Pharmacokinetics of radiolabeled polyclonal antiferritin in patients with Hodgkin's disease

The objective was to identify pharmacokinetic parameters predictive for tumor response and normal tissue side effects after i.v. administered radiolabeled rabbit antihuman ferritin IgG. Twenty-eight patients with recurrent Hodgkin's disease received 2 mg of rabbit antihuman ferritin i.v., labeled with 4-7 mCi of In-111 followed by two doses of 0.25, one dose of 0.3, or one dose of 0.4 mCi of Y-90-labeled antiferritin per kg of body weight 1 week later. Radioactivity and HPLC measurements of blood and urine samples and liver and tumor volumes identified on sequential whole-body scans provided the data for a pharmacokinetic analysis covering the first 6 days after the administration of the radioimmunoconjugate. Side effects and tumor response were recorded. Temporary hematological toxicity was noted in all patients. Sixteen patients showed a tumor response. The Y-90 blood level at 1 h after administration correlated with the severity of subsequent hematological toxicity. The rapid blood elimination half-life of radioactivity was 4.4 h. Less than 5% of the administered radioactivity was eliminated in the first 24 h urine. The slow blood elimination half-life was 44 and 37 h for In-111 and Y-90, respectively. One of 12 retreated patients produced anti-rabbit IgG antibodies. The volume of distribution was larger for Y-90 than for In-111-labeled antiferritin (160 versus 110% of estimated blood volume). Accidentally extravasated rabbit IgG was rapidly catabolized in perivascular tissues with an effective half-life of less than 35 h. Slower catabolism was noted for rabbit IgG in blood (t(1/2) = 40 h), liver (t(1/2) = 62 h) or tumor (t(1/2) = 40-80 h). Twelve of 13 patients with an effective tumor half-life > 57 h showed a tumor response. I.v. administered polyclonal rabbit antihuman ferritin, labeled with In-111 or Y-90 is stable in vivo and targets Hodgkin's disease. Intravascular Y-90 causes a vascular leak and a larger volume of distribution for antiferritin. Elevated Y-90 blood levels at 1 h and a tumor half-life of >57 h predict for hematological toxicity and tumor response, respectively.

Reoperation in adults with repair of tetralogy of fallot: indications and outcomes

OBJECTIVE

The purpose of this study is to review indications, surgical procedures, and outcomes in adults with repaired tetralogy of Fallot referred for reoperation.

METHOD

Sixty consecutive adults (age >/= 18 years) who underwent reoperation between 1975 and 1997 after previous repair of tetralogy of Fallot were reviewed. Mean age at corrective repair was 13.3 +/- 9.6 years and at reoperation 33.3 +/- 9.6 years. Mean follow-up after reoperation is 5.0 +/- 4.9 years.

RESULTS

Long-term complications of the right ventricular outflow tract (n = 45, 75%) were the most common indications for reoperation: severe pulmonary regurgitation (n = 23, 38%) and conduit failure (n = 13, 22%) were most frequent. Less common indications were ventricular septal patch leak (n = 6) and severe tricuspid regurgitation (n = 3). A history of sustained ventricular tachycardia was present in 20 patients (33%) and supraventricular tachycardia occurred in 9 patients (15%). A bioprosthetic valve to reconstruct the right ventricular outflow tract was used in 42 patients. Additional procedures (n = 115) to correct other residual lesions were required in 46 patients (77%). There was no perioperative mortality. Actuarial 10-year survival is 92% +/- 6%. At most recent follow-up, 93% of the patients are in New York Heart Association classification I or II. Sustained ventricular tachycardia occurred in 4 patients (7%) during follow-up.

CONCLUSIONS

Long-term complications of the right ventricular outflow tract were the main reason for reoperation. Mid-term survival and functional improvement after reoperation are excellent.

Safety and antitumor activity of recombinant soluble Apo2 ligand

TNF and Fas ligand induce apoptosis in tumor cells; however, their severe toxicity toward normal tissues hampers their application to cancer therapy. Apo2 ligand (Apo2L, or TRAIL) is a related molecule that triggers tumor cell apoptosis. Apo2L mRNA is expressed in many tissues, suggesting that the ligand may be nontoxic to normal cells. To investigate Apo2L's therapeutic potential, we generated in bacteria a potently active soluble version of the native human protein. Several normal cell types were resistant in vitro to apoptosis induction by Apo2L. Repeated intravenous injections of Apo2L in nonhuman primates did not cause detectable toxicity to tissues and organs examined. Apo2L exerted cytostatic or cytotoxic effects in vitro on 32 of 39 cell lines from colon, lung, breast, kidney, brain, and skin cancer. Treatment of athymic mice with Apo2L shortly after tumor xenograft injection markedly reduced tumor incidence. Apo2L treatment of mice bearing solid tumors induced tumor cell apoptosis, suppressed tumor progression, and improved survival. Apo2L cooperated synergistically with the chemotherapeutic drugs 5-fluorouracil or CPT-11, causing substantial tumor regression or complete tumor ablation. Thus, Apo2L may have potent anticancer activity without significant toxicity toward normal tissues.

Transient monocyte release of interleukin-10 in response to traumatic brain injury

A significant component of the immune response to trauma results in the systemic presence of cytokines which have the potential to suppress the patient's immune response to infection and contribute to post-injury complications. We assayed peripheral blood leukocytes obtained from 10 patients with head trauma to determine their production of interleukin (IL). Serum was assayed for the presence of IL-10, TGFbeta1, and IFNgamma by ELISA. Peripheral blood leukocytes were screened for intracellular IL-10 and IFNgamma by fluorescence-activated flow cytometry, and cytokine-specific mRNA was detected by the polymerase chain reaction. We detected an immediate, but transient, presence of IL-10 in the sera of all 10 patients who suffered head trauma. IL-10-specific intracytoplasmic immunofluorescence was also detected immediately after injury in peripheral blood monocytes, but not in lymphocytes or granulocytes. IL-10-specific mRNA was detected in peripheral blood leukocytes in only 50% of patients immediately after injury, when the highest serum levels of IL-10 were observed. Our data indicates that release of pre-formed IL-10 by monocytes contributes to the presence of IL-10 found in patient peripheral blood immediately after head injury.

Arrhythmia and survival in patients >18 years of age after the mustard procedure for complete transposition of the great arteries

Increasing numbers of patients who underwent Mustard repair as children are now adults. Loss of sinus rhythm, supraventricular arrhythmias, and sudden death have been described in pediatric series. However, little is known about the clinical course of adult patients. This retrospective cohort study examined 86 consecutive adults (age >18 years) who had undergone the Mustard procedure and were referred to an adult congenital cardiac clinic for ongoing follow-up. The incidence and predictors of arrhythmia, congestive heart failure, and death were determined. The median follow-up period was 8 years after age 18 or 23 years after Mustard repair. There were 8 deaths (9%), 2 were sudden. Congestive heart failure (CHF) requiring hospital admission occurred in 9 patients (10%). Pulmonary hypertension and systemic ventricular dysfunction were independent risk factors for death or CHF. Only 29 patients (34%) remained arrhythmia-free. Forty-one patients (48%) had at least 1 episode of supraventricular tachycardia (SVT), with most patients (30, 73%) having atrial flutter. SVT after the age of 18 was associated with CHF. Pulmonary hypertension, systemic ventricular dysfunction, and junctional rhythm before age 18 were independent risk factors for SVT. Pacemakers were implanted in 19 patients (22%); 13 of those were beyond age 18. Thus, adult survivors of the Mustard procedure continue to be at risk for premature death, CHF and supraventricular tachyarrhythmia.

