Tort reform and the obstetric access crisis. The case of the WAMI states

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.

Renal interstitial hydrostatic pressure and PGE2 in pressure natriuresis

The present study tested the hypothesis that the presence of renal prostaglandin E2 (PGE2) is necessary for full natriuretic response to increased renal interstitial hydrostatic pressure (RIHP) during increased renal perfusion pressure (RPP). In control untreated pentobarbital-anesthetized dogs (n = 7), fractional excretion of sodium (FENa) was 1.17 +/- 0.48, 1.07 +/- 0.24, and 2.69 +/- 0.57% at RPP of 90, 122, and 148 mmHg, respectively. These changes in FENa were associated with effective renal blood flows (ERBF) of 1.43 +/- 0.20, 1.49 +/- 0.23, and 1.99 +/- 0.40 ml.min-1.g kidney wt-1, respectively. Similarly, glomerular filtration rate (GFR) was 0.53 +/- 0.10, 0.71 +/- 0.10, and 0.72 +/- 0.14 ml.min-1.g kidney wt-1, respectively. Treatment with indomethacin, a cyclooxygenase inhibitor, significantly lowered FENa to 0.45 +/- 0.13, 0.77 +/- 0.21, and 1.19 +/- 0.59% at RPP of 91, 121, and 146 mmHg, respectively. Additionally, indomethacin treatment lowered ERBF (0.51 +/- 0.15, 0.52 +/- 0.10, and 0.85 +/- 0.21 ml.min-1.g kidney wt-1) and GFR (0.28 +/- 0.09, 0.34 +/- 0.09, and 0.47 +/- 0.09 ml.min-1.g kidney wt-1) at low, middle, and high RPP, respectively. PGE2 replacement (n = 6) into renal artery at 0.01 microgram.min-1.kg body wt-1 returned FENa, ERBF, and GFR to control levels over the same range of RPP, whereas prostacyclin (PGI2) infusion (n = 7) at the same dose did not. RIHP was 4.2 +/- 1.2, 4.2 + 0.5, and 7.5 +/- 1.7 mmHg with increasing RPP in control untreated group and increased to similar levels with indomethacin treatment and during PGE2 or PGI2 replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrovasculr Response to CO2 in Edematous Brain During Either Fentanyl or Isoflurane Anesthesia

Cerebral blood flow response to changes in PaCO2 was studied in the edematous cerebral cortex of 19 patients with malignant supratentorial tumors using laser Doppler flowmetry technology. General anesthesia for craniotomy was induced with thiopental, 3-5 mg/kg i.v., and N2O, 60% in O2. In random sequence, 8 patients were assigned to receive fentanyl, 6 +/- 1.6 (SEM). mug/kg i.v.; the other 11 received isoflurane, 0.56% end-tidal + 0.07 (SEM). After a craniotomy bone flap was turned and the dura was opened, laser flowmetry probes were placed over surgically undisturbed cortex that was known to be edematous from preoperative CT and MRI scans. Flow index measurements were first made at hypocarbia (PaCO2 = 24.2 +/- 0.9 and 21.5 +/- 2.1 mm Hg for the fentanyl and isoflurane groups, respectively). Minute ventilation was then decreased and cortical flow index was remeasured with PaCO2 = 34.2 +/- 0.6 and 33.0 +/- 0.8 mm Hg for the fentanyl and isoflurane groups, respectively. Hypocarbia during fentanyl-supplemented N2O-O2 anesthesia resulted in a cortical flow index that was 70 +/- 8% of the flow index at near normocarbia (p <0.05). During isoflurane N2O-O2 anesthesia, however, there was a wide variety of responses to hypocarbia, including three patients whose flow indices increased markedly. The mean flow index during hypocarbia was significantly (p <0.05) lower during fentanyl-N2O anesthesia than it was during isoflurane-N2O anesthesia. There was no predictable relationship between the type of brain tumor and the CBF response to hypocapnia during isoflurane-N2O anesthesia. It is concluded that, in edematous brain, cerebral cortical blood flow response to hypocarbia is more likely to be preserved during fentanyl-supplemented N2O-O2 anesthesia than it is during isoflurane-supplemented N2O-O2 anesthesia. In neuropathologic states where hyperventilation is thought to be necessary to reduce cerebral blood flow and decrease brain bulk, isoflurane may be less satisfactory than fentanyl as a supplement to N2O-O2 anesthesia.

