Transdiaphragmatic herniation of peritoneal dialysis fluid post Nissen's operation: an unusual cause for a mass on the chest radiograph

A child on dialysis for chronic renal failure and who had had a Nissen's fundoplication showed transdiaphragmatic herniation of the peritoneum simulating a right lower zone chest mass. The imaging and possible causes are considered.

Customary physical activity and survival in later life: a study in Nottingham, UK

OBJECTIVE

To assess the value of broadly based customary physical activity scores, derived from a questionnaire inventory, in predicting 10 year mortality among elderly people.

DESIGN

A 10 year survival analysis of participants in the first wave of the Nottingham longitudinal study of activity and ageing who, in face to face interviews in 1985, provided detailed information on customary physical activity, health, and lifestyle.

SETTING

Urban and suburban Nottingham

PARTICIPANTS

A total of 1042 people aged 65 years and over randomly sampled from general practitioner records.

MAIN RESULTS

On the basis of factor scores derived from the interview questionnaire, activity levels were graded as "high", "intermediate", or "low". In Cox regression models controlling for age, health status, and cigarette smoking at the time of the activity assessment, these gradings were significantly related to 10 year survival. Relative to the "high" activity groups, the risk of dying was significantly increased in both the "intermediate" (hazard ratio (HR) 1.53; 95% CI 1.12, 2.09) and "low" (HR 2.07; 95% CI 1.53, 2.79) groups for women, and in the "low" group (HR 1.59; 95% CI 1.12, 2.25) for men (p < 0.01 throughout).

CONCLUSION

Since the survival model controlled for age, health status, and cigarette smoking, it is unlikely that the activity gradings used here are simple proxies for physical health. It is concluded, therefore, that within the elderly population, recall based survey assessments covering a wide range of customary or habitual physical activities, can provide indices showing both cross sectional utility and predictive validity.

Evaluation of chronic oral toxicity and carcinogenic potential of lornoxicam in rats

As part of the preclinical development program for lornoxicam, a novel non-steroidal anti-inflammatory drug (NSAID), its chronic oral toxicity and carcinogenic potential was assessed in Sprague-Dawley rats. Male and female rats were administered lornoxicam by oral gavage at 0, 0.06, 0.16 or 0.40 mg/kg/day for 12 months or at 0, 0.01 or 0.06 mg/kg/day in a supplementary low-dose study of the same duration (main group: 20/sex/group; 4-wk recovery: five/sex/group; satellites for electrocardiography and toxicokinetics: five/sex/group). Drug-related toxicity mainly comprised mortality, reduced body weight gain, clinico-pathological changes indicative of anaemia resulting from blood loss, and renal damage, renal papillary necrosis and gastrointestinal mucosal lesions. The kidney-associated changes were not completely reversible during the recovery period. Toxicokinetic investigations demonstrated a dose-linear absorption of the drug. In female rats the terminal half-life was about twice that in males which led to a higher exposure of this gender to lornoxicam. A dose of 0.01 mg/kg/day was established as no-observed-effect level. In a 104-wk carcinogenicity study, lornoxicam was administered by oral gavage to male and female rats (50/sex/group) at 0 (control 1), 0 (control 2), 0.0625, 0.125 or 0.250 mg/kg/day. In females only, the high dose was reduced twice during the study due to toxicity observed (0.250 to 0.200 to 0.160 mg/kg/day). Drug-related changes were similar to those in the chronic studies and consistent with the anticipated side-effects of NSAIDs. No carcinogenic potential was revealed.

Mortality of captive British wartbiter crickets: implications for reintroduction programs

A fungal infection was identified as the cause of a high mortality rate of captive wartbiter cricket (Decticus verrucivorus) nymphs at the London Zoo (United Kingdom) in 1994. This species is threatened with extinction in the United Kingdom and the animals concerned were part of a captive breeding and reintroduction program. Following these findings, reintroductions were postponed and release sites were used only where there were no extant wartbiter crickets.

Cognition-enhancing drugs in dementia: a guide to the near future

OBJECTIVES

To facilitate access to the available literature and to assist clinicians with the decision to recommend the use of medications for the enhancement of cognition in dementia.

METHOD

A qualitative review of published research. Methodological issues confronting research in this area are described. An organizational scheme for the medication types, based on pathophysiologic processes relevant to Alzheimer's disease (AD), is reviewed. The paper makes extensive use of tablets to present the minimal data necessary for the reader to appraise critically all of the original publications found. The paper further presents in summary form the opinions of previous reviews on each of the medications.

RESULTS

We identified 45 medications in the published research in which humans with dementia were assessed as having a change in cognition. Immediate use of tacrine is supported by the evidence, but the degree of benefit is modest, and side effects are problematic.

CONCLUSION

A number of medications warrant further investigation. Tacrine can be offered to patients with careful education regarding the limited efficacy and potential side effects. Newer, perhaps safer, anticholinesterase inhibitors are now becoming available. Referral to a research study examining other medications is suggested, as are some "common sense" strategies.

A critical review of the origin and control of adrenal androgens

The reticularis and fasciculata zones of the adrenal cortex are the predominant sources of dehydroepiandrosterone (DHEA) and DHEA-sulphate and contribute directly or indirectly 60-75% of androstenedione and testosterone in women. The specific control of adrenal androgens remains unclear. While ACTH stimulates adrenal androgen secretion, the dissociation of cortisol and androgens occurring during adrenarche and under pathological conditions suggests other factors are involved. Recent studies using human adrenal cells in vitro have demonstrated that the ratio of androgen to cortisol produced is substantially independent of the age and gender of the adrenal, indicating that extra-adrenal factors are of greater importance. beta-Endorphin and joining peptide have been shown to stimulate androgen production in human adrenal cells and to influence ACTH-stimulated steroidogenesis in a manner that promotes adrenal androgen production. The activity of these pro-opiomelanocortin-derived peptides may explain the physiological and pathological dissociations of androgens and cortisol.

