The hepatocyte growth factor/scatter factor (HGF/SF) receptor, met, transduces a morphogenetic signal in renal glomerular fibromuscular mesangial cells

Previous studies have demonstrated that hepatocyte growth factor/scatter factor (HGF/SF) is secreted by mesenchymal cells and that it elicits motility, morphogenesis and proliferation of epithelia expressing the met receptor. We now report that HGF/SF may act as an autocrine factor in fibromuscular renal mesangial cells. These cells mechanically support glomerular endothelia, control the rate of plasma ultrafiltration and are implicated in the pathogenesis of a variety of chronic renal diseases. We detected met protein in the vascular stalk of metanephric glomeruli and in the mature mesangium. Mesangial lines from a mouse transgenic for a temperature-sensitive simian virus 40 T antigen expressed met mRNA and protein, and recombinant HGF/SF phosphorylated the met receptor tyrosine kinase. Cells were immortal in the permissive condition and HGF/SF enhanced proliferation in a defined medium. In the absence of the immortalising protein, division ceased and recombinant HGF/SF caused multipolar cells to become bipolar. The factor diminished stress fibres, their focal contacts and immunostaining for extracellular fibronectin, hence suggesting reduced substratum adhesion and enhanced motility. Mesangial lines also expressed HGF/SF mRNA and secreted bioactive factor; immunocytochemistry showed both ligand and receptor in individual cells. HGF/SF blocking antibody aggregated the cells, suggesting that mesangial-derived factor affects basal cell conformation in an autocrine manner. We conclude that mesangial cells express both HGF/SF and met, and the factor induces morphogenesis of cultured mesangial cells. Therefore HGF/SF may have an autocrine role in mesangial biology but further studies are now required to investigate the potential importance of the factor in vivo.

Effect of topical hyaluronic acid on experimental cholesteatoma

PURPOSE

Inflammation and connective tissue hyperplasia are believed to be important etiological factors in cholesteatoma pathogenesis. Previous work has shown that topically applied hyaluronic acid can reduce connective tissue proliferation in healing wounds and accelerate healing of tympanic membrane perforations. This study was undertaken to determine whether the antiproliferative effect of hyaluronic acid may inhibit propylene glycol-induced cholesteatoma in an animal model.

MATERIALS AND METHODS

A 60% propylene glycol solution was injected bilaterally into the middle ear cavities of 20 adult chinchillas. The control group (N = 10) received propylene glycol alone. In addition to propylene glycol injections, the experimental group (N = 10) received repeated bilateral topical applications of 1.5% hyaluronic acid onto the tympanic membranes. Animals were killed at 4 weeks for gross and light microscopic examination.

RESULTS

Seven control and 10 experimental animals survived the full 1-month study period. At the end of that time, cholesteatoma was found in 71% (10/14) of control ears and 70% (14/20) of experimental ears. Tympanic membrane structure did not differ significantly between groups by light microscopy and, in all animals, cholesteatomas originated by migration of hyperplastic epidermis through the tympanic membrane, as has been observed in previous studies using this animal model.

CONCLUSION

Under the conditions of this study, topical hyaluronic acid had no significant effect on cholesteatoma formation.

Colonic strictures in children with cystic fibrosis

PURPOSE

To determine the radiographic, clinical, surgical, and histologic findings in children with cystic fibrosis who develop strictures of the colon.

MATERIALS AND METHODS

Ten children (five boys, five girls; age range, 2.5-9.0 years; mean age, 5.5 years), who were treated at the practices of the authors, were retrospectively identified and their medical records reviewed.

RESULTS

Radiographic manifestations of the colonic disease included mucosal irregularity and spiculation with nodular thickening of the colonic wall and loss of normal colonic haustration. Luminal narrowing involved long segments of the colon. Longitudinal shortening of the colon was also a prominent feature. The decrease in caliber of the bowel ranged from mild narrowing to complete occlusion of the lumen. Histologic examination revealed severe submucosal fibrosis and fatty infiltration with transmural extension of the fibrosis to involve the serosa in some cases. Unlike in Crohn disease, however, acute inflammatory changes were minimal or absent.

CONCLUSION

Colonic stricture in children with cystic fibrosis is due to irreversible and frequently progressive narrowing of the colonic lumen.

Effectiveness of an inpatient geriatric service in a university hospital

OBJECTIVE

To assess the effectiveness of an acute interdisciplinary inpatient geriatric service in a university hospital.

DESIGN

Prospective randomized control study.

SETTING

Large urban university hospital.

PATIENTS

40 consecutive inpatients, randomized for inclusion on the geriatric service (study patients, n = 20) or to continue usual hospital care (control patients, n = 20) from among the geriatric consult population.

