Influence of excessive weight loss after gastroplasty for morbid obesity on respiratory muscle performance

BACKGROUND

Morbidly obese subjects are known to have impaired respiratory function and inefficient respiratory muscles. A study was undertaken to investigate the influence of excessive weight loss on pulmonary and respiratory muscle function in morbidly obese individuals who underwent gastroplasty to induce weight loss.

METHODS

Twenty one obese individuals with mean (SE) body mass index (BMI) 41.5 (4.5) kg/m2 without overt obstructive airways disease (FEV1/FVC ratio > 80%) were studied before and six months after vertical banded gastroplasty. Only patients who had lost at least 20% of baseline BMI were included in the study. Standard pulmonary function tests and respiratory muscle strength and endurance were measured.

RESULTS

Before operation the predominant abnormalities in respiratory function were significant reductions in lung volumes and respiratory muscle endurance and, to a lesser degree, reductions in respiratory muscle strength. All parameters increased towards normal values after weight loss with significant increases in functional residual capacity (FRC) from 84.0 (2.2) to 91.3 (2.5)% of predicted normal values (mean difference 7.3, 95% confidence interval of difference (CI) 4.2 to 10.5), total lung capacity (TLC) from 85.6 (3.0) to 93.5 (3.7)% of predicted normal values (mean difference 7.9, 95% CI 4.5 to 11.5), residual volume (RV) from 86.7 (3.1) to 96.4 (3.0) of predicted normal values (mean difference 9.7, 95% CI 5.2 to 14.1), expiratory reserve volume (ERV) from 76.6 (3.0) to 89.0 (3.4)% of predicted normal values (mean difference 12.4, 95%, CI 6.3 to 18.9), respiratory muscle strength: PImax from 92 (4.4) to 113 (4.6) cm H2O (mean difference 21, 95% CI 12.2 to 31.6), PEmax from 144 (5.6) to 166 (4.3) cm H2O (mean difference 22, 95% CI 12.9 to 32.0), and endurance: PmPeak/PImax from 56 (1.4) to 69 (2.0)% (mean difference 13, 95% CI 9.7 to 16.9). The strongest correlation was between weight loss and the improvement in respiratory muscle endurance.

CONCLUSIONS

Lung volumes and respiratory muscle performance are decreased in obese individuals. Weight loss following gastroplasty is associated with improvement in lung volumes and respiratory muscle function.

Tuberculosis among foreign-born persons in New York City, 1992-1994: implications for tuberculosis control

OBJECTIVE

To study the pattern of transmission of tuberculosis (TB) among foreign-born persons living in New York City.

DESIGN

A retrospective multicenter study comparing 158 foreign-born patients to 231 US-born patients diagnosed with TB between 1992 and 1994. The patients were stratified according to their Mycobacterium tuberculosis isolate DNA fingerprint patterns.

RESULTS

Nineteen (16%) of 122 isolates from foreign-born TB patients and 75 (42%) of 180 isolates from US-born TB patients had DNA fingerprint patterns (cluster patterns) indicative of recent exogenous transmission (P < 0.001). All cluster pattern strains from foreign-born cases were identical to those found among US-born patients. The likelihood of infection with a cluster pattern strain among foreign-born persons increased with duration of residence in the US, and was significantly associated with being homeless (P < 0.05), or having multidrug-resistant TB (P = 0.00072).

CONCLUSION

Although most (84%) cases of TB among foreign-born persons in New York City appear to result from reactivation of infections they acquired abroad, the ones who acquire new infections become infected with strains that are already circulating among the US-born TB patients in New York City, and they have risk factors similar to those faced by US-born tuberculosis patients.

Lymphocyte predominant Hodgkin disease: clinico-pathologic features and results of treatment--the Pediatric Oncology Group experience

PURPOSE

In this report, the Pediatric Oncology Group (POG) experience with lymphocyte predominant Hodgkin Disease (LPHD) in children is reviewed.

MATERIALS AND METHODS

From 1984-1993, the POG conducted 3 clinical trials for advanced stage HD and 2 for early stage HD. There were 26 cases of LPHD in 613 patients in these trials. Patients' ages ranged from 3.1-17.8 years (mean of 12.9 years). There was a marked male predominance.

RESULTS

Histologic subtypes were 17 nodular, 8 diffuse pattern; 1 was indeterminant. The sites involved at diagnosis were primarily the peripheral lymph nodes. Fourteen patients had stage (S) I disease; 9 had SII; 3 had SIII; there was no SIV disease. Only 4 of 26 patients had B symptoms. All 26 patients achieved complete remission, 10 with radiotherapy, 6 with chemotherapy and 10 with combined modality therapy. Treatment was not uniform since patients were registered on different protocols. Event-free survival after 5 years was 86.5 percent. Two patients developed and succumbed to large cell, T-cell type, non-Hodgkin lymphoma (NHL).

CONCLUSIONS

Optimal treatment for LPHD should focus on efforts to limit the risk of second malignancy.

Pharmacokinetics of triptorelin after intravenous bolus administration in healthy males and in males with renal or hepatic insufficiency

AIMS

Triptorelin is a gonadotropin-releasing hormone (GnRH) analogue with enhanced affinity for GnRH receptors and a prolonged half-life due to its resistance to enzymatic degradation. The sustained-release formulation of this molecule is advantageous in conditions requiring chronic hormone suppression.

METHODS

This was an open study to determine the pharmacokinetics of a single i.v. bolus dose of 0.5 mg triptorelin acetate in four groups of six male subjects; namely in healthy subjects (Group I), in patients with varying degrees of renal insufficiency (Groups II and III), and in patients with hepatic insufficiency (Group IV).

