Cannabinoid modulation of dynorphin A: correlation to cannabinoid-induced antinociception

Intrathecal administration of anandamide, delta9-tetrahydrocannabinol (THC) and (-)-3-[2-hydroxy-4-(1,1-dimethyheptyl)ptyl)phenyl]-4-(3-hydr oxypropyl)-cicloexan-1-ol (CP55,940) induced spinal antinociception accompanied by differential kappa-opioid receptor involvement and dynorphin A peptide release. Antinociception using the tail-flick test was induced by the classical cannabinoid THC and was blocked totally by 17,17'-bis(cyclopropylmethyl)-6',6,7,7'-tetrahydro-4,5,4'5'-diepoxy++ +-6,6'-(imino)[7,7'-bimorphinan]-3,3',14,14'-tetrol (norbinaltorphimine) indicating a significant and critical kappa-opioid receptor component. The endogenous cannabinoid, anandamide and the non-classical bicyclic cannabinoid, CP55,940, induced non-nor-BNI-sensitive effects. The N-piperidino-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-3-pyrazo le-carboxamide (SR141716A)-mediated attenuation of spinal antinociception imparted by the various cannabinoids indicates cannabinoid CB1 receptor involvement. THC-induced an enhancement of immunoreactive dynorphin A release which coincided with the onset, but not duration antinociception. The release of dynorphin A was also attenuated by SR141716A suggesting it is cannabinoid CB1 receptor-mediated. These data indicate a critical role for dynorphin A release in the initiation of the antinociceptive effects of the cannabinoids at the spinal level.

Knowledge and perceptions about breast cancer incidence, fatality and risk among Australian women

OBJECTIVE

Breast cancer is the most common fatal cancer among Australian women. This study aimed to provide an accurate national picture of women's understanding of breast cancer incidence, fatality and risk.

METHOD

A telephone survey explored the knowledge and perceptions of a sample of 2,935 Australian women in relation to breast cancer incidence, fatality, risk factors, risk perception and level of concern.

RESULTS

Australian women were well aware of breast cancer in general terms, however, there were major aspects of incidence and risk which were poorly understood. Only 5% of women nominated age as a risk factor, and only one-third were able to make an approximately correct estimate of the incidence of breast cancer in Australia.

CONCLUSIONS AND IMPLICATIONS

Recommendations for future information campaigns include targeting understanding of lifetime risk of developing breast cancer, age as a risk factor, survival from breast cancer and the need to separately address the perceptions of older versus younger women.

Identification of permanent hearing loss in children: are the targets for outcome measures attainable?

A collaborative nine-centre study was designed to follow the routes to identification of all children up to the age of seven years newly diagnosed with permanent hearing impairment (> or = 50 dB HL) during the period 1993-1994. Ages of identification were compared with the standards set by the National Deaf Children's Society (NDCS), ascertaining whether these targets could be achieved with current service provision. Of the 126 children identified, 104 had congenital sensorineural hearing loss: 19% were identified by the age of six months and 39% by their first year. These results fall short of the NDCS targets of 40% and 80%, respectively, and point to the need for modifications of current practice, such as the introduction of universal neonatal screening.

Choroidal tuberculosis diagnosed by polymerase chain reaction. A clinicopathologic case report

PURPOSE

To show the use of the polymerase chain reaction (PCR) in a granulomatous choroidal lesion to support a diagnosis of tuberculosis.

DESIGN

Observational case report.

TESTING

Nucleic acid target amplification of a choroidal specimen using PCR for detection of Mycobacterium tuberculosis was tested.

MAIN OUTCOME MEASURES

Positive nucleic acid target amplification for M. tuberculosis in the ocular sample was measured.

RESULTS

PCR was positive for M. tuberculosis with appropriate negative controls.

CONCLUSIONS

PCR was thought to be a useful supportive technique in the diagnosis of choroidal tuberculosis.

AutoCyte Interactive Screening System. Experience at a university hospital cytology laboratory

OBJECTIVE

To evaluate the AutoCyte Interactive Screening System (AutoCyte-Screen) as a prescreener for the cytologic detection of cervicovaginal abnormalities.

