Through a glass darkly: using behavior to assess pain

Behavior assessment is crucial to the process of evaluation of pain and discomfort in veterinary patients. Behavioral responses to pain and other stressors are a function of the interaction between the individual and its environment, and are influenced by many factors including species, breed, age, sex, source of pain, and coexisting disease. Behavioral changes associated with acute postoperative pain typically peak within 24 hours and wane progressively thereafter. The intensity and duration of postoperative pain correlate with the location and extent of tissue injury, but there is much inter-patient variation of each characteristic. Published methods of systematic evaluation of pain in animals include objective measures of physiologic responses to experimental pain, subjective or semi-objective assessment of postoperative behavior, and quantitative measures of postoperative behavior and physiology. The techniques of quantitative measures of behavior are similar to pain-rating instruments developed for use in young children. Although objective assessment tools are difficult to develop and time consuming to apply, their methodological rigor and objectivity allow evaluation of behavior with minimal observer bias. Until objective assessment tools become widely used clinically, the best approach is to actively seek out evidence of pain in our patients, assuming its presence whenever there is tissue injury or inflammation.

European Union System for the Evaluation of Substances (EUSES). Principles and structure

In the European Union, Directive 92/32/EC and EC Council Regulation (EC) 793/93 require the risk assessment of new and existing substances, respectively. Principles for this risk assessment have been laid down, supported by a detailed package of Technical Guidance Documents. Against this background the European Union System for the Evaluation of Substances (EUSES) has been developed. This software can be used to carry out tiered risk assessments of increasing complexity on the basis of increasing data requirements. The exposure assessment, effects assessment and risk characterisation are carried out for environmental populations as well as for human beings, including workers, consumers and man exposed through the environment. EUSES is the result of a co-ordinated effort of EU Member States, the European Commission and the European Chemical Industry.

Effect of patient-selected intensive insulin therapy on quality of life

The purpose of the study was to assess quality of life in patients with IDDM in relation to the type of insulin therapy. Two patient cohorts were studied. In cohort A, 77 patients deliberately intensified their traditional insulin injection therapy from up to two daily injections with syringe to multiple daily injections with insulin-pen; in cohort B, 55 patients changed from intensive therapy with pen to insulin pump-treatment (CSII). The therapeutic regimens were changed during a 5-day in-patient treatment and teaching course. The DCCT questionnaire was applied before and up to 6 months after changing of therapy. Treatment satisfaction increased after intensification of insulin therapy in both groups, mainly due to greater flexibility with leisure-time activities, and with the diet. Pump-users reported reduced problems with hypoglycemia (P < 0.02). HbA1c indicating acceptable metabolic control already before the study, remained unchanged. Therapy-associated inconvenience, mainly in association with lifestyle, improved in IDDM patients deliberately intensifying their insulin therapy by pens or pumps (CSII). Pump-treatment, rather than pen-therapy, conferred particular protection from hypoglycaemia.

[Enuresis nocturna--parents' and therepists' attitudes]

In a questionnaire study concerning voiding habits among seven year-old children starting school the prevalence of enuresis nocturna was 13.4% among girls and 22.2% among boys. For 5.4% of girls and 8.2% of boys the symptom occurred at least once a week. Half of the children had secondary enuresis. Forty-six percent had consulted their doctor about the problem and 44% had received some kind of treatment. Ten percent had tried an alarm bell and 33% had tried desmopressin.

European Union research strategies on vaccines

Vaccination presents one of the most cost-effective approaches to the majority of infectious diseases showing strong reductions in public health costs. Vaccination led to the eradication of smallpox, and we are moving now close to eradicating polio. Vaccines might also serve as therapeutic agents against diseases such as herpes and novel molecular biology techniques could provide possibilities for the development of new vaccines against cancer. However, despite the tremendous progress in preventing infectious diseases by vaccination, these diseases still account for 17 million of the 50 million deaths in the world each year. In economic terms, European private and public institutions led the world in introducing vaccines and currently provide over 65% of the vaccine volume supplied to developing countries. Aware of its increasing responsibilities in promoting research and public health and of the challenges posed by the reorganization of the world market, the European Commission has launched a series of initiatives in vaccine research and development to encourage cooperation between European industry, public institutions and academia and to support common research projects to the benefit of every Member State and the Community as a whole.

