Manganese toxicity in children receiving long-term parenteral nutrition

BACKGROUND

In patients receiving long-term parenteral nutrition (PN), cholestatic disease and nervous system disorders have been associated with high blood concentrations of manganese. In such patients, the normal homoeostatic mechanisms of the liver and gut are bypassed and the requirement for this trace element is not known; nor has it been certain whether hypermanganesaemia causes the cholestasis or vice versa. We explored the direction of effect by serial tests of liver function after withdrawal of manganese supplements from children receiving long-term PN. We also examined the relation between blood manganese concentrations and brain lesions, as indicated by clinical examination and magnetic resonance imaging (MRI).

METHODS

From a combined group of 57 children receiving PN we identified 11 with the combination of hypermanganesaemia and cholestasis; one also had a movement disorder. Manganese supplements were reduced in the first three and withdrawn in the remainder. MRI was done in two of these children. We also looked at manganese concentrations and MRI scans in six children who had received PN for more than 2 years without developing liver disease.

FINDINGS

In the hypermanganesaemia/cholestasis group, four of the 11 patients died. In the seven survivors baseline whole-blood manganese was 615-1840 nmol/L, and after 4 months it had declined by a median of 643 nmol/L (p < 0.01). Over the same interval total bilirubin declined by a median of 70 mumol/L (p < 0.05). Two of these children had movement disorders, one of whom survived to have an MRI scan; this showed, with T1 weighted images, bilateral symmetrically increased signal intensity in the globus pallidus and subthalamic nuclei. Such changes were also seen in five other children--one from the hypermanganesaemia/cholestasis group and four of six in the long-term PN group without liver disease (in all of whom blood manganese was above normal).

INTERPRETATION

The cholestasis complicating PN is multifactorial, but these results add to the evidence that manganese contributes. In view of the additional hazard of basal ganglia damage from high manganese levels in children receiving long-term PN, we recommend a low dose regimen of not more than 0.018 mumol/kg per 24 h together with regular examination of the nervous system.

The effect of structured versus conventional inhaler education in medical housestaff

Despite the importance of adequate inhaler technique in the care of asthma and chronic obstructive pulmonary disease, physicians have often been shown to have poor knowledge of correct inhaler use. At present, postgraduate teaching programs appear to leave physicians to acquire inhaler handling skills informally in the context of day-to-day patient care. We undertook the present study to determine if one brief structured educational intervention would be adequate to teach postgraduate physicians inhaler skills that would be retained over long periods of time. We also compared the efficacy of this intervention to traditional education methods. We recruited 52 postgraduate trainees in internal medicine at a large university hospital; 26 were in the educational intervention group and 26 were in the control group. Physicians in the intervention group were asked to respond to a questionnaire on inhaler use and to demonstrate the correct use of a metered-dose inhaler (MDI), an MDI with a pacing chamber and a multidose dry-powder inhaler. These intervention subjects were then instructed on proper inhaler usage by a qualified nurse educator. Eight months later, testing was repeated in the intervention group and was undertaken in the control group. Questionnaire scores were significantly higher in the intervention group at the 8-month follow-up than at baseline (59% vs. 42%; p < 0.05). Similarly, the scores of the intervention group at follow-up were significantly higher than those of the control group (59% vs. 39%; p < 0.05). There was no significant difference between the baseline scores of the intervention group and those of the control group. The mean demonstration score was significantly higher in the intervention group at follow-up than at baseline (68% vs. 39%; p < 0.001) and was also higher than that of the control group (68% vs. 44%; p < 0.001). There was no significant difference between the scores for all devices between the intervention group before education and the control group. Our data show that one brief teaching session is sufficient to produce a sustained improvement in knowledge and handling of inhalers by postgraduate physicians. The knowledge and skills of the physicians educated in our study were not only better than before they had received instruction, but were better than the knowledge and skills of postgraduate trainees from the same institution who had received no formal training. This latter observation suggests a failure of traditional unstructured postgraduate training programs to teach this practical patient care skill.

Complications associated with suction drains after microvascular anastomeses

Two head and neck cases in which free flaps were used for reconstruction are presented. The circulation of the flaps was compromised due to problems directly associated with suction drains. The methods of drain fixation are discussed.

Stress fracture of the body of the talus in athletes demonstrated with computer tomography

PURPOSE

This article describes a series of four previously unreported stress fractures of the body of the talus.

CASE SUMMARY

The four patients presented with ankle pain of gradual onset for periods of three weeks to 12 months. Radioisotope scans in all four patients showed identical pictures of markedly increased uptake in the region of the body of the talus. Computed tomographic scan images were also similar showing a distinct fracture line through the posterolateral aspect of the body of the talus extending into the subtalar joint. All four patients were treated differently ranging from rest to surgery, but no treatment appears totally successful.