Longitudinal trends in late-life insomnia: implications for prescribing

OBJECTIVE

To assess trends in insomnia and hypnotic drug use in a representative sample of elderly general practice patients.

DESIGN

Longitudinal study with three interview waves--1985, 1989 and 1993.

SETTING

Urban and suburban Nottingham.

PARTICIPANTS

1042 patients originally aged 65 and over randomly sampled from general practitioner lists.

MAIN OUTCOME MEASURES

Point prevalence estimates, status (case/non-case/died) at 4-year follow-up, episode incidence and survival functions.

RESULTS

At baseline (1985) 221 respondents met the survey criteria for insomnia. Of these, 36.1% continued to report severely disrupted sleep in 1989. Within this period 84 new cases of insomnia were identified (an incidence rate of 3.1% per person-year at risk). Controlling for age and sex, insomnia was unrelated to survival among prevalent cases, but significantly related to survival among incident cases (odds ratio = 1.7; 95% confidence interval = 1.1-2.5). Of 166 respondents using prescription hypnotics in 1985, 31.7% continued to report usage in 1989. Similarly, out of 41 new hypnotic drug users identified in 1989, 29.3% continued to report usage in 1993.

CONCLUSIONS

Important clinical differences in the natural history of insomnia are evident when incident and prevalent cases are compared. Nevertheless, outcomes at 4-year follow-up suggest that, for the majority of surviving cases identified in a prevalence screen and for a substantial minority of incident cases, late-life insomnia shows a level of chronicity incompatible with hypnotic drug therapy as currently recommended.

Subacute and chronic oral toxicity of lornoxicam in cynomolgus monkeys

Lornoxicam is a novel non-steroidal anti-inflammatory compound in the same chemical class as piroxicam and tenoxicam, with potent anti-inflammatory, antipyretic and analgesic activity. As part of the preclinical safety programme, its toxicity was evaluated in a dose-range-finding and 52-wk toxicity study in cynomolgus monkeys. In the dose-range-finding study, five groups of monkeys (two per sex per group) were dosed orally by gavage for 6 wk with 0, 0.25, 0.5, 1.0 or 2.0 mg lornoxicam/kg/day. Drug-related toxicity was observed in the 1.0 and 2.0 mg/kg/day dose groups only. This included mortality, diarrhoea, prostration, decreased body weight gain and food consumption, faecal occult blood, anaemia, leucocytosis, hypoalbuminaemia, gastrointestinal erosions and ulcerations. On the basis of these results, four groups of monkeys (six per sex per group) were given the compound orally by nasogastric intubation at dose levels of 0, 0.125, 0.25 or 0.5 mg/kg/day for 52 wk. The high-dose level was increased to 0.6 mg/kg/day from wk 39 to wk 52. Treatment was followed by a 4-wk recovery period for two animals per sex per group. Histologically, drug-related changes seen were gastrointestinal erosions, ulcerations and inflammation in males and females at 0.5/0.6 mg/kg/day. Treatment-related clinicopathological findings included decreased haematocrit and hypoproteinaemia (group 0.5/0.6 mg/kg/day males), and hypoalbuminaemia (group 0.5/0.6 mg/kg/day males and females). None of these changes were present after the recovery period, thus indicating reversibility. Plasma concentration of lornoxicam measured 2 hr after dosing increased in a dose proportional manner. The estimated area under the curve (AUC) at steady state increased in a dose-proportional manner and at 0.25 mg/kg was three- to fivefold higher than the human AUC following a 16 mg dose (8 mg b.i.d.). The no-observed-effect level in the chronic toxicity study was 0.25 mg/kg/day.

Pathophysiology of transient myocardial ischemia in acute coronary syndromes. Characterization by continuous ST-segment monitoring

BACKGROUND

Transient ischemia in stable coronary disease peaks in the morning, reflecting increased myocardial oxygen demand and coronary vasomotor tone after walking. In acute coronary syndromes, however, ischemia may result from transient thrombus formation or coronary spasm at the site of a ruptured plaque. We report on the pathophysiological mechanisms underlying transient ischemia in acute coronary syndromes despite optimal therapy, on the basis of analysis of heart rate changes preceding ischemia and its circadian variation.

METHODS AND RESULTS

Two hundred fifty-six patients with unstable angina or non-Q-wave myocardial infarction underwent continuous ST-segment monitoring for 48 hours while receiving maximal medical therapy. All ischemic episodes were characterized by their timing, duration, association with pain, and heart rate changes before the onset of ischemia. During 10,629 hours of monitoring, 44 patients (17.2%) had 176 episodes of transient ischemia. The mean heart rate at onset of ischemia was 68 +/- 12.8 bpm, and > 55% of ischemic episodes were not preceded by a significant increase in heart rate. Ischemic activity had a single nocturnal peak, with 64% of all episodes occurring between 10 PM and 8 AM, this nocturnal preponderance being evident for episodes with or without a preceding increase in heart rate. The characteristics and timing of transient ischemia were similar in unstable angina and non-Q-wave myocardial infarction, but transient ischemia was more frequent (27.3% versus 15.1%; P < .05) and prolonged (median, 20 versus 13.5 minutes; P < .01) in non-Q-wave myocardial infarction.

CONCLUSIONS

In acute coronary syndromes, transient ischemia has a low threshold, occurs predominantly without an increase in myocardial oxygen demand, and is present mainly at night rather than in the morning. These findings in patients receiving maximal medical therapy suggest significant pathophysiological differences underlying transient ischemia compared with stable coronary disease.

