Intraperitoneal lignocaine for pain relief after total abdominal hysterectomy

In this preliminary randomized study, we have measured pain scores at rest and on movement, 24 and 48 h after operation in 19 control patients, who received 50 ml of saline i.p., and in 20 test patients, in whom 50 ml of saline solution containing lignocaine 200 mg and adrenaline 1:500,000 were instilled into the peritoneal cavity after total abdominal hysterectomy. We found that there was no difference in linear analogue scores for nausea, pain on movement or morphine consumption after operation between the two groups, but pain scores at rest were significantly lower in the lignocaine group at 24 and 48 h compared with the saline group. In the lignocaine group, blood sampling over a 3-h period revealed a mean maximum serum concentration of 0.4 microgram ml-1 at 3 h and a highest concentration in any patient of 0.87 microgram ml-1.

Management of school leavers given a diphtheria and tetanus vaccine intended for children instead of the intended low dose preparation

In November 1995, 102 school leavers in two North Staffordshire schools were given high dose diphtheria and tetanus vaccine (intended for primary immunisation of children) rather than a preparation with a low dose of diphtheria vaccine intended for adults and adolescents. We describe the management of the incident and the action taken to minimise the risk of such an error being made again. Pupils who had received the high dose vaccine and a control group were surveyed with a self-administered questionnaire. Thirteen children out of 67 given the higher dose diphtheria vaccine consulted their general practitioner and the same number had time off school, compared with none of 25 from a control school. This excess morbidity was probably attributable to the higher dose of diphtheria vaccine.

Density-dependent seasonal dynamics of blacklegged tick (Acari:Ixodidae) nymphs

The midsummer seasonal decline in abundance of unfed Ixodes scapularis Say nymphs on experimental plots in New Jersey was density-dependent. Nymph density was manipulated on 9 plots (10 by 10 m each) in Morristown. National Historical Park, NJ, in early June 1994. Subsequent rates of decline were directly proportional to initial density (linear regression, R2 = 0.83). A 6-fold manipulation of density caused more than a 10-fold increase in per-capita disappearance rate. Absence of density-dependent mortality in simultaneous field cage experiments implicated dispersal at rates higher than reported previously, positive-density-dependent host finding success, or predation, possibly in the form of host grooming. Each of these possibilities has important implications for the role of unfed nymphs in the regulation of I. scapularis populations.

A comparison of the cytology of endomyocardial biopsy washings from heart transplants with biopsy histologic study and peripheral blood lymphocyte counts

Cytospin preparations of endomyocardial biopsy washings were examined on 117 occasions from 13 heart transplant recipients and categorized according to the pattern of cell types observed. Twenty-nine percent of samples were acellular, a further 10% too bloodstained for analysis, and 61% were cellular. Eight lymphocytic samples were found and in all cases there was at least grade 1B rejection (four grade 1B, three grade 2, and one grade 3A) on histologic study. However, histologic study showed at least 1B rejection in 48% of cases when cytospins showed mixed inflammatory cells, 33% of cases when cytospins were histiocytic and in 35% when cytospins were bloodstained or acellular. Furthermore 16 of these rejection episodes with nonlymphocytic cytospins were grade 2. Although the recovery of a lymphocytic cytospin was specific for rejection, the sensitivity of the test was poor. Even when the sample is adequate, this method of biopsy washings will predict only one third of cases of significant acute rejection (grade 2 or worse). The large proportion of unsuitable samples also severely limits the utility of endomyocardial biopsy washings for the diagnosis of rejection. Histiocytic cytospins were seen in 63% of samples when previous biopsy sites were reported on histologic study and also in all three samples when histologic study showed ischemic injury. A mixed inflammatory cell pattern was seen to a lesser extent (31% of samples) in relation to previous biopsy sites. High peripheral blood lymphocyte counts were found when endomyocardial biopsy washings were lymphocytic or mixed inflammatory and also when histologic study showed endocardial lymphocytic infiltration (Quilty effect).

Latex allergy: epidemiological study of 1351 hospital workers

OBJECTIVE

To determine the prevalence of latex sensitisation among a large group of healthcare workers, study the occupational and non-occupational factors associated with latex allergy, and characterise latex exposure in air and by gloves.

