Variation in stated management of acute myocardial infarction in five countries

We examined the variation in stated practice in the management of acute myocardial infarction (AMI) among doctors in Australia, Brazil, Chile, India and Thailand. Hospitals were identified as primary, secondary or tertiary by investigators from around their own region. All doctors within each hospital who would be expected to treat patients with AMI were asked to indicate which investigations and treatments they would offer to a patient with an AMI who develops angina on Day 3 after admission. The numbers of hospitals ranged from 5 to 26 per country, and doctor response rates varied from 70 to 100%. Within-country variation was large, and statistically significant variations were seen between countries in the use of most interventions. The large variation both between and within a range of countries across the economic spectrum suggests a widespread need for agreement about what constitutes appropriate management after AMI.

A comparison of IL-2 levels in nasopharyngeal and endotracheal aspirates of babies with respiratory syncytial viral bronchiolitis

BACKGROUND

Cytokines such as IL-2 are thought to be important in the pathogenesis of respiratory tract inflammation. Cytokine levels in nasopharyngeal aspirates (NPAs) have been used as a measure of respiratory inflammation in children with viral infections, but it is unclear whether they reflect levels in the lower respiratory tract.

OBJECTIVE

We sought to assess the correlation between IL-2 levels in the nasopharyngeal and endotracheal secretions of children intubated with respiratory syncytial virus (RSV)-positive bronchiolitis.

METHODS

NPA and endotracheal aspirates were collected concurrently from intubated infants with RSV-positive bronchiolitis. IL-2 levels were assayed by ELISA, and the results were compared according to collection site.

RESULTS

Nine paired specimens were collected. IL-2 levels ranged from 31 pg/mL to 8040 pg/mL. No significant difference was found in the geometric mean IL-2 values from the 2 collection sites. The intraclass correlation coefficient between NPA IL-2 levels and endotracheal aspirate IL-2 levels was 0.83.

CONCLUSION

IL-2 levels in NPAs are comparable with those in the lower respiratory tracts of infants with RSV-positive bronchiolitis. NPA cytokine levels provide a simple and useful means of assessing respiratory tract inflammation.

Mechanism of suppression of natural killer cell activity in trauma patients

Trauma patients develop a severe immunosuppression that includes suppression of natural killer (NK) cell activity although numbers of NK cells are not reduced. The mechanism of suppression of NK cell activity after major trauma is not known. The aim of the present study was to investigate the in vitro effect of plasma samples from trauma patients (TP) on the cytotoxic activity of normal NK cells. Buffycoat mononuclear cells (5x10(5)/well) were preincubated with either TP or plasma samples from age and sex matched healthy controls (CP) for 0, 16 or 40 h. These effector cells were then cultured with 51Cr labeled K-562 cells (2x10(4)/well) for 4 h at 37 degrees C and % lysis was calculated. No significant differences in % lysis between CP and TP were found with 0 or 16 h preincubation, however 40 h preincubation with TP severely suppressed NK cell function (p=0.003) as compared to preincubation with CP for the same period. Addition of neutralizing anti-IL-4, anti-TGF-beta1, or anti-IL-10 antibodies did not reverse the NK cell suppression. There was a partial reversal of NK cell suppression by catalase but not by SOD or L-NMMA. Removal of monocytes from buffycoat mononuclear cells also significantly reversed the NK cell suppression. These data suggest that suppression of NK cell activity in trauma patients may be an accessory cell dependent phenomenon and may partially depend on production of reactive oxygen metabolites (ROM).

Ethnomedical information and in vitro screening for angiotensin-converting enzyme inhibition of plants utilized as traditional medicines in Gujarat, Rajasthan and Kerala (India)

Plants utilized as traditional medicines in India have been investigated for their ability to inhibit the angiotensin converting enzyme (ACE). In total, 75 species belonging to 42 families have been investigated and new ethnomedical information has been obtained for 41 species. Four species were found to possess a high ACE inhibiting ability and were low in their tannin content.

Review of a home-based palliative care program for children with malignant and non-malignant diseases

This retrospective chart review presents the patient characteristics and utilization of the home-based palliative care program at The Hospital for Sick Children in Toronto. A total of 126 children dying from a broad spectrum of diseases was admitted during the period 1986-1994, referred from neurosurgery, genetic/metabolic, neurology, neonatology, nephrology, cardiology, general pediatrics, general surgery, and pulmonology. At the time of review, 15 patients remained alive and 18 had been discharged from the program. Mean age at the time of referral was 4.8 +/- 0.51 years and mean age at death was 5.3 +/- 0.55 years. The mean number of days in hospital was 26.5 +/- 14.6 while days spent at home averaged 98.4 +/- 15.2; thus 80% of the children's remaining time was spent at home. The average number of parent-team contacts was 3.5 +/- 0.9 by pager and 24.0 +/- 2.9 by telephone. Of the 93 patients who died in the program, 53% died at home, 18% died in community hospitals, and 29% died in a tertiary care facility. Analgesic medications were administered to 54% of the patients; 56% of these then required opioid analgesia for pain and symptom management. Home-based palliative care appeared to be an effective program for many children with a variety of terminal illnesses after adequate supports for the child and family had been established.

The use of lumbar puncture and laboratory tests for sepsis by Australian neonatologists

OBJECTIVE

To ascertain the current use of lumbar puncture (LP) and laboratory tests for possible or suspected sepsis by Australian neonatologists.

METHODS

A self administered anonymous response questionnaire.

