Randomized controlled trial of yoga and exercise in multiple sclerosis

OBJECTIVE

To determine the effect of yoga and of aerobic exercise on cognitive function, fatigue, mood, and quality of life in multiple sclerosis (MS).

METHODS

Subjects with clinically definite MS and Expanded Disability Status Score less than or equal to 6.0 were randomly assigned to one of three groups lasting 6 months: weekly Iyengar yoga class along with home practice, weekly exercise class using a stationary bicycle along with home exercise, or a waiting-list control group. Outcome assessments performed at baseline and at the end of the 6-month period included a battery of cognitive measures focused on attention, physiologic measures of alertness, Profile of Mood States, State-Trait Anxiety Inventory, Multi-Dimensional Fatigue Inventory (MFI), and Short Form (SF)-36 health-related quality of life.

RESULTS

Sixty-nine subjects were recruited and randomized. Twelve subjects did not finish the 6-month intervention. There were no adverse events related to the intervention. There were no effects from either of the active interventions on either of the primary outcome measures of attention or alertness. Both active interventions produced improvement in secondary measures of fatigue compared to the control group: Energy and Fatigue (Vitality) on the SF-36 and general fatigue on the MFI. There were no clear changes in mood related to yoga or exercise.

CONCLUSION

Subjects with MS participating in either a 6-month yoga class or exercise class showed significant improvement in measures of fatigue compared to a waiting-list control group. There was no relative improvement of cognitive function in either of the intervention groups.

A rare cause of anemia due to intestinal tuberculosis in a renal transplant recipient

A renal transplant recipient with stable allograft function presented with massive hemorrhagic diarrhea and severe anemia. No microbial infection could be found in stool cultures. Early colonoscopy showed severe colitis with ulceration. Histological samples confirmed granulomatous inflammation with acid-resistant Ziehl-Neelson-positive microorganisms of mycobacterial type. Polymerase chain reaction (PCR) analysis of native mucosal biopsies specified the infectious organism as Mycobacterium tuberculosis complex. The patient responded well to antimycobacterial therapy and was still asymptomatic after 6 months with a stable graft function. Our case shows that tuberculosis can be a severe clinical problem in transplant recipients. Most of the patients with intestinal tuberculosis, reported to literature, were diagnosed post mortem or after explorative laparotomy and bowel resection. Thus, intestinal tuberculosis should be considered when a transplant recipient shows abdominal symptoms with no clear evidence of another infection. Proper diagnosis and treatment resulted in a beneficial outcome in our patient.

New limits on the drift of fundamental constants from laboratory measurements

We have remeasured the absolute 1S-2S transition frequency nu(H) in atomic hydrogen. A comparison with the result of the previous measurement performed in 1999 sets a limit of (-29+/-57) Hz for the drift of nu(H) with respect to the ground state hyperfine splitting nu(Cs) in 133Cs. Combining this result with the recently published optical transition frequency in 199Hg+ against nu(Cs) and a microwave 87Rb and 133Cs clock comparison, we deduce separate limits on alpha/alpha=(-0.9+/-2.9) x 10(-15) yr(-1) and the fractional time variation of the ratio of Rb and Cs nuclear magnetic moments mu(Rb)/mu(Cs) equal to (-0.5+/-1.7) x 10(-15) yr(-1). The latter provides information on the temporal behavior of the constant of strong interaction.

Non-invasive physical treatments for chronic/recurrent headache

BACKGROUND

Non-invasive physical treatments are often used to treat common types of chronic/recurrent headache.

OBJECTIVES

To quantify and compare the magnitude of short- and long-term effects of non-invasive physical treatments for chronic/recurrent headaches.

SEARCH STRATEGY

We searched the following databases from their inception to November 2002: MEDLINE, EMBASE, BIOSIS, CINAHL, Science Citation Index, Dissertation Abstracts, CENTRAL, and the Specialised Register of the Cochrane Pain, Palliative Care and Supportive Care review group. Selected complementary medicine reference systems were searched as well. We also performed citation tracking and hand searching of potentially relevant journals.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing non-invasive physical treatments for chronic/recurrent headaches to any type of control.

DATA COLLECTION AND ANALYSIS

Two independent reviewers abstracted trial information and scored trials for methodological quality. Outcomes data were standardized into percentage point and effect size scores wherever possible. The strength of the evidence of effectiveness was assessed using pre-specified rules.