Enalapril in the long-term treatment of elderly hypertensives

The long-term antihypertensive effects of enalapril were assessed for a period of up to 1 year in 44 elderly patients with mild-to-moderate essential hypertension. Following a 2-week placebo period, patients who were assigned to enalapril were followed for 6 weeks in a randomized clinical trial. In patients who benefited from enalapril, treatment was continued and subjects were followed for up to 1 year. Supine and standing systolic and diastolic blood pressures were significantly reduced throughout the 1-year period compared with baseline. The dosage of enalapril was increased from 10 to 20 mg daily in 12 patients; 8 required additional antihypertensive agents. Enalapril is effective in the long-term treatment of hypertension; no loss of antihypertensive agents. Enalapril is effective in the long-term treatment of hypertension; no loss of antihypertensive effect occurs.

New high O2 carrying perfluorochemical emulsions: toxicity, radiosensitivity of GM-CFC and development of metastases in mice

The effects of two new concentrated perfluorochemical emulsions based on F-66E and PFOB, which carry significantly more oxygen than Fluosol-DA 20%, were tested on normal tissues (toxicity and radiation response) and on the development of metastases from Lewis Lung Carcinoma (3LL) in female C57 BL/6 mice. Twenty one days after injection of F-66E or PFOB emulsions (15 ml/kg body weight), the spleen and liver weights were significantly increased but had returned to normal after 2-3 months. Splenomegaly already observed in 3LL bearing mice was significantly increased by F-66E emulsion injection. The radiosensitivity of GM-CFC was not altered when unanesthetized GM-CFC was not altered when unanesthetized mice were pretreated with F-66E emulsions and/or carbogen 1 hr prior to and during irradiation. The rate of tumor take and the period before detection of tumors were not modified when an emulsion of F-66E was injected simultaneously or 10 days after 3LL cells. Mean survival of mice, and the number of metastases on lung surfaces were similar in F-66E injected mice and control mice.

Sufentanil, alfentanil, and fentanyl: impact on cerebrospinal fluid pressure in patients with brain tumors

In order to evaluate the safety of the new synthetic opioids, alfentanil and sufentanil, in neurosurgical patients, we administered sufentanil 1 microg/kg i.v., alfentanil 50 microg/kg i.v. followed by an infusion of 1 microg/kg/min, or fentanyl 5 microg/kg i.v. to 30 patients with supratentorial tumors anesthetized with nitrous oxide (N2O), 60% in O2. Lumbar cerebrospinal fluid pressure (CSFP) and mean arterial pressure (MAP) responses were recorded for 10 min thereafter, while ventilation was held constant [mean PaCO2 = 36.1 +/- 1.0 mm Hg (SEM)]. There was no change in CSFP after fentanyl. In contrast, both sufentanil and alfentanil caused increases in CSFP, equal to 89 +/- 31 % SE (p < 0.05) and 22 +/- 5% (p < 0.05), respectively. MAP decreased after administration of each opioid. Peak decreases in cerebral perfusion pressure (MAP - CSFP) were 14 +/- 3% after fentanyl, 25 +/- 5% after sufentanil, and 37 +/- 3% after alfentanil. It is concluded that because sufentanil increased CSFP in patients who have brain tumors, it also may be contraindicated in other neurosurgical patients at risk for intracranial hypertension. Alfentanil may share this propensity, since CSFP increased despite a profound reduction in MAP. Among the three opioids evaluated, only fentanyl appears to be appropriate for supplementing N2O-2 anesthesia in patients who have compromised intracranial compliance.