MAIN OUTCOME MEASURES

Subjects were followed for changes in length of stay, hospital costs, diagnostic testing, pharmacy use, functional status, discharge disposition, and readmission within 30 days after hospitalization.

RESULTS

Mean age of patients study 79.2 years (control 73.9 years). Sixty percent of study patients went home and 30% to nursing homes (control 20% home, 65% nursing homes) P = .03. Total length of stay mean 20.3 days study (control 32.7 days), length of stay after randomization mean 7.7 days study (control 11.2 days), mean overall hospital costs $23,906 study (control $45,189), and mean hospital costs after randomization study $4,671 (control $9,404) were not significantly different by F-tests due to wide variability. Laboratory use was reduced with mean 4.4 tests study (control 16.9) P = .01 and mean laboratory costs $263 study (control $828) P = .02. Functional ability improved (scale 1-7) with mean improvement study 0.8 (control 0.3) P = .09. Mean number of medications were lower in the study group by 30% P = .02; mean cost of medications at discharge was reduced with study $38 (control $112); and mean pharmacy charges after randomization decreased $462 study (control $1,268) P = .06. Readmission 30 days after discharge was not significantly different (study 21%, control 33%).

CONCLUSIONS

An interdisciplinary acute geriatric service can be cost effective in providing care to elderly patients in a university hospital. It can improve outcomes measured by decreased laboratory and pharmacy usage, improved functional status, and discharge to a lesser level of care without increasing length of stay or early readmission after discharge.

Left mainstem intubation with digital intubation technique: an unrecognized risk

To determine whether digital endotracheal intubation predisposes to left mainstem intubation, a prospective, convenience sample of postarrest cadavers in the emergency departments of two university medical centers was used. Six postarrest cadavers were reintubated by the same right-handed intubator using accepted digital intubation technique. Endotracheal tubes (7.5 mm internal diameter) with stylets were configured into an open "J" shape and were inserted to a depth of 30 cm to ensure endobronchial intubation. A portable anteroposterior chest radiograph documented whether the left or right bronchus was intubated. In four of the six cadavers, the endotracheal tube was inserted into the left mainstem bronchus. This represents a greater than 150-fold increase in the rate of left mainstem intubations relative to right mainstem intubations when compared with data from the literature. Digital intubation technique predisposes to left mainstem intubation. Practitioners must have heightened awareness that decreased right-sided breath sounds after digital intubation may represent an easily corrected left mainstem intubation rather than other pathology.

Human resource management in patient-centered pharmaceutical care

Patient-centered care may have the pharmacists and technicians reporting either directly or in a matrix to other than pharmacy administration. The pharmacy administrative people will need to be both effective leaders and managers utilizing excellent human resource management skills. Significant creativity and innovation will be needed for transition from departmental-based services to patient care team services. Changes in the traditional methods of recruiting, interviewing, hiring, training, developing, inspiring, evaluating, and disciplining are required in this new environment.

The use of acetone to dissolve a Styrofoam impaction of the ear

Foreign bodies in the ear occasionally thwart conventional means of removal. Styrofoam can be particularly problematic because it can be compressed and become tightly impacted in an ear canal. Furthermore, Styrofoam is friable and tends to fragment with usual removal methods. We report the case of a 6-year-old girl who was referred from another tertiary care hospital after failed efforts to remove a painfully impacted piece of Styrofoam from her left ear canal. Instillation of the organic solvent acetone into the ear canal was well tolerated and caused rapid and near-complete dissolution of the Styrofoam impaction. This is the first reported case of organic solvent dissolution of an otic foreign body. Ototoxic considerations are discussed as is a method for safe acetone instillation that minimizes the amount of acetone introduced into the ear canal.

Imaging of human brain activity at 0.15 T using fluid attenuated inversion recovery (FLAIR) pulse sequences

A 3-4% change in signal intensity correlated with visual stimulation was observed in the occipital lobes of three normal volunteers examined with MRI at 0.15 T using fluid attenuated inversion recovery pulse sequences. Similar results were observed at 1.0 T. A double difference technique in which difference images are themselves opposed provided an increase in sensitivity.

