Injury in West Virginia: a statewide survey

OBJECTIVE

To determine an estimate of the period prevalence of medically attended injury in West Virginia via a statewide random telephone survey.

METHODS

A statewide random telephone survey, the West Virginia Social Indicator Survey (WVSIS), was modified to incorporate questions regarding the incidence and mechanisms of injury. The WVSIS is periodically conducted on a representative cross-section of West Virginians to gather information about their social and economic conditions as well as to monitor change in the quality of their lives over time.

RESULTS

Of the 1,498 households interviewed, 412 (28%) reported having sustained injuries for which medical care had been obtained. This translates to a conservative estimate of 231,000 medically attended injuries within West Virginia in 1993. The average age of those injured was 35 years. Falls were the most frequently reported causes of injury, with motor vehicle crashes being the second most reported cause. Most injury victims (70%) were treated in an ED. Most respondents (67%) were able to suggest ways in which the injuries might have been avoided. Only 37% of the respondents with children < 13 years of age reported ever having received injury prevention information from a physician. The most commonly reported physician advice concerned childhood poisoning (34%).

CONCLUSIONS

Injury questions added to ongoing state health surveillance surveys provide valuable insight into population-based injury rates and potential preventive measures.

Colonic mucins in ulcerative colitis: evidence for loss of sulfation

Colonic tissue obtained at surgery from control individuals and patients with ulcerative colitis was used to isolate mucins and to prepare mucin glycopolypeptides by pronase digestion. These were compared with mucins labelled with [35S] sulfate and [3H]-glucosamine after organ culture tissue samples from the same patients. A significant loss of mucin sulfation was detected in the colitis patients by both metabolic labelling and chemical analysis of the glycopolypeptides. A change in the size distribution of purified mucin oligosaccharides fractionated on BioGel P6 after release by beta-elimination was seen in both radiolabelled and non-labelled colitis mucins compared with controls. Amino acid analysis of the glycopolypeptides showed a close similarity to the expected ratio of serine:threonine:proline for MUC2 and did not vary between control and colitis groups. Analysis of the mucins confirmed > 90% purity in the labelling experiments, characteristic behaviour on density gradient centrifugation and agarose gel electrophoresis in control and ulcerative colitis groups and differences in sulfation and turnover at various sites in the normal colon.

The emotional Stroop task and psychopathology

Attentional bias is a central feature of many cognitive theories of psychopathology. One of the most frequent methods of investigating such bias has been an emotional analog of the Stroop task. In this task, participants name the colors in which words are printed, and the words vary in their relevance to each theme of psychopathology. The authors review research showing that patients are often slower to name the color of a word associated with concerns relevant to their clinical condition. They address the causes and mechanisms underlying the phenomenon, focusing on J.D. Cohen, K. Dunbar, and J.L. McClelland's (1990) parallel distributed processing model.

2,5-Diarylisothiazolone: novel inhibitors of cytokine-induced cartilage destruction

A series of 2,5-diarylisothiazolones is reported that inhibit the IL-1 beta-induced breakdown of bovine nasal septum cartilage in an organ culture assay. The synthesis and preliminary SAR of these compounds are described. These compounds represent a novel, nonpeptide lead series approach to the mediation of the chronic cartilage breakdown associated with arthritic disease. These compounds are relatively resistant to reductive metabolism by liver microsomal preparations and appear to inhibit cartilage breakdown by interfering with the proteolytic activation of matrix metalloproteinases.

Near drowning in frigid water: a case study of a 31-year-old woman

A 31-yr-old woman demonstrated intact neuropsychological functioning after being submerged for at least 30 minutes in icy cold water. Following submersion, the patient received CPR for approximately 1 hr. Eight hours after submersion, the patient's temperature was 31 degrees C (87 degrees F). She remained nonresponsive for 2 days after the accident. Extensive neuropsychological testing was completed 3 mo after the accident with no objective or subjective deficits evidenced. This case of hypothermically mediated neuroprotection from anoxia in an adult supports the need for further research on the putative neurophysiological mechanisms invoked and the potential for application of clinically induced hypothermia in the acute management of other types of cerebral insults.