DISCUSSION

A single case of stress fracture of the neck of talus has previously been reported in a runner, but no previous cases of stress fracture of the body of the talus have been reported. The mechanism may be that in the presence of excessive subtalar pronation and plantar-flexion, the lateral process of the calcaneus impinges on the concave posterolateral corner of the talus. No treatment appeared totally successful but the authors would recommend a six week period of non-weight-bearing rest.

RELEVANCE

The diagnosis of stress fracture of the body of the talus should be considered in the athlete who presents with gradual onset of ankle pain.

Haemodynamic responses in muscle and adipose tissue and whole body metabolic responses during norepinephrine infusions in man

Circulatory metabolic and cardiovascular responses to 1-h-long infusions of norepinephrine (NE) (approx. 0.2 and 0.4 nmol/kg body weight per min) were measured on two separate occasions in six subjects. The infusions increased circulating NE concentrations 6- and 13-fold, respectively. Blood flow to adipose tissue, measured with the 133Xe clearance technique, increased from a basal value of about 3 ml/100 g per min, to about twice this value at 60 min with both doses of NE. In contrast muscle blood flow was unaffected. The higher dose of NE produced significant increments at 60 min in whole body oxygen consumption (approx. 9%), and circulating concentrations of glucose (approx. 18%), non-esterified fatty acids (approx. 200%) and glycerol (approx. 32%) which were greater than those observed with the low-dose infusion. Changes in blood pressure, pulse and CO2 exchange were observed within 5-10 min after the start of the infusion, whilst changes in adipose tissue blood flow were observed after 15-30 min. It is concluded that in humans (i) a dose of NE as low as 0.2 nmol/kg per min is sufficient to evoke both circulatory and metabolic responses; (ii) the pattern in the adipose tissue blood flow response to NE may help explain some of the conflicting reports about the haemodynamic effects of this hormone in adipose tissue; and (iii) blood flow and vascular resistance in different tissues may be affected in different ways by norepinephrine.

Intestinal site-dependent susceptibility to chronic indomethacin in the rat: a morphological and biochemical study

BACKGROUND

The cyclo-oxygenase inhibitor indomethacin induces a pattern of gastrointestinal injury in the rat that is site-dependent. This study compared the extent of injury to different regions of the rat intestine (small intestine, caecum and colon) with the corresponding changes in arachidonic acid metabolism in these areas, following long-term, low-dose indomethachin.

METHODS

Rats (eight per group) received either indomethacin (3 mg.kg/day) or control diet for either 6 or 12 weeks. At termination animals were bled, examined both macroscopically and microscopically for ulcers, and assayed for blood thromboxane B2, intestinal tissue prostaglandin E2 content and production of leukotriene B4. In a further eight animals luminal indomethacin concentrations from the small intestine, caecum and colon were measured following 6 weeks of chronic drug ingestion.

RESULTS

At 6 weeks, macroscopic ulcers were observed in 2/8 (small intestine), 3/8 (caecum) and 1/8 (colon) animals. The corresponding ratios at 12 weeks were 5/8, 8/8 and 0/8. In control animals, a site-dependent gradient of the prostaglandin E2 concentration was found. In indomethacin-dosed animals the intestinal prostaglandin E2 content was reduced significantly in the caecum at 6 weeks, and in all tissues at 12 weeks. An increased leukotriene B4 production was observed in the caecum only, at 12 weeks (P < 0.01), and the blood thromboxane B2 was reduced at both time points (P < 0.05).

CONCLUSION

There is a site-dependent gradient of the prostaglandin E2 concentration in the rat intestine. The rat caecum is particularly sensitive to long-term low-dose indomethacin, both in terms of chronic intestinal inflammation and changes in prostanoid metabolism. This site-dependent degree of injury may be associated with a local cyclo-oxygenase inhibition.

Overuse injuries in classical ballet

Successful management of classical ballet dancers with overuse injuries requires an understanding of the art form, precise knowledge of anatomy and awareness of certain conditions. Turnout is the single most fundamental physical attribute in classical ballet and 'forcing turnout' frequently contributes to overuse injuries. Common presenting conditions arising from the foot and ankle include problems at the first metatarsophalangeal joint, second metatarsal stress fractures, flexor hallucis longus tendinitis and anterior and posterior ankle impingement syndromes. Persistent shin pain in dancers is often due to chronic compartment syndrome, stress fracture of the posteromedial or anterior tibia. Knee pain can arise from patellofemoral syndrome, patellar tendon insertional pathologies, or a combination of both. Hip and back problems are also prevalent in dancers. To speed injury recovery of dancers, it is important for the sports medicine team to cooperate fully. This permits the dancer to benefit from accurate diagnosis, technique correction where necessary, the full range of manual therapies to joint and soft tissue, appropriate strengthening programmes and maintenance of dance fitness during any time out of class with Pilates-based exercises and nutrition advice. Most overuse ballet conditions respond well to a combination of conservative therapies. Those dancers that do require surgical management still depend heavily on ballet-specific rehabilitation for a complete recovery.