Thoracoscopic repair of a recurrent diaphragmatic hernia four years after initial trauma, laparotomy, and repair

Traumatic diaphragmatic hernia is not an uncommon problem and has been noted after either penetrating or blunt trauma. A high index of suspicion must be maintained in order to identify patients with this injury, as delay in identification may result in significant morbidity and death. It is essential that a thorough evaluation be performed, and if a diaphragmatic hernia is found, surgical repair is necessary. We present a case of thoracoscopic repair of an incarcerated recurrent diaphragmatic hernia appearing several years after successful open (via laparotomy) repair of an acute blunt traumatic hernia. A brief review of the surgical literature is also presented. With the broadening use of minimally invasive surgical techniques, we feel that their application to the repair of chronic diaphragmatic hernia is safe and effective, reduces morbidity, and results in a faster recovery.

Atrial arrhythmia after surgical closure of atrial septal defects in adults

BACKGROUND

Atrial flutter and atrial fibrillation are causes of morbidity in adults with an atrial septal defect. In this study, we attempted to identify risk factors for atrial flutter and fibrillation both before and after the surgical closure of an atrial septal defect.

METHODS

We searched for preoperative and postoperative atrial flutter or fibrillation in 213 adult patients (82 men and 131 women) who underwent surgical closure of atrial septal defects because of symptoms, a substantial left-to-right shunt (ratio of pulmonary to systemic blood flow, >1.5:1), or both at Toronto Hospital between 1986 and 1997.

RESULTS

Forty patients (19 percent) had sustained atrial flutter or fibrillation before surgery. As compared with the patients who did not have atrial flutter or fibrillation before surgery, those who did were older (59+/-11 vs. 37+/-13 years, P<0.001) and had higher mean pulmonary arterial pressures (25.0+/-9.7 vs. 19.7+/-8.2 mm Hg, P=0.001). There were no perioperative deaths. After a mean follow-up period of 3.8+/-2.5 years, 24 of the 40 patients (60 percent) continued to have atrial flutter or fibrillation. The mean age of these patients was greater than that of the 16 who converted to sinus rhythm (P=0.02). New-onset atrial flutter or atrial fibrillation was more likely to have developed at follow-up in patients who were older than 40 years at the time of surgery than in those who were 40 or younger (5 of 67 vs. 0 of 106, P=0.008). Late events (those occurring more than one month after surgery) included stroke in six patients (all but one with atrial flutter or fibrillation, one of whom died) and death from noncardiac causes in two patients. Multivariate analysis showed that older age (>40 years) at the time of surgery (P=0.001), the presence of preoperative atrial flutter or fibrillation (P<0.001), and the presence of postoperative atrial flutter or fibrillation or junctional rhythm (P=0.02) were predictive of late postoperative atrial flutter or fibrillation.

CONCLUSIONS

The risk of atrial flutter or atrial fibrillation in adults with atrial septal defects is related to the age at the time of surgical repair and the pulmonary arterial pressure. To reduce the morbidity associated with atrial flutter and fibrillation, the timely closure of atrial septal defects is warranted.

Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment

BACKGROUND

Although prophylactic administration of antiemetics reduces the incidence of postoperative nausea, vomiting, or both (PONV), there is little evidence to suggest this improves patient outcomes. The authors hypothesized that early symptomatic treatment of PONV will result in outcomes, including time to discharge, unanticipated admission, patient satisfaction, and time to return to normal daily activities, that are similar to those achieved with routine prophylaxis.

METHODS

Men and women (n = 575) scheduled for outpatient surgery during general anesthesia were randomized to receive either 4 mg intravenous ondansetron or placebo before operation and either 1 mg intravenous ondansetron or placebo if postoperative symptomatic treatment of PONV was necessary. Patients were stratified into subgroups by risk factors for PONV.

RESULTS

No differences occurred in the time to discharge, rate of unanticipated admission, or time to return to normal activity between the prophylaxis and treatment groups. The reported level of satisfaction with control of PONV was 93% in the treatment arm and 97% in the prophylaxis arm, which fall within the limits defined a priori as clinically equivalent. Female patients with a history of motion sickness or PONV who were undergoing highly emetogenic procedures had a higher reported level of satisfaction with prophylaxis than with treatment (100% vs. 90%, P = 0.043); however, the level of satisfaction with the overall outpatient surgical experience was not different.

CONCLUSION

Although PONV is unpleasant, the data indicate little difference in outcomes when routine prophylactic medications are administered versus simply treating PONV should symptoms occur.

Routine myocardial revascularization with the radial artery: a multicenter experience

BACKGROUND

Current literature documents use of the radial artery (RA) for myocardial revascularization only as an alternative conduit in cases where the saphenous veins have been previously harvested or are unsuitable for use. Large-scale routine clinical use of the RA as the conduit of choice has not been reported.

METHODS

This prospective study evaluated the harvest of the RA from 933 patients and the subsequent use of the conduit as a preferred coronary artery bypass graft second only to the left internal thoracic artery in 930 of these patients.

RESULTS

Unilateral RA harvest was performed in 786 patients and 147 patients had bilateral RA harvest. A total of 1080 RAs were harvested; 214 (19.8%) originated from the dominant forearm. There was a mean of 3.30+/-0.93 grafts per patient of which 2.43+/-0.83 were arterial grafts. The mean number of RA grafts was 1.43+/-0.53. Operative mortality was 2.3% with none due to the RA graft(s). There was no ischemia nor motor dysfunction in the operated hands. Thirty-two (3.4%) patients experienced transient thenar dysesthesia that resolved in 1 day to 6 weeks.

CONCLUSIONS

Our results demonstrate that routine total or near total arterial myocardial revascularization may be achieved safely and effectively with the use of one or both RAs in conjunction with the internal thoracic artery.

Characteristics of local electrograms with diastolic potentials: identification of different components of return pathways in ventricular tachycardia

BACKGROUND

Diastolic potentials are often sought as a possible site for catheter ablation in post-infarct ventricular tachycardia. However, delivery of energy at such sites is often unsuccessful. The purpose of this study was to determine the characteristics of local electrograms with diastolic potentials and to identify activation pattern which might indicate the critical portion of the return path of the ventricular tachycardia reentry circuit.