RESULTS

The maximum concentrations of triptorelin were found to be similar for all four study groups (geometric mean Cmax between 41.6 mg ml(-1) and 53.9 mg ml(-1)). The total clearance of triptorelin decreased with increasing renal impairment, and was even lower in patients with hepatic insufficiency (geometric mean CLtot: 210 ml min(-1), 113 ml min(-1), 86.8 ml min(-1) and 57.3 ml min(-1) for Groups I, II, III and IV, respectively). Serum triptorelin concentrations in all four groups were adequately described by a three-compartment model. The elimination half-life for patients with hepatic impairment was similar to that of patients with renal impairment (geometric mean t(1/2, z): 6.6 h, 7.7 h and 7.6 h for Groups II, III and IV, respectively), but significantly longer than in healthy volunteers (2.8 h for Group I). The first and second distribution half-lives were similar for the four groups studied, with geometric mean distribution half-lives of about 0.1 h (6 min) and 0.75 h (45 min), respectively.

CONCLUSIONS

Although both renal and hepatic function are important for the clearance of triptorelin, the liver plays the predominant role in subjects suffering from some degree of renal impairment.

Prevalence of melanocytic nevi and freckles in young Israeli males. Correlation with melanoma incidence in Jewish migrants: demographic and host factors

The role of host and environmental factors in the pathogenesis of multiple melanocytic nevi, atypical nevi, and freckles was studied in 1989 in a random sample of 3,040 Israeli males aged 17 years. Multiple melanocytic nevi were significantly associated with family history of melanoma or multiple melanocytic nevi (odds ratio (OR) = 15.0), fair or lightly pigmented skin color (OR = 2.7 and 2.3, respectively), and affiliation to the high or heterogenous melanoma risk group, determined by the incidence rates of melanoma in Jewish migrants from corresponding origin (OR = 3.1 and 2.1, respectively). An environment-related effect may account for the increased multiple melanocytic nevi risk among second- (OR = 8.2) compared with first-generation, native-born recruits (OR = 3.0) from the high melanoma risk group whose families had been living in Israel the longest. Atypical nevi were associated with fair (OR = 6.1) and lightly pigmented (OR = 3.5) skin color, high and moderate sunburn susceptibility (OR = 4.7 and 2.5, respectively), and family history of melanoma or multiple melanocytic nevi (OR = 4.7). Freckles were significantly associated with sun-sensitive phenotype, family history of melanoma or multiple melanocytic nevi (OR = 1.5). Conservative (OR = 1.9) or nonreligious status (OR = 1.9), and high (OR = 2.4) or heterogenous melanoma risk groups (OR = 1.8). These findings indicate that environmental factors may modify the occurrence of multiple melanocytic nevi and freckles in genetically susceptible ethnic groups.

Extent of Barrett's metaplasia: a prospective study of the serial change in area of Barrett's measured by quantitative endoscopic imaging

BACKGROUND

An accurate determination of the extent of Barrett's metaplasia is critical to the study of its natural history and response to therapy. Our hypothesis is that area calculations offer advantages over length estimates of Barrett's.

METHODS

Changes in both measures and estimates of progression or regression between two endoscopies in 17 patients were compared. Area was calculated using a computer image analysis technique.

RESULTS

Although there was no significant difference in length correlation versus area correlation between endoscopies (r = 0.90 vs 0.99), the mean change in absolute length (1.4 +/- 0.2 cm) was greater than the change in area (4.5 +/- 1.4 cm2, equivalent to a length of 0.67 +/- 0.2 cm, p = 0.001). The percent change in absolute length (26.9%) was greater than the change in area (16%, p = 0.001). Discordance of estimates of progression or regression between area and length was found in nine patients. The image technique detected no change in the area of squamous islands.

CONCLUSIONS

Imaging analysis can precisely measure the extent of Barrett's including squamous islands. Area showed little change, whereas measures of length were more varied. Computer based image analysis provides a more precise estimate of interval change of Barrett's.

Adolescent physical abuse and suicide attempts

OBJECTIVE

The rate of suicide attempts and the exposure to risk factors for suicide in an unselected sample of confirmed cases of physically abused adolescents recruited directly from the New York State Central Register for Nassau and Suffolk Counties was compared with those of a community sample of nonabused adolescents.

METHOD

Semistructured and structured diagnostic interviews were used in the assessment of psychopathology of adolescents and their parents

RESULTS

The proportion of adolescents attempting suicide did not differ for the two groups. However, the abused adolescents showed significantly greater exposure to risk factors for adolescent suicide, including family disintegration, and diagnoses of depression, disruptive behavior disorders, and substance abuse and dependence. Comparisons of the 8 physically abused adolescents who attempted suicide with the 91 who did not attempt suicide showed that the following factors were associated with significantly greater risk for suicide attempts: adolescents' perceptions of their families as lacking cohesiveness and maternal support, higher adolescent "hostility" ideation scores, adolescent diagnoses of disruptive disorders and conduct disorders, adolescent substance abuse/dependence, and exposure to a suicide attempt by a family member or a friend.

CONCLUSION

A transactional model of abuse, family and personal stressors, and the development of adolescent vulnerability leading to psychopathology is offered to explain the results.

Migrants, refugees and foreign policy: prevention and intervention strategies

The authors discuss policy development options to deal with migrants and refugees to developed countries. "Our principal argument--perhaps to state the obvious--is that international migration and refugee movements are foreign policy, not simply domestic, issues. Nevertheless, citizens and policy makers are all too often unaware that if they want to secure their borders against unwanted population flows, this cannot be done simply by unilateral decisions to regulate entry." The focus is on Germany and the United States.

The effect of incentive spirometry and inspiratory muscle training on pulmonary function after lung resection

BACKGROUND

A predicted postoperative forced expiratory volume in 1 second (FEV1) of less than 800 ml or 40% of predicted is a common criterion for exclusion of patients from lung resection for cancer. Usually, the predicted postoperative lung function is calculated according to a formula based on the number of lung segments that will be resected. Incentive spirometry and specific inspiratory muscle training are two maneuvers that have been used to enhance lung expansion and inspiratory muscle strength in patients with chronic obstructive pulmonary disease and after lung operation.