Measles virus induction of human endothelial cell tissue factor procoagulant activity in vitro

Measles virus infection of microvascular endothelium in vivo and ensuing endothelial cell activation may be important in the pathogenesis of subsequent inflammation in target organs. This study investigated the capacity of measles virus to induce procoagulant activity, in vitro, in endothelial cells isolated from human umbilical cord veins. Endothelial cells were infected with a clinical isolate of measles virus propagated in Vero cells. Cells were also incubated with bacterial lipopolysaccharide (10 micrograms/ml), herpes simplex virus type 1, cytomegalovirus or culture medium alone as positive and negative controls, respectively. Endothelial cell procoagulant activity was measured in a one-stage clotting assay. Measles virus stimulated both a time and dose-dependent endothelial cell procoagulant response by the induction of tissue factor synthesis, confirmed by both immunocytochemistry and its dependence on factor VII for activity. This activity was reduced by u.v.-irradiation of the virus. Infected cells were analysed by double immunofluorescent staining for both tissue factor and measles virus N-protein, and examined using confocal scanning laser microscopy. Cells expressing tissue factor were also positive for the measles virus N-protein. Low levels of interleukin-1 were detected in some viral inocula derived from measles virus-infected Vero cells, however neutralising antibody to interleukin-1 failed to inhibit the endothelial cell procoagulant response to measles virus, whereas it significantly reduced procoagulant activity induced in endothelial cells by recombinant interleukin-1. The capacity of measles virus to induce endothelial tissue factor in vitro, may be relevant to the thrombotic vasculopathy associated with measles virus infection in vivo.

Risk factor awareness: a randomized telephone survey of public knowledge

Health educators are often faced with the dilemma of developing materials or programs that begin at a level appropriate to the needs of individuals or the population as a whole. In 1992, a randomized telephone survey of the public's knowledge of risk factors relating to stroke was conducted in Saskatoon. The risk factors most frequently identified were poor diet (40%), hypertension (36%) and stress (36%). Respondents with a family history of stroke were significantly more likely to identify hypertension as a risk factor than those without such a history and significantly less likely to identify stress as a risk factor. In all, 24% reported a family history of acute myocardial infarction, and 28% reported a family history of stroke. Eighty percent were willing to learn more about the risk factors, and 88% were willing to make the appropriate lifestyle changes to reduce their risk of an event. Assessment of public knowledge can help in planning initiatives directed at prevention, early identification and appropriate referral.

Muscle and whole body metabolism after norepinephrine

The effect of an infusion of norepinephrine (0.42 nmol.kg-1.min-1) on energy metabolism in the whole body (using indirect calorimetry and the arteriovenous forearm catheterization techniques in eight healthy young male adults. The activity of the triglyceride-fatty acid cycle, which mainly operates in nonmuscular tissues, was also assessed by measuring glycerol turnover using [2H5]glycerol (to indicate lipolysis) and indirect calorimetry (to indicate net fat oxidation). Norepinephrine increased whole body oxygen consumption by almost 10% (P < 0.01), but the estimated oxygen consumption of muscles tended to decrease. Muscle blood flow (measured by 133Xe) and forearm blood flow (measured by strain-gauge plethysmography) were not significantly affected by norepinephrine, but the rate of uptake of nonesterified fatty acids and beta-hydroxybutyrate increased severalfold (P < 0.05), whereas that of glucose did not. The activity of the triglyceride-fatty acid cycle increased fourfold after norepinephrine administration, having a marginal effect on resting energy expenditure (approximately 1.5%) but accounting for approximately 15% of the increase in whole body energy expenditure. This study provides no evidence that skeletal muscle is an important site for norepinephrine-induced thermogenesis and suggests that an increase in the activity of the triglyceride-fatty acid cycle contributes to the norepinephrine-induced increase in energy expenditure of nonmuscular tissues.

