Open label tissue plasminogen activator for stroke: The Oregon experience

BACKGROUND

Tissue plasminogen activator (t-PA) is the first effective treatment for stroke. This study sought to explore the outcome of patients treated with t-PA in the community after approval of its use in the treatment of stroke in June, 1996.

METHODS

All patients with acute stroke within the 6-hospital Oregon Stroke Center network were screened for potential t-PA treatment. Baseline and 24-hour outcome assessments were performed with the use of the National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT); 3-month outcome was evaluated by using the Modified Rankin scale.

RESULTS

Thirty-three patients who met the criteria for t-PA therapy were treated within 3 hours of symptom onset. All but 2 strokes were in the anterior circulation; 48.5% were cardioembolic. The NIHSS scores at 24 hours after administration of t-PA (mean, 14.7) showed modest gains from baseline NIHSS scores (mean, 16.6). Twelve patients (36%) had minimal or no deficits at 3 months. Three patients (9%), all of whom had baseline NIHSS scores of 20 or more, had symptomatic intracranial hemorrhages, 2 of which were fatal (6%).

CONCLUSION

This study shows the feasibility of treating acute stroke with t-PA in the community. The percentage of fully recovered patients at 3 months mirrored those in the National Institute of Neurologic Disorders and Stroke (NINDS) trial.

Fatigue does not correlate with the degree of hepatitis or the presence of autoimmune disorders in chronic hepatitis C infection

BACKGROUND

Fatigue is probably the most commonly reported symptom in chronic hepatitis C virus (HCV) infection. It is unclear whether fatigue is related to the severity of underlying liver disease or other autoimmune disorders often described with chronic HCV infection.

OBJECTIVE

To quantify fatigue in terms of its impact on quality of life in a homogeneous cohort and examine its relationship to the status of liver disease or associated autoimmunity.

METHODS

The Fatigue Impact Scale (FIS) questionnaire (Fisk et al. Clin Infect Dis 1994; 18:S79-S83), a recently validated psychometric tool for assessing patients' perceptions of the functional limitations attributable to fatigue (40 statements; three subscales: physical, cognitive and psychological; maximum score = 160), was applied to a cohort of Irish women who were PCR-positive for HCV genotype 1b via inoculation with contaminated anti-D products in 1977. RIBA-positive, PCR-negative patients (n = 20) and healthy age-matched women (n = 50) served as controls. The degree of hepatitis was assessed using the Knodell histological activity index (HAI) score on previous liver biopsies. Clinical and laboratory evidence of cryoglobulinaemia, Sjogren's syndrome, connective tissue diseases, autoimmune thyroid disease and glomerulonephritis was sought.

RESULTS

The mean FIS score of the 66 PCR-positive women (mean 78+/-36; range 7-153) was significantly higher than in age-matched controls (mean 31+/-24, range 0-78, P<0.001) but not statistically different from that of the RIBA-positive, PCR-negative group. The FIS score did not correlate with the HAI score (median HAI = 4; range 2-9; Pearson's correlation coefficient r=0.01, P=0.9). Significant levels of cryoglobulins were detected in 10 (15.2%). The sicca complex was diagnosed in six patients, three of whom had associated cryoglobulinaemia. Thyroid antibodies, anti-nuclear antibody, rheumatoid factor, antimitochondrial antibody and anti-smooth muscle antibody were detected in 15.2%, 6%, 4.5%, 4.5% and 1.5%, respectively. There was no significant difference in the FIS score between the groups with autoimmune diseases and those without. The FIS score of the nine patients previously treated with interferon was not statistically different from the untreated group (P=0.39).

CONCLUSION

The perceived functional impact of fatigue on quality of life is significantly higher in patients with chronic HCV genotype 1b infection compared to healthy controls. However, it is unrelated to the degree of hepatitis and cannot be accounted for by the co-existence of autoimmune disorders alone.

Characterization of the autoantibody responses to recombinant E3 binding protein (protein X) of pyruvate dehydrogenase in primary biliary cirrhosis

