Is a pre-discharge checklist useful?

A pre-discharge checklist of requirements for equipment, services, benefits and follow-up has been developed in a general rehabilitation unit. An analysis of 66 inpatients discharged after rehabilitation following a stroke or amputation within the past 2 years suggests that such a checklist is a useful tool in ensuring that patients are sent home with optimum services and support. It is also a simple way of recording discharge data for audit and quality control purposes. It may be of benefit to a wider range of hospital services.

Teaching basic video skills as an aid in laparoscopic suturing

BACKGROUND

There is a perception among surgeons that performing laparoscopic suturing is unduly difficult. The purpose of this study is to document a program which aides in learning laparoscopic suturing.

METHODS

Fourteen volunteer medical students without prior experience were taught laparoscopic suturing. Videoscopic pelvitrainers were utilized for a 2-h training session. Extracorporeal and intracorporeal knot tying was demonstrated utilizing a three-throw square knot. After a 2-h practice session each student's time to complete an extracorporeal and intracorporeal suture was recorded.

RESULTS

The average times required for completion were: extracorporeal suture and knot 1 min 54 s; intracorporeal suture and knot 3 min 12 s.

CONCLUSIONS

Novice students were able to perform at extra and intracorporeal suturing with 2 h of practice, utilizing a systematic program of teaching basic video skills.

The hsv-2 la-1 oncoprotein is a member of a novel family of serine threonine receptor kinases

The large subunit of the herpes simplex virus type 2 ribonucleotide reductase (RR) (ICP10) is a chimera consisting of a serine/threonine (Ser/Thr) protein kinase (PK) domain preceded by a transmembrane (TM) segment at the amino terminus (LA-I oncoprotein) and the RR domain at the carboxy terminus. Human cells transformed by the LA-I oncogene constitutively express the oncoprotein on the cell surface and internalize it by the endocytic pathway as determined by immunogold staining and electron microscopy. The TM segment of the oncoprotein is required for cell surface localization, consistent with the interpretation that the oncoprotein is a growth factor receptor. Amino acid sequence alignment and comparative computer-assisted phylogenetic analyses of the LA-1 oncoprotein indicate that it is a member of the superfamily of growth factor receptor Ser/Thr kinases. However, many structural differences, including the presence of two SH3-binding motifs located within the PK catalytic domain suggest that the LA-I oncoprotein is a member of a novel subfamily.

Does routine screening for breast cancer raise anxiety? Results from a three wave prospective study in England

OBJECTIVE

To investigate whether mammography raises anxiety in routinely screened women who receive a negative result.

DESIGN

Prospective design in which women completed questionnaires at three key points in the breast screening process: at baseline (before being sent their invitation for breast screening), at the screening clinic immediately before or after screening, and at follow up, about nine months after baseline. Information was obtained from non-attenders as well as from attenders.

SETTING

Bromley District Health Authority, served by the South East London Breast Screening Service.

PARTICIPANTS

Two overlapping samples were used. Sample A comprised 1500 women aged 50-64 who were due to be called for first round screening at a mobile screening unit. Altogether 1021 (68%) returned a usable questionnaire and 795 of these (78%) also provided adequate information at nine month follow up: there were 695 attenders (including 24 women who received false positive results) and 100 non-attenders. Sample B consisted of 868 women who attended the screening unit in a three month period, 732 (84%) of whom provided adequate data. A total of 306 attenders (including 10 who received false positive results) occurred in both samples and provided adequate information on all occasions. The main analyses were based on these 306 women plus the 100 non-attenders. The analysis of retrospective anxiety took advantage of the larger sample size of 695 attenders.

MAIN RESULTS

On average, the women were not unduly anxious at any of the three points in the screening process. Among attenders, there was no difference between anxiety levels immediately before and immediately after screening. Anxiety was lowest at the clinic and highest at baseline but the changes were very small in absolute terms. Anxiety did not predict attendance: there were no differences in anxiety levels between attenders and non-attenders at baseline. As expected, women who received false positive results recalled feeling extremely anxious after they had received the referral letter but their retrospective anxiety was also higher than in the negative screenees at earlier stages in the breast screening process. They also reported having experienced more pain and discomfort during the x ray.

CONCLUSIONS

Anxiety does not seem to be an important problem in routinely screened women who receive a negative result. This finding is very reassuring in relation to a major criticism of breast screening programmes. Thus, apart from maintaining current procedures such as keeping waiting times to a minimum, there seems to be no need to introduce special anxiety reducing interventions into the national programme. On the other hand, the findings for women who received false positive results suggest that there are aspects of the experience of being recalled for assessment after an abnormal mammogram that warrant further attention. The relationship between contemporaneous and retrospective anxiety should also be studied.

Targeted delivery of a substrate for P-glycoprotein to renal cysts in vitro

Bodipy-verapamil has been tested as a fluorescent substrate for P-glycoprotein-mediated transepithelial secretion in MDCK-C5A epithelia. Net transepithelial secretion (Jnet) of [3H]vinblastine from basal-to-apical surfaces of monolayer epithelia is inhibited by taxotere, verapamil and Bodipy-verapamil primarily by a reduction in basal to apical vinblastine (Jb-a) transport. Bodipy-verapamil is itself subject to transepithelial net secretion by MDCK-C5A epithelia; at 5 microM a Jnet of -310 +/- 32 nmol cm-2 h-1 (n = 3) was observed. When MDCK-C5A cells are grown to form enclosed cysts in hydrated collagen gel. Bodipy-verapamil is accumulated within the cyst lumen showing that epithelial P-glycoprotein function may be used to target substrates to renal cysts.