The effect of arterialization of blood by hand warming on the interpretation of forearm metabolic studies

Although sampling of arterialized blood is widely used as an alternative to arterial sampling in metabolic studies, the arterialization procedures have been criticized because they may produce metabolic and haemodynamic effects that confound interpretation of results, especially in studies involving arteriovenous exchange of metabolites across the contralateral forearm. This study aimed to assess the effect of warming the hand for 10 or 20 min (a procedure which may be used to arterialize superficial venous blood) on the blood flow to the skin and muscle of the whole of the contralateral forearm. Hand warming, produced by placing the hand in a box kept at 67 +/- 3 degrees C for 10 min (standard errors of mean, SEM), produced no significant change in the blood flow of the whole forearm (4.14 +/- 0.28 versus 4.34 +/- 0.26 ml per 100 ml forearm min-1, measured with the hand circulation occluded), muscle (1.9 +/- 0.12 versus 1.82 +/- 0.15 ml per 100 ml forearm min-1, measured by 133Xe) or skin (5.2 +/- 4.0 versus 4.6 +/- 2.9 arbitrary units, measured by photoplethysmography). After 20 min of hand warming, there was no significant change in the concentration of a variety of metabolites in the deep venous blood draining the contralateral forearm. It is concluded that, unlike other 'arterialization' procedures, that used in this study had no important effect on the blood flow to the contralateral forearm or its distribution between muscular and non-muscular tissues. Therefore, this procedure of arterialization can be employed in arteriovenous studies that aim to assess the exchange of metabolites between blood and forearm tissues.

Results of clinical assessment after primary digital nerve repair

We have carried out a retrospective study of 88 consecutive digital nerve repairs in 84 patients who presented to this department between September 1989 and September 1991. 94% of the patients were operated on within 24 hours of the injury, and the nerves were repaired using magnifying loupes (x 4.5) 71 patients were assessed clinically 8 to 32 months post-operatively. 17% of the patients had excellent results, 51.1% good results, 22.8% fair results and 9.1% had poor results. Close correlation between age and recovery of sensation and between smoking and nerve recovery were found. Results were better in nerves that were cut cleanly (64.3% were excellent/good) than in crushed nerves (28.1%). Without the availability of an operating microscope, loupes give a satisfactory result in nerve repair, and this study compares well with reported series.

Effect of noradrenaline on glycerol turnover and lipolysis in the whole body and subcutaneous adipose tissue in humans in vivo

1. The effect of infusion of noradrenaline (0.42 mumol min-1 kg-1) on the exchange of nonesterified fatty acids, glycerol and other metabolites across subcutaneous abdominal adipose tissue was investigated in five healthy subjects using an arteriovenous catheterization technique and measurement of adipose tissue blood flow using the 133Xe clearance technique. At the same time, the net rate of fat oxidation in the whole body was assessed by indirect calorimetry, and the turnover of glycerol in the whole body and in subcutaneous adipose tissue was estimated using [5-2H]glycerol, which was administered as a primed constant infusion for 1 h before (basal turnover) noradrenaline administration and continued during the 1 h of noradrenaline infusion. 2. The noradrenaline infusion increased the plasma noradrenaline concentration from a basal value of 0.9 +/- 0.1 to 12.6 +/- 1.2 nmol/(mean +/- SEM) at 60 min. It also increased the arterialized concentration of glycerol by 50% (basal value 81 +/- 11 mumol/l-1) and that of plasma non-esterified fatty acids three-fold (basal value 357 +/- 86 mumol/l). 3. Noradrenaline increased the net release of glycerol by adipose tissue three-fold and that of non-esterified fatty acids three- to four-fold. Although the ratio of non-esterified fatty acid to glycerol release by adipose tissue increased in all subjects from a mean value of 2.7 in the basal period to 3.6 and 3.9 at 50 and 60 min of the noradrenaline infusion, respectively (P < 0.02), at no time point did the ratio differ significantly from 3.0.(ABSTRACT TRUNCATED AT 250 WORDS)

Microvascular replantation of a completely avulsed scalp

Total scalp avulsion is an unusual injury. To obtain good functional and cosmetic results, immediate revascularization using microsurgical techniques and replacement of the scalp in the correct anatomical position is the procedure of choice. This article describes a case report of successful replantation of a totally avulsed scalp from a 26-year-old male. Bilateral superficial temporal vessel anastomoses were performed using reversed autologous long saphenous vein grafts on the right side and direct repair on the left. Points of technique are discussed and the literature is reviewed.