RESULTS

Sixty-nine (73%) of 94 neonatologists responded. None performed LP routinely in preterm infants with respiratory distress syndrome (RDS) or asymptomatic term infants with maternal Group B streptococcus (GBS) colonisation. One (1.6%) performed LP in term infants with respiratory distress, and only 35 (51%) performed LP in preterm infants with suspected late-onset sepsis (LOS). Twenty-one percent did not perform LP on all preterm infants with RDS and septicaemia and 24% did not perform LP on all preterm infants with late-onset septicaemia. Sixty-six percent and 85% did not perform LP for laboratory evidence suggestive of sepsis in preterm infants with RDS and preterm infants with LOS, respectively. Forty-nine percent investigated asymptomatic term infants with maternal GBS colonisation.

CONCLUSIONS

Lumbar puncture and laboratory tests for possible or suspected sepsis are not used uniformly by Australian neonatologists. The presently available information in the scientific literature is ambiguous and systematic review and further scientific study are required to determine best practice guidelines.

Suppression of natural killer cell activity in patients with fracture/soft tissue injury

BACKGROUND

Natural killer cells (NKCs) participate in "innate" cell-mediated immunity. Fracture/soft tissue injuries are cytokine rich and may influence cell-mediated immunity.

OBJECTIVE

To study the effects of fracture cytokines on NKC function.

DESIGN

A case-control study.

SETTING

A level I trauma center and laboratory in a university medical center.

PARTICIPANTS

Patients requiring open fracture fixation and healthy volunteers.

INTERVENTIONS

Fracture supernatants and peripheral plasma were collected during open fracture fixation. Volunteer mononuclear cells were used as effector (NKC) sources. Mononuclear cells were preincubated with fracture supernatants, paired peripheral plasma, or normal plasma under various conditions.

MAIN OUTCOME MEASURES

Natural killer cell lysis of K562 target cells was assessed by chromium 51 release.

RESULTS

Fracture supernatants suppressed NKC function more rapidly than peripheral plasma. Fracture supernatants from 1 to 4 days after injury were most suppressive. Inactivation of complement and reactive oxygen species failed to restore lysis. Neutralizing antibodies to interleukin 4 and interleukin 10 further suppressed lysis. Antibodies to transforming growth factor beta1 failed to restore lysis. The addition of interferon gamma did not restore lysis but the addition of interleukin 12 did.

CONCLUSIONS

Fracture supernatants and peripheral plasma from patients with fractures suppress NKCs. The responsible mediators may be concentrated in fracture/soft tissue injuries. Responses to manipulation of the cytokine environment suggest that fracture cytokines may impair cooperation between NKCs and accessory cells.

A case of nondigitalis cardiac glycoside toxicity

A case is presented of cardiac glycoside poisoning in a 1-year-old patient from the plant Nerium oleander (common oleander). The patient had bradycardia, vomiting, altered level of consciousness, and no history of ingestion. Antibody-based digoxin assays may cross-react with other cardiac glycosides nonquantitatively. Chromatographic techniques can be used in the specific diagnosis.

Randomised trial of oral morphine for painful episodes of sickle-cell disease in children

BACKGROUND

Oral controlled-release morphine can provide effective analgesia through a non-invasive route and may facilitate outpatient management of severe episodes of sickle-cell pain. We compared the clinical efficacy and safety of oral morphine with continuous intravenous morphine in children with severe episodes of sickle-cell pain, by a double-blind, randomised, parallel-group design.

METHODS

56 children aged 5-17 years received loading doses of intravenous morphine of up to 0.15 mg/kg, followed by randomly assigned oral morphine 1.9 mg/kg every 12 h plus intravenous placebo (saline), or intravenous morphine 0.04 mg kg-1 h-1, plus placebo tablet. Breakthrough pain was treated with oral, immediate-release morphine 0.4 mg/kg every 2-3 h as required. Pain was assessed daily at 0900 h, 1300 h, 1700 h, and 2100 h with a picture face scale, a pictorial scale (Oucher), a behavioural-observational scale (CHEOPS), and by an investigator.

FINDINGS

50 children completed the study (28 boys, 22 girls; mean age 11.2 years [SD 3.5]; mean oral morphine dose 2.99 mg/kg daily [0.75]; mean intravenous morphine dose, 0.81 mg/kg daily [0.30]). Mean overall pain scores were similar for oral and intravenous morphine (CHEOPS, 6.3 [1.5] vs 6.4 [1.4], p = 0.8; Oucher, 31.5 [25.4] vs 39.2 [21.7], p = 0.3; Faces, 2.2 [1.4] vs 2.4 [1.3], p = 0.6; clinical rating, 1.7 [0.7] vs 1.9 [0.5], p = 0.3). Opioid analgesia was required for a mean of 4.2 days (1.7) and 5.4 days (2.6), respectively (p = 0.0591). Pain scores from all scales correlated significantly (r = 0.5865-0.8980, p = 0.0001). Frequency of rescue analgesia did not differ significantly between the oral and intravenous morphine groups (0.7 [0.8] vs 0.9 [0.7] doses daily, p = 0.2). Frequency and severity of adverse events did not differ significantly.

INTERPRETATION

Oral, controlled-release morphine is a reliable, non-invasive alternative to continuous intravenous morphine for the management of painful episodes of sickle-cell disease in children.

Dose comparison of remifentanil and alfentanil for loss of consciousness

BACKGROUND

This study evaluated the efficacy and safety of remifentanil, a potent mu agonist opioid with a rapid onset and offset of effect, as a sole induction agent for loss of consciousness (LOC) and compared it with alfentanil.

METHODS

Remifentanil and alfentanil were administered intravenously over 2 min in ascending doses (remifentanil 2, 3, 4, 5, 6, 8, 10, 15, 20 microg/kg; alfentanil 40, 60, 80, 100, 120, 160, 200 microg/kg) to unpremedicated healthy patients. Patients were observed for rigidity and LOC for 30 s after the end of infusion. If patients had not lost consciousness, 2 mg x kg(-1) x min(-1) thiopental was administered until LOC was achieved. Arterial blood samples, obtained at specified time intervals, were analyzed for remifentanil and alfentanil whole-blood concentration. Blood pressure and heart rate were also recorded at preset time intervals.

