Ambulatory use of high-dose intravenous morphine for severe pain

A case is presented that describes the use of an intravenous morphine infusion to treat severe pain in an outpatient setting. The patient had severe pain secondary to tumor involvement of the brachial plexus. Morphine was administered as a concentrated solution (50 mg/ml), using an autosyringe (model AS-2F) via a Hickman catheter. The dose was titrated to pain relief. A dose of 200-250 mg/h was required.

Psychosocial antecedents of narcissistic personality syndrome

The purpose of this study was to assess the psychosocial antecedents of narcissistic personality syndrome as defined in DSM-III. 60 undergraduate students completed the Constantinople Inventory of Psychosocial Development as a measure of Erikson's stages of ego-development, a measure of narcissism derived from the explicit diagnostic criteria presented in DSM-III, and the Machiavellian V scale. In support of both Kohut's and Erikson's theories, the results indicated that there were stage-specific predictors of the different dimensions of narcissistic personality syndrome.

Middle-ear mechanics in the CF-bat Rhinolophus ferrumequinum

The acoustic vibrations of the eardrum at the umbo and of the stapes have been measured in the greater horseshoe bat. The displacement amplitude response of the eardrum shows a second-order low-pass characteristic, typical of a lumped mass and stiffness system with a resonance frequency of about 55 kHz. The effective mass was calculated to be about 8 micrograms, and the specific stiffness 40 X 10(6) dyne/cm3, which is one hundred times greater than guinea pig. The measured level ratio appears to be greater (3X - 5X) than the geometric ratio (2X) probably due to flexing of the manubrium. The umbo-stapes phase lag exceeds 1 cycle at high frequencies, suggesting a system of at least four reactances. This is not consistent with the relatively slight change in lever ratio with frequency. One possibility for reconciling the two results is that the distributed mass and stiffness of the ossicles act as a transmission line for transverse vibrations. There is no evidence for a sharply peaked middle-ear response (although it is more sharply tuned than some species), nor for resonant absorption by the cochlea in the region of 83 kHz - the 'constant' frequency of this bat. The eardrum shows theoretically optimal matching to the air at 55 kHz and is reasonably efficient from 15 kHz to at least 110 kHz.

Basilar membrane tuning properties in the specialised cochlea of the CF-bat, Rhinolophus ferrumequinum

The greater horseshoe bat has greatly expanded frequency mapping, and morphological specialisations, in the first half turn of its cochlea and a sudden transition to normal mapping. Amplitude and phase of vibration have been measured on various structures in the expanded and normal regions and have not revealed any sharply tuned responses. Amplitudes are much lower than those found in other species and frequently show a deep notch in the 77-84 kHz region. The high-frequency cut-off frequencies are tonotopically organised but deviate from the Bruns map, so that hair-cell tuning appears to occur at a frequency at which basilar membrane vibration is small. In the basal region, phase differences were frequently found between the inner and outer parts of the basilar membrane. These appear to be due to interaction between two components of motion and are probably not indicative of a further filtering mechanism. There is no evidence for reflection of the travelling wave at the transition.

Phase II trial of mitoguazone in patients with advanced squamous cell carcinoma of the head and neck

We used mitoguazone (500 mg/m2 iv weekly, with 50-mg/m2 escalations weekly as tolerated) to treat 22 patients with squamous cell carcinoma of the head and neck which recurred after initial therapy. Nine of 22 (11%) patients responded: two had complete responses and seven had partial responses. Gastrointestinal toxicity and anemia were commonly seen. We conclude that mitoguazone is active in squamous cell carcinoma of the head and neck and should be incorporated into phase III trials.

Aseptic technique as a safety precaution in the preparation of antineoplastic agents

A subject of concern among personnel working in cancer chemotherapy treatment areas is the occupational hazard posed by the antineoplastic drugs. A review of the literature reveals a number of proposed safety precautions, including glove boxes, vertical air-flow hoods, masks, gloves, gowns, and routine medical examinations. The concept of using aseptic technique as a safety precaution is presented, with particular emphasis on the importance of maintaining negative pressure in vials. We also discuss the use of ultraviolet light to detect antineoplastic drug spills in a working environment and as a training and evaluation procedure.

Evidence for a cochlear origin for acoustic re-emissions, threshold fine-structure and tonal tinnitus

Delayed acoustic waves have been measured in the sealed ear canal in response to click and tone-burst stimuli. The response shows compressive nonlinearity, evidence for 'active' processing, and frequency tuning. At low sound levels group and phase delays correspond, and represent about 15 waves delay for the mid-frequency region. Frequency positions of pressure peaks and dips for continous tone stimulation can be predicted from the phase delays and persist well below threshold. Fine-structure in the audiogram is also related to these irregularities. Hydrostatic pressure, induced by body tilt, can eliminate audiogram fine-structure and reve rse the positions of peaks and dips for inverted body positions. This is interpreted as due to changes of internal reflection from the middle ear caused by acoustic impedance changes. Tinnitus can be induced by this inverted body posture, can be measured objectively in certain cases, and demonstrates properties such as synchronisation and beating with an external signal. These findings support the view of Kemp that the phenomena of acoustic re-emission, threshold fine-structure, and tinnitus are interrelated and originate within the cochlea.