STUDY DESIGN

Eight hundred fifty-six AutoCyte Preparation System from cervicovaginal samples were evaluated by AutoCyte-Screen. AutoCyte-Screen displayed 120 cell images and 6 low-power images for review by the cytotechnologist. The cytotechnologist classified the case as WNL, abnormal or unsatisfactory. AutoCyte-Screen then revealed its classification as either unsatisfactory, WNL, abnormal or undecided. These classifications were combined to form an interactive result that was compared to the diagnosis from previous manual review.

RESULTS

Interactive results were as follows: 251 (29.3%) abnormal, 581 (67.9%) WNL and 24 (2.8%) unsatisfactory. The abnormal interactive result contained 15 ASCUS/AGUS and 25 SILs; the WNL interactive result contained 5 ASCUS/AGUS and 2 SILs. No ASCUS/AGUS or SILs were in the unsatisfactory interactive category. The false negative proportion was 10.5% for the interactive diagnostic method vs. 15.7% for manual review for LSIL.

CONCLUSION

The interactive use of AutoCyte-Screen can effectively select those cases which are most likely to contain an epithelial abnormality and could therefore be used as a triage system to select cases for manual review. A case with an interactive result of unsatisfactory and abnormal should receive full manual review, while those classified as WNL may require a less extensive review for quality assurance purposes. This resultant decrease in the manual screening load could increase laboratory efficiency.

Wegener's granulomatosis--a review of diagnosis and treatment in 53 subjects

We reviewed 79 patients with clinically suspected Wegener's granulomatosis (WG) diagnosed in Nottingham between 1990 and 1997. Fifty-three patients were confirmed as having WG. We describe the symptoms and signs, features of diagnostic significance, ANCA results, biopsy sites, histology, treatment and outcome in this group. Nasal symptoms and signs had a positive predictive value of 63%, c-ANCA at presentation 100%, and positive nasal biopsy 100%. The negative predictive values were 41%; 79% and 74% respectively. From this study, we recommend that patients who have a negative ANCA and where there remains a clinical suspicion of WG, an ENT examination should be undertaken. Whilst a suspicious lesion should be biopsied and a positive histological picture has a 100% positive predictive value, a negative nasal biopsy does not exclude WG as 5 patients went on to develop a positive ANCA up to 4 years later. In 11 ANCA negative patients where there were signs of nasal mucosal disease, 6 had a positive biopsy and this highlights the importance of nasal biopsy. The c-ANCA should be repeated in patients with a negative c-ANCA and biopsy results at presentation, in whom there remains a clinical suspicion of WG.

A 1996 NASN research award winner. Health services provided by school nurses for students with chronic health problems

Increased numbers of students are entering schools with chronic health problems and in need of nursing and other health services. Some studies have been conducted in recent years describing nursing practice in schools. However, further study of school nursing practice was warranted owing to two major problems. The first was limited financial resources to provide needed nursing services. The second was inadequate documentation of both the health needs of students and current school nursing practice in meeting those needs. The purpose of this descriptive study was to examine the nature and extent of nursing services provided in the schools in the late 1990s and to identify potentially reimbursable nursing services being provided to students with chronic health problems. A survey was mailed to active members of the School Nurse Organization of Minnesota (SNOM). The findings indicated the considerable diversity in the practice setting as well as the large volume of nursing services being delivered in schools. Results will be essential in the acquisition of financial resources, including collaboration with third-party payors for reimbursement of nursing and other health services.

Differential blockade of the antinociceptive effects of centrally administered cannabinoids by SR141716A