The phallic child: its emergence and meaning in a clinical setting

The nature of the drive toward forming and maintaining intense attachments with other human beings has been examined in the light of case material from the play therapy sessions of a ten-year-old boy. The primary question addressed concerns the relationship of the attachment drive to other drive systems. Freudian theory, object relations theory, and attachment theory present competing paradigms for understanding the relationship between the drives. The Freudian paradigm sees human attachment as derivative from other drives, especially the sexual drive. In developing his attachment theory, Bowlby broke from the classical Freudian view. He postulated attachment as a primary and autonomous drive. Object relations theory, by contrast, sees sexuality as one manifestation of a more fundamental drive that is intrinsically relationship seeking. Each of these traditions has contributed to our understanding of human reality. A careful examination of the clinical material, however, strongly suggests that a drive toward relationship is intrinsic to libidinal energy. It is therefore concluded that the understanding of the relationship between the drives based on object relations theory provides us with the most adequate framework within which to understand the clinical material.

Problems with registration of cutaneous malignant melanoma in England

The aim of the study was to assess the completeness and accuracy of cancer registration for cutaneous malignant melanoma. The study was conducted in seven health districts in England and one health board in Scotland from 1987 to 1989 with a total resident population of 3.6 million. Records from pigmented lesion clinics and pathology laboratories collected during the Cancer Research Campaign's health education programme to promote the early detection of melanoma were matched with cancer registrations from a total of five regional cancer registries. In England 74% out of a total of 642 cases of invasive malignant melanomas (ICD 172) and 44% out of a total of 155 in situ melanomas (ICD 232) had been registered compared with 96% and 100% respectively in Scotland. A significantly higher proportion of late-stage cases was found among registered than among non-registered cases in England (P < 0.001). In all registries the majority of superficial spreading in situ melanomas were miscoded as invasive cases. The annual incidence of invasive malignant melanoma in the English study areas was found to be seven per 100,000 in men and 11 per 100,000 in women, similar to that reported in Scotland. The registries are best at recording thick or late-stage melanomas. As the skin cancer target for Health of the Nation depends on monitoring trends in the incidence of malignant melanoma, future improved ascertainment of cases and changes in the type of cases being registered must be taken into account.

HLA-B27 screening by flow cytometry

A flow cytometric assay for lymphocyte HLA-B27 expression using a two-color direct immunofluorescent assay was compared to traditional microlymphocytotoxicity testing on 209 clinical samples. For the flow cytometric assay, whole blood was mixed with a monoclonal anti-B27 conjugated to fluorescein-isothiocyanate (FITC) and anti-CD3 conjugated to phycoerythrin (PE). The samples were analyzed with flow cytometry by gating on CD3 positive events and anti-B27 staining intensity was evaluated as median channel fluorescence of the histogram peak. The median channel fluorescence was least with B27 negative and B7 negative samples (84 +/- 17), intermediate with samples that were B27 negative but B7 positive (118 +/- 13), and greatest with samples that were B27 positive (155 +/- 13). In addition to cross-reactivity with the B7 antigen (n = 38), the monoclonal anti-B27 cross-reacted with HLA-B37 positive samples (n = 3) and HLA-B39 positive samples (n = 3). Using a median channel fluorescence cutoff of 136, 39 of the 40 B27 positive samples gave positive results in the flow cytometric assay for a sensitivity of 97.6%. The specificity was 95.9% with 7 false positives of 169 B27 negative samples. The flow cytometric HLA-B27 assay is a convenient, useful screening test. For greatest specificity, samples positive by flow cytometry should be confirmed by conventional microlymphocytotoxicity or by use of other monoclonal antibodies directed against B27.

Chronic cough and hoarseness in patients with severe gastroesophageal reflux disease. Diagnosis and response to therapy

Gastroesophageal reflux may be responsible for atypical symptoms such as chronic cough and hoarseness. Our aim was to evaluate and treat patients with severe gastroesophageal reflux and chronic cough or hoarseness with intensive antireflux therapy. Twenty-seven patients with typical heartburn symptoms in addition to significant cough or hoarseness were treated with aggressive antireflux therapy. We recorded the response of each symptom to the antireflux therapy. Two patients were lost to follow-up. Twenty of the 25 (80%) patients showed some improvement in cough or hoarseness, nine (36%) had no atypical symptoms at follow-up. The response of heartburn to therapy was strongly predictive of successful therapy for the atypical symptoms. Cough and hoarseness improved in only two of the five patients with residual heartburn symptoms compared to 18 of 20 patients with no heartburn (P < 0.04). Only patients with no heartburn symptoms at follow-up had complete resolution of atypical symptoms. There were no important differences on ambulatory pH monitoring between partial and complete responders. Improvement in atypical reflux symptoms, such as chronic cough and hoarseness, is common with aggressive antireflux therapy. There are no findings on ambulatory esophageal pH monitoring that uniquely identify patients who are likely to respond to antireflux therapy.

