The management of diabetes in general practice

Over a period of 3 months 32 general practitioners in the Waikato kept copies of all consultations with patients with noninsulin-dependent diabetes mellitus. Of 229 patients with diabetes known to the practices 189 were seen on a total of 438 occasions. Mean fructosamine level was 2.93 mmol/L. Each consultation was analysed as to history obtained, examinations performed, investigations ordered and referrals made. Overall care was satisfactory except for the low incidence of checking for early signs of peripheral vascular disease or diabetic neuropathy affecting the feet and for diabetic nephropathy.

Prophylactic parenteral antibiotics in clean neurosurgical procedures: a review

Clean surgical procedures carry a risk of postoperative wound infection that is less than 5% in most hospitals. The use of prophylactic antibiotic agents in clean neurosurgical cases is controversial, and the neurosurgical literature through 1980 contains no controlled clinical trials to study its effectiveness in such cases. A report of 1732 consecutive procedures without a single postoperative wound infection in patients receiving systemic gentamicin, vancomycin, and streptomycin irrigation fluids is often quoted by neurosurgeons; however, these results have not yet been duplicated by others. Since 1980, there have been several controlled trials that support the use in clean neurosurgical cases of prophylactic antibiotics, including the vancomycin/gentamicin/streptomycin regimen and the first-generation cephalosporins. A report in 1986 of 1602 cases without a primary wound infection supports the use of a single perioperative dose of cefazolin. A review of causative organisms in postoperative wound infections demonstrates the preponderance of Gram-positive pathogens. Therefore, when antibiotic prophylaxis is indicated, adequate Gram-positive bacterial coverage, including protection against Staphylococcus infection, is required. With consideration of the present data, the cost of antibiotic therapy, and the danger of drug toxicity, a short perioperative regimen of cefazolin as prophylaxis is preferred in clean neurosurgical cases.

Case-control studies of the effect of environmental sanitation on diarrhoea morbidity: methodological implications of field studies in Africa and Asia

The problems and prospects in the use of case-control studies to assess the effects of improvements in environmental sanitation on diarrhoea morbidity are discussed on the basis of two field studies. It is concluded that an adequate design is available for assessing the effects of a single improvement on diarrhoeal disease. The estimates of effect appear to be valid and sufficiently precise. For addressing more complex questions of interactions, sample sizes would have to be increased substantially. The experience with two field studies suggests that there is hope that a simpler protocol may be feasible, in which only limited information is collected, in which few home visits are made, and in which analytical techniques are simple. Until more field studies have been conducted definitive conclusions cannot be reached on the applicability of such a simple, rapid and inexpensive approach.

A case-control study of the effect of environmental sanitation on diarrhoea morbidity in Malawi

A case-control design has been applied in the evaluation of improved environmental sanitation on diarrhoeal diseases in rural Malawi. The study demonstrates the feasibility of using such an approach to evaluate two levels of water supply and sanitation service quickly and at moderate cost. Sample sizes would need to be increased substantially to evaluate multiple levels of service or to investigate interactions between water supply and sanitation. The results indicate that children living in families who use good quality water supplies and latrines experience 20% less diarrhoea as reported to the health clinics during the warm, rainy season.

Nutritional support and measured energy expenditure of the child and adolescent with head injury

Energy expenditure, nitrogen excretion, and serum protein levels were studied from the time of hospital admission until 2 weeks after severe head injury in eight adolescents and four children with peak 24-hour Glasgow Coma Scale scores ranging from 3 to 8. The mean measured energy expenditure (MEE) was 1.3 times Harris and Benedict's predicted value for energy expenditure. Seventy percent of the patients achieved caloric balance (MEE X 1.2) by 4 to 14 days after injury, but balance was not consistently maintained. Five of the 12 patients had intermittent diarrhea, and two had increased gastric residuals. In five patients fluid restrictions were imposed due to either the syndrome of inappropriate secretion of antidiuretic hormone, pulmonary complications, or intracranial pressure complications. For the adolescents (aged 11 to 17 years) the mean calorie intake during the 1st week was 752 kcal/day and for the children (aged 2 to 5 years) it was 340 kcal/day. During the 2nd week the mean calorie intake for the adolescents was 1671 kcal/day and for the children was 691 kcal/day. Mean urinary nitrogen excretion was 307 mg/kg/day for the adolescents and 160 mg/kg/day for the children. The calculated mean nitrogen balance for the eight adolescents and the four younger children was -13.6 and -4.1, respectively. Mean albumin levels decreased from 2.9 gm/dl during the 1st week to 2.4 gm/dl during the 2nd week (normal 3.5 to 5.0 gm/dl). Mean total protein level during the 1st week was 5.4 gm/dl and increased to a mean of 6.0 gm/dl during the 2nd week (normal 6.0 to 7.8 gm/dl). Weight loss ranged from 2 to 26 lb during the 2-week period. From these studies it can be concluded that head injury in the child and adolescent induces a metabolic response that includes increased energy expenditure and decreased serum albumin levels similar to those observed for head-injured adults. Mean nitrogen excretion values are less than those in adults with a severe head injury.

