Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS) is a disorder of intestinal hypersensitivity and altered motility, exacerbated by stress. Functional magnetic resonance imaging (fMRI) during painful rectal distension in IBS has demonstrated greater activation of the anterior cingulate cortex (ACC), an area relevant to pain and emotions. Tricyclic antidepressants are effective for IBS. The aim of this study was to determine if low dose amitriptyline reduces ACC activation during painful rectal distension in IBS to confer clinical benefits. Secondary aims were to identify other brain regions altered by amitriptyline, and to determine if reductions in cerebral activation are greater during mental stress.

METHODS

Nineteen women with painful IBS were randomised to amitriptyline 50 mg or placebo for one month and then crossed over to the alternate treatment after washout. Cerebral activation during rectal distension was compared between placebo and amitriptyline groups by fMRI. Distensions were performed alternately during auditory stress and relaxing music.

RESULTS

Rectal pain induced significant activation of the perigenual ACC, right insula, and right prefrontal cortex. Amitriptyline was associated with reduced pain related cerebral activations in the perigenual ACC and the left posterior parietal cortex, but only during stress.

CONCLUSIONS

The tricyclic antidepressant amitriptyline reduces brain activation during pain in the perigenual (limbic) anterior cingulated cortex and parietal association cortex. These reductions are only seen during stress. Amitriptyline is likely to work in the central nervous system rather than peripherally to blunt pain and other symptoms exacerbated by stress in IBS.

Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU)

CONTEXT

Delirium is a common problem in the intensive care unit (ICU). Accurate diagnosis is limited by the difficulty of communicating with mechanically ventilated patients and by lack of a validated delirium instrument for use in the ICU.

OBJECTIVES

To validate a delirium assessment instrument that uses standardized nonverbal assessments for mechanically ventilated patients and to determine the occurrence rate of delirium in such patients.

DESIGN AND SETTING

Prospective cohort study testing the Confusion Assessment Method for ICU Patients (CAM-ICU) in the adult medical and coronary ICUs of a US university-based medical center.

PARTICIPANTS

A total of 111 consecutive patients who were mechanically ventilated were enrolled from February 1, 2000, to July 15, 2000, of whom 96 (86.5%) were evaluable for the development of delirium and 15 (13.5%) were excluded because they remained comatose throughout the investigation.

MAIN OUTCOME MEASURES

Occurrence rate of delirium and sensitivity, specificity, and interrater reliability of delirium assessments using the CAM-ICU, made daily by 2 critical care study nurses, compared with assessments by delirium experts using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.

RESULTS

A total of 471 daily paired evaluations were completed. Compared with the reference standard for diagnosing delirium, 2 study nurses using the CAM-ICU had sensitivities of 100% and 93%, specificities of 98% and 100%, and high interrater reliability (kappa = 0.96; 95% confidence interval, 0.92-0.99). Interrater reliability measures across subgroup comparisons showed kappa values of 0.92 for those aged 65 years or older, 0.99 for those with suspected dementia, or 0.94 for those with Acute Physiology and Chronic Health Evaluation II scores at or above the median value of 23 (all P<.001). Comparing sensitivity and specificity between patient subgroups according to age, suspected dementia, or severity of illness showed no significant differences. The mean (SD) CAM-ICU administration time was 2 (1) minutes. Reference standard diagnoses of delirium, stupor, and coma occurred in 25.2%, 21.3%, and 28.5% of all observations, respectively. Delirium occurred in 80 (83.3%) patients during their ICU stay for a mean (SD) of 2.4 (1.6) days. Delirium was even present in 39.5% of alert or easily aroused patient observations by the reference standard and persisted in 10.4% of patients at hospital discharge.

CONCLUSIONS

Delirium, a complication not currently monitored in the ICU setting, is extremely common in mechanically ventilated patients. The CAM-ICU appears to be rapid, valid, and reliable for diagnosing delirium in the ICU setting and may be a useful instrument for both clinical and research purposes.

Refractory anaemia with excess blasts (RAEB) in a child--an unusual clinicohaematological presentation--a case report

Myelodysplastic syndrome (MDS) is a disease of elderly patients but, rarely can be encountered in pediatric age group. The present case of MDS (RAEB subtype) was reported in a child who presented with proptosis and unique and rare feature of haemophagocytosis by myeloid series of cells.

Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

OBJECTIVE

To develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation.

DESIGN

Prospective cohort study.

SETTING

The adult medical and coronary intensive care units of a tertiary care, university-based medical center.

PATIENTS

Thirty-eight patients admitted to the intensive care units.

MEASUREMENTS AND MAIN RESULTS

We designed and tested a modified version of the Confusion Assessment Method for use in intensive care unit patients and called it the CAM-ICU. Daily ratings from intensive care unit admission to hospital discharge by two study nurses and an intensivist who used the CAM-ICU were compared against the reference standard, a delirium expert who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). A total of 293 daily, paired evaluations were completed, with reference standard diagnoses of delirium in 42% and coma in 27% of all observations. To include only interactive patient evaluations and avoid repeat-observer bias for patients studied on multiple days, we used only the first-alert or lethargic comparison evaluation in each patient. Thirty-three of 38 patients (87%) developed delirium during their intensive care unit stay, mean duration of 4.2 +/- 1.7 days. Excluding evaluations of comatose patients because of lack of characteristic delirium features, the two critical care study nurses and intensivist demonstrated high interrater reliability for their CAM-ICU ratings with kappa statistics of 0.84, 0.79, and 0.95, respectively (p <.001). The two nurses' and intensivist's sensitivities when using the CAM-ICU compared with the reference standard were 95%, 96%, and 100%, respectively, whereas their specificities were 93%, 93%, and 89%, respectively.

