Dichotically presented emotionally intoned words produce laterality differences as a function of localisation task

Two-syllable words (burden; furrow; mantle; ration) each spoken in happy, angry, sad, and neutral tones of voice were dichotically paired. For each presented word-pair, subjects were asked to localise ("left"; "right") or reject the presence of one pre-specified word on one block of trials and one pre-specified emotional tone on a second trial block. Right ear advantages (REAs) indicated by a superior hit rate averaging 9.6% were found for all words. Left ear advantages (LEAs) averaging 15.2% were obtained for emotional intonation, with additional evidence of differences between emotion categories. Results are discussed in terms of complementary hemispheric roles for linguistic and prosodic analysis.

The regulatory locus cinRI in Rhizobium leguminosarum controls a network of quorum-sensing loci

N-(3-hydroxy-7-cis-tetradecenoyl)-L-homoserine lactone (3OH, C14:1-HSL) is a quorum-sensing signalling molecule produced by Rhizobium leguminosarum. It is unusual in that it inhibits the growth of several strains of R. leguminosarum and was previously known as 'small bacteriocin'. The cinRI locus responsible for the production of 3OH,C14:1-HSL has been characterized; it is predicted to be on the chromosome, based on DNA hybridization. The cinR and cinI genes are in different transcriptional units, separated by a predicted transcription terminator. CinR regulates cinI expression to a very high level in a cell-density dependent manner, and cinI expression is positively autoregulated by 3OH,C14:1-HSL, the only identified N-acyl homoserine lactone (AHL) produced by CinI. No other AHLs were identified that strongly induced cinI expression. Mutation of cinI or cinR abolishes the production of 3OH,C14:1-HSL and also reduces the production of several other AHLs. This is thought to result from the expression of three other AHL production loci being affected by the absence of 3OH,C14:1-HSL. AHLs produced by these other loci include N-hexanoyl- and N-octanoyl-L-homoserine lactones and, unexpectedly, N-heptanoyl-L-homoserine lactone (C7-HSL). The expression of the rhiI gene on the symbiotic plasmid is greatly reduced in a cinI mutant, and the major regulatory effect appears to be mediated at least in part as a result of an effect on expression of RhiR, the regulator of rhiI. Thus, cinR and cinI appear to be at the top of a regulatory cascade or network that influences several AHL-regulated quorum-sensing loci. The expression of cinI-lacZ fusions is significantly reduced (but not abolished) when the symbiosis plasmid pRL1JI is present, resulting in a reduction in the level of 3OH,C14:1-HSL produced. Mutation of cinI had little effect on growth or nodulation. However, plasmid transfer was affected, and the results obtained indicate that 3OH,C14:1-HSL produced by either the donor or the recipient in mating experiments can stimulate transfer of pRL1JI.

Histopathological features of hepatitis C in renal transplant candidates [see comment]

BACKGROUND

Although hepatitis C virus (HCV) infection is common in renal transplant candidates, its clinical significance remains unclear in this population. Little detailed information is available about the histological severity of HCV infection in these patients. We evaluated the liver biopsy features of chronic HCV in a large population of renal transplant candidates and investigated associations between histopathological changes and host- and virus-related factors.

METHODS

Thirty-seven patients seropositive for anti-HCV with chronic renal failure (CRF) referred to UCLA Medical Center for kidney or kidney/liver transplantation during the period 1992-1997 were included. HCV genotype and viral load were measured. A multivariate analysis by logistic regression model was performed: age, gender, race, HCV load and genotype, CRF level, aspartate and alanine aminotransferase activity, duration of HCV infection, underlying nephropathy, and alcohol abuse were independent variables; liver histology score was assumed a dependent variable.

