Oral physostigmine and impaired memory in adults with brain injury

The purpose of this study was to examine the effects of physostigmine, a cholinergic agonist, on memory loss after traumatic brain injury (TBI), as compared to placebo or scopolamine, a cholinergic antagonist, using a double-blind, placebo-controlled design. Each subject received each active drug and placebo. Neuropsychological measures (Wechsler Memory Scale I and II, Selective Reminding Test, Trail-Making Test, Parts A and B, Digit Symbol, and Memory Questionnaire) and measures of clinical balance were completed at baseline, after each drug phase, and at 1 month follow-up. Thirty-six subjects completed the study with results showing an improvement in memory scores in 44% of subjects (responders) while taking oral physostigmine. The most sensitive measure was the Selective Reminding Test, specifically Long-term Storage. The impact of drugs on standing balance as compared to placebo was improved standing time in the responders: (1) with physostigmine when standing tandem with eyes closed (p < 0.05), and (2) with scopolamine when standing on one foot with eyes closed (p < 0.05). Results support the potential benefit of cholinergic agonists on memory after TBI and the need for further research of possible clinical markers for the drug.

Screening for carcinoma of the prostate: a GP based study

OBJECTIVE

To examine the feasibility and acceptability of screening for cancer of the prostate by digital rectal examination (DRE), prostate specific antigen (PSA) determination and subsequent transrectal ultrasound (TRUS) in selected patients in a single general practice in Hertfordshire.

SUBJECTS AND METHODS

A total of 568 of 856 men aged 55 to 70 accepted an invitation for a health check which included screening for prostate cancer. Of these, 80 individuals with either a raised PSA level or an abnormal DRE underwent TRUS. In 29 individuals biopsies were taken, 11 of which confirmed the presence of adenocarcinoma of the prostate giving an overall detected prevalence of 2%. Of the 11 tumours identified by screening, two were T1M0, four were T2M0, two were T3M0 and three were T3M1.

RESULTS

To assess the acceptability of the screening exercise a postal questionnaire was sent to all 568 participants: 83% replied and 69% reported no concern. Of the 67 individuals who had undergone TRUS, 69% reported discomfort. A total of 448 (95%) of respondents declared that they would be prepared to undergo the screening exercise again.

CONCLUSION

Screening for prostate cancer would seem to be technically feasible and generally acceptable. However, there is a considerable false positive rate in the PSA range 4 ng/ml to 10 ng/ml, particularly among men with clinical evidence of benign prostatic hyperplasia. To establish the true benefit of screening a large-scale prospective controlled study will be necessary.

Critical evaluation of current concepts in exposure assessment

The exploitation of natural resources and the improper use and disposal of thousands of chemicals have resulted in environmental pollution and a potential threat to human health on a global scale. Increasing public concern about environmental exposure to and consequent ill health from contaminants demands informed answers based on valid risk assessment. By assessing internal exposure to pollutants, human biomonitoring focuses on early markers of potential risks to prevent serious adverse effects. Exposure assessment may provide a rational basis for risk assessment, with knowledge of the adequacy of limit values; it may also uncover long-term changes in body burdens and thus help identify the sources and transfer pathways of environmental pollutants. The techniques of biological exposure assessment should be incorporated into epidemiological studies if suitable specimens are available, such as exhaled air, blood, urine, breast milk, or adipose or keratinous tissue. Special precautions must be taken in sampling, storage, and analysis if the findings are to be interpreted correctly and reliable conclusions drawn.

Critical evaluation of current concepts in exposure assessment

The exploitation of natural resources and the improper use and disposal of thousands of chemicals have resulted in environmental pollution and a potential threat to human health on a global scale. Increasing public concern about environmental exposure to and consequent ill health from contaminants demands informed answers based on valid risk assessment. By assessing internal exposure to pollutants, human biomonitoring focuses on early markers of potential risks to prevent serious adverse effects. Exposure assessment may provide a rational basis for risk assessment, with knowledge of the adequacy of limit values; it may also uncover long-term changes in body burdens and thus help identify the sources and transfer pathways of environmental pollutants. The techniques of biological exposure assessment should be incorporated into epidemiological studies if suitable specimens are available, such as exhaled air, blood, urine, breast milk, or adipose or keratinous tissue. Special precautions must be taken in sampling, storage, and analysis if the findings are to be interpreted correctly and reliable conclusions drawn.

Complications of ultrasound-guided transperineal prostate biopsy. A prospective study

A prospective study of the complications of transperineal prostate biopsy was undertaken in 171 patients; 150 (88%) returned a questionnaire 1 week after biopsy. The incidence of serious complications was low, with 1 patient requiring admission for presumed septicaemia and another developing acute retention of urine. Many patients had minor complications, with 42% having haematuria, 13% haemospermia and 31% pain. Only 18% needed analgesia following biopsy. Since transperineal prostate biopsy has such a low incidence of infective complications, we suggest that it should be considered in frail or elderly patients in whom septicaemia may be especially hazardous.