Evaluation of Caribbean strains of Macrocyclops and Mesocyclops (Cyclopoida:Cyclopidae) as biological control tools for the dengue vector Aedes aegypti

Fifteen Caribbean strains of copepods were assessed for their predation ability against mosquito larvae. Macrocyclops albidus from Nariva. Mesocyclops aspericornis from Oropouche, and Mesocyclops longisetus from E1 Socorro, Trinidad, were most effective against Aedes aegypti but not against Culex quinquefasciatus. Mesocyclops longisetus and Me. aspericornis prevented any mosquito survival over 25 wk of observation despite weekly challenges with Ae. aegypti. The copepods were tolerant to dosages of the insecticide temephos that are usually toxic to mosquito larvae. This indicated that copepods could be incorporated into an integrated control system. To determine whether pathogenic microbes might be introduced with copepods into drinking water, microbial studies were done on the copepods. These showed the presence of only Aeromonas sobria, Pseudomonas sp., Alcalignes sp., and gram-positive bacilli. Although none of these are highly pathogenic to humans, the application of these copepods has not yet been recommended for use in drinking water.

Risk factors for late-life insomnia in a representative general practice sample

BACKGROUND

Insomnia is widely reported and widely treated in general practice, yet relatively little research has focused on the natural history of the condition in primary care settings. As a result, there is at present little information to enable clinicians to assess insomnia risk, or anticipate outcomes in older general practice populations.

AIM

To estimate, using 8-year longitudinal data, the risk of insomnia onset associated with selected health and lifestyle factors.

METHOD

Survivors from a nationally representative sample (n = 1042) of elderly people originally interviewed in 1985 were reassessed in 1989 (n = 690) and 1993 (n = 410). At the first follow up in 1989, 84 new cases of insomnia were identified (a weighted incidence rate per person per year at a risk of 3.1%; 95% CI = 2.7-3.5). In logistic regression analyses controlling for age and sex, the risk of insomnia onset was then assessed in relation to the selected factors.

RESULTS

Three factors assessed in 1985 were significantly and independently related to incident insomnia: psychometric ratings consistent with depressed mood odds ratio (OR) = 4.41; 95% CI = 3.32-5.43); health index scores indicating lower physical health status (OR = 1.19; 95% CI = 1.06-1.31 per unit change in scale score); and moderate and low levels of physical activity (OR = 1.91 and 2.14; 95% CI = 1.91-3.62 and 2.14-3.64 respectively). However, although depressed mood represented a major risk factor, the most likely source of risk was physical rather than mental ill-health.

CONCLUSIONS

Psychiatric, somatic and lifestyle factors significantly and independently increase the risk of insomnia in older general practice patients. In predicting incident sleep disturbance, these factors exceed in importance the age and sex of patients.

"I find the term customer offensive"

Explores the tensions between cost and quality, need and market, and the effects on patient care and service providers within today's NHS. Builds on research carried out in two hospitals during 1993 to 1995, focusing on perceptions of quality and its management in the context of the nursing discipline. Indicates a divergence of perspectives on "customer requirements" and the emergence of a cultural divide within the total care process. Identifies and illustrates the significant potential for cost savings in health care, which may be achievable while simultaneously improving quality, and suggests that the "prize" for bridging the cultural divide might include a substantial financial gain as well as improved standards of care. In the context of health care, need, expectation, and finite resources are inextricably linked. A shared understanding of the interdependence between the three, and of the balance to be struck, is essential in health care provision today and into the twenty-first century. Suggests that there is some way to go.

Natural variability of transient myocardial ischaemia during daily life: an obstacle when assessing efficacy of anti-ischaemic agents?

OBJECTIVE

To assess the degree of variability of transient myocardial ischaemia during daily life in patients with coronary artery disease, which could confound the interpretation of trials of the therapeutic effects of anti-ischaemic agents.

DESIGN

Prospective method evaluation.

SETTING

Tertiary referral centre, outpatient clinic.

PATIENTS

Patients with stable angina, confirmed coronary artery disease, and a positive treadmill exercise test for ischaemia. Patients were not preselected on the basis of prior documented transient ischaemia during ambulatory ST segment monitoring.

INTERVENTIONS

A simulated drug-study with 4 monitoring phases in 16 subjects. To minimise variability in ischaemic activity, patients underwent weekly 48 hour ambulatory ST segment monitoring outside hospital off all prophylactic therapy on the same weekdays for 4 weeks.

MAIN OUTCOME MEASURE

Variability in the frequency and duration of transient myocardial ischaemia.

RESULTS

There was marked variability in both ischaemic activity and mean duration of ischaemia in patients with confirmed ischaemia, the greatest degree of variability being between patients and from day to day within weeks within patients, with a further contribution to variability being noted between fortnights within patients.

CONCLUSIONS

Despite assessment off all therapy and an adequate period of monitoring (48 hours) with small intervals between monitoring periods (5 days), marked variability in ischaemic activity was noted, and regression towards the mean was clearly shown. Ambulatory ST segment monitoring outside hospital is not a reliable method for assessing the therapeutic effects of anti-ischaemic agents.

Caring for dying children: nurses' experiences

Interviews with 25 nurses in this grounded theory study show that when nurses recognized that a child's death was inevitable, they struggled with both grief distress and moral distress. Their distress occurred within the context of the nurse-patient relationship. Nurses employed a range of strategies to manage their distress. Several conditions facilitated or constrained nurses' strategies, and resulted in far-reaching implications both professionally and personally.

The steroidogenic effects of beta-endorphin and joining peptide: a potential role in the modulation of adrenal androgen production

This study examines the androgen-stimulating properties of pro-opiomelanocortin-derived peptides, ACTH, beta-endorphin (beta-End) and joining peptide (JP). Ten different cell suspensions were prepared from ten human adrenal glands. ACTH and JP stimulated cortisol, androstenedione (delta 4) and dehydroepiandrosterone (DHEA) production (P < 0.05); beta-End stimulated only delta 4 and DHEA production. beta-End brought about significant increases in the delta 4 or DHEA to cortisol ratios. The addition of beta-End (10(-10) M) suppressed ACTH-stimulated cortisol production from 7573 +/- 2960 to 5994 +/- 2654 pmol/10(6) cells (means +/- S.E.M.; P < 0.05). The addition of beta-End did not affect ACTH-stimulated delta 4 production (210 +/- 88 and 236 +/- 105 pmol/10(6) cells). JP (10(-10) M) inhibited ACTH-stimulated cortisol production so that the mean values fell to 5186 +/- 2588 and also inhibited DHEA production, from 240 +/- 48 to 180 +/- 33 pmol/10(6) cells. These results suggest that the relative production of androgen to cortisol is greater in response to beta-End and JP than in response to ACTH. If blood levels of these peptides rise to herald adrenarche as reported for beta-End, suppression of cortisol production may result in an increase in ACTH to correct cortisol levels resulting in an increase in delta 4 and DHEA levels. This may explain the occurrence of increasing androgen levels at adrenarche.