Risk assessment and management of new and existing chemicals

An evaluation was made of the recently developed risk assessment methodologies for new and existing chemicals in the European Communities. The evaluation also included the methodologies to prioritize chemicals and procedures for risk management, i.e., the (draft) guidance document for the development of strategies for risk reduction. The way in which chemicals are prioritized is accepted with only very few comments. Clear progress has been made in the development and harmonization of risk assessment methodologies and the application of estimation methodologies. Nevertheless, improvements are necessary for the estimation of consumer and occupational exposure, the derivation, use and transparency of assessment factors for chemicals and classes of chemicals based on the mode of toxic action, environmental exposure models and their validation and relation with monitoring data. As far as risk management is concerned it was recommended to improve the integration of the myriad of directives and regulations, to clarify definitions, to provide clear guidance on the determination and weighing of advantages and implications of risk reduction measures and to develop tools, including voluntary agreements, to speed up the slow chemical-by-chemical approach.

Workplace violence in the hospital psychiatric setting. An occupational health perspective

1. Assault directed against psychiatric staff is emerging as a serious occupational health problem. Governmental regulatory agencies, unions, and academic research have identified workplace assault in the psychiatric setting as a serious workplace health issue. 2. Violence directed against psychiatric nursing personnel is increasing. Increases in assault are related to shorter hospitalizations, cutbacks in mental health services, and the increasing number of clients with criminal histories and personality disorders. 3. Reduction in staff assault can best be accomplished using an injury epidemiology occupational health focus. Identifying hazards, energy transfer mechanisms, and other environmental factors contributing to staff injuries can reduce or eliminate the morbidity associated with client assault.

Induction of immunosuppression by microemulsion cyclosporine in liver transplantation

Twenty-five liver transplant patients were administered liquid microemulsion cyclosporine (Neoral, 5 mg/kg b.i.d.) via a nasogastric tube until they could take oral medication. The first dose was given within 6 hr after surgery. Adequate trough levels of cyclosporine were obtained from the first postoperative day. The total exposure to the drug was low on the first postoperative day, but a significantly improved pharmacokinetic profile with a high maximal concentration and a low time to maximal concentration was found from the second postoperative day. The absorption from Neoral increased during the first week. After 1 week, a low within-patient variation coefficient for dose-adjusted cyclosporine trough levels was found (17%). The between-patient variation coefficient was low during the whole postoperative period (31%). We conclude that in liver transplant patients adequate immunosuppressant blood levels of cyclosporine can be obtained in the immediate postoperative period using Neoral without the need to go to the intravenous form of the drug.

Development and standardization of solid phase assays for the detection of anti-neutrophil cytoplasmic antibodies (ANCA). A report on the second phase of an international cooperative study on the standardization of ANCA assays

Anti-neutrophil cytoplasmic antibodies (ANCA) are diagnostic markers for systemic vasculitis. They are classically detected by an indirect immunofluorescence test using normal donor neutrophils as substrate. This assay lacks antigenic specificity and is not quantitative. The 'EC/BCR Project for ANCA Assay Standardization' is an international collaboration study with the aim to develop and standardize solid phase assays for ANCA detection. In this part of the study the isolation and characterization of proteinase-3 and myeloperoxidase, the two main target molecules for ANCA, and the development and standardization of ELISAs with these antigens are described. Six laboratories successfully isolated purified proteinase-3 preparations that could be used. Three of these preparations, together with one myeloperoxidase preparation, were subsequently used for ANCA testing by ELISA. The ELISA technique was standardized in two rounds of testing in the 14 participating laboratories. The coefficient of variation of these new assays decreased from values of approx. 50% in the first round to approx. 20% in the second round. We conclude that purified proteinase-3 and myeloperoxidase can be used in standardized ELISAs for ANCA detection. Whether such procedures offer advantages over the IIF test will be determined in a prospective clinical study.