We evaluated delta-9 tetrahydrocannabinol (Delta9-THC), delta-8 tetrahydrocannabinol (Delta8-THC), CP55,940 (CP55), 1-deoxy-11-hydroxy-Delta8-THC-dimethylheptyl (deoxy-HU210, a CB2-selective cannabinoid that also binds the CB1 receptor) and the endogenous cannabinoid anandamide (ANA) via i.c.v. and/or intrathecal (i.t.) routes of administration, alone and in combination with SR141716A (SR), a CB1 antagonist, using the tail-flick test. Our studies were performed in order better to characterize potential diversity in interactions of the cannabinoids with the cannabinoid (CB1) receptor. When SR was administered i.c.v. or i.p. before Delta9-THC, Delta8-THC or CP55 (i.c.v. or i.t.), SR was a potent antagonist and the blockade was complete (AD50 </= 8.1 microgram/mouse i.c.v. or AD50 </= 1.4 mg/kg i.p.). The AD50 values (dose of antagonist that produced a 50% antagonism of agonist effects) for blockade of Delta9-THC, Delta8-THC, CP55,940 (i.c.v. or i.t.) by SR (i.c.v. or i.p.) differed significantly for only two combinations [Delta8-THC/SR, both i.c.v. and CP55 (i.t.)/SR (i.p.)]. Conversely, SR (i.t.) produced an incomplete block of the antinociceptive effects of i.t. Delta9-THC, Delta8-THC and CP55 (AD50 = 28.6, 50.2 and 20.9 microgram/mouse, respectively). Blockade of the deoxy-HU210 (i.c.v.) by SR (either i.c.v. or i.p.) was incomplete and AD50 values could not be calculated. Although the maximal blockade of deoxy-HU210 (i.t.) by SR (i.t.) was only 50%, SR administered i.p. before deoxy-HU210 (i.t.) produced a potent and complete blockade (AD50 = 0.4 mg/kg). The effects of SR on ANA-induced antinociception were mixed. The maximal attenuation of the ANA (i.t.) by SR (i.t.) was 38%. SR (i.p.) blockade of ANA was complete, but the AD50 was 15.4 mg/kg, greater than 15-fold higher than that required to block Delta9-THC, Delta8-THC, CP55 or deoxy-HU210. In addition, SR (i.p. or i.t.) failed to block the hypothermic effects of ANA (i.t.), while completely reversing the hypothermic effects of Delta9-THC (i.t.). These data indicate that SR has a much greater efficacy at supraspinal than at spinal sites. Alternatively, such data suggest either a differential interaction of the cannabinoids at the CB1 receptor or the existence of subtypes of the CB1 receptor.

Characterization of delta9-tetrahydrocannabinol and anandamide antinociception in nonarthritic and arthritic rats

Little is known about the effectiveness of delta9-tetrahydrocannabinol (THC) and anandamide in blocking mechanical nociception. Even less is known about their antinociceptive efficacy in chronic inflammatory arthritis induced by Freund's complete adjuvant. The hypothesis was tested that THC and anandamide elicit antinociception in the paw pressure test, and that arthritic rats would exhibit a different response. In nonarthritic rats, THC- and anandamide-induced antinociception lasted 90 min and 15 min, respectively, while antinociception lasted 90 min and 30 min, respectively, in arthritic rats. Area under the curve calculations revealed no effect of arthritis on THC- and anandamide-induced antinociception. Another hypothesis was that paw pressure thresholds in arthritic rats reflect chronic cannabinoid receptor stimulation due to elevations in free anandamide levels. Yet, the CB1 receptor antagonist SR141716A failed to alter paw pressure thresholds in either nonarthritic or arthritic rats. Further investigation revealed that SR141716A significantly blocked THC antinociception, with no effect on anandamide. Thus, anandamide's effects did not result from CB1 receptor stimulation, and any potential contribution of endogenous anandamide in arthritis was not revealed. Finally, THC and anandamide appear to release an as yet unknown endogenous opioid, because naloxone significantly blocked their effects. This study indicates that anandamide and THC may act at different receptor sites to modulate endogenous opioid levels in mechanical nociception.

Elderly patients with heart failure: a study of satisfaction with care and quality of life

OBJECTIVE

To assess the level of patient satisfaction with care, patient quality of life, the relationship between these measures and hospital readmission rates, and patient outcomes.

METHODOLOGY

A prospective cohort study was conducted of all patients aged 60 years and over admitted to the John Hunter and Mater Hospitals, in the Hunter Area, in whom congestive heart failure contributed to the need for hospital admission. Patients recruited into the main study were then asked to complete a questionnaire on discharge from hospital. Patients were asked to complete the satisfaction questionnaire on discharge because this would reflect the patients' satisfaction with the overall stay. To provide a baseline quality-of-life score, patients were asked to complete a questionnaire 2 weeks after discharge.

FINDINGS

Overall scores on the satisfaction questionnaire were high, indicating that the patients were very satisfied with their care. There were six questions in which 17-35% of patients indicated some degree of dissatisfaction, four related to patient knowledge. No difference in satisfaction was found between patients who had or did not have a readmission. Quality-of-life results showed that patients who had a readmission had a significantly lower quality-of-life score at 12 month follow up (P=0.007) than those without a readmission.