CONCLUSIONS

The CAM-ICU demonstrated excellent reliability and validity when used by nurses and physicians to identify delirium in intensive care unit patients. The CAM-ICU may be a useful instrument for both clinical and research purposes to monitor delirium in this challenging patient population.

Circadian rhythm of objectively recorded hot flashes in postmenopausal breast cancer survivors

OBJECTIVE

Similar to the circadian rhythm of core body temperature, hot flashes have been found to exhibit a circadian rhythm in healthy, naturally postmenopausal women, with a peak in frequency at 18:25 h. However, to date, no studies have evaluated whether this same pattern is found among breast cancer survivors reporting hot flashes.

DESIGN

Daily hot flash frequencies were measured among 21 postmenopausal breast cancer survivors using validated 24-h sternal skin conductance monitoring.

RESULTS

Hot flashes were noted in all women, ranging in frequency from 1 to 30 per 24-h period. A majority of the sample (86%) experienced > or = 1 nighttime hot flash, with 48% exhibiting > or = 3 but < or = 7 nighttime hot flashes. For the total sample, a modest circadian rhythm was noted with a peak in hot flash frequency occurring at 16:10 h. However, significant variability was observed across individual women, and, as a whole, breast cancer survivors demonstrated distorted to obliterated rhythms.

CONCLUSIONS

Data suggest that hot flashes in postmenopausal breast cancer survivors do not follow the same circadian pattern as previously seen in healthy, naturally postmenopausal women. Findings have implications for (1) understanding the potential for sleep disturbances and fatigue in breast cancer survivors experiencing hot flashes, and (2) future research examining circadian rhythms of core body temperature and hot flashes in breast cancer survivors.

Ratio of free-to-total prostate specific antigen correlates with tumor volume in patients with increased prostate specific antigen

PURPOSE

We evaluated the relationship between the ratio of free-to-total prostate specific antigen (PSA) and prostate pathology, including grade, stage and tumor volume, among patients with prostate cancer who underwent radical prostatectomy.

MATERIALS AND METHODS

We prospectively analyzed 54 consecutive patients with prostate cancer who underwent radical prostatectomy and in whom frozen serum was available for assessment of free-to-total PSA ratio. Pathological review was done with whole mount sections, and total tumor volume was determined by planimetry. Comparison between free-to-total PSA ratio and pathological parameters was performed using the Pearson correlation coefficient.

RESULTS

Among the 54 patients mean total and free-to-total PSA ratio were 5.81 and 14.2 ng./ml., respectively, and free-to-total PSA ratio directly correlated with prostate volume (p = 0.037), and inversely correlated with Gleason score (p = 0.012) and extracapsular disease (p = 0.0074). Furthermore, there was a significant relationship between free-to-total PSA ratio and pathological stage pT2a/b in 39 cases versus pT3a/b in 15 (p = 0.005). Overall, there was no correlation between free-to-total PSA ratio and tumor volume. However, among 37 patients with an increased PSA, defined as greater than 4.0 ng./ml., a significant inverse relationship between free-to-total PSA ratio and tumor volume was identified (p = 0.01). Among this subset there was only a weak correlation with prostate volume (p = 0.049).

CONCLUSIONS

Our findings suggest that free-to-total PSA ratio may be predictive of tumor biology among those patients with a total PSA of greater than 4 ng./ml. as evidenced by good correlation with tumor grade and volume. This finding appears to be independent of prostate volume. These preliminary results suggest the need for additional studies among patients with an increased PSA designed to evaluate the potential role of free-to-total PSA ratio in combination with traditional clinical variables in the prediction of prostate cancer pathology.

The impact of delirium in the intensive care unit on hospital length of stay

STUDY OBJECTIVE

To determine the relationship between delirium in the intensive care unit (ICU) and outcomes including length of stay in the hospital.

DESIGN

A prospective cohort study.

SETTING

The adult medical ICU of a tertiary care, university-based medical center.

PARTICIPANTS

The study population consisted of 48 patients admitted to the ICU, 24 of whom received mechanical ventilation.

MEASUREMENTS

All patients were evaluated for the development and persistence of delirium on a daily basis by a geriatric or psychiatric specialist with expertise in delirium assessment using the Diagnostic Statistical Manual IV (DSM-IV) criteria of the American Psychiatric Association, the reference standard for delirium ratings. Primary outcomes measured were length of stay in the ICU and hospital.

RESULTS

The mean onset of delirium was 2.6 days (S.D.+/-1.7), and the mean duration was 3.4+/-1.9 days. Of the 48 patients, 39 (81.3%) developed delirium, and of these 29 (60.4%) developed the complication while still in the ICU. The duration of delirium was associated with length of stay in the ICU ( r=0.65, P=0.0001) and in the hospital ( r=0.68, P<0.0001). Using multivariate analysis, delirium was the strongest predictor of length of stay in the hospital ( P=0.006) even after adjusting for severity of illness, age, gender, race, and days of benzodiazepine and narcotic drug administration.

CONCLUSIONS

In this patient cohort, the majority of patients developed delirium in the ICU, and delirium was the strongest independent determinant of length of stay in the hospital. Further study and monitoring of delirium in the ICU and the risk factors for its development are warranted.

