Hospital-based HMO: an outpatient study

With the increasing pressure from managed care companies and in cooperation with its medical staff's independent practice association, the Vista Hill Foundation formed its own specialty health maintenance organization. This is a report on an outpatient study of treatment satisfaction among 124 mental healthcare providers (50% of whom were psychiatrists) and their 218 patient experiences. Treatment outcome was rated as "very satisfactory" or "satisfactory" in 82% of the studied cases. Managed care was found to cause "mild" to "moderate" treatment interference in 26% of the cases and "significant" to "major" interference in 6%. There was no interference reported in 60% of the cases studied. Our study demonstrates that a hospital provider and its managed care system can provide satisfactory care, but it also reveals the need to constantly review treatment programs to reduce interference. The study and report are part of Vista Hill Foundation's ongoing quality review efforts.

Opioid sensitivity of chronic pain: a patient-controlled analgesia method

Twenty-two patients with chronic pain of malignant or nonmalignant origin were given intravenous morphine by patient-controlled analgesia. A prestudy judgment was made from the characteristics of the pain as to whether it was nociceptive or neuropathic. Analgesic efficacy was assessed by a nurse-observer; adverse events were noted and plasma morphine and metabolitie concentrations measured. Three categories of opioid response were distinguished. Good responders obtained > 70 mm relief on the visual analogue scale, with minimal or manageable adverse events. Moderate responders obtained < 70 but > 30 mm relief with more problematic adverse events, and poor responders had < 30 mm relief with troublesome adverse events. This method for the study of opioid sensitivity allowed a wide dosage range to be studied. The simultaneous analgesic and adverse event measurements showed that the spectrum of observed response was wide, and response category could be judged for the majority by 4 h. In those with poor or moderate response, adverse event severity limited further dose increment. The relationship between pain characteristics and response showed that some pains judged to be neuropathic had a good response to opioid (5/13), and some pains judged to be nociceptive did not (5/14). The study suggests that the pattern of response is not as black and white as the prediction of good response from nociceptive pain and poor from neuropathic pain would suggest, although nociceptive pain was more likely than neuropathic pain to show a good response. For the moderate responders opioid titration may, in the absence of other effective treatments, be useful, but the analgesic endpoint may not be totally satisfactory. The method provides an operational definition of opioid sensitivity.

A multiple dose comparison of combinations of ibuprofen and codeine and paracetamol, codeine and caffeine after third molar surgery

In a randomised, double-blind, double-dummy, multiple dose, crossover study in 30 patients we compared an ibuprofen/codeine combination (400 mg ibuprofen/25.6 mg codeine phosphate) with a paracetamol/codeine/caffeine combination (1 g paracetamol/16 mg codeine phosphate/60 mg caffeine) for pain relief over 6 days after two-stage bilateral lower third molar removal. The ibuprofen combination produced significantly greater analgesia than the paracetamol combination, both on single-dose analysis of the first and second days and on multiple-dose measures for days 1, 2, 3 and 4. The mean incidence of adverse effects over the 6 days was 20% for both combinations. This trial design (crossover with multiple dosing in outpatients) is a sensitive way of testing for analgesia, and is potentially more predictive of adverse effect problems than single-dose studies. It confirms that multiple dosing may show increased efficacy.

Morphine responsiveness of chronic pain: double-blind randomised crossover study with patient-controlled analgesia

There is controversy about whether the lack of response of some chronic pain to opioid treatment is absolute or relative. It is widely believed that nociceptive pain is responsive to opioids whereas neuropathic pain tends not to be. We have used a method of patient-controlled analgesia (PCA) with simultaneous nurse-observer measurement of analgesia, mood, and adverse effects to address these issues. Ten patients with chronic pain were given morphine at two concentrations (10 and 30 mg/ml) by PCA in two separate sessions in a double-blind randomised crossover study. Before the study a clinical judgment was made as to whether each pain was nociceptive or neuropathic. Seven patients showed good analgesic responses (more than 70 mm pain relief on a visual-analogue scale) of pain at rest, two patients poor responses (less than 30 mm pain relief), and one a moderate response with both concentrations (30-70 mm pain relief). The response to morphine was consistent (greater and faster relief with the higher concentration) in nine patients. Two patients had pain on movement that responded moderately to low-concentration morphine and well to the higher concentration. All patients with pains judged to be nociceptive showed good analgesic responses compared with half of those with neuropathic pain. There was no evidence that analgesic responses in patients with neuropathic pain were due to changes in mood. This PCA method is a quick and efficient tool to determine the consistency of the analgesic response. Such consistency can guide the clinician as to whether continued or higher-dose opioid treatment will produce good analgesia. An inconsistent response points to the use of other pain-relieving strategies.