Autoantibodies to the pyruvate dehydrogenase complex (PDC) are present in the serum of more than 95% of patients with primary biliary cirrhosis (PBC), the major epitope being the inner lipoyl domain of the E2 component. Immunoblotting suggests a similar prevalence of antibodies to a tightly associated lipoic acid-containing protein, E3 binding protein (E3BP). Attempts to resolve E3BP from E2 have been unsuccessful, restricting study of the nature and significance of antibody responses to the individual proteins. In particular, it is unclear (1) whether there is true cross-reactivity between E3BP and E2 and, if so, which is the originating response and (2) whether autoantibodies preferentially bind a lipoylated epitope on E3BP as is the case with PDC-E2. In this study, complementary DNAs encoding rE2, full-length rE3BP, its single lipoyl domain (rLip), and core domain (rE3BPCore) were cloned, and the proteins were expressed in Escherichia coli. Sera from 47 PBC patients were studied by immunoblotting and enzyme-linked immunosorbent assay (ELISA) against rE2, rE3BP, rE3BPCore, and both unlipoylated (U) and lipoylated (L) rLip. All sera were reactive by ELISA to some degree with all recombinant proteins except rE3BPCore, to which only 6 of 47 showed any reactivity. Significant correlations (P <.0001) were observed when comparing absorbance values for rE3BP with both rLip (U) (r = 0.793) and (L) (r = 0.963). The mean absorbance for rLip (U, 0.26 +/- 0.05) was, however, significantly lower than the absorbance for rLip (L) (0.78 +/- 0.12; P <.0001). After probing by immunoblotting and elution of antibodies from rE2 and rE3BP, subsequent reprobing against the components in whole PDC revealed true cross-reactivity. In summary, the response to E3BP is primarily directed against the lipoylated domain of the protein. It still remains unclear, however, whether the initial breakdown of tolerance is to E2 or E3BP.

An HL7 (Health Level Seven) overview

HL7 is an organization with a short history and more activity now than ever before. Opportunities abound within HL& to assist in the development of the automation of healthcare and the deployment of information systems that create and support the electronic medical record. Finally, the continual advances in information systems technology enable HL7 to do more to meet the healthcare industry's needs.

The use of regenerable, affinity ligand-based surfaces for immunosensor applications

The regeneration of antibody-binding surfaces is of major importance for re-usable sensor formats such as required for direct 'real-time' biosensing technologies and is often difficult to achieve. Antibodies commonly bind the antigen with high avidity and may themselves be sensitive to regeneration conditions. The interaction of polyclonal anti-chlorpyriphos antibody with an immobilised chlorpyriphos-ovalbumin (chlor-oval) conjugate and the interaction of soluble recombinant CD4 with covalently immobilised anti-CD4 IgG are presented in order to highlight these difficulties. Affinity-capture is suggested as an alternative format as it facilitates surface regeneration, directed immobilisation and the attainment of interaction progress curves that conform to the ideal pseudo-first-order kinetic interaction model. Protein A, protein G and polyclonal anti-mouse Fe-coated surfaces were used to observe the interaction of captured anti-GST monoclonal antibody with glutathione-s-transferase (GST). It was shown that a protein A affinity-capture surface produced ideal interaction progress curves while both protein G and polyclonal anti-mouse Fe resulted in systemic deviations.

Randomised controlled effectiveness trial of a needs-based psychosocial intervention service for carers of people with schizophrenia

BACKGROUND

Family interventions are effective in reducing relapse in patients with schizophrenia, but there is little work demonstrating the effectiveness of the interventions in routine service settings.

AIMS

To test the effectiveness of a needs-based family intervention service for patients recruited as out-patients and their carers, including those of low expressed emotion status.

METHOD

Carers of out-patient schizophrenia sufferers selected only on illness history factors were randomly allocated to receive either family support alone or in combination with systematic psychosocial interventions based on an assessment of need. Delivery of family interventions attempted to involve the clinical team.

RESULTS

Relapse outcomes were superior for family-treated patients at six-month follow-up, although most of the clinical and symptom patient variables assessed remained stable, as did measures of carer burden.

CONCLUSIONS

The study demonstrated the effectiveness of family interventions in routine service settings. Problems with staff, patient and carer engagement and participation were identified.

Validation of assays for use with combination vaccines

A general methodology is presented for the validation of assays used for testing combination vaccines. The presentation is detailed and technical as our intention is to address challenges that we have encountered in the design and statistical analysis of assay validation studies. There are several noteworthy features which render the approach particularly useful in practice. It employs a statistical experimental design approach to the investigation of assay ruggedness with respect to manufacturing variability; it makes use of the assay variability results to determine the level of test-run replication necessary to achieve precision compatible with the product specifications; and, it provides a generic approach to assay validation. With combination vaccines, as with other pharmaceuticals, the analytical methods for release and stability must be validated early in the development programme Several things, though, distinguish this task with combination vaccines: (1) assays are typically pre-existing and often have been validated for use with an established sample matrix, e.g. a monovalent formulation; (2) sample matrices are complex and therefore more subject to manufacturing variability and more likely to cause assay interferences; and (3) the analytical workload is considerable due to the number of antigens. The methodology presented here was developed jointly by Merck Research Laboratories (West Point, PA) and Pasteur Mérieux Connaught, Inc. (Swiftwater, PA). Many of the issues discussed here have application outside of combination vaccines and are common features of all assay validations.

