Effects of peer-group intervention on metabolic control of adolescents with IDDM. Randomized outpatient study

In children with insulin-dependent diabetes mellitus (IDDM), deterioration in metabolic control frequently occurs during early adolescence. To prevent this predictable increase in blood glucose levels, we randomly assigned young adolescents with IDDM to an intervention based on problem solving with self-monitoring of blood glucose (SMBG) integrated into standard outpatient care or to standard care only for an 18-mo period. At follow-up, 50% of the standard-care adolescents exhibited greater than 1% increase in glycosylated hemoglobin (HbA1) levels over baseline values, indicating a deterioration in metabolic control, compared to only 23% of the intervention group. Follow-up HbA1 means +/- SD were 10.10 +/- 2.00% for intervention and 11.04 +/- 2.28% for standard-care adolescents, indicating a significantly lower value in the intervention group (P = .04). At follow-up, a greater percentage of intervention than standard-care adolescents reported using SMBG information when they exercised (60.0 vs. 33.3%, chi 2 = 4.29, P = .04). Our data suggest that clinic-based problem-solving groups can be more effective with young adolescents with IDDM than conventional treatment in preventing the expected deterioration in blood glucose.

Inspired oxygen and nitrous oxide concentrations in volunteers during nitrous oxide sedation with a Hudson mask

Ten volunteers were given varying ratios of oxygen and nitrous oxide at 4, 6 and 8 litres per minute using a Hudson mask delivery system. Maximum and minimum inspired oxygen concentrations, maximum inspired nitrous oxide concentrations and end tidal carbon dioxide concentrations were measured using the Datex Cardiocap CCI-104 monitor. Although pharyngeal oxygen fraction varies with the Hudson mask because the inspiratory flow exceeds the entrainment of the mask by a variable amount during much of the cycle, at 8 litres/minute flow with a ratio of 3 to 5, oxygen to nitrous oxide, safe levels of oxygen were delivered (range of means 26-31%) with basal nitrous oxide levels (mean maximum inspired N2O, 34%). When nitrous oxide sedation is used clinically, nitrous oxide must be used with consideration of safe oxygen levels. This study did not detect unsafe pharyngeal oxygen levels in the ratios investigated, where the maximum delivered nitrous oxide concentration was 75%.

A randomized clinical trial comparing ranitidine and antacids in critically ill patients

In a randomized trial of gastric pH control for stress ulcer prophylaxis, 200 mg/day ranitidine iv was compared to antacids in 86 patients admitted to an ICU. Six (15%) patients receiving ranitidine and six (13%) given antacids failed to maintain greater than 50% of the hourly gastric pH measurements at or above 4. Increasing the ranitidine dosage to 300 mg/day did not provide additional control. One patient in the antacid group developed an overt upper GI bleed secondary to endoscopically proven erosive disease. We conclude that iv ranitidine in a dosage of 200 mg/day is as effective as antacids in reducing gastric acidity and preventing stress ulcer disease in critically ill patients.

Western blot (immunoblot) analysis of the fimbrial antigens of Bacteroides nodosus

The roles of the fimbrial subunit and the putative basal protein antigens in the serological classification of Bacteroides nodosus have been examined by Western blot (immunoblot)-antibody binding studies of fimbriae isolated from a wide range of strains representative of different serogroups and serotypes. Fimbrial subunits were recognized by antiserum against the homologous serogroup but not generally by heterologous antisera, whereas recognition of the basal antigen was independent of serological classification. Secondary cross-reaction patterns among fimbrial subunits indicated that some serogroups may be more closely related than others. Examples include serogroups C and G and serogroups D and H. Similar analyses of isolates classified within serotypes A1 and A2, with serotype-specific antisera, showed that this subdivision is also determined by the fimbrial subunit and that significant variation does occur even at this level. These studies suggest that the various serogroups and serotypes of B. nodosus comprise a series of overlapping sets of antigenically related strains.

Protection of sheep against footrot with a recombinant DNA-based fimbrial vaccine

Recombinant Pseudomonas aeruginosa cells containing the Bacteroides nodosus fimbrial subunit gene under the transcriptional control of a strong promoter produce large amounts of B. nodosus-type fimbriae. We have carried out vaccination trials which show that these fimbriae are just as effective as either natural fimbriae or whole cell preparations of B. nodosus in inducing protective immunity against homologous footrot challenge. The recombinant-produced fimbriae are also effective therapeutically in accelerating the rate of healing of pre-existing footrot lesions. These results confirm that the structural subunit of the fimbrial strand is a primary protective antigen against footrot, and demonstrate the practicality and potential of recombinant DNA approaches to the development of new vaccines against B. nodosus and other Type 4 fimbriate pathogens.