The effect of nutritional support on outcome from severe head injury

Fifty-one brain-injured patients with peak 24-hour admission Glasgow Coma Scale (GCS) scores of 4 to 10 were prospectively randomly assigned to receive total parenteral (TPN) or enteral (EN) nutrition. Patients were studied from hospital admission to 18 days postinjury. Outcome was assessed by the Glasgow Outcome Scale at 3 months, 6 months, and 1 year postinjury. The TPN group received a significantly higher cumulative mean intake of protein than the EN group (mean +/- standard error of the mean: 1.35 +/- 0.12 vs. 0.91 +/- 0.9 gm/kg/day; p = 0.004). Mean cumulative caloric balance was also significantly higher in the TPN than in the EN group (75.6% +/- 5.13% vs. 59% +/- 4.26%; p = 0.02). Nitrogen balance was significantly more negative in the EN group during the 1st week postinjury (p = 0.002). The incidence of pneumonia, urinary tract infections, septic shock, and infections was not significantly different between groups. Classic nutritional assessment parameters such as anergy screens, total lymphocyte counts, and albumin levels were not significantly different between groups. The 11 patients in the EN group who did not tolerate tube feedings for 1 week postinjury had a significantly higher incidence of septic shock (p = 0.008). The change over time in GCS scores between groups was significantly different, with the TPN group showing a mean four-point increase in GCS score compared with a three-point increase in the EN group (p = 0.02). At 3 months the TPN group had a significantly higher percentage of favorable outcomes (43.5% vs. 17.9%, respectively; p = 0.05). At 6 months, 43.5% of the TPN group had a favorable outcome while 32.1% of the EN group had a favorable outcome (p = 0.29). By 1 year, 47.8% of the TPN group and 32.1% of the EN group had a favorable outcome (p = 0.20). In conclusion, more calories and protein usually can be administered to acute brain injury patients via the TPN route than by EN feedings via nasogastric or nasoduodenal routes. Traditional parameters for nutritional assessment are not useful in studying the efficacy of nutritional support during the first 2 weeks after head injury. Neurological recovery from head injury occurs more rapidly in patients with better early nutritional support.

The metabolic response to brain injury

Every year several million people sustain brain injury. The development of an optimal metabolic and nutritional support program for brain-injured patients relies on an understanding of the metabolic response and nutritional complications that occur with brain injury. Severely brain injured patients have increased serum and urine levels of norepinephrine, epinephrine, and cortisol. These patients also have increased oxygen consumption and urinary nitrogen excretion. This group has observed hypozincemia, hyperzincuria, increased serum C-reactive protein and copper concentrations, and hypoalbuminemia in nonsteroid-treated severely brain-injured patients. Experimental head injury produces interleukin-1 (IL-1) of brain origin. This cytokine mediates many of the aspects of the acute phase response, including all of the metabolic abnormalities reported by our group. IL-1, when administered intracerebroventricularly to experimental animals, appears to have enhanced biological activity compared to that administered systemically. Interleukin-1 activity has been found in significant amounts in the intraventricular fluid of head-injured patients. We suggest that IL-1 acts in concert with traditional stress hormones such as epinephrine, norepinephrine, and cortisol to produce the profound metabolic disturbances observed in the head-injured patient.