Unrelated bone marrow donor transplants for children with leukemia or myelodysplasia

Allogeneic bone marrow transplantation is the treatment of choice for many childhood leukemias. The donor of choice-an HLA matched sibling-is only available about 30% of the time. Unrelated donors are an alternative choice. In this report, we describe the results of unrelated donor bone marrow transplants (BMT) in 50 children with leukemia (25 acute lymphoblastic leukemia [ALL], 3 acute myeloid leukemia [AML], 3 juvenile chronic myelogenous leukemia [JCML], 10 chronic myeloid leukemia [CML]) or myelodysplastic syndrome (MDS; 9). The median age of the 31 male and 19 female patients was 9 years (range 2 to 18). Only 13 patients were serologically matched at HLA-A, B, DR, and DQ with their donors; 6 of these were reactive in mixed lymphocyte culture. The other 37 patients were mismatched for one (36 patients) or more (1 patient) HLA antigens. Pretransplant conditioning included cytosine arabinoside, cyclophosphamide, fractionated total body irradiation (TBI) (with lung, liver, and more recently, kidney shielding), and methylprednisolone. High-risk patients also received busulfan. Graft-versus-host disease (GVHD) prophylaxis consisted of T-cell depletion with IgM monoclonal antibody T10B9 plus complement and posttransplant cyclosporine-A. Forty-nine patients (98%) engrafted. Median times to greater than 500 polymorphonuclear leukocytes (PMN)/microL and greater than 25,000 platelets/microL were 18 and 20 days, respectively. Acute GVHD > or = grade II occurred in 16 patients (33%); 13 (81%) of these died. Chronic GVHD developed in 30 of 40 patients at risk, but was extensive in only 5. Event-free survival (EFS) for all patients was 44% +/- 7% (median follow-up was 49 months), and overall survival was 50 +/- 7%. Patients with low-risk disease (ALL or AML in first or second remission and CML in chronic phase) had a better EFS than children with high-risk disease (60% v 34%, P = .07). There was no significant difference in EFS between patients who were serologically matched with their donors (46%) and those who were partially mismatched (43%) (P = .97). These data compare favorably with published reports for children transplanted with HLA-matched sibling donors and should encourage earlier consideration of unrelated donor BMT in children with leukemia or myelodysplasia.

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. I. Work-load and referral patterns

From 1987 to 1989 a campaign to promote the early detection of cutaneous malignant melanoma was conducted in the areas of seven health authorities in England and Scotland (total population 3.6 million). Data were collected on 17,155 patients attending pigmented lesion clinics (PLCs) in each study area during the campaign. After a dramatic rise in PLC referral rates in the first month of the campaign the average monthly referral rate among the target population in the study period settled to an average of 13 per 10(5), a twofold increase compared with the pre-campaign period. Over 85% of patients at all PLCs were seen within 4 weeks of referral from their general practitioners. The melanoma to non-melanoma detection ratio was (1:33). The organization of future early detection initiatives needs careful review and planning, in order to improve their effectiveness in all sections of the population, and to enable health services to cope with the increased work-load.

Subsynovial vascular abnormality causing recurrent hemarthrosis in an 84-year-old man

We describe a patient with recurrent hemarthrosis of one knee. Investigation demonstrated a vascular abnormality of the synovium as the likely cause. Structural abnormalities of the synovial vasculature should be considered, in the absence of a systemic cause, as a potential source of bleeding in older patients with recurrent hemarthrosis.

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. II. Characteristics and incidence of melanoma

The effect on the detection and characteristics of melanoma, resulting from the Cancer Research Campaign's health education programme to promote the early detection of melanoma in the general population, was studied from 1987 to 1989. The seven study areas in England and Scotland yield a target population of 3.6 million. Data were collected from local clinic-based registers, pathology laboratories, and the cancer registries. The average annual incidence rates of melanoma were seven and 12 per 10(5) in males and females, respectively, age-standardized to England and Wales, 1988. These rates are similar to the national figures for Scotland, where there is a national melanoma register, but higher than those reported by the English and Welsh cancer registries. The incidence was significantly higher in females than males (P < 0.001), and increased with age. Fifty-three per cent and 65% of cases in males and females, respectively, were thin (Breslow thickness < or = 1.5 mm), similar to the national figures from Scotland. No significant decrease in the incidence of late-stage tumours was found in either sex as a result of the campaign. Because of difficulties with ascertainment of cases in England, the main evaluation will focus on future trends in mortality rates for melanoma.

Outcome of second line therapy in rheumatoid arthritis

OBJECTIVES

To study the functional outcome in patients with rheumatoid arthritis (RA) who tolerate second line drug therapy for five years.

METHODS

We enrolled into prospective controlled trials, 190 patients with rheumatoid arthritis who tolerated 'disease modifying' antirheumatic drug therapy for five years. Demographic data were recorded. Disease activity was measured every six months for two years and annually thereafter, using clinical and laboratory variables. Patient function was measured using the modified Health Assessment Questionnaire. The change in each variable was analysed using paired Wilcoxon tests.

RESULTS

Patient function improved significantly compared with baseline. The improvement was maximal after one to two years, and thereafter function started to decline slowly. After five years of treatment the patients' function was still significantly better than before treatment had started. There were highly significant improvements in all variables measured to assess disease activity, which remained well controlled throughout the five year period.