RESULTS

Liver disease was present in all HCV-infected patients. Logistic regression analysis revealed that histological damage was (P = 0.0017) independently associated with the CRF level; the severity of liver disease, as shown by univariate analysis, being significantly higher in CRF patients not requiring dialysis than among dialysis population. All patients on dialysis showed mild or moderate necroinflammatory activity; the majority (22/28 = 79%) of these individuals had fibrosis, three (3/28 = 11%) dialysis patients had established cirrhosis. Thirty-one (84%) of 37 patients were tested by polymerase chain reaction, 25 (81%) patients had detectable HCV RNA in serum, the mean HCV load among viremic patients was 10.9x10(5) copies/ ml. The most frequent HCV genotypes were la (8/24 = 33%) and 1b (7/24 = 29%), followed by genotype 2b (3/24 = 12%).

CONCLUSIONS

Pathological changes on liver biopsy were observed in all HCV-infected patients awaiting renal transplantation. The severity of histologic damage observed on liver biopsy was less in dialysis than predialysis CRF patients. All dialysis patients had mild or moderate necroinflammatory activity; fibrosis was frequent with 11% of them having cirrhosis. The HCV viral load was rather low; no relationship between liver histology changes and virological features of HCV or aminotransferase activity was apparent. Further studies with repeat liver biopsies after kidney transplantation to observe the evolution of HCV-related liver disease after immunosuppressive therapy are indicated. We suggest including liver biopsy in the evaluation of the HCV-infected renal transplant candidate.

Measurement of oilfield chemical residues in produced water discharges and marine sediments

During oil production, significant quantities of water are produced with the crude oil which, following treatment on the platform, are discharged to the marine environment. This produced water contains residues of oilfield chemicals added by the platform operators to the topside processing equipment to aid oil-water separation and mitigate operational problems. The levels of oilfield chemicals entering the marine environment via this route were investigated using electrospray ionisation tandem mass spectrometry (ESI-MS/MS) and wet chemical analysis techniques. The generic nature of different chemical types was shown by ESI-MS/MS. Studies of the partitioning behaviour of corrosion inhibitors and demulsifiers between the oil and water phases of the produced fluids suggested corrosion inhibitors partitioned primarily into the aqueous phase and demulsifiers into the oil phase. This was reflected in levels observed in produced water although, in the case of a corrosion inhibitor, lower than expected concentrations were measured. Scale inhibitors were discharged with the produced water at their dosing concentrations. Marine sediments in the proximity of two North Sea oil platforms contained low levels of benzalkonium quaternary ammonium salts (0.74-10.84 ng/g), typical corrosion inhibitor chemicals.

Prednisone withdrawal in kidney transplant recipients on cyclosporine and mycophenolate mofetil--a prospective randomized study. Steroid Withdrawal Study Group

BACKGROUND

Prospective randomized trials have shown a reduced rate of acute rejection (AR) in mycophenolate mofetil-treated kidney transplant recipients. We hypothesized that this increased protection from AR could allow successful prednisone (P) withdrawal in cyclosporine/mycophenolate mofetil/P-treated recipients.

METHODS

A multicenter, prospective, randomized, double-blind trial of P withdrawal at 3 months post-transplant was initiated. Entry criteria were: primary transplant, adult, no AR by 90 days, mycophenolate mofetil dose > or =2 g/day, cyclosporine dose = 5-15 mg/kg/ day, P dose = 10-15 mg/day. Study participants were randomized to have P tapered over 8 weeks (beginning at 3 months posttransplant) to 0 vs. 10 mg/day. Prestudy power analysis determined 500 recipients should be randomized for 80% statistical power to test equivalence of the primary endpoint, AR, or treatment failure at 1 year posttransplant. By design, the study was to be stopped if interim data precluded reaching equivalence. An established data safety monitoring board monitored the study.

RESULTS

After 266 patients were enrolled, the patient enrollment was stopped (after safety monitoring board review) because of excess rejection in the P withdrawal group. The Kaplan-Meier estimate of the cumulative incidence of rejection or treatment failure within 1 year posttransplant (+/-95% confidence interval) for the maintenance group was 9.8% (4.4%; treatment failure, 14.9%); for the withdrawal group, 30.8% (21.0%; 39.3%). Treatment differences in the distribution of time to event were highly significant (P = 0.0007). Of note, risk was higher in blacks (39.6%) versus nonblacks (16.0%) (P<0.001). At 1 year post-transplant, there was no difference between groups in patient or graft survival. For the patients with functioning grafts at 6 months posttransplant, withdrawal patients had lower cholesterol (P = 0.0005), had higher creatinine (P = 0.03), and were less likely to use antihypertensives (P = 0.001). These differences persist to 1 yr posttransplant.