Effects of interleukin 6 administration on platelets and haemopoietic progenitor cells in peripheral blood

Platelet numbers and circulating haemopoietic progenitor cells were examined in 12 patients with advanced malignancies who were receiving recombinant human interleukin-6 (rhIL-6) as part of an investigation of its thrombopoietic effects. Patients received recombinant glycosylated IL-6 by daily subcutaneous injection for 7 consecutive days in doses of 1, 3 or 10 micrograms/kg/day. Platelet numbers increased reaching a peak on days 12-15 with a mean on day 15 of 198.1% of pre-treatment values. This was accompanied by a significant fall in the mean platelet volume (mean decrease of 10.6%, P = 0.0044). No significant correlation was seen between the IL-6 dose and the change in platelet number. No significant differences were observed between pre- and post-treatment levels of circulating erythroid burst-forming units (E-BFU) and granulocyte macrophage colony-forming units (GM-CFU) but a small significant increase was seen in circulating primitive progenitor cells measured in a plastic-adherent (P delta) assay (P = 0.025). As positive controls, a group of patients treated with cyclophosphamide/G-CSF showed significant increases in GM-CFU (P = 0.018), E-BFU (P = 0.018) and P delta progenitors (P = 0.028). These data suggest that the thrombopoietic effects of IL-6 are mediated at a relatively late stage via effects on megakaryocyte differentiation, with a relatively small effect on circulating haemopoietic progenitors.

Water fluoridation in Ireland

The basis for the constitutional challenge to the Health (Fluoridation of Water Supplies) Act 1960 in the Republic of Ireland and the judgements of the High Court and Supreme Court are described. Pre-fluoridation baseline surveys and various surveys conducted over the last 30 years in the Republic of Ireland show, that amongst of fluoridated communities, children experience lower levels of dental caries and adults retain more of their natural teeth when compared with residents of non-fluoridated communities.

Women with chest pain: is exercise testing worthwhile?

OBJECTIVE

To determine the diagnostic value of the exercise tolerance test (ETT) in women presenting with chest pain.

DESIGN

Prospective study of all women presenting to a centre with chest pain between 1987 and 1993 who were assessed by an ETT and coronary angiography.

SETTING

The outpatient clinic of one consultant cardiologist in a tertiary referral centre.

PATIENTS

All women referred to this outpatient clinic with chest pain were screened. For inclusion, patients had to perform ETT and undergo coronary angiography. Of the 347 referred during this period, 142 were excluded because they were unable to perform ETT or because of Q waves or other abnormalities on their resting electrocardiogram.

RESULTS

Overall the sensitivity of the ETT was 68% and the specificity was 61%, with a positive predictive value of 0.61 and a negative predictive value of 0.68. There were 42 false positive and 31 false negative ETT results (36% of the study group). The predictive value of a negative test was higher in younger women (< 52 years) than in the older group (> or = 52 years) (P = 0.004), but the positive predictive value in the two groups was not significantly different. The predictive value of a negative test was also higher in those with two or fewer risk factors than in those with three or more risk factors (P = 0.001). The negative predictive value for those women above 52 years with three or more risk factors (24% of the study group) was only 0.25. Lack of chest pain during ETT was associated with a higher negative predictive value in the younger group than in the older women (P = 0.006).

CONCLUSIONS

In women with chest pain use of the ETT was a misleading predictor of the presence or absence of coronary disease in 36% of these patients. In particular, a negative test in older women with three or more risk factors had a very low predictive value. The inclusion of risk factors and division by age can, however, be used to identify a population at intermediate risk for coronary artery disease in whom the ETT result has the highest diagnostic utility.

Tenuous link between ischaemic threshold and both ambulatory ischaemia and symptom status over time in stable angina: a 5-year follow-up study

This study evaluates changes in ischaemic threshold over a 5-year period in patients with stable angina pectoris, who did not suffer any intervening cardiac event. Changes in ischaemic threshold are related to alterations in symptomatic status and ambulatory ischaemia. Over long-term follow-up, there is a significant fall in ischaemic threshold in such patients (mean heart rate at onset of ischaemia fell from 104 +/- 17.8 to 97 +/- 17.4 bpm: P < 0.001), but this is not matched by a worsening of either symptoms or ischaemia during daily life. In the 68% of patients that had a reduction in ischaemic threshold of > or = 5 bpm, 68% had either definite reduction or no change in symptoms and 84% had either reduction, abolition or no change in transient ischaemic activity. The dissociation between ischaemic threshold, ambulatory ischaemia and symptoms has implications for long-term monitoring and management of the patient with stable angina.

Dementia and 'borderline dementia' in Britain: 8-year incidence and post-screening outcomes

Survivors from a nationally representative sample of elderly people originally screened in 1985 were reassessed in 1989 and again in 1993. On each occasion respondents were rated as cognitively impaired, borderline impaired or unimpaired (using a brief information/orientation scale), with the validity of these ratings assessed in subsequent clinical interviews. Where follow-up screening was not possible, information was derived from death certificates and hospital case-notes. Over 8 years (1985-93) the overall incidence rate per person-year at risk was 1.58%, giving age-specific rates of 0.72, 1.32, 1.63, 3.46, 2.55 and 1.41% for the age groups 65-69, 70-74, 75-79, 80-84, 85-89 and > or = 90 respectively. Of 43 individuals classified at screening as borderline impaired in 1985 and 1989, 19 were diagnosed as demented at clinical interviews conducted within 16 weeks of screening. Four-year follow-ups among the remaining 24 showed that 15 had died, while 6 showed a worsened cognitive status. Controlling for both age and sex, aggregated 4-year mortality was significantly higher among those defined at screening in 1985 and 1989 as either impaired or borderline, when compared with the unimpaired.