Immunomodulatory and therapeutic properties of FK-565 in mice

The heptanoyl tripeptide, FK-565 is a biological response modifier with potent therapeutic properties for the treatment of experimental and spontaneous metastases. Doses of FK-565 greater than 5 mg/kg are required for in vivo augmentation of natural killer cells, macrophages, and for therapeutic activity, presumably because FK-565 is a peptide small molecular mass which is rapidly degraded and excreted. Optimal therapeutic activity is observed at approximately 25-50 mg/kg FK-565, administered i.v. three times per week for 4 weeks. In addition to its therapeutic properties, which were consistently greater than the positive control at optimal doses, FK-565 had significant immunoaugmentary properties for natural killer cells, macrophages, and T cells both in vitro and in vivo, suggesting that its therapeutic activity is due to immune augmentation.

Immunomodulatory and therapeutic properties of alkyl lysophospholipids in mice

This paper describes the immunomodulatory and therapeutic properties of the alkyl lysophospholipids [ALP; 1-O-octadecyl-2-O-rac-glycero-3-phosphocholine (ET-18-OCH3)]. ALP was able to activate macrophages both in vitro and in vivo as well as to act as an immunoadjuvant for syngeneic tumor vaccines. However, ALP appeared to be transferred, at least in part, to the macrophage membrane, and some of the tumoricidal macrophage-activating properties seem to be associated with the direct cytotoxic effect of membrane-released ALP. ALP also had some therapeutic activity for experimental and spontaneous metastases, requiring administration three but not two times weekly at near-toxic doses; this suggests that at least some of its therapeutic activity is due to direct cytotoxicity.

A single-blind, comparative study of hydrochlorothiazide/amiloride ('Moduret' 25) and hydrochlorothiazide/triamterene ('dyazide') in elderly patients with congestive heart failure

The efficacy and biochemical effects of two low-dose thiazide plus potassium-sparing diuretic preparations were compared in the treatment of elderly patients with stable, mild to moderate congestive heart failure. Sixty patients (mean age 80 years) were randomly allocated to treatment with 1 tablet daily of either 25 mg hydrochlorothiazide/2.5 mg amiloride or 25 mg hydrochlorothiazide/50 mg triamterene. The dose was increased to 2 tablets daily if necessary, after 2 weeks, for a further 6 weeks. Patients' response to treatment was assessed at 2, 4 and 8 weeks using a simple clinical scoring system for signs and symptoms of their condition, and routine biochemical analysis was carried out at baseline and the end of treatment. One patient was withdrawn from the study due to a rash which was probably related to hydrochlorothiazide/amiloride treatment. A further 11 patients were excluded from the analysis because of intercurrent illness or inadequate records. Analysis of the results from 48 patients showed that both treatments resulted in an improvement in clinical score and weight reduction, with more than three-quarters of the patients responding to treatment. No serious biochemical disturbances occurred; in particular, no new cases of hyponatraemia (serum sodium less than 130 mmol/l) developed. Both preparations, therefore, were effective and tolerated forms of treatment for mild to moderate congestive heart failure in the elderly and there were no significant differences between them.