Pharmacists' perceptions and practices regarding the purchase of multisource pharmaceuticals

This article describes the results of a survey of the perceptions and practices of pharmacists towards the purchase of multisource pharmaceuticals. A questionnaire was mailed to 1,000 randomly selected hospital pharmacists, 670 managed-care pharmacy directors, and 900 consultant pharmacists in June, 1991. Recipients were asked to provide educational background data, information on pertinent aspects of their work setting, and responses to a variety of questions about multisource pharmaceuticals. Of the 2,570 surveys mailed, 531 (20.7%) usable responses were received. Although not completely satisfied, pharmacists perceive the quality of multisource products to be better than 2 years ago. A variety of factors were found to influence purchasing decisions. Differences among the three groups were evident in several areas including: the importance of purchasing groups, institutional criteria, and patient preference. Overall, pharmacists made their decisions based on a number of issues, and attitudes among the three groups regarding the purchase of multisource products were quite similar.

Comparison of intravenous contrast agents for CT studies in children

One hundred and eighty children undergoing CT examination were randomly allocated to receive meglumine diatrizoate, iohexol, or iopamidol as their i.v. contrast agent. Minor side effects were detected in 85% of children receiving meglumine diatrizoate, in 18% of those receiving iohexol, and in 36% of those receiving iopamidol. Because many of these minor side effects cause patient motion or delay scanning after contrast medium injection, they potentially degrade image quality. These findings are an indication for the use of low osmolarity contrast agents for i.v. use in pediatric CT imaging.

Use of fluid-attenuated inversion-recovery pulse sequences for imaging the spinal cord

Fourteen patients with disease of the spinal cord were imaged with fluid-attenuated inversion-recovery (FLAIR) sequences in which the inversion time was chosen to substantially reduce or null the signal from CSF. Lesions were seen with greater conspicuity than with conventional contrast-enhanced and -unenhanced T1- and T2-weighted sequences in 11 cases.

Assignment of a gene (NEMI) for autosomal dominant nemaline myopathy to chromosome I

Nemaline myopathy (NEM) is a neuromuscular disorder characterized by the presence, in skeletal muscle, of nemaline rods composed at least in part of alpha-actinin. A candidate gene and linkage approach was used to localize the gene (NEM1) for an autosomal dominant form (MIM 161800) in one large kindred with 10 living affected family members. Markers on chromosome 19 that were linked to the central core disease gene, a marker at the complement 3 locus, and a marker on chromosome 1 at the alpha-actinin locus exclude these three candidate genes. The family was fully informative for APOA2, which is localized to 1q21-q23. NEM1 was assigned to chromosome 1 by close linkage for APOA2, which is localized to 1q21-q23. NEM1 was assigned to chromosome 1 by close linkage to APOA2, with a lod score of 3.8 at a recombination fraction of 0. Recombinants with NGFB (1p13) and AT3 (1q23-25.1) indicate that NEM1 lies between 1p13 and 1q25.1. In total, 47 loci were investigated on chromosomes 1, 2, 4, 5, 7-11, 14, 16, 17, and 19, with no indications of significant linkage other than to markers on chromosome 1.

MR of the brain using fluid-attenuated inversion recovery (FLAIR) pulse sequences

PURPOSE

Results from conventional T2-weighted spin-echo sequences were compared with those obtained using fluid attenuated inversion recovery (FLAIR) pulse sequences in order to assess their relative merits in detecting disease.

METHODS

Forty adult patients with suspected disease of the brain were examined with spin-echo sequences (TE = 20 and TE = 80), and results were compared with FLAIR sequences of several types with inversion times of 1800-3000 msec and echo times of 130-240 msec. Scans were assessed by two radiologists for lesion number, conspicuity, and extent.

RESULTS

A total of 48 lesions or groups of lesions were recognized with both sequences. In 22 instances, more lesions were seen with FLAIR sequences, and, in the remaining 26, equal numbers were seen. In 42 lesions, conspicuity was better with FLAIR sequences, equal in five and worse in one cystic lesion. Lesion extent was better assessed in 28 of the 48 cases with FLAIR sequences and equally well seen in the remainder.

CONCLUSION

By virtue of their long echo time and relative freedom from cerebrospinal fluid artifact FLAIR sequences provide high sensitivity to a wide range of disease. The basic sequence is easy to implement but is relatively time consuming.

Digital imaging with a photostimulable phosphor in the chest of newborns

To evaluate use of a digital photostimulable phosphor imaging system in the neonatal nursery, 150 newborns were divided into three groups of 50. In the first two groups, screen-film and computed radiographs of the chest were obtained at the same radiation exposure; in the third group, computed radiographs were obtained with a 50% dose reduction (half-exposure computed radiographs). All images were blindly evaluated by three readers who scored the quality of visualization of the mediastinum, lung, bone, soft tissues, and endotracheal and nasogastric tubes, and also image density. No statistical differences in visualization of tubes existed among the three groups. Visualization of the mediastinum, lung, bones, and soft tissues was statistically significantly better on computed radiographs than on half-exposure computed radiographs; visualization of the lungs, bones, and soft tissues was statistically significantly better on screen-film radiographs than half-exposure computed radiographs. Image density was statistically better on computed and half-exposure computed radiographs than on screen-film radiographs.