RESULTS

Neither drug could reliably produce LOC. With both drugs, there was a dose-dependent decrease in thiopental requirements and a dose-dependent increase in the incidence and severity of rigidity (P < 0.05). The median effective dose (ED50) for LOC with remifentanil was 12 microg/kg, and for alfentanil it was 176 mcrog/kg. The median effective concentration (EC50; whole-blood concentration) of remifentanil was 53.8 ng/ml and for alfentanil it was 1,012 ng/ml. Minimal hemodynamic changes were observed after either drug was given.

CONCLUSIONS

Remifentanil is 15 times more potent than alfentanil, based on the ED50 to achieve loss of response to a verbal command and 20 times more potent than alfentanil based on the EC50. Neither opioid is suitable as a sole induction agent.

The immune microenvironment of human fracture/soft-tissue hematomas and its relationship to systemic immunity

The immune environment of human soft-tissue injury is unstudied. We studied fracture soft-tissue hematomas (FxSTH) in 56 patients with high-energy bony fractures. FxSTH serum and mononuclear cells (MNC) as well as fracture patient plasma and blood MNC were studied. Twenty healthy controls donated plasma and MNC. Soluble tumor necrosis factor (TNF)-alpha, interleukin (IL-1 beta, IL-2, 6, 8, 10, 12, and interferon-gamma were studied by enzyme linked immunosorbent assay. Cells were studied by flow cytometry after cell-membrane stains for CD-14, TNF-alpha (mTNF), and human leukocyte antigen-DR, or intracellular stains for TNF (icTNF) and IL-10. Thirty-six patients with Injury Severity Score < 15 were analyzed further to evaluate the effects of isolated fracture on systemic immunity. Cytokines were rarely detectable in control plasma. TNF-alpha, IL-1 beta, IL-2, and interferon-gamma were rarely found in FxSTH serum or fracture patient plasma. All FxSTH sera were rich in IL-6, peaking before 48 hours (12,538 +/- 4,153 vs. 3,494 +/- 909 pg/mL, p = 0.02, U test). In Injury Severity Score < 15, IL-6 was not detectable in most early fracture patient plasma, but rose after 48 hours (p = 0.028). FxSTH serum IL-8 peaked after 48 hours (440 +/- 289 vs. 4,542 +/- 1,219 pg/mL, p = 0.006) and circulating IL-8 appeared after 72 hours. IL-6 and IL-8 showed gradients from FxSTH serum to paired PtS (p < 0.05, Wilcoxon). IL-10 was abundant (884 +/- 229 pg/mL) in FxSTH serum < 24 hours old. FxSTH serum IL-12 peaked late (3,323 +/- 799 pg/mL, day 4-7) then fell (p < 0.001, analysis of variance). Only IL-12 was higher in fracture patient plasma (1,279 +/- 602 pg/mL) than FxSTH serum (591 +/- 327 pg/mL) during the first 48 hours (p = 0.032, U test). On flow cytometry, control monocytes expressed 201 +/- 31 mTNF sites/cell, but icTNF was absent. mTNF was up-regulated after injury more in FxSTH monocytes (3,202 +/- 870 sites/cell) than peripheral blood monocytes (584 +/- 186 sites/cell) (p < 0.05 vs. peripheral blood monocytes by Wilcoxon, p < 0.001 vs. control monocytes by U test). Intracellular IL-10 was abundant in all MNC, but varied widely after injury. Fracture and peripheral blood monocytes expressed far less human leukocyte antigen-DR than control monocytes. Fractures create an inflammatory local environment. Proximal mediators are cell-associated and relatively confined to the wound, but soluble IL-6, IL-8, and IL-10 are abundant and probably exported. Systemic MNC have complex responses to local injuries. These may reflect the combined impact of multiple soluble cytokines initially generated within the wound. FxSTH appear to be a potentially important source of immunomodulatory cytokines in trauma.

How tubulin subunits are lost from the shortening ends of microtubules

Microtubules exhibit dynamic instability, switching between persistent states of growth and shortening at their ends. The switch between growth and shortening has been proposed to depend on end conformation where growing ends have "straight" tubulin protofilaments stabilized by a terminal cap of GTP-tubulin, while-shortening ends have lost their GTP-tubulin cap, allowing terminal GDP-tubulin dimers to curve inside-out and peel rapidly away from the microtubule lattice. This "conformational cap" model predicts that tubulin dissociation from shortening ends is a two-step process where the average lengths of curved GDP-tubulin protofilaments at a depolymerizing end will depend on the ratio of the rate of peeling to the rate of breakage of the longitudinal bonds between adjacent curved dimers. We have tested this model for the plus and minus ends of microtubules assembled with pure porcine tubulin off the ends of axoneme fragments in standard assembly buffer. Individual microtubule ends were imaged using video-enhanced differential interference contrast light microscopy. The rate of rapid shortening was systematically increased by isothermal dilution into assembly buffer containing various concentrations of Mg2+ or Ca2+ ions. At 1 mM Mg2+ and no Ca2+, shortening occurred at 20 (plus) and 45 (minus) microns/min. The ends appeared similar in contrast to growing ends and the core of the microtubule and the ends appeared blunt or slightly frayed by negative stain electron microscopy. Above 20 mM Mg2+ or above 5 mM Ca2+, microtubule shortening occurred at 60 (plus) and 115 (minus) microns/min or faster and "knobs" were distinctly visible at depolymerizing ends, particularly at the faster minus ends, and knob contrast remained constant during many micrometers of rapid shortening. Negative stain electron microscopy revealed that these knobs were "blossoms" of inside-out curved protofilaments, some extending for several helical turns (30 to 60 dimers in length) at constant curvature from the ends. At these high shortening velocities, the peeling of curved protofilaments was confined to within several dimers of the end of the microtubule cylinder, suggesting that dimer curling and protofilament peeling is constrained to the tip by interactions between adjacent straight protofilaments. Depolymerization is produced by conformational changes in GDP-tubulin since microtubules assembled with a slowly hydrolizable analog of GTP, GMPCPP, are stable even at 20 mM Mg2+ or 5 mM Ca2+. Monte Carlo simulations show that the ratio of the peeling to breakage rate constants can control the steady-state average length of curved GDP-tubulin protofilaments at the depolymerizing end.

