Diagnosis of delayed cerebral radiation necrosis following proton beam therapy

A 27-year-old man developed delayed cerebral radiation necrosis following proton beam therapy to an arteriovenous malformation. Neuroimaging with technetium 99m diethylenetriamine penta-acetic acid and positron emission tomographic scanning with fludeoxyglucose F 18 aided in his evaluation. Significant improvement of his neurologic deficits resulted from corticosteroid therapy. Clinical resolution was corroborated by serial computed tomographic scans demonstrating regression of the abnormality (a mass lesion). Various facets of radiation injury are discussed, including pathogenesis, risk factors, diagnosis, and therapy.

Technical aids in surgery. Two muscle-sparing thoracotomies--techniques and indications

Two types of muscle-sparing thoracotomies are described. They have been used over the past 11 years in 396 patients. These incisions are ideal for wedge resections, biopsies, exploratory thoracotomies, excisions of emphysematous blebs, decortications, and a variety of other operations, including pulmonary resections in selected patients. They provide entirely adequate exposure, while minimising the trauma of thoracotomy.

The 56 kDa androgen-binding protein in human genital skin fibroblasts: its relation to the human androgen receptor

We have recently described in genital skin fibroblasts (GSF) a relatively abundant 56 kDa protein with androgen-binding activity. This protein is missing in GSF of most patients with complete androgen insensitivity syndrome (CAI). The protein has many characteristics compatible with the androgen receptor; it has in fact been tentatively considered as a precursor or degradation form of the prototypic (approximately 100 kDa) human androgen receptor. We have prepared an antiserum to this protein, which allowed us to detect it as a direct product by in vitro translation of mRNA from GSF. It is thus very unlikely to be a degradation product of a larger precursor. Furthermore, covalent photolytic labeling of this protein with the androgen analogue [3H]mibolerone revealed a much lower affinity for this protein than is known for the androgen receptor. Finally, the GSF of two exceptional patients with complete androgen insensitivity syndrome due to negligible androgen receptor-binding activity express this protein normally, as determined on two-dimensional gels by Western blot analysis with the antiserum and by photolytic covalent labeling with androgen analogues. These data indicate that the protein is not a precursor or a degradation product of the receptor; nor is it androgen-induced. They are more compatible with the idea that the protein is another member of the steroid/thyroid/retinoic acid receptor supergene family, perhaps as an unorthodox product of the human androgen receptor gene.

Androgen receptor defects in patients with minimal and partial androgen resistance classified according to a model of androgen-receptor complex energy states

We have characterized intracellularly the androgen-receptor (A-R) complexes formed by genital skin fibroblasts from 2 unrelated males with qualitative defects of the androgen receptor: one has a small nonhypospadic penis as part of a syndrome of mild androgen resistance; the other was born with ambiguous external genitalia. The dissociation rate constants of testosterone, methyltrienolone (MT), dihydrotestosterone (DHT) and mibolerone (MB) from normal androgen receptors were determined at various temperatures: when plotted by the method of Arrhenius, they yielded a linear hierarchy of dissociation states with energies of state IV greater than III greater than II greater than I, respectively. Relative to this hierarchy, patient A-R complexes were displaced to higher, androgen-inappropriate energies in a mutant-distinctive pattern. MB- or MT-R complexes of both patients were thermolabile; however, both up-regulated normally in response to prolonged incubation with either hormone. Apparent equilibrium affinity constants (Kd) of the DHT- and MB-R complexes formed by both patients were normal; however, the binding capacity (Bmax) for MB in 1 case was subnormal. The distinctive biochemical phenotypes of A-R complexes in these 2 patients with androgen resistance will facilitate the definition of structure-function relations in the androgen receptor, a classical DNA-binding, transcription-regulating protein.

Are dietitians prepared to work with handicapped infants? PL 99-457 offers new opportunities

PL 99-457 mandates nutrition as one of eight disciplines to be included on the team providing services to handicapped infants (up to age 3) and their families. A case-managed range of services is required to enable the child to benefit from early interventions. Findings from a survey of a sample of entry-level Plan IV/V Programs, Coordinated Programs in Dietetics, and dietetic internships randomly selected from The American Dietetic Association's 1988 Directory of Dietetic Programs indicate that the growth and development of handicapped infants and their nutrition care are underexposed in most didactic and experiential components of the education of entry-level dietitians. A working group of nine nutritionists with expertise in both dietetic education and nutrition care of handicapped children met at a national conference and recommended competencies that they thought would enable entry-level registered dietitians to join interdisciplinary teams working with handicapped infants and their families. Registered dietitians on the team that prepares the Individualized Family Service Plan (IFSP) can strive to ensure that infants are well nourished and therefore more responsive to the other therapies proposed in the plan.