Recurrent corneal ulcerations associated with smokeable methamphetamine abuse

PURPOSE

We studied a case of chronic, recurrent, bilateral, corneal ulcerations associated with smokeable methamphetamine abuse, commonly known as "ice," in an otherwise healthy 31-year-old woman.

METHODS

Every few months the patient had recurrent corneal ulcerations. Each time, she was hospitalized and treated successfully with topical antibiotics.

RESULTS

Even though she had undergone numerous formal attempts at drug rehabilitation, she continued to have relapses, and ulceration recurred only during periods of smokeable methamphetamine abuse.

CONCLUSION

Illicit use of smokeable methamphetamine may result in corneal ulceration.

Development of a model system to compare cell separation methods for the isolation of fetal cells from maternal blood

Three major methods have been described for the isolation of fetal cells from maternal blood: fluorescence-activated cell sorting (FACS), immunomagnetic beads, and magnetic-activated cell sorting (MACS). To date, no study has directly compared fetal cell recovery using each of these methods. Here we describe our system using a "model' male fetal cell mixed into female peripheral blood mononuclear cells. Fetal cell yields and purities were assayed by a quantitative polymerase chain reaction (qPCR) using chromosomes Y- and 7-specific sequences. Fetal cell recovery was investigated by selection of CD71+ cells or depletion of CD45+ cells. Our data demonstrated variation in fetal cell recovery for all methods tested, although CD71+ selection by FACS gave the best and most consistent results.

Incidence and distribution of injury among schoolchildren aged 11-15

OBJECTIVES

To measure the incidence and age and sex distribution of self reported experience of injuries in the preceding 12 month period among a representative national sample of Scottish schoolchildren and to validate the findings against other data sources.

DESIGN

Self completed questionnaire administered in schools, April-June 1994.

SUBJECTS

4710 pupils aged 11, 13, and 15 years drawn from a representative sample of 270 classes with returns from 224 classes (83.2% completion rate).

OUTCOME MEASURES

Number, type, site, and severity of injuries reported.

RESULTS

41.9% of pupils reported a medically attended injury, with injury incidence significantly higher in boys than in girls. Using the abbreviated injury scale (maximum abbreviated injury score) one third of injuries were either moderate or severe.

CONCLUSION

The incidence and distribution of self reported injury is consistent with estimates based on other data sources thus confirming the utility of this method of injury surveillance in this age group.

A cognitive science perspective on kindling and episode sensitization in recurrent affective disorder

A cognitive science analysis of the interaction between psychological stress and the neurobiology of affective illness highlights a number of mechanisms relevant to the study of recurrence in major depressive disorder. It builds on observations previously offered by Post (1992) regarding the importance of kindling and sensitization effects in determining activation of neural structures, and proposes a model of knowledge structure activation that follows similar parameters. Vulnerability to depressive relapse/recurrence is determined by the increased risk of particular negative patterns of information processing being activated in depressed states. As is found in studies of kindling and behavioural sensitization, the likelihood of cognitive patterns being activated is dependent on the frequency of past usage, and increased reliance on these patterns of processing makes it easier for their future activation to be achieved on the basis of increasingly minimal cues. This model suggests that the processes related to relapse/recurrence and episode onset may not be isomorphic and, as such, treatments that emphasize relapse prevention strategies should take this distinction into account.

Prefrontal cortex and working memory for spatial response, spatial location, and visual object information in the rat

In the first experiment, rats were trained on a working memory task for a spatial response (right-left turn) information using a delayed matching-to-sample procedure. Following lesions of the medial prefrontal cortex (MPF), which includes anterior cingulate and medial precentral cortex, there was a profound working memory deficit even at the shortest delay. In the second experiment, rats were trained on a working memory task for spatial location information using a delayed matching-to-sample procedure. Following lesions of the MPF, there was only a mild working memory deficit, whereas following dorsal hippocampal lesions there was a profound working memory deficit even at the shortest delay. In the third experiment, rats were trained on a working memory task for visual object information using a delayed nonmatching-to-sample procedure. Following lesions of the MPF, there were no working memory deficits, whereas following lesions of the prelimbic and infralimbic cortex there was a profound working memory deficit even at the shortest delay. The results suggest that different neural subregions of the prefrontal cortex mediate working memory for specific attribute information.