CONCLUSION

Good control of disease activity and improved function can be achieved long term in approximately 30% of RA patients treated with injectable gold, sulphasalazine or penicillamine.

Revamping British nurse education with Project 2000: focus on children's nursing

The preregistration nurse education system in the United Kingdom is currently undergoing dramatic changes to meet the changing times and health care needs. Project 2000 has been an ongoing reality for nurses in the U.K. and demonstrates nursing's responsiveness to change and nurses' commitment to the public's health.

Medical considerations and practice guidelines for the neonatal occupational therapist

Provision of safe and effective occupational therapy in neonatal intensive care units requires an understanding of neonatal medical conditions and treatment modalities. This article explains basic medical concepts and technology with terminology frequently encountered in neonatal intensive care. Discussions of neonatal thermoregulation, respiratory care, hemodynamic monitoring, and metabolic support are presented as general areas of focus. Equipment usage and precautions are included. Several case studies illustrate the incorporation of medical knowledge into neonatal occupational therapy practice.

Preserved cardiac performance with reduced left ventricular mass in conscious exercising spontaneously hypertensive rats

OBJECTIVES

To investigate whether cardiovascular performance can be modified beneficially with left ventricular hypertrophy reversal and whether the associated sudden afterload increases may adversely affect overall cardiac performance.

METHODS

We studied cardiovascular performance with thermodilution techniques at rest and during maximal treadmill exercise after 3 weeks' treatment with the angiotensin converting enzyme inhibitor quinapril (3 mg/kg per day) in 19 male spontaneously hypertensive rats (SHR) aged 20 weeks.

RESULTS

Left ventricular mass was reduced significantly, without impairment of exercise performance, demonstrating that left ventricular hypertrophy reversal benefited or at least did not hinder cardiovascular adaptation to physiologic exercise in the SHR. Moreover, decreasing the afterload did not further improve the performance after the reversal of left ventricular hypertrophy.

Analysis of surgical movements during suturing in laparoscopy

Laparoscopic suturing is now recognized as a necessary component of minimally invasive surgery. Until recently it has been avoided due to the lack of proper instrumentation and systematic technique. The principles of magnified surgery are discussed as they apply to the laparoscopic field, with emphasis on visual perception, economy of motion, choreography of movements, and "flawless technique". The principles and techniques of needle loading, handling, and driving are presented, as are the series of movements involved in tying an intracorporeal square-slip knot.

Prototype high-speed tape target transport for a laser plasma soft-x-ray projection lithography source

A prototype high-speed tape target transport is constructed for use in a high-repetition-rate laser plasma source. To reduce plasma debris, a 1000-5000-A-thick film of target material is supported by thin Mylar tape backing. Tape is transported to the laser focal volume at a maximum velocity of 356 cm/s, a rate sufficient to accommodate laser repetition rates of 1 kHz. The transport is fully vacuum compatible and can be retracted and then isolated from the laser plasma vacuum enclosure during tape reel replacement. The operating characteristics of the transport are described.

Multicenter prospective evaluation of laparoscopic antireflux surgery. Preliminary report

BACKGROUND

A prospective study of 116 patients undergoing laparoscopic antireflux surgery was undertaken in four centers in the United Kingdom and the United States.

METHODS

Patients with a hiatal hernia (n = 80) underwent total Rosetti-Hell fundoplication, whereas those without a hiatal defect (n = 36) were treated by a partial fundoplication (Toupet). The follow-up period ranged from 3 to 24 months; median was 13 months.

RESULTS

The median duration of the operations was 2.5 h. Intraoperative complications were encountered in 16 patients (14.0%) and conversion to laparotomy was necessary for esophageal perforation in one. The postoperative recovery of gastrointestinal function was rapid and the median hospital stay from the time of the operation to discharge was 2 days, range 1-10. A good symptomatic result (> 70% reduction of preoperative symptom score) was observed in 106 patients (91%). There were no postoperative deaths but 15 patients (13.0%) developed complications in the immediate postoperative period. At 3 months, complete endoscopic healing of the esophagitis was observed in 65/92 patients (71%) and improvement by at least one grade was seen in 19 patients (21%). Twenty-four-hour pH monitoring, which was abnormal preoperatively in 93% of patients, was normal after surgery in 95%. There were 10 symptomatic failures (persistent reflux symptoms) and 14 patients (12%) developed adverse symptoms related to the procedure (gas-bloat 8, dysphagia 9, gastroparesis 1, explosive diarrhoea 1). Readmission to hospital within 3 months was necessary in 9 patients.

CONCLUSIONS

Laparoscopic antireflux surgery can be performed with a low morbidity. In the short term, 83% of patients were rendered symptom free. These results are similar to those reported after the equivalent open operations.