The independent metabolic effects of halothane and isoflurane anaesthesia

Twelve healthy, unpremedicated women scheduled for total abdominal hysterectomy were given either isoflurane (n = 6) or halothane (n = 6) anaesthesia. They all received general anaesthesia for a period of 3 h, with surgery being carried out only in the last hour. The anaesthesia consisted of thiopentone, pancuronium and a mixture of oxygen-enriched air (FiO2 = 34%) supplemented with 1 MAC of either isoflurane or halothane. The patients were maintained normothermic, and with an arterial SaO2 above 95% throughout the period of the study. The following measurements were made before, during and after anaesthesia (with and without surgery): oxygen consumption (VO2), carbon dioxide production (VCO2); circulating concentrations of various hormones (insulin, growth hormone and cortisol); various metabolites; selected amino acids and albumin; forearm arterio-venous concentration difference of glucose, lactate, free fatty-acids and selected amino acids (four patients in each group). Whole body VO2 decreased significantly by over 20% during anaesthesia (with or without surgery), P < 0.05). Although the circulating concentration of most amino acids showed little or no change during anaesthesia alone, there was a tendency for the flux of most metabolites to decrease, and this persisted during surgery (P < 0.05). During anaesthesia alone there was a twofold reduction in the plasma cortisol concentration (P < 0.05), and a decrease in albumin concentration (P < 0.01). With the onset of surgery, plasma cortisol concentration increased rapidly (in association with several other hormones and metabolites) but hypoalbuminemia persisted.

Overwhelming sepsis presenting as sudden unexpected death

Four children, including three infants, who died suddenly and unexpectedly are described. In three of the cases group A beta haemolytic streptococcus was cultured and in the fourth Streptococcus pneumoniae. The organism was grown from multiple sites including blood in two of them. Without microbiological investigation the diagnosis would have been sudden unexpected death syndrome.

Bryostatin 1-induced modulation of the acute lymphoblastic leukemia cell line Reh

We have previously reported that the phorbol ester, 12-O-tetradecanoylphorbol 13-acetate (TPA) induces further differentiation of the human acute lymphoblastic leukemia cell line Reh to a monocytoid B lymphocyte stage. In the present study, we investigated the differentiating capacity of another protein kinase C (PKC) activator, bryostatin 1 (bryo). Reh cells were treated in vitro with TPA, bryo, or interferon-alpha (IFN-alpha) for a period of 5 days during which cells were analyzed for changes in growth patterns, morphology, cytochemistry, and surface phenotype. Bryo caused a dose-dependent growth inhibition of Reh cells. Morphologically, the treated cells expressed monocytoid features with development of filopodia and numerous vacuoles indicating phagocytic activity. Bryo induced similar phenotypic changes to TPA, including induction of CD11c, increased expression of CD22 and down-regulation of CD10 and CD19. Enzymatically, bryo, like TPA, induced tartrate-sensitive acid phosphatase expression but failed to induce periodic acid Schiff (PAS) and nonspecific esterase (NSE). Bryo inhibited the TPA action on NSE and CD10. IFN-alpha showed additive growth inhibitory and phenotypic effects to bryo. Collectively, our findings indicate that bryo is capable of inducing further differentiation of the Reh cells along the B cell lineage similar to those of TPA.

Glycerol exchange across the human forearm assessed by a combination of tracer and arteriovenous exchange techniques

1. Whole-body kinetics and regional exchange of glycerol across forearm muscle were assessed in eight lean subjects by a combination of a tracer method (infusion of [2H5]glycerol) and arteriovenous catheterization. 2. During an apparent steady state, the enrichment of glycerol in deep venous blood from the muscle bed of the forearm was about half (4.40 +/- 1.72 atom per cent excess) that observed in arterialized blood (8.41 +/- 4.30 atom per cent excess). Under the same conditions, the circulating concentrations of glycerol in arterialized (91 +/- 24 mumol/l) and venous (87 +/- 32 mumol/l) blood were similar. 3. In a further group of 37 subjects it was found that about half had a positive arteriovenous concentration difference and the other had half a negative arteriovenous concentration difference (mean -1.6 +/- 11.9 mumol/l; range -25 to +22 mumol/l). 4. These results suggest: (a) that human muscle does not always release glycerol and may take it up; (b) that there is substantial isotopic exchange of glycerol across forearm muscle tissue, which is not reflected by the net exchange of glycerol; this could be due to slow equilibrium of enriched glycerol from the circulation, with unenriched free glycerol in the muscle pool, or due to the simultaneous metabolic utilization of enriched glycerol and metabolic production of unenriched glycerol; (c) that the estimation of glycerol flux rates is strongly dependent on whether the blood is arterialized or deep venous.

