 kDa for Synechococcus sp. OD24. The mass of the spinach PSII-OEC complex was 327 &plusmn; 64 kDa. Digital images of negatively stained PSII-OEC and PSII core complexes were recorded by STEM and analyzed by single particle averaging. All monomeric complexes showed similar morphologies and were of comparable length (14 nm) and width (10 nm). The averages revealed a pseudo-twofold symmetry axis, which is a prominent structural element of the monomeric form. Difference maps between the averaged projections of the oxygen evolving complexes and the core complexes from both species indicated where the 33-kDa extrinsic manganese stabilizing protein is bound. A symmetric organization of the PSII complex, with the PsbA and the PsbD proteins in the center and symmetrically arranged PsbB and PsbC proteins at the periphery of the monomeric complex, is proposed.

Fluid and electrolyte homeostasis in the elderly: physiological changes of ageing and clinical consequences

Characteristic of the normal ageing process are changes in the renal, hormonal and thirst regulatory systems involved in the control of sodium and water balance. In the presence of disease or drug use, the ageing changes put the elderly person at increased risk of either sodium retention or loss and of water retention or loss. Clinically, these alterations in water and sodium balance are commonly expressed as either hyponatraemia or hypernatraemia with central nervous system dysfunction as the symptomatic expression. Thus, the impaired homeostasis of the many systems affecting fluid balance in the elderly is readily influenced by many of the disease states and medications which are often present in the elderly with resultant adverse clinical consequences. Awareness of these age-associated circumstances can allow the physician to anticipate the impact of illnesses and drugs and to implement a rational approach to therapeutic intervention and management.

Progress in the moral reasoning of baccalaureate nursing students between program entry and exit

Changes in moral reasoning between entry into and exit from a baccalaureate nursing program and the relationship between student characteristics and moral reasoning at entry and exit were explored in this descriptive study. The moral reasoning of four cohorts of students was measured using the Defining Issues Test (DIT). Admission grade point average, prior college credits, and gender accounted for 10% of the variance in DIT P% scores at entry and 14% of the variance at exit from the program. Female students had significantly higher moral reasoning scores than men. Age did not contribute significantly to explaining DIT score variance. DIT P% scores at entry for all four cohorts were within the range of reported norms for college students. Exit scores for all four cohorts were between the normative means for undergraduate students and graduate students. DIT P% score gains between entry and exit were significant for all four cohorts. Students whose entry scores were in the lowest categories had the greatest mean gains.

An outbreak of Enterobacter hormaechei infection and colonization in an intensive care nursery

Enterobacter hormaechei was first identified as a unique species in 1989. Between 29 November 1992 and 17 March 1993, an outbreak of E. hormaechei occurred among premature infants in the intensive care nursery (ICN) at The Hospital of the University of Pennsylvania. The 10 infants whose cultures were positive for E. hormaechei (six were infected and four were colonized) had a lower median estimated gestational age and birth weight than did other ICN infants; other risk factors for infection or colonization with E. hormaechei were not identified. Cultures from three isolettes and a doorknob in the ICN were positive for E. hormaechei. Pulsed-field gel electrophoresis of isolates from six patients and two isolettes were identical. Observations of health care workers revealed breaks in infection control techniques that may have allowed transmission of this organism. We found that E. hormaechei is a nosocomial pathogen that can infect vulnerable hospitalized patients and that can be transmitted from patient to patient when infection control techniques are inadequate.

Ethanol endovascular management of brain arteriovenous malformations: initial results

OBJECTIVE

The goal was to determine the safety and efficacy of absolute ethyl alcohol treatment in the management of intra-axial brain arteriovenous malformations (AVMs).

METHODS

Seventeen patients (eight female and nine male patients; mean age, 41 yr) underwent ethanol endovascular therapy for treatment of their brain AVMs. Superselective amytal testing preceded all procedures. Neuroleptic intravenous anesthesia was used for 16 patients, and general anesthesia was used for 1 patient. Follow-up monitoring consisted of clinical evaluations, magnetic resonance imaging, and arteriography.

RESULTS

In follow-up evaluations (mean follow-up period, 13 mo) after embolization of brain AVMs, neither vascular recanalization nor the neovascular recruitment phenomenon was observed in any patient. Progressive AVM thrombosis at arteriographic follow-up evaluation was a constant feature. Seven patients were cured of their AVMs with ethanol endovascular therapy alone. Three patients were cured of their lesions with ethanol embolization plus surgical resection. One patient was cured of his lesion with ethanol embolization and radiation therapy of the residual nidus. Three patients underwent only partial therapy, with significant improvement in symptoms. Three patients are currently undergoing ethanol endovascular therapy. Complications occurred with 8 of 17 patients, most of which were transient. Two patients died because of late subarachnoid hemorrhages, one patient 4 months and one patient 14 months after partial therapy.

CONCLUSION

Progressive and permanent AVM occlusion is a common finding in arteriographic follow-up evaluations. In no patients did arterial recanalization or the neovascular recruitment phenomenon occur. Our initial results indicate that ethanol has a permanence that is seldom encountered with other embolic agents. With aggressive decadron therapy, the complications related to swelling in the brain are largely reversible.