Model for cochlear echoes and tinnitus based on an observed electrical correlate

Experiments in cat have revealed evidence of temporal correspondence between round-window recorded electrical potentials and delayed acoustical responses in the sealed ear canal at low sound levels. This would be difficult to explain if the acoustic response contained an appreciable component of delay due to a reverse travelling wave. An alternative interpretation is offered in which outer hair cells are assumed to undergo periodic volumetric changes correlated with their electrochemical activity. These volume changes would act on, and be divided between, the oval window, giving acoustic reemission and the basilar membrane, giving a secondary travelling wave. Owing to the active nature of the hair cell, the output is potentially greater than the input, so that when the secondary travelling wave exceeds the initial one, the amplitude will build up and continuous oscillation occurs, giving 'tinnitus'.

Subconjunctival corticosteroid therapy complicated by hyperinfective strongyloidiasis

A 57-year-old man was treated for a corneal ulcer with a penetrating keratoplasty, followed by six weeks of a regimen of 4 to 8 mg of dexamethasone injected subconjunctivally daily. Before therapy, he was clinically well and 10% eosinophils were noted on his differential white blood cell count. He developed a gastric peptic ulcer with hemorrhage and severe strongyloidiasis of the stomach and duodenum that worsened as the ulcer responded to medical therapy. The strongyloidiasis resulted in physiologic gastric outlet obstruction by decreasing gastrointestinal motility. There was evidence of hyperinvasive and disseminated strongyloidiasis, complicated by meningitis and Serratia marcescens bacteremia. He survived and received thiabendazole treatment for strongyloidiasis, which was successful. Subconjunctival corticosteroids caused a systemic effect that changed asymptomatic Strongyloides infection into hyperinvasive strongyloidiasis.

Reduction of plasma renin activity by inhibition of the fatty acid cyclooxygenase in human subjects: independence of sodium retention

We carried out the present studies to determine whether the suppression of plasma renin activity (PRA) that follows inhibition of prostaglandin (PG) synthesis can be dissociated from the sodium-retaining effects of these drugs. In an initial investigation we studied the effect of indomethacin on PRA in normal subjects in balance on a 10 mM Na+ diet to prevent Na+ retention. Under these experimental conditions indomethacin did not lower PRA even though the fatty acid cyclooxygenase was inhibited, as indicated by a greater than 70% reduction in the major urinary metabolite of prostaglandin E (PGE-M). Sodium depletion leads to enhanced sympathetic activity. We therefore studied the effect of indomethacin on a group of subjects in 10 mM Na+ balance in whom the effect of increased beta-sympathetic activity was blocked by the administration of propranolol. In this group, indomethacin caused 65% suppression of PGE-M and had no effect on Na+ balance, but reversibly reduced PRA in the supine and upright positions by 84% and 70%, respectively. In normal subjects in 10 mM Na+ balance, the isoproterenol-induced increase in PRA also was unaffected by indomethacin. These data establish that inhibition of the cyclooxygenase can result in a reduction of PRA that is independent of changes in Na+ balance or beta-sympathetic tone.

Saralasin infusion in the recognition of renovascular hypertension

Saralasin, an angiotensin II antagonist, was infused into 49 patients with renal artery stenosis, 10 patients with essential hypertension and normal renal arteriograms, and five patients with "low-renin essential hypertension." Renal venous renin and differential renal function studies were used to assess the functional significance of arterial stenoses. "Response" to saralasin, evidenced by a fall in blood pressure during infusion, occurred in no patients with "low renin" hypertension and in only 20% of patients with normal renal arteriograms. In contrast, saralasin "response" occurred in more than 80% of patients with renal artery stenosis and lateralizing functional studies and 100% of cases of "proven" renovascular hypertension (cure or improvement of hypertension after operative treatment). We suggest that saralasin infusion might be a valuable screening test for the recognition of renovascular hypertension.

The value of breast screening in women less than fifty years of age

In the four years our Breast Cancer Detection Demonstration Project has been receiving patients, 5,810 women under the age of fifty have been examined. Our findings definitely indicate screening of asymptomatic women by xeromammography is of advantage in this group whose greatest cause of death is cancer of the breast; 71.8% of their cancers were found by xeromammography. Of these 43.8% had in situ cancer and only 12.5% of those cancers found had axillary spread. This group should have a five-year cure rate of 87.1% rather than 63% as is the experience of unscreened women. The absorbed rads averaged 0.4632 to each breast per year. At the end of five years this would cause an estimated increase in risk from 7% to 7.162%. To increase survival rate by 24.1% against a theoretical increased risk of 0.16% is definitely worthwhile.

Studies of the fate of tyramine in dogs: the effect of monoamine oxidase inhibition, portafemoral shunt and coronary artery ligation on the kinetics of tyramine

Radioimmunoassay of tyramine (T) was used to investigate the kinetics of T in plasma of three groups of dogs (control, pretreated with monoamine oxidase inhibitor and those with portafemoral shunt). Furthermore, the influence of coronary artery ligation on the T content of the heart was studied. After i.v. administration of T-HCl (1.7mumol/kg, 0.3 mg/kg), there was a rapid initial decline in T plasma levels with an average T 1/2 of 4.3 minutes. Similar results were obtained in experiments in which the same dose of T-3H was used. There was a 10-fold difference between 3H and T concentrations. Pretreatment with a monoamine oxidase inhibitor resulted in a decrease in T metabolism as reflected by changes in pharmacokinetic parameters (estimated area under the curve AUC, 8166 vs. 1000 ng x min x ml-1, P less than .001; total body clearance, BC, 35.7 vs. 285 ml/min/kg. P less than .005). Similar results were obtained in dogs with portafemoral shunt. Coronary artery ligation resulted in an increase in the level of T in the infarction [1.2. +/- 0.3 (S.E.M.) ng/ml] compared to those of adult volunteers.