Effect of progesterone on prostaglandin F2 alpha secretion and outcome of pregnancy during cloprostenol-induced abortion in mares

OBJECTIVES

To determine the role of progesterone in the regulation of endogenous prostaglandin F2 alpha (PGF2 alpha) secretion during cloprostenol-induced abortion and to investigate use of progestins to prevent prostaglandin-associated abortion.

ANIMALS

16 pregnant mares.

PROCEDURE

To induce abortion, cloprostenol (250 micrograms/d) was administered daily until fetal expulsion or for up to 5 days. In experiment 1, 8 mares, 98 to 153 days' pregnant, received progesterone (300 mg/d) at 24-hour intervals for 5 days, starting 18 hours after the first cloprostenol administration. In experiment 2, 8 mares, 93 to 115 days' pregnant, received altrenogest (44 mg/d) at 24-hour intervals, starting 12 hours after the first cloprostenol administration. Historic control mares, 82 to 102 days' pregnant, received cloprostenol (250 micrograms/d) daily until fetal expulsion.

RESULTS

In control mares, fetal expulsion occurred after 2 to 3 cloprostenol administrations and was associated with significant increases in PGF2 alpha secretion. Abortion did not occur in 5 of 8 progesterone-treated mares and 8 of 8 altrenogest-treated mares, and endogenous PGF2 alpha secretion was inhibited, compared with values in aborting mares.

CONCLUSION

Circulating progestogen concentrations may have a role in the outcome of pregnancy during prostaglandin-induced abortion. Altered prostaglandin secretion may be a reflection of a direct effect of progesterone or may be caused by the abortion process.

CLINICAL RELEVANCE

Progestogens might be useful for prevention of abortion in mares in which pregnancy is at risk owing to diseases that are associated with excess prostaglandin secretion.

[Clinical consequences of intranasal insulin therapy in insulin-dependent diabetes mellitus]

Metabolic control, hypoglycaemia frequency and nasal mucosal physiology were evaluated in 31 insulin-dependent diabetics treated with intranasal insulin at mealtimes for one month and with subcutaneous fast-acting insulin for another month in a randomized crossover trial. During both periods the patients were treated with intermediate-acting insulin at bedtime. Six of the patients were withdrawn from the study during intranasal insulin therapy due to metabolic dysregulation. Insulin concentrations increased more rapidly and decreased more quickly during intranasal as compared with subcutaneous insulin administration. Metabolic control, assessed by haemoglobin A1c concentrations, deteriorated after intranasal as compared with subcutaneous insulin therapy. The bioavailability of intranasally applied insulin was low, since intranasal insulin doses were approximately 20 times higher than subcutaneous doses. The frequency of hypoglycemia was similar during intranasal and subcutaneous insulin therapy, and nasal mucosal physiology was unaffected after intranasal insulin. We conclude that due to low bioavailability and to a high rate of therapeutic failure, intranasal insulin treatment is not a realistic alternative to subcutaneous insulin injections at the present time.

Histamine releasing cells of the newborn. Mast cells from the umbilical cord matrix and basophils from cord blood

The cellular branch of the immune defence in the newborn has been shown to differ from adults in a number of ways. This report presents new data on the functions of the histamine-secreting cells of the newborn. Mast cells of the newborn were obtained from the human umbilical cord by enzymatic dispersion. The granules of the mast cells of the umbilical cord were found to contain both chymase and tryptase by immunohistochemical staining, and the presence of cell-bound IgE on the mast cell surface was demonstrated by staining sections of umbilical cord with peroxidase-conjugated anti-IgE. The enzymatic dispersion yielded 12,660 mast cells per gram umbilical cord (median), range 2,500-60,300 (n = 48). The mast cells were found to constitute 3.1% of the total nucleated cells in the dispersate (median), range 1.5-3.8%. The histamine release from these cells was measured using a glass microfibre-based method. Both the umbilical cord mast cells and the cord blood basophils released histamine stimulated with anti-IgE, concanavalin A and the calcium ionophore A23187. In contrast to mast cells from adult tissue, the phorbol ester TPA was found to be an efficient secretagogue in both mast cells and basophils from the newborn. After maximal stimulation with anti-IgE and phorbol ester the quantity of histamine released per millilitre of blood was significantly higher in cord blood than in adult blood. The spontaneous histamine release from cord blood basophils was also significantly higher than from adult blood basophils. The mast cells found in the umbilical cord matrix and the cord blood basophils represent a readily available source of metabolically active histamine releasing cells for exploration of the role of histamine-secreting cells in newborn immune defence.