Delusional phenomenology--dimensions of change

Although the application of cognitive techniques to both the measurement and modification of delusional beliefs has recently been developed in more theoretical detail (e.g. Chadwick & Lowe, 1994, Behaviour Research and Therapy, 32, 355-367) there has not been an effort to examine the variability of delusional phenomenology across time. In the present study we report on the treatment of 6 individuals who fulfilled DSM-III-R (American Psychiatric Association, 1987) criteria for Delusional Disorder and who received cognitive therapy targeted specifically on the single symptom of their delusional belief(s). Single-case time-series methodology was used to examine the associations between different aspects of delusional phenomenology through baseline and intervention study phases. Belief maintenance factors were found to be significantly associated with conviction in all 3 individuals who responded to the intervention. Negative behaviours, affect associated with the belief, preparedness to talk to others about the belief and insight were associated with conviction in some individuals but not others. Preoccupation and acting on the belief were aspects of delusional phenomenology that were found to systematically vary independent of belief conviction. The results support a multidimensional view of delusional phenomenology and the process of change during cognitive intervention.

An Integrated Approach for Maximising Local and Scientific Knowledge for Land Management Decision-Making in the New Zealand High Country

This paper describes the development of a process to facilitate the identification and introduction of sustainable land management practices in the high country of New Zealand. The process was designed to gather and structure community knowledge (both local and scientific) into a single, accessible decision support system (DSS). The development and provision of appropriate, and user-friendly monitoring tools is supported. An outline is given of how this integrated system can be used to integrate monitoring with adaptive management. Special reference is made to how this process is used as a large-scale ecological 'experiment', to enhance continually the knowledge base available for land use decision-making in the South Island high country of New Zealand.

Development of an emergency department-based injury surveillance system

STUDY OBJECTIVE

To describe the development of an emergency department-based injury surveillance system, to describe the problems encountered, and to briefly describe the data output and potential applications.

METHODS

Within our university-based hospital system and Level I trauma center register, injury data currently exist on all ED patients. Over a 1-year period, these data sets were linked with our ED log using the hospital identification number and date of service as the key merge variables. Elements in our data set included demographic information, ED-related variables, and codes for nature of injury and circumstances of injury. Data files for 1 month were inspected manually to validate the success of the merger. Problems encountered in developing the system were summarized.

RESULTS

A manual review of 1 month of data files from our hospital system, trauma register, and ED log revealed that the records of more than 97% (2,802) of 2,878 injury patients seen in our ED had additional data attached after the merger. No errors of commission were found, but errors of omission occurred. The barriers that were encountered during the development of this injury surveillance system are described.

CONCLUSION

Hospital data can be linked to the ED log to create an injury surveillance system that captures valuable information on patients admitted and discharged from the ED.

Comparative effects of selective cyclooxygenase 1 and cyclooxygenase 2 inhibitors on myeloperoxidase and 3 alpha-hydroxysteroid dehydrogenase

The clinical efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) is believed to result from the ability of these compounds to inhibit the inducible isoform of the enzyme cyclooxygenase, COX2. The gastrointestinal and renal side effects of these drugs, in contrast, are thought to relate to their ability to inhibit the constitutive isozyme, COX1. There is structural and pharmacological evidence that suggests that NSAIDs may also inhibit two unrelated enzymes, myeloperoxidase (MP) and 3 alpha-hydroxysteroid dehydrogenase (3 alpha-HSD), potentially with untoward consequences for the patient. Our laboratories have been investigating a new structural class of potential COX inhibitors, the tri-cyclic aromatics. In this study we have examined the inhibitory potency of selected compounds for the enzymes human COX1, human COX2, human MP, and rat liver 3 alpha-HSD. The compounds selected span a range of COX isoform selectivities, from specific for COX2 to selective for COX1 only, and include three representative tri-cyclic aromatics. We found that compounds within the tri-cyclic aromatic class do not act as potent inhibitors of either myeloperoxidase or 3 alpha-HSD. These results demonstrate the unique inhibitor selectivity that can be achieved with the tri-cyclic aromatics. Examples of COX1 selective, and COX2 selective inhibitors within this structural class are presented.