METHODS

In 17 patients with post-myocardial infarction ventricular tachycardia, 30 ventricular tachycardias were mapped with an 112 bipolar endocardial balloon at the time of surgery. Diastolic mapping of the return tract in ventricular tachycardia was performed. Four activation patterns were observed (15 figure 8 patterns, 2 circular patterns, 2 biregional patterns and 11 monoregional patterns). Of 3,360 local electrograms, 207 (6.2%) demonstrated a diastolic potential in ventricular tachycardia. They were classified into following four categories, based on the appearance and timing of the systolic component. Type A-1 electrogram: systolic activation was of low amplitude (< 2 mV) and was prolonged (> or = 100 msec), but preceded the onset of the surface QRS in ventricular tachycardia. Type A-2 electrogram: systolic activation was of low amplitude, was prolonged, but followed the onset of the surface QRS. Type B electrogram: systolic electrogram was fractionated, but relatively normal amplitude (2.0-3.6 mV). Type C electrogram: systolic electrogram was almost normal.

RESULTS

Of all electrograms with diastolic potentials, three type A-1 electrograms (1.4%) were located at the exit of the return pathway, 11 type A-1 electrograms (5.3%) were located at the pre-exit site. No type A-1 was found at an entrance/bystander area. 21 type A-2 electrograms (10.1%) were at the pre-exit and 83 type A-2 electrograms (40.2%) were located at the entrance/bystander area, but such electrograms were never found at the exit site. 71 type B electrograms (34.3%) and 18 type C electrograms (8.7%) were located at the entrance/bystander area. To distinguish the type A-2 electrograms at the pre-exit site from those at the entrance/bystander area, the diastolic potential to QRS interval was measured. This interval at the pre-exit was significantly shorter than that at the entrance/bystander area (-47.2 +/- 10.7 vs -96.3 +/- 31.3 msec, p = 0.0001).

CONCLUSION

Type A-1 electrograms indicated the exit or pre-exit site of return pathway. Type A-2 electrograms with diastolic potential to QRS interval < -50 msec indicated the pre-exit site. However, the other types of local electrograms with diastolic potential did not indicate the critical portion of the ventricular tachycardia circuit. These observations may be helpful during catheter mapping and ablation of patients with post-infarct ventricular tachycardia.

CONDENSED ABSTRACT

Diastolic potentials are often sought to direct catheter ablation in post-infarct ventricular tachycardia. We investigated the characteristics of local electrograms showing diastolic activity in an attempt to determine whether critical portions of the ventricular tachycardia circuit could be identified by a typical "signature." In 17 patients with a remote myocardial infarction, 30 ventricular tachycardias were mapped with 112 bipolar endocardial balloon at the time of surgery. Diastolic potentials in association with low amplitude (< 2 mV) and prolonged (> or = 100 msec) systolic electrograms preceding the onset of QRS were found at the exit site and pre-exit site of return pathway. A similar systolic electrogram occurring after QRS onset with a diastolic potential to QRS interval of < -50 msec was found at the pre-exit site. However, other local electrograms with diastolic activity were at sites remote from the exit or pre-exit of the return pathway. These observations may be helpful during catheter mapping and ablation in patients with ventricular tachycardia.

Rheumatic fever in the Kimberley region of Western Australia

The objective of this study was to assess the incidence and clinical presentation of acute rheumatic fever in children and young adults in the north west of Western Australia--a region known as the Kimberley. In this five year retrospective study, residents aged less than 30 years, suspected of having had acute rheumatic fever from 1988 to 1992, were identified and their hospital and clinic records were reviewed. There were 96 cases of acute rheumatic fever that met the revised Jones criteria during the five year period. There were 59 initial attacks and 37 recurrences that occurred in 81 people, of whom 80 were of Aboriginal descent. The overall incidence of acute rheumatic fever in the Kimberley region for those aged under 30 years is 136 cases per 100,000 per year and in the Aboriginal population is 241 per 100,000 per year. The group most at risk are Aboriginal school children aged 5-14 years who accounted for 50 cases and have an annual incidence of 375 cases per 100,000 per year. The clinical presenting features were carditis in 50 per cent, polyarthritis in 59 per cent, chorea in 22 per cent, and subcutaneous nodules in 1 per cent. The hospitalization rate was 80 per cent for new cases and 73 per cent for recurrences with average stays of 14.6 and 1.5 days respectively. Rheumatic heart disease (RMD) developed in 31 of the cases; two required surgery and there was one death attributable to RHD in this group. Rheumatic fever continues to be a significant health problem in the Aboriginal population in this region and the recurrence rate, despite secondary prophylaxis, is also unacceptably high.

Care: a value expressed in philosophies of nursing services

Philosophies are written to reflect the values of the institution. Nursing service philosophies describe the essential features of nursing as practiced in a specific site. In this study, 10 philosophies of nursing services from community and teaching hospitals were content analyzed. Care emerged as a theme in each of the philosophies. The care construct was further categorized as general care, care approaches, and care descriptors: goal-directed, quality, safe, cost-effective, effective, competent, and ethical. An exhaustive description of care as proposed by Colaizzi is presented.

Uncertainty in prostate cancer. Ethnic and family patterns

PURPOSE

Prostate cancer occurs 37% more often in African-American men than in white men. Patients and their family care providers (FCPs) may have different experiences of cancer and its treatment. This report addresses two questions: 1) What is the relationship of uncertainty to family coping, psychological adjustment to illness, and spiritual factors? and 2) Are these patterns of relationship similar for patients and their family care givers and for whites and African-Americans?

DESCRIPTION OF STUDY

A sample of white and African-American men and their family care givers (N = 403) was drawn from an ongoing study, testing the efficacy of an uncertainty management intervention with men with stage B prostate cancer. Data were collected at study entry, either 1 week after post-surgical catheter removal or at the beginning of primary radiation treatment. Measures of uncertainty, adult role behavior, problem solving, social support, importance of God in one's life, family coping, psychological adjustment to illness, and perceptions of health and illness met standard criteria for internal consistency. Analyses of baseline data using Pearson's product moment correlations were conducted to examine the relationships of person, disease, and contextual factors to uncertainty.

RESULTS

For family coping, uncertainty was significantly and positively related to two domains in white family care providers only. In African-American and white family care providers, the more uncertainty experienced, the less positive they felt about treatment. Uncertainty for all care givers was related inversely to positive feelings about the patient recovering from the illness. For all patients and for white family members, uncertainty was related inversely to the quality of the domestic environment. For everyone, uncertainty was related inversely to psychological distress. Higher levels of uncertainty were related to a poorer social environment for African-American patients and for white family members. For white patients and their family members, higher levels of uncertainty were related to lower scores on adult role behavior (shopping, running errands). For white family members, higher levels of uncertainty were related to less active problem solving and less perceived social support. Finally, higher levels of uncertainty were related to the importance of God for white patients and family care providers.

CLINICAL IMPLICATIONS

The clearest finding of the present study is that there are ethnic differences in the relationship of uncertainty to a number of quality-of-life and coping variables. This has immediate implications for the assessment of psychosocial responses to cancer and cancer treatment. Much of what is in curricula is based on clinical and research experience primarily with white individuals. The experience of uncertainty related to cancer and its treatment is influenced by the cultural perspectives of patients and their families. To assist patients and families with the inevitable uncertainties of the cancer experience, healthcare providers need to reconsider their ethnocentric assumptions and develop more skill in assessing patient and family beliefs, values, cultural perspectives, and the influence of these on patient and family uncertainties.

Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot

OBJECTIVES

We sought to determine the features associated with sustained monoform ventricular tachycardia (VT) in adult patients late after repair of tetralogy of Fallot (TOF) and to review their management.

BACKGROUND

Patients with repair of TOF are at risk for sudden death. Risk factors for ventricular arrhythmia have been identified from patients with ventricular ectopic beats because of the low prevalence of sustained VT.

METHODS

From a retrospective chart review of patients assessed between January 1990 and December 1994, 18 adult patients with VT were identified and compared with 192 with repaired TOF free of sustained arrhythmia.

RESULTS

There was no significant difference in age at repair, age at follow-up or operative history. Patients with VT had frequent ventricular ectopic beats (6 of 9 vs. 21 of 101), low cardiac index ([mean +/- SD] 2.4 +/- 0.4 vs. 3.0 +/- 0.8) and more structural abnormalities of the right ventricle (outflow tract aneurysms and pulmonary or tricuspid regurgitation) than control patients. Electrophysiologic map-guided operation was performed in 10 of 14 patients who required reoperation. VT has reoccurred in three of these patients. Four patients did not undergo operation (three received amiodarone; one underwent defibrillator implantation). Two patients with VT also had severe heart failure and died.

CONCLUSIONS

Most patients with VT late after repair of TOF have outflow tract aneurysms or pulmonary regurgitation, or both. These patients have a greater frequency of ventricular ectopic beats than arrhythmia-free patients after repair of TOF. A combined approach of correcting significant structural abnormalities (pulmonary valve replacement or right ventricular aneurysmectomy, or both) with intraoperative electrophysiologic-guided ablation may reduce the potential risk of deterioration in ventricular function and enable arrhythmia management to be optimized.

Comparative study of the ipsilateral full thickness forearm skin graft in closure of radial forearm flap donor site defects

The early experience of our unit with the technique of ipsilateral full thickness forearm skin grafting of the radial forearm flap donor site defect is described. The technique provides the advantages of a full thickness skin graft whilst avoiding the need to harvest skin from a remote area. We have compared the results with that of split skin grafts used contemporaneously for the same purpose in our unit; the advantages and disadvantages are outlined. Continued success has encouraged us to utilize this technique routinely with certain modifications which we describe.

Sequence specificity and biochemical characterization of the RusA Holliday junction resolvase of Escherichia coli

The RusA protein of Escherichia coli is an endonuclease that resolves Holliday intermediates in recombination and DNA repair. Analysis of its subunit structure revealed that the native protein is a dimer. Its resolution activity was investigated using synthetic X-junctions with homologous cores. Resolution occurs by dual strand incision predominantly 5' of CC dinucleotides located symmetrically. A junction lacking homology is not resolved. The efficiency of resolution is related inversely to the number of base pairs in the homologous core, which suggests that branch migration is rate-limiting. Inhibition of resolution at high ratios of protein to DNA suggests that binding of RusA may immobilize the junction point at non-cleavable sites. Resolution is stimulated by alkaline pH and by Mn2+. The protein is unstable in the absence of substrate DNA and loses approximately 80% of its activity within 1 min under standard reaction conditions. DNA binding stabilizes the activity. Junction resolution is inhibited in the presence of RuvA. This observation probably explains why RusA is unable to promote efficient recombination and DNA repair in ruvA+ strains unless it is expressed at a high level.

Analysis of whole-cell fatty acid profiles of verotoxigenic Escherichia coli and Salmonella enteritidis with the microbial identification system

Differentiation of strains within bacterial species, based on gas chromatographic analysis of whole-cell fatty acid profiles, was assessed with 115 strains of verotoxigenic Escherichia coli and 315 strains of Salmonella enteritidis. Fatty acid-based subgroups within each of the two species were generated. Variability of fatty acid profiles observed in repeat preparations from the same strain approached that observed between subgroups, limiting the usefulness of using fatty acid profiles to subgroup verotoxigenic E. coli and S. enteritidis strains.

Arrhythmia and mortality after the Mustard procedure: a 30-year single-center experience

OBJECTIVES

Our purpose was to assess the risk factors for late mortality, loss of sinus rhythm and atrial flutter after the Mustard operation.

BACKGROUND

The Mustard operation provides correction of cyanosis with low surgical risk in transposition of the great vessels. However, right ventricular failure, loss of sinus rhythm, atrial flutter and death are frequent long-term complications.

METHODS

Records of 534 children who underwent the Mustard operation at a single center since 1962 were reviewed for demographic, anatomic, electrocardiographic and physiologic predictors and outcomes.

RESULTS

There were 52 early deaths (9.7%). Survival analysis was undertaken for 478 early survivors with a mean follow-up interval of 11.6 +/- 7.2 years. There were 77 late deaths (16.1%), with sudden death (n = 31) the most frequent cause. Survival estimates were 89% at 5 years and 76% at 20 years of age. Risk factors were an earlier date of operation, operative period arrhythmia and an associated ventricular septal defect. Risk (hazard) of late death declined in the first decade, with further peaks in the second decade. Sinus rhythm was present in 77% at 5 years and 40% at 20 years. Loss of sinus rhythm was associated with previous septectomy, postoperative bradycardia and late atrial flutter. Freedom from atrial flutter was 92% at 5 years and 73% at 20 years of age. Risk factors for atrial flutter were the occurrence of perioperative bradyarrhythmia, reoperation and loss of sinus rhythm during follow-up. Risk of atrial flutter demonstrates a late increase.

CONCLUSIONS

Ongoing loss of sinus rhythm and late peaks in the risk of atrial flutter and death necessitate continued follow-up.

Small-dose propofol by continuous infusion does not prevent postoperative vomiting in females undergoing outpatient laparoscopy

This study was designed to test the hypothesis that there is a direct prophylactic antiemetic effect of small-dose propofol given by continuous infusion. Sixty female patients undergoing outpatient laparoscopy under general anesthesia were randomized to receive, in a double-blind fashion, either a bolus of 0.1 mg/kg followed by a constant infusion of 1 mg.kg-1.h-1 of propofol or an equivalent volume of 10% Intralipid (placebo) beginning 30 min before induction of anesthesia and continuing until discharge from Stage I postanesthesia care unit (PACU). Anesthesia was induced and maintained in a standard fashion in all patients. The number of emetic episodes before and after discharge from PACU, nausea scores (11-point numerical scale), and time to discharge were evaluated. No significant differences between Intralipid and propofol were found for any of the outcome variables tested. While small-dose propofol is an effective adjuvant in reducing chemotherapy-induced emesis, we were unable to demonstrate any beneficial effect of propofol in reducing postoperative nausea and vomiting when used as the sole prophylactic medication in this patient population. Propofol may have a synergistic effect when administered with other antiemetics, or the specific antiemetic effect of propofol, if it exists, may be dose-dependent and the dose used in this study was below the efficacy threshold.

The Genome Sequence DataBase version 1.0 (GSDB): from low pass sequences to complete genomes

The Genome Sequence DataBase (GSDB) has completed its conversion to an improved relational database. The new database, GSDB 1.0, is fully operational and publicly available. Data contributions, including both original sequence submissions and community annotation, are being accomplished through the use of a graphical client-server interface tool, the GSDB Annotator, and via GIO (GSDB Input/Output) files. Data retrieval services are being provided through a new Web Query Tool and direct SQL. All methods of data contribution and data retrieval fully support the new data types that have been incorporated into GSDB, including discontiguous sequences, multiple sequence alignments, and community annotation.

