Underage female DUI offenders: personality characteristics, psychosocial stressors, alcohol and other drug use, and driving-risk

164 underage female DUI offenders were evaluated on measures of personality, driving-risk, psychosocial stressors, alcohol and other drug use, alcohol abuse, and symptoms of depression. Empirical classification of 10 groups represented five distinct types. 31 youth who were classified as Antisocial exhibited highest rates of alcohol misuse, other drug use, deviant driving behavior, traffic offenses and accidents, and psychosocial stressors. About 56% or 92 appeared to experience impaired functioning serious enough to warrant interventions more intense than educational classes. A measure of driving-risk developed and used in studies of male adults, the Donovan Research Questionnaire, did not appear to differentiate driving-risk among the young women. In contrast to male drivers, who often expressed anger or aggression through driving, most subjects appeared to react to emotion-eliciting stimuli with feelings of low self-worth or dysphoric affect rather than anger. Specialized screening suitable for young female DUI offenders should be considered.

Autoimmune renal disease and tumour necrosis factor beta gene polymorphism

The genes encoding tumour necrosis factors (TNF) are located within the major histocompatibility complex. Since TNF may be involved in the pathogenesis of autoimmune disease the purpose of the present study was to investigate TNF beta gene polymorphism in two types of immune complex mediated glomerulonephritis, IgA nephropathy (IgAN) and idiopathic membranous glomerulonephritis (IMN) and to compare them with IDDM and healthy controls. DNA was studied by Southern-blot hybridisation methods using Nco I digestion and a TNF beta probe; two alleles were detected size 5.5 kb and 10.5 kb. In healthy controls (n = 107), 9% were 5.5 homozygotes, 47% heterozygotes and 44% 10.5 homozygotes. The corresponding figures in IMN (n = 51) were 21.5%, 61% and 17.5% (p = 0.002), in IDDM (n = 42) 24%, 50% and 26% (p = 0.027) and in IgAN (n = 77) 2.5%, 65% and 32.5% (p = 0.025). The increase in 5.5 homozygotes in both IMN and IDDM was found to be due to an increased frequency of the haplotype A1-B8-TNF beta 5.5-DR3 seen in both these diseases; whereas in IgAN the increased frequency of the 10.5 kb allele can be explained by an association of a Taq 1DQB1-T2 allele with the TNF beta 10.5 allele. These results demonstrate an association of TNF beta gene polymorphism with IMN and IgAN and confirm the associations found in IDDM. Although these disease associations can be explained by linkage disequilibrium with extended MHC haplotypes, a direct role of genetically determined TNF production in the etiology of these diseases remains to be excluded.

Is there an optimal time for the first cyclosporin dose in renal transplantation?

It is customary for patients undergoing kidney transplantation to receive their first dose of cyclosporin either just before or during the transplant operation. This ensures the early establishment of good levels of immunosuppression but might depress early graft function and contribute towards the development of acute tubular necrosis. In a controlled clinical trial, we have studied the effects of withholding cyclosporin for 12 h in patients undergoing cadaveric renal transplantation. Consecutive adult recipients of a cadaveric renal transplant were randomised to receive their first dose of cyclosporin (10 mg/kg p.o.) 6 h prior to transplant surgery or 12 h afterwards. All patients received azathioprine (1.5 mg/kg i.v.) and methylprednisolone (0.5 g i.v.) in addition during surgery. From the 2nd day onwards both groups were treated with an identical triple immunosuppressive regimen. The 27 patients who received their first dose of cyclosporin post-operatively had significantly better immediate and subsequent function than did the 26 patients who received their cyclosporin at the time of surgery. The delayed dosing was associated with improved graft survival and no increase in the frequency of rejection episodes. This regimen is recommended for all patients receiving triple therapy.

Noninvasive, real-time monitoring of renal function: the ambulatory renal monitor

The objective of this study was to develop a method for the noninvasive, continuous and real-time monitoring of renal function. A radiation detector attached to a miniature data logger was used to monitor the clearance of the glomerular filtration agent 99mTc-diethylenetriaminepentaacetic acid from the extracellular space. The rate constant (k) for this clearance showed an excellent correlation with simultaneous glomerular filtration rate (GFR) measurements performed with a standard 125I-iothalamate clearance technique in 50 patients. Moreover, the reproducibility of the k measurement for an individual or a population was superior to the GFR measurement performed with the standard clearance technique. The procedure was also used to monitor the renal function in patients at risk for acute renal failure during angiography or in the intensive care unit under noninvasive and near real-time conditions. The results show that the technique detects rapid changes in renal function with a resolution time of 5 min in patients with normal renal function and 15 min in patients with severely impaired renal function. Since the method is noninvasive, precise and provides a near real-time measurement of GFR, its use may lead to an improvement in the management of patients in situations in which a rapid measurement is the major concern.