Alteration and recovery of the spatial orientation of the collagen network of articular cartilage in adolescent rabbits following intra-articular chymopapain injection

We have used polarized light (POL) to monitor changes in the organization of the articular cartilage collagen network and matrix proteoglycans (PGs) after intra-articular injection of chymopapain (CP). POL viewing of sirius red stained sections revealed a loss of normal birefringence suggesting an apparent collapse of the collagen network following intra-articular CP. After 21 days, knees injected with 2.0 mg CP showed no return of normal birefringence, however, normal birefringence was noted in knees injected with only 0.2 mg CP. POL viewing of toluidine blue stained sections revealed a severe loss of matrix PGs followed by PG restoration in animals injected with 0.2 mg CP. The most important inference from the data is that articular cartilage can recover from enzyme-induced alterations in the spatial collapse of its fibrillar network. This is an important finding since it has often been inferred that damage to the collagen network leads invariably to progressive articular cartilage destruction.

The specificity of autobiographical memory and imageability of the future

Three studies examined whether the specificity with which people retrieve episodes from their past determines the specificity with which they imagine the future. In the first study, suicidal patients and nondepressed controls generated autobiographical events and possible future events in response to cues. Suicidal subjects' memory and future responses were more generic, and specificity level for the past and the future was significantly correlated for both groups. In the second and third studies, the effect of experimental manipulation of retrieval style was examined by instructing subjects to retrieve specific events or summaries of events from their past (Experiment 2) or by giving high- or low-imageable words to cue memories (Experiment 3). Results showed that induction of a generic retrieval style reduced the specificity of images of the future. It is suggested that the association between memory retrieval and future imaging arises because the intermediate descriptions used in searching autobiographical memory are also used to generate images of possible events in the future.

Cystic hydrops and spontaneous perforation in Fuchs' superficial marginal keratitis

PURPOSE

We studied a case of Fuchs' superficial marginal keratitis in which cystic corneal hydrops developed in one eye, and spontaneous corneal perforation occurred in the fellow eye.

METHODS

The patient underwent bilateral annular corneoscleral lamellar patch grafts for tectonic support.

RESULTS

The patient had an uncomplicated postoperative course and visual acuity of 20/25 bilaterally.

CONCLUSION

Stromal loss in Fuchs' superficial marginal keratitis may be severe enough to result in cystic corneal hydrops. Patients with this disorder should be counseled regarding the possibility of corneal perforation.

Pilot radioimmunotherapy trial with 131I-labeled murine monoclonal antibody CC49 and deoxyspergualin in metastatic colon carcinoma

An antimouse immune response is invariable following administration of murine monoclonal antibody (mAb), precluding effective multidose therapy. In advanced colorectal cancer patients, we carried out a pilot study with multiple doses of 131I-labeled CC49 administered with deoxyspergualin (DSG), an immunomodulator, to determine its effect on immune response. Cumulative toxicity and efficacy were also evaluated. Six patients with tumor-associated glycoprotein 72-expressing colorectal cancer were treated i.v. with 15 mCi/m2 131I-labeled to 20 mg mAb CC49 biweekly, along with concurrent DSG 200 mg/m2 daily for 5 days, for a maximum of four courses. None had received prior murine mAbs. All patients had targeting of radioactivity to known tumor sites following initial infusion. Four of six patients received all four courses of therapy, three without any acute side effects. In these patients, there was no change in serum clearance with variable tumor targeting following repeat infusions. Two patients had </= grade II anaphylactoid reactions, which were treated without sequelae. One of these had faster serum clearance of radioactivity following repeat infusions of 131I-labeled CC49. Human antimouse antibody titers in all patients were significantly less compared to concurrent times in patients receiving CC49 without DSG (P < 0.05). There was no correlation between the human antimouse antibody titer and serum clearance or tumor targeting of 131I-labeled CC49. There were no clinical responses. We concluded that multiple doses of murine antibody 131I-labeled CC49 can be safely administered with no change in serum or whole-body kinetics in 50% of patients treated biweekly. DSG may reduce the human immune response to the murine mAb.