Nutrient utilisation in muscle and in the whole body of patients receiving total parenteral nutrition

Forearm metabolite exchange was assessed by the arterio-venous catheterization technique in 5 parenterally fed patients (weight 55.22 kg +/- 4.18 kg; height 1.71 m +/- 0.04 m), who received an 'all-in-one' nutrition regimen whilst in remission from Crohn's disease. All patients received 12.8 g N, 4725 kJ from carbohydrate and 4200 kJ from fat (10416 kJ total energy). The exchanges were related to nutrient oxidation and nutrient balances in the whole body as assessed by indirect calorimetry and nitrogen excretion. At rest, the subjects were found to be in positive balances for carbohydrate (+0.78 +/- 0.13 kJ/min), fat (+1.85 +/- 0.26 kJ/min) and protein (+0.240 +/- 0.04 kJ/min). Resting forearm muscle was also in positive amino acid balance and positive carbohydrate balance. Despite the large estimated uptake of glucose by forearm muscle (+1860 +/- 84 nmol/100 ml tissue/min) there was no net release of pyruvate and lactate. Glutamate and the branched chain amino acids (BCAA) were the dominant amino acids taken up by muscle (26% and 30% of total uptake respectively) and glutamine was the dominant amino acid carrying nitrogen out of muscle (78% of total amino acid nitrogen release). The energy taken up by muscle as non-esterified fatty acids, triacylglycerol and ketone bodies was small relative to that associated with glucose uptake. The results suggest that during the hypercaloric parenteral nutrition regimen, a) increased peripheral glucose uptake is not necessarily associated with increased release of glycolytic products, b) in the absence of glutamine intake for at least 10 days, muscle retains enough capacity to synthesise and release sufficient quantities of glutamine so that it remains the dominant amino acid carrying nitrogen out of muscle, c) despite the use of the intravenous route for administration of nutrients, and unusual amino acid composition of the regimen, the overall pattern of forearm metabolism bears many similarities to that which occurs after a mixed meal in normal subjects.

Treatment of stages B3 and C seminoma with chemotherapy followed by irradiation therapy. Southwest Oncology Group Study

Beginning in 1981, 28 patients with advanced seminoma were treated with combination chemotherapy followed by irradiation to evaluate the possibility of improved survival using both modalities. The treatment protocol consisted of two courses of vincristine, actinomycin-D, and cyclophosphamide followed by reassessment. Those initially presenting with Stage B3 disease who achieved a complete response to two cycles of chemotherapy then underwent irradiation. All others were given a third course of chemotherapy before undergoing irradiation. The pre-radiation portion of this protocol produced a complete response rate of only 25 percent, substantially less than other, more recent, protocols. Radiation therapy produced a complete response in 69 percent of those who did not achieve a complete response from chemotherapy, increasing the complete response rate from 25 percent to 64 percent. Given this response rate to radiation therapy and the difficulty of dissection and associated morbidity with the surgical excision of postchemotherapy residual masses, the best option at this time may be observation with salvage chemotherapy and/or radiation reserved for those with disease progression.

Transperineal percutaneous iridium-192 interstitial template implant of the prostate: results and complications in 321 patients

A total of 321 patients with localized adenocarcinoma of the prostate treated by modified pelvic lymphadenectomy, Iridium-192 implant, and external beam iridium radiation were retrospectively reviewed. Analysis covered 8 years between 1981 and 1989 with a median population age of 72 (range 42 through 82 years). Disease-free survival for the entire group is 69% at 5 years with a median follow-up of 34 months (range 1.5 months to 98.5 months). As expected, both bulkier disease and positive nodal status adversely affected 5-year disease-free survival (p = 0.0001 for both). For tumors stage T1b (A2), T2a (B1), T2b (B2), T3 (C) the disease-free survival is 89.5%, 89.9%, 64.7%, and 48.8%, respectively; for NO disease 5-year disease-free survival is 76.5% versus N1/N2 disease with 5-year disease-free survival of 33.2%. Local control was excellent except for bulkier disease (p = 0.009). Tumors T1b, T2a, T2b, and T3 have 60-month local control rates of 95%, 93%, 83.6%, and 73.1%, respectively. Histologic grade also affected disease-free survival and local control with grade 1, grade 2, grade 3 showing 81.2%, 65.7%, and 45.1% disease-free survival at 5 years; and 93.6%, 82.2%, and 72.4% local control at 5 years. Estimates obtained using Kaplan-Meier method. Radiation induced morbidity was analyzed separately for all patients, there were 41 patients (13% of total) with 54 documented complications. There were no Grade 4 or 5 complications as per RTOG categories. Only 3 cases showed grade 3 complications (1%) and 51 cases showed grade 2 complications (15.9%). Grade 1 complications were not recorded. Of the grade 2 and grade 3 complications 30 were GU and 22 were rectal. The morbidity associated with combined interstitial implantation by transperineal percutaneous template and external beam iridium radiation for the localized prostate cancer is minimal with excellent local control and disease-free survival.