METHODS

Thirty-two patients with chronic obstructive pulmonary disease who were candidates for lung resection were randomized into two groups: 17 patients received specific inspiratory muscle training and incentive spirometry, 1 hour per day, six times a week, for 2 weeks before and 3 months after lung resection (group A) and 15 patients were assigned to the control group and received no training (group B).

RESULTS

Inspiratory muscle strength increased significantly in the training group, both before and 3 months after the operation. In group B, the predicted postoperative FEV1 value consistently underestimated the actual postoperative FEV1 by approximately 70 ml in the lobectomy subgroup and by 110 ml in the pneumonectomy subgroup. In group A, the actual postoperative FEV1 was higher than the predicted postoperative FEV1 by 570 ml in the lobectomy subgroup and by 680 ml in the pneumonectomy subgroup of patients.

CONCLUSIONS

In patients undergoing lung resection the simple calculation of predicted postoperative FEV1 underestimates the actual postoperative FEV1 by a small fraction. Lung functions can be increased significantly when incentive spirometry and specific inspiratory muscle training are used before and after operation.

A longitudinal study of behavioral pathology across five levels of dementia severity in Alzheimer's disease: the CERAD Behavior Rating Scale for Dementia. The Alzheimer's Disease Cooperative Study

As part of the Alzheimer's Disease Cooperative Study (ADCS) Instrument Development Project, the CERAD Behavior Rating Scale for Dementia (BRSD) was examined for its sensitivity to degree of cognitive impairment, its test-retest reliability, and its sensitivity to longitudinal change. Sixty-four normal elderly participants and 261 patients with AD stratified into severity groups based on Mini-Mental State Exam (MMSE) scores were rated on the BRSD at baseline and 12-month follow-up visits. A subset of subjects was evaluated at a 1-month follow-up visit. Baseline BRSD Total Score discriminated the normal group from each AD group, and mean Total Score significantly increased with increasing dementia severity. Test-retest reliability between baseline and 1-month Total Scores was satisfactory for all AD groups. Longitudinal change was evaluated by 12-month change scores, which were significant in only the normal and in one AD group. From the results, we argue that the value of behavioral pathology assessment in clinical trials would be enhanced if additive scores were based on groups of correlated items rather than on a broad array of behaviors, some of which may increase and others may decrease in frequency as AD progresses.

Assessing patterns of agitation in Alzheimer's disease patients with the Cohen-Mansfield Agitation Inventory. The Alzheimer's Disease Cooperative Study

As part of the effort of the NIA Alzheimer's disease cooperative study to develop improved instruments for quantifying effects in Alzheimer's disease (AD) clinical trials, patterns of agitated behaviors were evaluated with the Cohen-Mansfield Agitation Inventory (CMAI) in 241 AD patients and 64 healthy elderly controls with valid baseline assessment on the CMAI. The test-retest reliability of the CMAI over 1 month was good (r = 0.74 to 0.92). Physically and verbally nonaggressive behaviors were most often reported, whereas physically aggressive behaviors were rare. Frequency of agitated behaviors increased with dementia severity, especially for patients with a Mini-Mental Status Exam score of 0-4. Agitation tended to increase in the evening with dementia severity for the more impaired patients. Amount of agitation did increase after 12 months in all but controls and mildly demented patients. The CMAI shows promise for evaluating a unique aspect of behavior and may be useful in assessing the effects of cognitive enhancers and other types of psychotropic drugs on behavior in dementia patients.

A multicenter double-blind study of controlled-release physostigmine for the treatment of symptoms secondary to Alzheimer's disease. Physostigmine Study Group

OBJECTIVE

A multicenter trial to evaluate the efficacy of controlled-release physostigmine salicylate, a cholinesterase inhibitor, was conducted in 1,111 mild-to-moderate Alzheimer's disease (AD) subjects.

DESIGN

During dose titration, subjects received 18, 24, or 30 mg of physostigmine or placebo daily. After a 2-week washout period, 366 subjects with putative improvement were randomized to receive either placebo or their best dose of physostigmine in a 6-week double-blind trial. Nonresponding patients (439) were randomized to receive in a separate double-blind trial either placebo or their highest tolerated dose of physostigmine. The primary efficacy measures included the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS) and a Clinical Global Impression of Change (CGIC). Secondary measures included the Mini-Mental State Examination and two activities-of-daily-living scales.

RESULTS

At the end of the 6-week double-blind phase, physostigmine-treated patients scored 1.75 points higher than placebo-treated patients on the ADAS (p = 0.003) and 0.26 points higher on the CGIC (p = 0.012) in the intent-to-treat analysis. There was no significant improvement on the secondary outcome measures. Patients failing to respond to physostigmine during the dose titration phase failed to respond on any of the outcome measures during the double-blind period of re-exposure. Common adverse events included nausea, vomiting, diarrhea, and anorexia. There were no significant changes in liver function tests.

CONCLUSION

This study demonstrated statistically significant differences between physostigmine and placebo on both a performance-based cognitive functioning instrument and a clinician's global evaluation. The magnitude of the effect size was small and occurred only in the subset of patients who responded in the initial dose titration study period. Nevertheless, the results suggest that in a subset of patients, physostigmine can induce a degree of cognitive improvement over 6 weeks of treatment.