Memory for magnitude of reinforcement: dissociation between the amygdala and hippocampus

Rats were trained on a successive delayed conditional discrimination task measuring memory for magnitude of reinforcement. In the study phase of the task, the rats were given one of two cereals. One cereal contained 25% sugar; the other 50% sugar. One of the two cereals was always designated the positive stimulus and the other the negative stimulus. This study phase was followed by the test phase in which the rat was shown an object which covered a food well. If the rat was given the negative stimulus in the study phase of the trial, no food reward was placed beneath the object. Whenever the positive stimulus was presented a food reward was available beneath the object. Performance was measured as the latency to uncover the food well. After reaching criterion level, the rats were given amygdala, hippocampal, or control lesions. Amygdala-lesioned rats showed significant deficits in performance, whereas no long-term deficits were observed for the hippocampal-lesioned groups even at longer retention delays. In additional experiments, it was shown that amygdala-lesioned, like normal, rats had similar taste preferences. Finally, normal and hippocampal-, but not amygdala-, lesioned rats transferred readily to different cereals containing 25% or 50% sugar. Thus, it appears that the amygdala, but not the hippocampus, plays a significant role in explicit data-based or working memory for affect information based on magnitude of reinforcement.

Intracapsular prostatic omentalization: a new technique for management of prostatic abscesses in dogs

Twenty dogs with abscessation of the prostate gland were treated by celiotomy, drainage, and digital exploration of the gland through bilateral capsulectomy wounds. Omentum was introduced through the capsulectomy wounds and packed into the abscess cavities around the prostatic urethra. Most dogs were discharged from the hospital within 48 hours of the surgery. Long-term resolution of the problem (no recurrence within 12 months) was achieved in 19 dogs. One dog had recurrent abscessation that was managed by the placement of dependent Penrose drains. Temporary tube cystostomy was performed postoperatively in one dog for the management of transient dysuria. One dog with septic peritonitis resulting from preoperative abscess rupture was managed by concurrent open peritoneal drainage. Intracapsular prostatic omentalization was a simple and effective means of managing prostatic abscessation with minimal requirement for postoperative hospitalization of the patient. The frequency of serious complications, including postoperative urinary incontinence, was low.

The emergency department log as a simple injury-surveillance tool

STUDY OBJECTIVE

To describe the development of an injury-surveillance system based on the emergency department log.

SETTING

An ED with 40,000 visits annually, tertiary care center.

PARTICIPANTS

All patients to our ED during a 6-month period. ED logs are used to collect basic information such as demographics, chief complaint, mode of arrival, and disposition. Our log was modified for collection of injury-related information such as whether the ED visit was because of an injury and, if so, the mechanism of injury. A list of 16 mechanism-of-injury codes was developed on the basis of review of existing literature and on a 1-month review of injuries in our population. The ED log data were entered into a database, and descriptive analysis was performed.

RESULTS

A list of mechanisms of injury was developed that, when implemented, was successful in coding 93% of injured patients in our ED population. The expansion of the ED log for collection of injury data required minimal training and cost. An example of the data obtained is presented to demonstrate the type of information available. Of the 18,742 patients, the ED log identified 5,067 patients (27%) as having been injured. Most were male (2,972 of 5,067 [59%]), and most were between 15 and 40 years of age (2,857 of 5,067 [61%]). Common mechanisms of injury included falls (907 of 5,067 [19%]), transportation (706 of 5,067 [15%]), cuts or punctures (332 of 5,067 [7%]), sports (323 of 5,067 [7%]), and assaults (245 of 5,067 [5%]).