Transepithelial secretion, cellular accumulation and cytotoxicity of vinblastine in defined MDCK cell strains

Transepithelial vinblastine secretion in two defined MDCK strains displays saturation kinetics; (Strain 1) Km = 2.8 +/- 0.6 microM (six experiments), Vmax 35.9 +/- 1.93 pmol/cm2 per h (six experiments), Strain 2 Km 0.78 +/- 0.36 microM (three experiments), Vmax 12.1 +/- 4.5 pmol/cm2 per h (three experiments). Concentrations of vinblastine > 1 microM are associated with an increased passive vinblastine permeability (PA-B). This correlates with an increased transepithelial conductance/decreased permselectivity, suggesting that this may in part result from increased paracellular conductance. Verapamil inhibits vinblastine secretion, half-maximal inhibition of basal-to-apical flux (JB-A) is observed at 3.4 +/- 0.3 and 1.7 +/- 0.05 microM verapamil for Strain-1 and Strain-2 epithelial layers, respectively. Cellular accumulation of vinblastine across the apical membrane is small with respect to that across the basolateral surfaces. This polarity is unaffected by verapamil. The apical membranes, therefore, possess a low intrinsic permeability to vinblastine. Inhibition of cell growth by vinblastine is enhanced by verapamil. Both the effect of vinblastine, and its enhancement by verapamil, upon cell growth are reduced as initial cell seeding density increases.

Functional expression of P-glycoprotein in apical membranes of human intestinal Caco-2 cells. Kinetics of vinblastine secretion and interaction with modulators

The functional expression of P-glycoprotein has been studied in confluent epithelial layers of human Caco-2 cells, a polarized, highly differentiated cell line demonstrating an intestinal absorptive cell phenotype. Expression of P-glycoprotein was localized, by indirect immunofluorescence with monoclonal antibody MRK16, to the apical brush-border, approximately 20 microns above the base of the cells. Functional, high capacity expression of P-glycoprotein in Caco-2 cell layers was demonstrated by the saturable secretion of vinblastine, a typical substrate, from basolateral to apical surfaces: Km 18.99 +/- 5.55 microM, Vmax 1285.9 +/- 281.2 pmol.cm-2 h-1. The direct correlation of apical P-glycoprotein expression with vinblastine net secretory flux was demonstrated by the reduction of this flux after treatment with MRK16 antibodies. Vinblastine secretory flux was also reduced by treatment with verapamil (R- and S-isomers with equal affinity), nifedipine, taxotere, and 1,9-dideoxyforskolin. Kinetic analyses suggest that the inhibition of vinblastine secretory flux by verapamil and nifedipine was competitive, while that by dideoxyforskolin was non-competitive, in nature. The polarized expression and activity of P-glycoprotein in Caco-2 cells is direct evidence for its secretory detoxifying function in the intestine, subserving at least one role of the gastrointestinal epithelial barrier.

Mental health aspects of HIV infection

Of the multiple causes of mental disturbance in HIV infection, it is generally safest to consider organic causes first, including opportunistic infections, tumours, medications, and HIV encephalopathy. The psychological stress of the illness will cause different or overlapping presentations that include anxiety and depression. When managing these situations, one should also pay attention to the effects of stress on the social network of the infected person.

Drug absorption limited by P-glycoprotein-mediated secretory drug transport in human intestinal epithelial Caco-2 cell layers

The hypothesis was tested that the operation of an ATP-dependent export pump localized at the apical (brush border) surface of the intestinal epithelium may limit substrate absorption kinetics. Human intestinal Caco-2 cell-layers display saturable secretion of vinblastine from basal to apical surfaces (Km, 18.99 +/- 5.55 microM; Vmax, 1285.9 +/- 281.2 pmol cm-2 hr-1) that is inhibited by verapamil, consistent with the expression of the ATP-dependent P-glycoprotein drug efflux pump at the apical brush border membrane. Inhibition of P-glycoprotein by a variety of modulators (verapamil, 1,9-dideoxyforskolin, nifedipine, and taxotere) is associated with an increased vinblastine absorptive permeability. Vinblastine absorption displayed a nonlinear dependence upon luminal (apical) vinblastine concentration, and vinblastine absorption increased markedly at concentrations where vinblastine secretory flux was saturated (> 20 microM). Upon inhibition of P-glycoprotein by verapamil and 1,9-dideoxyforskolin, vinblastine absorption increased and was linearly dependent on vinblastine concentration. The limitation of P-glycoprotein substrate absorption by active ATP-dependent export via P-glycoprotein is discussed, together with the possibility that other classes of substrate may be substrates for different ATP-dependent export pumps.

Combination therapy in rheumatoid arthritis--no benefit of addition of hydroxychloroquine to patients with a suboptimal response to intramuscular gold therapy

OBJECTIVE

To determine if there is any advantage in adding hydroxychloroquine to intramuscular gold therapy in patients with rheumatoid arthritis (RA) with a suboptimal response to gold after 6 months of treatment.

METHODS

Prospective double blind placebo controlled study at the Centre for Rheumatic Diseases, Glasgow Royal Infirmary and Gartnavel General Hospital, Glasgow. Patients--440 patients with RA began intramuscular gold therapy. One hundred forty-two patients with a suboptimal response at 6 months were randomized to receive additional treatment with hydroxychloroquine (400 mg/day) or placebo, and followed for a further 6 months. Outcome measures were erythrocyte sedimentation rate, C-reactive protein, Ritchie articular index, grip strength, visual analog pain score, duration of morning stiffness, health assessment questionnaire, and rate of side effects.

RESULTS

There was no difference in outcome in terms of efficacy or toxicity.