METHODS

All 2062 employees of a general hospital in Hamilton, Ontario, Canada who regularly used latex gloves were invited to participate in a cross sectional survey, representing the baseline phase of a prospective cohort morbidity study. Attempts were made to recruit employees who were diagnosed with latex allergy before the survey. Glove extracts were assayed for antigenic protein, and area and personal air samples were obtained on two occasions (summer and winter) to estimate exposure to airborne latex protein. A questionnaire on medical and occupational information was administered by an interviewer. Skin prick tests were performed with latex reagents, three common inhalants, and six foods.

RESULTS

The mean (SD) latex protein concentrations were 324 (227) micrograms/g in powdered surgical gloves and 198 (104) micrograms/g in powdered examination gloves. Personal latex aeroallergen concentrations ranged from 5 to 616 ng/m3. There was a total of 1351 (66%) participants. The prevalence of positive latex skin tests was 12.1% (95% confidence interval (95% CI) 10.3% to 13.9%). This prevalence did not vary by sex, age, hospital, or smoking status but subjects who were latex positive were significantly more likely to be atopic (P < 0.01). Participants who were latex positive were also significantly more likely to have positive skin tests to one or more foods (Mantel-Haenszel odds ratio (OR) adjusted for atopy 12.1, 95% CI 7.6 to 19.6, P < 10(-9)). Work related symptoms were more often reported among latex positive people, and included hives (OR 6.3, 95% CI 3.2 to 12.5), eye symptoms (OR 1.9, 95% CI 1.2 to 2.8), and wheezy or whistling chest (OR 4.7, 95% CI 2.8 to 7.9). The prevalence of latex sensitivity was highest among laboratory workers (16.9%), and nurses and physicians (13.3%). When the glove consumption per healthcare worker for each department was grouped into tertiles, the prevalence of latex skin test positivity was greater in the higher tertiles of glove use for sterile (surgical) gloves (P < 0.005) but not for examination gloves.

CONCLUSIONS

In this large, cross sectional study of healthcare workers, the prevalence of latex sensitisation was 12.1% (9.5% among all those eligible), and there were significant associations with atopy, positive skin tests to certain foods, work related symptoms, and departmental use of gloves per healthcare worker. This cohort is being followed up prospectively and will be retested to determine the incidence of development of latex sensitivity.

Cost-effectiveness of initial therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors to treat hypercholesterolemia in a primary care setting of a managed-care organization

From January 1994 through May 1995, Prudential HealthCare-North Texas prospectively studied 299 member patients diagnosed with hypercholesterolemia for whom pharmacotherapy with one of four 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, also known as statins, was prescribed. The purpose of this study was to measure the relative cost-effectiveness (CE) of these drugs in a real-world setting. This study provides information to assist decision makers in managed-care organizations (MCO) in making formulary selections. The study used a prospective, randomized, balanced cohort design, examining patients who had been prescribed initial therapy with a statin drug as monotherapy. Costs (direct medical and indirect costs) and effectiveness (percent reduction in low-density lipoprotein cholesterol levels) were based on approximately the first 6 months of initial therapy. Both the MCO and patient perspectives were considered. In the base case, mean CE ratios were significantly lower for fluvastatin compared with lovastatin, pravastatin, and simvastatin from both the managed-care perspective and the patient perspective. Sensitivity analysis did not alter the CE conclusions, even under conditions of varying cost structures. Although differences were found in the effectiveness of lovastatin, pravastatin, and simvastatin measured in this study versus efficacy measured for these drugs in controlled clinical trials, sensitivity analysis suggests that these differences alone do not determine the superior CE of fluvastatin. Finally, this study supports the idea that well-designed formularies should consider drug CE (based on safety, effectiveness, and cost) and that integration of the pharmacy benefit management with other medical management is essential. These results provide evidence that fluvastatin may represent a more cost-effective formulary choice among statin products used for initial monotherapy of hypercholesterolemia.

