To what extent are the needs of severely disabled people met by community rehabilitation services? A follow-up study

PURPOSE

To evaluate which needs of disabled people would be met over a one year follow-up period and to examine which factors would be predictive of identifying those people who had more needs met from those who had fewer needs met.

METHOD

A follow-up study of a cohort of community dwelling disabled people (aged 16-65) from two NHS Health Districts in Southern England with contrasting patterns of rehabilitation provision, who had participated in a cross-sectional interview study one year previously which had assessed their met and unmet needs. The Southampton Needs Assessment Questionnaire was used to examine needs. Disability was evaluated with the OPCS Disability and Severity Scales and perceived health status with the SF-36.

RESULTS

Participation rate at follow-up was 92 %. Of the 300 baseline unmet needs reported by 69 of the 77 participants 33% had been met at follow-up. People whose disability had increased more and/or whose mental health status had improved more had greater percentages of their baseline needs met. There was a non-significant trend for smaller percentages of baseline needs to be met in Basingstoke than in Southampton.

CONCLUSIONS

At ground level, disabled people's views were taken into account, to some extent, in the provision of rehabilitation services. This input should be made at a higher level, in the overall shaping of services.

The Southampton Needs Assessment Questionnaire (SNAQ): a valid tool for assessing the rehabilitation needs of disabled people

OBJECTIVE

To validate the Southampton Needs Assessment Questionnaire (SNAQ) for use with disabled people during face-to-face interviews.

DESIGN

The SNAQ was designed to be used in a cross-sectional survey of disabled people with a physical disability with a follow-up study one year later. Content and criterion validity was examined using 32 disabled people who took part in the pilot study. Construct validity and internal reliability was examined using data from 93 disabled people who took part in the main survey. Responsiveness of the questionnaire was evaluated using the data gathered during a follow-up study of 77 people had taken part in the original study.

OUTCOME MEASURES

The OPCS Disability Severity Scales (OPCS) and the Functional Independence Measure (FIM) were used to measure level of disability of participants, the Nottingham Health Profile (NHP) and the UK version of the SF-36 to examine perceived health status.

PARTICIPANTS

People with a primary physical disability, aged 16-65, randomly selected from two disability registers in southern England.

MAIN RESULTS

Content and criterion validity were established. Construct validity and internal reliability of the SNAQ was good. Inter-rater reliability was not tested since only one researcher conducted the interviews. Test-retest reliability was not formally tested because of the probability that participants would learn from the first needs assessment questionnaire and that different results on a retest occasion could arise from this. The SNAQ was sensitive in picking up changes over time.

CONCLUSION

The SNAQ has shown good validity (content, coverage and construct), internal reliability, sensitivity and responsiveness. Further studies are needed to define the consequences of meeting or not meeting the rehabilitation needs of disabled people. Inter-rater reliability remains to be established.

Randomized, cross-over, controlled comparison of two inactivated hepatitis A vaccines

The immunogenicity, tolerability and interchangeability of two hepatitis A vaccines, Vaqta (Merck and Co.) and Havrix (SmithKline) were studied in a randomized, crossover, controlled clinical trial. Vaccine was administered to 201 volunteers at 0 and 26 weeks in one of four vaccine regimens: Havrix-Havrix; Havrix-Vaqta; Vaqta-Havrix or Vaqta-Vaqta. Seroconversion rates (>/=10 mIU/ml) for those whose first dose was Vaqta or Havrix, respectively, were: 41/96 (43%) versus 30/95 (32%) (P=0.15) at 2 weeks and 91/98 (93%) versus 84/97 (87%) (P=0.43) at 4 weeks, and 100% at 26 weeks. Geometric mean concentrations (GMC) of total antibody to hepatitis A virus (anti-HAV) for Vaqta and Havrix were 189 and 114 mIU/ml (P=0.011) at 4 weeks and 234 and 136 mIU/ml (P<0.001) at 26 weeks. At 30 weeks, the GMC after two doses of Havrix was 2612 mIU/ml compared with 5497 after two doses of Vaqta (P<0.001). The GMC in the Havrix-Vaqta group was 5672 mIU/ml compared with 3077 mIU/ml in the Vaqta-Havrix group (P<0.001). Less than half of vaccine recipients reported tenderness or pain. In this study, seroconversion rates of the two vaccines were similar. Vaqta produces significantly higher anti-HAV antibody than Havrix. Crossover immunization is well tolerated and results in high antibody concentrations, especially when Vaqta is the booster dose. The significance of higher anti-HAV antibody concentrations in terms of long-term protection is unknown.

Depth-profiling and diffusion measurements in ice films using infrared laser resonant desorption

A new infrared laser resonant desorption (LRD) technique has been developed that permits depth-profiling and diffusion measurements in ice. This LRD technique utilizes an Er:YAG rotary Q-switched laser with an output wavelength of lambda = 2.94 microm and a pulse duration of approximately 100 ns. The Er:YAG laser light resonantly excites O-H stretching vibrations in the H2O molecules that form the ice. This laser resonant heating induces H2O desorption at the ice surface. Control experiments were conducted on pure and isotopically mixed laminated ice films to determine the optimum experimental parameters for the LRD depth-profiling and diffusion measurements. Depending on laser energy, the measured desorption depth was either less than, comparable to, or larger than the optical penetration depth of approximately 0.8 microm at lambda = 2.94 microm. LRD studies were used to analyze H2 18O/H2 16O stacked multilayers and laminate sandwich structures. These measurements revealed that the LRD technique can depth-profile into ice films with submicrometer spatial resolution and high sensitivity. Two types of experiments employing LRD depth-profiling were demonstrated to monitor diffusion in ice. HCl hydrate diffusion in ice was measured versus time after depositing ice/HCl/ice sandwich structures. Na diffusion into ice was studied after adsorbing Na using a continuous Na source for a given exposure time at the diffusion temperature.

Met and unmet needs reported by severely disabled people in southern England

PURPOSE

To examine the met and unmet needs for rehabilitation of disabled people living in the community in Southern England.

METHOD

A cross sectional interview study of people with a primary physical disability, aged 1665. Disabled people were randomly selected from two existing disability registers, which comprised disabled people who had been identified by community rehabilitation services as being in need of regular surveillance by formal assessment of their care needs. A new semi-structured needs assessment questionnaire was developed and validated for the study (the Southampton Needs Assessment Questionnaire, SNAQ). Level of disability was examined with the OPCS Disability and Severity Scales.

RESULTS

Ninety three disabled people participated. Their median (IQR) OPCS score was 8 (6-10). Participants reported a median (IQR) of three unmet needs (2-7). The most prevalent unmet needs were for adaptations, equipment, physiotherapy and wheelchairs, rather than unmet needs for intellectual and social fulfilment.

CONCLUSIONS

Disabled people who were already in touch with community rehabilitation services continued to express unmet needs for further services. Meeting the more basic needs relating to people's housing, equipment, physiotherapy and wheelchairs may enable them to be more independent and fulfilled in other areas of their lives.

Analysis of topical cyclosporine treatment of patients with dry eye syndrome: effect on conjunctival lymphocytes

OBJECTIVE

To study the effect of topical cyclosporine on lymphocyte activation within the conjunctiva of patients with moderate to severe dry eye syndrome (Sjögren and non-Sjögren).