CONCLUSIONS

We conclude that for recipients on cyclosporine/mycophenolate mofetil/P with no AR at 90 days, the chance of developing subsequent AR is small; if P is tapered and withdrawn, the risk increases (but the majority remain free of acute and chronic rejection). After withdrawal, the risk of AR is different for blacks versus nonblacks. Withdrawal patients had a lower cholesterol level and less need for antihypertensives.

Evaluation of pre- and posttransplant donor-specific transfusion/cyclosporine A in non-HLA identical living donor kidney transplant recipients. Cooperative Clinical Trials in Transplantation Research Group

BACKGROUND

The beneficial effects of donor specific transfusion (DST) have become controversial in the cyclosporine era. This study was performed to evaluate the potential benefits of a new protocol for administering DSTs in the perioperative period.

METHODS

Non-HLA identical living donor kidney transplant recipients were randomized prospectively to control or to receive a DST 24 hr before transplant and 7-10 days posttransplant. All patients received similar immunosuppression according to protocol.

RESULTS

The protocol had 212 evaluable patients (115 transfused and 97 control). There were no differences in 1- and 2-year graft and patient survival, causes of graft failure, incidence and types of infection, repeat hospitalization, or the ability to withdraw steroids. Immunological hyporesponsiveness (by mixed lymphocyte culture) occurred more frequently in transfused patients (18%) than controls (3%) (P = 0.04). Blood stored for > or =3 days was associated with fewer early rejections than blood stored < or =2 days. Overall, class II antigen mismatches were associated with more rejection episodes than class I antigen mismatches. However, transfused patients, but not control patients, with more class I antigen mismatches were more likely to have rejections.

CONCLUSIONS

Administration of DSTs by the method described had no practical influence on patient or graft survival for up to 2 years. However, donor-specific hyporesponsiveness was more common in transfused patients (18 vs. 3%). Longer follow-up will be needed to determine whether DST will be associated with long-term benefit.

Early ascorbic acid depletion is related to the severity of acute pancreatitis

BACKGROUND

Ascorbic acid (AA) is an important endogenous antioxidant in plasma and has been shown to be decreased at the time of hospital admission in patients with acute pancreatitis. The aim of this study was to determine whether plasma AA concentration continues to decrease after admission and whether the extent of decrease is related to the severity of pancreatitis.

METHODS

Consecutive patients with mild (n = 62) and severe (n = 23) acute pancreatitis had plasma AA concentration measured on the day of recruitment and on days 2 and 5 by high-performance liquid chromatography.

RESULTS

The plasma AA concentration in patients with acute pancreatitis was significantly less than that in normal volunteers on days 0, 2 and 5 (P < 0.0001) and this was more marked in those with severe disease. There was a decrease in plasma AA concentration from day 0 to day 2 in patients with mild (P < 0.0001) and severe (P = 0.0005) pancreatitis, and from day 2 to day 5 in patients with severe pancreatitis (P = 0.023).

CONCLUSION

Endogenous plasma AA continues to decrease over the first 5 days in hospital and the extent is related to the severity of acute pancreatitis. Presented to a meeting of the Australasian Surgical Research Society, Auckland, New Zealand, August 1995 and published in abstract form as Aust N Z J Surg 1996; 66: 243

Effects of the Medicare Alzheimer's Disease Demonstration on caregiver burden and depression

STUDY QUESTION

Does improved access to community-based care reduce perceived burden and reported levels of depression among primary caregivers of people with dementia?

DATA SOURCES

Baseline and periodic caregiver interviews with participants in the Medicare Alzheimer's Disease Demonstration. Client and caregiver attributes and caregiver outcomes such as depression and burden scores were among the measures.