[Physiotherapy in chronic obstructive pulmonary disease: oscillatory breathing with flutter VRP1]

Chronic obstructive pulmonary disease (COPD) is characterized by sputum production and cough. It has been shown that mucus hypersecretion predisposes to recurrent bronchial infection and that reduction in airway secretions is associated with clinical improvement. Recently a new pipe-shaped device for chest physiotherapy, the flutter VRP1 ("VarioRaw:" Aubonne, Switzerland), was introduced in order to help clear bronchial hypersecretion. We determined the long-term efficacy of daily chest physiotherapy with the VRP1 in COPD and bronchial hypersecretion. 13 men and 7 women with COPD and sputum hypersecretion were studied; 10 were assigned to the physiotherapy group, and 10 to the control group getting sham therapy. After 3 months of physiotherapy, FVC, FEV1 and distance walked in 12 minutes increased in the treated group, but were almost unchanged in the sham-treated group. Arterial blood gases, the maximum voluntary ventilation, and respiratory rate at rest were unchanged in both groups. There was also an overall significant improvement in COPD symptoms in the physiotherapy group compared to baseline (p < 0.05). We conclude that long-term home physiotherapy with the flutter VRP1 is effective in COPD in improving airflow, functional ability and symptoms.

Learning from patients: a discharge planning improvement project

BACKGROUND

In 1991 Beth Israel Hospital (Boston) joined nine other hospitals in using the Picker/Commonwealth survey instrument to tap patients perceptions of their hospitalization experience. Beth Israel focused on one of the nine dimensions of the instrument-continuity and transition (discharge planning). FOUR WORK TEAMS: In 1992 four multidisciplinary work teams were formed-for cardiac surgical patients, stroke patients, patients on a medical unit, and patients on a medical and surgical unit. Each team conducted a patient/family discussion group, during which recently discharged patients and their families were asked about their preparation for discharge and asked for input on how to improve the process.

INTERVENTIONS

Each work team developed interventions on the basis of information specific to their patients. The cardiac work team, for example, developed interdisciplinary practice guidelines for patient care management for the entire postoperative period; the guidelines include a patient education component on what patients and families can expect during hospitalization.

OUTCOMES

Clinicians practice differently, inviting more patient feedback and other involvement in care, as a results of their involvement in the project. On the first annual patient survey, administered in 1994, only 6% of 1,179 randomly selected patients (versus 20% of the 100 patients first surveyed in 1993) indicated that they did not receive the information they needed to help themselves recover. CURRENT PROGRESS AND FUTURE DIRECTIONS: A standardized teaching packet containing material developed during the discharge planning improvement project is now distributed. In May 1995 the nursing department launched a patient and family learning center to better meet the health education needs of patients.

Ethics, national sovereignty and the control of immigration

"This paper examines the debate as to whether migration is a basic human right or if the claims of outsiders are superseded by the principle of national sovereignty--the moral obligation of states to do the best for their own citizens. In evaluating migration and refugees it focuses on issues of open borders, migration selectivity, the capacity of sovereign states to control entry, the claims of refugees, the relationship between sovereignty and justifiable intervention, and the role of public opinion and morals throughout migration policies."

Inhaled budesonide therapy for patients with stable COPD

A significant minority of patients with COPD have favorable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with high-dose inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to inhaled beta 2-agonist will serve to individualize steroid responders. We compared a 6-week course of 800 micrograms/d inhaled budesonide with placebo, separated by 4 weeks when no medication was taken, in a double-blind crossover trial, in 8 patients responding to inhaled beta 2-agonist, and in 22 nonresponders with stable COPD. In six of eight "responders to beta 2-agonist," there was a significant improvement in the FEV1 (defined as > or = 20%) following inhaled budesonide, as compared with placebo. In the 22 "nonresponders to beta 2-agonist," there was no significant improvement in the mean FEV1 (1.41 +/- 0.1 L before, and 1.61 +/- 0.1 L after treatment) with inhaled budesonide or placebo. Over the 6-week course of treatment by either budesonide or placebo, the nonresponders reported similar beta 2-agonist consumption (4.8 +/- 0.2 and 5.0 +/- 0.1 puffs per patient per day, respectively). However, there was a significant difference between the two periods of treatment in the responders as for the mean daily number of beta 2-agonist inhalations (2.4 +/- 0.1 in the budesonide period as compared with 5.3 +/- 0.1 in the placebo period; p < 0.005). We conclude that treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about 25% of patients with stable COPD, and this rate is increased to about 75% in patients who respond to beta 2-agonist inhalation.

Long term clinical comparison of single versus twice daily administration of inhaled budesonide in moderate asthma

BACKGROUND

Inhaled steroids are widely used in the treatment of mild to moderate asthma. However, long term compliance with inhaled steroids is poor and administration of a single daily dose may improve compliance.

METHODS

A double blind, randomised study was performed to determine whether inhaled steroids given once daily at bedtime are as efficacious as a twice daily regimen in the long term maintenance of moderate asthmatic patients. Forty adults of mean age 37 years with moderate asthma (mean (SE) forced expiratory volume in one second (FEV1) 73.6 (1.4)% predicted, mean morning peak expiratory flow (PEF) 328 l/min) were randomised to receive either a twice daily dose (400 micrograms morning and bedtime) of inhaled budesonide (group A) or a once daily dose of 800 micrograms (group B) and were followed for a period of 12 months. Asthma symptom scores (assessed according to a modified Borg scale), inhaled beta 2 agonist consumption, and peak expiratory flow rates were recorded daily. Spirometry and airways responsiveness to methacholine (PC20) were measured at the end of each period of three months of treatment.

RESULTS

There was no difference between the two groups at baseline and during the follow up period in the PC20 for methacholine. However, a difference was seen between the two groups in the mean daily number of beta 2 agonist inhalations (1.4 (0.1) puffs/patient/day in group A v 2.3 (0.1) in group B), the PEF variability (episodes of decrease in PEF of > 20%) (0.22 (0.01) episodes/patient/day in group A v 0.40 (0.02) in group B), and for asthma symptom scores (0.30 (0.04) in group A v 0.42 (0.06) in group B) for the 12 month period of the study.