MAIN RESULTS

Twenty-two studies with a total of 2628 patients (age 12 to 78 years) met the inclusion criteria. Five types of headache were studied: migraine, tension-type, cervicogenic, a mix of migraine and tension-type, and post-traumatic headache. Ten studies had methodological quality scores of 50 or more (out of a possible 100 points), but many limitations were identified. We were unable to pool data because of study heterogeneity. For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). Other possible treatment options with weaker evidence of effectiveness are pulsating electromagnetic fields and a combination of transcutaneous electrical nerve stimulation [TENS] and electrical neurotransmitter modulation. For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. Other possible treatment options with weaker evidence of effectiveness are therapeutic touch; cranial electrotherapy; a combination of TENS and electrical neurotransmitter modulation; and a regimen of auto-massage, TENS, and stretching. For episodic tension-type headache, there is evidence that adding spinal manipulation to massage is not effective. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization. There is weaker evidence that spinal mobilization is more effective in the short term than cold packs in the treatment of post-traumatic headache.

REVIEWERS' CONCLUSIONS

A few non-invasive physical treatments may be effective as prophylactic treatments for chronic/recurrent headaches. Based on trial results, these treatments appear to be associated with little risk of serious adverse effects. The clinical effectiveness and cost-effectiveness of non-invasive physical treatments require further research using scientifically rigorous methods. The heterogeneity of the studies included in this review means that the results of a few additional high-quality trials in the future could easily change the conclusions of our review.

Platelets and capillary injury in acute humoral rejection of renal allografts

Platelet accumulation in glomerular capillaries (GC) and peritubular capillaries (PC) has pathogenetic importance in antibody-mediated hyperacute renal allograft rejection. CD61 is expressed constitutively by platelets, by platelet microparticles arising from platelet activation, and is readily detectable by immunohistochemistry. This study examined the immunohistochemical localization of CD61 in acute humoral rejection (AHR) of renal allografts to explore the relationship of platelet accumulation to antibody-mediated rejection. Two observers graded the extent of CD61 staining in PC and GC from 0 (none) to 2+ (>50%) in 15 renal allograft biopsy specimens with AHR and compared these with tissues from allografts with acute cellular rejection (ACR) (n = 23); acute calcineurin inhibitor toxicity (ACIT) (n = 21) with thrombotic microangiopathy (TMA) (n = 11) and tubular toxicity only (n = 10); acute tubular necrosis (ATN) (n = 16); acute renal vein thrombosis (RVT) (n = 4); and histologically unremarkable native kidneys (n = 26). Selected tissues were examined by electron microscopy and stained for CD34 by immunohistochemistry. Histologically unremarkable native kidney tissues had CD61 only in scattered small lumenal granules in GC and PC. Mural and occlusive lumenal CD61 deposits (>0.5+) were observed in 13 of 13 (100%) allograft tissues with GC thrombi due to AHR (1) and ACIT TMA (9) and RVT (3). Twenty-seven of 66 allografts (40.9%) without glomerular thrombi had >0.5+ GC CD61 in AHR (60%), ACR (26%), tubular ACIT (60%), and ATN (44%). More than trace (>0.5+) PC mural and lumenal CD61 deposits were seen only in AHR (53.3%) and ACR (30%). PC CD61 correlated with interstitial hemorrhage (r = 0.64), neutrophilic capillaritis (r = 0.47), and interstitial inflammation (r = 0.47) (P <0.001 for each). PC CD61 was observed in 11 of 11 foci of necrosis due to AHR, RVT, and ischemia. In AHR, capillaries with CD61 deposits had few platelets, numerous microvesicles and membrane fragments, severe endothelial injury seen on electron microscopy, and reduced capillary CD34 expression. CD61 detection by immunohistochemistry revealed products of capillary platelet activation in allograft biopsy specimens without light microscopic thrombi. Observations in this study suggest that intracapillary platelet activation occurs in response to graft capillary injury from many causes and may not be specific for antibody-mediated rejection.

Functional quality of molar crown occlusal surfaces in the different design modes of Cerec 2

The goal of the present study was to objectify whether the design modes of "Correlation", "Function", and "Extrapolation" of the Cerec 2 system are suitable for generating a functionally perfect occlusal surface of a first mandibular molar crown. For this purpose, an occlusal surface was waxed up according to the biomechanical concept of MH Polz, and this served as the reference occlusal surface. Four different Cerec 2 comparison crowns (produced in the laboratory, Extrapolation mode, Correlation mode, Function mode) were produced and the positions of the cusps were measured. It was shown that the Correlation mode delivers the most accurate results, and the manually produced occlusal surface also showed good results. The occlusal surfaces of the crowns produced according to the Extrapolation and Function mode were clearly inferior.