Ultracentrifugal analysis of the junction complexes of the red cell membrane cytoskeletal network: application to hereditary spherocytosis and metabolically depleted cells

A method has been developed for the assessment of the number of spectrin dimer units associated with each actin protofilament junction, in the membrane cytoskeletal network (i.e. the degree of branching) of the red cell. Ghosts are first exposed to elevated temperature at low ionic strength to dissociate some 65% of the spectrin tetramers (that link the network junctions) into dimers, without causing their release from the actin filaments. Non-ionic detergent is then added to solubilize the membrane itself with its intrinsic proteins, so as to liberate the cytoskeletal material, and the mixture is immediately examined in the analytical ultracentrifuge. The predominant components observed are isolated junctions (20 S), free spectrin dimers and the residual undissociated cytoskeletal material, with very minor components, probably corresponding to multiple junctions, linked by spectrin tetramers. The junction boundary is homogeneous within the accuracy of measurement and is taken to correspond to a complex containing six spectrin dimers, known to predominate in situ. About 17% of the total network is liberated in this form and 12% as free spectrin dimers. In hereditary spherocytosis both the size of the junction complex (as reflected by its sedimentation coefficient) and the proportion of the complex and of free spectrin liberated are indistinguishable from normal values. We conclude that the reported deficit of spectrin in hereditary spherocytosis is not reflected by a lower degree of branching of the network, and, if the membrane area is not correspondingly reduced, this must mean that the junctions are more widely spaced and the spectrin tetramers therefore more extended. In metabolically depleted cells, in which the cytoskeletal proteins are known to be extensively dephosphorylated, there is no change in the sedimentation pattern and thus no detectable loss of spectrin from the junctions or weakening in the cohesion of the cytoskeletal network.

A single-site allosteric model of intracellular androgen-receptor interaction

We present a single-site, two-state model for analyzing the effect of time and ligand concentration on the extent and character of 5 alpha-dihydrotestosterone, methyltrienolone or mibolerone binding to the specific androgen receptor within cultured human genital skin fibroblasts. The model has three basic attributes: formation of the initial low-affinity androgen-receptor complex, and its transformation to a higher affinity state are irreversible, first-order processes; and receptors released from complexes in each state not only differ from each other and from their pre-liganded progenitor, but can also reassociate with androgen to yield complexes in their respective parental states. The rate constants of dissociation and apparent equilibrium binding constants of the two affinity states were determined for each of the three androgens within normal cells and those of a transformation-defective mutant. When these values are combined with estimates of the rate constants at which the complexes are formed and transformed, the model accurately simulates time-dependent changes in the slopes and character of experimental Scatchard plots. It can also generate Scatchard plots that are concave, convex or sigmoidal simply by making sequential changes in its formation or transformation constants. Thus, our model can explain complex ligand-receptor binding kinetics that have heretofore been interpreted according to alternate models of transformation and binding-site multiplicity with or without properties of cooperativity, and it supports the notion that receptor recycling involves intermediate receptor states.

Impaired spermatogenesis is not an obligate expression of receptor-defective androgen resistance

We are studying a man who presented at age 21 years with severe extragenital subvirilization despite high-normal to above-normal levels of plasma testosterone for at least 5 years. At puberty, his penis, scrotum, and testes matured normally, and he did not develop gynecomastia; however, his voice, muscularity, and facial, sexual, and body hair remained immature. A 2.5-ml ejaculate yielded normal results for sperm density, morphology, and motility. Because persistent undervirilization was emotionally disabling, he has received pharmacologic doses of testosterone enanthate intramuscularly for 3.5 years. The treatment has improved his virilization and masculine self-image substantially, and his semen analysis has remained well within the normal range. The androgen receptor in his genital skin fibroblasts has a distinctively mutant phenotype: it has a low affinity (increased apparent equilibrium dissociation constant, Kd) for 5 alpha-dihydrotestosterone and two synthetic androgens, mibolerone (MB) and methyltrienolone (MT), and its binding capacity (Bmax) is normal for the other two ligands, but questionably low for MT. In addition, it up-regulates its activity normally in response to prolonged incubation with androgen, and its androgen-receptor complexes are not thermolabile. Our study of this man permits two conclusions: impaired spermatogenesis is not the irreducible expression of receptor-defective androgen resistance in man; and androgen pharmacotherapy may be remedial for those in whom extragenital subvirilization is emotionally costly and subnormal spermatogenesis is not an inevitable side effect of such therapy.

Nutrition services in state and local public health agencies: how do we measure up in 1987?

In 1987, a second biennial mail survey of public health nutritionists in 54 state official public health agencies identified 2,048 budgeted positions compared with 2,931 in 1985, a 30% loss in the state and local health agencies. To achieve the recommended staffing ratio of one public health nutritionist per 50,000 population for policy, program planning, and program management, an estimated 2,812 more nutritionists are needed for a total of 4,850, or a 60% increase. The number of state personnel systems requiring graduate public health training decreased from 19 to 6, while the number requiring R.D./registration eligibility increased from 24 to 33. Fifty-five percent of positions for public health nutritionists are funded from the Special Supplemental Food Program for Women, Infants, and Children, and 10% from the Maternal and Child Health Block Grant. Positions funded from state general revenue doubled from 8% in 1985 to 15% in 1987, while local revenue stayed at about 10%. The midpoint of state salary ranges for the public health nutritionists varied from $14,310 to $38,310. Perceived constraints to expanding nutrition services were inadequate state funding, low agency visibility, and low legislative priority. At a time when consumer interest in nutrition is high and research associates dietary factors with major public health problems, the challenge is to advocate more aggressively for public health nutrition services and funding.