CONCLUSIONS

Although both regimens provide good clinical control, twice daily doses of 400 micrograms inhaled budesonide are more effective than a single dose of 800 micrograms at bedtime in the long term control of stable moderate asthma.

Visuoconstructive deficit following infarction in the right basal ganglia: a case report and some experimental data

Visuospatial disorders are typically described as a consequence of right hemisphere, cortical lesions. We report the case of a female with visuoconstructive deficits with an infarct in the right basal ganglia, with no evidence of visual field defect, hemi-inattention, or sensory or motor loss. Using a process approach to obtain additional quantitative data, we showed that her visuoconstructive disorder could not be attributed to a defect in visual perception, per se. All other aspects of her neuropsychologic skills were normal. These findings provide additional support for the role of subcortical structures in spatially-related motor function and for the utility of applying experimental techniques to clarify the nature of deficits.

A comparison of crossover versus parallel-group design in the evaluation of analgesic efficacy after molar extraction

This study compares the analgesic effects of two standard combinations (Empirin with codeine versus Mersyndol) and placebo as measured by crossover versus parallel-group design. The analgesic results obtained with three groups of 12 to 13 crossed over subjects with two extractions divided into six subgroups of five to seven subjects for each sequence were qualitatively the same and statistically at least as strong as those obtained by analysis of parallel groups of 38 to 42 extractions per group. By both methods the analgesics were statistically significantly more effective than placebo. The difference between the two products was not statistically significant, although the score for Mersyndol was somewhat better by both methods of study. The crossover data did not allow judgments concerning side effects in spite of its greater efficiency in quantifying pain relief.

[Structure and process components of trauma care services in emergency departments]

Increasing attention is being paid by staffs of hospitals and directors of our national health agencies to providing emergency medical services for trauma care. The results of a nationwide survey documenting the structure and process components of trauma care in all 24 acute care hospitals in Israel are presented. Although these hospitals provide 24-hour trauma service, there are no formal guidelines for required resources in emergency departments. The results show extreme interhospital variation in physical structure of trauma services and in manpower, protocols and critical resource. However, it is evident that the main focus for intervention in the quality of initial trauma care in hospitals in Israel, is to establish and implement organizational standards.

Inspiratory muscle training during treatment with corticosteroids in humans

In a previous study performed by us, functional alterations in the inspiratory muscles were evaluated in patients receiving corticosteroids for diseases other than respiratory. We have shown that patients who received high-dose steroids for several weeks developed inspiratory muscle weakness that was reversible following withdrawal of the drug treatment. The present study was designed to evaluate the ability of specific inspiratory muscle training (SIMT) to prevent the effects of a therapeutic dosage of corticosteroids on inspiratory muscle function in patients receiving the drug for diseases other than pulmonary, with no underlying respiratory or muscular disease. Twelve patients, 5 men and 7 women, with ages ranging from 19 to 41 years, who received corticosteroids for diseases other than respiratory were recruited into two groups: 6 patients were assigned to the control group and got sham training and 6 patients received SIMT while receiving corticosteroids in a single-blind group-comparative trial. In both groups, there was no difference between the post-treatment and pretreatment values as regard to the FEV1/FVC relationship. However, in the control group but not in the training group, there was a small but significant decrease, from 99.2 +/- 3.0 to 94.3 +/- 2.8 (mean +/- SEM, p < 0.01) in FEV1 (percent of predicted normal values) and from 103.5 +/- 4.0 to 88.7 +/- 3.1 (p < 0.001) in the FVC, following treatment. All subjects had normal inspiratory muscle strength, as expressed by the maximal inspiratory mouth pressure (PImax) at residual volume, and inspiratory muscle endurance as expressed by the relationship between peak pressure and the PImax before treatment. Following administration of corticosteroids, there was a gradual decrease in both inspiratory muscle strength (from 117.5 +/- 9.4 to 80.5 +/- 3.3 cm H2O, p < 0.005) and endurance (from 82.7 +/- 2.6 to 40.2 +/- 1.7%, p < 0.001) in the control group. On the contrary, despite corticosteroid therapy, there were no significant changes in the inspiratory muscle function in the patients whose inspiratory muscles were specifically trained. We conclude that corticosteroids have a significant deteriorating effect on respiratory muscle function in humans. This weakness is preventable by using SIMT during corticosteroid treatment.

The effects of age on the pharmacokinetics and biotransformation of theophylline in vivo and in vitro in the Mongolian gerbil (Meriones unguiculatus)

The effect of post maturational aging on the in vivo disposition of theophylline was examined in the Mongolian gerbils (Meriones unguiculatus) aged 30-39 (old), 12-18 (middle-aged) and 3 (young) months following a 20 mg/kg i.p. dose. Biotransformation of theophylline was also examined in liver microsomes from non-induced and 3-methylcholanthrene induced gerbils. Analysis of theophylline plasma kinetics showed decreased clearance, increased half-life and increased volume of distribution in old vs. young animals. Clearance to the 1,3-dimethyluric acid metabolite was similar for all age groups, while clearance to the 1-methyluric acid metabolite was significantly lower in the middle-aged group compared to that of young and old gerbils. Urinary recovery of 1-methylurate was increased in old vs. young and middle-aged animals while recovery of theophylline was decreased. 3-Methylcholanthrene induction resulted in decreased recovery of theophylline and increased recovery of 1,3-dimethylurate and 1-methylurate in young and middle-aged gerbils compared to non-induced controls. Decreased microsomal protein content was observed in old vs. young and middle-aged gerbils and an age-related decrease in cytochrome P-450 content (nmol P-450/g liver) was also observed. The rate of dimethylurate formation was decreased 37% in microsomes from old vs. young and middle-aged gerbils. 3-Methylcholanthrene administration resulted in a 2- and 1.5-fold increase in the rate of 1,3-dimethylurate formation in young and middle-aged gerbils, respectively. The results of these experiments indicate that the Mongolian gerbil may be useful for the study of the biochemical mechanisms underlying age-related changes in the biotransformation and kinetics of theophylline.