The effect of three different periodontal pre-treatment procedures on the success of telescopic removable partial dentures

In this prospective study, 120 teeth consisting of maxillary and mandibular canines and premolars were divided into three groups each containing 40 teeth. The teeth were assigned randomly in quadrants to three different periodontal treatment protocols. The first group was treated with professional prophylaxis only. The second group received additional deep scaling. With the third group, additional surgical periodontal flap surgery and scaling was performed. Both papillary bleeding index (PBI) and probing depth (PD) were evaluated before, during and after treatment. During the subsequent prosthetic treatment phase all teeth were then used as telescope abutments supporting a removable prosthesis. The documentation of the attachment level (AL) was then used as a clinical parameter. One year after the incorporation of telescopic removable partial dentures (RPDs), PD, PBI and AL were again evaluated. The resulting periodontal parameters were compared between the different groups using the general linear model (GLM) repeated measures and the Kruskal-Wallis test for non-parametric variables. Differences within the three treatment groups were determined using the t-test, e.g. the Wilcoxon test for dependent variables (P < 0.05). A significant decrease in inflammatory indices (PBI) was found for all types of periodontal treatment (P < 0.03 for all groups). Additionally, the reduction in PD was significant for all of the three groups (P < 0.001 for all groups). The greatest reduction in PD was observed in the group in which a surgical approach was used. Evaluation of the attachment level after the incorporation of the telescopic RPDs showed that tooth position did not influence the periodontal prognosis and that the use of telescopic RPDs exerted no ascertainable negative influence on the periodontium of the abutment teeth.

A study of the impact of long-term tobacco smoking on postoperative intensive care admission

Smoking is a risk factor for intra-operative pulmonary complications and a wide range of postoperative pulmonary, cardiovascular, infection and wound-related complications. These may all lead to unplanned postoperative intensive care admission. We tested the hypothesis that smokers have an increased incidence of postoperative intensive care admission and more postoperative complications than nonsmokers in a general and orthopaedic surgical population. The following information was assessed in 6026 surgical patients: age, sex and smoking status (pack-years), history of heart and lung disease, American Society of Anesthesiologists (ASA) physical classification, intensive care admission and postoperative complications. Two thousand five hundred and twenty-six (46%) were smokers but for 620 patients (10.3%) smoking status was not confirmed. Postoperative intensive care admission was required by 319 patients (5.3%). Patients with > 50 pack-years were admitted to the intensive care more frequently than were smokers with < or = 50 pack-years history and nonsmokers (p < 0.001). Ex-smokers with > 50 pack-years history had the same risk of postoperative admission to intensive care as smokers with > 50 pack-years history. Smokers admitted to intensive care with > 50 pack-years history had a higher incidence of chronic lung disease (p < 0.005) and heavy alcohol consumption (p < 0.001). These smokers also had a higher incidence of postoperative pulmonary complications (odds ratio = 3.91, p < 0.01). The mortality rate was 37% in smokers with > 50 pack-years history and 24% in nonsmokers (odds ratio = 2.02, p = 0.08). We conclude long-term tobacco smoking (> 50 pack-years) carries a higher risk of postoperative admission to intensive care, and there seems to be a dose relationship between the amount of tobacco consumed and the risk of postoperative intensive care admission.

Dynamic structural disorder of the FeO2 moiety in oxymyoglobin studied by nuclear resonant forward scattering of synchrotron radiation

Oxy- as well as deoxymyoglobin exhibit a pronounced temperature dependence of the quadrupole splitting of the heme iron as detected by conventional Mössbauer spectroscopy. With nuclear resonant forward scattering (NFS) of synchrotron radiation, which can be viewed as Mössbauer spectroscopy in the time domain, it is shown that this spectroscopic behavior, although it is phenomenologically similar in the two cases, is based on completely different physical mechanisms. It is demonstrated that stochastic fluctuations of the iron electric field gradient in MbO(2), which are due to the dynamic structural disorder of the FeO(2) moiety, are the reason for the temperature-dependent alterations of the coherent quantum beat pattern in the NFS spectra of MbO(2), in contrast to deoxyMb where transitions between orbital states of iron take place. This subtle spectroscopic difference cannot be inferred from conventional Mössbauer spectroscopy.