Recurrent intracranial hemorrhage in an adult with moyamoya disease: case report, radiographic studies and pathology

Moyamoya disease is an unusual vascular disorder highlighted by progressive bilateral internal carotid artery occlusion and collateralization of intracranial blood flow. Recurrent multifocal cerebral ischemic events and isolated intracerebral hemorrhage are known to occur in this disorder. We report a 52 year old man who over a nine year period had four apparent intracranial hemorrhages. Serial angiograms demonstrated the evolution of moyamoya disease. Pathologic examination confirmed multiple vascular lesions, including two that were clinically silent.

An abundant 56 kD protein with low affinity androgen binding: another member of the steroid/thyroid receptor family?

We have found in genital skin fibroblasts an abundant 56 kD protein which appears related to the androgen receptor. The protein is detected in the soluble fraction by two-dimensional polyacrylamide gel electrophoresis as two spots with isoelectric points of 6.7 and 6.5 respectively. Photoaffinity labelling of GSF with 8 nM or 50 nM [3H]-methyltrienolone selectively labels the two protein spots but with an apparently lower affinity than is known for the androgen receptor. The two protein spots stem from one protein as judged from peptide patterns of partial proteolytic digests and the equal labelling of both spots with methyltrienolone. Cells from subjects with mutant androgen receptors generally lack the 56 kD protein and labelling with methyltrienolone fails, but the protein is not the androgen receptor itself. We propose the hypothesis that the 56 kD protein is synthesized from the same gene as the androgen receptor and that androgen may not be its natural ligand.

Traumatic perforations of the esophagus

Over the past 15 years nine patients with traumatic mechanical perforations of the esophagus have been treated. Seven perforations were iatrogenic, two were accidental. One patient treated conservatively did well. Two patients were operated on without delay. Their hospitalization was short and they had no complications. Six patients were referred to surgery after a delay ranging from 5 days to 17 days from the time of perforation. Their hospitalization ranged from 9 to 113 days, averaging 62.7 days. Complications were common and two patients died. In order to assure survival of patients with esophageal perforation, early aggressive treatment is essential in nearly all instances. In an occasional patient with a small and clean perforation at the esophageal inlet, conservative treatment may be justified.

Promoting breastfeeding at a migrant health center

A program to promote breastfeeding was introduced at a migrant health center in North Carolina. Strategies for promoting breastfeeding as a feeding method particularly suited to the migrant lifestyle were identified and implemented. Donated layettes were used to encourage attendance of prenatal patients at a class on breastfeeding. Women planning to breastfeed were given cards to alert the delivering hospital of their intention. These hospitals were provided with bilingual flipcharts to use in communicating with non-English speaking patients. Of the 158 women who came to the center for one or more prenatal visits, 101 attended a class or received individual counseling on breastfeeding; during this 13-month period, 52 per cent of 64 women who attended the class were breastfeeding at time of their hospital discharge (Mexican-Americans 60%, Black Americans 44%). In a comparison of similar ethnic distribution, the corresponding rate was 10%.

A study of androgen-resistant subjects indicates that the 6.7 pI/56 kDa protein in genital skin fibroblasts is related to the androgen receptor

Two-dimensional gel electrophoresis of cultured human skin fibroblast lysates reveals a silver-stained "spot" of molecular mass 56 kilodaltons (kDa) and isoelectric point (pI) 6.7, occasionally as part of a doublet with a minor pI 6.5 partner. Its presence in each of 23 genital skin fibroblast strains (6 labium majus, 17 prepuce) and its absence in 30 of 32 control non-genital skin fibroblast strains accords with the 3-fold greater concentration of androgen-receptor activity in the former. However, the size and intensity of the spot do not change when cells are preincubated for 48 hours with 3 nM methyltrienolone (MT, a non-metabolizable androgen), and it is pulse-labeled with [35S]methionine to an autoradiographically equal extent, with or without incubation in 3 nM MT for 2 or 16 hours. Furthermore, the protein identified by the spot is found in the labium majus skin fibroblast strains from 2 of 12 unrelated subjects with complete androgen resistance due to negligible androgen-receptor activity, but it is absent from those of 2 others who have the same phenotype despite a normal level of qualitatively abnormal androgen-receptor activity. Hence, it is very unlikely to be an androgen-induced protein, and it cannot be a functional version of the androgen receptor itself. Its absence in 12 of 14 labium majus strains of subjects with complete androgen resistance, regardless of 5 alpha-reductase activities, indicates that it is neither a constitutive cytotypic marker of genital skin fibroblast differentiation nor a reflection of that enzyme. When intact prepuce fibroblasts are covalently labeled by photolysis with 50 nM [3H]MT, the only specific labeling detectable after two-dimensional electrophoresis is in the 6.7 and 6.5 pI doublet of the 56 kDa protein. Considering the sensitivity of silver staining and the incomplete concordance between the androgen-receptor activity of a strain and the size/intensity of its 6.7 pI/56 kDa spot on the gels, we postulate the latter to be a comparatively abundant androgen-binding protein that is causally related to the androgen receptor. The precise nature of this relation remains to be elucidated by use of novel immunologic and/or nucleic acid probes for this protein and for the mature androgen receptor. In any event, the presence or absence of the 6.7 pI/56 kDa protein in genital skin fibroblast lysates is a new marker of genetic heterogeneity within the class of complete androgen resistance.