CONCLUSION

This finding has supported our hypothesis that a higher level of quality of life would be related to fewer readmissions.

Amyotrophic lateral sclerosis: current issues in classification, pathogenesis and molecular pathology

The classification of amyotrophic lateral sclerosis (ALS) is reconsidered in the light of developments in the molecular pathogenesis and histopathology of the condition. A current view is encapsulated in the El Escorial World Federation of Neurology criteria for the diagnosis of ALS. While intended for research purposes, use of these criteria for entry into clinical trials may result in the exclusion of some patient groups with related disorders that are likely to share aetiological mechanisms but which are not classified as 'definite ALS' or 'probable ALS'. The relationship between ALS and the more restricted motor disorders of progressive lateral sclerosis and progressive muscular atrophy, together with cerebral degenerations including ALS-dementia and ALS-related frontal lobe dementia, are reviewed. The possibility is raised that they all represent syndromic manifestations of a similar pathogenetic cascade whose clinical phenotype depends upon the anatomical selectivity of involvement in each individual. The new evidence regarding the central role of oxidative stress and abnormal glutamatergic neurotransmission in familial and sporadic ALS seem applicable across these disorders. New evidence regarding the molecular pathology of inclusion bodies in these various syndromes, including ubiquitinated inclusions and hyaline conglomerate inclusions, shows striking similarities between them. Marked differences in the anatomical distribution of lesions determine the predominance and type of motor and cognitive features in each syndrome. This concept of a clinicopathological spectrum is potentially of equal relevance to other late onset neurodegenerative disorders including multisystem atrophies, the Lewy body disorders and various manifestations of Alzheimer's disease. It will gain increasing importance as therapies evolve from the symptomatic to those directed at underlying pathogenetic events.

Pathological diagnostic criteria for dementia associated with cortical Lewy bodies: review and proposal for a descriptive approach

In recent years dementia histologically characterised by the presence of cortical Lewy bodies has been increasingly recognised. There is now need for a scheme for an internationally acceptable scheme for pathological diagnosis and classification so that clinical, pathological and molecular features of disease can be correlated. Recent observations made by different groups in large patient series have used slightly different pathological criteria resulting in at least seven different diagnostic terms. In some patients the only cortical pathology is the presence of Lewy bodies, while in the majority of patients there are coexisting pathological changes which either overlap with those seen in Alzheimer's disease (AD). Cortical Lewy bodies can also be present in patients who do not have any obvious cognitive abnormality. A problem with equating studies from different groups is that different criteria have been used to define AD, so that establishing the relevance of cortical Lewy bodies themselves to cognitive decline and separating this from the contribution which may be related to the AD pathology is problematic. The lesions which appear to be of most relevance to potential cognitive decline in DLB are cortical Lewy bodies, Lewy-related neurites, senile plaques, neurofibrillary tangles, neuronal and synaptic loss, spongiform change, and cortical cholinergic deficits. It is possible to operationally classify patients with cognitive decline and cortical Lewy bodies into three main groups, Cortical Lewy body disease, Cortical Lewy body disease with plaques, and Cortical Lewy body disease with plaques and tangles. There are frequent cases which overlap these groups making operational classification difficult in practice. A descriptive classification, in which the severity of different pathological changes is rated, is easy to use in practice. As new molecular risk factors for AD or DLB are revealed they will need to be related to morphological and clinical features. A descriptive diagnostic assessment for DLB will facilitate such studies and makes no judgements as to what these relationships will be.

Vocal fold abductor paralysis as a solitary and fatal manifestation of multiple system atrophy

A patient is presented who had bilateral abductor vocal fold paralysis pathologically proven to be due to multiple system atrophy (MSA) in the absence of other neurological features. MSA is a degenerative neurological condition that includes olivopontocerebellar atrophy, Shy-Drager syndrome and striatonigral degeneration. The usual predominant features of MSA are cerebellar ataxia, autonomic dysfunction and Parkinsonism. Stridor is present in over one third of patients and has been reported previously as a presenting symptom in MSA: however previously reported patients have always gone on to develop other neurological symptoms. The usual investigations of bilateral abductor vocal fold paralysis caused by MSA will not reveal the pathological process and we believe that magnetic resonance imaging (MRI) of the medulla and brain stem and autonomic function tests are probably the investigations of choice. It is a worthwhile exercise attempting to identify MSA as the cause of stridor as the prognosis is good in the medium term if appropriate support is offered.