Automated reconstruction of endoscopic images of the esophagus

Endoscopic devices distort the image of a region under examination. Previous work has shown that there are computational methods which can precisely reconstruct planar structures in a model of the esophagus and that reconstruction in human subjects is operator independent. The purpose of this report is to show that much of the process can be automated and to provide additional evidence that the reconstruction is both accurate and reproducible.

[Effect of corticosteroids on inspiratory muscle function]

Functional alteration in inspiratory muscles was evaluated in patients receiving corticosteroids for nonrespiratory diseases. Inspiratory muscle strength, as expressed by maximal inspiratory mouth pressure (PImax), and inspiratory muscle endurance (PmPeak/PImax), determined with a pressure threshold breathing device, were evaluated in 8 patients with normal pulmonary and inspiratory muscle function. There was a gradual decrease in both inspiratory muscle strength and endurance when corticosteroids were given. Tapered decrease in steroid dosage resulted in marked improvement in both strength and endurance, and the improvement was even more significant 6 months later. We also evaluated the ability of specific inspiratory muscle training to prevent the effects of therapeutic corticosteroids on inspiratory muscle function in 6 patients, as compared to 6 control patients who received sham training. Following corticosteroids there was a gradual decrease in both inspiratory muscle strength and endurance in those getting sham training. However, there was no significant change in inspiratory muscle function in those getting inspiratory muscle training. We conclude that corticosteroids result in significant deterioration in respiratory muscle function. This weakness is reversible by tapering steroid dosage, but can be prevented by specific inspiratory muscle training during corticosteroid treatment.

Conjunctival orbital cyst

A 61-year-old woman had gradual onset of ptosis and painless proptosis of her left eye of 1-year duration. Orbital computed tomography (CT) showed a well-circumscribed superior nasal orbital tumor with uniform density. The mass was removed by anterior orbitotomy and histopathologically diagnosed as a conjunctival cyst. Recent reports have increased awareness of this entity. This case typifies findings of conjunctival orbital cysts. These cysts should be considered when a differential diagnosis is formulated for orbital tumors with a similar presentation.

Esophageal balloon cytology and subsequent risk of esophageal and gastric-cardia cancer in a high-risk Chinese population

Linxian, China has some of the highest rates of esophageal/gastric cardia cancer in the world. In 1983, esophageal balloon cytology screening was performed in 3 communes in northern Linxian. Of the participants, 10,066 with no evidence of cancer were followed prospectively for 7 1/2 years to evaluate the ability of the initial cytologic diagnoses to identify individuals at increased risk for developing cancer of the esophagus or gastric cardia. A total of 747 incident cases of esophageal or cardia cancer and 322 deaths due to these tumors were identified during the follow-up period and used in this analysis. The risks for esophageal or cardia cancer incidence and mortality increased in parallel with the presumed severity of the 1983 Chinese cytologic diagnoses. After adjusting for potential confounding factors, relative risks for esophageal or cardia cancer incidence, by initial cytologic diagnosis, were normal = 1.00 (reference), hyperplasia = 1.25, dysplasia 1 = 2.20, dysplasia 2 = 4.22 and near-cancer = 5.96. Our results suggest that esophageal balloon cytology, as performed and interpreted in Linxian in 1983, successfully identified individuals at increased risk for developing cancer of the esophagus or gastric cardia.

The airway in the obstetrical patient

Airway management of the parturient has serious implications for the anesthetist. Meticulous patient evaluation and preparation is essential. A management plan that can be implemented in the event of failed intubation should be familiar to all anesthetists who are involved in obstetrical anesthesia.

Reversal of megaduodenum and duodenal dysmotility associated with improvement in nutritional status in primary anorexia nervosa

Anorexia nervosa is considered one type of eating disorder that may result in severe malnutrition. Patients with this disorder commonly complain of postprandial nausea, abdominal pain, and distension. We describe the radiologic and motility abnormalities associated with anorexia nervosa in a 21-year-old female. Barium gastrointestinal series demonstrated marked dilation of the duodenum, with prolongation of intestinal transit. A 4-hr fasting gastroduodenal motility study showed no propagating migrating motor complexes (MMC). Prolonged, but nonpropagating, bursts of high-amplitude phasic and tonic contractions were seen in the duodenum. In contrast, antral contractions were of low amplitude and esophageal motor function was normal. Metoclopramide and edrophonium caused an increase in gastroduodenal motor activity, but increased contractions were not associated with symptoms. Following a renutrition program that raised the patient's weight from 64 to 80% of her ideal body weight, the radiographic abnormalities and gastrointestinal dysmotility resolved completely. These observations suggest that anorexia-associated gastrointestinal motor dysfunctions are a consequence, not the cause of the generalized protein-calorie malnutrition associated with anorexia nervosa. The facts that motility in different parts of the gut is affected to different degrees and that gastric and duodenal muscle responds normally to exogenous stimulation argue against a generalized myogenic dysfunction and, rather, point to a reversible dysfunction of neural regulation.

Concepts of "tissue PO2" in relation to O2 delivery

Resistance to O2 diffusion is reflected in the difference in pO2 between O2 reservoirs of hemoglobin (Hb) and myoglobin. The very low normal myocyte pO2 (less than one torr but adequate for optimal oxidative ATP synthesis) compared to venous pO2 indicates that blood does not achieve equilibrium with tissue during its passage through capillaries. In the lung, diffusion rate of O2 from alveolus to capillary is normally sufficient to achieve essential equilibrium. However, system-wide capillary pathology and reduced Hb saturation has been observed with distal local ischemia. In peripheral vascular disease (PVD) patients, we found a mean arterial pO2 of 77 torr (normal over 90 torr). Classical concepts based on "tissue pO2" values derived from venous blood or oxygen electrodes inserted into tissue need re-evaluation. Readings of O2 electrodes moved through tissue range widely from intracapillary levels down toward intracellular levels and do not reflect the pO2 of any particular site. Intravenous pO2 is the result of residual O2 after incomplete diffusion out of capillaries during transit through a tissue, and is not an equilibrium value with some tissue pool. The effect of HbO2 p50 on oxygen release during the passage of blood through a capillary bed, generally judged on the basis of percentage percent saturation at "tissue pO2", should be judged on the basis of the change in pO2 (the diffusion driving force) associated with a particular degree of HbO2 saturation at a particular p50. The thesis that O2 diffusion rate is a major determinant of oxygen delivery is supported by pO2 responses to treatment of PVD that does not alter blood flow or p50.