Clinical stages of dementia and the dexamethasone suppression test

1. This study was undertaken to evaluate the relationship between clinical aspects of primary degenerative dementia and suppression or non-suppression in the dexamethasone suppression test. 2. We studied 34 male patients with primary degenerative dementia (as diagnosed by DSM-III criteria). Dexamethasone 1 mg p.o. was administered at 11:00 PM and blood was drawn for cortisol determination at 4:00 PM the next day. 3.

CLINICAL FACTORS INCLUDED

age, age at onset, duration of dementia, history of psychiatric illness, severity as measured by Global Deterioration Scale (GDS) score, and "malignancy" of dementia (rated by years of onset to institutionalization and as a ratio of Global Deterioration Scale to duration of primary degenerative dementia). 4.

RESULTS

56% of primary degenerative dementia patients failed to suppress. The highest degree of non-suppression was seen in Global Deterioration Scale 5 and 6 subjects (Table). 5. An unexpected finding was that a large number of Global Deterioration Scale 7 patients demonstrated normal post-dexamethasone suppression of the hypothalamic-pituitary-adrenal axis. 6. Some contradictions in previously reported studies may be explained by this pattern.

Model analysis of the bases of multistationarity in the humoral immune response

A formal analysis of the regulation of antibody production has been developed. It comprises two complementary approaches: a logical analysis in terms of discrete (boolean) variables and functions and a more classical analysis in terms of differential equations. A first paper dealt mostly with the logical description which provided global information on how complex the network needs to be in order to account for some main aspects of the immune response, without having to specify the details of the cellular interactions or to introduce a great number of parameters. Here we present the continuous approach and, in particular, a detailed study of the steady states and a discussion of their role in the dynamics of the immune response. The model subject to this analysis is a minimal one, which takes into account a small number of well-established facts concerning lymphocyte interactions and some reasonable assumptions. The core of the model is a negative feedback loop between the helper (TH) and suppressor (TS) T lymphocytes on which autocatalytic loops of the TH and TS populations on themselves are grafted. The salient feature of this minimal scheme is the prediction, for given environmental and parametrical conditions, of a multiplicity of steady states. This multistationarity occurs both in the absence of antigen or for constant antigen levels. Variations in the external constraints provoke switches among the steady states which might be related to the various modes of the humoral immune response, and depend on the doses of antigen injected and on the previous antigenic history of the system. In particular, high and low dose paralysis appear to be associated with two distinct steady state branches.

Extracellular correction of the androgen-receptor transformation defect in two families with complete androgen resistance

We have characterized the cellular and extracellular phenotype of the mutant androgen receptor (AR) from two families who have complete androgen resistance despite a normal androgen-binding capacity (Bmax) in their genital skin fibroblasts (GSF). The cellular receptors fail to up-regulate their basal AR activity in response to prolonged incubation with 5 alpha-dihydrotestosterone (DHT), or with two synthetic androgens, methyltrienolone (MT) and mibolerone (MB), and form A-R complexes with increased equilibrium (Kd) and non-equilibrium (k) dissociation constants. In addition, they are thermolabile when recently dissociated, but not in their native state. A-R complexes made in normal or mutant cytosol at 4 degrees C elute from DEAE-Sephacel at approximately 0.25 M KCl (untransformed), with or without prior passage through Sephadex G-25; when made in cells at 37 degrees C, extracted with 0.4 M KCl in a buffer containing 10 mM Na2MoO4, and desalted by G-25, they elute at less than or equal to 0.1 M KCl. Normal KCl-extracted DHT- and MB-R complexes dissociate (37 degrees C) at the same slow, linear rate as their in-cell counterparts (transformed); the mutant ones dissociated more slowly than their rapidly-dissociating in-cell counterparts and, to a variable extent, nonlinearly-an early faster phase, a later slower (transformed). Thus, as judged by two conventional criteria of steroid-R complex transformation, the mutant A-R complexes can transform, possibly in two steps, under certain cell-free conditions. This behavior differentiates a class of structural AR mutations whose molecular definition awaits application of recombinant DNA techniques to the X-linked AR locus.

Biological activity, binding, and metabolic fate of Ac-[Nle4, D-Phe7]alpha-MSH4-11NH2 with the F1 variant of B16 melanoma cells

The alpha-MSH (alpha-melanocyte-stimulating hormone) agonist, Ac-[Nle4, D-Phe7]alpha-MSH4-11NH2 (hereafter called ND4-11 alpha-MSH), is at least 10-fold more potent than alpha-MSH as a stimulus of tyrosinase activity in F1 variant cells of B16 melanoma. The binding to these cells during an incubation with 5 nM (3H)ND4-11 alpha-MSH at 37 degrees C is maximal at 0-30 min, 22 fmol/10(6) cells, but declines to 40% of this value at 4 hr. in the presence of 5 nM (3H)ND4-11 alpha-MSH at 37 degrees C, the acid soluble (cell surface) radioactivity decreased rapidly from 11.4 fmol/10(6) cells at 5 min to 4.6 fmol/10(6) cells at 4 hr. Chromatographic analysis of media and cellular samples revealed that there was no evidence of degradation of (3H)ND4-11 alpha-MSH in the medium but there was evidence of intracellular degradation of (3H)ND4-11 alpha-MSH. Ammonium chloride (10mM) resulted in an increase in acid resistant radioactivity (internalized hormone) at 4 hr. The binding to F1 variant cells during an incubation with 0.155 nM or 5 nM (3H)ND4-11 alpha-MSH at 4 degrees C was constant from 4 hr to 24 hr. Under these conditions, there was no time-dependent change in the acid soluble radioactivity from 4 to 24 hr. Scatchard analysis of (3H)ND4-11 alpha-MSH binding to F1 variant cells at 4 degrees C demonstrated that there were approximately 4500 receptors per cell and an association constant of 17.1 nM-1. These results are consistent with a process of (3H)ND4-11 alpha-MSH binding to its receptor followed by internalization of the receptor-hormone complex and then intracellular degradation of the hormone.