METHODS

Biopsy specimens were obtained at baseline and after 6 months of cyclosporine treatment from eyes of 32 patients with moderate to severe dry eye syndrome; 19 were cyclosporine treated (0.05% cyclosporine, n = 13; 0.1% cyclosporine, n = 6) and 13 were vehicle treated. Within this group there were 12 with Sjögren syndrome and 20 with non-Sjögren syndrome. Biopsy tissue was analyzed using immunohistochemical localization of binding of monoclonal antibodies to lymphocytic markers CD3, CD4, and CD8 as well as lymphocyte activation markers CD11a and HLA-DR.

RESULTS

In cyclosporine-treated eyes, biopsy results of conjunctivae showed decreases in the number of cells positive for CD3, CD4, and CD8, while in vehicle-treated eyes, results showed increases in these markers, although these differences were not statistically significant. Following treatment with 0.05% cyclosporine, there was a significant decrease in the number of cells expressing the lymphocyte activation markers CD11a (P<.05) and HLA-DR (P<.05), indicating less activation of lymphocytes as compared with vehicle treatment. Within the Sjögren patient subgroup, those treated with 0.05% cyclosporine also showed a significant decrease in the number of cells positive for CD11a (P<.001) as well as CD3 (P<.03), indicating a reduction in number of activated lymphocytes.

CONCLUSION

Treatment of dry eye syndrome with topical cyclosporine significantly reduced the numbers of activated lymphocytes within the conjunctiva. Arch Ophthalmol. 2000;118:1489-1496

Creation of a stress-activated p90 ribosomal S6 kinase. The carboxyl-terminal tail of the MAPK-activated protein kinases dictates the signal transduction pathway in which they function

Mitogen-activated protein kinase-activated protein kinases (MAPKAPKs) lie immediately downstream of the mitogen-activated protein kinases (MAPKs), extracellular signal-regulated kinase (ERK), and p38 MAPK. Although the family of MAPKAPKs shares sequence similarity, it demonstrates selectivity for the upstream activator. Here we demonstrate that each of the ERK- and p38 MAPK-regulated MAPKAPKs contains a MAPK docking site positioned distally to the residue(s) phosphorylated by MAPKs. The isolated MAPK docking sites show specificity for the upstream activator similar to that reported for the full-length proteins. Moreover, replacement of the ERK docking site of p90 ribosomal S6 kinase with the p38 MAPK docking site of MAPKAPK2 converts p90 ribosomal S6 kinase into a stress-activated kinase in vivo. It is apparent that mechanisms controlling events downstream of the proline-directed MAPKs involve specific MAPK docking sites within the carboxyl termini of the MAPKAPKs that determine the cascade in which the MAPKAPK functions.

Is Intranet technology the low cost, quick fix solution for Scotland's clinical information technology chaos? Results of a pilot study

For health care professional staff immediate access to recent clinical documents is seen as the first priority for developments in Information Technology. Large amounts of clinical data are held on computer systems to which staff have little or no access. A pilot study has been undertaken to evaluate the use of Intranet technology, electronically extracting large volumes of data from various feeder systems in real time and allowing access via standard Internet browsers. Over 700,000 reports have been successfully transferred from three differing sources with more than 2000 new records added per week. Intranet technology would seem to be a low cost solution, capable of rapid implementation, that could overcome the most important bottleneck in clinical computing.

Vacuolar chloride transport in Mesembryanthemum crystallinum L. measured using the fluorescent dye lucigenin

To study vacuolar chloride (Cl(-)) transport in the halophilic plant Mesembryanthemum crystallinum L., Cl(-) uptake into isolated tonoplast vesicles was measured using the Cl(-)-sensitive fluorescent dye lucigenin (N,N'-dimethyl-9,9'-bisacridinium dinitrate). Lucigenin was used at excitation and emission wavelengths of 433 nm and 506 nm, respectively, and showed a high sensitivity towards Cl(-), with a Stern-Volmer constant of 173 m(-1) in standard assay buffer. While lucigenin fluorescence was strongly quenched by all halides, it was only weakly quenched, if at all, by other anions. However, the fluorescence intensity and Cl(-)-sensitivity of lucigenin was shown to be strongly affected by alkaline pH and was dependent on the conjugate base used as the buffering ion. Chloride transport into tonoplast vesicles of M. crystallinum loaded with 10 mm lucigenin showed saturation-type kinetics with an apparent K(m) of 17.2 mm and a V(max) of 4.8 mm min(-1). Vacuolar Cl(-) transport was not affected by sulfate, malate, or nitrate. In the presence of 250 microm p-chloromercuribenzene sulfonate, a known anion-transport inhibitor, vacuolar Cl(-) transport was actually significantly increased by 24%. To determine absolute fluxes of Cl(-) using this method, the average surface to volume ratio of the tonoplast vesicles was measured by electron microscopy to be 1.13 x 10(7) m(-1). After correcting for a 4.4-fold lower apparent Stern-Volmer constant for intravesicular lucigenin, a maximum rate of Cl(-) transport of 31 nmol m(-2) sec(-1) was calculated, in good agreement with values obtained for the plant vacuolar membrane using other techniques.

Genetic variation in the bovine myostatin gene in UK beef cattle: allele frequencies and haplotype analysis in the South Devon

Work on Belgian Blue cattle revealed that an 11 base pair (bp) deletion within the bovine myostatin gene (GDF8) is associated with the double-muscled phenotype seen in this breed. Investigations focusing on other European breeds known to show double-muscling identified several mutations within the coding region of the gene associated with the double-muscled phenotype in different breeds. The number of mutations found suggest that myostatin is highly variable within beef cattle. Variations that alter the structure of the gene product such that the protein is inactivated are associated with the most pronounced form of double-muscling as seen in the Belgian Blue. However, other mutations may have a less extreme affect on muscle development. While overt double-muscling gives rise to a high incidence of dystocia (calving difficulty), it is possible that some variants may give enhanced muscling, but with limited calving problems. We describe sequence analysis of the myostatin gene in ten beef breeds commonly used in the UK and show that the 11-bp deletion responsible for double-muscling in the Belgian Blue is also present in the South Devon cattle population. Allele frequencies and haplotypes in the South Devon and a polymerase chain reaction (PCR) based test for the deletion are described. PCR amplification across the deleted region provides a quick and effective test with clear identification of heterozygous individuals. We discuss our results with regard to the effect of genotype on phenotype and differences observed between the Belgian Blue and the South Devon.

African American female physicians in South Carolina: role models and career satisfaction

BACKGROUND

This study examined the factors that influenced African American women to select medicine as a career and their satisfaction with their career choice.

METHODS

Of 132 African American female physicians in South Carolina, 62 responded to a survey of open-ended questions about why they chose medicine, what they liked and disliked about their career, and who influenced their decision to become a physician.

RESULTS

The majority chose medicine for altruistic reasons and found that medicine provided challenge and the opportunity to make a positive difference. Family members, teachers, and physicians served as the common external influences in their decision to become a physician. Managed care, paper work, and time demands constituted the most disliked aspects of medicine.