A comparison of field techniques used to pressure-infuse intravenous fluids

Application of pressure infusion bags may increase intravenous (IV) flow rates three-fold. Commercially available pressure infusers, manual squeezing of the IV fluid bag, inflating a blood pressure (BP) cuff around the bag, and kneeling on the bag have been used by prehospital personnel attempting to augment fluid infusion rates. To test the efficacy of each these methods, seven experienced paramedics were asked to employ each method in two trials using a 1-liter bag of saline through a 14-gauge, 5.7cm catheter and a standard administration set. Gravity flow from 80 cm served as the control. Pressure infusers generated flow rates of 257+/-54 ml/min and 296+/-53 ml/min when inflated to 300 mmHg and maximum pressure respectively. This rate was 2-2.5 times that of gravity flow (123+/-2 ml/min) and significantly greater than those rates obtained by any other method (p less than .0005). Manually squeezing the bag also was significantly better than was gravity flow with flow rates of 184+/-46 ml/min and 173+/-40 ml/min achieved by each of two different squeezing methods (p less than .01). Neither blood pressure (BP) cuff application and inflation (135+/-28 ml/min) nor kneeling on the bag (125+/-36 ml/min) was better than gravity alone. These results indicate that pressure infusers should be used to the exclusion of other field methods of supplying infusion pressure. If pressure infusers are not available, manually squeezing the bag is the only alternative acceptable in the field.

Predictive diagnosis of myotonic dystrophy with flanking microsatellite markers

Linkage was shown between the myotonic dystrophy locus (DM) and a highly polymorphic AC repeat marker within the kallikrein (KLK1) locus (Z = 3.00, theta = 0.0). Linkage between KLK1 and the highly polymorphic AC repeat marker within the apolipoprotein C2 (APOC2) locus, which had been established in normal families, was confirmed in myotonic dystrophy families (Z = 4.37, theta = 0.11). These highly polymorphic AC repeat markers flank DM on chromosome 19. The gene order is cen-APOC2 (0.03) DM (0.08) KLK1-qter with recombination frequencies shown in parentheses. Genotypes for the AC repeat markers can be determined simultaneously by multiplex PCR and separation of the two base pair differences between adjacent alleles on sequencing gels. In informative families, this approach provides rapid diagnosis and is more accurate than methods using markers restricted to the proximal side of the myotonic dystrophy gene.

Comparison of iohexol with barium in gastrointestinal studies of infants and children

This study evaluates iohexol as a contrast agent in the gastrointestinal tract in children. In the first part of the study, iohexol in concentrations of 180 and 300 mg l/ml was compared in double-blind manner with barium. Sixty-four patients were studied. No significant difference in changes of blood pressure and pulse rate was found between the three groups of patients studied. Diarrhea was significantly more common in the children receiving iohexol than in children receiving barium. The diarrhea was not due to previously identified high-risk factors in the children, nor was it due to concurrent medication. When image quality was assessed in each anatomic region of the gastrointestinal tract, fewer nondiagnostic ratings occurred with barium than with iohexol. With barium, fewer ratings of poor mucosal coating and slightly fewer ratings of suboptimal contrast density occurred. The second part of the study was an open evaluation of iohexol 180 mg l/ml in 18 patients in whom barium was clinically contraindicated. Three of 53 assessments were nondiagnostic. Mucosal coating was poor in 6%, and contrast density was suboptimal in 8% of patients. The results of this study indicate that barium is the preferred contrast agent for routine evaluation of the gastrointestinal tract in children. Good-quality images can be obtained, however, with iohexol in concentrations of 180 or 300 mg l/ml, and iohexol is an excellent contrast agent for evaluation of the gastrointestinal tract in those patients in whom barium is relatively or absolutely contraindicated.

Growth plate injury of the hand and wrist in renal osteodystrophy

We present two cases of growth plate injury of the hand and wrist in young patients with renal rickets and osteodystrophy but no history of antecedent trauma. The postulated mechanism of injury is subclinical biomechanical stress on the involved extremity superimposed on the already weakened metaphysis and growth plate. Thus, the findings may be viewed as an insufficiency injury to the metaphysis and growth plate. Physicians should be aware that, in the absence of unusual athletic activity, epiphysiolysis of the upper extremity is uncommon and requires a search for underlying metabolic bone disease.