Oral morphine in cancer pain: influences on morphine and metabolite concentration

One hundred fifty-one patients with chronic cancer pain were studied during chronic treatment with oral morphine. Plasma concentrations of morphine and metabolites (M3G and M6G) were measured. The ratio of plasma morphine to metabolites was not affected by dose. Generalized linear interactive modeling analysis using morphine dose, age, sex, renal and hepatic dysfunction, and concomitant medication as explanatory variables accounted for 70% of the variance in plasma concentrations of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Increasing morphine dose was a significant factor for increased plasma concentrations of morphine, M3G, and M6G. Other significant factors were: age greater than 70 years (increased M3G and M6G plasma concentrations), plasma creatinine greater than 150 mumol/L (increased M3G and M6G plasma concentrations), male sex (decreased morphine and M6G plasma concentrations), raised creatinine plus coadministration of tricyclic antidepressants (increased M3G plasma concentrations), ranitidine (increased morphine plasma concentrations), and raised creatinine plus coadministration of ranitidine (increased M6G plasma concentrations).

Construction and Use of a Nonradioactive DNA Hybridization Probe for Detection of Pseudomonas syringae pv. Tomato on Tomato Plants

Pseudomonas syringae pv. tomato, the causal agent for bacterial speck of tomato, produces the phytotoxin coronatine. A 5.3-kilobase XhoI fragment from the chromosomal region controlling toxin production was cloned into the plasmid pGB2, and the resulting recombinant plasmid, pTPR1, was tested for its ability to serve as a diagnostic probe for P. syringae pv. tomato. In a survey of 75 plant-associated bacteria, pTPR1 hybridized exclusively to those strains that produced coronatine. The detection limit for this probe, which was labeled with the Chemiprobe nonradioactive reporter system, was approximately 4 × 10 3 CFU of lesion bacteria. During the 1989 growing season, a total of 258 leaf and fruit lesions from nine tomato fields were screened for P. syringae pv. tomato by using pTPR1 and the culture method of detection. The best agreement between the two methods, 90%, occurred early in the season with samples taken from relatively young (5-week-old) plants. Young plants also had a higher percentage of P. syringae pv. tomato-positive lesions. P. syringae pv. tomato was the only coronatine producer recovered from the nine tomato fields. All 244 P. syringae pv. tomato strains isolated during this study reacted strongly with the probe. The P. syringae pv. tomato population of healthy field tomato leaves was determined by a pTPR1 colony hybridization procedure. Every probe-positive colony that was isolated and characterized was identified as P. syringae pv. tomato. The pTPR1 probe should expedite disease diagnosis and facilitate epidemiological studies of this pathogen. It also should aid in screening transplant seedlings for bacterial speck infestation.

Buprenorphine disposition in patients with renal impairment: single and continuous dosing, with special reference to metabolites

The disposition of buprenorphine has been studied in two patient groups to assess the influence of impaired renal function on the metabolism of buprenorphine and two of its metabolites, buprenorphine-3-glucuronide (B3G) and norbuprenorphine (NorB). A single i.v. dose of 0.3 mg was given to 15 patients (nine with dialysis-dependent renal failure) undergoing lower abdominal or peripheral body surface surgery. Blood was sampled up to 24 h. Concentrations of buprenorphine, B3G and NorB were assayed by a differential radioimmunoassay technique. There were no differences in buprenorphine kinetics between anaesthetized healthy patients and those with renal impairment: mean elimination half-lives 398 and 239 min; clearance 651 and 988 ml min-1; apparent volume of distribution at steady state 313 and 201 litre, respectively. Both metabolites were undetectable following the single i.v. dose. In a second group of 20 patients (eight with renal impairment), buprenorphine was administered by continuous infusion for provision of analgesia and control of ventilation in the ITU (median infusion rate 161 micrograms h-1 (range 36-230 micrograms h-1) for a median duration of 30 h (2-565 h). Buprenorphine clearance in patients with normal and impaired renal function was similar (934 and 1102 ml min-1, respectively), as were dose-corrected plasma concentrations of buprenorphine. In patients with renal failure, plasma concentrations of NorB were increased by a median of four times, and B3G concentrations by a median of 15 times.

Benzydamine cream for the treatment of post-herpetic neuralgia: minimum duration of treatment periods in a cross-over trial

In a double-blind multiple-dose cross-over study benzydamine 3% cream was compared with placebo for the treatment of post-herpetic neuralgia. Pain relief, pain intensity, sleep, escape analgesic consumption and side effects were assessed by diary methods for the 2 week treatment periods, with 1 week run-in and 1 week wash-out. There were no significant differences between the 2 treatments. The implications of the results for other antiprostaglandin remedies recommended for treatment of post-herpetic neuralgia are discussed. An important observation with methodological significance for similar studies of chronic conditions was that short treatment periods may produce false positive results. Patients' expectations are high, and if the first study treatment is ineffective, initial significant benefit may be noted when crossing over to the next treatment; this may not last longer than 1 week. Cross-over studies in which neither treatment is effective may, therefore, produce erroneous results if treatment periods are shorter than 2 weeks.