CONCLUSION

There is no justification for using a combination of intramuscular gold and hydroxychloroquine in patients with RA with a partial response to gold.

Repair of aortico-left ventricular tunnel associated with subpulmonary obstruction

Aortico-left ventricular tunnel is a rare congenital cardiac defect. Because the tunnel traverses the upper portion of the interventricular septum, the potential exists for an aneurysmal tunnel to obstruct the outflow of the right ventricle. We report our clinical experience with such a patient, and emphasize the importance of a two-patch technique to avoid its occurrence.

Ischemia/reperfusion-induced feline intestinal dysfunction: importance of granulocyte recruitment

Although previous studies have reported that neutrophils play an important role in mediating the microvascular injury observed after reperfusion of ischemic intestine, the contribution of these phagocytic cells to the mucosal dysfunction remains unclear. Three series of experiments consisting of an untreated group, a short-term monoclonal antibody (MAb) IB4 treatment group (MAb IB4 given on the day of the experiment), and a long-term MAb IB4 treatment group (3-day pretreatment with MAb IB4) were performed using autoperfused segments of cat ileum exposed to 3 hours of ischemia followed by 1 hour of reperfusion. Mucosal myeloperoxidase activity, an index of mucosal granulocyte levels, increased from 12 to 25 U/g wet wt in the untreated group. In the short-term MAb IB4 experiments, baseline values were very similar to those of the untreated group but no increase in myeloperoxidase activity was observed after ischemia/reperfusion. Long-term pretreatment with MAb IB4 reduced baseline values of myeloperoxidase activity to approximately 1 U/g wet wt; the values remained at this level throughout the experiment. The permeability of the mucosal barrier was quantitated by measuring blood-to-lumen clearance to 51Cr-ethyl-enediaminetetraacetic acid (EDTA). The water absorptive capacity of the intestine was also measured. In the untreated group, mucosal permeability to 51Cr-EDTA increased sixfold and water absorption was abolished after reperfusion. Both short-term and long-term administration of MAb IB4 prevented the net fluid loss into the lumen, but only long-term administration of MAb IB4 blunted the increased mucosal permeability induced by ischemia/reperfusion. These data suggest that interstitial granulocytes contribute significantly to the mucosal dysfunction associated with reperfusion of the ischemic intestine.

Polarized efflux of 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein from cultured epithelial cell monolayers

We have investigated the polarity of the efflux of the intracellular pH fluorochrome 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein (BCECF) from layers of epithelial Madin-Darby canine kidney (MDCK, Strains I and II) and human intestinal (Caco-2, HCT-8 and T84) cells grown on porous membranes. In Strain I MDCK cells, BCECF efflux was effectively reduced by indomethacin (50% inhibition with 100 microM) and 5-nitro-2-(3-phenylpropyl-amino)-benzoate (NPPB; 50% inhibition with 10 microM). Replacement of external Cl- with bromide, iodide or nitrate did not alter BCECF efflux, while substitution with methanesulphonate resulted in a small but significant reduction. All five cell lines form confluent epithelial layers when grown on porous membranes. Efflux of BCECF from Strain I MDCK epithelial layers into the apical solution was approximately three times greater than into the basal solution. Addition of indomethacin to the apical solution attenuated efflux into the apical but not the basal solution, while basal indomethacin was effective against basal efflux. NPPB has a similar specificity of action. Adrenaline, a stimulant of electrogenic Cl- secretion, did not alter the pattern of BCECF efflux. BCECF efflux was also polarized, with apical efflux greater than basal efflux, in MDCK Strain II and Caco-2 epithelial layers. In contrast, BCECF efflux into the basal and apical media was equivalent in layers formed from HCT-8 and T84 cells. However, indomethacin reduced efflux in all five epithelial lines, although the relative sensitivities of the apical and basal efflux rates to indomethacin varied, as did the sensitivity to the sidedness of application of indomethacin. In MDCK and HCT-8 epithelial layers, transepithelial vinblastine secretion mediated by P-glycoprotein was not inhibited by indomethacin. The data are consistent with the hypothesis that BCECF efflux is a manifestation of a novel ATP-dependent xenobiotic secretory efflux mechanism in renal and gastrointestinal epithelia. The factors regulating the polarity of BCECF efflux, both the indomethacin-sensitive and -insensitive components, have yet to be elucidated.

Fragmentation and re-integration of experience

Secular and religious counselors require a model of psychotherapy that conceptualizes human beings as conscious, goal-seeking entities. Such a model, based on the construct "being in one's own world," is sketched in broad outline in this essay. The building blocks for the model are the "intentional modes" that lie at the heart of the self-world dialectic in which we live our lives. It is demonstrated how these "intentional modes" are organized into a gestalt-like whole referred to as the "existential gestalt." From the diagram of the existential gestalt the concepts of "intentional clarity" and "modal congruence" are derived. These concepts enable us to understand the processes of the fragmentation and re-integration of experience that lie at the heart of psychotherapy. Inclusiveness and purposefulness, two additional factors that are important for assessing the adequacy of the existential gestalt, are also briefly touched upon.