CONCLUSION

Altruistic reasons and/or an interest in science motivated most of these African American female physicians to study medicine. Family members most often were their principal role models.

Reduced 15-lipoxygenase-2 immunostaining in prostate adenocarcinoma: correlation with grade and expression in high-grade prostatic intraepithelial neoplasia

Arachidonic acid (AA) metabolites are implicated in the oncogenesis of several tumors, including prostate cancer. 15-Lipoxygenase-2 (15-LOX-2) is a novel AA-metabolizing enzyme with a limited tissue distribution, which includes prostate, lung, skin, and cornea. Previous studies have shown that 15-LOX-2 is present in benign prostate secretory cells and reduced in prostate adenocarcinoma and that production of the 15-LOX-2 metabolite 15S-hydroxyeicosatetraenoic acid is reduced in malignant compared with benign prostate. The objective of this study was to determine the frequency with which 15-LOX-2 immunostaining is reduced in prostate carcinoma and to correlate reduced expression with tumor differentiation (grade) and other pathologic parameters in radical prostatectomy specimens. Paraffin immunoperoxidase with a polyclonal antibody specific for 15-LOX-2 was performed on tumors and benign portions from 70 cases, and the percentage of tumor immunostaining for 15-LOX-2 was assessed. Whereas uniform 15-LOX-2 immunostaining was observed in secretory cells of benign glands, it was markedly reduced or absent in most adenocarcinomas: 23 of 70 tumors showed completely absent 15-LOX-2 immunostaining, and 45 of 70 cases showed negative immunostaining in more than 50% of the tumor. The extent of reduced 15-LOX-2 immunostaining correlated with tumor differentiation, with retained expression particularly in Gleason score 5 tumors versus a significant reduction of 15-LOX-2 in higher-grade tumors (mean +/- SD tumor 15-LOX-2 positive: Gleason score 5 = 67%+/-30%, Gleason score 6 = 16%+/-30%, Gleason score 7 = 23%+/-28%, Gleason score > or =8 = 41%+/-46%). In 16 cases with multifocal tumors or different foci of the same tumor with different grades, the higher-grade foci had significantly reduced 15-LOX-2 expression compared with the lower-grade foci. In peripheral zone tumors without complete loss of 15-LOX-2 expression, there was a significant inverse relationship between 15-LOX-2 immunostaining and tumor volume. There was not a significant correlation between 15-LOX-2 immunostaining and serum PSA or pathologic stage. In a subset of 27 cases, 15-LOX-2 expression in high-grade prostatic intraepithelial neoplasia (HGPIN) glands was significantly reduced compared with benign glands. These data show that in contrast to the uniform expression of 15-LOX-2 in differentiated secretory cells of benign prostate, reduced 15-LOX-2 is a common alteration in prostate carcinoma, and this correlates with tumor cell differentiation. That reduced expression is seen in HGPIN suggests that this may be an early alteration in carcinoma development.

Disabled people and professionals differ in their perceptions of rehabilitation needs

BACKGROUND

This study set out to explore whether there are systematic differences in unmet needs for rehabilitation services and resources as identified by disabled people and nominated key professionals.

METHODS

A cross-sectional interview survey of 87 pairs of community-dwelling disabled people (aged 16-65) and their nominated key professionals was conducted in southern England. The Southampton Needs Assessment Questionnaire (SNAQ) was used to examine unmet needs and the Office of Population Censuses and Surveys (OPCS) Disability and Severity Scale to examine level of disability.

RESULTS

Eighty-seven pairs of disabled people and their nominated key professionals participated. People were severely disabled (median OPCS score 8; interquartile range 6-9). Disabled participants reported significantly more unmet needs than did professionals. There was zero concordance on identified unmet needs between disabled participants and professionals in 56 per cent of cases. Concordance between disabled participants and professionals was significantly better if the disabled participant had reported more unmet needs. There was a trend for general practitioners to be poorer at reporting disabled participants' needs than other professionals. There was fair agreement between disabled participants and professionals in five areas of unmet need only (in descending order): adaptations, physiotherapy, equipment, assistance with 'non-care' activities and the use of a day centre. In all the other areas of unmet need the agreement was poor.

CONCLUSIONS

Needs for rehabilitation services and resources (for disabled people) are perceived differently by disabled people and professionals. Until we know who is right about rehabilitation needs, it is important to determine both users' and providers' views when planning and commissioning services.

Prostaglandin E2-induced sensitization of bradykinin-evoked responses in rat dorsal root ganglion neurons is mediated by cAMP-dependent protein kinase A

Primary cultures of neonatal rat dorsal root ganglion (DRG) neurons were used to examine the mechanisms underlying both the direct activation and the sensitization of sensory neurons by prostanoids. Prostaglandin E2 (PGE2) elevated cytosolic calcium concentration ([Ca2+]i) in a subpopulation of small (< 19 microm) diameter, capsaicin-sensitive DRG neurons. PGE2 also stimulated substance P (SP) release from DRG cultures. In contrast to bradykinin, PGE2 did not stimulate phosphoinositidase C (PIC) and the PGE2-evoked increase in [Ca2+]i was dependent on extracellular calcium. Pre-treatment with PGE2 potentiated bradykinin-evoked increases in [Ca2+]i in small diameter neurons and increased the number of cells that responded to low concentrations of bradykinin. A similar effect was seen with prostaglandin I2 (PGI2) but not prostaglandin F2alpha (PGF2alpha). PGE2 pretreatment also potentiated bradykinin-evoked release of SP, inducing a leftward shift in the bradykinin concentration-response curve and an increase in the maximum response. PGE2 stimulated adenylyl cyclase activity in DRG cultures, at concentrations and times consistent with those required to observe both the direct and sensitizing effects of the prostanoid on [Ca2+]i responses. Furthermore, the direct and sensitizing effects of PGE2, on both [Ca2+]i responses and SP release, were mimicked by the membrane permeant cAMP analogue dibutyryl cAMP and inhibited by H89, an inhibitor of cAMP-dependent protein kinase A (PKA). These observations are consistent with the hypothesis that both direct activation and sensitization of sensory neurons by prostanoids, such as PGE2, are mediated by PKA-dependent phosphorylation mechanisms.

Comparable efficacy of administration with face mask or mouthpiece of nebulized budesonide inhalation suspension for infants and young children with persistent asthma

A randomized, double-blind, placebo-controlled, parallel-group study including 481 children at 37 centers in the United States demonstrated the efficacy and safety of budesonide inhalation suspension in doses of 0.25 mg once daily, 0.25 mg twice daily, 0.5 mg twice daily, and 1.0 mg daily in infants and young children with persistent asthma. The retrospective analysis presented here compares the efficacy of treatment with the suspension administered through a face mask or mouthpiece. All patients receiving budesonide inhalation suspension via face mask or mouthpiece showed clinical improvements in nighttime and daytime asthma symptoms as compared with administration of a placebo. The improvements were of similar magnitude as those observed in an analysis of all patients treated. Improvements in nighttime asthma symptoms were statistically significant with budesonide at 0.25 mg daily (p = 0.040), 0.25 mg twice daily (p = 0.008), and 0.5 mg twice daily (p = 0.046) delivered by face mask. In patients using mouthpieces, nighttime asthma symptoms improved significantly in the 0.25-mg twice-daily (p = 0.005) and 1.0-mg daily (p = 0.035) groups. Patients receiving budesonide at 0.5 mg twice daily via a face mask improved significantly in daytime asthma symptoms (p = 0.009). The use of breakthrough medication was reduced in patients receiving budesonide via face masks or mouthpieces relative to placebo, and treatment was well tolerated in all study groups. This retrospective analysis suggests that nebulized budesonide inhalation suspension can be administered effectively by either face mask or mouthpiece to young children with persistent asthma.