CONCLUSION

With minimal training and cost, the ED log can be adapted for collection of injury data on all patients seen in the ED.

The relationship between premorbid neuroticism, cognitive dysfunction and persistence of depression: a 1-year follow-up

In a previous report of patients with unipolar major depressive disorder, we found that deficits in autobiographical memory predicted depression levels over a 7-month interval. This follow-up examined predictors of recovery as defined by a period of 8 weeks with no or minimal symptoms of depression and examined the extra predictor variable, neuroticism. In a sample of 21 patients, episode duration was significantly correlated with high levels of premorbid neuroticism, dysfunctional attitudes and overgeneral autobiographical memories produced in response to emotionally negative cue words. When severity of depression was partialled out, high N score was significantly but independently correlated with each of these cognitive variables. The implication of these attitudinal and information processing biases were explored.

The alpha isoform of protein kinase C inhibits histamine-stimulated adenylate cyclase activity in a particulate fraction of the human gastric cancer cell line HGT-1

The isoform of protein kinase C responsible for the inhibition of histamine-stimulated adenylate cyclase by the phorbol ester, 12-O-tetradecanoylphorbol 13-acetate (TPA), has been investigated in a particulate fraction prepared from the human gastric cancer cell line HGT-1. The alpha and epsilon isoforms of protein kinase C were detected in HGT-1 cells and in a 40,000 x g particulate fraction by immunoblotting procedures. The inhibitory effect of TPA on histamine-stimulated adenylate cyclase was enhanced by the presence of Ca2+, but decreased in a concentration-dependent manner by anti-peptide antibody to protein kinase C alpha, but not to protein kinase C epsilon. Addition of Ca2+ and TPA to the 40,000 x g particulate fraction stimulated the phosphorylation of the protein kinase C substrate myelin basic peptide 4-14. Protein kinase C alpha is probably the isoform responsible for inhibition of histamine-stimulated adenylate cyclase in HGT-1 cells.

Isolation of a protein target of the FKBP12-rapamycin complex in mammalian cells

The immunosuppressive drug, rapamycin, interferes with an undefined signaling pathway required for the progression of G1-phase T-cells into S phase. Genetic analyses in yeast indicate that binding of rapamycin to its intracellular receptor, FKBP12, generates a toxic complex that inhibits cell growth in G1 phase. These analyses implicated two related proteins, TOR1 and TOR2, as targets of the FKBP12-rapamycin complex in yeast. In this study, we have used a glutathione S-transferase (GST)-FKBP12-rapamycin affinity matrix to isolate putative mammalian targets of rapamycin (mTOR) from tissue extracts. In the presence of rapamycin, immobilized GST-FKBP12 specifically precipitates similar high molecular mass proteins from both rat brain and murine T-lymphoma cell extracts. Binding experiments performed with rapamycin-sensitive and -resistant mutant clones derived from the YAC-1 T-lymphoma cell line demonstrate that the GST-FKBP12-rapamycin complex recovers significantly lower amounts of the candidate mTOR from rapamycin-resistant cell lines. The latter results suggest that mTOR is a relevant target of rapamycin in these cells. Finally, we report the isolation of a full-length mTOR cDNA that encodes a direct ligand for the FKBP12-rapamycin complex. The deduced amino acid sequence of mTOR displays 42 and 45% identity to those of yeast TOR1 and TOR2, respectively. These results strongly suggest that the FKBP12-rapamycin complex interacts with homologous ligands in yeast and mammalian cells and that the loss of mTOR function is directly related to the inhibitory effect of rapamycin on G1- to S-phase progression in T-lymphocytes and other sensitive cell types.

How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help?