Lisinopril treatment of hypertension in patients with impaired renal function

Lisinopril is a new, long-acting, nonsulfhydryl angiotension-converting enzyme (ACE) inhibitor that is excreted unchanged by the kidney. The antihypertensive efficacy and safety profiles of lisinopril were assessed in 24 patients (15 men, 9 women; mean age 52.3 years; range 21-75 years) with hypertension associated with impaired renal function (glomerular filtration rate GFR 60 ml/min or less), in an open study of 12 weeks' duration. Previous antihypertensive drugs were discontinued at entry into the study. Lisinopril was given orally once daily; the starting dose was 2.5 mg in patients with a GFR of less than 30 ml/min, and 5 mg in all other patients. The dosage of lisinopril was titrated upward to 40 mg daily according to BP response. A diuretic could then be added if hypertension was inadequately controlled. Twenty-three patients completed the study. Mean sitting BP was reduced from 177 +/- 21.2/106 +/- 9.1 mm Hg (mean +/- SD) at entry to the study to 145 +/- 21.4/88 +/- 8.3 mm Hg after 12 weeks of treatment (p less than 0.001). The median dose of lisinopril used was 10 mg (range 2.5-40 mg) and only 4 patients had a diuretic added to the lisinopril. Overall GFR was unchanged during the study: mean baseline value was 37 +/- 16.4 ml/min (range 10-60 ml/min) at the beginning of the study and 40 +/- 21.0 ml/min at the end. As in a previous pharmacokinetic study in similar patients, a tendency toward drug accumulation was noted only in those patients with the most severe renal impairment.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of human interferon species using gel extraction and monoclonal antibodies: implications on clinical use of interferon preparations

Human interferons from various sources have been characterized using sodium dodecyl sulfate polyacrylamide gel electrophoresis followed by electrotransfer onto nitrocellulose and reaction with specific polyclonal and monoclonal antibodies. When gel slices were extracted, alpha-interferon subspecies possessed antiviral activity predominantly in the 18.6-19.7K region bands, the beta-interferon in the 22.1K band, and gamma-interferon in the 16.5-18.0K bands. Three of the monoclonal antibodies (Ab 138, Ab 126, Ab 098) reacted with a characteristic triplet of biologically active bands (18.6K, 19.1K, 19.7K) obtained using the Namalwa cell interferons, while two (Ab 194 and Ab 232) reacted only with the 18.6K band and Ab 523 reacted with the 19.7K band. With the human leukocyte interferons, Ab 098, Ab 194, and Ab 232 reacted with the active 18.6K band. The Ab 138, Ab 126, and Ab 523 reacted specifically with certain lower molecular weight active bands (13K region). A comparison of the antiviral activity and reactivity towards monoclonal and polyclonal antibodies presents a differentiation of the subspecies of interferons in the wide array of closely related proteins in interferon preparations packaged for clinical use.

Two fatalities resulting from Tessalon (benzonatate)

Two fatal cases involving Tessalon (benzonatate) were quantitated by ultraviolet (UV) and high performance liquid chromatography (HPLC). The first case involved an infant found choking; Tessalon perles were found with the child. The second case involved a successful suicide of an 18-year-old that consumed a "handful" of phenytoin and benzonatate and expired within 1 hr of the ingestion. Blood, brain and kidney concentrations are reported. These are believed to be the first two reported cases involving this compound.

Cardiac and renal hyperplasia in newborn genetically hypertensive rats

Newborn spontaneously hypertensive rats (SHR), compared with Wistar-Kyoto (WKY) controls, usually show cardiac and renal hyperplasia. To determine whether these anomalies are common to genetically hypertensive rats, we examined newborn rats from models of essential hypertension (Kyoto, Montreal, Dunedin and Lyon strains of hypertensive rats), renal hypertension (Milan strain of hypertensive rats) and experimental hypertension [deoxycorticosterone acetate (DOCA)-salt hypertensive Wistar rats]. The hearts, kidneys and livers of these newborns were collected on site at various centres and sent to Montreal for protein and DNA determinations. The results showed that protein and DNA, corrected for body weight in models of essential hypertension, were increased in the heart and kidney, and normal or decreased in the liver at birth. This pattern differed in offspring of the Milan strain (renal hypertension) and of DOCA-salt hypertensive animals (experimental hypertension). Since cardiac and renal hyperplasia associated with the hypertensive trait in four different genetic models of spontaneous hypertension was distinct from that observed in renal and experimental hypertension, it is conceivable that a specific cardiovascular growth pattern is a reflection not of a simple linkage or consequence, but of a causal association with spontaneous hypertension.