Production of interleukin-10 in human fracture soft-tissue hematomas

Clinical trauma suppresses immunity and experimental wound fluids have been shown to be immunosuppressive. To ascertain whether human wounds contain immunosuppressive cytokines, we assayed serum from fracture/soft-tissue hematomas (FSTH) of 22 patients for interleukin (IL)-10, transforming growth factor (TGF)-beta 1, and IL-4. Results were correlated to concurrent plasma cytokine concentrations in the same patients and in volunteer plasma. IL-10 was present in high concentration (1376 +/- 539 pg/mL) in all (7/7) FSTH < 24 h old. In FSTH > 24 h old, IL-10 was found intermittently and at lower levels (239 +/- 106 pg/mL, p = .011 vs. FSTH < 24 h old). IL-10 was rarely detectable in fracture patient plasma and never detectable (< 20 pg/mL) in normal plasma. No significant variations of IL-4 or total TGF-beta 1 were found in FSTH or plasma. FSTH are significant potential sources of IL-10 activity in trauma patients, which may be overlooked when only plasma is assayed. The potential for a relationship between cytokines found locally at sites of injury and clinical immune modulation in trauma requires further study.

Recognition and treatment of ethanol abuse in trauma patients

OBJECTIVE

To evaluate physicians' recognition of possible ethanol-related complications in trauma patients, and to compare benzodiazepine requirements in patients with positive and negative blood-ethanol concentrations.

DESIGN

Retrospective investigation.

SETTING

University medical center (level I trauma center).

PATIENTS

One hundred thirty-one trauma patients more than 18 years of age who were admitted for at least 24 hours.

OUTCOME MEASURES

(1) Physicians' recognition of ethanol (EtOH) as a potential factor complicating patient recovery in trauma patients admitted with positive blood-EtOH concentrations. (2) The amount of benzodiazepines administered to trauma patients with positive EtOH-blood concentrations compared to trauma patients with no detectable EtOH in their blood.

RESULTS

The presence of EtOH in the blood or the potential for EtOH withdrawal was mentioned in the progress notes of approximately one fourth of the patients with positive blood-EtOH concentrations. Thiamine was administered in 8.2% of patients with EtOH-related injuries. Benzodiazepine requirements were significantly higher in patients with positive versus negative blood-EtOH concentrations.

CONCLUSIONS

Prompt recognition and charting of suspected ethanol abuse is recommended, in conjunction with prompt administration of thiamine. It should be anticipated that patients with positive blood-ethanol concentrations will require higher doses of benzodiazepines compared to trauma patients without ethanol-related injuries.

Psychiatric diagnoses in the child and adolescent members of extended families identified through adult bipolar affective disorder probands

OBJECTIVE

To investigate the type and distribution of psychiatric disorders in the child and adolescent members of extended pedigrees identified through bipolar probands.

METHOD

The child and adolescent offspring (24 male, 26 female, aged 6 to 17 years) and the adult parents (60) of 14 bipolar pedigrees ascertained for the National Institutes of Mental Health Genetics Initiative Study of Bipolar Affective Disorder were personally assessed using structured psychiatric interviews. A parent was also interviewed about each child or adolescent offspring.

RESULTS

Twelve of the 50 interviewed offspring received a lifetime DSM-III-R diagnosis of an affective disorder. This included six cases of bipolar disorder, five cases of major depressive disorder, and one case of dysthymia. Eight of the offspring who received an affective disorder diagnosis also qualified for an anxiety disorder (four), a disruptive behavior disorder (two), or both (two). Offspring who had a parent with an affective disorder had a 5.1-fold higher risk for receiving an affective disorder diagnosis than did offspring with healthy parents.

CONCLUSIONS

In a consecutive series of families identified through a proband with bipolar disorder, there were significant increases in the prevalence of affective disorder diagnoses in the child and adolescent offspring. The distribution of illness in offspring was compatible with the presence of important genetic factors which contribute to early-onset affective illness.

Suppression of natural killer cell activity in biliary obstruction

Prior studies regarding immune function in bile-duct ligated rats have illustrated blunted immune function. The present study measures natural killer (NK) cell activity. Rats underwent bile duct ligation (BDL) or sham celiotomy (SC) and were sacrificed at 1, 2, and 3 weeks after surgery. Ficoll-Hypaque density centrifugation was used to obtain a purified preparation of splenocytes. NK cell activity was determined by incubating varying concentrations of splenocytes with chromium-labelled YAC-1 tumor cells for 4 hours. Chromium release was measured by a gamma counter and expressed as per cent activity (compared with 100 per cent activity obtained by complete lysis with detergent). The experiments were repeated after preincubation in tissue culture flasks to remove an adherent cell population. NK cell activity was decreased at all spleen cell:target cell ratios studies at 1 week after BDL. At 2 weeks after BDL, NK cell activity was decreased at all but the lowest two concentrations; and 3 weeks after BDL, NK cell activity was decreased only at the highest concentrations used. Separation of an adherent cell fraction restored NK cell activity. This suppression in NK cell activity one week after BDL may account, in part, for the poor response of BDL animals to bacterial and immune challenge. Restoration of activity after removal of an adherent cell fraction suggests that macrophages may be at least partly responsible for this inhibition.