Ventricular fluid interleukin-1 activity in patients with head injury

Patients with severe head injury are hypermetabolic and hypercatabolic, and manifest several components of the acute phase response. Interleukin-1 (IL-1) is a cytokine that mediates many aspects of the acute phase response, and rats with experimental head injury produce IL-1 of brain origin. IL-1 administered intracerebroventricularly to experimental animals has disproportionately greater systemic biologic effects compared with IL-1 injected intravenously. In this study, patients with severe head injury were evaluated to determine whether IL-1 activity in the ventricular fluid was increased and whether IL-1 levels correlated with some of the altered metabolic responses. Twelve hospitalized patients with head injury (24-hour peak admission Glasgow Coma Scale scores of 4 to 10) were evaluated on admission and longitudinally for 21 days after injury. IL-1 activity in ventricular fluid from patients with head injury was significantly elevated whereas IL-1 activity in cerebrospinal fluid from age- and sex-matched patients undergoing lumbar puncture for myelograms was not detectable (P less than 0.005). The patients with head injury had clinical and biochemical indicators of IL-1 activity such as fever, hypozincemia, and increased C-reactive protein levels that improved during the period of hospitalization. It is speculated that the elevated IL-1 activity may play a role in the altered metabolic response of patients with severe head injury.

Effect of total parenteral nutrition upon intracranial pressure in severe head injury

Animal investigations suggest that administration of hyperosmolar total parenteral nutrition (TPN) solutions may potentiate cerebral edema following head injury. Intravenous nutrition (TPN) is often required after head injury due to intolerance to enteral feeding (EN). This study evaluates the effect of TPN on intracranial pressure (ICP) measurements in severely brain-injured patients. Ninety-six severely brain-injured patients were randomly assigned to receive TPN or EN and were studied from hospital admission until 18 days postinjury. The TPN was started within 48 hours postinjury and the EN was started when tolerated. Peak daily ICP was not significantly different on admission and over time (overall mean +/- standard error of the mean 32.01 +/- 1.62 for TPN versus 32.5 +/- 1.25 for EN). Intracranial pressure was greater than 20 mm Hg in 75% of TPN patients and 73% of EN patients. Conventional therapy failed to control elevated ICP in 36% of TPN patients and 38% of EN patients. Of these patients, subsequent barbiturate therapy failed to control ICP in 56% of TPN patients and 64% of EN patients. Serum osmolality was not significantly different between groups at admission or over the course of the study. The TPN group tended to have higher mean serum glucose levels for the first 13 days postinjury, while the EN group had a higher mean serum glucose content thereafter, but these differences were not statistically significant. This study shows that TPN can be given safely to the severely brain-injured patient without causing serum hyperosmolality or affecting ICP levels or ICP therapy.

In vitro formation of a lariat structure containing a G2'-5'G linkage

We have examined the effects of base changes at the lariat branch site of a modified adenovirus major late precursor mRNA (pre-mRNA). Replacement of the A residue at the lariat attachment site with a G residue was studied. Incubation of this altered pre-mRNA with nuclear extracts of HeLa cells yielded less spliced mRNA (10-fold) than similar reactions with the wild type pre-mRNA. The intron lariat formed during the reaction with the mutant transcript contained the predominant branch (2'-5' phosphodiester linkage) to an upstream A residue. In contrast, the intron/exon 2 lariat contained the predominant branch to the substituted G residue. These results indicated that detectable spliced RNA was formed when the lariat was attached at the A residue but not when the lariat was attached to the substituted G residue. A second mutation was introduced into the transcript by substituting an additional G residue at the alternative A branch site. When transcript derived from this plasmid was incubated with nuclear extract, cleavage occurred at the 5' splice site, and an intron/exon 2 lariat was produced, but spliced RNA was not detected. T1 RNase digestion and primer extension analyses of this intron/exon 2 lariat revealed that all of the lariat formed on the G residue at the normal attachment site.

Clinical outcome of nosocomial pneumonia following imipenem/cilastatin therapy

Eighteen patients in a neurosurgery intensive care unit who had nosocomial pneumonia and/or bacteremia were treated with imipenem/cilastatin. The 16 patients who were evaluable had pneumonia; 4 of these had concurrent bacteremia. Eleven patients had a satisfactory clinical response (69 percent) and all patients with positive blood cultures had the organism eradicated. There were 44 organisms isolated from the initial culture of bronchial secretion and 32 of these organisms were gram-negative bacilli (72.5 percent). One patient with pneumonia who initially had Pseudomonas aeruginosa sensitive to imipenem developed resistance during therapy. Adverse effects were minimal; one case of nausea occurred, which was thought to be related to a short infusion time. The most prominent laboratory abnormality was an increase in platelet count, seen in 50 percent of treated patients.