Testosterone secretion during early pregnancy in mares

We have characterized the testosterone secretion pattern during the first 80 d of pregnancy in mares and determined the sources that contribute to circulating testosterone levels during this period. Ten untreated, pregnant mares (Group 1), 10 altrenogest-treated, pregnant mares (Group 2), and 10 altrenogest-treated, pregnant mares in which the CL was eliminated by administration of PGF-2alpha on Day 16 (Group 3) were used in this study. Complete luteolysis occurred following PGF-2alpha administration in all mares in Group 3. Six of the 10 mares in Group 3 did not have an active CL until after Day 60 of pregnancy (Group 3a) and were included in the analysis. The remaining four mares developed a new CL on Days 32, 40, 43 and 49 of pregnancy and were excluded from analysis. Mares without a functional CL (Group 3a) had significantly lower testosterone concentrations than mares with a functional CL (Groups 1 and 2), during the period before equine chorionic gonadotropin (eCG) secretion. At the onset of eCG secretion, testosterone concentrations increased rapidly but the rate of increase decreased with time in mares with a functional CL (Groups 1 and 2). In mares without a functional CL (Group 3a), testosterone concentrations did not increase at the onset of eCG secretion but increased at a gradually increasing rate after Day 50. The lower testosterone concentration in mares without a functional CL before eCG secretion suggests that the CL contributes significantly to the circulating testosterone concentration during the period before eCG secretion. The close time relationship between the onset of eCG secretion and the increase in testosterone secretion in mares with a functional CL and the lack of a testosterone increase in pregnant mares without a functional CL suggest that the increase in testosterone secretion after Day 35 of pregnancy is the result of eCG-stimulated, luteal testosterone synthesis.

Tissue disaggregation for flow cytometric DNA analysis: comparison of fine-needle aspiration and an automated mechanical procedure

Flow cytometric DNA analysis was performed on unfixed frozen samples from 56 breast cancer patients. From each patient, two samples were analyzed. The only difference in the handling of the paired samples was the mechanical disaggregation of one sample by fine-needle aspiration compared to an automated mechanical disaggregation method (Medimachine) of the other sample. With the two methods for tissue disaggregation, the same resolution of the DNA histograms was obtained, indicated by median coefficients of variation (CV) of 1.5% for the DNA diploid G1 peaks. Also, the frequencies of DNA diploid and aneuploid cases as well as the fractions of DNA aneuploid cells were comparable. This indicates that the two methods did not differ in ability to detect DNA aneuploid tumor clones. Automated mechanical disaggregation resulted in DNA histograms with significantly less debris and with lower S-phase fractions. In practice, the procedure of automated mechanical disaggregation was rapid, easy, and safer because of minimal handling of the unfixed tissue compared to the fine-needle aspiration.

Para-[18F]fluorobenzylguanidine kinetics in a canine coronary artery occlusion model

BACKGROUND

The kinetics of para-[18F]fluorobenzylguanidine ([18F]PFBG) were investigated in a canine coronary artery occlusion model.