Increase in brain nitric oxide synthase activity in daunorubicin-treated rats

Anthracyclines such as daunorubicin are very effective anticancer agents. These drugs are known to cause side effects including cardiotoxicity. Anthracyclines are neurotoxic to laboratory animals. Nitric oxide is a novel and very important chemical messenger in the brain. However, at higher levels, nitric oxide causes well defined neurotoxicity. Therefore, we determined nitric oxide synthase activity in rat brain after daunorubicin treatment in an effort to explain the neurotoxicity produced by anthracyclines. Male Sprague-Dawley rats were treated with different subcutaneous doses of daunorubicin (0.1-4.0 mg/kg/week for five weeks) while control animals were injected with phosphate buffered saline. There was a significant increase (80%) of nitric oxide synthase activity in daunorubicin-treated animals as compared to controls. This activity was inhibited by N-monomethyl-L-arginine (NMMA), nitroarginine, N-6-aminohexyl-5-chloro-1-napthalene sulfonamide (W-7), a calmodulin antagonist, suggesting that the nitric oxide synthase activity is calmodulin dependent. Further, our in vitro studies demonstrated that daunorubicin interacted with calmodulin as measured by N-phenyl-1-napthylamine (NPN) fluorescence. These results indicate that daunorubicin increases nitric oxide synthase activity in rat brain which may increase the levels of nitric oxide. The increased levels of nitric oxide may cause neurotoxicity. Our results further indicate that daunorubicin interacts with calmodulin and enhances nitric oxide synthase activity which is dependent on calmodulin.

Isolation of a spermatozoa motility inhibiting factor from chicken seminal plasma with antibacterial property

A 78-kDa spermatozoa motility inhibiting factor (SMIF) was purified from chicken (Gallus domesticus) seminal plasma by anion exchange (DE-53) followed by affinity chromatography on concanavalin A-Sepharose. The factor is thermostable and inhibited the spermatozoa motility in a dose dependent manner. In addition, SMIF inhibited the growth of gram negative bacteria, Pasteurella multocida but not gram positive Streptococcus equi. The factor lost its spermatozoa immobilizing property after treatment with trypsin, chymotrypsin or pepsin. The inhibition of SMIF by beta-mercaptoethanol suggest the involvement of disulfide bonds in its activity. Similarly, this property was lost in presence of chicken seminal plasma or incubating SMIF with anti-SMIF antibodies. Evidence is provided for the presence of a high molecular weight protein (> 100 kDa) in chicken seminal plasma that neutralizes the motility inhibiting property of SMIF. No significant decrease in spermatozoa ATP was observed in presence of SMIF suggesting that the loss of spermatozoa motility was due to factors other than depletion in cell's energy. Using anti-SMIF antibodies, a cross-reactive protein was identified in the blood, liver and reproductive tissues of chicken and the seminal plasma of cattle and buffalo. However, the cross-reactive protein failed to inhibit chicken spermatozoa motility. The significance of SMIF in chicken seminal plasma is discussed.

CT-GUIDED FNAC AND BIOPSY : OUR EXPERIENCE

Twenty five patients with mass lesions in the chest, abdomen, pelvis, and paraspinal region underwent contrast enhanced computed tomographic scan (CT Scan) followed by CT guided FNAC or Tru-cut biopsy. CT was found to be extremely valuable in ensuring needle placement within the lesion. It also helped in avoiding the necrotic areas and obtaining tissue from an area most likely to yield an adequate sample. A post-procedure scan helped in ruling out post-procedure complications.

Trial of intravesical versus extravesical ureteroneocystostomy in renal transplant recipients

We carried out a trial to evaluate the complication rate of intravesical (LP) versus extravesical (Lich) ureteroneocystostomy in recipients of renal transplantation. Ureteric stenosis was the predominant complication in the LP technique, which was more difficult to correct. Complications by the Lich technique were urinary leaks, which were managed successfully by prolonged bladder drainage. We conclude that the Lich technique is simpler to perform and avoids the complication of ureteric stenosis, and should therefore be the procedure of choice for ureteric implantation in recipients of renal transplants.

Decreased insulin-like growth factor I-mediated protein tyrosine phosphorylation in human olivopontocerebellar atrophy and lurcher mutant mouse

We examined insulin-like growth factor I (IGF-I)-dependent phosphorylation and protein tyrosine kinase (PTK) activity in cerebellar cortex of normal humans, patients with olivopontocerebellar atrophy (OPCA) ("C" kindred) and in lurcher mutant mouse, a suggested animal model for OPCA. PTK activity and IGF-I-dependent protein tyrosine phosphorylation was significantly reduced in cerebellar cortex of human OPCA patients as compared to the normal controls. Immunoblot analysis also demonstrated a decrease in cerebellar 80 kDa phosphotyrosine protein in these patients. By autoradiography, IGF-I receptors were localized in the molecular layer of 30-day-old control and lurcher mutant mice cerebella. However, the lurcher mutant mice showed a decrease in [125I]-IGF-I binding in the molecular layer as compared to the littermate controls. The IGF-I receptor autophosphorylation was also markedly reduced in 15-day- and 22-day-old lurcher cerebella. These results suggest that the process of cerebellar degeneration in human OPCA and lurcher mutant mouse may be associated with altered IGF-I receptor binding and protein tyrosine phosphorylation.