The patient with critical neurological disease

The known metabolic abnormalities and nutritional requirements of the brain injury, spinal cord injury, and acute stroke patient have been presented. Further investigations are required in all these conditions to identify specific nutritional requirements and metabolic abnormalities. The specific role of nutritional support on outcome, immune function, and body structure requires further study.

Genetic analysis of cystic fibrosis: linkage of DNA and classical markers in multiplex families

Linkage of cystic fibrosis (CF) to DNA and classical markers was studied in 36 families of two or three generations with at least two living affected children. Among the 79 affected children, no recombinants were detected between the disease and the markers MET and pJ3.11, previously shown to be linked to CF. No linkage between the human trypsin gene family (which appears to include at least 10 members) and CF was found, although not all genes of the trypsin family have been screened yet. In one of the CF families, recombination between MET and pJ3.11 was detected in an unaffected sib. Data from our families suggest that the gene order of markers among chromosome 7q is: (7cen;p8.33)collagen(COL1A2);DOCR1-917;paraoxonase+ ++(PON);(MET-cf-J3.11);T-cell receptor beta chain (TCRB);qter. There was no evidence for (or against) either postzygotic selection or meiotic drive to explain the high frequency of CF in Caucasian populations.

A clinical study with brain brachytherapy for malignant gliomas

A clinical trial with neutron brachytherapy for malignant glioma is now in progress at the University of Kentucky Medical Center. In the initial three year period, 32 patients entered the study. There were 24 males and eight females, and the peak incidence was seen in the seventh decade. All patients underwent surgical resection of tumor followed by Cf-252 implantation and external radiotherapy. The implantation procedure was well tolerated by the patients and demonstrated a short-term benefit in survival of patients who were able to complete planned radiotherapy. Older patients had less tolerance to radiotherapy. The evaluation of the beneficial effects of Cf-252 brachytherapy will require patients who are able to tolerate the whole course of therapy.

Serum and urine zinc response in head-injured patients

A prospective longitudinal evaluation of serum zinc concentrations was performed in 26 head-trauma patients, and 24-hour urine zinc excretion was determined in 15 of these subjects. Patients had markedly depressed admission serum zinc concentrations (mean +/- standard error of the mean: 40.2 +/- 3.2 micrograms/dl; normal values: 70 to 120 micrograms/dl), which gradually increased during the 16-day study period. All subjects demonstrated increased urinary zinc losses throughout the study period. Urinary zinc excretion was greater in patients with more severe head injuries. Indeed, patients with more severe head trauma had mean peak urinary zinc losses of greater than 7000 micrograms/day (normal less than 500 (micrograms/day). The implications of this altered zinc metabolism for protein metabolism, wound healing, and immune function, and the specific role of zinc in brain function and recovery from injury are discussed.

Metabolic and nutritional sequelae in the non-steroid treated head injury patient

Energy production, substrate oxidation, serum protein levels, and weight change were studied in 16 non-steroid treated patients with severe head injury. Patients were evaluated during an average of 31.3 days from hospital admission to discharge. The mean measured energy expenditure (MEE) was 1.40 +/- 0.5 times predicted energy expenditure. Caloric balance [calories received = calories expended] was achieved by the 2nd week. Despite caloric balance and the administration of at least 1.5 g of protein per kg of body weight per day, the mean nitrogen balance was negative. There was a positive nitrogen balance in only 2 patients. These patients received a mean of 1.43 times the MEE in total kilocalories and 2.3 g of protein per kg of body weight. Fat and protein oxidation exceeded protein and fat administration for 3 weeks postinjury. Albumin levels dropped from a mean of 3.09 +/- 0.2 on admission to 1.98 +/- 0.4 within 2 weeks. The initial retinol binding protein levels were within the normal range, and the levels increased over time. There was marked weight loss (mean, 15.6 +/- 5.9 lb). Head injury induces a profound traumatic response identified by increased energy expenditure, a negative nitrogen balance, weight loss, hypoalbuminemia, and altered substrate oxidation. This response seems to be caused by the head injury alone and is not due to the administration of corticosteroids.