Use of a personal computer to support an investigational drug service

A description of the rationale for the computerization of an Investigational drug service, (IDS) including the potential for benefits in three major areas: (1) policy & procedure, (2) financial analysis, and (3) drug accountability. Through the use of readily available computer software, dispensing, and billing procedures have been streamlined. Software with spreadsheet capability facilitates analysis of the financial status of the IDS. A specially designed software package allows maintenance of the drug account-ability records for investigational protocols.

The effect of the American Heart Association step one diet on hyperlipidemia following renal transplantation

Cardiovascular disease is a frequent cause of morbidity and mortality following renal transplantation. The percentage of deaths due to ischemic cardiovascular disease and cerebrovascular accidents nearly equals that caused by infection among patients receiving their first transplant, according to data from the European Dialysis and Transplant Association Registry. Hypercholesterolemia is a risk factor for cardiovascular disease frequently identified following renal transplantation, and diets low in fat and cholesterol have been suggested as treatment. Previous studies have not reported the response of LDL cholesterol to dietary treatment, and it is this form of cholesterol that is most closely related to cardiovascular disease. The American Heart Association has provided nutritionists with guidelines for the treatment of hyperlipidemic patients which include the Step One Diet. Previous dietary studies of renal transplant recipients have allowed a slightly higher intake of fat than that currently recommended by the AHA. We wondered if an easily reproducible diet well known to nutritionists such as the AHA Step One Diet would be effective in lowering cholesterol levels in hyperlipidemic renal transplant recipients. The purpose of our study was not to define the mechanisms of posttransplant hyperlipidemia, but rather to assess the effectiveness of dietary intervention on hyperlipidemia following renal transplantation.

Local pulmonary ventilation using nonradioactive xenon-enhanced ultrafast computed tomography

Using ultrafast computed tomography, we have developed a technique for measuring local ventilation in a volume of 1 cm3 in the normal supine lung. The technique employs the inert gas xenon in its nonradioactive form and makes use of its radiopaque properties. The inhalation of xenon results in changes in density which can be detected and measured in Hounsfield units using ultrafast computed tomography. Using this property and assuming a monoexponential form for the washin curve of the inert gas, it is possible to calculate ventilation at a local level. The methodology also permits measurements of minute ventilation during the procedure, thus permitting standardization. Using this technique, we calculated local ventilation in six normal subjects and have demonstrated a minor gradient in ventilation between the dorsal and ventral regions of the lung while in the supine position.

The elderly victim of rape

A common misconception about sexual assault is that the rapist is motivated by a sexual desire stimulated by a victim seductive in her behavior or dress. A retrospective analysis of 740 reported sexual assaults revealed 21 cases involving a victim between the ages of 60 and 90 years of age. The elderly victim was more often white and the assailant more often black than when younger victims are involved. Also, the data suggest that the rape of elderly women may involve a relatively few rapists, and that their assaults are of a serial nature. This study concludes that these rapists are motivated by anger, possibly racially related, and a need to express power, rather than by sexual desire.

Codeine 20 mg increases pain relief from ibuprofen 400 mg after third molar surgery. A repeat-dosing comparison of ibuprofen and an ibuprofen-codeine combination

A combination of 20 mg codeine base and ibuprofen 400 mg was compared with ibuprofen 400 mg in a randomised double-blind cross-over study of multiple doses in 25 patients after 2-stage bilateral third molar removal. The combination produced significantly greater pain relief and doubled the hours of minimum pain intensity and maximal relief on the day of surgery. The patients rated the combination significantly better than ibuprofen alone, and the combination was preferred by 16 of the 22 patients expressing a preference. There was no significant increase in side-effect incidence with the combination. The 30% increase in analgesic effect may be of clinical benefit, and this trial design, cross-over with multiple dosing in out-patients, may be a sensitive test for analgesics, potentially more predictive of side-effect problems than single-dose studies.

Radioimmunoassay of buprenorphine in urine: studies in patients and in a drug clinic

A radioimmunoassay kit (DPC buprenorphine double antibody) was evaluated with clinical samples and samples from a drug clinic. Urine samples were collected over a 2-day period from 5 hospital in-patients receiving sublingual buprenorphine, 400 to 2000 micrograms/day, for the relief of chronic pain. Samples were measured before and after enzymatic hydrolysis. Urine buprenorphine concentrations were measurable at all doses studied (minimum value 5.6 ng/mL) and were greater with larger doses. The increase in concentration after hydrolysis averaged 49% and was similar for all doses studied. The authors conclude that the method has extensive cross-reactivity with glucuronides of buprenorphine and its metabolites and that samples may be analyzed without prior hydrolysis. The prevalence of buprenorphine use in 97 patients attending a drug clinic was also studied. Sixty (62%) had measurable urinary buprenorphine concentrations of 1 ng/mL or more by direct assay. The buprenorphine users were significantly younger and reported significantly greater use of opiates than nonusers.