Active parental consent in school-based research. An examination of ethical and methodological issues

To date, most school-based research has used passive parental consent. However, the Family Privacy Protection Act of 1995 aims to change these requirements. The proposed legislation requires written parental consent if minors are to be asked "sensitive" questions as part of any program or activity funded in whole or in part by the federal government. This act is representative of a growing trend toward restricting research involving minors. Whether or not this act is passed by Congress, two lines of concern are highlighted by this legislation. The first deals with ethical issues surrounding consent procedures. For instance, are parental rights compromised when active consent is not mandated? A second line of inquiry pertains to the effect of active consent procedures on response rates and sample bias. In this article, the authors discuss ethical issues surrounding passive and active consent procedures and then report response rates from two projects in which active consent procedures were implemented.

Sudden cardiac death in the adult with congenital heart disease

Preliminary results of a review of sudden cardiac death in the adult with congenital heart disease were presented at the Canadian Adult Congenital Heart (CACH) Network meeting during the Canadian Cardiovascular Society's annual meeting in October 1994. Of 125 patients who were known to have died, sufficient details were available for 92 to determine the circumstance of death. Sudden death occurred in 23 patients (estimated incidence 5.3 per 1000 patients followed per year) at an average age of 33.5 +/- 11.9 years. Surgical procedures included intracardiac repair in 12, palliative procedures in only six and no cardiac surgery in six. Nine patients with sudden death had Eisenmenger syndrome. Right or left ventricular abnormalities were present in 15 of 21 patients with premorbid echocardiographic evaluation. A prior history of ventricular arrhythmia was available in only three patients. Sudden death is a significant cause of mortality in adults with congenital heart disease. Determination of risk factors will be an important aspect of the patient database under development by the CACH Network.

Liver MR imaging: comparison of respiratory triggered fast spin echo with T2-weighted spin-echo and inversion recovery

BACKGROUND

The purpose of this study was to compare a fast spin-echo sequence combined with a respiratory triggering device (R. trig. FSE) with conventional T2-weighted spin-echo (CSE) and inversion recovery (STIR) sequences for the detection of focal hepatic lesions.

METHODS

We performed a prospective study of 33 consecutive patients with known or suspected hepatic tumors. All patients underwent R. trig. FSE, CSE, and STIR imaging at 1.5 T. Acquisition times were 10.7 min for the CSE sequence and ranged from 12 to 15 min for STIR and from 5 to 7 min for R. trig FSE. For each sequence, liver-spleen contrast-to-noise ratio (CNR) and liver-lesion CNR were determined quantitatively. Image artifact and sharpness were graded by using a four-point scale on each sequence by two independent readers. Both readers also independently identified hepatic lesions (up to a maximum of eight per patient). For patients with focal lesions, the total number of lesions detected (on each sequence) and the minimum size of detected lesions were also determined by each reader.

RESULTS

No significant difference was detected between R. trig. FSE and CSE or STIR in either liver-spleen CNR or liver-lesion CNR. R. trig. FSE images were equivalent to CSE and superior to STIR in sharpness (p < 0.01) and presence of artifact (p < 0.01). R. trig. FSE detected a higher number of lesions (reader 1: n = 92, reader 2: n = 86) than CSE (reader 1: n = 70, reader 2: n = 69) and a significantly higher number than STIR (reader 1: n = 71, reader 2: n = 76). Lesion structure was significantly better defined with R. trig. FSE than with STIR (p < 0.01) and CSE (p < 0.05).

CONCLUSIONS

Compared with CSE and STIR, R. trig. FSE produces hepatic images of comparable resolution and detects an increased number of focal hepatic lesions in a shorter period of time.

Autogenous soft-tissue procedures and osseointegrated alloplastic reconstruction: their role in the treatment of complex craniofacial defects

Between 1990 and 1994, twenty-seven patients with extraoral craniofacial defects were treated at the Craniofacial Osseointegration and Maxillofacial Prosthetic Rehabilitation Unit in Edmonton. Fourteen patients required management by a combination of alloplastic and autogenous techniques to optimize their reconstructive result. Autogenous soft-tissue procedures were performed almost twice as often in patients whose deformity was the result of trauma. Autogenous soft-tissue procedures included soft-tissue expansion, static facial slings, free and pedicled vascularized bone grafts, eyebrow reconstruction, brow lifts, and scar revisions. These reconstructive procedures are illustrated in three cases.

A selective and differential medium for Vibrio harveyi

A new medium, termed Vibrio harveyi agar, has been developed for the isolation and enumeration of V. harveyi. It is possible to differentiate V. harveyi colonies from the colonies of strains representing 15 other Vibrio species with this medium. This medium has been shown to inhibit the growth of two strains of marine Pseudomonas spp. and two strains of marine Flavobacterium spp. but to allow the growth of Photobacterium strains. Colonies displaying typical V. harveyi morphology were isolated from the larval rearing water of a commercial prawn hatchery with V. harveyi agar as a primary isolation medium and were positively identified, by conventional tests, as V. harveyi. This agar displays great potential as a primary isolation medium and offers significant advantages over thiosulfate-citrate-bile salts-sucrose agar as a medium for differentiating V. harveyi from other marine and estuarine Vibrio species.

Effect of rice cereal feedings on bone mineralization and calcium homeostasis in cow milk formula fed infants

OBJECTIVE

We conducted a prospective randomized, single-blinded clinical trial to test the hypothesis that intake of formula plus cereals between the ages of 16 and 26 weeks postnatally (as compared to formula alone) would lead to lower bone mineral content (BMC), higher parathyroid hormone (PTH) concentration, lower serum calcium (Ca), magnesium (Mg) and osteocalcin (OC); and increased continuous night sleep.

METHODS

At 16 weeks postnatally, 41 healthy, term infants were randomized to formula alone or formula and cereal.

RESULTS

We found no significant differences in growth or sleep pattern, nor in BMC between groups. Serum PTH concentration was significantly increased in the cereal group at 26 weeks.

CONCLUSION

We speculate that the increase in PTH is due to relative Ca deficiency or is responsive to increased phosphate load in the cereal group.

Supratentorial primitive neuroectodermal tumors in children

A retrospective review of 36 children diagnosed with a supratentorial primitive neuroectodermal tumor (PNET) at the Hospital for Sick Children was performed for the period 1970-1995. All children but one received their initial treatment at our institution. There were 18 males and 18 females and the median age at diagnosis was 35 months. Twenty-two PNETs were lobar, 3 were deep in the hemisphere, and 10 were located in the pineal region. One child presented with intracranial leptomeningeal disseminated disease. The tumors were mostly undifferentiated although 22 had some evidence of differentiation along one or more neuroepithelial lines. Five children had a biopsy, 24 had subtotal resection, and 7 had gross total resection. Twenty-six children had adjuvant radiotherapy and 13 had chemotherapy. At last follow-up 30 patients were dead and 6 were alive. The median survival was 23 months and the 2, 3, and 5 year survivals were 50%, 34%, and 18% respectively. All of the survivors received craniospinal radiation and 4 received chemotherapy. There was a statistically significantly worse survival in young children. There was a trend to better survival in children treated since 1984, and in children undergoing gross total resection. Because of the extremely poor survival, we recommended that all children undergo gross total resection followed by chemotherapy. For children older than 3 years of age craniospinal radiation should also be given.