The metabolic needs of head trauma victims

Malnutrition increases the morbidity and mortality associated with severe illness, injury, and sepsis. The neuroendocrine changes associated with trauma intensify the body's metabolic demands. The neuroendocrine response to trauma is discussed. Methods to determine calorie needs of head trauma patients are presented, along with a case study.

Morphogenetic expression of Bacteroides nodosus fimbriae in Pseudomonas aeruginosa

Type 4 fimbriae are found in a range of pathogenic bacteria, including Bacteroides nodosus, Moraxella bovis, Neisseria gonorrhoeae, and Pseudomonas aeruginosa. The structural subunits of these fimbriae all contain a highly conserved hydrophobic amino-terminal sequence preceding a variable hydrophilic carboxy-terminal region. We show here that recombinant P. aeruginosa cells containing the B. nodosus fimbrial subunit gene under the control of a strong promoter (pL, from bacteriophage lambda) produced large amounts of fimbriae that were structurally and antigenically indistinguishable from those produced by B. nodosus. This was demonstrated by fimbrial isolation and purification, electrophoretic and Western transfer analyses, and immunogold labeling and electron microscopy. These results suggest that type 4 fimbriated bacteria use a common mechanism for fimbrial assembly and that the structural subunits are interchangeable, thereby providing a basis for the development of multivalent vaccines.

Massive hemoptysis

Hemoptysis is usually a symptom of cardiopulmonary disease and is generally not in itself associated with death. A blood loss into the tracheobronchial tree of 600 ml in 24 hours or at a rate that poses a threat to life is referred to as massive hemoptysis. Hypervascularity within the bronchial circulation, usually associated with diffuse inflammatory disease of the lung, is common in patients with massive hemoptysis. Management should be directed at maintenance of oxygenation and localization of the source of bleeding. Temporizing maneuvers such as iced saline lavage, intravenous administration of vasopressin, endobronchial tamponade and bronchial artery embolization will often stabilize the patient in preparation for definitive surgery. Such a sequential plan of management may result in a 50% reduction in the rate of death from massive hemoptysis, which is otherwise 50% to 100%.

Noncardiogenic pulmonary edema during intrabiliary infusion of mono-octanoin

Mono-octanoin (glycerol-1-mono-octanoate) is a medium-chain diglyceride used to dissolve gallstones. We describe a patient in whom noncardiogenic pulmonary edema developed during intrabiliary infusion of monooctanoin. The temporal sequence suggests that the drug infusion initiated the lung injury.

Pacemaker follow-up: its role in the detection and correction of pacemaker system malfunction

The goal of pacemaker follow-up is not only to detect battery depletion but also to detect all malfunctions of the pacing system and, when possible, to correct such problems using programming. During one year, we discovered 61 such malfunctions in a clinic of 1065 patients (5.7%). These were more frequent in the first year (7.7%) than in the third to fifth years of follow-up (range 3.1-4.8%). The incidence rose again in the sixth and subsequent years (7-7.7%). Despite a significant occurrence of malfunctions (5.2%) among multiprogrammable pacemakers, the necessity for operative intervention for their correction was low (1.2%). Sensing problems were the most common (57%) and the most likely to be corrected by reprogramming (85%); problems involving loss of capture were less likely to be corrected by programming (38.5%). Battery depletion accounted for only 18% of malfunctions, occurring earliest in the forty-third month of follow-up. Pulse generator longevity of those devices reaching end of battery life during the study period was 68.6 +/- 16.7 months (mean + SD). We conclude that specialized pacemaker follow-up continues to be necessary despite improved pulse generator reliability and longevity. Indeed, with reprogramming, it presently plays an even more important role than in the past. Follow-up should be oriented not only to the detection of battery depletion but also toward a comprehensive surveillance of pacemaker system function.

Cerebrospinal fluid myelin basic protein as a prognostic marker in patients with head injury

Despite increasing interest in identifying biochemical and serologic markers to judge the severity of closed head injury in comatose patients, clinical variables remain the most readily available methods for assessing prognosis. In a series of 35 severely head-injured comatose patients, the cerebrospinal fluid (CSF) level of myelin basic protein (MBP) was analyzed by radioimmunoassay. MBP levels during the first week after injury were significantly correlated with the Glasgow outcome score at 7 days (p less than .005), 3 months (p less than .005), and 6 months (p less than .05) postinjury. Measurement of CSF MBP appears to be a useful laboratory adjunct to clinical assessment, for judging the outcome of severely head-injured patients.