STUDY DESIGN

Applicants to the demonstration (all voluntary) were randomly assigned into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. (The actual monthly entitlement varied among the eight demonstration communities due to regional cost differences and inflation adjustments over the four-year demonstration period.)

DATA COLLECTION

A total of 5,307 eligible individuals received a baseline assessment at the time of application to the demonstration and at least one semi-annual reassessment. Clients and their caregivers were periodically reassessed producing a total of 20,707 observations.

PRINCIPAL FINDINGS

Persons in the treatment group had a high exposure to case management and a greater likelihood of community service use relative to those in the control group. Treatment group membership was associated with statistically significant, but very small reductions in caregiver burden (in four of eight sites) and depression (three of eight sites) over a 36-month tracking period. These findings are not sustained with all cases combined, or among a higher-resource demonstration model considered separately.

CONCLUSIONS

Both the fact that these programmatic differences did not translate into substantial treatment group reductions in caregiver burden or depression, and the consistency of these findings with those of prior case management evaluations suggest the need to reformulate this programmatic intervention into areas not previously tested: 24-hour care, crisis intervention, coordination with primary care, or chronic disease management.

Are smoke-free policies implemented and adhered to at sporting venues?

OBJECTIVE

This study investigated the level of implementation of and adherence to smoke-free policies in two major sporting venues in Perth.

METHOD

Smoking status and attitude toward the smoke-free policies in the venues were determined in a random sample of spectators as they entered each venue. An observational study of randomly selected non-smoking seated areas in each venue was conducted on the same day to determine compliance with smoke-free policies. A butt-count was conducted to validate these observations.

RESULTS

There was a high level of both awareness and agreement with the smoke-free policies, however, this level of agreement was higher in non-smokers than smokers. The results of the observational study and the butt-count indicated that the policies were implemented and there was a high level of adherence with the smoke-free policy at both venues.

CONCLUSION

The results provide further evidence that smoke-free policies in sporting venues are both supported and adhered to by spectators.

IMPLICATIONS

The implementation of the smoke-free policies at venues is highly effective in protecting non-smokers from the effects of environmental tobacco smoke.

Analysis of quorum-sensing-dependent control of rhizosphere-expressed (rhi) genes in Rhizobium leguminosarum bv. viciae

The rhi genes of Rhizobium leguminosarum biovar viciae are expressed in the rhizosphere and play a role in the interaction with legumes, such as the pea. Previously (K. M. Gray, J. P. Pearson, J. A. Downie, B. E. A. Boboye, and E. P. Greenberg, J. Bacteriol. 178:372-376, 1996) the rhiABC operon had been shown to be regulated by RhiR and to be induced by added N-(3-hydroxy-7-cis-tetradecenoyl)-L-homoserine lactone (3OH, C14:1-HSL). Mutagenesis of a cosmid carrying the rhiABC and rhiR gene region identified a gene (rhiI) that affects the level of rhiA expression. Mutation of rhiI slightly increased the number of nodules formed on the pea. The rhiI gene is (like rhiA) regulated by rhiR in a cell density-dependent manner. RhiI is similar to LuxI and other proteins involved in the synthesis of N-acyl-homoserine lactones (AHLs). Chemical analyses of spent culture supernatants demonstrated that RhiI produces N-(hexanoyl)-L-homoserine lactone (C6-HSL) and N-(octanoyl)-L-homoserine lactone (C8-HSL). Both of these AHLs induced rhiA-lacZ and rhiI-lacZ expression on plasmids introduced into an Agrobacterium strain that produces no AHLs, showing that rhiI is positively regulated by autoinduction. However, in this system no induction of rhiA or rhiI with 3OH,C14:1-HSL was observed. Analysis of the spent culture supernatant of the wild-type R. leguminosarum bv. viciae revealed that at least seven different AHLs are made. Mutation of rhiI decreased the amounts of C6-HSL and C8-HSL but did not block their formation, and in this background the rhiI mutation did not significantly affect the expression levels of the rhiI gene or rhiABC genes or the accumulation of RhiA protein. These observations suggest that there are additional loci involved in AHL production in R. leguminosarum bv. viciae and that they affect rhiI and rhiABC expression. We postulate that the previously observed induction of rhiA by 3OH,C14:1-HSL may be due to an indirect effect caused by induction of other AHL production loci.