Relation between distal airspace size, bronchiolar attachments, and lung function

BACKGROUND--Smoking related fixed airway obstruction may be due to airway scarring and narrowing or decreased support due to loss of adjacent alveolar walls. In this study of resected specimens, preoperative pulmonary function was compared with results of a morphometric study of lung structure. METHODS--Morphometric measurements were made on 42 inflation fixed lung specimens as follows: airspace wall surface area per unit volume (AWUV) was measured on at least 25 l mm2 histological fields from each specimen, expressed as a mean, and the mean of the lowest five measurements for each case (LF5). Minimum diameter, maximum diameter, diameter ratio (ellipticality), lumen area, and lumen circumference were measured on at least 16 non-respiratory bronchioles from each lung. Peribronchiolar alveolar support was measured as mean interalveolar attachment distance (IAAD). Measurements of pulmonary function included forced expiratory volume in one second (FEV1) (absolute and % predicted values; n = 42), slope of phase III (single breath nitrogen test; n = 28), closing volume (expressed as a percentage of vital capacity (CV/VC%); n = 28). RESULTS--Bronchiolar size was not independently related to the tests of lung function used. Percentage predicted FEV1 was related to mean IAAD, ellipticality, and mean AWUV. CV/VC% showed significant relation with ellipticality, mean AWUV, and LF5 AWUV. Slope of phase III increased with increasing IAAD. Significant correlations were found between ellipticality and AWUV (mean and LF5), and between ellipticality and IAAD. Both IAAD and ellipticality were significantly increased in patients with abnormally low FEV1. CONCLUSION--Destruction of airspace walls, particularly those attached to the peripheral bronchioles, is more influential in determining airflow limitation than bronchiolar size.

Psychosocial recovery after head injury

Psychosocial recovery after head injury was prospectively examined at 1 and 12 months postinjury in a group of 102 hospitalized adult head-injured patients representing a broad range of head injury severity. For comparison purposes, 102 friend controls were used. Outcome was assessed with a battery of psychosocial measures including the Sickness Impact Profile, the Head Injury Symptom Checklist, and the Modified Function Status Index. The results indicate that head-injury patients experience significant psychosocial problems (eg, ability to return to work, resume leisure activity, concentrate and remember information, feelings of irritability) at both 1 and 12 months postinjury but these difficulties improve over time. Whereas improvements occur in both psychosocial and physical areas of functioning, improvements are greater in the physical area. The nature and extent of difficulties seen vary as a function of head injury severity, and time from injury to observation. Finally, the results suggest that not all problems reported by head-injured patients are solely related to the injury (eg, irritability, anxiety, fatigue, or headaches).

Lifespan of human lymphocyte subsets defined by CD45 isoforms

The lifespan of thymic-derived or T lymphocytes is of particular interest because of their central role in immunological memory. Is the recall of a vaccination or early infection, which may be demonstrated clinically up to 50 years after antigen exposure, retained by a long-lived cell, or by its progeny? Using the observation that T lymphocyte expression of isoforms of CD45 corresponds with their ability to respond to recall antigens, we have investigated the lifespan of both CD45R0 (the subset containing responders, or 'memory' cells) and CD45RA (the unresponsive, or 'naive' subset) lymphocytes in a group of patients after radiotherapy. Here we report rapid loss of unstable chromosomes from the CD45R0 but not the CD45RA pool. Immunological memory therefore apparently resides in a population with a more rapid rate of division. Differing survival curves for the two subsets are best described by a model in which there is also reversion in vivo from the CD45R0 to the CD45RA phenotype. Expression of CD45R0 in T cells may therefore be reversible.

Elderly patients and their medication: a post-discharge follow-up study

Fifty-six elderly patients (age range 65-98 years) discharged from a geriatric unit were visited at home on or after the 5th post-discharge day (median day 8) and their medication assessed. By the day of the visit, 15 of the 56 had not had a new prescription issued (27%) and 27 patients (48%) had old prescribed medication at home. Forty-one new scripts, issued by general practitioners, should have contained 128 medications if the general practitioners wished to continue unchanged the medication given on hospital discharge. Fourteen drugs (11%) had been added and 17 drugs (13%) omitted. The number of prescriptions issued unchanged was 26/41 (63%). Inaccurately labelled containers and/or changed drug names were found in 28%. Contrary to hospital advice, 47% of medications were issued in childproof containers. Poor communication between hospital and general practitioners is only part of the problem. Methods to expedite the delivery of new prescriptions should be developed.