Demonstration in multiple species of inducible hepatic cytochromes P-450 and their mRNAs related to the glucocorticoid-inducible cytochrome P-450 of the rat

We have recently demonstrated that P-450p, a form of rat liver cytochrome P-450 inducible by steroids such as dexamethasone and pregnenolone-16 alpha-carbonitrile, by the macrolide antibiotic triacetyloleandomycin, and by phenobarbital, is immunochemically related to and shares 73% NH2-terminal amino acid sequence homology with rabbit cytochrome LM3c. Extending this interspecies comparison we now report that liver microsomes prepared from the rabbit, hamster, gerbil, and mouse contain inducible cytochromes P-450 that resemble P-450p in: (a) converting triacetyloleandomycin to a metabolite that forms a distinct spectral complex with cytochrome P-450 heme, (b) catalyzing the demethylation of erythromycin, and (c) reacting on immunoblots with antibodies directed against P-450p or LM3c. These three characteristics changed in parallel within treatment groups of a given species receiving different inducers of cytochrome P-450. However, there were striking qualitative and quantitative interspecies differences in the responses to inducers. For example, rifampicin was the most efficacious inducer of LM3c in the rabbit and yet was not at all an inducer of P-450p in the rat whereas pregnenolone-16 alpha-carbonitrile, an inducer in the rat, failed to induce LM3c in the rabbit. Immunoblot analysis of these microsomes revealed in each species except the rabbit a single immunochemically related protein. A second immunoreactive protein was present in microsomes from male and female and rifampicin- and dexamethasone-treated female rabbits. Two cloned cDNAs, which hybridized to a species of liver mRNA directing the synthesis of P-450p in a cell-free translation system, were used to probe Northern blots of liver RNAs. These revealed a single band of hybridizable mRNA in each species (except RNA from the rabbit which gave no signal even under conditions of reduced stringency) that was induced in qualitative proportions to that of the accumulated immunoreactive protein. We conclude that P-450p appears to be conserved in evolution and is represented in each of the species tested by one or more immunochemically related proteins which exhibit similar catalytic activities to those of P-450p.

Identification of the cytochrome P-450 induced by macrolide antibiotics in rat liver as the glucocorticoid responsive cytochrome P-450p

We administered triacetyloleandomycin (TAO) to rats and found that this macrolide antibiotic is the most efficacious inducer of liver microsomal cytochrome P-450 (P-450) examined to date. Liver microsomes prepared from TAO-treated rats contained greater than 5.0 nmol of P-450/mg of protein and a single induced protein as judged by analysis on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. This protein comigrated with P-450p, the major form of P-450 induced in liver microsomes of rats treated with pregnenolone-16 alpha-carbonitrile (PCN) or dexamethasone (DEX). On immunoblots of such gels developed with antibodies to P-450p, the TAO-induced protein reacted strongly as a single band. There was strict parallelism between the amount of immunoreactive P-450p in liver microsomes prepared from untreated rats or from rats treated with phenobarbital, TAO, DEX, or PCN, the ability of these microsomes to catalyze conversion of TAO to a metabolite which forms a spectral complex, and the ethylmorphine and erythromycin demethylase activities. Antibodies to P-450p specifically blocked microsomal TAO metabolite complex formation and ethylmorphine and erythromycin demethylase activities. Moreover, anti-P-450p antibodies completely immunoprecipitated solubilized TAO metabolite complexes prepared by detergent treatment of liver microsomes obtained from TAO-treated rats. Finally, we found that the major form of P-450 isolated from liver microsomes of TAO-treated rats and purified to homogeneity was indistinguishable from purified P-450p as judged by molecular weights, spectral characteristics, enzymatic activities, ability to bind TAO, peptide maps, and amino-terminal amino acid sequences. We concluded that, in addition to glucocorticoids, macrolide antibiotics are specific inducers of P-450p.

Modulation of the activity of PALA by dipyridamole

PALA is thought to inhibit an early step in de novo pyrimidine synthesis, causing depletion of intracellular pyrimidine nucleotides. Dipyridamole, a nucleoside transport inhibitor which can block restoration of nucleotide levels via the salvage pathway, was tested for its ability to augment the cytotoxicity of PALA against normal and malignant human cells in vitro. At the clinically relevant concentration of 1 microM, dipyridamole increased the cytotoxicity of PALA against a melanoma, a colon carcinoma, a promyelocytic leukemia (HL-60), and normal marrow (CFU-GM) in clonogenic assays. Dipyridamole produced 50% inhibition of uridine uptake in these cells at concentrations of less than 0.1 microM and reduced the LD50 of PALA by approximately 50% in mice. These results indicate that dipyridamole can markedly potentiate the activity of PALA in vitro and in vivo.