Isolation and characterization of Bacteroides nodosus fimbriae: structural subunit and basal protein antigens

We examined the isolation of fimbriae from Bacteroides nodosus. It was found that the best preparations were obtained from the supernatant of washed cells cultured on solid medium, from which fimbriae could be recovered in high yield and purity by a simple one-step procedure. Analysis of such preparations by sodium dodecyl sulfate gel electrophoresis showed that greater than 98% of the protein consisted of fimbrial structural subunits whose molecular weight was ca. 17,000. These preparations also usually exhibited minor contamination with a polypeptide of ca. 80,000 molecular weight, as well as trace amounts of lipopolysaccharide. Attempts to release additional fimbriae by the traditional means of subjecting the bacterial cells to physical stress, such as shearing or heating, resulted primarily in an increase in the level of contamination, without significant gain in the yield of fimbriae. Removal of the 80,000-dalton component could not be achieved by any of a variety of techniques normally used in fimbriae purification, including isoelectric precipitation, MgCl2 precipitation, and CsCl gradient ultracentrifugation, implying a direct physical association with the fimbrial strand. Electron micrographs of fractions containing this protein show cap-shaped structures attached to the ends of what appeared to be fimbrial stubs. These observations suggest that the 80,000-dalton polypeptide may actually constitute the basal attachment site which anchors the fimbria to the outer membrane, analogous to a similar protein recently described in enterotoxigenic strains of Escherichia coli. In B. nodosus, this 80,000-dalton protein is a major surface antigen, and like the fimbrial subunit, exhibited variation in electrophoretic mobility between serotypically different isolates.

Cloning and expression in Escherichia coli of the gene encoding the structural subunit of Bacteroides nodosus fimbriae

Bacteroides nodosus is the primary causative agent of ovine foot rot. Virulent isolates of this bacterium contain fimbriae which appear to play a major role in both infectivity and protective immunity. This paper presents the cloning and expression in Escherichia coli of the gene encoding the structural subunit of the fimbriae of B. nodosus. Total DNA was isolated from B. nodosus VCS 1001 (serogroup A), digested with HindIII, and inserted into the positive-selection vector pTR262. Recombinant E. coli clones were screened directly with anti-fimbrial antiserum by using a colony immunoassay. Several positive colonies were identified, each of which contained the same 5.5-kilobase HindIII insert. The prototype has been designated pBA101. Some clones also contained additional flanking sequences from the B. nodosus genome. Western transfer analyses verified that the positive clones were producing the B. nodosus fimbrial structural subunit, molecular weight ca. 17,500. The level of expression of the antigen in E. coli was comparable to that in B. nodosus itself and was unaffected by the insertion site or orientation of the cloned fragment, indicating that synthesis was being directed from an internal promoter. Restriction mapping and deletion analyses localized the fimbrial subunit gene to the vicinity of a PvuII site near the central region of the original HindIII insert. The expressed antigen was located in the membrane-cell wall fraction and may be exposed on the surface of the recombinant E. coli cells.

A theoretical protocol for nutritional maintenance in head-injured patients

Multiple trauma increases the nutritional needs of patients. Although head-injury victims present special problems, the modality of enteral nutritional offers specific advantages which avoid the complications of malnutrition. The success of enteral nutritional therapy is dependent on knowledgeable nursing assessment and intervention. Certainly, it is a therapeutic maneuver that should be considered in the care of the head-injured, multi-trauma patient.

Parathyroid carcinoma: features and difficulties in diagnosis and management

The objective of this review was to study the clinical course and the applicable diagnostic criteria in 12 patients with functioning parathyroid carcinoma, two patients with nonfunctioning parathyroid carcinoma, and a fifteenth patient who had an atypical intrathyroid tumor. The biologic patterns fell into four groups. The patients with functioning parathyroid carcinoma had either a prolonged tumor existence punctuated by hypercalcemic episodes ameliorated by operation to remove the tumor or an aggressive course with widespread metastases. The nonfunctioning cancers were aggressive cancers. The fourth group had one patient (others could have been considered) in whom a definitive diagnosis could not be made. The initial recognition of this cancer is sometimes difficult because consistent diagnostic features, either clinically or pathologically, are lacking. Enbloc resection at the first operation remains the best chance for cure. Surgical resection of recurrent disease appears to be the most effective palliative approach. Death results from hypercalcemia rather than from organ replacement by tumor.