The structural basis for in situ activation of DNA alkylation by duocarmycin SA

Duocarmycin SA is a member of a growing class of interesting lead compounds for chemotherapy, distinguished by the manner in which they bind to and react with DNA substrates. The first three-dimensional structure of a DNA adduct of an unnatural enantiomer from this family has been determined by (1)H NMR methods. Comparison to the previously determined structure of the natural enantiomer bound in the same DNA-binding site provides unique insights into the similarities and critical distinctions producing the respective alkylation products and site selectivities. The results also support the hypothesis that the duocarmycin SA alkylation reaction is catalyzed by the binding to DNA, and provide a deeper understanding of the structural basis for this unique mode of activation.

Imbalance of stromelysin-1 and TIMP-1 in the mucosal lesions of children with inflammatory bowel disease

BACKGROUND

Degradation of the extracellular matrix and ulceration of the mucosa are major features of inflammatory bowel disease (IBD). One of the most important enzymes in degrading the matrix and produced in excess by cytokine activated stromal cells, is stromelysin-1. The activity of stromelysin-1 is controlled by tissue inhibitor of metalloproteinase (TIMP-1), its natural inhibitor. In model systems excess stromelysin-1 produces mucosal degradation.

METHODS

Quantitative competitive RT-PCR was used to analyse stromelysin-1 and TIMP-1 transcripts; western blotting was used to measure the amount of stromelysin-1 and TIMP-1 protein in biopsy samples from children with IBD.

RESULTS

In biopsies from patients with active Crohn's disease (n=24), ulcerative colitis (n=23), and controls (n=16), TIMP-1 transcripts and protein were abundant and unchanged. Stromelysin-1 transcripts and protein were markedly elevated in mucosal biopsies obtained from inflamed sites of patients with active IBD but were not elevated in adjacent endoscopically normal mucosa (n=10). Elevated levels of stromelysin-1 transcripts in active Crohn's disease (n=5) returned to normal levels following treatment with enteral nutrition.

CONCLUSIONS

Stromelysin-1 is markedly overexpressed at inflamed sites in patients with IBD whereas TIMP-1 remains unaltered. Excess stromelysin-1 is likely to be responsible for loss of mucosal integrity in IBD.

Enteroaggregative Escherichia coli expresses a novel flagellin that causes IL-8 release from intestinal epithelial cells

Enteroaggregative Escherichia coli (EAEC) is an emerging cause of acute and persistent diarrhea worldwide. EAEC infections are associated with intestinal inflammation and growth impairment in infected children, even in the absence of diarrhea. We previously reported that prototype EAEC strains rapidly induce IL-8 production by Caco-2 intestinal epithelial cells, and that this effect is mediated by a soluble, heat-stable factor released by these bacteria in culture. We herein report the cloning, sequencing, and expression of this biologically active IL-8-releasing factor from EAEC, and its identification as a flagellin that is unique among known expressed proteins. Flagella purified from EAEC 042 and several other EAEC isolates potently release IL-8 from Caco-2 cells; an engineered aflagellar mutant of 042 does not release IL-8. Finally, cloned EAEC flagellin expressed in nonpathogenic E. coli as a polyhistidine-tagged fusion protein maintains its proinflammatory activity. These findings demonstrate a major new means by which EAEC may cause intestinal inflammation, persistent diarrhea, and growth impairment that characterize human infection with these organisms. Furthermore, they open new approaches for diagnosis and vaccine development. This novel pathogenic mechanism of EAEC extends an emerging paradigm of bacterial flagella as inflammatory stimuli.

The Missing Link: Early Methane ("T") Dwarfs in the Sloan Digital Sky Survey

We report the discovery of three cool brown dwarfs that fall in the effective temperature gap between the latest L dwarfs currently known, with no methane absorption bands in the 1-2.5 µm range, and the previously known methane (T) dwarfs, whose spectra are dominated by methane and water. The newly discovered objects were detected as very red objects in the Sloan Digital Sky Survey imaging data and have JHK colors between the red L dwarfs and the blue Gl 229B-like T dwarfs. They show both CO and CH(4) absorption in their near-infrared spectra in addition to H(2)O, with weaker CH(4) absorption features in the H and K bands than those in all other methane dwarfs reported to date. Due to the presence of CH(4) in these bands, we propose that these objects are early T dwarfs. The three form part of the brown dwarf spectral sequence and fill in the large gap in the overall spectral sequence from the hottest main-sequence stars to the coolest methane dwarfs currently known.

Continent urinary reconstruction versus ileal conduit: a contemporary single-institution comparison of perioperative morbidity and mortality

OBJECTIVES

To compare postoperative morbidity and mortality in a concurrent and contemporary series of patients who underwent radical cystectomy with ileal conduit versus orthotopic neobladder.

METHODS

The data of 198 patients were reviewed, 117 with orthotopic reconstruction and 81 with ileal conduit during a 5-year time frame. Thirty-day morbidity, mortality, reoperative rates, and parameters associated with the surgical procedures were obtained from chart review.

RESULTS

No perioperative or postoperative deaths occurred in either group. The median operative time for the ileal conduit was 201 minutes (range 140 to 373), and for the orthotopic neobladder, it was 270 minutes (range 230 to 425). The median blood loss was 389 and 474 mL, respectively. The median length of hospitalization was 8 days for the ileal conduit group and 7 days for the orthotopic neobladder group. Diversion-related complications recognized within 30 days that ultimately required a return to the operating room occurred in 3.4% of those with a neobladder and 1.2% of those with an ileal conduit.

CONCLUSIONS

The orthotopic neobladder is a longer and technically more complex procedure than the ileal conduit procedure. However, no demonstrable difference in morbidity or perioperative complications were found between the two procedures in our review.

Tissue characterization using magnetic resonance elastography: preliminary results

The well-documented effectiveness of palpation as a diagnostic technique for detecting cancer and other diseases has provided motivation for developing imaging techniques for noninvasively evaluating the mechanical properties of tissue. A recently described approach for elasticity imaging, using propagating acoustic shear waves and phase-contrast MRI, has been called magnetic resonance elastography (MRE). The purpose of this work was to conduct preliminary studies to define methods for using MRE as a tool for addressing the paucity of quantitative tissue mechanical property data in the literature. Fresh animal liver and kidney tissue specimens were evaluated with MRE at multiple shear wave frequencies. The influence of specimen temperature and orientation on measurements of stiffness was studied in skeletal muscle. The results demonstrated that all of the materials tested (liver, kidney, muscle and tissue-simulating gel) exhibit systematic dependence of shear stiffness on shear rate. These data are consistent with a viscoelastic model of tissue mechanical properties, allowing calculation of two independent tissue properties from multiple-frequency MRE data: shear modulus and shear viscosity. The shear stiffness of tissue can be substantially affected by specimen temperature. The results also demonstrated evidence of shear anisotropy in skeletal muscle but not liver tissue. The measured shear stiffness in skeletal muscle was found to depend on both the direction of propagation and polarization of the shear waves.