There is encouraging evidence that structured psychological treatments for depression, in particular cognitive therapy, can reduce subsequent relapse after the period of initial treatment has been completed. However, there is a continuing need for prophylactic psychological approaches that can be administered to recovered patients in euthymic mood. An information-processing analysis of depressive maintenance and relapse is used to define the requirements for effective prevention, and to propose mechanisms through which cognitive therapy achieves its prophylactic effects. This analysis suggests that similar effects can be achieved using techniques of stress-reduction based on the skills of attentional control taught in mindfulness meditation. An information-processing analysis is presented of mindfulness and mindlessness, and of their relevance to preventing depressive relapse. This analysis provides the basis for the development of Attentional Control Training, a new approach to preventing relapse that integrates features of cognitive therapy and mindfulness training and is applicable to recovered depressed patients.

Malingering response styles on the memory assessment scales and symptom validity tests

This study identified malingering strategies of test performance and investigated their presence in the responses to computer-mediated versions of Rey's Dot-Counting and 15-Items tests, a forced-choice symptom validity procedure and the Memory Assessment Scales (MAS). Sixty volunteer subjects were randomly assigned to control (n = 30) or malingering (n = 30) groups. The control subjects were instructed to perform their best and the malingerers were instructed to fake a poor performance on the tests. As expected, malingering subjects scored significantly worse than control subjects on virtually all tests. Malingerers had slower response times on most tests. They also performed worse on recognition tasks in contrast to performance on recall tasks. Their response style was characterized by intentional wrong and random responding on recognition tasks. Malingerers did not show the expected worse-than-chance responding on the forced-choice symptom validity procedure. Current tests of symptom validity may not have sufficient sensitivity to detect milder forms of malingering.

Embolectomy of a Bird's Nest Vena Caval Filter

In this case report we describe a successful embolectomy of a partially migrated Bird's Nest Caval Filter with attached embolic material. We used transesophageal echocardiography to guide the surgical approach. The patient recovered uneventfully from both the embolectomy and the subsequent pelvic operation.

Mechanism of selective inhibition of the inducible isoform of prostaglandin G/H synthase

Selective inhibition of the inducible isoform of prostaglandin G/H synthase (cyclooxygenase-2; COX2; EC 1.14.99.1) can be achieved with compounds of the general form of aryl methyl sulfonyls and aryl methyl sulfonamides. DuP 697 and NS-398 are representative examples of these compounds. Both inhibit the constitute (COX1) and inducible (COX2) isoforms of the enzyme with equal potency shortly after mixing, but their potencies increase with time for COX2 selectively. This time-dependent inhibition follows first-order kinetics, and the rate constant for inactivation of COX2 is dose dependent for both compounds. Kinetic analysis allows us to determine KI and kinact (the maximal rate of inactivation) for each inhibitor. The potency of both compounds is substrate concentration dependent, as expected for time-dependent competitive inhibitors. COX2 that has been incubated with these inhibitors, and then extensively dialyzed against buffer, shows no recovery of enzyme activity, while complete recovery of activity is seen for COX1. Thus, these inhibitors irreversibly inactivate COX2 with time, while showing minimal reversible inhibition of COX1. We isolated these inhibitors after long incubation with excess enzyme and subsequent denaturation of the enzyme. Both inhibitors showed no loss of potency resulting from interactions with COX2, suggesting that inhibition is not mediated by covalent modification of the enzyme. These data suggest that binding of these inhibitors to COX2 induces a slow structural transition of the enzyme that results in its selective inactivation.

Successful treatment of essential thrombocythaemia and recurrent abortion with alpha interferon

A 27-year-old woman with essential thrombocythaemia (ET) had three miscarriages. She was treated with alpha interferon which was continued after she became pregnant again. The platelet count remained well controlled and at term she delivered a healthy baby with normal blood counts. The case demonstrates the effectiveness of IFN in preventing recurrent miscarriage associated with ET and the safety of IFN with respect to fertility and fetal development.