Crystallization of a fragment of human fibronectin: introduction of methionine by site-directed mutagenesis to allow phasing via selenomethionine

Crystals of a fragment of human fibronectin encompassing the 7th through the RGD-containing 10th type III repeats (FN7-10) have been produced with protein expressed in E. coli. The crystals are monoclinic with one molecule in the asymmetric unit and diffract to beyond 2.0 A Bragg spacings. A mutant FN7-10 was produced in which three methionines, in addition to the single native methionine already present, have been introduced by site-directed mutagenesis. Diffraction-quality crystals of this mutant protein have been grown in which methionine was replaced with selenomethionine. The introduction of methionine by site-directed mutagenesis to allow phasing from selenomethionyl-substituted crystals is shown to be feasible by this example and is proposed as a general approach to solving the crystallographic phase problem. Strategies for selecting propitious sites for methionine mutations are discussed.

Cell cycle-dependent inhibition of p34cdc2 synthesis by transforming growth factor beta 1 in cycling epithelial cells

Cycling epithelial cells were shown to reversibly arrest in late G1 phase following treatment with transforming growth factor beta 1. Associated with this G1-S phase arrest was a decrease in the synthesis and histone H1 kinase activity of p34cdc2. Transforming growth factor beta 1 did not reduce p34cdc2 levels by modulating the turnover of newly synthesized p34cdc2. The decrease in p34cdc2 synthesis preceded any detectable effect on DNA synthesis. Moreover, the action of transforming growth factor beta 1 was regulated in a cell cycle-specific manner; epithelial cells were sensitive to transforming growth factor beta 1 only during the G1 phase. The results suggest that p34cdc2 might be a useful biochemical marker for investigating the mechanism(s) of transforming growth factor beta 1 signaling.

Endothelial cells adhere to the RGD domain and the fibrinogen-like terminal knob of tenascin

We have found that endothelial cells adhere much more strongly than fibroblasts to domains of tenascin and fibronectin. Endothelial cells adhered weakly, without spreading, to bacterial expression proteins corresponding to the tenth fibronectin type III (FN-III) domain of fibronectin, which contains the RGD. A larger fibronectin protein, containing this domain and the three amino-terminal ‘synergy’ domains gave strong adhesion and spreading. Two widely separated domains of tenascin gave adhesion. The third FN-III domain, TNfn3, which contains an RGD sequence in human and chicken tenascin, gave very strong adhesion and spreading of endothelial cells when tested as an isolated domain. Larger segments containing TNfn3 and the adjacent TNfn2 gave weaker adhesion, probably because the RGD sequence is partially blocked. Adhesion to this domain required divalent cations, was exquisitely sensitive to soluble GRGDSP peptide, and was blocked by antisera to the integrin alpha v beta 3. The second tenascin adhesion domain was the fibrinogen-like C-terminal knob, TNfbg. Cells adhered to but did not spread on this domain. This adhesion required divalent cations and was also sensitive to GRGDSP peptide, so it may be mediated by an integrin receptor. We have explored a range of conditions for preparing the adhesion substratum, and our results may resolve the controversy over whether tenascin can act as a substratum adhesion molecule. When coated for short times (1-2 hours) on plastic, tenascin had no adhesion activity, in contrast to fibronectin and the expression proteins, which gave strong adhesion under these conditions. When coated for longer times (12-24 hours) on plastic, the tenascin substratum supported good adhesion, but not spreading, of endothelial cells. Tenascin coated on nitrocellulose gave substantially stronger adhesion than on plastic, but still required long coating times for maximal activity. Adhesion of endothelial cells to native TN was inhibited by GRDGSP peptide. The cell adhesion activity demonstrates the presence on endothelial cells of tenascin receptors, which may play a supportive role in angiogenesis, in the structure of blood vessels, or in binding tenascin to the cell surface to elicit or enhance a signalling function.

Characterization of paralogous and orthologous members of the superoxide dismutase gene family from genera of the halophilic archaebacteria

Four species representing three genera of halophilic archaebacteria were examined for the presence of genomic sequences that encode proteins of the superoxide dismutase family. Three species, Halobacterium cutirubrum, Halobacterium sp. strain GRB, and Haloferax volcanii, contain duplicated (paralogous) genes of the sod family; a fourth species, Haloarcula marismortui, contains only a single gene. These seven genes were cloned and sequenced, and their transcripts were characterized by Northern (RNA) hybridization, S1 nuclease protection, and primer extension. The expression of one of the two genes in H. cutirubrum, Halobacterium sp. strain GRB, and Haloferax volcanii was shown to be elevated in the presence of paraquat, a generator of superoxide radicals. The other genes, including the single gene from Haloarcula marismortui, exhibited no elevated expression in the presence of paraquat. The 5' and 3' flanking regions of all the genes contain recognizable promoter and terminator elements that are appropriately positioned relative to the 5' and 3' transcript end sites. Between genera, the orthologous paraquat-responsive genes exhibit no sequence similarity in either their 5' or 3' flanking regions, whereas the orthologous nonresponsive genes exhibit limited sequence similarity but only in the 5' flanking region. Within the coding region, the two paralogous genes of Haloferax volcanii are virtually identical (99.5%) despite the absence of similarity in the flanking regions. In contrast, the paralogous genes of H. cutirubrum and Halobacterium sp. strain GRB are only about 87% identical. In the alignment of all seven sequences, there are nine codon positions where both the TCN and AGY serine codons are utilized; some or all of these may well be examples of convergent evolution.