Stroke volume and cardiac output decrease at termination of obstructive apneas

Patients with obstructive sleep apnea (OSA) experience repetitive nocturnal oscillations of systemic arterial pressure that occur in association with changes in respiration and changes in sleep state. To investigate cardiac function during the cycle of obstruction (apnea) and resumption of ventilation (recovery), we continuously measured left ventricular stroke volume (LVSV) and mean arterial blood pressure (MAP) during non-rapid-eye-movement sleep in six males with severe OSA (apnea/hypopnea index > or = 30 events/h associated with oxygen saturation < 82%). LVSV was assessed continuously using an ambulatory ventricular function monitor (VEST; Capintec). The apnea-recovery cycle was divided into three phases: 1) early apnea (EA), 2) late apnea (LA), and 3) recovery (Rec). In all subjects recovery was associated with an abrupt decrease in LVSV [54.0 +/- 14.5 (SD) ml] compared with either EA (91.4 +/- 14.7 ml; P < 0.001) or LA (77.1 +/- 15.2 ml; P < 0.005). Although heart rate increased with recovery, the increase was not sufficient to compensate for the decrease in LVSV so that cardiac output (CO) fell (EA: 6,247 +/- 739 ml/min; LA: 5,741 +/- 1,094 ml/min; Rec: 4,601 +/- 1,249 ml/min; EA vs. Rec, P < 0.01; LA vs. Rec, P < 0.025). Recovery was also associated with a significant increase in MAP. We speculate that such abrupt decreases in LVSV and CO at apnea termination, occurring coincident with the nadir of oxygen saturation, may further compromise tissue oxygen delivery.

An audit of appropriate tests in renal biopsy coagulation screens

Hematological, biochemical, and clinical data was collected over a 15-month period on all adult (greater than 16 years) patients assessed for percutaneous biopsy of native kidneys in a major renal unit. The frequency, causes, interrelationships, and treatment of the abnormalities, along with factors resulting in delay or cancellation of renal biopsies were subsequently subjected to audit. Overall, 30 of 147 coagulation screens were abnormal. The most common coagulopathy was a prolonged bleeding time (BT), which accounted for 58.6% of these. A prolonged BT was not clearly related to other hematological or biochemical indices, and proved to be treatable with arginine vasopressin (DDAVP). The majority of abnormalities occurred in isolation (23/30), and eight of 30 were related directly to current anticoagulant or antiplatelet medication. All but two patients with abnormalities proceeded to renal biopsy after successful corrective measures, but 21 of 30 were delayed by between 1 hour and 14 days. None of the remaining 117 biopsies were delayed, although seven were cancelled for a variety of reasons. The prothrombin consumption index provided no additional useful management information. Our clotting screen, modified by this audit, should safely and efficiently detect clotting abnormalities before renal biopsy.

HLA-DP region gene polymorphism in primary IgA nephropathy: no association

Many features suggest that a genetically mediated abnormality of the IgA immune response is central in the pathogenesis of IgA nephropathy (IgAN). Candidate disease susceptibility genes include those encoding the MHC class II antigens, HLA-DR, -DQ, and -DP, and we have recently described an HLA-DQB1 association in IgAN. Polymorphisms of the HLA-DP region loci have been shown to associate with autoimmune diseases which share immunological features with IgAN; coeliac disease (CD) and dermatitis herpetiformis (DH). We have therefore examined restriction fragment length polymorphisms (RFLPs) of the DP alpha and DP beta chain genes (DPA1 and DPB1 respectively) in IgAN, and have studied three caucasoid populations (North, Mid, Southern Europe) to determine whether ethnic variation in genetic susceptibility exists. DNA was extracted from blood (IgAN, UK n = 89, Italy n = 75, Finland n = 49; Controls, UK n = 99, Italy n = 54, Finland n = 45), and studied by Southern blot hybridization techniques using the restriction enzymes BgI II and Msp I and cDNA 32P-labelled DPA1 and DPB1 probes respectively. The frequency distribution of the DPA1 and DPB1 fragments was similar between the three caucasoid IgAN patient groups compared to their respective controls. There was no association of DPA1 or DPB1 RFLPs with clinical features. These results suggest that HLA-DP region genes are not important in conferring disease susceptibility to IgAN and do not influence clinical disease expression. Moreover, different immunogenetic mechanisms operate in IgAN, CD, and DH.