The significance of heregulin in breast cancer tumor progression and drug resistance

The erbB-2 receptor plays an important role in the prognosis of breast cancer and is expressed at high levels in nearly 30% of tumors in breast cancer patients. While evidence accumulates to support the relationship between erbB-2 overexpression and poor overall survival in human breast cancer, understanding of the biological consequence(s) of erbB-2 overexpression remains elusive. The discovery of heregulin has allowed us to identify a number of related but distinct biological endpoints which appear responsive to signal transduction through the erbB-2/4 receptor. These endpoints of growth, invasiveness, and differentiation have clear implications for the emergence, maintenance, and/or control of malignancy, and represent established endpoints in the assessment of malignant progression in human breast cancer. Preliminary studies in vitro have shown that heregulin induces a biphasic growth effect on cells with erbB-2 overexpression. Interestingly, we observed that expression of heregulin correlates with a more aggressive/invasive, vimentin-positive phenotype in breast cancer cells lines. Therefore, we have postulated that heregulin is involved in breast cancer tumor progression. We have shown that heregulin induces in vitro chemoinvasion and chemotaxis of breast cancer cells as well as growth in an anchorage dependent and independent manner. Interestingly, a heregulin neutralizing antibody inhibits chemotaxis and results in cell growth inhibition and blockade of the invasive phenotype. Strikingly, genetically engineered cells which constitutively express heregulin demonstrate critical phenotypic changes that are associated with a more aggressive phenotype. Specifically, these cells are no longer dependent on estrogen for growth and are resistant to tamoxifen in vitro and in vivo, and moreover these cells metastasize to lymph nodes in athymic nude mice. These tumors appear to have lost bcl-2 expression as compared with the control tumors. In addition, presumably by activation/regulation of topoisomerase II, the heregulin-transfected cells become exquisitely sensitive to doxorubicin and VP-16. Clearly, mechanistic aspects of the erbB-2/4 and heregulin interaction need to be understood from a therapeutic standpoint which could provide additional insights into synergistic treatments for certain patients, or improve treatment regimens for a large number of women. The study of heregulin and its co-expression with erbB-2/4 receptor and the assessment of its involvement in the progression from the in situ stage of breast tumors to the invasive one will additionally increase the relevance of heregulin as a prognostic/diagnostic factor. We believe that our studies provide new insights into breast cancer diagnosis, prognosis, and treatment.

The role of primary chemotherapy in early breast cancer

Primary chemotherapy was first attempted in the early 1970s in an attempt to improve local control and survival in patients with large breast tumors. While it is now clear that primary chemotherapy can achieve high response rates and allow more conservative surgery, it is less apparent if survival is improved in these patients. It is logical, then, to consider moving this form of treatment to an earlier stage of disease in which the probability of resistant clones is less in patients with lower tumor burden. Many questions still remain unanswered in the evaluation of the role of primary chemotherapy in the treatment of early breast cancer: Is the best method of diagnosis fine needle aspiration or incisional biopsy? What diagnostic tests are important before chemotherapy? Can better conservative local treatment be achieved using the primary modality of chemotherapy? Is local control, disease response, and/or survival improved by using chemotherapy before local measures? Several important studies have been performed in the treatment of early stage disease with primary chemotherapy and will be discussed with these questions in mind. In addition, investigation of markers that predict response to chemotherapy may help us better select patients who would benefit from primary chemotherapy. Those patients who are determined to have a poorer prognosis would be candidates for novel investigational treatments.

Efficient plasmid DNA replication in Xenopus egg extracts does not depend on prior chromatin assembly

Small plasmids replicate efficiently in unfertilized Xenopus eggs provided they are injected before rather than after activation of the cell cycle. Here we use Xenopus egg extracts to test the hypothesis that efficient replication results from chromatin assembly prior to activation giving preloaded plasmids a head start toward the formation of a replicating pseudonucleus (Sanchez, J.A., Marek, D., and Wangh, L.J. (1992) J. Cell Sci. 103, 907-918). As in ovum, plasmid DNA preincubated in unactivated egg cytoplasmcytostatic factor extracts) replicate more efficiently after extract activation than does the same DNA added to the same extract after activation. Unlike in ovum, however, plasmids that replicate efficiently in vitro do not assemble into chromatin during preincubation and become topologically knotted instead. But even DNA knotting does not explain subsequent efficient replication. Also, plasmids preassembled into chromatin in vitro do not replicate efficiently in activated egg cytoplasm unless first preincubated in a CSF extract. We conclude that unactivated eggs contain replication-enhancing activities that can act independently of plasmid chromatin assembly and DNA topology. These postulated "preloading" factor(s) may be related to licensing factor, an activity that controls initiation of DNA replication in eukaryotic cells. The experimental conditions described here will permit characterization of preloading/licensing factor(s) in the context of a small plasmid substrate.

Health personnel: perceived differences in professional relationships and work role

This study questions the validity of the assumption that the workplace culture and experiences of health personnel are largely similar. The study compares nurses, occupational therapists, physiotherapists and speech therapists concerning their perceptions of professional issues within their own profession, and their perceptions of professional issues within the medical profession. Respondents completed a questionnaire containing 55 items referring to their own profession, and 55 items referring to the medical profession. Six scales were derived from the large survey instrument addressing issues regarding status/cohesiveness of the profession, professional relationships, and the role of the patient in health delivery in the respondent's profession, and in the medical profession. Nurses emerged as different to other health personnel on most dimensions. Few differences emerged among allied health professionals. Physiotherapists were more positive than occupational therapists about the status/cohesiveness of their profession, and regarded the contributions of the patient to health delivery as less important. Speech therapists did not differ significantly from occupational therapists on any dimension.

Conformational similarity and systematic displacement of complementarity determining region loops in high resolution antibody x-ray structures

Comparison of seven high resolution x-ray structures shows that the conformations of canonical complementarity determining region (CDR) loops, which are shared by these antibodies, are very similar. However, large spatial displacements (up to 2.7 A) of the essentially identical CDR loops become evident when the antibody beta-sheet frameworks, to which the loops are attached, are least-squares superposed. The loop displacements follow, and amplify, small positional differences in framework/loop splice points. Intradomain structural variability and, to a lesser extent, domain-domain orientation appear to cause the observed loop divergences. The results suggest that the selection of framework regions for loop grafting procedures is more critical than previously thought.

Ventricular tachycardia in ischaemic heart disease: insights into the mechanisms from cardiac mapping and implications for patient management

Ventricular tachycardia following myocardial infarction in man is thought to be due to a reentrant mechanism, with a zone of slow conduction forming the critical element of the return pathway. Cardiac mapping has helped characterize the anatomical and functional nature of reentrant pathways, and is used to direct antiarrhythmic surgery and catheter ablation. This review will explore how cardiac mapping has contributed to our understanding of reentrant ventricular tachycardia. The role of diastolic mapping will be emphasised, and the implications for future management of ventricular tachycardia discussed.