Evidence for the activation of the endogenous opiate system in hamsters infected with human blood flukes, Schistosoma mansoni

Nociceptive thresholds were investigated in golden hamsters infected with the human blood fluke, Schistosoma mansoni. Increases in thermal thresholds suggestive of analgesia were evident by 20-25 days of infection. These increased further during a 40-42 day period. The altered responses were suppressed by the opioid antagonist naloxone. Non-invasive inhibition of the activity of the pineal gland by exposure to light also reduced nocturnal analgesia in schistosome infected animals. Naloxone antagonism and pineal inhibition of morphine- induced analgesia was obtained similarly in control, uninfected animals. Taken together, these findings suggest strongly that infection with S. mansoni results in a chronic activation of the endogenous opiate system.

Ceftazidime versus tobramycin/ticarcillin in treating hospital acquired pneumonia and bacteremia

Thirty-five patients in a neurosurgical intensive care unit who had nosocomial pneumonia and bacteremia were randomly assigned to receive either ceftazidime (Cef) or the combination of ticarcillin and pharmacokinetically adjusted doses of tobramycin (T/T). Fifteen of 17 patients (88%) who received Cef were cured or improved compared to 15 of 18 (83%) who received T/T. The original pathogen was eradicated from the respiratory secretion in 10 of 15 patients receiving Cef compared to only 6 of 18 patients receiving T/T (p = 0.12). All patients in both treatment groups who had positive blood cultures cleared the organism from the bloodstream. No cases of drug toxicity, including renal toxicity, were seen in either group. Cef used as a single agent in nosocomial pneumonias and bacteremias performed at least as well as T/T.

Modulation of cytarabine uptake and toxicity by dipyridamole

The effect of dipyridamole, an inhibitor of membrane nucleoside transport, on the uptake and toxicity of cytarabine was examined in normal and malignant tissues. Preliminary pharmacokinetic data were obtained in mice and humans to determine appropriate dipyridamole dosage ranges for in vitro testing. At concentrations achievable in man, dipyridamole produced 75% and 94% reductions in cytarabine uptake in freshly harvested normal mouse and human bone marrow cells, respectively. Under the same conditions, greater than 90% reductions in cytarabine uptake were also seen in both L1210 murine leukemia and HL-60 human leukemia cells. In addition, treatment with dipyridamole also reduced the growth inhibitory effects of cytarabine on HL-60 cells in culture and protected mice from toxic doses of this antimetabolite. These results demonstrate the ability of dipyridamole to modulate the activity of cytarabine in both murine and human cells.

The development of hospital wide patient-education director competencies

Members of the patient-education divisions of the Michigan Society of Healthcare Education and Training and the Great Lakes Chapter of the Society of Public Health Education drafted a model job description and related competencies, using representative position descriptions and a role delineation project as a basis. The product of this effort can serve as a model for hospital administrators hiring patient educators, professional organizations supporting patient education, universities and colleges training such specialists, and patient-education specialists pursuing continuing education.

Intracerebral neutron brachytherapy for hemispheric glioblastoma multiforme. A pilot study

The University of Kentucky Brain Tumor Study and Research Group has developed a new treatment protocol of interstitial brain brachytherapy using Californium-252 neutron source implantation in 1980. Only patients with malignant gliomas were eligible for this pilot study. Nine patients entered the Phase I trial of the protocol study between November 1980 and October 1981. According to the design of the protocol, all patients who had a verified histologic diagnosis of glioblastoma multiforme underwent postoperative intracerebral Cf-252 neutron source implantation, followed by 6 000 cGy of external photon beam irradiation. The purpose of this pilot study was to test the feasibility of interstitial Cf-252 neutron source implantation and only one implant afterloading applicator was used for brachytherapy. The implant applicator was placed in the center of tumor and the procedure was performed under CT guidance. In the assessment of the procedure, Karnofsky functional performance status, intellectual status, neurological examination, CT scans, and complications were used. All patients tolerated the procedure well and no serious complications were encountered. Despite the quality of these early treatments, there was some evidence of short-term benefit in duration of survival of the patients. We believe that further technical improvement to achieve an adequate isodose distribution to cover the tumor volume might result in longer duration improvement in survival.