Physostigmine reversal of scopolamine-induced hypofrontality

The muscarinic receptor antagonist scopolamine produces a transient memory deficit in healthy humans. This deficit has been offered as a model of the cholinergic deficit of Alzheimer's disease (AD). However, we have previously shown that scopolamine produces a deficit of cortical perfusion maximal in the frontal lobe, dissimilar to the parietal cortex deficit characteristic of AD. The current experiment was aimed at replicating and extending this observation by critically testing the central cholinergic origin of both cognitive and perfusion deficits. Nine healthy subjects participated in regional cerebral blood flow (rCBF) measurements at baseline, after scopolamine (7.2 micrograms/kg i.v.), and after both physostigmine (22 micrograms/kg i.v.) and neostigmine (7 or 11 micrograms/kg i.v.). rCBF was quantified by the xenon 133 inhalation method. As expected, scopolamine reduced cortical perfusion, mainly in the frontal cortex, and produced a memory deficit. Physostigmine, but not neostigmine, reversed all three variables partially or completely. These results support the hypothesis that all three consequences of scopolamine, namely, reduction of mean flow, frontal deficit, and memory impairment, are cholinergically mediated. Furthermore, because neostigmine poorly crosses the blood-brain barrier, these findings confirm that the effect is centrally mediated and cannot be explained by peripheral effects. However, they also confirm the frontal cortex locus of action for both scopolamine and its reversal by physostigmine and therefore suggest a major dissimilarity to the characteristic rCBF appearance of AD. This study extends our previous preliminary findings with tacrine and strengthens the suggestion that only nicotinic receptors are associated with the characteristic parietal deficit of AD.

Improved respiratory function and analgesia control after endovascular AAA repair

PURPOSE

Endovascular abdominal aortic aneurysm (AAA) repair has been proposed as a minimally invasive alternative to conventional surgery and may offer significant advantages in respiratory function and analgesic requirements due to the absence of an abdominal incision.

METHODS

Respiratory function and analgesic requirements were quantified in 22 age-matched patients undergoing aneurysm repair under general anesthesia. Twelve patients underwent endovascular aneurysm repair, while 10 AAA patients had conventional surgery. One endovascular patient required conversion to conventional repair.

RESULTS

The endovascular group required postoperative artificial ventilation for a shorter time (6 versus 21 hours, p < 0.05) and had lower PCA (patient-controlled analgesia) morphine consumption (41 versus 133 mg, p < 0.05) than the conventional group. The endovascular group also had significantly better forced expiratory volume and forced vital capacity at both 3 and 5 days when expressed as percentages of the preoperative values (p < 0.05).

CONCLUSIONS

Endovascular AAA repair attenuates respiratory dysfunction associated with conventional surgery and reduces perioperative analgesia requirements.

The value and use of the Qualified Medicare Beneficiary Program: early evidence from Tennessee

The Qualified Medicare Beneficiary (QMB) Program eliminated the out-of-pocket costs of obtaining health care services under the Medicare program for some low-income beneficiaries who were previously ineligible for Medicaid. The program is underused, and little is known about its effects. The article describes the QMB Program and compares program beneficiaries with others whose out-of-pocket payments are covered by Medicaid. Using Medicare claims data covering QMBs in Tennessee, we found that the program financed a relatively high rate of use of Medicare services and saved low-income Medicare beneficiaries hundreds of dollars per month in out-of-pocket costs. Social workers can promote the program and increase the use of its covered services appropriately, thereby by maximizing its potential benefits to low-income people.

Changes in equivalent and gradient refractive index of the crystalline lens with accommodation