The stability of L-glutamine in total parenteral nutrition solutions

An assessment was made over a period of 14 days of the rate of glutamine degradation in different intravenous solutions kept at 22-24 degrees C, 4 degrees C, -20 degrees C and -80 degrees C. At room temperature (22-24 degrees C) degradation rates in mixed parenteral nutrition solutions and aminoacid/dextrose solutions ranged from 0.7-0.9%/day, in Perifusin 0.6%/day, and in dextrose alone as low as 0.15%/day. At 4 degrees C, glutamine degradation was <0.1-0.2%/day in all solutions examined, at -20 degrees C it was minimal (<0.04%/day) and at -80 degrees C, it was undetectable. Glutamine degradation was found to be associated with the formation of equimolar quantities of ammonia. No glutamate formation was detected. It is concluded that it is possible to store glutamine in parenteral nutrition solutions kept at 4 degrees C, with about 2% loss over a period of 14 days. The degradation is sufficiently slow to consider the use of intravenous glutamine in nutritional therapy.

The difficult ankle

Ankle sprains are extremely common in sport and usually respond to conservative management, but many apparent ankle sprains do not respond to treatment and remain painful. Alternative diagnoses must be considered. These require careful clinical assessment and often further investigations.

Quantifying intermediary metabolites in whole blood after a simple deproteinization step with sulfosalicylic acid

We assessed the reproducibility, recovery, and stability of several circulating metabolites--glucose, pyruvate, lactate, alanine, glutamate, glutamine, 3-hydroxybutyrate, acetoacetate, and glycerol--in the presence of sulfosalicylic acid (SSA), which was used to deproteinize blood. The assays, which involved reactions linked to NADH/NAD+, were carried out at 37 degrees C and measured at 355 nm with a Cobas-Bio centrifugal analyzer. The intra- and interbatch CVs were less than 2.1%, except for the interbatch CV for 3-hydroxybutyrate at low concentration (15-30 mumol/L), which was 5.4%. Analytical recovery of metabolites added to blood ranged from 96.4% to 103.0%. Of the metabolites studied, all were stable at -20 degrees C for 90 days in the SSA-blood extract, except for glutamine and acetoacetate, which progressively decreased with time. We conclude that these nine circulating metabolites can be satisfactorily measured after a single deproteinizing step with SSA. This single-step procedure has several advantages over many of the currently used methods.

Amino acid metabolism in human subcutaneous adipose tissue in vivo

1. Arteriovenous differences for alanine, glutamate and glutamine were measured across subcutaneous adipose tissue and forearm muscle in normal subjects. 2. After an overnight fast, adipose tissue showed net production of alanine and glutamine and uptake of glutamate in each of 11 subjects. 3. In seven subjects, adipose tissue blood flow was measured and the measurements were continued for 6 h after eating a mixed meal. The pattern of amino acid metabolism across the adipose tissue was remarkably little disturbed after the meal, except for a short period of apparent uptake of alanine as the concentration of that amino acid rose. 4. The pattern of amino acid metabolism across adipose tissue was qualitatively similar to that across the forearm, although it differed quantitatively in that glutamate uptake was more prominent (compared with glutamine release) in the adipose tissue. 5. The rates of alanine and glutamine release observed suggest that adipose tissue may play a substantial role in the whole-body production of these amino acids.

Quantifying intermediary metabolites in whole blood after a simple deproteinization step with sulfosalicylic acid

We assessed the reproducibility, recovery, and stability of several circulating metabolites--glucose, pyruvate, lactate, alanine, glutamate, glutamine, 3-hydroxybutyrate, acetoacetate, and glycerol--in the presence of sulfosalicylic acid (SSA), which was used to deproteinize blood. The assays, which involved reactions linked to NADH/NAD+, were carried out at 37 degrees C and measured at 355 nm with a Cobas-Bio centrifugal analyzer. The intra- and interbatch CVs were less than 2.1%, except for the interbatch CV for 3-hydroxybutyrate at low concentration (15-30 mumol/L), which was 5.4%. Analytical recovery of metabolites added to blood ranged from 96.4% to 103.0%. Of the metabolites studied, all were stable at -20 degrees C for 90 days in the SSA-blood extract, except for glutamine and acetoacetate, which progressively decreased with time. We conclude that these nine circulating metabolites can be satisfactorily measured after a single deproteinizing step with SSA. This single-step procedure has several advantages over many of the currently used methods.