Does brachytherapy have a role in the treatment of prostate cancer?

The goal of radiation therapy is to deliver a high dose to the tumor while preserving normal surrounding tissue. For early-stage prostate cancer, the ultimate conformal irradiation is to place radioactive sources directly into the gland either as permanent or temporary seeds. Permanent seed implantation is capable of delivering two times the radiobiologically equivalent dose of external beam irradiation to the prostate and tumor. In the past, the results of prostate brachytherapy were likely poor owing to the technical difficulty in accurately placing the radioactive seeds uniformly throughout the prostate. The use of low-dose-rate I-125 to treat high-grade cancers probably also contributed to the poorer results as compared with external beam irradiation. Over the last 10 years, however, technologic advances in transrectal ultrasonography, computer dosimetry, and template-based transperineal techniques have dramatically improved the accuracy and consistency of the brachytherapist to place radioactive sources directly into the prostate gland. Transperineal ultrasound or CT directed seed implantation has replaced the older retropubic method. Brachytherapists are now able to accurately map out the gland prior to the implant and carefully evaluate preoperatively seed placement. The availability of such radioactive sources as iodine-125, palladium-103, and iridium-192 has also given the brachytherapist isotopes that can be more carefully matched to the biology and stage of the tumor. More sensitive definitions of failure have prompted radiation oncologists and urologists to carefully evaluate the efficacy of external beam irradiation and surgery. Accurate comparison of the efficacy of brachytherapy to surgery and to external beam radiation requires a randomized study. Comparisons of retrospective studies are fraught with the problems of the heterogeneous nature of early-stage prostate cancer. Imbalances in stage, grade, initial PSA extraprostatic disease, and nodal status of patient groups make comparisons difficult. Most of the long-term data for permanent seed implantation are the result of work at a single institution. These results will need to be repeated at other institutions treating patients in a similar manner. Because techniques vary from institution to institution, permanent implant results will need to be carefully evaluated for technique as well as stratified for pretreatment variables. Pretreatment PSA and grade appear to be more sensitive variables than stage in predicting failure after radiation. As more patients are diagnosed with very early and nonpalpable disease, future studies will need to stratify patients based on these pretreatment factors. Patients with early-stage disease but identified as high risk for extraprostatic disease will require more intensive regimens. The treatment outcomes based on biopsy results are inconclusive. A lack of consensus on the definition of a truly positive biopsy remains forthcoming. The value of a positive prostate biopsy as an outcome predictor for clinical failure is still unclear. The use of prostate nuclear cell antigen staining may help clarify the issue. Comparison of treatment outcome based on absolute PSA is also difficult. The Seattle series suggest that brachytherapy by permanent seed implantation is as efficacious as external beam irradiation for early-stage disease in patients with a low PSA (< 10 ng/mL). As the PSA value rises above 10 ng/mL, the probability of failure after external beam rises substantially. Results from the Seattle series suggest an advantage to seed implant alone or the judicious application of seed implant boost to external beam radiation for these patients with more advanced cancer. The most sensitive measurement of therapeutic outcome is progression-free survival. Few studies to date have evaluated progression-free survival.

Endothelial control of lower limb blood flow in chronic heart failure

BACKGROUND

Limitation of the blood supply to skeletal muscle in chronic heart failure may contribute to the symptoms of fatigue and diminished exercise capacity. The pathophysiology underlying this abnormality is not known. The purpose of this study was to assess the effect of endothelium dependent and independent vasodilator agents on blood flow in the leg of patients with heart failure.

METHODS AND RESULTS

Blood flow in the leg was measured in patients with heart failure (n = 20) and compared with that in patients with ischaemic heart disease and normal left ventricular function (n = 16) and patients with chest pain and normal coronary arteries (n = 8). External iliac artery blood flow was measured using intravascular Doppler ultrasound and quantitative angiography. Flow was recorded at rest and in response to bolus doses of the endothelium independent vasodilator, papaverine. Endothelium dependent responses were measured by infusion of acetylcholine and substance P. Mean (SEM) baseline blood flow was reduced at rest (2.9 (0.4) v 4.5 (0.3) ml/s, P < 0.001) and vascular resistance was raised (37.4 (3.6) v 27.1 (3.0) units, P < 0.05) in patients with heart failure compared with that in controls. The peak blood flow response to papaverine (8 mg), acetylcholine (10(-7)-10(-5) mol/l), and substance P (5 pmol/min) was reduced in heart failure, with greater impairment of the response to acetylcholine than substance P. There was a correlation between baseline blood flow in the heart failure group and diuretic dose (r = -0.62, P = 0.003), New York Heart Association classification (r = -0.65, P = 0.002), and left ventricular ejection fraction (r = 0.80, P = 0.0004).

CONCLUSIONS

There is reduced blood flow and raised vascular resistance at rest in the legs of patients with heart failure. The degree of impaired blood flow in the leg correlates with the severity of heart failure. There is impairment of the response to both endothelium dependent and independent vasodilators. Abnormal function of the vascular myocyte in heart failure may explain these results as would structural abnormalities of the resistance vessels.

A malariometric survey in Turkana District, Kenya: chemosensitivity in vivo of Plasmodium falciparum infections and identity of the vector

We have carried out a limited survey in vivo of the efficacy of chloroquine (n = 39) and pyrimethamine-sulfadoxine (n = 29) as treatments for falciparum malaria in Kaling, Turkana District, northern Kenya. Both treatments were effective, achieving clinical cure (> 75% reduction in parasitaemia on day 2 with clinical improvement, and negative blood slide on day 7) in both children and adults. A limited entomological survey suggested that the main malaria vector in this area was Anopheles arabiensis.