The effect of corticosteroids on inspiratory muscle performance in humans

Functional alterations in the inspiratory muscles were evaluated in patients receiving corticosteroids for diseases other than respiratory. Inspiratory muscle strength, as expressed by the maximal inspiratory mouth pressure (PImax), and inspiratory muscle endurance (PmPeak/PImax), using a pressure threshold breathing device, were evaluated in eight patients with normal pulmonary and inspiratory muscle functions (two patients with rapidly progressive glomerulonephritis, two with glomerulonephritis with minimal changes, two with idiopathic thrombocytopenic purpura, and two with subacute thyroiditis). There was a gradual decrease in both inspiratory muscle strength and endurance following corticosteroid administration. After 8 weeks of treatment PmPeak/PImax decreased from 84.4 +/- 2.4 to 67.9 +/- 3.1 percent (p < 0.001), while inspiratory muscle strength dropped from 126.9 +/- 9.6 to 86.5 +/- 7.4 cm H2O (p < 0.005). Gradual steroid dosage tapering resulted in marked improvement in both strength and endurance; the inspiratory muscle strength rose significantly to 112.2 +/- 8.1 cm H2O (p < 0.0005) when steroid treatment was stopped, and even more significantly 6 months later (to 123.1 +/- 8.1 cm H2O [p < 0.0001]), and the PmPeak/PImax rose to 60.6 +/- 3.4 percent (p < 0.001) and to 74.7 +/- 3.2 percent (p < 0.0001), respectively. We conclude that corticosteroids have a significant deteriorating effect on respiratory muscle function in humans. This weakness is reversible while tapering steroid dosage. Steroid therapy should be reconsidered in patients with underlying lung disease.

Thallium-201 scintigraphy for assessment of a gallium-67-avid mediastinal mass following therapy for Hodgkin's disease

Differentiating thymic rebound from recurrent tumor may be difficult in pediatric patients following chemotherapy for Hodgkin's disease. We present a patient who had both a negative 67Ga scan and computed tomography (CT) of the chest at diagnosis and demonstrated gallium avidity and CT evidence of a new mediastinal mass at the completion of chemotherapy. There was, however, no other clinical or laboratory evidence of disease recurrence. Thallium-201 imaging was subsequently performed and demonstrated no significant radionuclide accumulation within this anterior mediastinal mass. CT shows only the presence of a mass, but not it's nature. Gallium-67 scintigraphy, while used widely as an indicator of tumor viability, may demonstrate increased uptake in cases of thymic rebound. Thallium-201 imaging has previously been shown to demonstrate increased uptake in mediastinal malignancy. Conversely, no significant mediastinal uptake of 201Tl, as in this case, provides additional supportive evidence for a benign mediastinal entity such as thymic rebound.

The revival of nitric acid for the treatment of anogenital warts

The destruction of small lesions by tissue denaturation (fixation) rather than erosion (acid hydrolysis) is accomplished by nitric acid of moderate strength in which nitric acid reduction products are generated by nitric acid oxidation of added organic acids. Such solutions show a temperature-dependent increase or loss of nitrite during storage, with loss of therapeutic activity when nitrite levels decrease after storage at cooler temperatures. Use of a preparation technique that completely consumes all the oxidizable organic components added to generate nitrite results in a stable preparation that is effective, well tolerated, and convenient in the treatment of anogenital warts (condylomata acuminata). Of 50 patients monitored after treatment with a 6.6 mol/L nitric acid preparation with no residual oxidizable organic agents, results were good in 39 patients, satisfactory in four patients, and unsatisfactory in seven patients. These observations lead to a simplified stable preparation of modest nitric acid concentration with adequate nitrate reduction products for efficacy in the topical ablation of small skin lesions such as condylomata acuminata.

Oxygen transport in peripheral arterial occlusive disease: effects of calf blood dialysate

The obvious relationship of arterial blood flow to tissue hypoxia has led to the relative neglect of secondary mechanisms that might influence the functional and morphologic consequences of major vessel obstruction. Oxygen diffusion through capillaries, both locally and systemically, may be disturbed in subjects with chronic local ischemia. Follow-up data after a double-blind, placebo-controlled evaluation of the effect of treatment with a calf blood dialysate confirm that such treatment may alleviate the consequences of peripheral arterial obstructive disease even though there is no improvement in blood flow through the arterial system involved.

A mutational analysis of the polypyrimidine tract of introns. Effects of sequence differences in pyrimidine tracts on splicing

The polypyrimidine (py) tract of introns is required for efficient spliceosome assembly and splicing of pre-mRNAs. A detailed mutational analysis of the py tract of an adenovirus 2 intron was carried out. Utilizing a "precursor in pieces" vector system, it was possible to synthesize py tract mutant pre-mRNAs that were otherwise identical. The mutant pre-mRNAs that were otherwise identical. The mutant pre-mRNAs were analyzed for in vitro splicing, for formation of splicing complexes, and for binding to proteins in the HeLa nuclear extract. Chimeric pre-mRNAs that contained the yeast branch point consensus sequence (UAC-UAAC) and altered py tracts were also analyzed. Mutational analysis showed the following. First, any mutation in the py tract that affected splicing did so by interferring with complex A formation in spliceosome assembly. Second, introduction of purines into the py tract is detrimental only if the length of the tract is shortened and if there is a reduction in the number of consecutive uracil residues. Third, uracil and cytosine do not have equivalent functions in the py tract. Our results with chimeric pre-mRNAs also show that a strong py tract can partially replace a weak branch point sequence and a strong branch point sequence can partially replace a weak py tract. Finally, the one surprising finding obtained when examining protein binding was that a mutant pre-mRNA did not bind to heterogeneous nuclear ribonucleoprotein C proteins and yet spliced close to wild type level.