Fine-needle aspiration biopsy in diagnosis of pulmonary masses

Fine-needle aspiration biopsy (FNAB) is a diagnostic method indicated in patients with pulmonary lesions that cannot be reached with a bronchoscope and when cytologic examinations of the sputum are persistently negative. Cells are aspirated under fluoroscopic control and stained using the Papanicolaou method for cytologic examination. Results are available within hours, and the material can be used for other studies. Between 1975 and 1984, the authors performed 845 FNABs in 342 patients. Diagnosis was established in 306 patients, or 89.5 per cent. Malignant neoplasm was diagnosed in 284 instances, benign disease in 22. In 176 patients with malignant tumors, the diagnosis was based on FNAB exclusively. In 108 patients who were operated on, the results of FNAB matched histology in 97 per cent. The aspiration specimen was inadequate in 36 patients, most of whom had diffuse lung disease. The incidence of complications was extremely low. FNAB is safe and reliable. It is recommended for use in clinical workup of undiagnosed pulmonary masses. FNAB enables rational planning of treatment when other diagnostic methods fail. The authors do not recommend FNAB for use in cases of diffuse pulmonary disease.

Partial androgen resistance due to a distinctive qualitative defect of the androgen receptor

Using whole genital skin fibroblasts, we have characterized a novel androgen receptor mutation in a family with partial androgen resistance. The proposita was born with bilateral labioscrotal folds and a single perineal urogenital orifice. Her similarly affected maternal aunt was raised as a female with the support of gonadectomy and vaginoplasty. The mutant androgen receptor has a normal maximum binding capacity (Bmax), but an increased apparent equilibrium dissociation constant (Kd) with 5 alpha-dihydrotestosterone (DHT) and 2 synthetic androgens, methyltrienolone (MT) and mibolerone (MB). Preformed mutant DHT-receptor complexes dissociate (k) at a near-normal rate, but their MT and MB counterparts dissociate twice as quickly as normal. The native free mutant receptor is not more thermolabile than normal, but its recently dissociated counterpart is. Prolonged incubation of the cells with each of the 3 androgens causes the mutant receptor to acquire a normal increment of increased androgen-receptor activity. This androgen-sensitive pattern of misbehavior of the present mutant receptor distinguishes it from those responsible for 3 other families with partial androgen resistance studied previously. These differences will help to identify structure-function domains on the androgen receptor protein, particularly in conjunction with the use of DNA probes to analyze mutations at the X-linked androgen receptor locus.

Progress toward meeting the 1990 nutrition objectives for the nation: nutrition services and data collection in state/territorial health agencies

Promoting Health, Preventing Disease, Objectives for the Nation, specifies nutrition as a priority area for improving the health of Americans by 1990. Eleven of the 15 nutrition objectives target adults or the public while four address pregnant and lactating women, infants, and children. To determine progress by states toward achieving the nutrition objectives, the Association of State and Territorial Public Health Nutrition Directors conducted a survey in 1985 to which 54 state and territorial nutrition directors responded. Three-fourths of the nutrition personnel focused efforts on maternal and child populations, and were supported largely by federal funds from the Special Supplemental Food Program for Women, Infants, and Children (WIC) and the Maternal and Child Health Block Grant. Only 15 per cent were funded by state and local sources. While most agencies reported using nutrition consultation in adult health programs, only 25 per cent paid for these personnel. Data to monitor progress were commonly available for only five of the 15 objectives. Achievement of the nutrition objectives by states will require a more comprehensive approach to nutrition programming with increased allocation of appropriate resources and expansion of health data systems.

Survey of nutritionists in state and local public health agencies

A spring 1985 survey of 50 state and four territorial public health nutrition directors identified 2,931 budgeted positions for public health nutritionists--1,128 in state agencies and 1,803 in local health departments. To achieve the recommended staffing ratio of one public health nutritionist per 50,000 population, an estimated 1,827 more public health nutritionists are needed nationwide with more needed in some states than in others. About half of the state personnel systems require registration or registration eligibility to assure expertise of public health nutrition personnel; about one-third also require graduate training in public health for leadership, planning, and policymaking positions. Sixty-two percent of the funding for state and local health agency nutritionist positions is from the Special Supplemental Food Program for Women, Infants, and Children (WIC). When that is added to the 11% of funds from the Maternal and Child Health Block Grant, 73% of the public health nutritionist positions are federally supported to serve women of childbearing age, infants, and children. That leaves the remaining state and local funding sources and the federal Prevention Block Grant (2%) to pay salaries of nutritionists to serve the general public, including men, postmenopausal women, and the elderly.