Predictors of perioperative morbidity and mortality in lung volume reduction surgery

BACKGROUND

Selection criteria for lung volume reduction surgery are still being refined. We sought to determine whether preoperative features could be used to predict early morbidity or mortality.

METHODS

We reviewed preoperative characteristics of the first 89 patients who underwent lung volume reduction surgery at the Alfred Hospital. Data included arterial blood gases, prednisolone use, pulmonary function tests, 6-minute walk test, and anesthetic time. Length of stay and reintubation for respiratory failure were used as markers of morbidity.

RESULTS

Findings included PaCO2 of 43 +/- 0.7 mm Hg, PaO2 70 +/- 1.1 mm Hg, percent predicted values for forced expiratory volume in 1 second 29.6% +/- 0.8%, TLCO% predicted 35.2 +/- 1.4%, and 6-minute walk test of 315 +/- 10.6 m (mean +/- SEM). Mean length of stay was 19 +/- 2 days, with 17 (19%) patients reintubated for respiratory failure. Mortality rate was 5.6% at 1 year post surgery, with no deaths in patients less than 65 years old. Multivariate analysis revealed that length of stay, reintubation and mortality were predicted by age and surgical time (p < 0.05), with no correlation with any other variables tested. Age greater than 70 years was associated with a significant risk of mortality (OR 9.0; p = 0.04).

CONCLUSIONS

Age greater than 70 years and anesthetic time greater than 210 minutes predict both perioperative morbidity and mortality.

The prognostic significance of S-phase analysis in stage Ta/T1 bladder cancer. A Southwest Oncology Group Study

OBJECTIVES

An intergroup study (SWOG 8795) comparing two forms of adjunctive therapy (immuno and chemo), bacillus Calmette-Guerin (BCG) and mitomycin C (MMC), furnished preregistration index tumors for 244 patients with superficial, papillary stage Ta/T1 TCC. These were examined by flow cytometry to learn whether DNA ploidy or proliferation (low vs high S-phase fraction (SPF) helped to predict disease recurrence or progression.

METHODS

Cell cycle analysis using commercially available (Multicycle) programs was performed on 249 Ta/T1 bladder cancers. Tumor grade, available for 223 cases, was assigned by a single study pathologist. The SWOG statistical office reviewed follow-up information and other data and performed statistical analysis.

RESULTS

Disease recurrence occurred in half the cases studied. The most parsimonious model predictive of recurrence included only treatment arm and tumor grade, with the MMC arm and tumor grade greater than I indicating worse prognosis (p = 0. 014). Neither ploidy nor SPF predicted recurrence-free survival or contributed prognostic information that was additive to tumor grade. Within 5 years of follow-up, disease progression or death from bladder cancer occurred for 29/223 (13%) of patients. The most parsimonious model for progression-free survival included only grade greater than I (p<0.001) and high SPF (p = 0.029) (relative risk: tumor grade, 4.3, high SPF, 1.9).

CONCLUSIONS

Knowledge of tumor proliferation (low versus high SPF) contributes prognostic information about tumor progression that is additive to tumor grade.

A simplified method of harvesting and dilating the radial artery achieves acceptable clinical outcomes

BACKGROUND

The recent successful revival of the radial artery as a coronary-bypass conduit has been attributed to a minimally traumatic harvesting technique without diathermy, combined with long-term oral calcium antagonist therapy. We describe a simplified technique of harvesting the radial artery, which reduces procurement time and maintains conduit relaxation.

METHODS

Radial arteries were harvested using diathermy and topical glyceryl trinitrate-verapamil dilator solution. Postoperatively, intravenous glyceryl trinitrate, but no calcium antagonist was used. The clinical results in the first 100 consecutive patients receiving radial artery grafts (RA group), procured using this technique, were compared with a group of 100 patients receiving saphenous vein conduits (SV group) immediately prior to the introduction of the radial artery at our institution.

RESULTS

There were no demographic differences between the two groups, other than the SV group being slightly older. There was one intraoperative death in each group. There was no difference in the rate of peri-operative myocardial infarction or length of stay in the intensive care unit. At a median follow-up time of 16 months for the RA group, and 25 months for the SV group, the survival rates were 97 and 94%, respectively. All survivors were in the New York Heart Association class I. In the SV group, two postoperative angioplasties were performed.

CONCLUSIONS

These early results suggest that this method of procuring the radial artery using diathermy, glyceryl trinitrate and no postoperative calcium antagonists, is rapid, safe and effective. The continued use of this technique is justified, while awaiting the results of long-term angiographic studies.

Outcomes of coronary artery bypass grafting: A 3 year analysis using the society of thoracic surgeons database

BACKGROUND

Accurate risk factor analysis is a critical element in contemporary cardiac surgical practice. In the USA, the Society of Thoracic Surgeons Database allows institutions and individual surgeons to carry out detailed patient risk assessment and to review their cardiac surgical outcomes in a comparative fashion.

METHODS

To evaluate outcomes of isolated coronary artery bypass grafting, data from all patients operated upon at the Alfred Hospital, Melbourne, Australia, over a 3 year period were entered into the Society of Thoracic Surgeons Database.

RESULTS

Our results (mortality and morbidity) compared favourably with those contained within this large international database.

CONCLUSION

It is hoped that a similar Australasian database can be established to facilitate a meaningful local risk assessment and a comparative analysis of outcomes of cardiac surgical procedures.

Interface between vascular dementia and Alzheimer syndrome. Nosologic redefinition

Vascular dementia is redefined so as to include noninfarct vascular dementia: vascular dementia caused by underlying vascular factors other than cerebral infarction. Data are presented that bring into focus the interface between vascular dementia and Alzheimer syndrome, and the ambiguous transition between multifocality and diffuse or generalized disease. By cross-cutting both stroke and nonstroke vascular groups, arteriosclerosis, abnormal blood pressure, abnormal electrocardiogram, and other vascular factors are implicated in the distal causality of both infarct and noninfarct vascular dementia.

Inhibition of interferon, cytokine, and lymphocyte proliferative responses in elite swimmers with altitude exposure

To determine the immunologic consequences of athletic training at altitude, blood samples were taken at rest from 10 swimmers and 8 control nontraining but altitude-exposed members of the 1996 Australian Olympic Swimming Team, near the start and completion of a 21-day training camp at 2102 m. Blood leukocyte numbers dropped in both groups (p < 0.05), with the decrease greater in the swimmers (-38% swimmers, -3% controls). Concanavalin A (ConA)-induced blastogenesis decreased in both groups (p < 0.01), but the drop was greater in the control group (-32% swimmers, -56% controls, p < 0.05). Lipopolysaccharide (LPS)-induced blastogenesis more than doubled in both groups (281% swimmers, 249% controls, p < 0.01). Increases in mitogen-induced interleukin-1beta (IL-1beta), IL-4, and interferon-gamma (IFN-gamma) production and a decrease in IL-2 levels were observed in both groups after altitude exposure (all p < 0.05). The percentage of cells expressing HLA-DR fell (-33% swimmers, -20% controls, p < 0.01), whereas those expressing CD-4 expression increased (16% swimmers only, p < 0.01). Although training at medium-level altitude alters some immunologic parameters, the training-induced changes may be secondary to those induced by altitude alone.