Correlation of anthropometric measurements, strength, anterior cruciate ligament size, and intercondylar notch characteristics to sex differences in anterior cruciate ligament tear rates

We performed a prospective study based on the hypothesis that physiologic differences exist between men and women in strength after adjustments for body weight; that the size of the anterior cruciate ligament is proportionate to the strength of its antagonists, the quadriceps muscles; and that women have a relatively small anterior cruciate ligament, thus predisposing them to a disproportionate number of anterior cruciate ligament injuries. One hundred matched high school basketball players, 50 male and 50 female, were evaluated with anthropometric measurements, body fat analysis, muscle strength evaluation, and magnetic resonance imaging measurements of the intercondylar notch and cross-sectional area of the anterior cruciate ligament at the outlet. The male players were taller and heavier than their female counterparts, although they had 11% less body fat. Male players had statistically greater quadriceps and hamstring muscle strength than female players, even when adjustments were made for body weight. With adjustments for body weight, the size of the anterior cruciate ligament in girls was found to be statistically smaller than in boys. There was no statistically significant difference in the notch width index between the sexes. The study data support our hypothesis that sex differences in anterior cruciate ligament tear rates are caused primarily by several interrelated intrinsic factors. Most importantly, stiffness and muscular strength increase stress on the anterior cruciate ligament in female athletes. The anterior cruciate ligament, when adjustments have been made for body weight, is smaller in female athletes, and therefore, probably does not compensate for the lack of stiffness and strength.

A longitudinal analysis of the pediatric surgeon workforce

OBJECTIVE

To describe the trends in the pediatric surgeon workforce during the last 25 years and to provide objective data useful for planning graduate medical education requirements.

SUMMARY BACKGROUND DATA

In 1975, the Study on U.S. Surgical Services (SOSSUS) was published, including a model to survey staffing. A pediatric surgeon workforce study was initiated in conjunction with SOSSUS as a population, supply, and need-based study. The study has been updated every 5 years using the same study model, with the goals of determining the number and distribution of pediatric surgeons in the United States, the number needed and where, and the number of training programs and trainee output required to fill estimated staffing needs. This is the only such longitudinal workforce analysis of a surgical specialty.

METHODS

Questionnaires were sent to 100 pediatric surgeons representing the 62 standard metropolitan statistical areas (SMSAs) in the United States with a population of 200,000 or more to verify the names and locations of all active pediatric surgeons and to gain information about the 5-year need for new pediatric surgeons by region. A program was developed to predict the number of pediatric surgeons relative to the total population and the 0-to-17-year-old population in the subsequent 30 years using updated data on the present number and ages of pediatric surgeons, age-specific death and retirement rates, projections of U.S. population by age group, and varying numbers of trainees graduated per year. As each 5-year update was done, previous projections were compared with actual numbers of pediatric surgeons found. The trends during the last 25 years were analyzed and compared and additional information regarding the demographics of practice, trends in reimbursement, and volume and scope of surgery was obtained.

RESULTS

The birth rate has been stable since 1994. The 0-to-17-year-old population has been increasing at 0.65% per year; a 0.64% annual rate is projected to 2040. At present, 661 pediatric surgeons are distributed in every SMSA of 200,000 or more population, with an average age of 45 and an average age of retirement 65. The actual number of pediatric surgeons in each 5-year survey has consistently validated previous projections. Trainee output has increased markedly in the past 10 years. The rate of growth of the pediatric surgeon workforce at present is 50% greater than the forecasted rate of increase in the pediatric age group, and during the past 25 years the rate of growth of the pediatric surgeon workforce has been double that of the pediatric population growth. Nationally, significant changes in reimbursement, volume of surgery, and demographics of practice have occurred.

Resolution of gastritis induced by Helicobacter pylori 4-5 weeks after successful eradication of infection using a triple therapy regimen of pantoprazole, amoxycillin and clarithromycin for one week

This open-label study was designed to determine the extent of histological resolution of gastritis induced by Helicobacter pylori infection 4-5 weeks after successful eradication of the infection. Eradication was achieved using a triple therapy regimen consisting of a twice daily dose of pantoprazole 40 mg, clarithromycin 500 mg, and amoxicillin 1,000 mg taken for 1 week only. No other medications were given thereafter. Four biopsies were processed for histological examination of each patient, two from the antral and two from the corporeal mucosa, first at the start of the study and then again 4 weeks after cessation of the medication trial. Scoring for H. pylori colonization and the severity of gastritis was determined for each patient according to the Sydney system. 53 of 57 patients in this study had their H. pylori infection successfully eradicated by the regimen mentioned and could be histologically evaluated. According to the severity of gastritis in the antral mucosa, patients were studied in 3 groups: mild, moderate and severe gastritis. 17 of 19 cases with mild gastritis showed complete resolution of the inflammation, with residual inflammatory changes persisting in 2 cases only. 22 of the 26 cases with moderate gastritis showed almost complete recovery except for minor residual inflammatory changes as judged by irregularity of intracytoplasmic mucine storage. Persistent residual inflammatory changes in the lamina propria were detected in 4 cases. Of the 8 cases with severe gastritis 5 showed subsidence of the inflammatory changes, but the mucosa in these cases revealed some scarring, distortion of the glandular epithelium and atrophy. In 3 cases residual inflammation persisted.

CONCLUSION

One-week therapy with a twice daily dose of pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1,000 mg, used to eradicate H. pylori causing active inflammation of the gastric mucosa, has led to subsidence of the acute inflammatory changes in all the cases with residual inflammation persisting in 17%. Severe gastritis may cause irreparable damage to the gastric mucosa. The density of H. pylori colonization does not appear to be related to the severity of gastritis, nor to the successful eradication achieved.