Plasma membrane water permeabilities of human oocytes: the temperature dependence of water movement in individual cells

Membrane water permeability values were measured in individual fresh human pre-ovulatory oocytes using real time microscopy in a microscope diffusion chamber. The cells were exposed to anisosmotic conditions, their volume responses measured, and from these data the Lp values were computed employing the Kedem-Katchalsky analyses of irreversible thermodynamics. Lp values were measured at four temperatures for each oocyte between 37 degrees C and 10 degrees C, and the temperature-related Arrhenius activation energy (Ea) calculated. It was apparent that individual oocytes exhibited a wide range of Lp values; at 37 degrees C Lp values ranged between 0.33 and 1.80 microns/atm/min. However, each oocyte exhibited the expected inverse linear correlation between Lp and temperature, with high linear correlations (R2 values between 0.73 and 0.96). A mean value for Ea of 8.61 +/- 5.11 Kcal/mol was computed. It is apparent that pre-ovulatory human oocytes express a range of biological diversity in terms of membrane water transport, and this fact needs to be considered when attempting to formulate cryopreservation protocols for storage of these oocytes.

Are gender effects being neglected in schizophrenia research?

Research on schizophrenia published in four professional journals--Journal of Abnormal Psychology, Archives of General Psychiatry, Journal of Nervous and Mental Disease, and American Journal of Psychiatry--over a 5-year period from January 1985 through December 1989 was examined for gender composition of subject samples and gender analyses of findings. Results indicate a continued predominance of male subjects in schizophrenia research, with males outnumbering females two to one, and frequent neglect of possible gender differences within mixed-sex samples. Possible explanations for the male bias are considered and greater research and editorial attention to possible gender effects are urged.

Transepithelial vinblastine secretion mediated by P-glycoprotein is inhibited by forskolin derivatives

[3H]Vinblastine transport across MDCK (renal epithelial) cell layers has been characterised. The basal-to-apical [3H]vinblastine flux (JA-B) (at 10 nM) exceeded apical-to-basal flux by 19.6 fold. Net vinblastine secretion (JB-A - JA-B) was inhibited by verapamil (0.1 mM) primarily by a reduction in JB-A, consistent with net vinblastine secretion resulting from an inhibition of P-glycoprotein. 1,9-Dideoxy-forskolin and forskolin (0.1 mM) both resulted in significant inhibition of JB-A and net vinblastine secretion of 64.3 +/- 3.1% and 29.1 +/- 4.8% respectively. 7 beta-deactyl-7 beta-(gamma-N-methylpiperazino)-butyryl-forskolin was ineffective. Half-maximal inhibition of vinblastine secretion by 1,9-dideoxy-forskolin was observed at 65 microM. 1,9-dideoxy-forskolin is unable to stimulate adenylate cyclase, suggesting that this forskolin derivative is a potentially important lead antagonist of P-glycoprotein for circumvention of pleiotropic drug resistance.

Effects of cyclosporin A and FK506 on ischemia/reperfusion-induced neutrophil infiltration in the cat

Isolated segments of cat small intestine were subjected to 3 hr of ischemia followed by 1 hr reperfusion (I/R). Mucosal biopsies were obtained for measurement of myeloperoxidase (MPO) activity, an index of tissue neutrophil count, and leukotriene B4 (LTB4) production. Animals were pretreated with either cyclosporin A (CsA) or FK506, which are potent immunosuppressants. Both agents significantly attenuated the neutrophil infiltration induced by I/R. FK506, but not CsA, reduced the elevated mucosal LTB4 production normally observed following reperfusion. The results of this study suggest that FK506 and CsA may be important agents in modulating neutrophil infiltration in acute inflammatory conditions.

INFORM: integrated support for decisions and activities in intensive care

Many medical decision support systems that have been developed in the past have failed to enter routine clinical practice. Often this is because the developers have failed to analyse in sufficient detail the precise user requirements, because they have produced a system which takes too narrow a view of the patient, or because the decision support facilities have not been sufficiently well integrated into the routine clinical data handling activities. In this paper we discuss how the AIM-INFORM project is setting out to deal with these issues, in the context of the provision of decision support in the intensive care unit.

Epithelial secretion of vinblastine by human intestinal adenocarcinoma cell (HCT-8 and T84) layers expressing P-glycoprotein

P-glycoprotein expression was demonstrated in two human intestinal adenocarcinoma cell-lines (HCT-8, ileocaecal and T84, colonic) by immunoprecipitation of a 170-180 kDa protein with monoclonal antibody JSB-1. Both HCT-8 and T84 formed functional epithelial cell layers of high transepithelial electrical resistance (greater than 700 omega.cm2) when grown on permeable matrices. These epithelial layers demonstrated vectorial secretion (net vinblastine fluxes in the basal-to-apical direction of 0.135 and 0.452 pmol h-1 cm-2 in HCT-8 and T84 cell layers, respectively, from bathing solutions containing 10 nM vinblastine). These vectorial vinblastine secretions were sensitive to inhibition by verapamil. Passive transepithelial vinblastine permeation was limited by the presence of intercellular (tight) junctions, as demonstrated by the high transepithelial electrical resistance, and verapamil increased this passive vinblastine permeation concomitant with a reduction in the electrical resistance. Cellular vinblastine loading was significantly greater from the basal side, and this was also susceptible to inhibition by basal verapamil. The demonstration of vectorial transport of vinblastine in human intestinal colonic adenocarcinoma cell layers is direct evidence in favour of the hypothesis that the function of mdr1 in epithelial from the gastrointestinal tract is to promote detoxification by a process of epithelial secretion. This study also highlights that cellular vinblastine accumulation depends not only upon P-glycoprotein function, but also upon differential apparent membrane permeabilities and the presence of intercellular (tight) junctions that may restrict drug permeation and cellular accumulation to apical or basal membrane domains.