Where need meets opportunity: youth development programs for early teens

Early adolescence is a time of burgeoning independence, autonomy, and focus on peers. It is also a time when individual interests, skills, and preferences become salient to young people. Not surprisingly, out-of-school programs designed to capture the interest of early teens are diverse in focus and varied in structure, ranging from sports teams to drop-in recreation centers, from museum apprenticeships to mentoring relationships between an individual teen and an adult. This article describes the array of various organizations that offer programs and services for youths in their early teens. It explains the philosophy of positive youth development that has emerged as a unifying theme in this long-standing but newly self-conscious field. Principles of best practice are reviewed, as are five key implementation challenges: increasing participation by youths; expanding access to programs, especially in low-income communities; improving funding; evaluating program effectiveness; and coordination with other youth services. The article closes with a discussion anticipating the new opportunities that accompany the attention and funding now going toward positive youth development programs that enrich the lives of young people through informal learning.

Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome

STUDY OBJECTIVE

To compare the 1-year cosmetic outcome of wounds treated with octylcyanoacrylate tissue adhesive and monofilament sutures and to correlate the early, 3-month, and 1-year cosmetic outcomes.

METHODS

We prospectively randomized 136 cases of traumatic laceration to repair with octylcyanoacrylate tissue adhesive or 5-0 or smaller monofilament suture. A wound score was assigned by a research nurse, and validated by a second nurse blinded to the treatment, at 5 to 10 days after injury (early), 3 months, and 1 year. Standardized photographs were taken at 3 months and 1 year and shown to a cosmetic surgeon blinded to the method of closure, who rated the wounds on a validated cosmesis scale.

RESULTS

We were able to examine 77 lacerations at 1 year for follow-up. No differences were found in the demographic or clinical characteristics between groups. Likewise, at 1 year no difference was found in the optimal wound scores (73% versus 68%, P =.60) or in visual analog scale cosmesis scores (69 versus 69 mm, P =.95) for octylcyanoacrylate and sutures, respectively. Agreement was poor between early and 3-month wound scores (kappa=.34; 95% confidence interval [CI],.10 to.58) but a strong association existed between 3-month and 1-year wound scores (kappa=.71; 95% CI,.52 to.90). We noted a moderate correlation between 3-month and 1-year results on the visual analog cosmesis scale (intraclass correlation,.48; 95% CI, .30 to.63).

CONCLUSION

One year after wound repair, no difference is noted in the cosmetic outcomes of traumatic lacerations treated with octylcyanoacrylate tissue adhesive and sutures. The assessment of wounds 3 months after injury and wound repair provides a good measure of long-term cosmetic outcome.

Diagnosis of spontaneous splenic rupture with emergency ultrasonography

Rapid evaluation of the hypotensive patient in the emergency department is essential. The availability of ultrasonography in the ED, performed by emergency physicians and surgeons, has made it easier to evaluate the hypotensive trauma patient. We describe a 44-year-old man transferred to our institution from a community hospital for evaluation of syncope and hypotension with no obvious cause. On arrival the patient began to complain of slight lower abdominal pain. The patient's physical examination revealed minimal abdominal tenderness. A rapid ultrasound examination performed at bedside revealed the presence of intraperitoneal fluid. Examination of the spleen suggested likely rupture. The patient was promptly taken to surgery for splenectomy and discharged home in 4 days.

Three-dimensional structure of the major autoantigen in primary biliary cirrhosis

BACKGROUND & AIMS

Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease characterized by the presence of antimitochondrial autoantibodies in patients' serum. The major autoantigen, recognized by antibodies from > 95% of patients with PBC, has been identified as the E2 component (E2p) of the pyruvate dehydrogenase multienzyme complex. Immunodominant sites on E2p have been localized to the inner of the two lipoyl domains, where the essential cofactor lipoic acid is attached covalently. The aim of this study was to determine the three-dimensional structure of the inner lipoyl domain of human E2p.

METHODS

The domain was expressed in Escherichia coli; after purification, its structure was analyzed using nuclear magnetic resonance spectroscopy.

RESULTS

The structure of the lipoyl domain from human E2p was determined, and the implications of the structure for autoimmune recognition were assessed.

CONCLUSIONS

Knowledge of the structure further defines the major epitope and may help in the design of antigen-specific immunotherapy for treatment of PBC.