One-week triple regime therapy consisting of pantoprazole, amoxicillin and clarithromycin for cure of Helicobacter pylori-associated upper gastrointestinal diseases

This study was designed to determine the efficacy and safety of 1-week triple therapy regime consisting of pantoprazole, amoxicillin and clarithromycin in the cure of Helicobacter pylori infection leading to duodenal ulcer disease and/or gastritis. Sixty-one patients (47 males, 14 females with a mean age of 34 years) belonging to different ethnic groups suffering from H. pylori-associated duodenal ulcer and/or gastritis for an average of 2.46 years were recruited. Having satisfied primary selection criteria, patients received pantoprazole 40 mg b.i.d., clarithromycin 500 mg b.i.d. and amoxicillin 1,000 mg b.i.d. for 7 days. All medications were stopped there after H. pylori eradication was determined 4-6 weeks after treatment by a repeat endoscopy, a rapid urease test, H. pylori culture and histology assessment as indicators of cure. All three tests must be negative to consider the infection to have been successfully eradicated. Fifty-seven patients completed the efficacy analysis per protocol. Dramatic symptomatic improvement was noted in most patients immediately after stopping treatment and it was sustained at 6 weeks. At the end of the study, the healing rate of duodenal ulcers (complete re-epithelialization) following 1-week treatment only, as indicated above, and without any maintenance therapy was 66.7%, that of gastritis was 55.7%, and that of erosions was 64.3%. The overall eradication rate for H. pylori, however, was 93% (95% CI 83.0-98.1%). Furthermore, histologic evaluation revealed a remarkable resolution in the activity of gastritis in all the patients who had successful eradication of the infection.

Spice extracts as dose-modifying factors in radiation inactivation of bacteria

Three spices, chili, black pepper, and turmeric, were tested for the effect of their aqueous extracts on the sensitivity of three bacteria, Escherichia coli, Bacillus megaterium, and Bacillus pumilusspores, to gamma-radiation. It was found that the extracts of the three spices offered protection to these organisms against inactivation by gamma-radiation. These spice extracts were also tested for their protection of naked plasmid DNA. Radiation-induced degradation of plasmid pUC18 DNA was reduced in the presence of the spice extracts. The maximum protection was offered by the chili extract followed by that of black pepper and turmeric. The two known antioxidants, curcumin and piperine from turmeric and black pepper, respectively, were shown to protect the plasmid DNA from the degradation by gamma-radiation. Experiments with the plasmid pUC18 DNA indicated that the spice extracts probably protected microorganisms by protecting their DNA. These studies indicated the importance of spices among ingredients in food as dose-modifying factors during radiation processing.

Cytological diagnosis of adenoid cystic carcinoma breast--a case report

The cytologic features of a case of adenoid cystic carcinoma of breast diagnosed on fine needle aspiration cytology (FNAC) in a 52 years old female are described. FNAC was carried out on outer quadrant of breast. The characteristic cytological features were numerous single to branching small round to Avoid cells at places forming microacini. Numerous pink hyaline globules of variable sizes were seen along with finger like projections containing basement membrane material.

Psychiatric morbidity among victims of bomb blast

Thirty one victims of bomb blast in a bus caused by terrorist activity in Dausa district, Rajasthan on 22.5.96, were evaluated for psychological reactions 3 days & 2 weeks after the incident. All hospitalized & non hospitalised bomb blast victims were assessed within 3 days of injury by objective predictors (percent of burnt area, facial disfigurement, limb amputations, fractures etc.) and subjective predictors (emotional distress and perceived social support). Detailed history, physical and mental state examination of all patients was carried out and for those having scores more then 17 on GHQ-60 (Hindi version), IPIS was administered. Diagnosis was made by 3 senior consultant psychiatrists of Psychiatric Centre, Jaipur, on the basis oflCD-10. At day 3 of 31 patients studied 11 (35.45%) had psychiatric morbidity. Out of which 6 (19.35%) had acute stress reaction, 3 (9.68%) had depression and 2 (6.45%) dissociative amnesia. Most commonly reported symptoms on IPIS were depersonalisation, derealisation, sleep disturbances specially generalised sleep loss, loss of appetite, nightmares, situational anxiety, depression, mental irritability, dulness of feelings, self blame, guilt, loss of interest, suicidal ideas, and worry about money, spouse, work and children. Most common physical injury was burns, followed by hearing disturbances, wounds received due to glass <& metal pieces and non specific pains and aches. Findings of follow up have been discussed and battery of tests for evaluation of victims of acute trauma has been suggested.

Election - a stressful life event

54 patients who sought consultation at this centre after developing psychiatric illness following local panchayat elections in Rajasthan were studied. The study aims to find out whether election is a stressful life event, relationship of socio-demographic characteristics, role of process of election, and nature of psychiatric illness as related to election stress. This group was compared to general psychiatric patients randomly selected from the same hospital, with or without other stressful life events (n=60). Socio-demographic variables, nature of their illness, ways of coping with the stress and relationship of predisposition to mental illness have been studied in both groups. Findings have been discussed and implications highlighted.

Test for linear trend in 2 x K ordered tables with open-ended categories

A method of evaluating trend (positive or negative) in 2 x K ordered tables is suggested for cases in which the scores for the first (K-1) categories are known a priori but the score for the last category is not known. Such a category is termed as open-ended category in this paper. Ordered tables with an open-ended category are often encountered while evaluating the Cochran-Armitage-Mantel (CAM) trend. In the present paper, the distribution of the test statistic is presented and simulations are carried out to check the asymptotics. The method is then exemplified by an existing data set.

The effect of rings on microbial load of health care workers' hands

BACKGROUND

The hands of health care workers (HCWs) serve as a major route for transmission of nosocomial infection. Although handwashing is known to reduce cross-transmission of infection, the influence of rings on the efficacy of handwashing and the carriage of bacteria on the hands has not been well established.

METHODS

In this study, 50 HCWs with rings were paired by unit with 50 HCWs without rings. Cultures were obtained by use of a timed-friction rinse before and after a timed handwashing. Standard laboratory procedures were followed for identification of the bacteria.

RESULT

When colony counts before handwashing are taken into consideration, a significant difference is seen after handwashing between the two groups (R2 = 0.56). The regression model showed that the slope was significantly steeper (p < 0.0014) for the group with rings. This effect is more apparent when the colony count on hands is greater than 1000 colony forming units before handwashing.