The ocular dimensions and refraction of the eye were measured for accommodation stimulus levels of 0.0, 1.5, 3.5, 5.5, and 8.0 D for 11 subjects aged 18 to 28 years, mean 21.2 +/- 2.62 years using keratometry, autorefraction, A-Scan ultrasonography, and video phakometry techniques. The subjects had refractive errors in the range + 0.50 to -4.25 D, mean -1.88 +/- 1.64 D. With the maximum level of accommodation the anterior chamber depth decreased by 0.23 +/- 0.09 mm, the lens thickness increased by 0.28 +/- 0.09 mm, and no significant differences were recorded in axial length or vitreous chamber depth. The radius of curvature of the anterior surface of the crystalline lens decreased from 11.54 +/- 1.27 to 6.59 +/- 0.97 mm and the posterior surface from -6.67 +/- 0.97 to -5.30 +/- 0.4 mm. We determined the equivalent refractive index to be 1.4277 +/- 0.0011, with no significant differences at different levels of accommodation. When the crystalline lens was modeled as a gradient refractive index (GRIN) structure with elliptical iso-indicial lines, the mean surface refractive index of the lens was 1.3859 +/- 0.0009 for an assumed central refractive index of 1.406. The power of the anterior surface of the lens increased from 4.38 +/- 0.49 to 7.59 +/- 0.34 D, the posterior surface increased from 7.67 +/- 1.28 to 9.32 +/- 0.64 D, and the GRIN power increased from 9.70 +/- 1.31 to 13.74 +/- 0.77 D for the maximum accommodative stimulus of 8.00 D. On the basis of the model used, a substantial part of the increase in power of the crystalline lens with accommodation resulted from the change in refractive index distribution within the lens.

Proteosomes, emulsomes, and cholera toxin B improve nasal immunogenicity of human immunodeficiency virus gp160 in mice: induction of serum, intestinal, vaginal, and lung IgA and IgG

Intranasal immunization of mice with human immunodeficiency virus (HIV) rgp160 complexed to proteosomes improved anti-gp160 serum IgA and IgG titers, increased the number of gp160 peptides recognized, and stimulated anti-gp160 intestinal IgA compared with immunization with uncomplexed rgp160 in saline. These enhanced responses were especially evident when either a bioadhesive nanoemulsion (emulsomes) or cholera toxin B subunit (CTB) was added to the proteosome-rgp160 vaccine. Furthermore, anti-gp160 IgG and IgA in vaginal secretions and fecal extracts were induced after intranasal immunization with proteosome-rgp160 delivered either in saline or with emulsomes. Formulation of uncomplexed rgp160 with emulsomes or CTB also enhanced serum and selected mucosal IgA responses. Induction of serum, vaginal, bronchial, intestinal, and fecal IgA and IgG by intranasal proteosome-rgp160 vaccines delivered in saline or with emulsomes or CTB is encouraging for mucosal vaccine development to help control the spread of HIV transmission and AIDS.

Suspected ehrlichial infection in five cats from a household

Ehrlichiosis is a poorly recognized condition of cats that may be associated with anemia, leukopenia, thrombocytopenia, or dysproteinemia. Affected cats may have indirect fluorescent antibody titers to Ehrlichia canis and E risticii. We reviewed the clinical evaluation and response to treatment of 5 cats in a household where ehrlichial disease was suspected as the cause of recurrent leukopenias and thrombocytopenias. All of the cats had E risticii indirect fluorescent antibody titers and western blot confirmation of antibodies to 4 of the 9 major antigens of E risticii. Response to doxycycline was monitored serologically and hematologically in each cat, and indicated that administration of doxycycline at a dosage of 10 mg/kg of body weight, PO, every 12 hours, for a minimum of 21 days is necessary for treatment of this condition.

Microembolization during endovascular and conventional aneurysm repair

PURPOSE

Endovascular aneurysm repair has been advocated as a "minimally invasive" alternative to conventional aneurysm surgery. However, because of manipulation within the aneurysm sac, endovascular techniques may result in massive microembolization.

METHODS

In this study lower limb microemboli were quantified in 29 patients undergoing conventional (11 straight and 7 bifurcated grafts) and endovascular aneurysm repair (8 aortoiliac, 1 straight, and 2 bifurcated grafts) by insonation of the superficial femoral artery with a 2 MHz Doppler probe. Emboli were detected as high-intensity, short-duration signals on the background Doppler trace. Differentiation of gaseous emboli from particulate emboli was achieved by calculation of the sample volume length (emboli velocity x duration = sample volume length) for each embolus (N = 4927). Previous experiments had determined that a sample volume length < 1.4 cm represented particulate embolization.

RESULTS

The number of gaseous, particulate, and total emboli were significantly greater in the endovascular group compared with the conventional group (p < 0.05).