Changes in neutrophil morphology and morphometry following exposure to cigarette smoke

Acute cigarette smoking delays neutrophils within the pulmonary circulation in some smokers. Evidence from an in-vitro Micropore filter model of the pulmonary capillaries indicates that this may be due to a smoke induced decrease in cell deformability. In order to determine whether changes in cell shape are associated with the observed decrease in neutrophil deformability following smoke exposure, cell morphology, using scanning electron microscopy, and morphometric measurements, made using transmission electron microscopy, were performed on aliquots of neutrophils harvested from whole blood in non-smoking subjects before and after exposure in vitro to cigarette smoke. Smoke exposure increased the maximum diameter and circumference of neutrophils, without changing their area. There was also a change in the maximum to minimum cell diameter ratio, which indicated that the cells had become less spherical. Scanning electron microscopy showed that smoke exposed cells had developed blebbing of their surface membranes, suggestive of an oxidative injury to the cell membrane rather than the shape changes associated with cell activation. These changes in the morphology and morphometry of smoke exposed neutrophils may contribute to the reduction in cell deformability induced by cigarette smoke.

Microscopic and macroscopic measurements of emphysema: relation to carbon monoxide gas transfer

BACKGROUND

Studies of the relation between the severity of structural change in emphysema and physiological abnormality have been based on macroscopic assessments, which have not been truly quantitative or sensitive enough to detect early changes. With a highly reproducible method for measuring emphysema using histological sections and a semiautomatic image analysis system, this quantitative assessment of emphysema was compared with a semiquantitative macroscopic assessment of emphysema and measurements of carbon monoxide gas transfer.

METHODS

Microscopic and macroscopic measurements of emphysema on 44 thoracotomy specimens were compared; only two were from non-smokers. Airspace wall surface area per unit volume was measured microscopically with an automatic image analyser and expressed as both the mean airspace wall surface area per unit volume and the mean value of the five fields with the lowest values. Macroscopic emphysema was measured directly on a tracing of the midsagittal slice using a digitising tablet attached to a microcomputer and expressed as a percentage of the total area of lung. In cases with centriacinar emphysema the number of discrete lesions was counted.

RESULTS

The area of macroscopic emphysema ranged from 0 to 78% of the total area of lung examined, but most patients had less than 1% involvement so that the distribution was highly skewed. Both mean airspace wall surface area per unit volume and the mean of five fields with the lowest airspace wall surface area per unit volume were normally distributed, with mean airspace areas ranging from 8.8 to 25.4 mm2/mm3 (mean 18.1 mm2/mm3). In lobes with centriacinar emphysema the number of discrete lesions correlated with airspace wall surface area per unit volume and with preoperative carbon monoxide transfer factor (TLCO) per unit lung volume. However, other measurements of macroscopic emphysema did not correlate with loss of alveolar wall surface area, and there was considerable overlap between subjects with no or minimal macroscopic emphysema and those with more severe disease. TLCO correlated with both mean airspace wall surface area per unit volume and the mean of five fields with the lowest airspace wall surface area per unit volume but not with the severity of macroscopic emphysema.

CONCLUSION

If emphysema is to be quantified it must be measured microscopically; macroscopic measurements do not, in general, reflect the microscopic loss of airspace wall.

Psychotropic-absent behavioural improvement following severe traumatic brain injury

We present a case study in which severe agitation was reduced and independent functioning increased in a traumatically brain-injured individual. The subject's behaviour for the year prior to admission was characterized by increasing rates of maladaptive behaviours and corresponding increases in pharmacological attempts at behaviour management. Upon admission, the subject was totally dependent on others for all activities of daily living. A data-based systematic withdrawal of a number of psychotropic medications and the addition of an anticonvulsant medication was conducted in an AB experimental design. Reductions of medications in conjunction with behavioural interventions resulted in immediate reduction in rate of maladaptive behaviours. Further reductions in psychotropic medications and the addition of the anticonvulsant medication resulted in continued rapid deceleration of rate of occurrence of maladaptive behaviours with a concomitant increase in lucid statements and independent functioning. A follow-up conducted at 6 months showed the subject to be independent in performance of activities of daily living in a semi-independent living situation, with maladaptive behaviours continuing to be well managed.

Indomethacin and postprandial gallbladder emptying

Patients with gallstone disease commonly have impaired gallbladder emptying. To see whether non-steroidal anti-inflammatory drugs (NSAIDs) prevent gallstone formation by improving gallbladder emptying, we assessed the effect of indomethacin on postprandial emptying in healthy subjects and in patients with gallstone disease. Subjects received indomethacin 25 mg three times a day for a week and matching placebo for another week. Compared with placebo, indomethacin improved postprandial gallbladder emptying in all 7 patients with gallstone disease. This finding was not recorded in healthy subjects with normal gallbladders. The prevention of gallstone formation associated with ingestion of NSAIDs may be due mainly to a prokinetic effect on the gallbladder since there is no evidence to suggest that these drugs affect cholesterol crystal nucleation at ordinary therapeutic doses in man or animals.