The effect of loop diuretics on fluid reabsorption from the rat proximal convoluted tubule

The effects of the 'loop diuretics' bumetanide, furosemide and piretanide on fluid reabsorption from the rat proximal convoluted tubule have been tested to assess whether a Na(+)-Cl- cotransport mechanism can support fluid reabsorption from this nephron segment. Proximal convoluted tubules were perfused in vivo at 25 nl min-1 with chloride Ringer solutions containing [3H]inulin. Fluid reabsorptive rate (Jv) was 2.05 +/- 0.07 nl mm-1 min-1 (n = 115) from control chloride Ringer. Bumetanide at 10(-6) and 10(-5) M reduced Jv by about 40%. Bumetanide at 10(-7) M, furosemide (10(-4) and 10(-5) M) and piretanide (10(-4) and 10(-5) M) had no effect on Jv. At 10(-3) M, furosemide and piretanide reduced Jv by about 45%. The results show that luminal application of loop diuretics lowers fluid reabsorption from the proximal convoluted tubule and the order of potency for inhibiting reabsorption is bumetanide greater than furosemide identical to piretanide. The specificity of the loop diuretics at their effective concentrations needs to be confirmed, however, before attribution of a role for Na(+)-Cl- co-transport in the support of proximal tubule fluid reabsorption.

Congenital biliary dilatation: a spectrum of disease detailed by ultrasound

Recently we have examined six children with the diagnosis of choledochal cyst who demonstrate a greater spectrum of biliary involvement than expected. Classically choledochal cysts have been divided into types and subtypes based on the configuration of common bile duct dilatation; however, this simplified information is misleading since surgical management is dependent on the exact extent of intrahepatic and extrahepatic biliary abnormalities. The pre-operative ultrasound examination must be meticulous to provide enough pertinent anatomic details. Much of the intrahepatic anatomy is not visualized at surgery nor on the operative cholangiograms where reflux of contrast into the intrahepatic ducts may not be consistently achieved.

Accuracy and time requirements of a bar-code inventory system for controlled substances

The effect of a bar-code system on personnel time requirements and data-entry accuracy in an existing automated controlled substances inventory system was determined. In the previous system, technicians used a keyboard and alphanumeric codes to enter into the computer data about the physical transfer of controlled substances among hospital areas. A system for barcode data entry was adapted for use with the existing procedure. After learning to use the bar-code system, four experienced technicians entered data by the keyboard method for eight days and the bar-code method for eight days during a 32-day study period. The amount of time required to enter all transactions and the accuracy of data entry were measured. Mean data-entry times for the keyboard and bar-code methods were not significantly different, most likely because of the greater number of manipulations needed for bar-code data entry. The mean percentage error associated with the bar-code method (0.79%) was significantly less than the error associated with the keyboard method (1.53%). For this particular computer system in which bar-code data entry was adapted to existing procedures, use of bar codes to enter controlled substances inventory data was not substantially faster but was more accurate than a traditional key-board data-entry method.

Establishing an outcome-based quality assurance program in a pharmaceutical production services area

The development and implementation of a Quality Assurance (Q.A.) program based on desired outcomes for a Pharmaceutical Production Services area is discussed. The article describes the determination of desired outcomes and how to put the criteria into a workable audit format. A sample audit, along with actual results obtained, illustrate the kinds of problems that can be found and corrected with this format. Calculations for determining percent compliance values, which can be summarized for quarterly hospital Q.A. reports, are also discussed. During the five months the program has been in use it has proven to be an effective method of ensuring the dispensing of high quality pharmaceuticals.

Evaluation of a dual-screen, dual-emulsion mammography system

We compared a new dual-screen, dual-emulsion film system for X-ray mammography with a widely used single-screen, single-emulsion combination for routine contact mammography in 100 patients with a variety of mammographic findings. By using a five-point rating scale (1 = poor, 5 = excellent), four blinded readers found the conventional combination superior in density (by 0.46 points on the rating scale), resolution (by 0.64 points), contrast (by 0.46 points), visibility of calcification (by 0.50 points), visibility of soft-tissue masses (by 0.37 points), and overall quality (by 0.47 points). No difference was seen in the graininess of the films. In our study, the conventional system was consistently found to be slightly better than the dual-screen, dual-emulsion combination. The dual-emulsion mammograms required more careful scrutiny, particularly for detection of faint microcalcifications.