Immunomodulatory and therapeutic properties of bestatin in mice

In this report, we describe the immunomodulatory properties and therapeutic efficacy of bestatin. Macrophage activation, but not natural killer cell augmentation, was observed both in vitro and in vivo. Immunostimulation of T-cell activity was observed in assays of allogeneic mixed lymphocyte response, but cytotoxic effector cells did not develop after an allogeneic mixed lymphocyte-tumor cell culture. Bestatin also had T-cell adjuvant activity when it was admixed with a suboptimal vaccine composed of irradiated tumor cells. We observed significant therapeutic activity against preexisting experimental and spontaneous metastases when bestatin was administered at high doses per animal for 4 weeks.

Psychological factors and outcome of electrode implantation for chronic pain

The utility of using psychological assessments as a basis for predicting pain relief after electrode implantation is examined. Two raters independently reviewed the functional pain protocols of chronic pain patients who were candidates for deep brain (n = 13) or spinal cord (n = 17) electrode implants and predicted whether each would have a good or poor treatment response. At follow-up, five deep brain (39%) and four spinal cord (24%) patients were classified as having good responses to treatment. Predictions of outcome based on psychological data were accurate for 80% of the patients. These results suggest that functional pain assessment is useful as a part of preimplantation screening and emphasize the importance of psychological factors in the outcome of treatment for chronic pain.

Hyporesponsiveness to augmentation of murine natural killer cell activity in different anatomical compartments by multiple injections of various immunomodulators including recombinant interferons and interleukin 2

Augmentation of natural killer (NK) cell activity has been observed after the single administration of a wide variety of biological response modifiers (BRM); however, multiple injections of BRM have resulted in hyporesponsiveness to NK augmentation in both preclinical and clinical studies. In these studies, hyporesponsiveness to augmentation of NK cell activity occurred after multiple injections of interferon (IFN recombinant human IFN-alpha A/D and recombinant IFN-gamma) and interleukin 2 and was found to be systemic (lungs, liver, blood, and spleen). In contrast, hyporesponsiveness to augmentation by multiple injections of maleicanhydride divinyl ether (MVE-2) or Propionibacterium acnes was limited to the spleen and peripheral blood lymphocytes, with continued augmentation of NK cell activity in the peritoneum, lungs, and liver. Despite the hyporesponsiveness to augmentation of NK activity by multiple IFN injections, NK activity could still be augmented by a single injection of another BRM. The NK cell hyporesponsiveness induced in the spleen by MVE-2 was also reversed by a single administration of IFN or polyinosinic-polycytidylic and poly-L-lysine solubilized by carboxymethyl cellulose but not by OK-432 or P. acnes. These results demonstrate that the nature of the hyporesponsiveness to NK augmentation, which is induced by multiple treatments with BRM, varies with the type of agent. The noncytokine BRM that were studied induced hyporesponsiveness only in specific lymphoid compartments but not in major nonlymphoid organs, whereas cytokine BRM induced a systemic hyporesponsiveness. The hyporesponsive state induced by the different types of BRM, also varied in regard to the pattern of susceptibility to augmentation of NK activity by unrelated BRM.

Hyporesponsiveness to augmentation of murine natural killer cell activity in different anatomical compartments by multiple injections of various immunomodulators including recombinant interferons and interleukin 2