CONCLUSIONS

A standardized, timed handwashing procedure was effective in decreasing the bioload of HCWs' hands. The effect of rings on the bioload was significant in this study.

Community education programs to promote mammography participation in rural New York State

BACKGROUND

Rural women are less likely to receive screening mammography at recommended intervals. This study evaluated efforts to promote screening mammography among women in rural communities through community education interventions and low-cost mobile mammography van services.

METHODS

Two matched sets of communities were identified in an isolated rural region. One area received community education programs in addition to the mammography van for 2 years; the second area received only the van services. The educational programs were designed using diagnostic research methods; they included recruitment of opinion leaders to organize small group breast screening education sessions, an information campaign using direct mail, and primary health care provider education.

RESULTS

A household telephone survey conducted 6 months after completion of these programs indicated that mammography utilization and perceived mammography norms were higher among women in the Program area than among women in the Comparison area. Process data were consistent with these findings. Clinical examination and self-examination behaviors were not influenced by the programs.

CONCLUSIONS

This study showed that well-focused educational interventions for rural women can increase utilization of screening mammography when access and cost barriers also are reduced.

Effect of menthol cigarettes on biochemical markers of smoke exposure among black and white smokers

STUDY OBJECTIVES

Black smokers have been reported to have higher serum cotinine levels than do white smokers, and have higher rates of most smoking-related diseases, despite smoking fewer cigarettes per day. Another striking racial difference is the preference for mentholated cigarettes among black smokers. The contribution of menthol to variability in biochemical markers of cigarette smoke exposure (end-expiratory carbon monoxide and serum cotinine) was evaluated in a biracial sample.

DESIGN

Descriptive cross-sectional.

SETTING

A university smoking research laboratory.

PARTICIPANTS

Sixty-five black and 96 white adult established smokers who were paid for their participation.

MEASUREMENTS

Information was obtained through direct observation, self-report (interview and self-administered questionnaires), measurement of butts collected for a week, and laboratory analyses of the biochemical markers of exposure.

RESULTS

Compared with the white smokers, the black smokers had significantly higher cotinine and carbon monoxide levels per cigarette smoked and per millimeter of smoked tobacco rod (both p < 0.001). After adjusting for race, cigarettes per day, and mean amount of each cigarette smoked, menthol was associated with higher cotinine levels (p = 0.03) and carbon monoxide concentrations (p = 0.02).

CONCLUSIONS

The use of menthol may be associated with increased health risks of smoking. Menthol use should be considered when biochemical markers of smoke exposure are used as quantitative measures of smoking intensity or as indicators of compliance with smoking reduction programs. In addition, the effect of menthol on total "dose" should be considered in any efforts to regulate the amount of nicotine in cigarettes.

Sexual behaviour and dysfunction in divorce seeking couples

50 divorce seeking couples, when compared with 30 well adjusted couples, showed that sex-related factors and sexual dysfunctions were related to divorce seeking behaviour. A significantly high number of couples in the study group, reported a bad honeymoon, unsatisfactory coital experience, lack of cooperation from the spouse and variant sexual habits. The findings emphasis the importance of imparting adequate knowledge about sex and management of sexual dysfunctions, as part of marital therapy.

Psychiatric morbidity and personality profile in divorce seeking couples

To what extent psychiatric morbidity and personality factors contribute to marital disharmony and decision to divorce is still an unanswered question in Indian setting. This study was undertaken with aims to find out (1) the prevalence of psychiatric morbidity in persons seeking divorce; (2) the prevalence of psychiatric morbidity in persons who had good marital adjustment; (3) the nature of psychiatric morbidity observed in these subjects, and (4) the personality profile of these subjects. Fifty randomly selected divorce seeking couples (n=100) from the matrimonial court of Jaipur City and thirty couples with good marital adjustment (n=60) selected from the community were studied. Probable psychiatric cases identified by administering GHQ (Hindi version) were diagnosed according to ICD-10 and personality profile of all cases was studied by using 16 PF. High psychiatric morbidity (50%) was found among divorce seeking couples in comparison to control group (13%). There was a high prevalence of neurone disorders (22%) and mood disorders (16%) in experimental group. Schizophrenia and related disorders (10%) and substance abuse disorder (2%) were seen only in the experimental group. Specific personality factors related to divorce seeking individuals and persons with stable marriage have been identified. The implications of this study are highlighted.

Transferrin receptor expression in nonsmall cell lung cancer. Histopathologic and clinical correlates

BACKGROUND

In the search for tumor-related antigens with survival-predictive value, previous studies have yielded varied conclusions regarding the expression of one such antigen, the transferrin receptor in lung cancer. The goal of this study was to define the frequency of expression of transferrin receptor in lung cancer specimens and gather preliminary data regarding the prognostic value of this tumor-related antigen.

METHODS

Tissue immunoreactivity was studied with a murine monoclonal antibody to transferrin receptor in patients with nonsmall cell lung cancer who underwent surgical resection at the Medical Center Hospital of Vermont during the period from January, 1988, to May, 1991.

RESULTS

The study group consisted of 32 patients (21 males and 11 females) with an average follow-up length of 27 months (standard deviation of 16 months). There were 17 patients with adenocarcinoma, 14 with squamous cell carcinoma, and 1 with large cell carcinoma. At the end of data accumulation, a total of 16 deaths had been recorded (8 with squamous cell, 8 with adenocarcinoma). Normal lung tissue did not stain for transferrin receptor; however, 13 of 17 (76%) adenocarcinomas, 13 of 14 (93%) squamous cell carcinomas, and the 1 large cell carcinoma stained positively for transferrin receptor. Staining for transferrin receptor was graded according to pattern and intensity and categorized as absent-weak or strong. Survival analysis was performed to evaluate patient outcome based on a variety of clinical and experimentally determined characteristics. Groups based on N-status (N0 vs. N1 + N2, P = 0.08), stage (Stage 1 vs. Stage 2 + 3 P = 0.13), age (younger than 60 vs. 60 years or older, P = 0.09), and transferrin receptor staining (absent-weak vs. strong, P = 0.14) achieved nearly significant differences in survival. Further analysis of the differences in survival for groupings based on transferrin receptor staining found that these differences in survival reached significance for patients with larger tumors (T2 or T3, P = 0.02).