Survey of pharmacy directors' experience with staff vacancies and recruitment

Hospital pharmacy directors were surveyed in September 1987 about staff pharmacist turnover, recruitment, and retention. Questionnaires were mailed to pharmacy directors at 541 hospitals in the United States. Three hundred thirty-nine questionnaires were returned (62.7% usable response rate); more than 50% of the questionnaires sent to each geographic region were completed. Only 129 respondents reported difficulty filling vacant staff pharmacist positions within the past 12 months, although 320 believed there is a pharmacist shortage. Seventy-eight reported having positions that remained unfilled for three to six months. For more than 90% of the vacant positions, two-thirds of the duties were in drug distribution. Five hundred thirty-three pharmacists were reported to have left their positions in the past 12 months; the directors said salary and working hours were the reasons most often given, and that 47.5% left to work at other hospitals and 13.1% at chain community pharmacies. National advertisements and the use of professional recruitment agencies were the recruitment methods most frequently mentioned, and salary increases, recognition through feedback from management, and participation in management decisions were the methods most commonly mentioned for retaining pharmacists. Salary was the most frequently reported reason for hospital pharmacist turnover, and nearly half of the pharmacists leaving their positions went to other hospitals.

The effect of DIDS on fluid reabsorption from the proximal convoluted tubule of the rat: dependence on the presence of bicarbonate

The effects of the anion transport inhibitor DIDS (4,4'-diisothiocyano-stilbene-2,2'-disulphonate) on fluid reabsorption by the rat proximal convoluted tubule were investigated by the stationary microperfusion (split-drop) method. Addition of 10(-5) mol 1-1 DIDS to luminal and capillary perfusates in the presence of peritubular bicarbonate (25 mmol 1-1) increased the reabsorptive half-time (t 1/2) from 35.1 +/- 4.5 to 57.0 +/- 6.2 s, corresponding to a decrease in fluid reabsorption (Jv) from 1.33 +/- 0.06 to 0.89 +/- 0.09 nl min-1 mm-1. Omission of bicarbonate per se from the peritubular capillaries reduced Jv to 0.41 +/- 0.03 nl min-1 mm-1 and this reabsorptive flux was completely inhibited by the addition of 2 mmol 1-1 NaCN to both the luminal and peritubular perfusates. In the absence of bicarbonate, the addition of DIDS at either 10(-4) or 10(-5) mol 1-1 to both lumen and capillary perfusates had no significant effect on either t 1/2 or Jv. These results show that the inhibitory action of DIDS on fluid reabsorption is dependent on the presence of bicarbonate. However, the proximal tubule also reabsorbs water in the absence of bicarbonate by a mechanism that is dependent on cellular metabolism, but is insensitive to DIDS at the concentrations used in this study.

Evaluation of computer-assisted instruction versus traditional new-employee training

Personnel time and costs associated with computer-assisted instruction (CAI) and traditional "one-on-one" instruction in basic computer drug-order entry procedures were compared. Both programs consisted of an introduction to the training session, familiarization of users with the computer hardware and keyboard, and step-by-step instructions in unit dose and intravenous admixture order-entry procedures. The CAI module was developed by a pharmacist with no prior programming experience. It was designed to be used side-by-side with the actual inpatient pharmacy computer system. Fifth-year pharmacy students in their clinical clerkship rotation served as the study population. The personnel (both subject and pharmacy supervisor) time and costs associated with each method were evaluated for significant differences by a two-tailed Student's t test. Of 21 subjects who participated in this study, 11 received CAI and 10 received traditional instruction. CAI was associated with significantly less mean total personnel time (99.64 +/- 18.78 minutes) than one-on-one instruction (133.60 +/- 22.89 minutes). Mean total salary expense was significantly lower for CAI ($13.03 +/- 2.15) than for one-on-one instruction ($28.79 +/- 4.91). Program development time for the CAI module was 18.5 hours longer than that for the one-on-one program. The CAI module cost $1577.77 more to develop than the one-on-one program; however, 24 new employees would be required to offset development costs if the hardware were already available and 100 new employees if hardware had to be purchased. Computer-assisted instruction of new employees in computer order-entry procedures can be a cost-effective alternative to traditional training methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Paleoradiologic evaluation of the Egyptian royal mummies

We examined radiographs of 12 Egyptian royal mummies obtained by two of the authors (W.R. and J.E.H.) and never before published. These radiographs demonstrate findings not previously described in Egyptian mummies, including congenital lunate-triquetral fusion and destructive skeletal lesions not explainable on the basis of vandalism by tomb robbers. Antemortem fractures, degenerative joint disease, and arterial vascular calcification were also seen. In 11 of the 12 cases, there was chondrocalcinosis of intervertebral discs or menisci, probably an artifact of embalming. Visceral packing and skeletal deformity due to wrapping were observed, as well. Radiology provides important paleopathologic and archeologic information for the accurate, comprehensive study of Egyptian mummies.