Coronary sinus morphology in patients with atrioventricular junctional reentry tachycardia and other supraventricular tachyarrhythmias

BACKGROUND

Coronary sinus access by electrode catheters is easier in patients with atrioventricular junctional reentry tachycardia (AVJRT) than in patients with other supraventricular tachyarrhythmias. The reason for this has not been addressed.

METHODS AND RESULTS

The size and shape of the proximal coronary sinus were measured in 15 patients with AVJRT and 14 control subjects after angiographic visualization. Coronary sinus dimensions, morphology, and angle of origin from the right atrium were measured. The proximal coronary sinus in patients with AVJRT was larger than in the control population. The mean ostium diameter was 12.2 +/- 2 mm compared with control dimensions of 8.5 +/- 1.5 mm, P = .00001. At a distance of 5 mm from the ostium, the coronary sinus measured 10.2 +/- 1.8 mm compared with 8.1 +/- 1.9 mm, P = .007. The dilatation persisted 10 mm into the coronary sinus, with a measurement of 9 +/- 1.4 mm compared with 7.6 +/- 2 mm, P = .04. In 73% of AVJRT patients, the proximal coronary sinus had the appearance of a wind sock. This morphology was seen only in 7% of control patients, in whom the coronary sinus was tubular (in 93%). There was considerable interindividual variability in the angle of origin.

CONCLUSIONS

The proximal coronary sinus in patients with AVJRT was significantly different from a control population. The ostium was 44% larger and remained more dilated to at least 10 mm from the ostium. The appearance was like a wind sock in AVJRT patients and tubular in the control patients. These findings may have important implications for arrhythmia pathogenesis in such patients.

Development and use of ELISA to quantify type II phospholipase A2 in normal and uremic serum

Previously we reported that uremic plasma contained eight times more phospholipase A2 (PLA2) activity than control plasma (Costello et al., Clin Chem 1990;36:198-200). That study, however, did not distinguish between various PLA2s that could contribute to the observed increase. Therefore, we developed a sandwich ELISA to specifically quantify serum type II PLA2. By ELISA, uremic sera contained significantly more type II PLA2 than control sera (median = 1025 micrograms/L, range = 52-3320 micrograms/L vs median = 9.2 micrograms/L, range = 4.6-17.5 micrograms/L; P = 0.002). When serum samples were incubated with 1-[14C]oleate-labeled autoclaved Escherichia coli, activity was increased 14.6-fold in uremic vs normal serum, with a median of 6.5 mumol/min per liter (range 1.1-16.3) vs a control median of 0.49 mumol/min per liter (range 0.32-0.60; P = 0.002). Thus, ELISA detects about eightfold more immunoreactive type II PLA2 in uremic serum than does enzymatic analysis. Evidently, the increase in PLA2 activity previously observed in uremic plasma is primarily due to increased concentrations of type II PLA2.

Endocardial mapping of ventricular tachycardia in the intact human ventricle. III. Evidence of multiuse reentry with spontaneous and induced block in portions of reentrant path complex

OBJECTIVES

This study was conducted to characterize the functional nature of the reentrant tract responsible for ventricular tachycardia due to ischemic heart disease.

BACKGROUND

A zone of slow conduction forming the return path is though to form a critical component of the reentrant mechanism in ventricular tachycardia. Despite its importance, detailed knowledge of the return path is rare in clinical studies.

METHODS

Multielectrode arrays were used intraoperatively to obtain unipolar and high gain bipolar recordings of left ventricular endocardium in patients undergoing map-directed surgical ablation of ventricular tachycardia. A total of 224 local electrograms were analyzed for each tachycardia.

RESULTS

Of 10 consecutive patients undergoing intraoperative cardiac mapping, detailed recording of the return tracts of eight ventricular tachycardias were obtained in three patients. The recordings demonstrated that return tracts can be complex and extensive, with multiple paths of entry and exit. Potential and actual alternate paths were observed. Spontaneous and induced block occurred within portions of the complex. Intermittent block in one of two paths of entry resulted in intermittent cycle length changes of the tachycardia without a change in configuration. Block in one exit path resulted in a shift to alternative exit paths, with dramatic changes in ventricular activation and tachycardia configuration. Termination of the tachycardia could result from block close to the entrant or exit portion of the return tract. Different tachycardias were seen to share common portions of a return tract.

CONCLUSIONS

These observations enlarge and extend our knowledge of the functional repertoire of complex reentrant tracts that occur in infarct-related ventricular tachycardia. The use of common portions of a reentrant tract by several tachycardias is confirmed. Utilization of alternate pathways can account for changes in configuration and cycle length. Spontaneous and induced block can occur at points of entry and exit in a reentrant tract and may identify optimal targets for ablation attempts. Further advances will require greater emphasis on diastolic activation mapping.

Interaction between erbB-receptors and heregulin in breast cancer tumor progression and drug resistance

The type I growth factor receptor family is increasingly recognized as important in the development and maintenance of breast cancer. The family currently consists of four closely related members: the epidermal growth factor receptor (EGF-R/erbB-1), erbB-2, erbB-3 and erbB-4. Putative ligands which bind directly to or indirectly activate erbB-2/3/4 have been characterized recently. This still growing family of EGF-related growth factors includes gp30, its homolog heregulin (HRG), the rat homolog neu differentiation factor (NDF), glial growth factors (GLIA), ARIA and a 50 kDa factor from COLO 16 cells. The understanding of the function, biology and interactions of these growth factor receptors and their ligands will have far-reaching implications for the prognosis and treatment of breast cancer. This review focuses on advances and future directions for further investigations intended to clarify the mechanism and significance of erbB/ligand interactions in breast cancer.

Development and use of ELISA to quantify type II phospholipase A2 in normal and uremic serum

Previously we reported that uremic plasma contained eight times more phospholipase A2 (PLA2) activity than control plasma (Costello et al., Clin Chem 1990;36:198-200). That study, however, did not distinguish between various PLA2s that could contribute to the observed increase. Therefore, we developed a sandwich ELISA to specifically quantify serum type II PLA2. By ELISA, uremic sera contained significantly more type II PLA2 than control sera (median = 1025 micrograms/L, range = 52-3320 micrograms/L vs median = 9.2 micrograms/L, range = 4.6-17.5 micrograms/L; P = 0.002). When serum samples were incubated with 1-[14C]oleate-labeled autoclaved Escherichia coli, activity was increased 14.6-fold in uremic vs normal serum, with a median of 6.5 mumol/min per liter (range 1.1-16.3) vs a control median of 0.49 mumol/min per liter (range 0.32-0.60; P = 0.002). Thus, ELISA detects about eightfold more immunoreactive type II PLA2 in uremic serum than does enzymatic analysis. Evidently, the increase in PLA2 activity previously observed in uremic plasma is primarily due to increased concentrations of type II PLA2.