Ligand-specific thermal misbehavior of synthetic androgen-receptor complexes in genital skin fibroblasts of subjects with familial ligand-sensitive androgen resistance

We have used 5 alpha-dihydrotestosterone (DHT) and two synthetic, non-metabolizable androgens, methyltrienolone (MT) and mibolerone (MB), to study intact genital skin fibroblasts from four subjects with familial incomplete androgen resistance. In each, the free androgen receptor has normal binding capacity at 37 degrees C and normal half-lives at 37-43 degrees C. In three the mutant receptor misbehaves in a pattern that is ligand-specific and temperature-dependent. At 37 degrees C the equilibrium (Kd) and non-equilibrium (k) dissociation constants, and the ability to augment binding activity during prolonged exposure to androgen, are impaired with DHT, but not with MT; with MB, only the k is abnormal. Mutant MT-receptor complexes dissociate normally even at 42 degrees C; yet, in cells post-incubated at 42 degrees C with cycloheximide and a saturating concentration of ligand, their pool size decays in the rank order, MT greater than MB greater than normal. This measure of lability is nonlinear as a semilogarithmic function of time; it varies directly with temperature and the concentration of cycloheximide, but inversely with that of ligand. Thus, MT and MB evoke distinct forms of thermal dysfunction from the androgen receptor in ligand-sensitive androgen resistance. This observation will help to elucidate the combinatorial properties of normal androgen-receptor complexes that enable them to regulate gene transcription differentially in various androgen target tissues.

Preparing public health nutritionists to meet the future

Public health nutrition personnel have been defined as those specialized nutrition professionals and paraprofessionals who provide nutrition services through agencies whose mandate is health protection and promotion, disease prevention, and/or primary care to people in the community. Educators preparing graduate level nutritionists for future demands of federal, state, and local public health programs must read the scientific, technological, and societal trends, including changes in demographics, health delivery systems, communications technologies, and consumer demands. As research more clearly defines the role of nutrition and diet in human health, nutritionists should be educated to monitor trends and be proactive in seeking emerging opportunities. It is nutritionists' responsibility to assure that scientific findings in nutrition, dietetics, and food science are considered in policy formulation as well as in the technical input into agency and community programs. The nutritionist who understands the changing values and life-styles of diverse populations uses acceptable techniques to motivate any necessary behavior changes. To be effective in the community, he/she uses community assessment, epidemiological, and program planning skills basic to public health practice. In the current climate of cost containment, the public health nutritionist will successfully compete for dwindling funds by managing programs with skill and documenting cost benefits and cost-effectiveness.

The use of talc for pleurodesis in the treatment of resistant empyema

The use of talc in the infected pleural space has not been reported previously. Five patients who had empyema of the pleura in the fibrinopurulent stage and did not respond to treatment with tube drainage and antibiotics were treated by talc insufflation to stimulate pleural adhesions. Pleurodesis was achieved in all 5 patients, with complete recovery from empyema. No untoward effects were observed. These results suggest that talc pleurodesis may be an acceptable solution to the problem of empyema resistant to other methods of treatment.

Towards a logical analysis of the immune response

We present a new way to conceive, formalize and analyse models of the immune network. The models proposed are minimal ones, based essentially on the well-established negative feedback loop between helper and suppressor T cells. The occurrence of T-T interactions in both helper and suppressor circuits. These T-T interactions are represented here by autocatalytic feedback loops on TH and TS. The fact that immature B cells are sensitive to negative signaling, as was originally suggested by Lederberg (1959). There is a functional inactivation of immature B cells encountering antigen or anti-idiotypic antibody. This prevents further differentiation to a stage where the B cells become fully responsive. We describe the role of a logical method in the generation and analysis of the models, and the complementarity between this logical method and the more classical description by continuous differential equations. Logical analysis and numerical simulations of the differential equations show that the emerging model accounts for, the occurrence of multiple steady states (a virgin state, a memory state and a non-responsive state) in the absence of antigen, the kinetics of primary and secondary responses, high dose paralysis, low dose of paralysis. Its fit with real situations is surprisingly good for a model of this simplicity. Nevertheless, we give it as an example of what can now be done in the field rather than as a stable model.

Repair of recurrent inguinal hernia with Marlex mesh

Fifty-seven patients with large recurrent inguinal hernia had undergone repair using Marlex mesh. Fifty-six patients had excellent results, one patient suffered a recurrence. There were two wound infections and no deaths. Polypropylene is an excellent prosthetic material for replacement of attenuated or destroyed posterior wall of the inguinal canal. It is biologically inert and resistant to infection.