A comparison of computer-assisted instruction and printed information as methods of pharmacy continuing education

A continuing education (CE) program was developed to teach hospital pharmacists parameters for monitoring adult total parenteral nutrition (TPN) patients. The effectiveness of a computer-assisted instruction (CAI) module as a method of CE was compared with that of printed information (PI). The computer program was developed using an Apple IIe personal computer and Apple Pilot. Forty-nine hospital pharmacists were given a pretest, the CAI or PI program, a posttest immediately after the instruction, and a retention test 2 weeks later. The CAI group (n = 23) had mean test scores of 53.3% for the pretest, 87.7% for the posttest, and 81.9% for the retention test. The PI group (n = 26) had mean test scores of 54.2% for the pretest, 84.7% for the posttest, and 78.2% for the retention test. Both methods were effective CE programs based on increases in mean test scores from pretest to posttest. Retention-test scores showed a statistically significant drop from posttest scores for each group. A comparison of mean retention-test scores with mean pretest scores for each group demonstrated that participants in each group had retained a statistically significant amount of material from baseline knowledge. When differences in mean pretest, posttest, and retention-test scores were compared between the two groups, no statistically significant differences were found. CAI and PI were equally effective methods of continuing education.

Skeletal abnormalities of acrogeria, a progeroid syndrome

We report the skeletal abnormalities in a 4 1/2-year-old boy with acrogeria, a progeroid syndrome of premature aging of the skin without the involvement of internal organs seen in Hutchinson-Gilford progeria syndrome. Acro-osteolysis of the distal phalanges, delayed cranial suture closure with wormian bones, linear lucent defects of the metaphyses, and antegonial notching of the mandible are the predominant skeletal features of the disorder. The skeletal features described in 21 other reported cases of acrogeria are summarized.

Arthrography in evaluation of birth injuries of the shoulder

Birth injuries of the shoulder and proximal humerus of infants can be difficult to evaluate on plain radiographs because of lack of ossification in the proximal humeral epiphysis. We here describe arthrography of the infant shoulder and advocate it as a useful diagnostic procedure in the evaluation of humeral fractures and brachial palsies. Two infants with birth injuries of the shoulder are described. The value of dynamic fluoroscopic evaluation of the injured joint in conjunction with arthrography is illustrated in evaluation of a brachial plexus palsy.

Periventricular cavitations in the first week of life

Eleven infants were encountered (nine premature, two term) in whom well-defined small periventricular cavitations were found by sonography in the first week of life. The sonographic findings bore remarkable similarity to subependymal pseudocysts in neonates previously described in autopsy specimens. The cavitations, which were identified predominantly along the superolateral aspects of the lateral ventricles, did not evolve in the manner of postnatally acquired periventricular leukomalacia. The location of the cavitations differed from the site of previously reported lesions of posthemorrhagic and postinfectious germinolysis along the medial aspect of the caudothalamic groove. Neurosonologists and neonatologists should be alerted to this finding and encouraged to follow these infants as a separate group to learn whether neurodevelopmental sequelae occur in these children.

Quality assurance: ensuring pharmacy personnel follow procedures for handling cytotoxic drugs

The development of a quality assurance activity for the handling of cytotoxic drugs in a hospital pharmacy department is explained. The exposure of hospital pharmacy personnel to cytotoxic drugs even in small amounts may present a health hazard. A method was developed to periodically evaluate and verify pharmacy staff adherence to procedures for the safe handling of cytotoxic drugs. The program development included the development of checklists to audit IV admixture and satellite clinics, outpatient and pharmacy production area, and pharmacy receiving and storage area. The basis for development of these checklists was the ASHP Technical Assistance Bulletin on Handling Cytotoxic Drugs in the Hospital and OSHA Guidelines.

Dynamic radiographic evaluation of obscure wrist pain in the teenage patient

Chronic wrist pain in the teenage patient constitutes a diagnostic challenge. Carpal instability patterns and internal joint derangements may be difficult to diagnose by physical examination and conventional plain radiographs. Dynamic radiographic studies frequently provide a better understanding of abnormal wrist mechanics. We reviewed our experience with fluoroscopy and radiocarpal arthrography in 14 teenage patients with chronic wrist pain. Videotape fluoroscopy was performed in all 14 patients. Dynamic radiocarpal arthrography was then performed in 10 patients in whom fluoroscopic findings were normal or more information was needed. These imaging methods led to a diagnosis in 64% of the patients and excluded a significant anatomic carpal abnormality in the other patients. In the teenage patient, internal derangements of the intercarpal ligaments are usually posttraumatic rather than attritional in origin. Dynamic radiographic techniques provide an accurate means for the diagnosis of these specific anatomic carpal abnormalities.