Cerebellar glioblastoma in childhood

Cerebellar glioblastoma multiforme in childhood is extremely rare. Only ten such cases have been reported to date. Although treatment results are reported to be extremely poor, complete tumor clearance was achieved in a patient treated with superfractionated radiotherapy. She received high dose postoperative radiotherapy using a three times per day technique and is disease-free for more than three years posttherapy. This suggests that improved tumor response can be obtained by high dose postoperative radiotherapy using a modified fractionation technique.

The role of radiation treatment in craniopharyngioma

The long natural course of craniopharyngioma and short-term follow-up period in many reports make comparison of various treatment results difficult. Some patients may enjoy virtually symptom-free lives despite known recurrence. Some patients with recurrence may have a good response to retreatment. Such unpredictable behavior and treatment responses have led to considerable disparity in clinical reports concerning the best treatment method. Treatments using surgery alone and/or low dose postoperative radiation treatment could prolong survival time, but may not prevent recurrence leading to ultimate failure. High dose postoperative radiotherapy following radical surgery should be an ideal approach in dealing with this tumor.

Nephrotoxicity of parenterally administered cyclosporine after orthotopic liver transplantation

The frequency of nephrotoxicity in the absence of identifiable prerenal or postrenal causes within five days of operation in 27 liver transplant recipients was found to be 71% in those treated with i.v. cyclosporine alone, 37.5% with i.m. cyclosporine alone, and 16.7% with prednisolone and azathioprine. Renal failure following i.v. cyclosporine was characterized by an immediate fall in urine output and creatinine clearance with well-preserved tubular function--findings consistent with a reduction in renal blood flow or glomerular filtration rate, or both.

Cerebral vascular response to moderate blood loss: modification by hypertension

To study the effect of non-hypotensive hemorrhage on cerebral blood flow in normo- and hypertensive states, chloralose anesthetized cats were subjected to graded blood loss (5 ml/kg) every 30 min. Cerebral blood flow was measured using radiolabelled microspheres or H2 clearance. Hypertension was produced by infusion of phenylephrine to a diastolic blood pressure of 100 mm Hg. Control animals suffered no net blood loss. PCO2 was between 28 and 32 mm Hg for all groups over the entire experiment. In normotensive cats, cerebral blood flow increased following withdrawal of 10 ml/kg of blood. In hypertensive cats, cerebral blood flow increased after withdrawal of 20 ml/kg of blood. These findings were consistent for all brain regions examined. Animals without blood loss, whether normo- or hypertensive showed no consistent change in cerebral blood flows. Possible explanations for these findings, particularly neurally mediated responses, are discussed.

Cutaneous reactions in head-injured patients receiving phenytoin for seizure prophylaxis

Two types of adverse effects are caused by phenytoin, reversible dose-dependent central nervous system effects and non-dose dependent hypersensitivity effects. The most common presenting symptom of the hypersensitivity reaction is the development of a morbilliform rash. During a 45-month period, 151 head-injured patients received phenytoin for seizure prophylaxis using an 11-mg/kg i.v. and a 13-mg/kg i.m. parenteral loading dose followed by an i.m. or p.o. maintenance dose for therapeutic blood concentrations (10 to 20 micrograms/ml). The patients were followed for 18 months. The incidence of skin reaction to phenytoin was 19.4%, or 24 of 124 patients. Cutaneous reactions occurred from Day 5 through Day 91 of phenytoin therapy. Two patients had more serious reactions after the cutaneous reaction. One patient developed exfoliative dermatitis, and 1 had a pseudolymphoma type syndrome. Both recovered. Patients with cutaneous reactions had higher absolute eosinophil counts (P = 0.01). Other laboratory parameters of the white blood count and the total lymphocyte counts did not differ significantly. Patients receiving dexamethasone had a higher incidence of rash, but this did not reach statistical significance. Because recent data have not documented a seizure-prophylactic effect of phenytoin, only a head-injured patient who has experienced a first posttraumatic seizure should receive the drug.