Selective IgA deficiency associated with glomerulonephritis and oligoarthritis

A 59 year old woman with selective IgA deficiency associated with oligoarthritis and glomerulonephritis is described. She was seropositive for rheumatoid factor and renal histological examination showed a focal glomerulonephritis. High titre rheumatoid factor and a focal glomerulonephritis were also present in the only other well documented report of selective IgA deficiency and renal disease. Histological examination of the kidney suggested that the glomerulonephritis was mediated by immune complexes.

Crescentic transformation in primary membranous glomerulonephritis

A 31 year old man first developed steroid-resistant idiopathic membranous glomerulonephritis in 1981. Stable normal renal function was maintained until August 1988 when he suffered a clinical relapse with heavy proteinuria and declining renal function. Immunosuppressive therapy with prednisolone and cyclophosphamide was instituted in an attempt to arrest this relapse. Despite this, he later developed acute renal failure with histological evidence of crescentic transformation of his nephritis. This unusual transformation was not associated with features of systemic vasculitis or positive anti-glomerular basement membrane and anti-neutrophil cytoplasmic antibodies.

Cardiac blood-pool scintigraphy in rats and hamsters: comparison of five radiopharmaceuticals and three pinhole collimator apertures

Preclinical evaluation of cardiac drugs may require evaluation of cardiac function in intact animals. To optimize the quality of radionuclide measurements of ventricular function in small animals, a comparison was made of gated blood-pool scans recorded with five blood-pool radiopharmaceuticals (99mTc-labeled human polyclonal IgG, 99mTc-human serum albumin labeled by two methods, and red blood cells radiolabeled with 99mTc via in vivo and in vitro methods) in rats and three pinhole apertures in hamsters. The quality of the radiopharmaceuticals was evaluated by comparing count density ratios (LV/BACKGROUND and LV/LIVER) and ejection fractions recorded with each agent. The edge definition of the left ventricle and count rate performance of the 1-, 2-, and 3-mm apertures was evaluated in hamsters. In general, the images obtained with the radiolabeled cells were superior to those obtained with the labeled proteins and no significant differences between the protein preparations were detected. Left ventricular ejection fractions calculated with all five radiopharmaceuticals were not significantly different. The best quality images were obtained with the 1-mm pinhole collimator. Ejection fraction and acquisition time were inversely related to aperture size. A good compromise between resolution and sensitivity was obtained with the 2-mm pinhole collimator.

Immunoglobulin heavy chain switch region gene polymorphisms in glomerulonephritis

Much evidence suggests that primary IgA nephropathy (IgAN) and idiopathic membranous nephropathy (MN) are immune complex mediated diseases. Moreover, genetic factors may play an important role in their pathogenesis. Recently, restriction fragment length polymorphisms (RFLPs) of the immunoglobulin heavy chain genes have been described which appear to associate with glomerulonephritis. We have studied RFLPs of the switch region of the IgM (S mu) and IgA1 (S alpha 1) heavy chain in MN and IgAN. DNA obtained from British Caucasoids with IgAN (N = 75), MN (N = 43), and normal controls (N = 73), was digested with the restriction enzyme Sac1, and studied using Southern blot techniques and hybridization with a 32P labelled DNA probe homologous to S mu. This probe detects RFLPs at the S mu and S alpha 1 loci. The genotypic and allelic frequencies of the S mu and S alpha 1 alleles in IgAN and MN was similar to normal controls. Caucasoid subjects with IgAN from Northern and Southern Europe (Finland and Italy, respectively) were also studied to determine whether an ethnic variation in genetic susceptibility to IgAN exists. The frequency of the S mu and S alpha 1 alleles was similar between the patient groups and their respective local healthy controls. These results do not support the recent findings of an association with RFLPs of the S mu and S alpha 1 loci in IgAN and MN, and suggest that the immunoglobulin heavy chain switch region genes are not important in conferring disease susceptibility to IgAN or MN.