Reduced affinity of the androgen receptor for 5 alpha-dihydrotestosterone but not methyltrienolone in a form of partial androgen resistance. Studies on cultured genital skin fibroblasts

We have studied a child with posterior labial fusion, clitoral phallus, female urethra, and a short, blind vagina born to a mother with decreased axillary and pubic hair. Her karyotype is 46,XY. At 2 yr of age, the child's basal level of plasma testosterone was less than 0.35 nM and after human chorionic gonadotropin stimulation, it rose to 2.6. Testis and epididymis histology were normal. Her cultured genital (labial) skin fibroblasts have normal testosterone 5 alpha-reductase activity, and metabolize 5 alpha-dihydrotestosterone (DHT) normally, but they do not augment (up-regulate) their basal androgen-receptor binding activity during prolonged incubation with DHT. With DHT, the androgen receptor in her genital skin fibroblasts has a normal binding capacity (maximum binding capacity = 25 fmol/mg protein), but an increased rate constant of dissociation (k = 11.6 X 10(-3) min-1; normal, 6 +/- 1.2 (+/- SD)), and a decreased apparent equilibrium binding affinity (Kd = 0.6 nM; normal, 0.22 +/- 0.09) that is evident in the results of 2-h assays but not of those lasting 0.5 h. With the synthetic androgen, methyltrienolone, all three binding properties of the receptor are normal, and her receptor activity up-regulates normally. We interpret these results to mean that the subject has a ligand-selective defect in the time-dependent transformation of initial, low-affinity androgen-receptor complexes to serial states of higher affinity, presumably as the result of a structural mutation at the X-linked locus that encodes the androgen receptor protein.

Financing nutrition services in a competitive market

Budget deficits and inflationary medical care costs threaten nutrition services, which until recently have been funded largely by federal, state, and local revenues. Nutritionists and dietitians responding to demands in the marketplace should develop innovative programs and pursue new sources for financing through the private sector, third-party payers, business/industry health promotion, and consumer fees for their services, as well as targeted federal, state, and locally funded food assistance, nutrition education, and health care programs. Trail-blazing dietitians are successfully offering their services in health maintenance organizations (HMOs), hospital or industry fitness programs, private practice, voluntary health agencies, and official agency programs. With the new federalism, nutritionists must articulate their role in comprehensive health care and market their services at the state and local levels in addition to the federal level. Nutrition services are defined to include assessment, planning, counseling, education, and referral to supportive agencies. Data management, managerial, and marketing skills must be developed for dietitians to compete effectively. Basic educational preparation and continuing education for practicing professionals must develop these competencies.

Partial androgen resistance associated with secondary 5 alpha-reductase deficiency: identification of a novel qualitative androgen receptor defect and clinical implications

We studied a family in which three brothers were born with ambiguous genitalia and had poor virilization at puberty. One patient (II-5) required less surgery to repair his hypospadias and is lean, muscular, and hairy compared to his brothers (II-1, II-2). Their adult levels of plasma testosterone (T) range from 765-2250 ng/dl. The plasma T to 5 alpha-dihydrotestosterone (DHT) ratios were 29 (n = 5) in patient II-1, 25 (n = 2) in patient II-2, and 14 (n = 2) in patient II-5, compared to 12 +/- 3 (SD) in normal men. The mean urinary etiocholanolone to androsterone ratios were 1.9 (n = 2) in patient II-1, 2.0 in patient II-2, and 1.3 in patient II-5, compared to 0.87 +/- 0.34 in normal men. The mean urinary ratios of 5 beta-tetrahydrocorticosterone to 5 alpha-tetrahydrocorticosterone were 0.98 (n = 2) in patient II-1, 1.25 in patient II-2, and 0.71 in patient II-5, compared to 0.53 +/- 0.22 in normal men. Genital skin fibroblasts (GSF) from patient II-1 had unusually low 5 alpha-reductase (5 alpha-R) activity (0.3 pmol/mg protein X h; n = 6), but those of patient II-5, a normal brother (II-3), and a sister (II-4; with impaired development of sexual hair) had normal values of 6.5 (n = 2), 9 (n = 3), and 9 (n = 2) pmol/mg protein X h, respectively. The maximum specific DHT receptor-binding activity (Bmax) and the rate constant of dissociation (k) of DHT-receptor complexes in the GSF from each of these individuals were normal, but the apparent equilibrium dissociation constants (Kd) for DHT were 1.16 +/- 0.28 (n = 4) in II-1, 0.39 +/- 0.20 (n = 6) in the sister, and it was 0.19 +/- 0.09 (n = 3) in the unaffected brother and 0.22 +/- 0.09 nM (n = 26) in normal men. The Bmax with the synthetic, nonmetabolizable androgen, methyltrienolone (R1881), and the k of R1881-receptor complexes were normal, but the Kd for R1881 in the GSF of II-1 was 1.4 nM (n = 2), compared to 0.16 +/- 0.05 (n = 8) in normal men, and prolonged exposure to R1881 failed to augment (up-regulate) the basal R1881-binding activity in his cells.(ABSTRACT TRUNCATED AT 400 WORDS)

Human minimal androgen insensitivity with normal dihydrotestosterone-binding capacity in cultured genital skin fibroblasts: evidence for an androgen-selective qualitative abnormality of the receptor