Addictive behavior of older adults

Very little is known about addictive alcohol use by older people. In the present paper personal effects reasons for drinking (i.e. drinking for the effects of alcohol) and concerns about drinking were used as indicators of addictive drinking behavior among a sample of 826 people aged 65 and older who participated in survey interviews in their homes. The relationship of addictive drinking behavior to frequency of drinking, quantity of drinks per occasion, and depressant drug use was examined. Alcohol use was higher among males and young-old (aged 65-74), while depressant medication use was higher among females and old-old (aged 75+). However, with the exception of use of over-the-counter medications containing codeine (which was significantly higher among current drinkers), no relationship existed between alcohol use and use of depressant medications. Personal effects reasons for drinking and concerns about drinking were related both to alcohol and depressant medication use. Frequency of drinking was associated with higher endorsement of both personal effects and social reasons, whereas volume of alcohol consumption (drinks per drinking day) was associated only with personal effects drinking. In addition, use of depressant medications by drinkers was significantly related to consuming alcohol for personal effects reasons (but unrelated to consuming for social reasons) and with having concerns about one's own drinking. These results suggest that even within the generally low levels of alcohol consumption of older people, addictive-use patterns emerge. In addition, the results confirm the importance of including depressant medication use in evaluating the drinking behavior of older people.

Dietary intake of micronutrient antioxidants in relation to blood levels in patients with systemic sclerosis

OBJECTIVE

To document habitual intakes of micronutrient antioxidants in patients with systemic sclerosis (SSc) in light of studies reporting subnormal levels of ascorbate and selenium in this patient group.

METHODS

Dietary intakes of vitamin C, selenium, alpha-tocopherol, beta-carotene, and sulfur amino acid precursors of glutathione were assessed using the 7 day weighed record in 12 patients with SSc and in 12 healthy control subjects. The intakes of the first 4 substances were examined in relation to plasma/serum levels, while intakes of sulfur amino acids were examined in relation to urinary inorganic sulfate.

RESULTS

Antioxidant and sulfur amino acid intakes were similar in patients and controls, although the patients had lower levels of selenium (median 74 compared to 87 milligrams in controls; p = 0.014) and of vitamin C in plasma (median 6.0 compared to 11.1 milligrams/l in controls; p = 0.08). Inorganic sulfate concentration in urine was similar in patients and controls.

CONCLUSION

Our results suggest that reduced blood levels of the water soluble antioxidants selenium and ascorbic acid in patients with SSc are not due to dietary deficiency. Other explanations must therefore be sought.

The results of water fluoridation in Ireland

The visit of Dr. Trendley Dean to Dublin in the mid-1950s helped accelerate the decision to introduce water fluoridation as a public health measure in the prevention of caries in the Republic of Ireland. A challenge to the constitutional validity of the Health (Fluoridation of Water Supplies) Act 1960 failed and in 1964 the water supplies of Dublin city were fluoridated. Over the next seven to eight years all the major urban communities in the Republic of Ireland were fluoridated. Currently, 67 percent of the 3.5 million people in the country reside in fluoridated communities. Studies conducted over the last 20 years show that residents of fluoridated communities have better dental health than those in nonfluoridated communities--the mean dmft is lower in children and the number of natural teeth present in adults is higher.

Regulation of the human bilirubin UDP-glucuronosyltransferase gene

The human UGT1 gene is a single copy gene consisting of four common exons and more than 13 variable exons which span more than 200 kb of the human genome. A single variable exon is spliced to the four common exons to form the mRNA for synthesis of a single UDP-glucuronosyltransferase (UGT) isoenzyme. Treatment of humans or hepatoma cell lines with drugs such as phenobarbital causes the induction of hepatic bilirubin UGT by increased transcription from the UGT1 gene. The upstream region of UGT1*1 (bilirubin UGT) was sequenced and found to contain consensus sequences for several transcriptional regulatory elements including a 'BARBIE box'. An unusual 'TATA' promoter sequence A(TA)6TAA was also observed. The 5' region flanking the UGT1*1 exon when cloned into reporter constructs and transfected into four cells lines was capable of promoting reporter gene expression, but not when transfected into monkey kidney cell fibroblasts (COS-7 cells) indicating a cell specific expression. Sequential deletion of the 5' flanking region in the plasmid constructs did not cause any significant reduction in reporter expression. Treatment of cells transfected with these plasmid constructs with drugs did not cause a significant increase in reporter expression except with retinoic acid plus WY 14643. Introduction of an additional two base pairs (TA) into the 'TATA' box of the 5' gene sequence (as observed in Gilbert's patients) did not significantly change reporter expression levels. The regulation of the biliruibin UGT gene by drugs is not yet understood and it will be important to identify additional genetic elements possibly further than -2kb upstream of the UGT1*1 coding region, which regulate the expression of this gene.

Significant differences between side-mounted and end-mounted intracoronary Doppler flow probes for the measurement of blood flow velocity

Use of the intracoronary Doppler flow probe is an established method for the assessment of coronary blood flow velocity. The aim of this study was to perform an in vitro comparison of two commonly used Doppler probes, which differ in the location of the piezoelectric crystal (end-mounted vs side-mounted). Blood flow velocity was measured over a wide range of flow rates in a flow simulator using heparinized whole blood. Measurements were made with both Doppler probes assessed in two positions (supported and unsupported) within the tubing. The results were compared with estimated true velocities. Further measurements were made with six side-mounted probes, correcting for the assumed crystal mounting angle and for the angle calculated from magnified images of the individual crystals. Mean velocities for end- and side-mounted probes correlated highly with predicted velocities (all r > or = 0.99), but the side-mounted probes significantly overestimated velocity by > 100%. Estimation of the true crystal mounting angle of the side-mounted probe revealed considerable variability (range 30-42 degrees) and was lower than the recommended angle correction factor of 60 degrees. Velocities corrected for the individual crystal mounting angles agreed more closely with predicted mean velocities. Although both probes are adequate for the assessment of relative changes in flow, the side-mounted probe considerably overestimates mean velocity, which is partly explained by the variable mounting angle of the crystal. The demonstrated limitations of the side-mounted Doppler flow probe in vitro should be considered in undertaking measurement of intracoronary blood flow velocity.