Differential expression of renal adenosine A(1) receptors induced by acute renal failure

The distribution of renal adenosine A(1) receptors was investigated in rats with glycerol- or mercuric chloride (HgCl(2))-induced acute renal failure. Receptors were localised by autoradiography using [(3)H]8-cyclopentyl-1,3-dipropylxanthine ([(3)H]DPCPX), a selective A(1) adenosine receptor antagonist. In saline-injected control animals, significant labelling with [(3)H]DPCPX was detected in glomeruli, the inner stripe of outer medulla, and the inner medulla. Sixteen hours following induction of glycerol-induced acute renal failure (ARF), a 34% increase in labelling in glomeruli was noted compared to saline-injected controls, and by 48 hr, glomerular labelling had increased by 200%. In addition, 48 hr following glycerol injection, significant labelling was now detected in the cortical labyrinth and medullary rays whilst, in the inner medulla, labelling had decreased by 34%. By contrast to glycerol-induced ARF, the only significant change noted 48 hr following induction of HgCl(2)-induced ARF was a 39% decrease in labelling in the inner medulla. It is concluded that glycerol-induced ARF results in differential expression of renal adenosine A(1) receptors with increased expression in the cortex and reduced expression in the inner medulla. Increased density of A(1) receptors in glomeruli may account, at least in part, for the increased renal vasoconstrictor response to adenosine and depressed glomerular filtration rate noted previously in this type of acute renal failure.

Neutrophil oxidative activity is differentially affected by exercise intensity and type

The differential effects of exercise intensity and type on neutrophil activation were assessed in eight well-trained male runners. Each subject undertook, on different days, three separate 40 min interval (8 x 5 min) treadmill bouts: an intense uphill run (90% VO2 max), a moderate-intensity near-level run and an eccentrically-biased downhill run (both at 52% VO2 max). Blood granulocyte count increased (p< 0.05) after all three treadmill bouts (range 25-108%). Chemiluminescence activity of isolated neutrophils decreased (p< 0.05) immediately after (-58%) and 1-h after (-72%) uphill running, but became significantly elevated (p< 0.05) at 6-h after the near-level (+71%) and downhill (+84%) runs. The ability of neutrophils to release the superoxide anion radical was reduced (p< 0.05) immediately after near-level (-29%) and uphill (-21%) running in cells stimulated with opsonized zymosan. Epinephrine concentration increased by 430% (p=0.01) after uphill but not with near-level or downhill running. The plasma concentration of elastase increased (p< 0.05) immediately after uphill and near-level running, and one hour after uphill running. These results suggest that a population of neutrophils mobilised into the circulation became directly activated in response to exercise, and that neutrophil oxidative activity is affected differentially by both the intensity and type of exercise undertaken.

A Src SH2 selective binding compound inhibits osteoclast-mediated resorption

BACKGROUND

The observations that Src(-/-) mice develop osteopetrosis and Src family tyrosine kinase inhibitors decrease osteoclast-mediated resorption of bone have implicated Src in the regulation of osteoclast-resorptive activity. We have designed and synthesized a compound, AP22161, that binds selectively to the Src SH2 domain and demonstrated that it inhibits Src-dependent cellular activity and inhibits osteoclast-mediated resorption.

RESULTS

AP22161 was designed to bind selectively to the Src SH2 domain by targeting a cysteine residue within the highly conserved phosphotyrosine-binding pocket. AP22161 was tested in vitro for binding to SH2 domains and was found to bind selectively and with high affinity to the Src SH2 domain. AP22161 was further tested in mechanism-based cellular assays and found to block Src SH2 binding to peptide ligands, inhibit Src-dependent cellular activity and diminish osteoclast resorptive activity.

CONCLUSIONS

These results indicate that a compound that selectively inhibits Src SH2 binding can be used to inhibit osteoclast resorption. Furthermore, AP22161 has the potential to be further developed for treating osteoporosis.

Intestinal trehalase activity in a UK population: establishing a normal range and the effect of disease

Trehalose is a disaccharide, the main dietary source being mushrooms. It has been approved as an additive in the preparation of dried food. Isolated intestinal trehalase deficiency is found in 8% of Greenlanders, but is rare elsewhere. The normal range of trehalase activity and the incidence of isolated trehalase deficiency in the UK have not been reported. Patients (n 400) were investigated for suspected malabsorption. Endoscopic distal duodenal biopsies were taken for histological assessment and maltase, sucrase, lactase and trehalase estimation. Disaccharidase activities were determined by Dahlqvist's technique (Dahlqvist, 1968). Most patients (n 369) had normal duodenal histology. In these, square root transformation of trehalase activity produced a normal distribution. The normal range (mean +/- 2 SD) was 4.79-37.12 U/g protein. One patient had an isolated borderline trehalase deficiency. The thirty-one patients with villous atrophy had significantly reduced disaccharidase activities. With ingestion of a gluten-free diet, maltase, sucrase and trehalase activities recovered to normal in most patients, whereas lactase activity did not. The normal range and very low incidence of isolated enzyme deficiency is comparable with that described in populations from the USA and mainland Europe. Activity is significantly reduced in untreated coeliac disease and recovers with treatment with a gluten-free diet. There is no place for routine determination of trehalase activity in the UK population and there should be no concern over the introduction of trehalose-containing dried foods.

Surgical management of noninvasive bladder cancer (stages Ta/T1/CIS)

Transurethral removal of bladder cancer is performed for diagnostic and therapeutic reasons. Tissue is returned for histologic determination of tumor grade and stage. For tumors that do not invade the detrusor muscle, resection can be curative although there is a high rate of new tumor occurrence. Surgical removal not only eradicates visible existing lesions but also retrieves material for histologic evaluation. This examination allows a determination of tumor grade as well as stage. Because of the importance of good histologic information in determining prognosis and, possibly, the need for further therapy, the method of surgical removal is important.

Bilateral sequential single lung transplantation for pulmonary hypertension and Eisenmenger's syndrome

BACKGROUND

Lung transplantation, with and without intracardiac repair for pulmonary hypertension (PH) and Eisenmenger's syndrome (EIS), has become an alternative transplant strategy to combined heart and lung transplantation (HLT).

METHODS

Thirty-five patients with PH or EIS underwent either bilateral sequential single lung transplantation (BSSLT, group I, n = 13) or HLT (group II, n = 22). Another 74 patients, who underwent BSSLT for other indications, served as controls (group III). Immediate allograft function, early and medium-term outcomes, lung function, and 2-year survival were compared between the groups.