We have studied a kindred in which two parts of siblings, maternal first cousins, have a form of "minimal" androgen insensitivity that permits morphogenesis of unambiguous male external genitalia, but interferes with normal virilization at puberty. All four had gynecomastia that required reductive surgery. Apart from this common phenotype, they varied considerably in the temporal and regional aspects of their subvirilization and appreciably in their androgenic responsiveness to pharmacological doses of testosterone. The cultured genital skin fibroblasts from one set of siblings have an androgen-receptor activity with the following properties: (1) a normal maximum-binding capacity (Bmax) with 5 alpha-dihydrotestosterone (DHT), or the synthetic androgen, methyltrienolone (MT; R1881) as ligand; (2) a higher than normal apparent equilibrium dissociation constant (Kd) for DHT (0.77 nM) but not for MT; and (3) an elevated dissociation rate (k) of DHT-receptor (0.013 min-1, 37 degrees C), but not MT-receptor, complexes within intact cells. In addition, prolonged incubation with MT, but not DHT, augments the specific androgen-binding activity of the mutant cells as much as that of the controls. Normal cells yield lower values of apparent Kd for DHT (0.1-0.3 nM) after 2- than after 0.5-hr incubation (0.3-1.8 nM), and 1-hr values are intermediate. This occurs despite concurrent catabolic consumption of DHT from the medium and is considered to reflect transformation of initial, low-affinity DHT-receptor complexes to subsequent, higher-affinity states by a process that depends on time and initial ligand concentration. The mutant complexes described here can readily attain the highest state of affinity with MT, but have an impeded, variably expressed ability to do so with DHT. These findings suggest that a structural mutation at the X-linked locus that encodes the androgen-receptor protein is responsible for its androgen-selective dysfunction. Synthetic, nonhepatotoxic androgens, with corrective effects in vitro comparable to those of MT, may be therapeutically useful for these subjects.

Transurethral polytetrafluoroethylene injection for post-prostatectomy urinary incontinence

Transurethral polytetrafluoroethylene (Teflon) injections were performed on 69 men with incontinence following prostatectomy. The etiology of incontinence was transurethral resection of the prostate in 27 patients (group 1), open prostatectomy in 15 (group 2) and radical prostatectomy in 27 (group 3). All patients had been incontinent for more than 1 year and had failed to improve with conservative management. Cure or improvement occurred in 85.1 per cent of the patients in group 1, 79.9 per cent in group 2 and 48.1 per cent in group 3. Reasons for failure included severe bladder instability, severe periurethral fibrosis and leakage of paste. Clinically significant particle migration was not observed.

Familial external genital ambiguity due to a transformation defect of androgen-receptor complexes that is expressed with 5 alpha-dihydrotestosterone and the synthetic androgen methyltrienolone

We have studied various properties of the binding of 5 alpha-dihydrotestosterone (DHT) or the synthetic, nonmetabolizable androgen methyltrienolone (R1881; 17 beta-hydroxy-17 alpha-methylestra-4,9,11-trien-3-one) to the androgen receptor of genital skin fibroblasts (GSF) from controls and a subject with familial, receptor-positive, partial androgen insensitivity. The mutant cells form R1881-receptor complexes that dissociate 7 times more rapidly than normal at 30 degrees C, and they do not increase their specific R1881-receptor activity in response to a 72-hr period of incubation with R1881, whereas the cells from normal individuals do so two- to three-fold. As previously reported [Pinsky et al, 1981; Kaufman et al, 1981], the mutant cells have similar abnormalities with DHT as with R1881. When the patient's cells are incubated for 120 min with varying concentrations (0.05-3 nM) of R1881 or DHT, Scatchard analysis shows that their androgen-receptor activity has an apparent equilibrium dissociation constant (Kd) for each ligand that is six-fold greater than that of normal cells (approximately 0.2 nM). Normal GSF have higher, more variable values of Kd (0.3-1.8 nM) for either ligand after 30 compared to 120 min of incubation, and the 60-min values are intermediate. This explains why we previously reported that the patient's cells had a 30-min Kd for DHT in the normal range [Pinsky et al, 1981]. Sucrose gradient centrifugation of mutant GSF cytosol incubated with DHT in the presence of 10 mM sodium molybdate yields a normal 6.5-8S peak of DHT-receptor complexes. From these data we conclude that normal GSF form initial, low-affinity androgen-receptor complexes that are transformed into one (or more) higher-affinity (? activated) states by a process that depends on time and initial concentration of androgen; the subject's GSF can form low-affinity androgen-receptor complexes but cannot generate the normal high-affinity state of the complexes, and this lack precludes augmentation of their androgen-receptor activity in response to prolonged incubation with either androgen; and failure of molybdate to stabilize the androgen-receptor activity in GSF cytosol is not a more sensitive indicator of structurally altered androgen-receptor proteins than are other qualities described heretofore.

Lung abscess caused by Streptococcus pneumoniae type 3. The importance of counterimmunoelectrophoresis in laboratory diagnosis

We are reporting the case of an 18-month-old girl with a post-pneumonic lung abscess. The counterimmunoelectrophoresis (CIE) of the patient's urine during the bacteremic phase of the disease gave a precipitation line with pneumococcal antiserum. Later in the course of the disease, after the diagnosis of lung abscess had been established, the pus drained from the abscess gave positive reactions with pneumococcal omnivalent serum and type 3 pneumococcal antiserum. At this stage, the pus was sterile and blood cultures were negative. This case demonstrates that the CIE test is a simple procedure which gives a rapid and exact diagnosis up to the serotype level.