Studies on morphine disposition: plasma concentrations of morphine and its metabolites in anesthetized middle-aged and elderly surgical patients

The effects of aging on the disposition of morphine and its metabolites have been investigated in 10 middle-aged patients (36 to 55 years of age) undergoing lower abdominal or body surface surgery, and compared with 10 elderly patients (65 to 83 years of age) undergoing similar surgery. All patients received 10 mg morphine sulphate pentahydrate IV over 30 seconds as part of a balanced anesthetic technique. Peripheral venous blood samples were collected to 180 min, and plasma concentrations of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) were assayed by differential radioimmunoassay. There were no differences between the two groups for morphine elimination half-life (middle-aged patients, 129 min; elderly patients, 162 min), mean residence time (154 and 207 min), and apparent volume of distribution at steady state (116 and 107 l). However, clearance was significantly greater in the younger patients (853 vs. 559 ml/min; p less than 0.02). The area under the curve (AUC0-180) for M3G and M6G were similar in the two patient groups, as were the peak metabolite concentrations and times to peak concentrations. M6G has been shown in both animals and humans to exert analgesic properties. Despite the reduced clearance of the parent drug, there was an unaltered AUC for M6G, presumed due to the greater decrease in glomerular filtration rate seen during anesthesia in the elderly patient. This phenomenon may result in enhanced analgesic efficacy from a given dose of morphine in the elderly patient.

Studies on morphine disposition: influence of renal failure on the kinetics of morphine and its metabolites

The influence of renal failure on the disposition of morphine and its metabolites was studied in nine patients with end-stage renal failure undergoing transplantation, and compared with five healthy anaesthetized patients. All patients received morphine sulphate pentahydrate 10 mg i.v. over 30 s, as part of a balanced anaesthetic technique. Venous blood samples were collected for up to 24 h, and plasma concentrations of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) assayed by a differential radioimmunoassay method. There were no differences between the two groups for morphine elimination half-life (renal failure: 290 min; anaesthetized controls: 286 min), or clearance (renal failure: 533 ml min-1; controls 741 ml min-1). However, the volume of distribution at steady state was greater in the control group (241 litre v. 141 litre; P = 0.002). The peak concentrations of M3G and M6G were greater in the renal transplant patients (P = 0.001 and P = 0.01, respectively), as were the AUC (0-24 h) (P = 0.002 and P = 0.002). M6G has been shown to possess analgesic properties in both man and experimental animals, and therefore the increased AUC for M6G may contribute to the prolonged effect seen with morphine when given to patients with impaired renal function.

Studies on morphine disposition: influence of general anaesthesia on plasma concentrations of morphine and its metabolites

The kinetics of morphine were studied during balanced anaesthesia in 10 patients undergoing lower abdominal or body surface surgery, and compared with those obtained in nine awake patients receiving morphine i.v. for the relief of chronic non-cancer pain. All patients received morphine sulfphate pentahydrate 10 mg i.v. over 30 s. Venous blood samples were collected for up to 180 min, and plasma concentrations of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) assayed by a differential radioimmunoassay technique. There were no differences between groups with respect to the elimination half-life (awake group: 207 min; anaesthetized group: 153 min), volume of distribution at steady state (awake: 147 litre; anaesthetized: 128 litre), or clearance (awake: 587 ml min-1; anaesthetized: 766 ml min-1). Peak concentrations of M3G were similar in the two groups, but the peak concentration of M6G was greater in the anaesthetized patients. The AUC for M3G and M6G (0-180 min) also were greater in the anaesthetized patients, presumably as a result of decreases in renal blood flow and glomerular filtration rate during halothane anaesthesia.

Transcutaneous electrical nerve stimulation in the management of acute postoperative pain

Twenty patients undergoing decompressive lumbar laminectomy were randomly allocated, in a double-blind manner, to receive active or inactive transcutaneous electrical nerve stimulation (TENS) as part of the management of their postoperative pain. All patients received the same non-narcotic general anaesthetic. The efficacy of the TENS was assessed by using a patient-controlled analgesia system (PRODAC) which delivered morphine i.v. This system recorded the number of demands for analgesia and the total dose administered in the first 24 h. In addition, plasma morphine concentrations were measured hourly for the first 6 h and again at 24 h. There was no statistical difference between the two groups in the number of patient demands for analgesia, morphine dose or plasma morphine concentration. TENS offered no advantage over a placebo in the management of acute postoperative pain in these patients.