Evaluation of left ventricular diastolic function using an ambulatory radionuclide monitor: relationship to left ventricular systolic performance

Abnormalities of left ventricular (LV) filling may occur prior to systolic dysfunction in patients with both coronary and noncoronary heart disease. To determine the incidence of diastolic dysfunction and to assess the relationship of such dysfunction to systolic performance, we measured systolic and diastolic function at rest in a series of healthy volunteers (n = 10) and in patients with cardiovascular disease (n = 42). Twenty patients had coronary artery disease (CAD) with prior myocardial infarction, six patients had CAD without myocardial infarction, and the remaining 16 patients had a variety of noncoronary heart diseases, including valvular heart disease, dilated cardiomyopathy, and hypertensive disease. The 42 patients manifested a wide variation in LV systolic function (ejection fractions ranged from 6% to 65%). Patients with reduced LV ejection fraction (EF) manifested a reduction in cardiac output and peak ejection rate proportionate to the reduction in EF. Diastolic function showed a fall in LV peak (PFR) and average (AFR) filling rates; these were reduced in proportion to the fall in EF. Heart rate was an insensitive index of the magnitude of impairment of LV systolic function. These data suggest that measurements of diastolic function do not provide additional information in patients with impaired systolic function.

Interstitial nephritis associated with indapamide

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T-cell receptor beta-subunit gene polymorphism and autoimmune disease

We have investigated the distribution of genotypes of a restriction fragment length polymorphism of the T-cell receptor beta-subunit gene in Caucasoid controls and patients with insulin-dependent diabetes mellitus, celiac disease, dermatitis herpetiformis, and idiopathic membranous nephropathy and also in South Indian controls and diabetics. We found no significant differences between the controls and patients with any disease in either ethnic group, a result which contrasts with previous reports of associations with both insulin-dependent diabetes mellitus and idiopathic membranous nephropathy. However, the most striking finding was a marked disparity between the genotype distribution in our Caucasoid control population and that previously reported by other investigators.

HLA DQ region gene polymorphism associated with primary IgA nephropathy

IgA nephropathy (IgAN) has been associated with HLA-DR4. We have recently described two non-allelic Taq I DQ beta gene-associated fragments sized 2.0 kb (T2) and 6.0 kb (T6), which strongly associate with DR4. T2 represents a polymorphism of the DQ beta gene and has been redesignated DQw8 (10th International HLA Workshop). The origin of the T6 fragment has not been determined, but probably represents a polymorphism of either the DQ beta or DX beta gene. When present together T2 and T6 define a subgroup of DR4 subjects at high risk of developing autoimmune disease. We have, therefore, studied DQ beta gene polymorphisms in IgAN. The DR antigen distribution was similar in IgAN and normal controls. The T2+/T6+ phenotype was present in 49% patients with IgAN compared to 15% of controls [P less than 0.0001, chi 2 = 32.8, Cramer's V = 0.41; relative risk = 5.5 (range, 2.8-11.0)]. Seventy-two percent of DR4+ IgAN patients and 29% of DR4+ controls were T2+/T6+ (P = 0.007, chi 2 = 17.0). These findings confirm the hypothesis that disease susceptibility genes are important in IgAN, and suggest that the putative gene(s) are located within or near to the DQ subregion. Moreover, similar DQ beta gene associations have been found in IDDM and pemphigus vulgaris, pointing to a common immunogenetic mechanism predisposing to several autoimmune diseases.

Left ventricular performance during psychological stress

Left ventricular ejection fraction, systolic blood pressure and plasma norepinephrine were measured in six normotensive and six mildly hypertensive subjects during rest and psychological stress. Compared with rest, 8 of the 12 subjects developed significant (P less than 0.05) changes in ejection fraction (increase in 6, decrease in 2); 10 of 12 subjects developed significant elevations of plasma norepinephrine; and all developed significant increases in systolic blood pressure. When the stress effects were examined for the total group, as opposed to within subjects, there were significant increases in plasma norepinephrine (P less than 0.001) and systolic blood pressure (P less than 0.001) but, interestingly, mean ejection fraction and stroke volume remained unchanged, implying stress led to increased left ventricular contractility.

Gated blood pool tomography: a technology whose time has come

Tomographic gated blood pool imaging is a natural extension of the technologies of planar gated blood pool scanning and rotating Anger camera single photon emission computed tomography (SPECT). The high photon flux, optimum 140 keV energy, and volume sampling of tomography permit reconstruction of the data in any perspective. The true three-dimensional nature of this process allows the evaluation of regional wall motion of all the cardiac chambers, unencumbered by overlapping structures. The heart can be viewed from any angle, including a long axis, short axis, apical four chamber, and a true inferior view. In addition to evaluation of regional wall motion, precise determination of chamber volumes and ejection fractions is possible. Early clinical experience has demonstrated the superiority of tomographic gated blood pool imaging over planar blood pool imaging for precisely defining subtle functional abnormalities. The enormous amount of data generated by this procedure taxes the capacity of most nuclear medicine computer systems. However, the availability of 32-bit processors and large amounts of image memory in new machines should ultimately reduce this processing time to less than ten minutes. The combination of complete visualization and quantitation suggests that a renaissance for blood pool imaging is on the horizon.