Public health impact on drug residues in animal tissues

Consumers have expressed concern regarding the health impact of drug residues in their food. Animal residues in animal tissues above the legal tolerance clearly have an impact on human health. Tolerances represent the maximal level or concentration of antimicrobial residues permitted in animal tissues at the time of slaughter. The tolerances are intended to ensure that residual drugs will have no harmful effects if ingested. This paper describes the existing evidence for specific health hazards for certain pharmacological classes of drugs and explains the risks associated with drug residues in meat and poultry above the established tolerance. The primary focus is on possible public health consequences that may occur as a result of acute exposure to illegal residues. In addition, long-term effects are discussed with added comments about the effect of residues on the intestinal flora. Most residues of veterinary drugs occur in food at such low levels that they rarely pose a chronic or long-term health hazard to consumers. The importance of food safety through the reduction of residues in our food supply cannot be overemphasized. Food safety remains a major challenge confronting contemporary society.

Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group

The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties [PTCA]). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio [OR] = 1.03, 95% confidence interval [CI] 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.

Initial genomic scan of the NIMH genetics initiative bipolar pedigrees: chromosomes 3, 5, 15, 16, 17, and 22

As part of the four-center NIMH Genetics Initiative on Bipolar Disorder we carried out a genomic scan of chromosomes 3, 5, 15, 16,17, and 22. Genotyping was performed on a set of 540 DNAs from 97 families, enriched for affected relative pairs and parents where available. We report here the results of the initial 74 markers that have been typed on this set of DNAs. The average distance between markers (theta) was 12.3 cM. Nonparametric analysis of excess allele sharing among affected sibling pairs used the SIBPAL program of the S.A.G.E. package to test three hierarchical models of affected status. D16S2619 gave some evidence of linkage to bipolar disorder, with P = 0.006 for Model II (in which bipolar 1, bipolar 2 and schizoaffective-bipolar type individuals are considered affected). Nearby markers also showed increased allele sharing. A second interesting region was toward the telomere of chromosome 5q, where D5S1456 and nearby markers showed increased allele sharing; for D5S1456, P = 0.05, 0.015 and 0.008 as the models of affected status become more broad. MOD score analysis also supported the possible presence of a susceptibility locus in this region of chromosome 5. A pair of adjacent markers on chromosome 3, D3S2405 and D3S3038, showed a modest increased allele sharing in the broad model. Several isolated markers had excess allele sharing at the P < 0.05 level under a single model. D15S217 showed a MOD score of 2.37 (P < 0.025). Multipoint analysis flagged the region of chromosome 22 around D22S533 as the most interesting. Thus, several regions showed modest evidence for linkage to bipolar disorder in this initial genomic scan of these chromosomes, including broad regions near previous reports of possible linkage.

Alternative splicing in lecithin:cholesterol acyltransferase mRNA: an evolutionary paradigm in humans and great apes

Lecithin:cholesterol acyltransferase (LCAT), an important enzyme affecting reverse cholesterol transport, is expressed in liver and cultured fibroblasts. Sequencing of LCAT cDNA clones demonstrated the coexistence of two mRNA products. In addition to the normal transcript, we identified an alternate message with a splice-mediated insertion of a 95 bp Alu cassette at the junction of exons 5 and 6. In humans, the alternate transcript represents 5-20% of the complete LCAT message in cultured fibroblasts and liver. It is present in humans and the great apes but not in lesser apes (gibbon, siamang) or lower-order primates (e.g., old or new world monkeys). Sequencing of intron 5 of the LCAT locus in several primates revealed a G-->A transition at the splice donor recognition site in the Alu repeat of the gibbon and a G-->A substitution in the last position of the 95 bp Alu sequence of the rhesus monkey, an old world monkey. Both substitutions have been associated with exon skipping in other genes. These results demonstrate that alternative splicing of LCAT mRNA is variant among primates and suggest a potential role of Alu elements in the evolutionary diversity of proteins.

Alteration of local cerebral glucose utilization following intravenous administration of heroin in Fischer 344 rats

The 2-deoxyglucose method was used to study the effects of acute administration of small intravenous doses of heroin on rates of glucose utilization in rat brain to identify small brain regions that may be involved in the acute behavioral effects of heroin. In contrast to previous studies which have used relatively large doses, the doses of heroin used in this study have been shown to be self-administered [Martin, T.J., Dworkin, S.I. and Smith, J.E., Alkylation of mu-opioid receptors by beta-funaltrexamine in vivo: comparison of the effects on in situ binding and heroin self-administration in rats., J. Pharmacol. Exp. Ther., 272 (1995) 1135-1140.]. Administration of 18 microg/kg of heroin resulted in higher rates of glucose utilization in the medial olfactory tubercle, anterior nucleus accumbens and dorsolateral caudate while having no other effects on limbic structures compared to saline-treated animals. Conversely, the rate of glucose utilization was lower than control in the habenula, dorsal raphe, and central gray following adminstration of 18 microg/kg of heroin. Administration of two higher doses (60 and 100 microg/kg) resulted in lower rates of glucose utilization in the thalamus, habenula, inferior colliculus, dorsal raphe and central gray compared to saline. The higher rates of glucose utilization in the limbic areas were specific for the lowest dose of heroin, whereas the effect of lowering the rate of glucose utilization compared to control in the thalamus and inferior colliculus were an increasing function of dose. In the habenula and dorsal raphe, however, the dose-effect function was inverted. These data indicate that the alterations of glucose utilization in rat brain by heroin are site-specific and the systems involved as well as the nature of the alteration differs for individual doses of heroin.