Morphine and ibuprofen compared using the cold pressor test

The analgesic efficacy of single doses of oral morphine sulphate solution (10 mg) and ibuprofen 600 mg was compared in 12 volunteers using a double-blind, double-dummy, placebo-controlled design on the cold pressor experimental pain model. Measurement of pain intensity was made before medication and then at 30, 60, 90, 120 and 180 min; blood samples were taken at these times for measurement of morphine and glucuronide metabolites by radioimmunoassay. Sessions were at least 5 days apart. Correlations were sought between analgesic effect and plasma concentrations of either morphine or morphine-6-glucuronide. Morphine produced significant reduction in both peak pain intensity and area under the pain intensity curve compared with placebo; the threshold time was significantly increased by morphine compared with placebo. Ibuprofen was statistically indistinguishable from placebo on all three measures of analgesia. Analgesic effect and plasma concentrations of morphine showed significant correlation (P = 0.053). The study confirmed reports of the opiate sensitivity of the cold pressor model, and the apparent insensitivity of the model to non-steroidal anti-inflammatory drugs.

Comparison of whole blood and plasma morphine

Thirty paired samples of plasma and whole hemolyzed blood were obtained from patients undergoing surgery. Morphine concentrations were measured with the DPC serum morphine kit without prior treatment. In a regression analysis, the equation to the regression line was blood = 1.02 plasma + 1.0 ng/mL, and the correlation coefficient was 0.994. Radioimmunoassay screening of postmortem blood samples can be performed without prior sample treatment.

Postoperative orthopaedic pain--the effect of opiate premedication and local anaesthetic blocks

The postoperative analgesic effect of opiate premedication and local anaesthetic blocks was studied in 929 patients having orthopaedic surgery. The median time to first request for postoperative analgesia was less than 2 h when neither opiate premedication nor block was used; opiate premedication increased the time significantly to more than 5 h; local anaesthetic block produced a further significant increase to 8 h and opiate premedication used with local anaesthetic block extended the median time further to more than 9 h. Women requested analgesia significantly earlier than men, independent of treatment. Age had no significant effect. Prolonging the time before more pain relief is required may be worthwhile for both patients and staff.

Comparisons of specific crosses from Yorkshire-Landrace, Chester White-Landrace and Chester White-Yorkshire sows

One hundred thirty Yorkshire-Landrace (YL), Chester White-Landrace (CL) and Chester White-Yorkshire (CY) F1 crossbred sows were mated randomly to Duroc (D), Hampshire (H), Farmers Hybrid 414 (FH414) or Farmers Hybrid 929 (FH929) boars. These matings produced 321 litters and 3,379 pigs, which were used to determine the effect of sire breeding and dam breeding on preweaning and postweaning performance of the pigs and litters. Litter size born alive, litter size at 56 d, litter weight at 56 d and litter weight per day of age to 100 kg were lower in litters sired by H boars than in those sired by D boars. However, sizes and weights of litters sired by D and H boars were not different from those sired by FH414 and FH929 boars. Litter sizes at birth were larger for litters out of CL and CY sows than those out of YL sows, but significant differences were not found for litter sizes at 21 d, 56 d or at marketing. Pigs sired by H boars were heavier at birth than pigs sired by D boars. Pigs sired by H boars did not differ significantly in weights at 21 and 56 d or in postweaning daily gains or days to 100 kg from pigs sired by D boars. Pigs out of CL dams were heavier at birth, 21 d and 56 d of age than pigs out of CY dams, but did not differ significantly in postweaning gains or in days to 100 kg. Pigs sired by D and H boars had less ultrasonic fat than pigs sired by FH414 and FH929 boars. Pigs sired by FH929 boars were leaner than pigs sired by FH414 boars.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical spectrum of the upper gastrointestinal effects of nonsteroidal anti-inflammatory drugs. Natural history, symptomatology, and significance

Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve rheumatic pain and are in extensive use. Symptomatic complications of NSAIDs requiring the discontinuation of their use occur in 2 to 10 percent of patients with rheumatic diseases in sharp contrast to the common asymptomatic problems of gastroduodenal erosions, ulcerations, and bleeding, with resulting anemia in more than 40 percent of these patients. Opinions concerning the clinical significance of these complications are not uniform. The natural history of the effects of NSAIDs on the gastroduodenal mucosa reveals a sequence of initial subepithelial hemorrhage over a 24-hour period followed by gastroduodenal erosions and ulcerations in the next two weeks. From one week to three months, gastroduodenal erosions and ulcerations disappear in about half of the patients as an adaptation to continuing NSAID ingestion occurs. Hemorrhage may occur at any time in most patients and in a small minority (1 percent) it is massive. Non-aspirin NSAIDs (NANSAIDs) exhibit significantly fewer complications than do aspirin. These complications, however, demand considerable clinical attention and are ordered in a constant hierarchy, suggesting variable risks of complications among agents. NSAIDs are a blessing for those who have chronic pain, but that blessing does not prevent significant asymptomatic complications in the same patients. Prophylaxis for high-risk groups, such as women over the age of 65 years, should be subjected to study.