Structure, function, and evolution of the family of superoxide dismutase proteins from halophilic archaebacteria

The protein sequences of seven members of the superoxide dismutase (SOD) family from halophilic archaebacteria have been aligned and compared with each other and with the homologous Mn and Fe SOD sequences from eubacteria and the methanogenic archaebacterium Methanobacterium thermoautotrophicum. Of 199 common residues in the SOD proteins from halophilic archaebacteria, 125 are conserved in all seven sequences, and 64 of these are encoded by single unique triplets. The 74 remaining positions exhibit a high degree of variability, and for almost half of these, the encoding triplets are connected by at least two nonsynonymous nucleotide substitutions. The majority of nucleotide substitutions within the seven genes are nonsynonymous and result in amino acid replacement in the respective protein; silent third-codon-position (synonymous) substitutions are unexpectedly rare. Halophilic SODs contain 30 specific residues that are not found at the corresponding positions of the methanogenic or eubacterial SOD proteins. Seven of these are replacements of highly conserved amino acids in eubacterial SODs that are believed to play an important role in the three-dimensional structure of the protein. Residues implicated in formation of the active site, catalysis, and metal ion binding are conserved in all Mn and Fe SODs. Molecular phylogenies based on parsimony and neighbor-joining methods coherently group the halophile sequences but surprisingly fail to distinguish between the Mn SOD of Escherichia coli and the Fe SOD of M. thermoautotrophicum as the outgroup. These comparisons indicate that as a group, the SODs of halophilic archaebacteria have many unique and characteristic features. At the same time, the patterns of nucleotide substitution and amino acid replacement indicate that these genes and the proteins that they encode continue to be subject to strong and changing selection. This selection may be related to the presence of oxygen radicals and the inter- and intracellular composition and concentration of metal cations.

Cell- and heparin-binding domains of the hexabrachion arm identified by tenascin expression proteins

We have produced a set of bacterial expression proteins corresponding to 10 segments of tenascin and two of fibronectin and tested them for heparin binding and cell adhesion. We used polymerase chain reaction cloning to terminate the segments precisely at domain boundaries. Heparin binding activity was mapped to two different tenascin segments: one comprising the fourth and fifth fibronectin type III domains, and to TNfbg, the fibrinogen-like terminal knob. TNfbg, but none of the other tanascin segments, also supported adhesion of primary rat embryo skin fibroblasts. The fibroblasts did not spread on TNfbg but remained rounded. Cell binding to TNfbg occurred in the presence or absence of divalent cations and was not inhibited by RGD peptides, suggesting that integrins are not involved. Fibroblast binding to TNfbg was strongly inhibited by soluble heparin, by treating the cells with heparitinase, or by culture conditions that cause undersulfation of proteoglycans. These observations suggest that cell attachment to TNfbg is mediated by cell surface proteoglycans. We have also made full-length cDNA constructs for the largest and smallest splice variants of human tenascin, as well as one truncated after the 14th epidermal growth factor-like domain, in the pNUT mammalian cell expression vector. Stably transfected baby hamster kidney cell lines secreted large quantities of tenascin, and this was assembled into normal hexabrachions, the arm length corresponding to the construct.

Immunization status of casualty attenders: risk factors for non-compliance and attitudes to 'on the spot' immunization

Outbreaks of vaccine preventable infections have focused attention on 'missed opportunities' for immunizing children. The immunization status of 520 consecutive children attending Casualty during a 10 day period was studied. Only 70% of children had received their diphtheria, tetanus, pertussis (DTP) and poliomyelitis immunization at the appropriate time, 13% had completed the schedule later than recommended and 17% had immunizations overdue by 4 weeks or more. For measles (mumps/rubella) vaccine (MM or MMR) 75% were up to date, 10% were given late and 15% were overdue. A subset of 171 families was interviewed to evaluate factors affecting compliance. Families possessing a Social Security 'Health Care Card', whose father was unemployed, who spoke poor English or who had lived in Australia for 5 years or less were significantly more likely (P < 0.02) to be inadequately immunized. There were 84 children whose immunization was overdue and who were well enough to be immunized. The parents of 70 (83%) of these 84 said that they would agree to 'on the spot' immunization if it were available; 14 (17%) parents refused, the commonest reason for refusal being that the parents felt that the child was too sick at the time to be immunized.

First and second metatarsophalangeal joint dislocation. A case report

A case of dislocated first and second metatarsophalangeal joints was reported along with the mechanics and mechanism of injury. The practitioner must be familiar with the mechanism of injury and radiographic classification to determine the proper indications for closed versus open reduction. The authors' review of the literature did not reveal a similar case involving a dislocation of the first and second metatarsophalangeal joints.

Pre-oxygenation: the Hudson mask as an alternative technique

The use of a simple oxygen facemask (Hudson) with high oxygen inflow (48 l.min-1) was investigated as a technique for pre-oxygenation, comparing it with the Magill system (oxygen flow: 100 ml.kg-1.min-1). One hundred and thirty-eight patients scheduled for elective gynaecological and orthopaedic surgery were studied: group 1, Hudson mask and group 2, Magill system (ASA 1-2, n = 107); group 3, Hudson mask and group 4, Magill system (ASA 3, n = 30). Pre-oxygenation was assessed by measuring the times to 97%, 95% and 93% arterial desaturation (finger pulse oximetry) following 3 min of pre-oxygenation. The times taken to achieve these end-points in all the study groups suggest that the Hudson mask offers an alternative technique for pre-oxygenation.

Dermatoglyphics in nasobronchial allergic disorders

Fifty persons having nasobronchial allergy diagnosed by a positive skin test were compared with age and sex matched normal individuals for dermatoglyphic palmer patterns. The palmer prints were obtained on white art paper using Kores duplicating ink. In female patients, total number of whorls was less, more so on digit IV of left hand. Digit V of right hand had low frequency of ulnar loops, the d-t ridge count was low. In male patients, ulnar loops were less frequent on digit III of right hand. Total finger ridge count was less in both sexes. High frequency of arches was observed in female patients and in total. Digit V of left hand in females and in total patients revealed high frequency of arches. a-b ridge count was high in males and in total patients.