Interaction of interleukin 7 (IL-7) with glycosaminoglycans and its biological relevance

We have investigated the binding of interleukin 7 (IL-7) to sulfated glycosaminoglycans and evaluated its biological consequences. IL-7 binds to heparin and heparan sulfate, to a lesser extent to dermatan sulfate and does not bind to chondroitin sulfate. It was eluted from heparin by 0.3-0.6 M NaCl and from heparan sulfate by < 0.3 M NaCl. We also measured the affinity of IL-7 for heparin using an affinity co-electrophoresis method and found an affinity of 25 nM. In spite of these findings, IL-7 does not bind to the S17 cell line which supports lymphopoiesis. However, addition of heparin to cultures of an IL-7-dependent pre-B cell line (2E8) inhibited IL-7-stimulated proliferation and IL-7 complexed with heparin was more resistant than free IL-7 to protease treatment. Taken together, these results suggest that heparin may act as a carrier for IL-7, blocking its interaction with target cells and protecting it from degradation during transit.

Detection of ambulatory ischaemia is not of practical clinical value in the routine management of patients with stable angina. A long-term follow-up study

It has been reported that medically treated patients with stable angina and positive exercise test for ischaemia have an adverse 1-2 year outlook if they are shown also to have transient, and predominantly silent, ischaemic episodes detected by ambulatory ST segment monitoring during their daily activities: it has been suggested that this investigation could be used to identify patients more likely to benefit from early investigation and treatment. We assessed the long-term (up to 65 months) prognostic significance of transient ischaemic episodes during daily activities in 172 patients routinely attending cardiac outpatients with medically treated stable angina who had undergone exercise testing and 48 h of ambulatory ST segment monitoring between February 1988 and August 1989 for this purpose. A positive exercise test for ischaemia was not a prerequisite for inclusion. One hundred and four patients (60.5%) had a positive exercise test for ischaemia and 72 (42%) had transient ischaemia during daily activities (63 had both tests positive). Over a median 50-month follow-up period 54 patients suffered at least one cardiac event (primary event: cardiac death n = 7; non-fatal myocardial infarction n = 11; unstable angina n = 18; elective CABG/PTCA n = 18). Two further patients suffered non-cardiac death. Cardiac events, either objective (cardiac death or non-fatal myocardial infarction) or subjective (unstable angina or revascularisation) were no more likely to occur in those with transient ischaemia during daily life when compared with those without, at follow-up times up to 65 months.(ABSTRACT TRUNCATED AT 250 WORDS)

A clinical, cytogenetic, and molecular study of 40 adults with the Prader-Willi syndrome

A clinical, cytogenetic, and molecular study has been carried out on 40 adults with a firm diagnosis of Prader-Willi syndrome. A cytogenetically detectable deletion was observed in 58% while further subjects had a deletion which was detectable by molecular methods only, giving a total of 76%. Four cases of maternal uniparental disomy (UPD) were all female. Three of them were heterodisomic while the fourth was isodisomic. Two male probands were heterozygous at all loci tested yet did not have UPD. Although methylation studies showed that one of them had a single band using probe PW71, the other one had two bands. Psychiatric studies suggest that females with maternal UPD are indistinguishable psychologically from those with a paternal deletion in 15q11q13.

The effects of cardiopulmonary bypass on systemic and coronary levels of von Willebrand factor

Von Willebrand factor antigen (vWF Ag) is a marker of endothelial injury which has been shown to rise during surgical procedures, including cardiopulmonary bypass (CPB). The aim of this study was to determine whether intermittent aortic cross-clamping during CPB causes the release of vWF Ag from the coronary vascular bed, which would suggest coronary vascular endothelial cell perturbation. Fifteen consecutive patients undergoing CPB with aortic cross-clamping during coronary artery bypass surgery and/or valve replacement by the same surgeon were studied. Paired venous and coronary sinus samples were taken pre- and post-thoracotomy, prior to cross-clamping on CPB, and 1, 5 and 10 minutes after release of the aortic cross-clamp. Plasma vWF Ag (IU/ml) was measured by ELISA. Venous vWF Ag measured prior to skin incision was 0.75 +/- 0.11 IU/ml (mean +/- SEM) and fell to 0.53 +/- 0.07 IU/ml after institution of CPB but prior to aortic cross-clamping (P < 0.01 vs pre-incision sample). Coronary sinus vWF Ag measured prior to aortic cross-clamping was 0.54 +/- 0.06 IU/ml (P = NS vs paired venous sample). At 1, 5 and 10 min after release of the aortic cross-clamp there was a progressive rise in vWF Ag in both venous and coronary sinus samples (1 min: 0.67 +/- 0.05 IU/ml vs 0.75 +/- 0.10 IU/ml, 5 min: 0.73 +/- 0.07 IU/ml vs 0.76 +/- 0.09 IU/ml, 10 min: 0.74 +/- 0.08 IU/ml vs 0.79 +/- 0.09 IU/ml; P = NS venous vs coronary sinus, respectively). Levels of vWF Ag were highest immediately prior to the termination of CPB (venous: 0.95 +/- 0.12 IU/ml; coronary sinus: 0.91 +/- 0.14 IU/ml). We conclude that cardiac surgery using CPB with aortic cross-clamping is associated with a progressive rise in coronary sinus and venous levels of vWF Ag.(ABSTRACT TRUNCATED AT 250 WORDS)

Timed sequential analysis of creatine kinase in the diagnosis of myocardial infarction in patients over 65 years of age

AIM

To assess the value of timed sequential analysis of creatine kinase (CK) activity for the early diagnosis of acute myocardial infarction (AMI) in patients over 65 years of age.