Aerosol pentamidine-induced bronchoconstriction. Predictive factors and preventive therapy

OBJECTIVE

To describe the frequency of aerosol pentamidine-induced bronchoconstriction, its relationship to non-specific airway responsiveness, and its response to preventive therapy using salbutamol, ipratropium bromide, or sodium cromoglycate.

METHODS

Consecutive HIV-infected individuals starting prophylactic AP were eligible if they had not been previously treated with this agent. Simple spirometry was performed before and 10 min after a single 60-mg dose given through an ultrasonic nebulizer. Methacholine challenge was performed in all subjects 24 h to four days after the initial AP dose. Subjects with a change in FEV1 (delta FEV1) greater than or equal to 10 percent decrease after the initial AP dose were restudied on three separate occasions (greater than 24 hours apart) after premedication with two puffs of salbutamol (200 micrograms), ipratropium bromide (40 micrograms), or sodium cromoglycate (2 mg), in random order.

RESULTS

Fifty-three subjects were studied. The median delta FEV1 after a single dose of AP was -7.0 percent (range: -47 percent, 1.8 percent). The delta FEV1 following AP was only partially predicted by the degree of nonspecific bronchial responsiveness as measured by a standard methacholine challenge. Age, current smoking, history of asthma, baseline FEV1, or a prior episode of PCP failed to predict the delta FEV1 following AP. Eighteen subjects (34 percent) had a delta FEV1 greater than or equal to 10 percent decrease (median: -17.0 percent). In these subjects, after premedication with salbutamol, ipratropium bromide, and sodium cromoglycate, the median delta FEV1 was 1.0, 0.8, and -9.6 percent, respectively.

CONCLUSION

Aerosol pentamidine produced a decrease in FEV1 greater than or equal to 10 percent in 34 percent of subjects. This was not accurately predicted by the methacholine response. The bronchoconstriction induced by AP was effectively prevented by either salbutamol or ipratropium, whereas cromoglycate was only partially effective.

Reversibility of cardiac xenograft rejection in primates

More than 500 people died in 1988 because of the shortage of human heart donors. Cardiac xenografts from concordant primates may help to relieve this shortage. Two groups of ABO-matched cynomolgus monkey-to-baboon heterotopic cardiac xenografts were studied. Group 1 (n = 4) control animals had no immunosuppression. Group 2 (n = 6) baboons received cyclosporine, azathioprine, and methylprednisolone acetate. Myocardial biopsy, mixed lymphocyte culture, donor-specific crossmatch, and panel-reactive antibody determinations were performed after transplantation. Biopsy-proven rejection episodes (myocyte necrosis) were treated intravenously with steroids. A follow-up biopsy was performed 7 days after the first biopsy. If rejection persisted, antithymocyte globulin (10 mg/kg/day) was given for 7 days, and another biopsy was performed. Group 1 (control) graft survival was 8, 9, 9, and 10 days (mean, 9 days). Group 2 (immunosuppressed) graft survival was 3, 16, 18, 51, 84, and 392 days (mean, 94 days). Each immunosuppressed baboons' xenograft had myocyte necrosis and variable degrees of edema, cellular infiltrates, and vascular thrombosis consistent with mixed cellular and humoral rejection within 1 week. Only one rejection episode resolved with high-dose steroid therapy alone. Two baboons' rejection episodes resolved with antithymocyte globulin treatments, but rejection recurred in both. Low levels of or delayed progression of panel-reactive antibody was associated with long-term xenograft survival. Severe steroid-resistant rejection with cell-mediated and humoral immune elements developed early in our primate cardiac xenografts despite triple-drug immunosuppression. Use of antithymocyte globulin was associated with temporary resolution of rejection, but progressive increases in lymphocytotoxic antibody led invariably to eventual graft loss despite rare long-term survival.

Facial deformity in childhood: severity and psychological adjustment

This study examines the hypothesis that severe facial deformities may be less of a psychological burden than those that are more mild. Twenty-seven experimental children and 12 controls, plus 26 siblings of the experimental group and 12 control siblings, were assessed using tests of intelligence, self-concept and ratings of behaviour. The results provided some support for the hypothesis being considered.

Persons and organisms

The philosophical quest for unity leads to the desire for a clear and adequate conception of human reality as a "mind-body unity." This quest for unity has led both to conceptions of considerable heuristic value and to overly reductionistic approaches that impoverish our full relation to reality. Three basic themes are developed in this essay: 1. That on an ontological level dualistic and monistic approaches to mind-body remain equally plausible. 2. That on a practical level, epistemological considerations require us to retain a dualistic approach suggested by the terms "person" and "organism." 3. That psychotherapy (whether religious or secular) must ground itself in the notion of "person." Differences between the concepts of "person" and "organism" are delineated on six specific points. Finally, it is suggested that a holistic approach to health requires both constructs.