Nitrous Oxide-Oxygen Analgesia: The Performance of the MC Mask Delivery System

Nitrous oxide administration via an oxygen facemask such as the Mary Catterall (MC) is an accepted technique for supplementing regional anaesthesia. This study assessed the range of nitrous oxide and oxygen concentrations delivered to the trachea using a mechanical lung model. The inspired concentrations of these two gases were determined by the total fresh gas inflow rates, their concentrations in the fresh gas mixture and the peak inspiratory flow rate of the analogue lung. A 1: 1 nitrous oxide-oxygen mixture in the fresh gas with an inflow rate of 4–6 1/min is recommended to ensure adequate oxygen delivery into the trachea as well as achieving the therapeutic concentrations of nitrous oxide (20–30%).

An evaluation of oxygen delivery using nasal prongs

Oxygen delivery using nasal prongs was assessed using a lung model for spontaneous ventilation. The analogue lung was attached to a manikin, which provided a model of the 'face and pharynx' to which the nasal prongs were applied. Oxygen concentrations were measured in the model trachea at varying fresh gas inflow and peak inspiratory flows. The study demonstrated enormous variability in the both the peak-inspired (26.3-90.0%) and end-expired concentrations (25.2-78.6%) of oxygen delivered to the trachea. There was a regular relationship between the ratio of peak inspiratory flows, expressed over fresh gas inflow and the end-expired oxygen concentrations which could allow estimation of inspired oxygen concentration.

Nitrous oxide administration using commonly available oxygen therapy devices

Administration of nitrous oxide is useful for providing sedation and analgesia. The therapeutic range for nitrous oxide is 20-30%. Several oxygen treatment devices have been used for administering nitrous oxide, but little is known about the concentrations of nitrous oxide and oxygen delivered to the trachea. We have studied this, using an analogue lung model, with several oxygen therapy devices. With a 1:1 nitrous oxide-oxygen mixture in the primary flow for all systems, end-expired nitrous oxide concentrations varied between 6.5% and 34.3%. Therapeutic concentrations were produced using the Hudson (nominal oxygen concentration 60%) fixed-performance mask, the variable performance Hudson mask at 4 litre min-1, the MC masks at 4 and 6 litre min-1 and the nasal prongs at 6 and 8 litre min-1. Simultaneous end-expired oxygen concentrations for all devices tested were within a safe range.

Successful renal transplantation in a patient with systemic sarcoidosis and renal failure due to focal glomerulosclerosis

In 1987, a patient presented with pulmonary sarcoidosis and progressive renal failure. Percutaneous renal biopsy showed focal glomerular sclerosis (FGS). Over the subsequent 4-year period, her renal failure progressed to require hemodialysis. During this time, her pulmonary sarcoidosis was treated with daily corticosteroid therapy and she remained in clinical remission. The patient received a one-haplotype-identical living-related renal transplant from her mother. The patient is now 25 months posttransplant with a serum creatinine of 106 mumol/L (1.2 mg/dL). Her sarcoidosis continues to be in clinical remission. In this report, we review the rare association of a primary glomerular lesion causing renal failure in patients with sarcoidosis. In addition, we detail the first successful renal transplant in such a patient.

A high flow semi-open system for preoxygenation: an evaluation

We have compared an alternative breathing system for preoxygenation comprising a Hudson face mask with high oxygen inflow (48 litre min-1) and a Mapleson A breathing system (100 ml kg-1 min-1). The study consisted of two parts: the first involved adult volunteers (10 male, seven female) and the second part used a lung model for spontaneous ventilation with a sinusoidal ventilatory wave pattern. In the volunteers, preoxygenation was achieved at mean times of 138 (SD 31.3) s and 164 (SD 36.7) s with the high flow semi-open and Mapleson A systems, respectively. In the lung model, at peak inspiratory flow rates of 30 and 40 litre min-1, the preoxygenation times were 139 and 120 s, respectively, with the semi-open system and 167 and 156 s with the Mapleson A system. The high flow semi-open system may be an alternative for current techniques, provided peak inspiratory flows are not excessive.

Septic atrial thrombus. A complication of central venous catheterisation

A 77-year-old man underwent repair of a vesicocolic fistula following which he had a protracted stay in the intensive care unit due to recurrent septicaemia, which was initially caused by bowel anastomosis breakdown. Management included central venous cannulation and pulmonary artery catheter monitoring. A septic, mobile right atrial thrombus developed, which was successfully treated. The literature on this condition is reviewed.

Lymphocyte inhibitory and chemotactic factors produced by bursal and thymic lymphocytes

Bursal (B) and thymic (T) lymphocytes from chickens sensitized to Mycobacterium tuberculosis (PPD) or human gamma globulin (hGG) produced an avian lymphocyte-inhibitory factor designated as LyIF-PPD or LyIF-hGG, respectively. A chemotactic factor (LCF) for peripheral blood leukocytes was elaborated only by T-cells sensitized to PPD and hGG. These factors were partially purified by HPLC and were characterized physiochemically. Maximum inhibitory activity for LyIF-PPD and LyIF-hGG occurred in peak fractions corresponding to molecular weight ranges of 29,000 to 52,000 daltons and 15,000 to 29,000 daltons, respectively. The inhibitory activity of B- and T-LyIF-hGG was lost after chymotrypsin and neuraminidase treatment. Maximum chemotactic activity for LCF-PPD and LCF-hGG was in peak HPLC fractions corresponding to molecular weight ranges of 9,000 to 16,000 daltons and 8,000 to 16,500 daltons, respectively. Chemotactic activity of LCF-PPD and LCF-hGG was lost following chymotrypsin treatment while it was not reduced after neuraminidase treatment. Both inhibitory and chemotactic activities were stable at 56 C for 30 min and resistant to changes in pH from 5 to 9. The precursor molecule for the lymphokine is made after antigen immunization, but activated in the presence of the sensitizing agent.