CONCLUSIONS

Transferrin receptor is expressed in the majority of lung cancers and the presence of transferrin receptor in nonsmall cell lung cancers may be an indicator of poorer prognosis in certain groups of patients.

Upregulation of neuronal nitric oxide synthase and mRNA, and selective sparing of nitric oxide synthase-containing neurons after focal cerebral ischemia in rat

Nitric oxide synthase-containing neurons are presumed to be resistant to neurodegeneration and neurotoxicity, however this resistance has not been demonstrated after focal cerebral ischemia. We therefore measured the temporal profile of neuronal nitric oxide synthase (NOS-I) mRNA and immunoreactivity and NADPH-diaphorase reactivity over a one week period after permanent middle cerebral artery (MCA) occlusion in 48 male Wistar rats and compared these data to ischemic cell damage as evaluated on hematoxylin and eosin (H & E) stained sections by light microscopy. NOS-I mRNA increased as early as 15 min after MCA occlusion in the ipsilateral striatum and maximal expression of NOS-I was found in the ipsilateral cortex and striatum 1 h after MCA occlusion. The numbers of NOS-I-containing neurons in the ipsilateral cortex and striatum were significantly greater (P < 0.05) than NOS-I-containing neurons in the contralateral hemisphere at 2-48 h after the onset of ischemia. The number of NOS-I-containing neurons peaked at 4 h after MCA occlusion. Neurons exhibited shrinkage or were swollen at 1 to 4 h after MCA occlusion. At 24-48 h after ischemia, neurons in the ischemic lesion appeared to be eosinophilic or ghost like on H & E stained sections. However, some of these neurons retained morphological integrity on the NOS-I immunohistochemical sections. At 168 h after ischemia, all neurons within the lesion appeared necrotic on H & E stained sections; however, scatterred neurons expressed NOS-I and NADPH-diaphorase. The rapid upregulation of NOS-I and mRNA in the ischemic lesion suggests that NOS-I is involved in focal cerebral ischemic injury; the expression of NOS-I by neurons that retain their morphological structure in the area of the infarct suggests that NOS-I-containing neurons are more resistant to the ischemic insult. Our data also indicate a close association of NOS-I immunoreactivity and NADPH-diaphorase reactivity in ischemic brain.

Psychiatric morbidity in displaced leprosy patients

One hundred confirmed leprosy patients, all of them migrated from elsewhere, were examined for psychiatric co-morbidity. Forty-six of them were from an 'ashram' and the others were from a slum area. 76% of the patients were found to be having psychiatric illness. Of these, 55% were having neurotic depression and 21% had anxiety neurosis. Single, unemployed, socio-economically backward and patients with physical deformities were suffering significantly more often with psychiatric symptoms. Psychiatric morbidity was found to be more frequent in the patients staying in slum than in those in the 'ashram' where they had some security.

p53-immunoreactive protein and p53 mRNA expression after transient middle cerebral artery occlusion in rats

BACKGROUND AND PURPOSE

We investigated the temporal distribution of the p53-immunoreactive protein in conjunction with cellular damage and the expression of the p53 mRNA after focal cerebral ischemia in rats.

METHODS

Male Wistar rats (n = 66; controls, n = 7) were subjected to 2 hours of middle cerebral artery occlusion and were killed at various times of reperfusion (0.5 to 168 hours) for p53 immunohistochemistry and Northern blot analysis.

RESULTS

A cellular expression of mutant p53-immunoreactive protein was found localized to anatomic sites exhibiting severe neuronal damage. A maximal induction of mutant p53-immunoreactive protein was found at 12 hours after reperfusion and subsequently declined. No wild-type p53 protein expression was detected after ischemia. A time-dependent expression of p53 mRNA was observed in both hemispheres. The peak level of p53 mRNA occurred at 24 hours after reperfusion.

CONCLUSIONS

Our data indicate that the expressions of p53-immunoreactive protein and p53 mRNA are upregulated after transient focal cerebral ischemic insult in rats. The concomitant appearance of p53 and cell damage in ischemic brain suggests that p53 expression may impact cell biological response to an ischemic insult.

Chemokine expression in trinitrochlorobenzene-mediated contact hypersensitivity

The expression of the murine IP-10 and MCP-1 genes has been examined in the skin of mice during contact hypersensitivity reactions to the hapten trinitrochlorobenezene (TNCB). In both naive and passively sensitized animals, challenge with TNCB resulted in elevated expression of both genes as early as 4 h as detected by Northern hybridization analysis. Twenty-four hours after challenge, expression was markedly reduced in naive animals but remained elevated in sensitized animals. This prolonged expression of chemokine gene products correlates with the tissue swelling response generally used as a measure of delayed-type hypersensitivity (DTH) in this model and suggests that the continued expression of these genes results from the stimulation of hapten-specific T helper cells. Examination of cell type expression patterns by in situ hybridization using 3H-radiolabeled riboprobes confirmed the results of Northern hybridization experiments. Both genes were expressed predominantly in cells exhibiting the morphology of connective tissue fibroblasts, although the distribution of cells positive for IP-10 mRNA expression differed from that of cells expressing MCP-1 mRNA. IP-10 expression was localized almost exclusively to a population of connective tissue cells surrounding the fur follicle. MCP-1 expression was rarely found associated with fur follicles but instead was distributed throughout the dermis in cells embedded in the collagenous extracellular matrix. Surprisingly, neither endothelial cells lining the small vessels located deep within the dermis nor epidermal keratinocytes were positive under any of the conditions utilized in the present study. Expression of both IP-10 and MCP-1 has been previously reported in a variety of distinct cell types in vitro. The present results indicate that only a subset of the cell types with such potential are stimulated to express these chemokine genes in vivo during hapten-mediated DTH responses, implying the presence of subtle cell type- and tissue-specific control mechanisms.