RESULTS

Comparisons between groups I and II showed no significant difference in any variables except percent predicted forced vital capacity. Immediate allograft function was significantly inferior (p < 0.05) and the blood loss was greater (p < 0.01) in group I when compared with those in group III. However, this resulted in no significant difference in early and medium-term outcomes, and 2-year survival between the 2 groups.

CONCLUSIONS

BSSLT for PH and EIS can be performed as an alternative procedure to HLT without an increase in early and medium-term morbidity and mortality. Results are comparable with BSSLT performed for other indications.

Longitudinal growth in infants and young children treated with budesonide inhalation suspension for persistent asthma

BACKGROUND

Results of recent growth studies suggest that inhaled glucocorticosteroids may affect growth in children.

OBJECTIVE

Three 52-week, open-label extension studies (studies A, B, and C) were conducted to compare the effects of budesonide inhalation suspension (BIS) with conventional asthma therapy (CAT) on long-term safety, including intermediate-term growth, in 3 different pediatric asthma populations.

METHODS

Pediatric asthma patients (ages 6 months to 8 years) from 3 multicenter, randomized, 12-week, double-blind, placebo-controlled studies were eligible to enroll in the 52-week, open-label extension studies. The extension studies were multicenter, randomized, open-label, active-controlled, parallel-group studies performed at 26 centers in the United States. Subjects in each extension study were randomized in a 2:1 ratio to receive either BIS or CAT. BIS was initially administered at a dose of 0.5 mg once (studies A and C) or twice daily (study B), with attempts made at each clinical visit to gradually reduce the dose to the minimum effective dose that maintains asthma control, as judged by the investigator. CAT consisted of any available therapy for asthma, including inhaled glucocorticosteroids in studies B and C only. Height SD scores, growth velocity, and skeletal age (only in studies B and C) were examined.

RESULTS

In total, 670 subjects were randomized; 223 subjects received CAT and 447 received BIS. Mean ages at entry were 63.0 months and 60.9 months in CAT and BIS groups, respectively. Median total daily doses of BIS ranged from 0.5 to 1. 0 mg and the mean duration of treatment exposure was 304 +/- 119 days and 342 +/- 83 days in CAT and BIS groups, respectively. Changes in height SD scores differed significantly between the BIS and CAT groups in study A (-0.19, P =.003), and there was a small, statistically significant decrease in growth velocity (-0.8 cm/y, P =.002) in the BIS-treated group compared with the CAT group. No significant differences were observed between BIS and CAT groups in the changes in height SD scores or in growth velocities in studies B (+0.10 and +0.7 cm/y, respectively) and C (+0.12 and +0.8 cm/y, respectively). No differences in skeletal age were observed between BIS and CAT groups in studies B and C.

CONCLUSION

There was a small, statistically significant decrease in growth velocity in the BIS-treated group compared with the CAT group in the study (study A) where inhaled glucocorticosteroid use was prohibited before entry and in the CAT group during the study. In the studies (B and C) where inhaled glucocorticosteroids were allowed in the CAT group, no differences were observed in height SD scores or growth velocity. The clinical relevance of these effects, including impact on final adult height, remain to be determined in prospectively planned studies that assess growth in children.

Radical prostatectomy and collaborative care pathways

The purpose of this study was to describe the development, implementation, and evaluation of a collaborative care pathway for radical retropubic prostatectomy. The experience of Vanderbilt University Medical Center is described, and the literature was reviewed. In addition, an example of the radical prostatectomy care pathway is provided for an illustration of a care path. The experience of using collaborative care pathways at Vanderbilt Medical Center has resulted in decreased length of stays, decreased blood utilization, and decreased overall costs. Also, staff satisfaction has improved all without compromising patient care. Collaborative care pathways have been shown to be a cost effective way of standardizing patient care without sacrificing the quality of patient care. In addition, they allow for an easier way to critically evaluate outcomes, costs, and patient and staff satisfaction.

Distinguishing the roles of the two different cGMP-binding sites for modulating phosphorylation of exogenous substrate (heterophosphorylation) and autophosphorylation of cGMP-dependent protein kinase

The role of each of the two different cGMP-binding sites (referred to as slow and fast sites) of type I cGMP-dependent protein kinase (PKG) in altering the rate of catalysis of phosphorylation of exogenous substrates (heterophosphorylation) or the rate of autophosphorylation has not been resolved. In the present study, the cGMP concentration required for half-maximal activation (A(50)) of wild-type PKG type Ibeta (WT) was 5-fold higher for heterophosphorylation than for autophosphorylation. cGMP occupation of the slow site was associated with an increase in the autophosphorylation rate, whereas occupation of the fast and slow site together was associated with a decrease in the autophosphorylation rate compared with the rate observed with occupation of the slow site alone. The contributions of each cGMP-binding site were investigated using PKG mutants containing substitutions of an invariant threonine residue that is critical for high affinity cGMP-binding in each site. Site-directed mutagenesis of Thr-317 of the fast site (T317A) increased the cGMP A(50) for heterophosphorylation 4-fold at 30 degrees C, with nominal effect on cGMP A(50) for autophosphorylation compared with WT. The analogous slow site mutation (T193A) increased the cGMP A(50) for heterophosphorylation and autophosphorylation 32- and 64-fold, respectively. Compared with WT, the cGMP A(50) of the double mutant (T193A/T317A) for heterophosphorylation was increased 300-fold, whereas the cGMP A(50) for autophosphorylation was similar to that of T193A. Thus, occupation of both cGMP-binding sites of PKG is required for maximal stimulation of heterophosphorylation, whereas occupation of the slow site alone is sufficient for stimulation of the rate of autophosphorylation, and additional occupation of the fast site reduces this rate.

Functional lower urinary tract voiding outcomes after cystectomy and orthotopic neobladder

PURPOSE

We reviewed our experience with orthotopic continent urinary reconstruction after radical cystectomy to determine the functional voiding patterns and compare different methods of reservoir construction.

MATERIALS AND METHODS

The study included 100 consecutive patients who underwent cystectomy and orthotopic neobladder. Reservoir construction consisted of a W-shaped ileal reservoir in 40 patients, ileal reservoir with afferent limb in 26, a Padua ileal reservoir in 18, right colon in 14 and sigmoid colon in 2. The functional voiding outcome was determined by a detailed patient interview and chart review.

RESULTS

There were no perioperative deaths. All patients regained good daytime urinary control and none required protective pads, although 18% used protective padding at night because of nocturnal leakage. Eight patients (8%) performed self-intermittent catheterization because of poor reservoir emptying. There were no substantial differences in outcomes among the various methods of reservoir construction.

CONCLUSIONS

Excellent functional voiding outcomes are obtained with radical cystectomy and orthotopic bladder reconstruction. Comparable results can be achieved with use of either large bowel or ileum and with various methods of bowel folding as long as principles of preservation of the periurethral sphincter muscle, and construction of an adequate capacity and low pressure reservoir are maintained.

Early post-prostatectomy pelvic floor biofeedback

PURPOSE

We determined whether biofeedback enhanced pelvic floor exercises begun 6 weeks after radical prostatectomy improve the early recovery of continence.