The AutoCyte preparation system for gynecologic cytology

OBJECTIVE

To determine if thin-layer processing of cervicovaginal samples improves detection of cytologic abnormalities by reducing problems related to direct smear preparation.

STUDY DESIGN

Eight hundred fifty-two cervical samples were collected as part of a multicenter trial of the CytoRich/AutoCyte system. The Cervex Brush was used for specimen collection. Following preparation of a conventional Papanicolaou smear, the brush was placed in a vial of fixative. A thinlayer CytoRich preparation was prepared by sedimentation following centrifugation through a density gradient and then stained by the AutoCyte Preparation System according to the manufacturer's guidelines. The two preparations were masked and screened, and a diagnosis was rendered. Abnormal results from were reviewed by a pathologist. The specimens were later unmasked and the diagnoses compared.

RESULTS

CytoRich and conventional cervical cytologic smears detected an equivalent number of squamous intraepithelial lesions (SILs) (27 vs. 29) and atypical squamous cells of undetermined significance (ASCUS) (19 vs. 21). Both methods missed an equivalent number of SILs (four vs. five). CytoRich detected more infections (151 vs. 115) and had 66% fewer nonspecific inflammatory diagnoses. CytoRich also had fewer "limited" adequacy evaluations (211 vs. 236).

CONCLUSION

CytoRich preps improve adequacy; increase detection of infections, such as candidiasis and trichomoniasis; and are accurate in the diagnosis of SILs. CytoRich appears to be an equivalent and possibly better preparation for cervicovaginal cytology.

Cultural Diversity in Florida Nursing Programs: A Survey of Deans and Directors

To determine how nursing programs in the state of Florida promote and integrate cultural diversity, a survey of deans and directors was conducted. Of 90 deans and directors surveyed, 46 (51%) responded. The ethnic composition of students and faculty in the respondents' programs was examined in comparison with that of the Florida population. Hispanics, Blacks, and Asians were found to be underrepresented in nursing faculty as compared with their proportion in the state population. The majority of deans and directors ranked the goal of promoting cultural diversity of moderate importance. The two most critical issues perceived by the respondents were the lack of cultural knowledge, sensitivity, and awareness, and the academic problems and educational deficits of minority students. In 50% of the programs surveyed, culture content was integrated throughout the curriculum. Other programs either integrated culture content in specific classes or offered a course in transcultural nursing. Although numerous approaches are currently being employed to recruit ethnically diverse faculty and students, the data suggest that more extensive and innovative efforts are needed to overcome existing barriers. As nursing faces the challenge of caring for a multicultural society in the 21st century, nursing leaders and organizations must collaborate to resolve the issues and problems revealed in this survey.

PET scanning and the human immunodeficiency virus-positive patient

The use of PET scanning in patients with human immunodeficiency virus infection and fever of unknown origin, confusion and/or weight loss was investigated.

METHODS

Eighty patients were examined using PET. Fifty-seven patients had half-body scans with [18F]fluorodeoxyglucose (FDG), and 23 patients had brain studies performed with FDG. Fourteen patients also had [11C]methionine studies (2 chest, 1 abdomen and 11 brain) performed.

RESULTS

Thirteen patients with lymphoma had the extent of the disease clearly identified in both nodal and extranodal sites. Patients with a variety of infections (Cryptococcus neoformans, Pseudomonas aeruginosa, Mycobacterium tuberculosis and Mycobacterium avium intracellulare) had disease localized for appropriate biopsy or sampling procedures. A half-body FDG-PET scan had a sensitivity of 92% and a specificity of 94% for localization of focal pathology that needed treatment. High uptake of FDG (greater than liver) had a positive predictive value for pathology needing treatment of 95%. FDG brain studies showed that 16 patients with CD4 T-lymphocyte counts less than 200 cells/ml had reduced cortical uptake compared with that in basal ganglia. FDG scans were abnormal in all 19 patients with focal space occupying lesions identified by magnetic resonance scans. The standardized uptake values (SUVs) over cerebral lesions due to toxoplasma were in the range of 0.14-3.7 (13 patients) and due to lymphoma were in the range of 3.9-8.7 (6 patients). Three more patients with progressive multifocal leukoencephalopathy had SUVs in the range of 1.0-1.5 over the lesions. Another patient had a low-grade oligodendroglioma (SUV = 2.9). Carbon-11-methionine uptake also was high in patients with cerebral lymphoma but did not add to the discrimination between toxoplasmosis and lymphoma in these patients obtained with the FDG scan.