The LDH ratio as a marker for response to plasma exchange in HUS/TTP of the adult

BACKGROUND

Plasma exchange improved the outcome of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) of the adult markedly, but a high number of non-responders remain. Identifying these patients at an early stage would help to optimize therapy.

AIM

determine the value of serologic measures in predicting the response to plasma exchange.

MATERIAL AND METHODS

We performed a retrospective chart review of 30 patients with HUS/TTP of the adult treated with plasma exchange. According to the treatment protocol, a mean of 42 +/- 8.2 ml plasma per kilogram of body weight was exchanged daily for 3 days and continued every second day thereafter. Prior to each session, clinical status and serologic markers for hemolysis and kidney function were obtained. To assess the early individual response to plasma exchange, the decline of LDH from the first to the third cycle was calculated as: LDH concentration before the third session/LDH concentration before the first session (LDH ratio).

RESULTS

During the observation period (median 195, range 6-1500 days), 80% of the patients responded to therapy with plasmapheresis. None of the serologic measures or clinical signs obtained before initiation of plasma exchange showed a significant correlation with the outcome. After 2 sessions of plasma exchange, only LDH and platelet level had improved markedly in responding patients. The LDH ratio was the best predictive marker for the individual response. An LDH ratio < 0.6 predicted a favorable outcome with a sensitivity of 0.96 and a specificity of 0.83.

CONCLUSION

The LDH ratio might be a useful marker for separating patients responding to plasma exchange from those not responding at an early stage.

A descriptive study of medical and chiropractic patients with chronic low back pain and sciatica: management by physicians (practice activities) and patients (self-management)

BACKGROUND

A practice-based study of ambulatory patients with low back pain noted a long-term outcome advantage for self-referred chiropractic (DC) patients over medical (MD) patients within a subgroup of patients with chronic low back pain and radiating pain below the knee. The frequency of self-care education by physicians in both provider cohorts coupled with current thinking on management of chronic low back pain led to an exploration and description of physicians' noncore practice activities and patients' self-management attitudes and behaviors.

METHODS

A longitudinal, practice-based, observational study was undertaken in 14 general practice and 51 chiropractic community-based clinics. We enrolled 2945 consecutive patients with ambulatory low back pain of mechanical origin; of these, 268 comprised the subgroup of patients with chronic low back pain and radiating pain below the knee. The patients' low back status was followed for 1 year. Data on physicians' practice activities were obtained from doctor questionnaires completed at each patient visit and from chart abstraction. Patient data obtained from self-administered questionnaires at enrollment included sociodemographics, complaint characteristics, health status, and health encounter preferences. Questionnaires mailed at 2 weeks, 1 month, 3 months, 6 months, and 12 months collected data on low back complaint status and satisfaction with treatment. At 1 to 3 years follow-up, mailed questionnaires collected data on patients' self-management attitudes and behaviors.

RESULTS

Physicians' core practice activities were as expected. Exercise plans and self-care education (>55%) were conspicuous in the frequency of their use in the DC cohort. MD patients appeared to rely more on family and friends for support during periods of back trouble. DC patients were characterized by greater self-efficacy motivation (P = .000). Both groups showed evidence of self-care activities during and between bouts of back pain, although MD patients were far more likely to choose bed rest (P = .007).

CONCLUSIONS

The chiropractic encounter may have enhanced patients' self-efficacy motivation, leading to better coping abilities and better pain and disability outcomes. Understanding, respecting, and capitalizing on the role and influence of psychosocial factors can help all physicians become more effective healers and counselors for their patients with back pain.

To HITH or not to HITH: making a decision about establishing hospital in the home

Hospital in the home is increasingly being considered as an alternative for the provision of acute care. This article provides an overview of Hospital in the Home in Australia, discussing some of the issues that should be considered when determining whether to establish or fund hospital in the home programs such as whether efficiency is increased, care is improved and whether patients perceive more choice. These issues are discussed in the context of a transparent funding strategy that is aimed at achieving predefined goals and objectives.

Efficacy of spinal manipulation for chronic headache: a systematic review

BACKGROUND

Chronic headache is a prevalent condition with substantial socioeconomic impact. Complementary or alternative therapies are increasingly being used by patients to treat headache pain, and spinal manipulative therapy (SMT) is among the most common of these.

OBJECTIVE

To assess the efficacy/effectiveness of SMT for chronic headache through a systematic review of randomized clinical trials.

STUDY SELECTION

Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals.