The concurrent validity of the MacAndrew Alcoholism Scale among at-risk adolescent females

This study investigated the empirical validity of the MacAndrew Alcoholism Scale as a measure of alcohol abuse, marijuana use, and related multiple substance use in a sample of N = 160. Classification accuracy was 45% for alcohol abuse, 48.8% for marijuana use, and 66% for related multiple substance use (n = 12). There were few differences in personality functioning as measured by the California Psychological Inventory between true positives and false negatives. Both groups exhibited adolescent qualities, i.e., irresponsibility, attraction to pleasure seeking, and minor rebelliousness. False negatives appeared to be slightly less impulsive and somewhat less secure about themselves. Both groups were also similar in terms of reported use of alcohol. They used alcohol to enhance a sense of well-being, i.e., to gain pleasure and to reduce dysphoric affect, but not to reduce inhibitions in social relationships. However, true positives tended to use alcohol to help cope with problems in personal relationships, such as rejection. Some limitations of the study, especially in relation to recent formulations of female alcoholism by MacAndrew (1986), were discussed.

Redistribution of visceral blood volume in upright exercise in healthy volunteers

Exercise induced changes in the blood volume of visceral organs (cardiopulmonary and liver, spleen, and kidneys) were determined by scintillation camera imaging of the distribution of technetium-99m-labeled red blood cells in the thorax and abdomen of ten healthy adult volunteers. Graded upright bicycle exercise was performed to the point of exhaustion with the volunteer positioned with his/her back to the scintillation camera and data recording was synchronized to the pedal cycle to minimize patient motion artifacts within the data. The first image from each level of exercise was analyzed by placing regions of interest over the spleen, liver, kidneys, and right lung. The counts in each organ were expressed as a percent of activity at zero workload. Analysis of data using Hotelling's t-squared analysis to see if overall differences existed between the last four measurements (up to the time of exhaustion) regarding percent change from baseline for spleen, kidney, liver, and right lung were made. The splanchnic bed had a significant decrease in blood volume. The spleen decreased 39%, while the liver decreased 14%. For the kidney and liver, no significant differences were achieved (p greater than 0.24, p less than 0.15, respectively). The lung increased its blood volume to 128% of control, significant with p less than 0.02. This data demonstrates that in healthy volunteers there is normal redistribution of blood volume during maximal exercise with a significant reduction in blood volume of the spleen as well as a significant rise in blood volume within the lungs.

Continuous monitoring of left ventricular function by an ambulatory radionuclide detector in patients with coronary artery disease

Global left ventricular function and a modified V5 electrocardiographic (ECG) lead were continuously monitored by a radionuclide recorder in 12 normal subjects and 39 patients with coronary artery disease while the subjects were performing various daily activities. The ambulatory studies revealed that walking on a level surface caused 11 of 12 normal subjects and 18 of 32 patients to increase their left ventricular ejection fraction by greater than 6% units. A transient decrease in left ventricular ejection fraction (6 to 18%) lasting greater than or equal to 1 min was observed on 36 occasions in 16 patients with coronary artery disease; 12 episodes were accompanied by chest pain or shortness of breath and 24 were asymptomatic. Electrocardiographic ST segment depression suggestive of ischemia was recorded in 6 of the 12 symptomatic and 5 of the 24 asymptomatic episodes. In 10 of the 12 symptomatic episodes, left ventricular ejection fraction began to decrease 30 to 90 s before the onset of symptoms. These studies suggest that continuous monitoring of both left ventricular function and the ECG may permit stratification of episodes of ST depression suggesting ischemia by the degree of left ventricular dysfunction they produce.

The effects of stress on left ventricular ejection fraction

The left ventricular ejection fraction (EF) was studied in 17 healthy volunteers with a new ambulatory left ventricular function monitor. Heart rate, EF, and blood pressure measurements were made during rest, a psychiatric stress interview, cold exposure, exercise, and eating. An increase in EF was seen during emotional stress (from 0.45 +/- 0.09 to 0.51 +/- 0.13, P less than 0.001). This increase was comparable to that observed during exercise (0.52 +/- 0.14) and eating (0.52 +/- 0.10, P less than 0.001). In contrast, cold exposure caused a decrease in EF (0.43 +/- 0.13, P less than 0.05). These observations demonstrate the powerful hemodynamic consequences of common behaviors as well as the utility and feasibility of studying such behavioral factors in ambulatory subjects.