Immunomodulation by adriamycin - effect on the production of cytotoxic and inflammatory antitumor immune-responses

We have recently demonstrated in a mouse renal adenocarcinoma tumor system that the antitumor effect of adriamycin (ADM) in combination with interleukin-2 (IL2) is superior to treatment with either ADM or IL2 alone. Based on this observation we postulated that modulation of host's immune competence by ADM and/or IL2 may be partly responsible for the antitumor effects of the combination treatment. Indeed, pretreatment with ADM was found to potentiate the production of both cytotoxic and non-cytotoxic immune responses. A single dose of ADM significantly increased the number of nucleated cells in the spleen in a time related fashion. A small but selective increase in CD4+ cells without an apparent change in CD8+ subset of T cells was observed following treatment with ADM. ADM potentiated augmentation of NK activity by IL2, but had no effect on the production of lymphokine activated killer (LAK) cells by IL2. In contrast, treatment with a combination of ADM and IL2 resulted in increased LAK activity and the frequency of LAK-precursors in the spleen. ADM also enhanced the development of tumor specific inflammatory delayed hypersensitivity (DH) response. Mice expressing tumor specific DH were resistant to rechallenge with viable tumor cells and their spleen cells inhibited the tumor growth in a local adoptive transfer assay. Thus, antitumor effects of combined ADM/IL2 treatment may in part involve augmented production of cytotoxic and T cell-mediated inflammatory antitumor immune responses.

Restricted replication of vesicular stomatitis virus in T lymphocytes is coincident with a deficiency in a cellular protein kinase required for viral transcription

Vesicular stomatitis virus (VSV) fails to replicate in mouse T lymphocytes unless the cells have been mitogenically stimulated with concanavalin A (Con A). We have examined the possibility that the failure of VSV to replicate in unstimulated T lymphocytes can be attributed to a deficiency in a host protein kinase which activates the viral P protein by phosphorylation, thus rendering it transcriptionally competent. Soluble extracts were prepared from purified mouse T lymphocytes, with or without prior treatment with Con A. The ability of these extracts to phosphorylate bacterially synthesized P protein of two VSV serotypes was measured in vitro. Activity of the protein kinase on the P proteins of the Indiana or New Jersey serotypes of VSV increased, on average 2.4- and 2.1-fold respectively, after treatment of the cells with 3 micrograms/ml Con A. Higher concentrations of Con A induced proportional increases (up to 10-fold) in the activity of the host protein kinase. Activities of the kinase phosphorylating the P protein in separate populations of CD4- and CD8-containing murine T lymphocytes increased similarly on mitogenic activation. No biochemical or immunological differences were observed between the T cell protein kinase and the previously characterized protein kinase (casein kinase II) from BHK-21 cells. The activity of the kinase that phosphorylates the P protein did not vary in CV-1 cells on treatment with alpha- or gamma-interferon, both of which inhibited VSV replication. Similarly, casein kinase II activities in Raji and SIRC cells, which do not normally support VSV growth, were the same as in BHK-21 cells. Thus restriction of VSV replication in these cells, in contrast to T lymphocytes, was not associated with a deficiency in the host casein kinase II activity.

Family environment of psychiatric patients : study of a north Indian sample

The study aimed at finding out the relationship of family environment to schizophrenia, affective disorders and neurosis in comparison to control group matched on socio-economic status in a North Indian Sample. 600 subjects-150 schizophrenic patients, 150 patients with affective disorders, 150 neurotics, diagnosed according to ICD-9, were studied. Results (one way ANOVA) revealed that there exists a significant difference in family environment of three categories of patients with psychiatric disorders as well as in comparison to control group. Significantly low scores of cohesiveness, independence, expressiveness, active-recreational orientation and organization, control and moral religious emphasis were found in schizophrenics. Similarly in the families of patients with affective disorders there were less cohesion and control and more expressiveness, conflict, independence and moralrelegious emphasis, while the family of neurotics had low levels of cohesion, intellectual-cultural orientation, active-recreational orientation, organisation and control.

General practitioners' attitude towards psychiatric disorders and psychiatric patients: a survey of jaipur city

A survey of 40 randomly selected general practitioners was carried out to find out their attitudes towards psychiatric disorders and psychiatric patients by administering a specially designed proforma which recorded sociodemographic characteristics as well as attitudes. Majority of GPs were of the opinion that psychiatric disorders are inherited, can occur in any normal person living under stress, are treatable. They had positive attitude towards psychiatric illness but showed more social distance with mentally ill-person. Results are discussed and their implications are highlighted.