DATA EXTRACTION

Information about outcome measures, interventions and effect sizes was used to evaluate treatment efficacy. Levels of evidence were determined by a classification system incorporating study validity and statistical significance of study results. Two authors independently extracted data and performed methodological scoring of selected trials.

DATA SYNTHESIS

Nine trials involving 683 patients with chronic headache were included. The methodological quality (validity) scores ranged from 21 to 87 (100-point scale). The trials were too heterogeneous in terms of patient clinical characteristic, control groups, and outcome measures to warrant statistical pooling. Based on predefined criteria, there is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There is moderate evidence that SMT is more efficacious than massage for cervicogenic headache. Sensitivity analyses showed that the results and the overall study conclusions remained the same even when substantial changes in the prespecified assumptions/rules regarding the evidence determination were applied.

CONCLUSIONS

SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality. Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length.

Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

BACKGROUND

Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain.

OBJECTIVE

This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome.

METHODS

Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome.

RESULTS

Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study.

CONCLUSION

Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.

Developing better casemix education for rural New South Wales

Casemix is now an important mechanism for the planning, evaluation and funding of health services in Australia. In New South Wales (NSW) it was believed that while staff from most hospitals in metropolitan Sydney had become both literate and vocal about casemix, staff from rural areas were less familiar and much less likely to participate in casemix initiatives. In conjunction with the NSW Casemix Clinical Committee (NCCC), NSW Health considered a special program of casemix education for rural NSW. Before an education program was attempted, NSW Health inquired into the specific needs for casemix education in rural NSW. Qualitative and quantitative methods of analysis were used. Results of the quantitative analysis indicate that the understanding of casemix classifications is highest among managers. Of concern were the relatively low proportion of Allied Health staff who had more than a vague understanding of the Sub- and Non-Acute Patient (SNAP) classification; the lack of any knowledge of the Mental Health Costing And Service Classification (MH-CASC) by nursing staff; and the lack of any knowledge of the emergency department classification: Urgency, Disposition and Age-related Groups (UDAG), either by clinical or nursing staff. The results of the qualitative analysis show that casemix education for rural areas needs to differ from metropolitan education programs. The analysis also highlights the perception of casemix in rural areas and the special circumstances in rural hospitals that place limits on the ability to use casemix more fully.

Assessing the value of hospital-in-the-home: lessons from Australia

OBJECTIVES

To identify factors that influence the cost-effectiveness of hospital-in-the-home (HITH) and to discuss the impact of funding arrangements in creating incentives or disincentives for the establishment of HITH services.

METHODS

A review of HITH services in Australia was undertaken. Based on the review, factors affecting the relative costs of HITH and conventional care were identified, in particular, the effect of funding and organisational arrangements on the incentives for managers and providers to choose between HITH and conventional care.

RESULTS

The review of HITH services identified a wide range of models of HITH in Australia. Factors identified as important to the success of HITH included demographic and location issues, referral mechanisms, the choice of staffing and the management of the programme. However, it was clear that the structure of the programme often related to funding arrangements. Issues such as 'incentive funding', establishment costs and opportunity for cost-shifting were identified as being relevant to incentives for the efficient provision of HITH.

CONCLUSIONS

Evaluations are essential to inform decisions about whether HITH is likely to be a viable and cost-effective alternative to inpatient care. However, the relative costs of HITH and conventional care will depend on local factors. From the point of view of the decision-maker, these will be affected by funding and organisational arrangements. Funders must be aware that complex financial incentives may mask the true costs of HITH services relative to hospital services. They need to ensure that the incentives created by funding arrangements are transparent.

The news on health care funding: a study of reporting in the Australian print media for 1996

OBJECTIVES

To review the coverage of health care funding and resourcing issues in the quality printed media in Australia.

METHODS

Content analysis of all articles in six major print publications with detailed commentary on four major issues.

RESULTS

One thousand one hundred and fifty articles were published over 12 months, most in the front three pages. Coverage of many issues was prompted by an event, such as an election, government budget or policy announcement. Although issues were rarely personalized, the use of an individual authoritative spokesperson was, with some individuals becoming well recognised as experts. In general, these experts represented vested interest or lobby groups. The media discussion rarely dealt with the system as a whole, and generally approached a topic or issue in isolation from its inter-relationships with other issues.

CONCLUSION

Health care funding stories are newsworthy but more for their political interest than as reflection of a social debate about values. Media reports rarely deal with the complexity of health policy issues, or challenge the assumptions and positions put forward.