Stability of propranolol hydrochloride suspension compounded from tablets

The stability of a propranolol hydrochloride suspension compounded from commercially available tablets was studied. Propranolol hydrochloride 10-mg tablets were triturated to a powder and incorporated into a commercially available suspension vehicle to yield a suspension with a theoretical propranolol hydrochloride concentration of 1 mg/mL. The suspension was divided into portions and stored in amber glass bottles at either room (25 degrees C) or refrigerated (2 degrees C) temperature for four months. The concentration of propranolol hydrochloride in the samples was determined by a stability-indicating, high-performance liquid chromatographic (HPLC) assay at 0, 30, 60, 90, and 120 days. Also at these times, the pH of the samples was measured, and the samples were inspected visually for evidence of microbial growth and ease of resuspension. The concentration of propranolol hydrochloride in the samples remained within 90% of the initial concentration throughout the study period. No important changes in the pH of the samples and no visible evidence of microbial growth were noted. This extemporaneous suspension of propranolol hydrochloride compounded from commercially available tablets is stable for at least four months when stored at room or refrigerated temperature.

Stimulation of fibroblast proliferation and prostaglandin production by purified recombinant murine interleukin 1

Recombinant murine interleukin 1 (IL-1) obtained from a clone of Escherichia coli containing an IL-1 expression plasmid was purified to homogeneity using a sequential extraction procedure and gel filtration chromatography. The purified recombinant IL-1 exhibited a pI of approximately 5.2 and a sp act of 6 X 10(6) units/mg. These values are in agreement with those obtained with natural murine IL-1. The purified recombinant IL-1 enhanced the proliferation of human HEL and WI-38 fibroblasts in a serum-free medium. In addition, IL-1 stimulated fibroblast PGE2 5- to 30-fold over a 24-hr period. The effects of IL-1 on fibroblast activation were obtained with the same concentrations of IL-1 that are effective in the mouse thymocyte assay. These results unequivocally establish the ability of IL-1 to modulate fibroblast proliferation and function.

Stability of 5-aminosalicylic acid suspension

The stability of 5-aminosalicylic acid in a suspension prepared extemporaneously for administration by enema was studied. The suspension was prepared (tragacanth was the suspending agent) and then placed in 3-ounce amber glass prescription bottles; five bottles were stored at room temperature and five were refrigerated for 90 days. Using samples from each bottle, concentrations of 5-aminosalicylic acid were determined in triplicate by high-performance liquid chromatography at 0, 30, 60, and 90 days. Throughout the study period, all samples retained more than 90% of the day 0 concentration of 5-aminosalicylic acid. At each storage time, concentrations in samples stored at either room temperature or under refrigeration were not significantly different. In this extemporaneously prepared suspension, 5-aminosalicylic acid was stable for 90 days at room temperature and under refrigeration.

The radiographic appearance of the endorectal pull-through

Children and young adults with ulcerative colitis and polyposis syndromes requiring colectomy are increasingly undergoing the endorectal pull-through procedure. We reviewed the contrast studies of the neorectum of 27 patients and the abdominal radiographs in 26 patients after the endorectal pull-through operation. Normal features included smooth mucosa with loss of the small bowel features, dilatation of the neo-rectum on consecutive examinations, and an enlarged presacral space. The normal appearance before closure of the ileostomy varied depending upon the amount of distension of the pull-through segment; redundant ileum within the rectal muscle sleeve was seen in the two patients. Abnormalities included rectovaginal fistulas, sinus tracts, focal strictures requiring dilatation, complete obstruction, mucosal irregularities, and generalized narrowing with lack of distensibility. These abnormalities are attributable to inflammation and were associated with a poor clinical outcome. A contrast examination of the pull-through segment is useful to exclude the presence of serious inflammatory change before ileostomy closure or in the patient with excessive diarrhea or obstruction.

Sonography of ruptured appendicitis

Three girls and 4 boys with the final diagnosis of ruptured appendicitis underwent 19 sonographic studies, 5 before any therapy was instituted and 14 follow-up studies. Four abscesses identified before treatment and 2 seen postoperatively were ovoid, irregularly marginated, and contained low-amplitude echoes. Gastrointestinal ileus with gas-and fluid-filled loops of bowel made the studies technically difficult. Follow-up studies also showed fluid collections distant from the original abscesses. The complete resolution of the abscess was followed sonographically in 1 patient treated with antibiotics. Ultrasound can be useful in confirming or suggesting the diagnosis of ruptured appendicitis in the child with abdominal pain, but careful attention to detail is necessary in these technically difficult studies.