Acute and chronic pituitary failure resembling Sheehan's syndrome following bites by Russell's viper in Burma

Pituitary function was investigated in 9 patients in shock after Russell's viper bites and in 24 individuals who had been severely envenomed 2 weeks to 24 years previously. 3 out of 9 patients had hypoglycaemia and inappropriately low serum cortisol, plasma growth hormone, and plasma prolactin concentrations. 4 who died had pituitary haemorrhage and 1 had adrenal haemorrhage as well. Of the 24 who had apparently recovered from bites, 7 had clinical features of hypopituitarism and no response in plasma growth hormone or prolactin concentrations to symptom-producing insulin-induced hypoglycaemia. 4 of these 7 had a sluggish serum cortisol response to 'Synacthen Depot' and 5 had an abnormal cortisol response to hypoglycaemia. 4 men with symptoms who were tested had low serum testosterone concentrations; serum thyroxine was also low in these men but not in 2 women with menstrual disturbances and impaired insulin responses. Of the 17 individuals without clinical evidence of endocrine disease, 4 had pituitary hormonal abnormalities. Russell's viper envenoming may thus produce a disorder resembling Sheehan's syndrome.

Serum beta-human chorionic gonadotropin levels relate poorly with the size of a tubal pregnancy

Ectopic implantation usually begins with relatively normal growth of trophoblast and serum beta-hCG progression. However, the trophoblast eventually erodes into vessels and a variable degree of bleeding and hematoma compromises its growth. The serum beta-hCG level then usually begins to demonstrate some degree of abnormal progression. For our patients, the length of the ectopic pregnancy varied widely, depending mainly on when the individual patient chose to seek medical treatment. Infertility patients followed from the moment of conception would thus be expected to show a better correlation between early beta-hCG levels and the size of the tubal pregnancy. Preconditions for the operative laparoscopic management of a tubal pregnancy usually include that the tube be unruptured, less than 3 cm in diameter, and readily accessible via the laparoscopic approach. Ackerman et al. suggested there was a general correlation between the serum beta-hCG level and tubal rupture, and the present data demonstrate an overall positive correlation between the size of the tubal pregnancy and the serum level. However, the range of levels is so broad for any given size of mass or tubal status that this correlation is not meaningful clinically. A reliable method to determine the size and status of a tubal pregnancy before laparoscopy would be valuable. Unfortunately, we did not find the preoperative serum beta-hCG level to be useful for making this prediction.

Factors in the outcome of transsphenoidal surgery for prolactinoma and non-functioning pituitary tumour, including pre-operative bromocriptine therapy

Radical transsphenoidal surgery in 58 patients with large non-functioning pituitary tumours relieved pressure symptoms and disconnection hyperprolactinaemia without loss of pituitary function, and verified the diagnosis. Pre-operative bromocriptine did not cause any shrinkage of non-functioning tumours (n = 8), even up to 48 weeks. Thirty-two patients not given postoperative radiotherapy are being followed-up, and although two show minor CT scan evidence of tumour regrowth, for the others the delay in radiotherapy is enabling reproduction where required. In 20 patients with non-invasive macroprolactinomas radical surgery caused no loss of pituitary function but cured eight, of whom one has relapsed; none of eight invasive prolactinomas was cured by surgery. Pre-operative bromocriptine caused marked size reduction in seven of seven macroprolactinomas, but if continued beyond 6 weeks induced tumour fibrosis and uneven shrinkage which made surgery dangerous and unproductive. Selective transsphenoidal surgery relieved hyperprolactinaemia in 70% of patients with meso- (n = 15) or microprolactinoma (n = 24) usually without loss of pituitary function: the relapse rate was 1 per 88 patient years of follow-up. Invasive prolactinomas, and macroprolactinomas showing uneven shrinkage with a short (up to 4 weeks) course of bromocriptine should have radiotherapy rather than surgery, while the patients most suited to surgery are those with mesoprolactinomas, or some macroprolactinomas with compact intrasellar shrinkage after short-term bromocriptine. Microprolactinomas generally did not benefit from surgery as compared to conservative therapy. In none of the tumour groups were the surgical findings an accurate predictor of postoperative pituitary function.

Fluradoline and aspirin for orthopedic postoperative pain

Fluradoline (150 or 300 mg), a novel tricyclic with both antidepressant and analgesic properties in animals, was compared with aspirin, 650 mg, and placebo when given orally for postoperative orthopedic pain in a double-blind, single-dose, parallel-group study. Analgesic measurements were made by two trained nurse observers using standard verbal rating and visual analogue scales. Aspirin was statistically superior to placebo on all analgesic measures, demonstrating assay sensitivity. Fluradoline, 300 mg, was distinguished from placebo and fluradoline, 150 mg, but not from aspirin, 650 mg. Overall, fluradoline, 300 mg, was equivalent to aspirin, 650 mg. Fluradoline, 300 mg, produced a significant elevation in mood score. Neither aspirin, 650 mg, nor fluradoline caused untoward side effects, but fluradoline, 300 mg, increased blood pressure.