METHODS AND RESULTS

Five dogs were imaged by positron emission tomography (PET) before and after complete surgical ligation of the left anterior descending coronary artery. PET studies included a 10-minute dynamic [13N]NH3 perfusion scan, followed 1 hour later by 3-hour dynamic [18F]PFBG scanning. [18F]PFBG and [13N]NH3 images demonstrated homogeneous myocardial uptake/perfusion before infarction. One hundred eighty minutes after [18F]PFBG administration, myocardial accumulation was decreased by 60% (day 2, 0.0065% +/- 0.0015% injected dose/ml) and 58% (day 16, 0.0069% +/- 0.003% injected dose/ml) compared with a similar myocardial region of interest from the preinfarction (0.016% +/- 0.005% injected dose/ml) study. Myocardial accumulation of [13N]NH3 at 9 minutes showed a 52% (day 2) and 7% (day 16) decrease compared with the preinfarction study. The accumulation of [18F]PFBG in the infarction was decreased significantly at 120 and 180 minutes on all postinfarction studies (p = 0.01). In three dogs a significant decrease in the myocardial norepinephrine concentration was documented in the area of infarction (237 +/- 94 ng/gm) versus the noninfarcted (1018 +/- 48 ng/gm) myocardium (p = 0.001).

CONCLUSIONS

A decreased accumulation of [18F]PFBG was observed in the area of myocardial infarct in this canine model. The magnitude of the decrease in [18F]PFBG was larger than that seen with [13N]NH3 on day 16 after infarction, suggesting reperfusion and persistent sympathetic neuronal dysfunction.

[Involuntary diurnal urinary incontinence among children--is it curable?]

Thirty-two children aged 5-13 years were treated with urotherapy for daywetting. After treatment and observation for three months 41% became dry, 38% were improved and 16% were unchanged. Two patients were lost to follow-up. Our conclusion is that urotherapy has a place in the treatment of daywetting in children that are well-motivated to cooperate.

The cervical spine in rheumatoid arthritis: relationship between neurologic signs and morphology of MR imaging and radiographs

OBJECTIVE

Comparison of clinically observed neurologic long tract signs in a heterogeneous group of patients with rheumatoid arthritis (RA), with morphologic abnormalities of the cervical spine as depicted on radiographs and magnetic resonance (MR) images.

DESIGN

The patients were prospectively assigned to one of three classes on the basis of their neurologic status. Lateral cervical spine radiographs and sagittal T1-weighted and gradient echo images were performed. The qualitative MR features evaluated were erosion of the dens and atlas, brain stem compression, subarachnoid space encroachment, pannus around the dens, appearance of the fat body caudal to the clivus, and the signal intensity of the pannus. The quantitative imaging parameters were the cervicomedullary angle and the distance of the dens to the line of McRae.

PATIENTS

Sixty-three consecutive patients with RA and subjective symptoms, especially neck or occipital pain, and/or clinical objective signs consistent with a compromised cervical cord were included in this study.

RESULTS AND CONCLUSIONS

Damage documented with radiographs and MR imaging in patients with RA is often severe, even in those without neurologic signs (class 1). None of the abnormalities confined to the atlantoaxial level correlated significantly with neurologic classification. Subarachnoid space encroachment anywhere in the entire cervical spine did correlate significantly with neurologic classification.

Sustained-release metoclopramide plus methylprednisolone versus placebo plus methylprednisolone as antiemetic prophylaxis during non-cisplatin chemotherapy. A randomized double-blind cross-over trial

In a randomized double-blind cross-over trial, sustained-release metoclopramide (S) plus methylprednisolone (M) was compared with placebo (P) plus methylprednisolone as antiemetic prophylaxis during two cycles of non-cisplatin chemotherapy. S was administered as 60 mg every 12 h commencing on the evening before chemotherapy up to total of 300 mg metoclopramide in 2.5 days. Evaluation of nausea and vomiting was done by self-assessment schemes and visual analog scales. Fifty patients were included and 36 fulfilled both cycles. Mild nausea and vomiting were experienced by 81% and 83% in the S + M and P + M groups, respectively, while 42% and 39% showed complete control of nausea and vomiting during the first day of treatment. Moderate-dose S did not add to the antiemetic efficacy of M in non-cisplatin chemotherapeutic regimens.

Exploring the benefits of full-service EDI networks

The financial and administrative rewards of electronic claims transmission have been realized by the healthcare industry for more than a decade. However, some EDI administrators see a need for full-service EDI networks that can save providers thousands of dollars in transactions fees. By accessing a full-service EDI network, providers can send claims to any payer through one source. Providers sending claims electronically no longer need to sort claims for transmission or print to paper; they can submit all claims to one source.