Female adolescents of alcohol misusers: disordered eating features

Studies show that children of alcohol-abusing parents constitute an at-risk population. This study attempted to understand the impact of parental alcohol misuse on the disordered eating behaviors of their female adolescent children, based on a sample of 532 teenagers from alcohol-misusing parents in Minnesota. These female adolescents had significantly higher prevalence rates of all the seven eating disordered symptoms that were studied. The study also identified a few protective factors: Those who did not develop any of the disordered eating symptoms were more satisfied with their present weight. Further, they worried less about abuse from parents and perceived that their school personnel cared about them.

A comparison of various methods of collecting self-reported health outcomes data among low-income and minority patients

In a randomized trial of different data collection methods, we challenged the untested assumption that reliable data cannot be obtained from lower-income and/or minority patients by self-administered questionnaires. We tested three methods of data collection among a sample of lower-income and minority patients (n = 697) in Indianapolis at a site for the Type II Diabetes Patient Outcomes Research Team. The study included a questionnaire literacy screening instrument to assess patients' functional literacy. Based on their functional literacy, patients were randomized to one of three methods of data collection: mail-out/mail-back, hand-out/assisted, or the in-home interview. We constructed a tiered system for reassigning nonresponders to alternative methods of data collection, using the in-home interview as the fall-back strategy. We compared the response rates, item completion rates, and internal consistency reliabilities of self-reported health status measures between patients with and without literacy limitations and across the three methods of data collection. Patients with and without literacy limitations, across methods of data collection, provided high-quality data, as evidenced by high item completion rates (> 84%) and high reliability assessments (internal consistency reliability coefficients > .80) for each health status measure. As part of the tiered study design, nonresponders randomized to either the mail-out/mail-back or the hand-out/assisted method were interviewed. These patients were significantly older, had significantly lower education and income levels, and had significantly poorer self-reported visual function as compared with those who responded to the originally assigned method. We conclude that expensive, labor-intensive data collection methods, such as in-home interviews, are not necessary for many low-income, minority patients to generate high-quality, reliable health status data. Using appropriate screening instruments, those patient subgroups needing special help can be screening instruments, those patient subgroups needing special help can be identified and targeted for more expensive data collection methods. This tiered approach has policy implications for the cost, feasibility, and quality of data collection in health outcomes research.

Treating stress incontinence with the bladder neck support prosthesis

OBJECTIVE

To evaluate a vaginal device designed to support the bladder neck in women with urinary stress incontinence.

STUDY DESIGN

Thirty physically active women completed the study. All underwent urodynamic evaluation at baseline and with the best fitting Bladder Neck Support Prosthesis (Johnson and Johnson Medical Inc., Arlington, Texas) in place. A bladder diary was maintained before enrollment and during 4 weeks of device use. Outcome measures included changes in the number of reported incontinence episodes, urine loss on stress testing, and changes in urodynamic parameters with the device in place. Patient comfort, convenience, and satisfaction were also evaluated.

RESULTS

Thirty women completed the study. Twenty-five (84%) were dry with the device in place. Weekly incontinence episodes decreased from ten to three (p < 0.05). Significant changes in functional urethral length, pressure transmission ratio, and Q-tip angle were noted. No evidence of urethral obstruction was noted. The subjects found the device comfortable, easy to use, and convenient.

CONCLUSIONS

The bladder neck support prosthesis reduces stress incontinence symptoms significantly and normalizes urodynamic parameters like a colposuspension.

Clofazimine induced cardiotoxicity--a case report

A 66-year-old Indian male who had been treated for recurrent erythema nodosum leprosum with 300 mg of clofazimine per day for 11 months presented to hospital with a 4 week history of severe gastrointestinal upset. Soon after admission he developed several short runs of ventricular tachycardia with a morphology suggestive of torsade de pointe. The patient had a slightly low magnesium level which was corrected within 2 days; however, his rhythm disturbance persisted for 5 days despite management with intravenous lidocaine. His gastrointestinal symptoms abated 2 weeks after clofazimine was discontinued. Subsequent investigations showed that the patient had a keratopathy and myelin-type figures in his polymorphonuclear white cells similar to that seen with the cardiotoxic drugs chloroquine and amiodarone. It is postulated that clofazimine alone or in conjunction with electrolyte disturbance was responsible for the patient's cardiac arrythmia.

Profiles for the analysis of immunoglobulin sequences: comparison of V gene subgroups

A format for the structure-oriented analysis of immunoglobulin (Ig) variable region sequences is presented and applied to generate sequence profiles for comparison of heavy- and light-chain subgroups. The profile allows simultaneous evaluation of sequences and structural information and can be used for a number of different applications.

Photoactive terthiophenes: the influence of serum on anti-HIV (human immunodeficiency virus) activities

A number of carboxylic acid derivatives of the photoactive terthiophene, alpha-terthienyl, were found to possess impressive UVA-dependent activity against the human immunodeficiency virus, HIV-1; but only when assayed in the absence of serum, indicating that the latter contained interfering components. Good antiviral activity required a high rate of singlet oxygen production, in accordance with previous observations on thiophenes.

Large-scale preparation and biochemical characterization of a new high purity factor IX concentrate prepared by metal chelate affinity chromatography

Metal chelate affinity chromatography on copper-charged Chelating Sepharose has been used to purify a factor IX concentrate from 4,000- to 5,000-kg pools of human plasma, with an overall yield of 194 IU/kg. Unwanted proteins and solvent-detergent reagents added to inactivate lipid-enveloped viruses were removed during the chromatographic step. The freeze-dried product was > 80% pure factor IX with a mean specific activity of > 160 IU/mg protein. The concentrate showed no evidence of clotting factor activation by in vitro tests for potential thrombogenicity or by direct assay for activated factor IX. The concentrate did not exhibit proteolytic activity against a range of synthetic peptide chromogenic substrates. Full functional factor IX activity was retained and there was no evidence of protein degradation. Metal chelate affinity chromatography therefore appears to present less physicochemical challenge to the protein than other factor IX purification methods, while allowing the preparation of a clinical factor IX concentrate at a large scale.

Fetal lateral ventricles: reassessment of normal values for atrial diameter at US

PURPOSE

To assess the normal range of cerebral ventricular atrial diameters during the second and third trimesters of pregnancy.

MATERIALS AND METHODS

The transverse diameter of the atrium of the lateral ventricle was prospectively measured in 739 consecutive antenatal ultrasound examinations by positioning electronic calipers on the luminal margins of the ventricular wall, perpendicular to the long axis of the ventricle.

RESULTS

The mean ventricular atrial diameter for the combined group of all 739 studies was 5.4 mm +/- 1.2 (standard deviation). The transverse diameter of the ventricular atrium did not progressively increase with advancing gestational age. All fetuses younger than 17 menstrual weeks had ventricular atrial diameters less than 8 mm. Four fetuses had ventricular diameters of 10 mm or greater.

CONCLUSION

A reasonable upper limit of normal for transverse atrial diameter for gestational age of 25 weeks and above appears to be 10 mm. Prior to 25 weeks, diameters over 8 mm are unusual in the healthy fetus and signal the need for a detailed evaluation of fetal anatomy.