Augmentation of natural killer (NK) cell activity has been observed after the single administration of a wide variety of biological response modifiers (BRM); however, multiple injections of BRM have resulted in hyporesponsiveness to NK augmentation in both preclinical and clinical studies. In these studies, hyporesponsiveness to augmentation of NK cell activity occurred after multiple injections of interferon (IFN recombinant human IFN-alpha A/D and recombinant IFN-gamma) and interleukin 2 and was found to be systemic (lungs, liver, blood, and spleen). In contrast, hyporesponsiveness to augmentation by multiple injections of maleicanhydride divinyl ether (MVE-2) or Propionibacterium acnes was limited to the spleen and peripheral blood lymphocytes, with continued augmentation of NK cell activity in the peritoneum, lungs, and liver. Despite the hyporesponsiveness to augmentation of NK activity by multiple IFN injections, NK activity could still be augmented by a single injection of another BRM. The NK cell hyporesponsiveness induced in the spleen by MVE-2 was also reversed by a single administration of IFN or polyinosinic-polycytidylic and poly-L-lysine solubilized by carboxymethyl cellulose but not by OK-432 or P. acnes. These results demonstrate that the nature of the hyporesponsiveness to NK augmentation, which is induced by multiple treatments with BRM, varies with the type of agent. The noncytokine BRM that were studied induced hyporesponsiveness only in specific lymphoid compartments but not in major nonlymphoid organs, whereas cytokine BRM induced a systemic hyporesponsiveness. The hyporesponsive state induced by the different types of BRM, also varied in regard to the pattern of susceptibility to augmentation of NK activity by unrelated BRM.

Biochemical characterization and purification of human B cell stimulatory factor (BSF)

B cell stimulatory factor (BSF) activity was generated over a period of five days by phytohemagglutinin-stimulated E rosette-positive peripheral blood lymphocytes. This activity was subjected to a multistep purification procedure including ammonium sulfate precipitation, anion-exchange chromatography, gel filtration, procion red-agarose chromatography and reverse phase high performance liquid chromatography (RP-HPLC). The last purification step dissected BSF activity into two active fractions, one corresponded to the interleukin 2 (IL 2) activity whereas the other active fraction was free of IL 2 activity. Preparative isoelectric focusing analysis defined isoelectric points of pH 7.2 for both BSF and IL 2. Molecular weight analysis of BSF was carried out by preparative sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis. BSF activity was eluted from gel strips corresponding to a molecular mass of 16 and 17 kDa. The 16-kDa fraction was free of IL 2 activity whereas the 17-kDa fraction overlapped with IL 2. Since recombinant IL 2 was capable of exhibiting significant BSF activity in anti-IgM or Staphylococcus aureus Cowan strain I-dependent assay systems, it cannot be excluded that IL 2 itself is a BSF. Nevertheless these studies demonstrate the existence of a BSF free of IL 2 activity.

The effect of glycerol on cochlear function and ionic concentration

The use of glycerol continues to be a popular clinical test for diagnosing reversible hearing loss in patients with Meniere's disease, although its mechanism of action remains obscure. The purpose of this investigation was to study experimentally the alterations in the ionic composition and function of the cochlea which occur following glycerol administration. Immediate decreases in inner ear pressure and increases in AP threshold were seen. Delayed decreases in the endocochlear potential with increases in inner ear electrolytes occurred. However, we were unable to find any substantial changes in inner ear oxygen concentrations. Our findings support the concept that the principal action of glycerol is in osmotic reduction of inner ear pressure.

Preparation and characterization of monoclonal antibodies directed at epitopes of human IFN-gamma

Five monoclonal antibodies (A7, B24, I14, L12, and M2) recognizing different epitopes of the human natural IFN-gamma were prepared by immunizing BALB/c mice with a highly purified human natural IFN-gamma preparation (10(7) U/mg). All five antibodies had high IFN-gamma-binding activity but exhibited differential IFN-gamma-neutralizing activities. Furthermore, none of them neutralized the antiviral activity exhibited by either IFN-alpha or IFN-beta preparations, indicating thus their specificity for IFN-gamma. The A7, L12, M2, and I14 monoclonal antibodies, but not the B24, blocked the augmentation of natural killer cytotoxicity, mediated by peripheral blood monocyte-depleted lymphocytes, by Escherichia coli-derived IFN-gamma or natural IFN-gamma but not by IFN-alpha 2. All five monoclonal antibodies precipitated an identical molecular complex containing two major protein components with molecular weights of 20,000 (20 kD) and 25,000 (25 kD) and two minor components with molecular weights of 17,000 (17 kD) and 45,000 (45 kD). Treatment of the immunoprecipitated IFN-gamma molecule with endoglycosylase F led to a stepwise removal of the carbohydrate portions on both the 25 and 20 kD chains, which resulted in the appearance of both 16 kD and 18 kD chains. The hereby reported monoclonal anti-IFN-gamma antibodies will prove useful as probes for purification and for rapid assay of human IFN-gamma molecule.