Vascular surgical society of great britain and ireland: limb outcome following failed femoropopliteal polytetrafluoroethylene bypass for intermittent claudication

BACKGROUND: Femoropopliteal (FP) bypass using polytetrafluoroethylene (PTFE) is still considered by many surgeons to be a reasonable procedure for severe intermittent claudication (IC) without limb-threatening ischaemia. The consequences of FP graft failure were examined. METHODS: Over 8 years, 54 patients had 55 FP grafts (that subsequently occluded) inserted for severe IC (42 PTFE and 13 vein grafts) above (30) or below (25) the knee. There were no operative deaths. During the same interval a total of 191 FP grafts were placed, 100 of which were vein grafts. Patient demography and risk factor analysis was similar for both groups. RESULTS: Nineteen patients required amputation subsequent to a failed graft, all of these following PTFE grafts. Mean time to occlusion was 12.2 (range 0-79) months. For PTFE grafts, the mean(s. d.) ankle index rose from 0.51(0.14) to 0.95(0.15) after operation but fell to 0.25(0.15) after occlusion, confirming a highly significant deterioration from preoperative levels, which was not seen in vein graft occlusions. CONCLUSION: Long-term FP bypass patency rates with vein are superior to those obtained with PTFE. Failed PTFE grafts show a significant deterioration in pressure indices compared with preoperative values. FP grafts for IC carry an intrinsic risk of limb loss which is much greater when vein is not used (P < 0.001).

Complementary health practitioners' attitudes, practices and knowledge related to women's cancers

OBJECTIVE

To document the attitudes, practices and knowledge of 3 groups of complementary practitioners (naturopathic doctors, chiropractors and massage therapists) regarding women's cancers in general and ovarian cancer specifically.

DESIGN

A mailed survey questionnaire was followed by a reminder card and a second mailing of the questionnaire.

SETTINGS

National samples were obtained for naturopathic doctors and chiropractors. The massage therapist sample was drawn from Ontario only because of the absence of a national listing of massage therapists.

MAIN OUTCOME MEASURES

Practitioners reported response to patients' suspicious symptoms. Practitioners' perceptions of patients' motivations for seeking treatment. Practitioners' satisfaction with interactions with conventional practitioners. Practitioners' perceptions of their role in the care of women at risk of, or diagnosed with, cancer. Practitioners' perceptions of their knowledge regarding women's cancers. Practitioners' knowledge specific to ovarian cancer.

RESULTS

A total of 894 completed questionnaires were returned, providing a response rate of 56%. The vast majority of practitioners who saw women with symptoms possibly related to cancer referred them to a family physician or a cancer specialist. Motivations that practitioners most frequently heard expressed by women seeking complementary treatments were "maximizing quality of life," "seeking natural approaches to healing" and "looking to stay well when disease is in remission." Most respondents were dissatisfied with patient-related communication with both family physicians and cancer specialists. The majority of complementary practitioners indicated that they have an important role to play in the postdiagnostic care of women with cancer. Considerable interest was expressed in further education concerning ovarian cancer.

CONCLUSIONS

Whereas the professions reached through this survey differ in important ways from each other, they share an interest in being involved in the care of women with cancer, as well as an enthusiasm for the development of continuing professional education programs to help them better serve their clients.

Muscle fibre atrophy in critically ill patients is associated with the loss of myosin filaments and the presence of lysosomal enzymes and ubiquitin