The interrelationships of ego strength, self-esteem, death anxiety, and gender in undergraduate college students

The interrelationships of ego strength (Barron Ego Strength Scale), death anxiety (Death Anxiety Scale), and self-esteem (Texas Social Behavior Inventory) were studied in undergraduate university males (n = 20) and females (n = 59). Significant negative relationships between death anxiety and self-esteem and ego strength, and a significant positive relationship between self-esteem and ego strength were shown by both males and females. Moreover, males showed significantly higher self-esteem and ego strength scores, and significantly lower death anxiety scores than did females.

Family characteristics of diabetic adolescents: relationship to metabolic control

This research compares the family environments of diabetic adolescents in good (HbA1c less than 10), fair (10 greater than or equal to HbA1c less than or equal to 14), and poor (HbA1c greater than 14) control. Fifty-eight adolescents diagnosed with type 1 diabetes and their parents (mothers) were independently assessed with structured interviews, the Moos Family Environment Scale, and adolescents also completed the Piers-Harris Children's Self-Concept Scale. As compared with adolescents in poor control, those in good control reported fewer diabetes-related symptoms and had less anxiety and a more positive self-concept. Well-controlled youths also reported more cohesion and less conflict among family members. More parents of well-controlled youths stated that family members were encouraged to behave independently. In addition, more parents of poorly controlled adolescents believed that diabetes had negatively affected the child's personality, physical well-being, schooling, and participation in activities away from home. These findings suggest a complex interplay between the diabetic adolescent's psychological and physical functioning, metabolic control, and the family environment.

A group approach to the management of diabetes in adolescents and young adults

An interdisciplinary team of health professionals developed a model treatment program to improve adherence, self-management, and metabolic control for five inner city, black, young adult, diabetic women. Following an initial in-hospital evaluation, the staff met with the patients as a group once a month for 18 mo. The professional approach was suppurative and nonjudgmental to assist the group members in developing confidence and assuming responsibility for the successful management of their diabetes. Discussions covered the group's educational needs, insulin requirements, and psychosocial problems of adjusting to living with chronic disease. Analysis of clinical findings showed a significant improvement in plasma glucose, hemoglobin A1c, and cholesterol levels.

Research on diabetes management and the family: a critique

Research on diabetes management and the family has been traditionally viewed within a linear model, in which parental attitudes toward diabetes are seen as the principal influence on the child's adjustment and metabolic control. Recently the focus of research has shifted to the broader family milieu, with an emphasis on patterns of cooperation and conflict among all family members in implementing the treatment regimen. As investigators have begun to study the entire family, the linear model of parental influences has been overshadowed by a systems model of family interaction, based on the concept of mutual influences among all individuals in the family. Several methodological problems have characterized research in this area, such as inadequate assessments of family functioning, unreliable indices of metabolic control, and insensitivity to differences in age and disease variables. Future studies of diabetes management will have much to gain from consideration of the role of the father and siblings in treatment, attention to the diabetic child's impact on family functioning, and recognition of sources of support and stress outside the family that affect adaptation to diabetes.

Reciprocity in vocal interactions of mothers and infants

Social responses of 24 mothers and 3-month-old infants were continuously observed and coded in the home to examine reciprocal influences in early vocal interactions. One of 4 dyadic vocal states (simultaneous vocalization, mother vocalizing alone, infant vocalizing alone, mutual silence) was assigned to each consecutive 1-sec interval of the 90-min observational records. The sequence of dyadic vocal states was represented by a first-order transition probability matrix. Transitions between states involving maternal and infant vocal onsets and offsets were analyzed. Results indicated that vocal onsets for both mother and infant were more likely when the other dyad member was vocalizing. There was no evidence of reciprocal influences for vocal offsets. It is suggested that differentiating response onset and offset is necessary for understanding vocal reciprocity in mother-infant interaction.

Correlates of hypoglycemic fear in type I and type II diabetes mellitus

We examined whether fear of hypoglycemia in insulin-dependent diabetes mellitus was associated with (a) higher levels of trait anxiety and general fearfulness, (b) difficulty in differentiating symptoms of anxiety and hypoglycemia, and (c) past experience with hypoglycemia. Joslin Diabetes Center outpatients with Type I and Type II diabetes (N = 232), all requiring insulin, were surveyed. Type I patients experienced significantly more fear of hypoglycemia than Type II patients. For the Type I and Type II groups, higher scores on the Worry subscale of the Hypoglycemia Fear Survey (HFS-W) were associated with higher levels of trait anxiety and fear. Higher scores on the Behavior subscale (HFS-B) were associated with higher levels of fear. Among Type I subjects only, HFS-W scores were also positively associated with past hypoglycemic experience and with difficulty in differentiating anxiety and hypoglycemic symptoms. These latter relations remained significant even after the variance resulting from trait anxiety and fear was removed. Other significant associations with HFS-B scores were not observed.