Determination of the pulmonary capillary wedge position in patients with giant left atrial V waves

Thirteen patients with giant left atrial V waves during preoperative cardiac catheterization were admitted into the study group. While awake and breathing spontaneously, simultaneous recordings of electrocardiographic leads II and V5, radial arterial traces, and pulmonary arterial or pulmonary capillary wedge traces were obtained. Measurements were made on four consecutive cardiac cycles in the unwedged and wedged positions for the following intervals: Q wave to the radial arterial upstroke (220 +/- 20 milliseconds) and peak (360 +/- 10 milliseconds), Q wave to the pulmonary arterial upstroke (170 +/- 20 milliseconds) and peak (350 +/- 20 milliseconds), Q wave to the V wave upstroke (280 +/- 20 milliseconds) and peak (570 +/- 20 milliseconds), and QT interval (420 +/- 20 milliseconds). These findings indicate that the radial arterial and pulmonary arterial upstrokes and peaks occur nearly simultaneously. Upon wedging, the V wave upstroke occurs significantly later in the cardiac cycle (P less than .05) compared with the pulmonary arterial upstroke, and the V wave peak occurs significantly later compared with both the pulmonary arterial and the radial arterial peak (P less than .05). A rapid, simple beat-to-beat method for differentiating pulmonary arterial from pulmonary capillary wedge positions in the presence of giant left atrial V waves is the superimposition of the pulmonary arterial trace on the radial arterial trace. When a wedge position is attained, there is an immediate rightward shift in the upstroke and peak of the pulmonary arterial pressure trace, which can be easily identified by observing the relationship between the pulmonary arterial and systemic arterial traces.

Analysis of morphine and its major metabolites by differential radioimmunoassay

The analysis of morphine, morphine-3-glucuronide (M-3-G) morphine-6-glucuronide (M-6-G) by differential radioimmunoassay using iodinated label and three different antisera is described. These methods were used to measure concentrations of morphine and its conjugated metabolites in human plasma, over a 3-h period, following a single 10 mg intravenous dose. In 13 patients peak concentrations of M-3-G (739 nmol/L +/- 73.7 SEM) were approximately 10 times greater than those of M-6-G (71.3 nmol/L +/- 8.6 SEM). Times to reach these peaks were similar for both metabolites. Decay of morphine from plasma followed a biexponential pattern with a mean terminal half-life of 59.3 min (+/- 8.1 SEM, n = 11). Accurate determination of the half-lives of the glucuronides was not possible due to the short sampling period, but M-6-G seemed to have a similar half-life to morphine, while M-3-G was eliminated more slowly.

Influenza vaccine: the effects of the 1986/1987 viral strains

One hundred and twenty healthy volunteers were recruited for a study to evaluate the reactogenicity and serological response of differing doses of the 1986/87 World Health Organization-recommended influenza viral strains. Each vaccine was prepared by Institut Merieux and contained A/Mississippi/1/85, A/Chile/1/83 and B/Ann Arbor/1/86. One vaccine was formulated as a 10/10/10 micrograms HA and the other as a 15/10/15 micrograms HA. No significant advantage could be found with the 15/10/15 micrograms HA combination and it was recommended, therefore, that a 10/10/10 micrograms HA formulation was to be preferred. This vaccine demonstrated a minimal cross-sensitivity to the A/Singapore/6/86 influenza strain. In view of the prevalence of the A/Singapore strain, a second study was subsequently undertaken with a monovalent A/Singapore/6/86-like vaccine in a further 62 volunteers. This demonstrated an overall sero-conversion rate of 90%. Local side-effects with both vaccines were lower than in a similar study in 1984 and this may reflect a reduction in endotoxin levels achieved by a minor modification in the manufacturing technique. These studies confirmed the efficacy of a trivalent A/Mississippi, A/Chile, B/Ann Arbor influenza vaccine and the efficacy of, and necessity for, an additional A/Singapore vaccine.

Role of porins in intrinsic antibiotic resistance of Pseudomonas cepacia

The measured outer membrane permeability of Pseudomonas cepacia to the beta-lactam nitrocefin was low: approximately 10 times less than that of Escherichia coli and comparable to that of Pseudomonas aeruginosa. The purified P. cepacia porin demonstrated an average single channel conductance in 1 M KCl of 0.23 nS.