Muscle wasting and weakness are common features of patients with critical illnesses, and may impair their recovery. This study examines whether cytoskeletal and contractile proteins are damaged, and which proteolytic mechanisms might be involved, in the muscle fibre atrophy or necrosis associated with the acute myopathy of critically ill patients. Ninety-eight muscle biopsies were obtained by the conchotome method from 57 critically ill patients and examined morphometrically and by immunohistochemical labelling. Sequential biopsies showed a mean reduction in fibre cross-sectional areas of 3-4% per day. More intense immunolabelling for desmin was seen in the smaller fibres of 52% of the biopsies, while immunolabelling for dystrophin, actin and myosin heavy chains was maintained. Myosin ATPase activity was weak in the smaller fibres in some biopsies, and electron microscopy showed the loss of myosin filaments in atrophic fibres. These changes suggest that loss of the filamentous structure of myosin, without degradation of the immunolabelled epitopes, leads to the collapse of the intermyofibrillar desmin network. Fibres with abnormal desmin labelling showed increased cathepsin B, lysozyme and ubiquitin immunolabelling. Nine cases showed increased immunolabelling for heat shock protein 72. The changes in desmin immunolabelling were more prevalent in patients with higher APACHE II scores on admission, but were not related to other clinical features. The results indicate that fibre atrophy is associated with myosin filament depolymerization and the presence of several proteolytic enzymes. In our study, these changes occurred in patients who were critically ill but who did not receive large doses of steroids or neuromuscular blocking agents.

Capitated risk-bearing managed care systems could improve end-of-life care

Capitated or salaried managed care systems offer an important opportunity to provide high quality, cost-effective end-of-life care. However, capitated healthcare delivery systems have strong incentives to avoid patient populations in need of such care. Care currently provided at the end of life in fee-for-service practice is commonly deficient, with high rates of avoidable pain and other burdens. Only hospice offers a better track record, yet access to hospice is limited, and length of stay is short. Traditional staff- or group-model managed care plans, with their emphasis on prevention, patient education, cost efficiency, service coordination, and integrated provider networks, present a dynamic set of conditions and organizational structures that would support real change. Advantages derived from managed care systems providing quality end-of-life care include coordinated care across delivery sites, interdisciplinary teams, integrated services, and opportunities to develop innovative care programs, service arrays, utilization controls, and accountability for care standards. We propose a special comprehensive system of managed care, which we call MediCaring, for seriously ill persons nearing the end of life. MediCaring would encompass the best elements of palliative care within a managed care structure: comprehensive, supportive, community-based services that meet personal and medical needs, a focus on patient preferences, symptom management, family counseling, and support. Other programs, such as hospice, have shown that continuity and coordinated care, financed through a capitated payment and directed at a special population, are both feasible and effective. There are obstacles to improving care at the end of life. Managed care systems, like most of medical care, have largely ignored the terminally ill patient. Current financing arrangements make it financially undesirable for insurers to recruit or retain the very sick; very ill patients can be costly over a prolonged time. In addition, inertia and habit inhibit change, and there are few criteria by which to judge whether care at the end-of-life is "good." Nevertheless, capitated or salaried managed care systems committed to enhanced end-of-life care seem well positioned to achieve it if payment reimbursements were revised to encourage this end.

Microvascular endothelial activation in the skeletal muscles of patients with multiple organ failure

The relationship between microvascular damage and the presence of muscle fibre atrophy and necrosis has been investigated in skeletal muscle biopsies taken from 57 patients with multiple organ failure. Immunohistochemical studies showed no loss of capillaries and no luminal thrombosis, while neutrophil leucocytes were more prevalent in the patients' biopsies than in controls. Deposition of the complement membrane attack complex (C5-9MAC) in capillaries was observed in 41% of cases. Endothelial activation was suggested by an increased intensity of expression of ICAM-1, and by an increased proportion of capillaries expressing P selectin and E selectin, although this was not directly associated with neutrophil accumulation. Endothelial swelling was present in many biopsies with 38% of the biopsies having larger capillary profiles on immunohistochemical labelling for von Willebrand factor (vWF), thrombomodulin and CD34, and on Ulex europaeus agglutinin 1 binding. Endothelial swelling was confirmed by image analysis and morphometric evaluation of capillary ultrastructure, however, the capillary luminal area was not reduced as the capillaries were dilated. Increased vWF labelling was associated with C5-9MAC deposition and with fibre necrosis, but the vascular changes were not related to fibre atrophy nor to clinical indices of the severity of the patients' illness. The results suggest that microvascular damage and ischaemia may not be major factors in the pathogenesis of muscle fibre damage in multiple organ failure, but that endothelial activation is a common occurrence. The variability in the patterns of markers of endothelial activation, and the small proportion of capillaries affected, may reflect the complexity of the endothelial response to circulating or locally produced cytokines.