METHOD

Samples were collected on admission and eight to 12 hours later from 156 patients over 65 years of age. Routine cardiac enzyme activities were determined and serial electrocardiograms (ECGs) recorded. The predictive value of timed samples for CK activity, standard cardiac enzyme activities, and ECGs was compared with the final diagnosis on discharge.

RESULTS

Forty one patients had a discharge diagnosis of AMI, 83 of angina pectoris, and the remaining 32 patients had other diagnoses. Electrocardiograms had a sensitivity of 55% and a specificity of 96%, giving a predictive value of 86% for a negative and 84% for a positive ECG. Standard cardiac enzymes had a predictive value of 99% for a negative result but only 68% for a positive result. The logarithm of the rate of change of CK activity had a predictive value of 97% for a negative result and 95% for a positive result.

CONCLUSION

This study has shown that slope analysis of CK activity can be used for the early diagnosis of AMI in patients over 65 years of age, and that this was not affected by the presence of possible confounding diagnoses.

The effects of intracoronary substance P and acetylcholine on coronary blood flow in patients with idiopathic dilated cardiomyopathy

Attenuation of the increase in blood flow caused by acetylcholine in the peripheral vasculature and coronary circulation of patients with heart failure has been interpreted as an impairment of endothelium-dependent vasodilation. The aim of this study was to compare in man the effects of acetylcholine, which also has endothelium-independent actions, with substance P, which appears to be a pure endothelium-dependent vasodilator, on epicardial and resistance coronary arteries in patients with idiopathic dilated cardiomyopathy. The effects of intracoronary acetylcholine (10(-7) M and 10(-6) M) and substance P (5, 10 and 25 pmol.min-1) on epicardial coronary artery diameter and coronary blood flow velocity were measured with an intracoronary Doppler flow probe and quantitative coronary angiography in 11 patients with idiopathic dilated cardiomyopathy and 10 control subjects. Epicardial coronary artery diameter did not change with acetylcholine but increased significantly with substance P in both groups (cardiomyopathy patients: 3.3 +/- 0.2 mm (mean +/- SEM) at baseline vs 3.9 +/- 0.2 mm with substance P25 pmol.min-1, P < 0.01; controls: 3.1 +/- 0.2 mm at baseline vs 3.9 +/- 0.3 mm with substance P25 pmol.min-1, P < 0.05). Coronary flow ratios with acetylcholine were lower in cardiomyopathy patients (10(-7) M: 1.4 +/- 0.1 vs 2.3 +/- 0.4, P = 0.05; 10(-6) M: 1.8 +/- 0.2 vs 3.2 +/- 0.5, P = 0.05 vs controls).(ABSTRACT TRUNCATED AT 250 WORDS)

Creatine kinase isoform electrophoresis for the early confirmation of myocardial infarction detected by timed sequential CK slope analysis

Creatine kinase (CK)-MM and -MB isoforms were evaluated for the early diagnosis of myocardial infarction in patients aged over 65 years admitted to a district general hospital with acute chest pain. Samples were collected for standard cardiac enzymes, timed CK slope analysis, and CKMM and CKMB isoform analysis from 48 patients admitted with acute chest pain. CKMM and CKMB isoform analyses were conducted using a Helena Rep electrophoresis system under standard conditions supplied by the company. In addition to the results of the biochemical tests the discharge diagnosis of the patients were also recorded. CKMM isoform analysis resulted in three false-negative classifications of patients and one false-positive. The predictive value of this test was 100% for a positive result and 94% for a negative result. CKMB isoform analysis was less accurate and there were six false-negative results and five false-positive results. The predictive value of a positive result was 75% and 85% for a negative result. CK isoform analysis became unreliable when mean total CK levels in serum were 210 IU/l (+/- 171). CK isoform analysis may be of use in the investigation of patients whose samples have a total CK concentration greater than the reference range but was no better than timed CK slope analysis for the detection of myocardial infarction in patients aged more than 65 years.

Use of cloned and expressed human liver UDP-glucuronosyltransferases for analysis of drug glucuronide formation and assessment of drug toxicity

Five cloned human hepatic UDP-glucuronosyltransferase (UGT) cDNAs were stably expressed in tissue culture cell lines. More than 100 drugs and xenobiotics were used as substrates for glucuronidation catalyzed by the cloned human transferases to determine the chemical structures accepted as substrates. UGT-HP1 exhibited a limited substrate specificity for planar phenolic compounds, whereas UGT-HP4 was more accepting of nonplanar phenols, anthraquinones, flavones, alphatic alcohols, aromatic carboxylic acids, steroids and many drugs of varied structure. UGT-HP3 (bilirubin UGT) catalyzed the glucuronidation of ethinylestradiol. UGT-H6 and UGT-H25 (steroid/bile acid UGTs) also catalyzed the glucuronidation of some xenobiotics. Levels of UGT-HP4 activity towards some substrates were sufficient to allow determination of kinetic parameters for the enzyme reaction. Further, metabolism of drugs could be studied by addition to the recombinant cell lines in culture and extraction of the media allowed analysis of glucuronide formation. The protection afforded against cytotoxic drugs was observed. The data presented here demonstrate the potential of using these recombinant cell lines for investigation of phase II metabolism by human UGTs and subtle differences in protein structure which affect their specificity.

Peripheral nerve injury

Knowledge of the actions of conventional neurotrophic factors on peripheral neurons is accumulating rapidly, and growth factors that were discovered outside the nervous system have been found to have neurotrophic actions. The nature and initiation of proximal neuronal responses to nerve injury, the interactions of Schwann cells and growth cones, and the functions of macrophages in the peripheral nervous system are all areas of active investigation. Results of the surgical treatment of injuries to the brachial plexus and spinal accessory nerve are reported.

The radiology of sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown aetiology. The role of radiology is not only to support the clinical diagnosis but also as an adjunct to monitor the course and progression of the disease. The cornerstone of radiological assessment is the plain radiograph, however newer imaging methods are producing more information in relation to the anatomical distribution and pathophysiology which may ultimately have a profound effect on the management of this protean disease.