[Shore-term stimulation with myeloid growth factors expands bone marrow hematopoiesis. A magnetic resonance spectroscopic study]

The present study is intended to investigate the expansion of haematopoiesis by localised volume selective proton magnetic resonance spectroscopy (MRS) during treatment with myeloid growth factors. Six consecutive patients were treated with daily subcutaneous injections of recombinant human granulocyte colony-stimulating factor (rhG-CSF, n = 2) or granulocyte-macrophage colony-stimulating factor (rhGM-CSF, n = 4) for five days before marrow harvest. MRS investigations were performed prior to treatment (day 0), day 5 and day 12. The patients responded with a rise in blood absolute neutrophil count from median 3.3 x 10(9)/l (range 1.3-7.3 x 10(9)/l) before to 15.6 x 10(9)l (range 6.8-22.0 x 10(9)/l) after treatment. Concomitantly an increase in bone marrow cellularity and myeloid:erythroid ratios documented the stimulation of myelopoiesis. During priming, the light-density cell proliferation rate in marrow samples increased from median 21.9 (range 4.5-31) x 10(3) cpm to 54.7 (range 13.9-94) x 10(3) cpm and the total number of myeloid progenitors enumerated as day 7/14 GM-CFUs per volume aspirated marrow increased from median 11/8 x 10(3) (range 4.0-87.5/2.2-103.0) to 64/76. x 10(3) (range 28.4-1180.6/23.2-2850.0). MRS detected a significant increase in bone marrow "relative water content" day 12, one week after myeloid growth factor treatment was stopped, from median 30.5% (range 16-45) to 79% (range 56-93) (p < 0.05). Haematopoiesis was concommittantly detected in new areas of femur.(ABSTRACT TRUNCATED AT 250 WORDS)

An Investigation of Clustering as a Tool in Quantitative Structure-Activity Relationships (QSARS)

Abstract By means of clustering, one is able to manage large databases easily. Clustering according to structure similarity distinguished the several chemical classes that were present in our training set. All the clusters showed correlation of log WS with log K ( OW ) and melting point, except EINECS-cluster 1. This cluster contains only chemicals with melting points below room temperature, resulting in a log WS-log K( OW ), relationship. The observed weak correlation for this cluster is probably due to the insufficient number of available screens. Such a limited amount of screens allows relatively very different chemicals to share the same cluster. Using statistical criteria, our approach resulted in three QSARs with reasonably good predictive capabilities, originating from clusters 1639, 3472, and 5830. The models resulting from the smaller clusters 6873, 8154, and 16424 are characterised by high correlation coefficients which describe the cluster itself very well but, due to our stringent bootstrap criterion, they are close to randomness. Clusters 6815 and 18083 showed rather low correlations. The models originating from clusters 1639, 3472, and 5830 proved their usefulness by external validation. The log WS-values calculated with our QSARs agreed within 1 log-unit to these reported in the literature.

Quantification of right ventricular function with magnetic resonance imaging in children with normal hearts and with congenital heart disease

In clinical treatment of children with congenital heart disease (CHD) assessment of right ventricular (RV) function is important. Available imaging techniques have been of limited value because of technical factors and the complex geometry of the right ventricle. To validate magnetic resonance (MR) imaging measurements of RV function in children, gradient echo MR imaging of both ventricles and MR flow mapping of great vessel and tricuspid flow was performed in 20 children with CHD affecting the right ventricle and in 22 healthy children ranging in age from 5 to 16 years. Close correlation between RV versus LV stroke volumes (r = 0.96) and RV stroke volume versus great artery (r = 0.97) or tricuspid flow (r = 0.97) was observed with small interobserver and intraobserver variability. Results of healthy children were end-diastolic volume: 70 +/- 9 ml/m2, end-systolic volume: 21 +/- 5 ml/m2, and ejection fraction: 70% +/- 4%. In the patient groups clinically important differences were noted. We conclude that MR imaging provides accurate noninvasive measurements of RV function in healthy children and patients with (operated) CHD.