Increased renal drug metabolism in treadmill-exercised Fischer-344 male rats

Renal cytochrome P-450 levels, metabolism of acetaminophen (APAP) and aminopyrine, and activities of several phase II-associated enzymes [UDPGT, beta-glucuronidase, and glutathione-S-transferase (GST)] were determined in sedentary and exercised young and middle-aged Fischer-344 male rats. After an 8-week exercise regimen consisting of treadmill running at a moderate intensity, renal microsomal cytochrome P-450 levels were increased 60% and 37% in young and middle-aged runners, respectively. Exercise was found to increase renal deacetylation of APAP to the nephrotoxic metabolite p-aminophenol by 54% in young and 26% in middle-aged rats. Aminopyrine N-demethylase activity was increased 97% in the young runners only. In contrast, UDPGT, beta-glucuronidase, and GST activities were unchanged by treadmill running. NADPH-cytochrome c reductase activity, determined in young animals only, was also unaltered by exercise. Advanced age decreased renal cortical cytochrome P-450 content by 34% while having no effect on p-aminophenol production. Aminopyrine N-demethylase activity was increased by 130% with increased age. The only phase II-associated enzyme altered by age was GST activity, as sedentary middle-aged animals exhibited a 43% decrease in activity when compared with young rats. Young exercised rats did not gain weight as rapidly as sedentary rats, and middle-aged rats had a slight loss in weight during exercise. Moreover, running resulted in 30-36% less food consumption during the experimental period. In conclusion, this study demonstrated that exercise increased renal phase I drug metabolism without influencing phase II processes; furthermore, a substrate-specific modification of the response to exercise was observed in the aged rats.(ABSTRACT TRUNCATED AT 250 WORDS)

[Unusual treatment for myasthenia gravis associated with asthma]

Abnormal antibody production is now recognized as the basis of many diseases, among them myasthenia gravis (MG) and a variant of bronchial asthma. It is not unusual to find 2 or even more of these diseases in the same patient. A patient in whom both MG and bronchial asthma were diagnosed is presented. In both diseases the respiratory muscles are mechanically disadvantaged, which may result in severe dyspnea. In our case, despite specific treatment for both diseases severe attacks of dyspnea still occurred. Specific inspiratory muscle training was followed by significant clinical improvement. There was indirect evidence that respiratory muscles can be trained in patients with MG. Thus, patients with MG with respiratory muscle involvement may benefit from respiratory muscle training.

Requirement of cellular uptake for adenosine inhibition of p-nitrophenol glucuronidation in isolated rat hepatocytes

Adenosine (ADO) has been shown previously to inhibit p-nitrophenol glucuronidation in a concentration-dependent manner when concurrently incubated in isolated rat hepatocytes for 30-60 min. In the current study, preincubation of ADO (500 microM) in isolated hepatocytes for 30 min prior to addition of 100 microM p-nitrophenol resulted in a greater inhibition of glucuronidation when compared to that without preincubation (80 vs 50% inhibition). The inhibitory effect of 250 microM ADO on glucuronidation was decreased from 60 to 10% in the presence of the ADO transport inhibitor nitrobenzyl thioinosine during the 30-min preincubation period. Without prior incubation, 100 microM dibutyryl cyclic AMP (DBcAMP) produced an inhibition of glucuronidation similar to that of 500 microM ADO. In contrast to ADO, there was no significant difference in the inhibitory effect of DBcAMP on p-nitrophenol glucuronidation with or without a 30-min preincubation. Thus, DBcAMP and ADO appear to inhibit glucuronidation through different mechanisms. Furthermore, these results indicate that the inhibitory effect of ADO on p-nitrophenol glucuronidation is dependent to a large degree on the cellular uptake of ADO into hepatocytes, while a portion of the inhibitory effect may arise from the generation of intracellular cyclic AMP.

[Inspiratory muscle training combined with general exercise reconditioning in chronic obstructive pulmonary disease]

In a controlled clinical trial, we compared the effect of 6 months of specific inspiratory muscle training combined with general exercise reconditioning, with that of general exercise reconditioning alone. We measured the effects of the 2 regimens on inspiratory muscle strength, endurance, and exercise performance in patients with chronic obstructive pulmonary disease (COPD), 2 groups of 10 patients each. Inspiratory muscle strength (expressed as the PImax at RV) increased significantly from 43.2 +/- 3.0 to 67.8 +/- 2.9 cm H2O (p < 0.0001) and respiratory muscle endurance (expressed as the relationship between PmPeak, the pressure achieved with the heaviest load tolerated for at least 60 sec, and PI max) increased significantly from 60.2 +/- 2.5 to 85.6 +/- 2.8% (p < 0.001) in the first group (combined treatment). After the 6-month training period, in both groups there were significant increases in 12-minute walk and endurance work time at 2/3 of Wmax (maximal work each subject achieved on a progressive bicycle exercise test of maximum work load). However, those in the first group showed significantly greater improvement in distance walked and endurance time than the others. We conclude that specific inspiratory muscle training for 6 months improves inspiratory muscle strength and endurance in patients with COPD. This training, combined with general exercise reconditioning, also results in improvement in exercise tolerance significantly greater than that of general exercise reconditioning alone.