Assessing relatives' needs for psychosocial interventions in schizophrenia: a relatives' version of the Cardinal Needs Schedule (RCNS)

BACKGROUND

The methodology for measuring the needs of patients with severe mental illness is now well established through the MRC Needs for Care Assessment Schedule and its modification in the form of the Cardinal Needs Assessment. This paper reports the rationale and construction of a relatives' version of the Cardinal Needs Schedule and looks at preliminary data reporting on reliability and validity.

METHODS

Potential problem areas for relatives were identified from the literature. The criteria determining Cardinal Needs for each problem included objective threshold, carer concern, and carer cooperation. The reliability of the Schedule was assessed in a study whereby 27 relatives of patients with established schizophrenic illness completed two Schedules administered by two independent raters within a short time period.

RESULTS

The Schedule was acceptably reliable for most areas of need although there were some difficulties associated with the cooperation criteria. Concurrent measures of relatives and patients including EE, relative distress and patient psychopathology indicated that the Relatives' Cardinal Needs Schedule shows acceptable validity when used with a sample of 45 relatives.

CONCLUSIONS

The paper suggests that the Schedule may prove to be a useful tool for both clinicians and researchers interested in establishing and evaluating family interventions.

Nurses' assessments and management of pain in children having orthopedic surgery

The specific aims of this research project were to (a) describe selected verbal, nonverbal, and physiological arousal indicators of the child's pain; (b) describe which pain indicators were most influential to nurses in decision-making about interventions for managing the child's pain; (c) describe pain interventions used by nurses; (d) compare postoperative analgesic orders to recommended dosages for the children; and (e) explore relationships between the child's self-report of pain and medication dosages administered. Subjects included 19 children aged 5-17 years who experienced 20 orthopedic surgical procedures (one child had two surgeries one week apart). Data were collected by staff nurses for the first five days after surgery. Pain levels were reported using the Oucher Scale. Postoperative pain was reported at moderate levels and showed only a gradual decrease throughout the hospital stay. Nonverbal pain indicators included crying and tense face. The child's complaint of pain and reported Oucher scores were most influential in influencing nurses to intervene in the child's pain. Nonpharmacological comfort measures included positioning and reassurance. All children received medications for pain; 49% of the orders were within the recommended therapeutic dosage range. A small but significant correlation was found between the child's reported pain level and the morphine equivalents of pain medication received. Recommendations included development of nursing flow charts that provide space to record pain levels and nursing interventions, in-service education for nurses on nonpharmacological interventions, and further research with a larger sample and a single pain rating scale.

A placebo-controlled trial of ranitidine in patients with early human immunodeficiency virus infection

Previous uncontrolled reports have suggested that H2-antagonists may possess immunomodulatory activity in human immunodeficiency virus (HIV)-infected patients. Such trials reported improvements in HIV-related symptoms, increased absolute CD4 cell numbers, and improvements in other measures of host immunity. The present trial was a randomized, placebo-controlled, double-blind trial of ranitidine 300 mg (orally twice daily) in subjects with early HIV infection (absolute CD4 cells, 400-700/mm3). Eighty-one subjects entered the trial and 73 completed 16 weeks on study medications. There were no significant differences in the time-weighted average change from baseline between the 2 treatment groups in absolute CD4 cell number, plasma HIV RNA level, or most other surrogate markers of HIV infection. Serum beta2-microglobulin levels were significantly lower in placebo than ranitidine recipients. Ranitidine should not be recommended for the treatment of HIV-infected patients unless it is used for established indications.

A case of auto-erotic asphyxia in a long-term psychiatric setting

The syndrome of auto-erotic asphyxia (AEA) involves the deliberate induction of cerebral hypoxia to produce or enhance sexual excitement. This sexual practice is normally only discovered when death results from the act because these individuals rarely seek professional advice. The practice of AEA in the living case presented here was initially misinterpreted as parasuicidal behaviour. This type of sexual behaviour should always be considered a differential for parasuicidal activity involving asphyxia. Aetiology, treatment and the need for health professionals to be aware of this syndrome are discussed.

The mouse atlas and graphical gene-expression database

The large amounts of gene-expression data on mouse development are now too extensive to be stored in any format other than that of a database. Furthermore, as this data is intrinsically graphical and as, in the early developmental stages at least, its boundaries do not map directly to those of anatomical tissues, the natural way to store it is in graphical format. We are therefore constructing a database able to handle such graphical gene-expression data by mapping it onto 3-D reconstructions of mouse embryos whose tissues have been delineated. This article reviews the progress that has been made in this project and describes its two major components, CD-ROMs of the 3-D reconstructions to be held on the user's computer and a gene-expression database that will be maintained at a host site, the two being linked over the internet by a complex Java-based interface for submitting data and querying the database.Copyright 1997 Academic Press Limited Copyright 1997Academic Press Limited