MATERIALS AND METHODS

We randomized 30 patients who underwent radical retropubic prostatectomy into a group that received 5 biofeedback sessions and a control group.

RESULTS

Overall 87% of patients were pad-free at 6 months with similar results in the treatment and control groups (86% versus 88%). There was no statistically significant difference in pad test results or voiding diary records in the 2 groups.

CONCLUSIONS

A treatment program of biofeedback enhanced pelvic floor exercises begun 6 weeks after radical retropubic prostatectomy did not significantly affect continence in this study.

Short-term risedronate treatment in postmenopausal women: effects on biochemical markers of bone turnover

The development of new biochemical markers has made it possible to assess the effects of therapeutic agents on bone turnover more rapidly and precisely. In this early phase II study, we analyzed the effects of short-term, high-dose treatment with risedronate, a potent pyridinyl bisphosphonate, on markers of bone resorption and formation. Resorption markers included urinary free deoxypyridinoline (D-Pyr) crosslinks, N-terminal telopeptide (NTx) and C-terminal telopeptide (CTx) type I collagen crosslinks. Bone formation markers included osteocalcin (OC), bone-specific alkaline phosphatase (BSAP) and the C-terminal peptide of type I procollagen (PICP). All three resorption markers showed rapid, significant (p<0.05) decreases from baseline following daily administration of 30 mg risedronate for 2 weeks. The mean decreases at 2 weeks were 28% for D-Pyr, 61% for NTx and 73% for CTx, respectively. Over the next 10 weeks after treatment, D-Pyr approached baseline while NTx and CTx remained well below baseline values. The markers of bone formation showed little change during therapy but decreased significantly at 4-10 weeks after therapy - an expected outcome of bisphosphonate therapy. Moreover, there was a significant correlation between the early effects on bone resorption markers and the delayed effects on formation markers. This study demonstrates that the approved dose of risedonate (30 mg/day) for Paget's disease is effective at decreasing bone turnover after 2 weeks of treatment, as observed by the sensitive response of bone turnover markers.

Risk factors for surgical wound infection and bacteraemia following coronary artery bypass surgery

BACKGROUND

There has been no consensus from previous studies of risk factors for surgical wound infections (SWI) and postoperative bacteraemia for patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS

Data on 15 potential risk factors were prospectively collected on all patients undergoing CABG surgery during a 12-month period.

RESULTS

Of 693 patients, 62 developed 65 SWI using the Centres for Disease Control definition: 23 were sternal wound infections and 42 were arm or leg wound infections at the site of conduit harvest. There were 19 episodes of postoperative bacteraemia. Multivariate analysis revealed that: (i) diabetes, obesity and previous cardiovascular procedure were independent predictors of SWI; and (ii) obesity was an independent risk factor for postoperative bacteraemia.

CONCLUSIONS

These findings suggest that improved diabetic control and pre-operative weight reduction may result in a decrease in the incidence of SWI. But further prospective studies need to be undertaken to examine (i) whether the increased SWI risk in diabetes occurs with both insulin- and non-insulin-requiring diabetes, and whether improved peri-operative diabetes control decreases SWI; and (ii) what degree of obesity confers a risk of SWI and postoperative bacteraemia, and whether pre-operative weight reduction, if a realistic strategy in this patient group, results in a decrease in SWI.

Comparison of serum and urine assays for biochemical markers of bone resorption in postmenopausal women with and without hormone replacement therapy and in men

Biochemical markers of bone resorption have been used to characterize metabolic bone disease and assess therapeutic response. Most studies have used the urinary measurement of collagen crosslinks, but serum assays have recently been developed that may have less analytic and biologic variability. In the present study, we measured urine and serum N- and C-terminal crosslinked telopeptides of type I collagen (NTX and CTX) and serum bone sialoprotein (BSP) in postmenopausal women with or without hormone replacement therapy (HRT) and in men of similar age. In these populations, the variability of serum and urine markers was similar, except that serum NTX showed somewhat lower variability in postmenopausal women. Urine and serum assays correlated well with one another and were significantly lower in postmenopausal women on HRT compared with untreated women. The difference in women on HRT was similar for sNTX, uNTX and BSP (35-40%) and greater for sCTX and uCTX (52-53%). There was an inverse correlation between markers and bone mineral density, largely attributable to the high correlation in women not on HRT. Fractional excretion of NTX and CTX were estimated at 0.20+/-0.07 and 0.44+/-0.11, respectively. These values were independent of the concentration of the marker or of creatinine in the urine. We conclude that serum markers are useful measures of bone resorption in these populations, in whom the use of such markers is likely to be helpful in the management of osteoporosis.

Towards a relational self: social engagement during pregnancy and psychological preparation for motherhood

This study works towards a theoretical model of the relational self derived from the intensive examination of a small number of case studies of women going through their first pregnancy. The study is idiographic, grounded in the women's own accounts of the experience, and it is primarily qualitative. It employs interviews, diaries, repertory grids and interpretative phenomenological analysis. The theory argues that pregnancy can accentuate the symbiotic relation of one's perception of self and others, and that this aids psychological preparation for mothering. Increasing contact with key others can be psychologically informative: the woman may perceive herself as becoming more like key other(s); close involvement with existing family can facilitate the woman's preparation for taking on the new role of mother. The model is explicated with illustrations from the women's accounts. It is then discussed in relation to the existing literature.

Efficacy of antimicrobial-impregnated bladder catheters in reducing catheter-associated bacteriuria: a prospective, randomized, multicenter clinical trial

OBJECTIVES

To examine the efficacy of bladder catheters impregnated with minocycline and rifampin in reducing catheter-associated bacteriuria.

METHODS

A prospective, randomized clinical trial was conducted at five academic medical centers. Patients undergoing radical prostatectomy were randomized to receive intraoperatively either regular silicone bladder catheters (control catheters) or silicone bladder catheters impregnated with minocycline and rifampin (antimicrobial-impregnated catheters). Catheters remained in place for a mean of 2 weeks. Urine cultures were obtained at about 3, 7, and 14 days after catheter insertion. Bacteriuria was defined as the growth of organism(s) in urine at a concentration of 10(4) colony-forming units per milliliter or greater.

RESULTS

Kaplan-Meier analysis demonstrated that it took significantly longer for patients (n = 56) who received the antimicrobial-impregnated catheters to develop bacteriuria than those (n = 68) who received the control catheters (P = 0.006 by the log-rank test). Patients who received the antimicrobial-impregnated catheters had significantly lower rates of bacteriuria than those in the control group both at day 7 (15.2% versus 39.7%) and at day 14 (58.5% versus 83.5%) after catheter insertion. Patients who received the antimicrobial-impregnated catheters had significantly lower rates of gram-positive bacteriuria than the control group (7.1% versus 38.2%; P <0.001) but similar rates of gram-negative bacteriuria (46.4% versus 47.1%) and candiduria (3.6% versus 2.9%). The antimicrobial-impregnated catheters provided zones of inhibition against Enterococcus faecalis and Escherichia coli, both at baseline and on removal.

CONCLUSIONS

Bladder catheters impregnated with minocycline and rifampin significantly reduced the rate of gram-positive catheter-associated bacteriuria up to 2 weeks after catheter insertion.