Benzyl alcohol attenuates the pain of lidocaine injections and prolongs anesthesia

BACKGROUND

Benzyl alcohol is reported to be painless on injection and to provide limited dermal anesthesia. Benzyl alcohol has also been recommended as an adjuvant to lidocaine to reduce lidocaine's injection pain. There is insufficient data on pain of injection and duration of anesthesia for lidocaine containing benzyl alcohol.

OBJECTIVE

We conducted a randomized, placebo-controlled, double-blinded comparison of intradermal 1% lidocaine with 0.86% benzyl alcohol and plain 1% lidocaine for pain of injection and duration of anesthesia.

METHODS

Twenty subjects received the above two agents plus normal saline with and without 0.9% benzyl alcohol, with all solutions adjusted to 375 +/- 13 mosm/L.

RESULTS

Lidocaine containing benzyl alcohol was 27% less painful upon injection and provided anesthesia 29% longer than plain lidocaine.

CONCLUSION

Benzyl alcohol is itself an effective anesthetic and can reduce the pain of injection for lidocaine without adversely affecting its anesthetic properties.

Clinical experience with the implantable cardioverter defibrillator

The implantable cardioverter defibrillator has played an increasingly greater role in the management of episodes of sudden cardiac-related death related to ventricular tachycardia or ventricular fibrillation. This study reviews the cases of 142 patients who underwent insertion of an implantable cardioverter defibrillator, 104 who received a device alone (group I) and 38 who underwent insertion of the device in combination with other cardiac surgical procedures (group II). The overall operative mortality was 3.5% and this did not differ between the two groups. The complication rate was higher for group II than for group I patients, and consisted primarily of an increased incidence of atrial arrhythmias (53% versus 13%; p < 0.001). Late complications included three device infections requiring removal of the defibrillator. The late mortality did not differ between the two groups and was primarily related to congestive heart failure. Sudden cardiac-related death was an uncommon late event, with an actuarial freedom from sudden cardiac-related death of 98%, 97%, and 87% at 1, 2, and 5 years, respectively. The morbidity and mortality rate are low in association with the insertion of an implantable cardioverter defibrillator, even when this is combined with other cardiac surgical procedures. Its insertion is also associated with a low subsequent rate of sudden cardiac-related death.

Pain of injection and duration of anesthesia for intradermal infiltration of lidocaine, bupivacaine, and etidocaine

BACKGROUND

Bupivacaine and etidocaine are local anesthetics said to be long acting based on nerve block data. There are insufficient data on pain of infiltration and duration of anesthesia when either is used for dermal infiltration to assess suitability for skin surgery.

OBJECTIVE

We conducted a randomized, placebo-controlled, double-blinded comparison of intradermal 1% etidocaine, 0.5% bupivacaine, and 2% lidocaine for pain of injection and duration of anesthesia.

METHODS

Twenty subjects received the above three agents plus normal saline, each with and without epinephrine 1:200,000, with all solutions adjusted to pH 5.95 +/- 0.15.

RESULTS

Lidocaine hurt least and etidocaine hurt most. Adrenalized solutions were more painful than plain. For plain solutions bupivacaine lasted longest and lidocaine lasted shortest by far. For adrenalized solutions bupivacaine lasted 27% longer than lidocaine and 45% longer than etidocaine.

CONCLUSION

Where epinephrine is contraindicated and long anesthesia matters, use plain bupivacaine. When epinephrine can be used, lidocaine lasts almost as long as bupivacaine and hurts less.

Injury in West Virginia: an introduction to injury control and prevention

Each year, one of every four Americans sustains an injury severe enough to seek medical attention. Injuries account for 25% of all emergency department visits, 12% of all hospital admissions, and cost the nation over $180 billion annually. Despite being the leading cause of mortality for Americans under the age of 40, there is a lack of awareness of the epidemic of injuries and effective methods for their prevention. Many consider injuries to be the result of unavoidable accidents or unfortunate acts of God. In reality, injuries are diseases which have associated risk factors, demographic distributions, seasonal variations, epidemic episodes, and are predictable and preventable. This article describes injuries in West Virginia and discusses basic principles of injury control and prevention.