CONCLUSIONS

These data demonstrate that peripheral microembolization is significantly higher during endovascular aneurysm repair than during conventional surgery. Methods to reduce embolization must be developed before endovascular aortic surgery is widely adopted.

Incorporation of iododeoxyuridine in multicellular glioma spheroids: implications for DNA-targeted radiotherapy using Auger electron emitters

A promising new treatment for glioma involves Auger electron emitters such as 125I or 123I conjugated to deoxyuridine (IUdR). However, the presence in tumour deposits of non-proliferating cells with clonogenic potential poses a major limitation to this cycle-specific therapy. We have used multicellular tumour spheroids derived from the human glioma cell line UVW to study [125I]IUdR-targeted radiotherapy in aggregates containing cells in different proliferative states. Autoradiographic identification of labelled cells indicated that nuclear incorporation of [125I]IUdR decreased markedly with increasing size of spheroid. IUdR incorporation was maximal in the surface layer of cells and decreased with depth within spheroids. Radiopharmaceutical uptake corresponded closely to the regions of cell cycling as indicated by staining for the nuclear antigen Ki67. The uptake of drug was enhanced by increasing the duration of incubation from 52 h to 104 h. These observations suggest that significant sparing of non-cycling malignant cells would result from treatment delivered as a single injection of radiolabelled IUdR. To achieve maximal therapeutic effect. IUdR should be administered by multiple injections, by slow release from biodegradable implants or by slow-pump delivery.

Anger regulation deficits in combat-related posttraumatic stress disorder

We describe a typology of regulatory deficits associated with anger in combat-related posttraumatic stress disorder (PTSD). Cognitive, arousal, and behavioral domain deficits in anger regulation were observed clinically in PTSD patients with high levels of anger who were participating in a multi-year trial of a structured anger treatment. We also describe a category of patients whose anger type we have termed "ball of rage." These patients exhibit regulatory deficits in all three domains of anger regulation. We offer a conceptual framework to advance the understanding of anger associated with PTSD and to guide its effective treatment.

Plant-derived immunocontraceptive vaccines

The use of transgenic or virus-infected plants to produce vitally needed vaccines for developing nations has been made possible by rapid advances in plant molecular biology and biotechnology during the last decade. Plant-based vaccines would be a welcome development for many impoverished countries that lack the capital-intensive infrastructure required to produce much-needed vaccines. The approach would also be ideally suited to the delivery of oral immunocontraceptive vaccines to a wide range of herbivore species. This review looks at the progress made to date in the use of plants for vaccine production, how this technology may be used in the future to deliver immunocontraceptive vaccines to free-ranging wildlife species, and the many problems that will have to be overcome if this promising approach is to ever 'bear fruit'.

Effects of training in monitoring accuracy on processing speed in mental retardation

Monitoring accuracy during choice RT allows subjects to maintain fast, safe RT bands and avoid overly fast, unsafe RT bands. 5 retarded adults received trial-by-trial feedback on accuracy over a number of sessions to train monitoring of accuracy and to improve RT performance. Training was introduced according to a multiple-baseline-across-subjects (with reversal) design. Training had no significant effect on subsequent RT performance, suggesting that inefficient monitoring of accuracy may be a structural characteristic of mental retardation.

Strongyloides stercoralis: maintenance of exceedingly chronic infections

Two hypotheses were tested to identify the mechanism(s) by which chronic Strongyloides stercoralis infections are maintained in experimental dogs as a model to explain delayed onset recrudescence in humans. Investigations tested the hypotheses that chronic infections result from 1) periodic reactivation of third-stage larvae from a reservoir of dormant parasites outside the gastrointestinal tract or 2) the periodic rejuvenation of postreproductive female worms remaining from a previous infection, lodged in the mucosal crypts. Populations of parenteral larvae survived in mature experimentally infected female dogs for 66 days; individual worms survived for 88 days, but there was no evidence that these larvae re-established patent, adult worm infections. Late in these infections, female worms were present in greater than predicted numbers with no evidence that autoinfection had occurred, suggesting that some postreproductive worms were long-lived. In separate trials, long-lived spent females were once again capable of producing viable larvae when the host was treated with corticosteroids.