Interleukin-2-receptor blockade with daclizumab to prevent acute rejection in renal transplantation. Daclizumab Triple Therapy Study Group

BACKGROUND

Monoclonal antibodies that block the high-affinity interleukin-2 receptor expressed on alloantigen-reactive T lymphocytes may cause selective immunosuppression. Daclizumab is a genetically engineered human IgG1 monoclonal antibody that binds specifically to the alpha chain of the interleukin-2 receptor and may thus reduce the risk of rejection after renal transplantation.

METHODS

We administered daclizumab (1.0 mg per kilogram of body weight) or placebo intravenously before transplantation and once every other week afterward, for a total of five doses, to 260 patients receiving first cadaveric kidney grafts and immunosuppressive therapy with cyclosporine, azathioprine, and prednisone. The patients were followed at regular intervals for 12 months. The primary end point was the incidence of biopsy-confirmed acute rejection within six months after transplantation.

RESULTS

Of the 126 patients given daclizumab, 28 (22 percent) had biopsy-confirmed episodes of acute rejection, as compared with 47 of the 134 patients (35 percent) who received placebo (P=0.03). Graft survival at 12 months was 95 percent in the daclizumab-treated patients, as compared with 90 percent in the patients given placebo (P=0.08). The patients given daclizumab did not have any adverse reactions to the drug, and at six months, there were no significant differences between the two groups with respect to infectious complications or cancers. The serum half-life of daclizumab was 20 days, and its administration resulted in prolonged saturation of interleukin-2alpha receptors on circulating lymphocytes.

CONCLUSIONS

Daclizumab reduces the frequency of acute rejection in kidney-transplant recipients.

Atherosclerotic renovascular disease in the elderly: angioplasty with stenting versus reconstructive surgery

We reviewed our experience of surgical and radiological intervention in 43 patients between 1987 and 1994 with angiographic renovascular disease. We retrospectively compared the effect of angioplasty with stenting versus reconstructive surgery on renal function and blood pressure in those patients with significant atherosclerotic renovascular stenosis. Twenty patients with moderate/non ostial stenosis (less than 60% stenosis) and two with fibromuscular displasia underwent renal angioplasty only. Indications for intervention were refractory hypertension (n = 20), flash pulmonary oedema (n = 8) and/or renal salvage (n = 31). All patients were hypertensive. Angioplasty with stenting was performed in ten patients, (2 female, 8 male), mean age 69 years, 9 with bilateral disease. Plasma creatinine was greater than 240 mumol/L in seven patients. A unilateral procedure was performed in 9 patients. Unilateral reconstructive surgery was performed in eleven patients (4 female, 7 male), mean age 63 years. Plasma creatinine was greater than 240 mumol/L in eight patients. Ten had bilateral disease. In the angioplasty/stenting group there were three technical failure. The mortality rates in the angioplasty/stenting group and surgical group were 10% and 27% respectively. Fifty-one and 165 patient months had elapsed in the stenting and surgical groups respectively. Blood pressure fell in each group, mean decrease in mean arterial pressure (MAP) 16 mmHg (p = 0.025) and 30 mmHg (p < 0.01) respectively. Improvement or stabilisation of renal function was achieved in 67% and 91% of cases respectively. Two surgical patients were able to discontinue haemodialysis. The two methods of treatment appear to be equally effective in lowering blood pressure. Reconstructive surgery offers greater improvement in renal function with the possibility of withdrawal of dialysis, at the expense of a higher mortality rate.

Lumbar-hip flexion motion. A comparative study between asymptomatic and chronic low back pain in 18- to 36-year-old men

STUDY DESIGN

The amount of lumbar and hip flexion and the relative contribution within movement during standing forward bending was recorded on a group of asymptomatic men and a group of men with a history of chronic low back pain.