Placebo-controlled study of pramiracetam in young males with memory and cognitive problems resulting from head injury and anoxia

The current study evaluated under double-blind placebo-controlled conditions, the safety and efficacy of 400 mg pramiracetam sulphate TID in treating memory and other cognitive problems of males who have sustained brain injuries. The results of the study indicate that subject performance in measures of memory, especially delayed recall, evidenced clinically significant improvements after the administration of pramiracetam sulphate as compared to placebo. This improvement was maintained during an 18-month open-trial period on the medication as well as during a 1-month follow-up period after the pramiracetam was discontinued.

Use of phenytoin to treat horses with Australian stringhalt

Five horses with Australian stringhalt were treated with 15 mg/kg phenytoin orally for 2 weeks. During the second week of the trial, 3 of the horses were given an additional dose of 10 mg/kg phenytoin. The response to treatment was clinically assessed by grading the severity of the gait abnormality at the walk, trot, turning and backing twice daily. There was a significant (P less than 0.05) improvement in the gait abnormality when pre-treatment values were compared with the mean of the last 3 assessments before treatment stopped. When reassessed 2 weeks after treatment ceased, there remained a significant (P less than 0.05) improvement compared with pre-treatment values at the trot and on backing, but not at the walk or turning. Surface electromyographic recordings were made weekly from the long digital extensor muscle, and there was a change to a near normal recording by the end of treatment. Plasma phenytoin concentrations were monitored during the trial, and the dose rates used achieved a steady state with a mean plasma level of 37 +/- 7 mumol/l. There was wide variability between plasma concentrations in different horses, although there was no difference in absorption between administration of the phenytoin as a paste, or when it was mixed in the feed. Although mild tranquilization was seen after treatment, there were no clinical, haematological or biochemical signs of toxicity from the phenytoin therapy.

Fatigue and depression in brain-injured patients correlated with quadriceps strength and endurance

Many brain-injured (BI) patients complain of persistent fatigue that may alter their lifestyles. In order to assess muscular strength and endurance after brain injury, 22 BI men, greater than 9 months postinjury and aged 20 to 51 years, were separated into two groups based on a complaint of fatigue (fatigue n = 13, nonfatigue n = 9); each performed one maximal isometric knee extension at 60 degrees and 20 maximal isokinetic contractions at 20 rpm using a Cybex II dynamometer. A third group of age-matched, able-bodied men (n = 10) were used as controls. A battery of tests assessing the presence of fatigue (using a symptom checklist and two rating scales), depression, anxiety, and health status were given at the time of isokinetic/isometric testing. The mean fatigue rating, a subjective score, for the fatigue group of BI subjects was significantly worse than the other groups (p less than .01). There was a positive correlation between clinically significant Zung depression scores and fatigue rating (r = .46) and between Zung anxiety scores and fatigue rating. The depression scores for those who complained of fatigue were significantly higher than the other groups (p less than .005). Maximal isometric contractions were no different among the three groups. The mean maximal isokinetic torque during the 20 repetitions was greater in controls than in the BI groups, but did not reach statistical significance (p less than .25). There were no significant declines in isokinetic torque in the 20 repetitions for any of the groups, and the fatigue index was nearly equal for all three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative effects of brain and non-brain injuries on neuropsychological and psychosocial outcome

Based on the 242 consecutive surviving head injury cases and 132 general trauma cases, this study examined the contribution of brain and non-brain injuries to cognitive and psychosocial outcome 1 month postinjury. The study also examined the relationships among various head injury severity indices. The head injury severity indices were all correlated but patients with Glasgow Coma Scale scores in the mild range had broadly ranging scores on the other head injury severity indices (Abbreviated Injury Scale and time to follow commands). Neuropsychological outcome was related to brain injury severity, but was not independently influenced by severity of other systems injuries. Psychosocial outcome related to both brain and non-brain injuries independently. When evaluating trauma outcome, it is important to consider the contributions of both brain and other system injuries.

Thick malignant melanomas (greater than 3 mm Breslow) with good clinical outcome: a histological study and survival analysis

Thick malignant melanomas in general tend to have a poor prognosis, but exceptions occur where there may be no further recurrence. The reasons for this difference in clinical behaviour are not fully understood. We have looked at thick malignant melanomas (greater than 3.0 mm) in the East of Scotland that have no evidence of metastasis after a minimum of 6 years follow-up and compared the clinical and histological features with a similar group, associated with histological evidence of metastasis and/or death. Both groups received similar treatment regimes. We have identified 41 patients with thick melanomas in the former group. When compared with the control group, factors found to be significantly different between the two groups were: the nature of the lower margin of the tumour; vascular invasion; and anatomical location.