A distinctive pediatric renal neoplasm characterized by epithelioid morphology, basement membrane production, focal HMB45 immunoreactivity, and t(6;11)(p21.1;q12) chromosome translocation

We report two cases of a hitherto undescribed pediatric renal neoplasm that is distinctive at the morphological, immunohistochemical, ultrastructural, and cytogenetic levels. On light microscopy, the tumors are composed of nests of polygonal, clear to eosinophilic cells associated with a subpopulation of smaller cells that surround hyaline material. Despite their epithelioid morphology, these tumors do not label immunohistochemically for epithelial markers but instead label focally for melanocytic markers HMB45 and Melan A. The hyaline material is positive with periodic acid-Schiff and methenamine-silver histochemical stains, and labels immunohistochemically for type 4 collagen. Ultrastructural examination confirms that it represents basement membrane material. Cytogenetic analysis reveals the identical t(6;11)(p21.1;q12) chromosome translocation as the sole abnormality in these two tumors, confirming their identity and distinctive nature.

Potentials and limitations of the low-molecular-weight protein lysozyme as a carrier for renal drug targeting

Selective targeting of drugs to the kidney may enable an increased renal effectiveness combined with a reduction of extrarenal toxicity. Intrarenal delivery to the proximal tubular cell can be achieved using low-molecular-weight proteins, such as lysozyme. Administration of high dosages of lysozyme, required to study the effects of such conjugates in vivo, however, is restricted since a partial escape of the renal reabsorption and the occurrence of unwanted effects on systemic blood pressure and renal function may occur. The purpose of this study was to investigate the optimal parenteral administration schedule and the maximum dose of lysozyme, providing the most optimal tubular reabsorption and at the same time a minimal effect on blood pressure and renal hemodynamics, comparing continuous infusion of lysozyme with single dose injections. Urinary lysozyme excretion increased dose-dependently, both during continuous infusion and intravenous bolus injections. However, this loss of intact lysozyme into the urine was much higher after 3 injections of in total 250 mg x kg(-1) x 6 h(-1) (51.8+/-3.7% of the dose) compared to the same dose administered by continuous infusion (11.7+/-2.4%, P < 0.001). Continuous infusion of lysozyme up to 1000 mg x kg(-1) in 6 hours had no effect on systemic blood pressure, whereas a bolus injection of lysozyme (167 mg x kg(-1)) resulted in reversible blood pressure lowering of 52.2+/-2.2% (P<0.001). A dose-dependent decline of the glomerular filtration rate was observed at dosages of lysozyme higher than 100 mg x kg(-1) x 6 h(-1), with a maximal reduction of 53.0+/-3.7% after infusion of 1000 mg x kg(-1) x 6 h(-1). Effective renal plasma flow was less affected and only lowered statistically significant at dosages of 500 (-12.6+/-3.3%, P<0.05) to 1000 mg x kg(-1) x 6 h(-1) (-17.2+/-3.9%, P<0.01). We conclude that bolus injections of lysozyme should not be used for renal targeting purposes since it results in considerable tubular loss of lysozyme in the urine as well as cardiovascular side effects. In contrast, continuous infusion of lysozyme using dosages sufficient for renal drug targeting (maximally 15 mg x kg(-1) x h(-1)) only has minimal effects on blood pressure and renal hemodynamics, with a minimal urinary lysozyme loss as well.

Strongly linked current flow in polycrystalline forms of the superconductor MgB2

The discovery of superconductivity at 39 K in magnesium diboride, MgB2, raises many issues, a critical one being whether this material resembles a high-temperature copper oxide superconductor or a low-temperature metallic superconductor in terms of its behaviour in strong magnetic fields. Although the copper oxides exhibit very high transition temperatures, their in-field performance is compromized by their large anisotropy, the result of which is to restrict high bulk current densities to a region much less than the full magnetic-field-temperature (H-T) space over which superconductivity is found. Moreover, the weak coupling across grain boundaries makes transport current densities in untextured polycrystalline samples low and strongly sensitive to magnetic field. Here we report that, despite the multiphase, untextured, microscale, subdivided nature of our MgB2 samples, supercurrents flow throughout the material without exhibiting strong sensitivity to weak magnetic fields. Our combined magnetization, magneto-optical, microscopy and X-ray investigations show that the supercurrent density is mostly determined by flux pinning, rather than by the grain boundary connectivity. Our results therefore suggest that this new superconductor class is not compromized by weak-link problems, a conclusion of significance for practical applications if higher temperature analogues of this compound can be discovered.