Therapists' and chronic pain patients' perceptions of treatment outcome

Pain is a complex phenomenon which is influenced by multiple factors; likewise, assessment of chronic pain patients' response to treatment is influenced by many variables. A physician, psychologist, physical therapist, and occupational therapist rated the extent of recovery of 40 chronic pain patients who had spent 4 to 6 weeks in an inpatient chronic pain treatment program. Each patient also rated his/her own degree of improvement. In addition, therapists and patients reported which factors were the primary determinants of their outcome ratings. Although therapists rated the patients as significantly more improved than the patients rated themselves, there was still a high degree of similarity between therapists' and patients' view of recovery. Therapists and patients were in high agreement concerning which patients were classified as treatment successes or failures. Furthermore, activity level and ability to cope with pain were frequently endorsed by therapists and patients as important determinants of recovery rating. Contrary to a previous report, the results of this study suggest that pain patients are not necessarily poor judges of (their own) treatment results. Perhaps more importantly, this study supports the use of a broad-based multidimensional approach to assessing treatment outcome for chronic pain patients.

Tracheobronchial compression in acyanotic congenital heart disease

Children with acyanotic congenital heart disease frequently develop respiratory difficulties such as atelectasis, pneumonia, or infantile lobar emphysema. In some cases, the cause of the respiratory difficulty is compression of the tracheobronchial tree by hypertensive dilated pulmonary arteries, since this type of heart disease frequently demonstrates large left-to-right intracardiac shunts. Sites of predilection for compression include the left main bronchus, the left upper lobe bronchus, the junction of the right bronchus intermedius and right middle lobe bronchus, and the left side of the distal trachea. Cardiac anomalies which predispose to this type of compression include ventricular septal defect, patent ductus arteriosus, interruption of the aortic arch, and tetralogy of Fallot. Pulmonary arteriopexy may relieve the tracheobronchial compression.

Splenic rupture and splenectomy due to fall from wheelchair

This report describes the effect of blunt abdominal trauma incurred when a quadriplegic patient slid sideways, catching his flank between the wheelchair arm and a slightly reclined wheelchair back. The patient experienced almost immediate pain in the left shoulder, and gradual cardiovascular collapse. The diagnosis of splenic rupture, followed by splenectomy, was life-saving. Pertinent literature is cited and attention is drawn to the necessity for early diagnosis in blunt abdominal trauma.

Central nervous system infection and immune response in mice inoculated into the lip with herpes simplex virus type 1

Virus may be recovered from various areas of the central nervous system (CNS) of mice for as long as 11 days after inoculation of herpes simplex virus type 1 (HSV-1) into the lip. The probability of isolation from any particular region of the CNS seems to be a function of the distance of that area from the root-entry zone of the trigeminal nerve. It is also mouse strain-dependent, with much more extensive evidence of brain infection being found in BALB/c and C3H rather than C57BL/6 mice, in which it is limited to the pons. The virus could not be isolated from the CNS of BALB/c mice after 10 days, though HSV-1 is readily recovered from the trigeminal ganglia at least through day 38. Significant concentrations of HSV-1-specific immunoglobulin (Ig) were demonstrated consistently in cerebrospinal fluid (CSF) from day 12 after exposure to virus. The persistence of relatively high concentrations of IgM in the CSF indicates that much of this antibody may be synthesized locally in the brain.