The favorable effect of early parenteral feeding on survival in head-injured patients

This prospective randomized controlled clinical trial compares the effects of early parenteral nutrition and traditional delayed enteral nutrition upon the outcome of head-injured patients. Thirty-eight head-injured patients were randomly assigned to receive total parenteral nutrition (TPN) or standard enteral nutrition (SEN). Clinical and nutritional data were collected on all patients until death or for 18 days of hospitalization. Survival and functional recovery were monitored in survivors for 1 year. Of the 38 patients, 18 were randomized to the SEN group and 20 to the TPN group. Demographically, the two groups of patients were similar on admission. There was no significant difference in the severity of head injury between the two groups as measured by the Glasgow Coma Scale (p = 0.52). The outcome for the two groups was quite different, with eight of the 18 SEN patients dying within 18 days of injury, whereas no patient in the TPN group died within this period (p less than 0.0001). The basis for the improved survival in the TPN patients appears to be improved nutrition. The TPN patients had a more positive nitrogen balance (p less than 0.06), and a higher serum albumin level and total lymphocyte count. More adequate nutritional status may have improved the patients' immunocompetence, resulting in decreased susceptibility to sepsis. The data from this study strongly support the favorable effect of early TPN on survival from head injury.

Cutaneous stimulation of the bladder in multiple sclerosis: a case report

We report on the use of transcutaneous electrical nerve stimulation to improve bladder emptying in a multiple sclerosis patient with a hypotonic bladder. Urodynamic testing demonstrated decreased bladder capacity, earlier first sensation and increased bladder pressure during trials of stimulation.

Failure of prophylactically administered phenytoin to prevent late posttraumatic seizures

This randomized double-blind placebo-controlled study was undertaken in a series of 179 patients to determine whether phenytoin administered soon after head injury lessens the incidence of late posttraumatic epilepsy. When delayed hypersensitivity to phenytoin developed, the patient was switched to phenobarbital. The patients were followed for 18 months to detect the occurrence of seizures and to serially measure plasma phenytoin concentrations. There was no significant difference in the percentage of patients having late seizures in the treated and placebo groups (p = 0.75). The time between injury and seizures did not significantly differ between the two groups. The results provide no support for the continued use of phenytoin in the low therapeutic range for prophylaxis against late posttraumatic seizures. It cannot be concluded that higher phenytoin plasma concentrations and higher compliance rates than obtained in this study would not have significantly decreased the occurrence of late posttraumatic epilepsy. The finding that no patient with a phenytoin plasma concentration of 12 microgram/ml or higher had a seizure raises the question of whether phenytoin in blood concentrations in higher therapeutic ranges might lessen the occurrence of posttraumatic epilepsy, and should be studied further. Posttraumatic epilepsy is a major public health problem deserving a large cooperative trial to determine if phenytoin at higher blood levels than obtained in this study, or other currently available or newly developed drugs, can prevent the occurrence of posttraumatic epilepsy.

Failure of prophylactically administered phenytoin to prevent early posttraumatic seizures

A randomized double-blind placebo-controlled study was carried out to determine whether phenytoin administered soon after injury lessens the incidence of epilepsy in the 1st week after severe head trauma. In this study, 244 patients were randomized into either a phenytoin or placebo group. The patients in the phenytoin group were administered phenytoin intravenously or intramuscularly within 24 hours of hospital admission. Patients in the placebo group received intravenous or intramuscular diluent. The patients were switched from parenterally administered phenytoin or placebo as soon as oral doses could be tolerated. Over 78% of the phenytoin patients had plasma concentrations of at least 10 micrograms/ml at 1, 3, and 7 days after injury. There was no significant difference in the percentage of patients having early seizures in the treated and placebo groups (p = 0.99). There was no significant difference in the interval from injury to first seizure between the treated and placebo groups (p = 0.41). The early administration of phenytoin did not lessen the occurrence of seizures in the 1st week after head injury. Since the effectiveness of seizure prophylaxis has not been established, the authors suggest that anticonvulsant drugs be administered only after an early seizure has occurred.

Failure of prophylactically administered phenytoin to prevent post-traumatic seizures in children

We report the results of a randomized, double-blind, placebo-controlled study to determine whether phenytoin administered soon after a head injury lessens the incidence of late post-traumatic epilepsy in children. 41 patients were randomized into either a phenytoin or placebo group and followed for 18 months. The patients were administered phenytoin or placebo intravenously or intramuscularly within 24 h of hospital admission. The patients were parenterally administered phenytoin or placebo until oral doses could be tolerated. There was no significant difference in the percentage of children having seizures in the treated and placebo groups (p = 0.25).