CONCLUSION

In hospitals with access to PET facilities, FDG scanning allows the rapid evaluation of the whole body, including the brain, of patients with human immunodeficiency virus infection, with a report potentially available within 4 hr of injection. Sites of infection and tumor were identified, and discrimination between cerebral pathologies was possible.

Implementation of guidelines for No-CPR orders by a general medicine unit in a teaching hospital

BACKGROUND

No-cardiopulmonary resuscitation (CPR) orders are frequently used to limit the use of cardiopulmonary resuscitation in patients who die in hospital. International research has consistently highlighted major deficiencies in the formulation, documentation and communication of such orders. There has been little Australian research into No-CPR orders and the impact of clinical guidelines.

AIMS

This audit aimed to examine compliance with published guidelines for No-CPR orders previously developed by the hospital Clinical Ethics Committee.

METHODS

The notes of all patients who died while under the care of the General Medicine Unit during June-December 1994 were reviewed to evaluate the use of No-CPR orders. Adherence to hospital No-CPR guidelines was evaluated as well as the principal diagnosis, age, level of care and competence of patients to state their wishes.

RESULTS

A No-CPR order was documented in 61% (n = 40) of the 66 patients who died during this period. Of these patients 80% were judged to be incompetent and were unable to be involved in decisions not to resuscitate. There was substantial compliance with the guidelines, with the exception of documenting involvement of nursing staff.

CONCLUSIONS

No-CPR orders are frequently implemented as a result of failure to respond to curative therapy and do not represent abandonment of the patient. Although this study demonstrates the value of No-CPR guidelines and the audit process, the findings raise fundamental issues regarding the involvement of nursing staff, and of patients, that need to be further addressed.

Chitosan as a nasal delivery system: the effect of chitosan solutions on in vitro and in vivo mucociliary transport rates in human turbinates and volunteers

In these studies, we examined the effect on mucociliary transport rates (MTR) of various 0.25% (w/v) chitosan solutions applied to human nasal tissue both ex vivo and in vivo. In the first study a range of chitosans with different molecular weights were applied to freshly amputated human nasal turbinates, and their effect on MTR was recorded. The transient inhibitory effect on turbinate MTR that was found for most of the chitosan preparations showed a marked dependence on the volume of chitosan solution applied and the molecular weight of the chitosan tested. The higher the molecular weight of the chitosan and the more chitosan applied, the longer the original MTR was depressed. A small scale human trial, investigating the effect of chitosan glutamate, on saccharin clearance times, was also undertaken. The study showed that a once daily application of a 0.25% solution of the chitosan for 7 days had no effect on either saccharin clearance times or nasal histology as examined by light microscopy.

Wernicke's encephalopathy with ballooned neurons in the mamillary bodies: an immunohistochemical study

Two cases of Wernicke's encephalopathy with the rare phenomenon of ballooned neurons in the mamillary bodies are reported. Both patients suffered from acute Wernicke's symptoms starting approximately two weeks before death. The mamillary bodies contained grossly enlarged, ballooned neurons, in one case associated with focal necrosis. The affected neurons were immunoreactive for phosphorylated neurofilament (160 and 200 kDa), and synaptophysin. Ubiquitin and alpha beta-crystallin expression were not detected. The mamillo-thalamic tract appeared normal in both cases. There was a marked associated microglial reaction, as shown by the antibody Ki-MIP. It is concluded that the ballooning of mamillary neurons reflects an acute retrograde reaction to primarily axonal damage. Rather than being a rare manifestation of the disease, these cases may constitute a typical intermediate early stage (10-15 days) in the development of Wernicke's encephalopathy).