IL-4 suppresses cytokine gene expression induced by IFN-gamma and/or IL-2 in murine peritoneal macrophages

The effect of IL-4 on inflammatory gene expression in murine peritoneal macrophages stimulated with IFN-gamma in combination with IL-2 has been examined. These agents cooperatively induce the expression of mRNA for TNF-alpha and IP-10. Murine rIL-4 suppresses cytokine mRNA expression depending on the stimulus used and the mRNA being measured. Expression of TNF-alpha mRNA in macrophages stimulated with IFN-gamma, IL-2, or the combination is markedly suppressed by IL-4 whereas LPS-induced TNF-alpha mRNA is unaffected. In contrast, IP-10 mRNA expression is more sensitive to suppression by IL-4 when stimulated by LPS than by IFN-gamma/IL-2. IL-4-mediated suppression does not alter the time course of mRNA expression. Treatment of IFN-gamma/IL-2-stimulated macrophages with cycloheximide blocks the suppressive effect of IL-4, suggesting that de novo synthesis of an intermediate protein is part of the suppressive mechanism. The IL-4-mediated suppression of IFN-gamma/IL-2-driven TNF-alpha gene expression appears to be mediated at the level of transcription. These findings support a role for IL-4 as an antiinflammatory cytokine and suggest that macrophage inflammatory function will be dependent on the precise stimulus composition of the tissue microenvironment.

IL-4 suppresses cytokine gene expression induced by IFN-gamma and/or IL-2 in murine peritoneal macrophages

The effect of IL-4 on inflammatory gene expression in murine peritoneal macrophages stimulated with IFN-gamma in combination with IL-2 has been examined. These agents cooperatively induce the expression of mRNA for TNF-alpha and IP-10. Murine rIL-4 suppresses cytokine mRNA expression depending on the stimulus used and the mRNA being measured. Expression of TNF-alpha mRNA in macrophages stimulated with IFN-gamma, IL-2, or the combination is markedly suppressed by IL-4 whereas LPS-induced TNF-alpha mRNA is unaffected. In contrast, IP-10 mRNA expression is more sensitive to suppression by IL-4 when stimulated by LPS than by IFN-gamma/IL-2. IL-4-mediated suppression does not alter the time course of mRNA expression. Treatment of IFN-gamma/IL-2-stimulated macrophages with cycloheximide blocks the suppressive effect of IL-4, suggesting that de novo synthesis of an intermediate protein is part of the suppressive mechanism. The IL-4-mediated suppression of IFN-gamma/IL-2-driven TNF-alpha gene expression appears to be mediated at the level of transcription. These findings support a role for IL-4 as an antiinflammatory cytokine and suggest that macrophage inflammatory function will be dependent on the precise stimulus composition of the tissue microenvironment.

Phase I trial of continuous infusion interleukin-2 and doxorubicin in patients with refractory malignancies

A phase I trial was performed to assess the immunomodulatory activities, maximum tolerated doses, and the toxicity of recombinant interleukin-2 (rIL-2) administered in combination with doxorubicin to patients with refractory malignancies. Therapy was administered to successive cohorts of four to six patients who were treated at three different dose levels (1A, 1B, 2A). Levels 1-2 refer to doxorubicin (40 or 60 mg/m2) given as an intravenous (i.v.) bolus on day 1, and levels A-B refer to rIL-2 (1.0 or 3.0 x 10(6) U/m2) given as a continuous i.v. infusion on days 2-5, 9-12, and 16-19. Cycles were repeated every 28 days. Seventeen patients were entered in the trial. Dose limiting toxicity consisted of neutropenia, and the maximum tolerated dose (MTD) of the combination was doxorubicin 40 mg/m2 and rIL-2 3.0 x 10(6) U/m2. No objective responses were observed. Lymphocytosis related to rIL-2 occurred and flow cytometry demonstrated significant increases in the following subsets: CD3+CD25+HLADr+ and CD11b-CD16c+CD8-. Natural killer cell activity and lymphokine-activated killer (LAK) cell precursors were increased in patients treated at dose levels 1A and 1B (40 mg/m2 doxorubicin), but no consistent changes in LAK activity were noted. No clinical responses were seen and the overall toxicity of this combination was moderate to severe. Administration of doxorubicin prior to rIL-2 does not enhance the immunologic effects of rIL-2.

Glycosylated hemoglobin and diabetic retinopathy

Estimation of glycosylated hemoglobin (HbA1c) levels by modified Fluckinger and Winterhalter's method was done in 25 normal persons, 25 diabetic patients without retinopathy, and 25 diabetic patients with retinopathy. The HbA1c values were significantly higher in diabetic patients with or without retinopathy than in the control group (P less than .001). In diabetic patients with retinopathy, the mean value of HbA1c was higher in proliferative retinopathy than in background retinopathy, but statistical analysis showed this was not significant (P greater than .6).

A study of impact of stressful life-events in neurotic patients

Stressful life events preceding neurotic disorders, their impact on neurotic patients in comparison to normal subjects and relationship of impact of stressful life-events to depression and anxiety scores were studied prospectively in 100 consecutive neurotic patients, diagnosed according to ICD-9 and 100 matched normal subjects in psychiatric O.P.D. of S.M.S. Hospital, Jaipur, by administering presumptive stressful life event scale, Beck's depression inventory and Max Hamilton anxiety rating scale. It was found that number of stressful life events was higher in neurotic patients and their impact was also perceived significantly higher in them. Significantly higher depression and anxiety scores had positive corelation to number and impact of stressful life events in-neurotic patients. Cause and effect relationship of impact of stressful life events to neuroses has been discussed.

Communicating with cancer patients

In a prospective study, 100 cancer patients and their relatives were separately interviewed using a structured interview to examine whether the diagnosis of cancer should be communicated to patients and relatives; the reasons for doing so or not, the emotional reactions of patients and families; any change in the attitude of relatives; behaviour of patients and patient's expectation, on diagnosis, of the course of their illness. The majority of patients, who knew their diagnosis (71%), wanted to be told the truth. The majority of relatives wanted to know the truth themselves (81%) without the patients being told (77%). Patients did show immediate emotional reactions like anxiety and dejection, however they appeared to accept the diagnosis. Findings suggest that in an Indian setting the attitude of family members is more positive. The role played by sociocultural factors in the acceptance of the truth is discussed.