Halothane metabolism in acyanotic and cyanotic patients undergoing open heart surgery

The metabolism of halothane was examined in patients with acyanotic and cyanotic congenital heart disease undergoing open heart surgery. Statistically significant (P less than 0.05) pre-surgical differences between acyanotic and cyanotic groups included pH (7.46 +/- 0.02 vs 7.36 +/- 0.02), PaO2 (277 +/- 58 vs 51 +/- 3 torr), O2 saturation (97 +/- 1 vs 74 +/- 4%), and hematocrit (45 +/- 3 vs 58 +/- 2%). Serum fluoride levels were significantly greater in cyanotic than in acyanotic groups 2-4 hours after initial exposure to halothane. Both groups had significant intragroup increases in serum levels of fluoride, bromide, and trifluoroacetic acid. Significant increases in serum levels of lactate dehydrogenase, creatinine phosphokinase, and glutamic oxaloacetate transaminase were observed in both groups, whereas, the cyanotic patients had additional significant increases in blood urea nitrogen and direct bilirubin. The cyanotic group also had higher total and direct serum bilirubin levels than the acyanotic group. Therefore, patients with cyanotic congenital heart disease had greater reductive metabolism of halothane than acyanotics. However, cyanotic and acyanotic patients had essentially similar postoperative derangements in hepatic and renal function.

Involvement of outer membrane of Pseudomonas cepacia in aminoglycoside and polymyxin resistance

Pseudomonas cepacia was found to be resistant to the outer membrane-permeabilizing effects of aminoglycoside antibiotics, polymyxin B, and EDTA. Permeabilization of P. cepacia to the fluorescent probe 1-N-phenylnaphthylamine was not achieved at concentrations 100- to 1,000-fold above those required to permeabilize Pseudomonas aeruginosa. Furthermore, in contrast to P. aeruginosa cells, intact cells of P. cepacia did not bind the fluorescent probe dansyl-polymyxin. However, purified lipopolysaccharide (LPS) from P. cepacia bound dansyl-polymyxin with approximately the same affinity as did LPS from P. aeruginosa. Also, binding of dansyl-polymyxin to P. cepacia (and P. aeruginosa) LPS was inhibited by polymyxin B, streptomycin, gentamicin, and Mg2+. These data suggest that P. cepacia does not utilize the self-promoted pathway for aminoglycoside uptake and that the outer membrane is arranged in a way that conceals or protects cation-binding sites on LPS which are capable of binding polycations such as aminoglycosides or polymxyin.

Epinephrine reduces systemic absorption of extradural diacetylmorphine

The effect of epinephrine on the vascular absorption of morphine from the extradural space is uncertain; this study examined the effect of epinephrine on the related but more lipophilic opiate diacetylmorphine (diamorphine, heroin) because any effects of vasoconstriction on diacetylmorphine absorption should be maximally apparent. With this experiment, we hoped to resolve whether epinephrine does or does not alter vascular absorption of extradurally injected opiates. Thirty patients undergoing lumbar laminectomy were given either extradural diacetylmorphine, 5 mg, extradural diacetylmorphine, 5 mg with 1:200,000 epinephrine, or 1:200,000 epinephrine followed 5 min later by 5 mg extradural diacetylmorphine. Plasma morphine concentrations were measured by radioimmunoassay because of the rapid conversion of diacetylmorphine to morphine in plasma; repeated blood samples were obtained the first 30 min after injection into the epidural space. Significantly lower plasma morphine levels occurred between 3 and 20 min when epinephrine was added to diacetylmorphine. Peak plasma morphine levels (mean +/- SEM) were 179 +/- 37 nmol/L with diacetylmorphine alone, 87 +/- 16 nmol/L with diacetylmorphine and epinephrine given together and 44 +/- 11 nmol/L with epinephrine pretreatment, all significantly different from one another. The mean peak plasma morphine concentration was 8.7 +/- 1.1 min for diacetylmorphine alone, but addition of epinephrine (together or sequentially) meant that 15 of 20 patients had no peak level before 120 min. Epinephrine reduced absorption of diacetylmorphine from the extradural site by at least 55% over the first 30 min. The incidence of patients with more than 9 hr analgesic duration was significantly (P = 0.033) greater in patients who had diacetylmorphine and epinephrine.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of spinal noradrenergic system in transmission of pain in patients with spinal cord injury

15 patients with deafferentation pain due to spinal cord injury were investigated for a spinal mechanism of pain transmission. Epidural morphine 5 mg in 5 ml of water had an analgesic effect in 5 patients, 3 of whom also had pain relief with epidural clonidine. Epidural clonidine 150 micrograms in 5 ml of saline had an analgesic effect in 7 patients who did not respond to epidural morphine. Neither epidural morphine nor clonidine was effective in the other 3 patients, 2 of whom obtained relief with epidural buprenorphine 0.3 mg in 5 ml of saline. 1 patient did not find relief with any of the injections. These data suggest that a spinal noradrenergic system may be as important as the opioid system in the transmission of pain in patients with spinal cord injury.