OBJECTIVES

To compare the relative contribution of the hip and lumbar spine to forward bending in the two groups.

SUMMARY OF BACKGROUND DATA

The hips and lumbar spine both contribute to the forward bending motion, and an aberrant pattern of contribution in one or both regions could be related to the presence of chronic low back pain.

METHODS

Thirty-two white men aged 18-36 years (15 with chronic low back pain and 17 asymptomatic) were assessed using a three-dimensional motion analysis system that allowed uninterrupted forward bending.

RESULTS

The men with chronic low back pain demonstrated a significant reduction in the mean total range and mean maximum lumbar flexion relative to the asymptomatic group. Mean hip flexion was not significantly different. Data analysis for 120 degrees of gross flexion revealed a subgroup of men with chronic low back pain with a significant decrease in hip flexion.

CONCLUSIONS

When assessing the relative motion of the lumbar spine and hips in standing forward flexion, there was measurable difference between asymptomatic men and a group of chronic low back pain patients. In particular, two subgroups of individuals with chronic low back pain appeared; one moved relatively similarly to the asymptomatic group, whereas the other sub-group demonstrated reduced hip mobility. These findings indicate the importance of assessing the lumbar and hip flexion motion in chronic low back pain patients to determine if a movement abnormality is present.

Locally applied transdermal nitrate patches for the treatment of ischaemic rest pain

Patients with severe peripheral vascular disease may suffer considerable pain which can be difficult to control with conventional analgesics. We sought to assess the analgesic effect of transdermal nitrate patches in such patients. A prospective trial was performed in 15 patients with ischaemic rest pain due to atherosclerotic peripheral vascular disease. Pain control and oral analgesic requirement were assessed. Fourteen of the 15 had a good or moderate response to the nitrate patches with a subsequent reduction in oral analgesic requirement. The patients with primarily small vessel disease had the greatest improvement in pain control. We conclude that topical nitrates may be used to provide rapid and safe analgesia for patients with ischaemic rest pain.

Helical CT angiography for examination of living renal donors

OBJECTIVE

This prospective study was intended to determine if helical CT arteriography plus conventional radiography is sufficiently accurate to replace and less costly than excretory urography and conventional renal arteriography, the techniques currently used to examine living renal donors.

SUBJECTS AND METHODS

Patients underwent CT arteriography with a helical CT scanner. Conventional radiographs were obtained during the pyelographic phase to evaluate the urothelium. Findings on CT arteriograms were compared with findings on conventional arteriograms and at surgery.

RESULTS

Of 57 patients who underwent CT arteriography, 46 also underwent conventional arteriography and 40 underwent surgery. For those 46 patients, we found agreement between results of CT arteriography and conventional arteriography in 89% of kidneys. For those 40 patients, we found agreement between results of CT arteriography and findings at surgery in 90% of kidneys and agreement between results of conventional arteriography and findings at surgery in 87% of kidneys. Of the 57 patients, six (11%) had findings on CT angiograms that precluded further consideration for donation.

CONCLUSION

Eight to ten percent of renal arteries are not seen on renal arteriograms when compared with findings at surgery. Our results indicate that CT arteriography is as accurate as conventional arteriography at revealing the number of vessels that perfuse and drain the kidneys and can replace conventional arteriography. Use of CT angiography plus conventional radiography instead of excretory urography and conventional arteriography can result in a 35-50% reduction in cost of the imaging studies in potential renal donors.

Cholesterol embolisation. A lethal complication of instrumentation of an aneurysmal aorta: a case report

A case of cholesterol embolisation (CE) following instrumentation of an aneurysmal aorta is presented. The patient developed myalgias, livedo reticularis in the buttocks, suprapubic area and legs, that progressed to patchy gangrene and renal failure. Maximum conservative management including heparin, iloprost and haemodialysis was ineffective, in keeping with previous reports that there is no known therapy for CE. The aetiology, presentation, treatment and prognosis of this condition is discussed. With the ever increasing use of endovascular treatment of abdominal aortic aneurysms, this complication may be more frequently encountered.