The effect of severe dietary restriction on intramuscular glutamine concentrations and protein synthetic rate

An investigation was carried out to examine the relationship between fractional muscle protein synthetic rate (FSR) and intramuscular glutamine concentration ({GLN}(i)) in rats that had a dietary intake which was deficient in both protein and energy. Young male rats (38 days old) were fed for 48 h on either 1) 25% of the ad lib intake of a 20% protein diet, or 2) glucose alone, sufficient to provide the same energy intake as in 1). In a separate study, 33 day old rats were starved completely for 48 h. Appropriate controls were included in both studies. Muscle FSR, which was reduced by 40% in both groups of energy restricted rats (P<0.001), was associated with a small increase in {GLN}(i) (P<0.05). Starvation produced a 60% reduction in FSR (P<0.01) and a 45% (P<0.05) reduction in {GLN}(i). It is concluded that reductions in muscle protein synthesis can occur by mechanisms independent of intramuscular glutamine concentration.

Ketone body metabolism in lean male adults during short-term starvation, with particular reference to forearm muscle metabolism

1. Thirty-three arteriovenous forearm catheterization studies were carried out in 19 lean subjects starving for 12-14 h (n = 13), 30-36 h (n = 7) and 60-66 h (n = 13). Forearm blood flow was measured in order to calculate the flux of various substrates. At the same time, whole-body oxidation of fat, carbohydrate and protein was calculated using indirect calorimetry and urinary nitrogen excretion. 2. After an overnight fast (12-14 h), whole-body resting energy expenditure was accounted for by the oxidation of protein (15%), carbohydrate (17%) and fat (68%). At 30-36 h and 60-66 h of starvation, essentially all the non-protein energy was derived from the oxidation of fat (directly plus indirectly via ketone bodies). 3. After an overnight fast, acetoacetate and 3-hydroxybutyrate were taken up by forearm muscle at a rate which could account for 5% of the resting O2 consumption of this tissue. As starvation progressed, forearm muscle took up more acetoacetate and released 3-hydroxybutyrate so that the net uptake of ketone bodies was sufficient to account for about 10% of the resting O2 consumption at 30-36 h of starvation and about 20% at 60-66 h of starvation.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary albumin excretion in healthy adult subjects: reference values and some factors affecting their interpretation

A conventional radioimmunoassay has been used to measure urinary albumin concentration in overnight, recumbent and daytime, ambulant samples from 127 healthy, normotensive volunteers (mean age 33.3 yr SD 12.4; 59 males, 68 females). Reference values were obtained for urine albumin concentration (mg/l), albumin/creatinine ratio (mg/mmol), and albumin excretion rate (microgram/min). The frequency distributions of these variables were positively skewed, but became Gaussian on logarithmic transformation of the data. Albumin excretion was significantly higher in daytime, ambulant samples than in overnight, recumbent samples (p less than 0.001). Surface area was not correlated with urine albumin concentration but it was negatively correlated with urine albumin/creatinine ratio (p less than 0.05) due to the association between surface area and creatinine excretion. Urine albumin concentration was negatively correlated with age, but this was due to a higher urine flow rate in older subjects. There was no significant association with sex or with mean arterial blood pressure in the normal range. Two repeated measurements showed that variability was high and comparable for urine albumin concentration, albumin/creatinine ratio and albumin excretion rate: it was not significantly less in overnight, recumbent than in day-time, ambulant samples.

In vivo mutagenic effect of methyldopa. 1. Dominant lethal test in male mice

The dominant lethal test was used to evaluate the mutagenic potential of methyldopa, an antihypertensive drug, in male mice. In the series treated, animals were exposed to 480 or 960 mg/kg of the drug as a suspension in 1% gum acacia via the oral route. A separate group of males served as control. Following treatment each male of the control, as as well as the treated series, was mated to two untreated virgin females each week for a period of 6 consecutive weeks. All mated females were sacrificed on the 10th day of separation and their ovaries and uterine contents were examined. Corpora lutea, implantations and resorptions were recorded. The drug treatment did not impair the mating capacity and fertility. Pre- and post-implantation losses were assessed. Higher incidences of post-implantation losses and abortion, and lower incidences of total implantations particularly at higher dose levels clearly reveal a dominant lethal effect of the drug.

Transperineal percutaneous iridium-192 implant of the prostate

Interstitial implantation of radioisotopes has become an increasingly popular modality for the management of localized adenocarcinoma of the prostate. Despite the recognized disadvantages, including technical difficulties of accurate seed placement, uncorrectable dose, inhomogeneities in implant volume, limitations in the range of irradiation, and radiation exposure to personnel handling active sources, permanent implantation of either iodine-125 or gold-198 seeds has been widely advocated. A technique of transperineal implantation with afterloading that circumvents many of the problems associated with permanent types of implants is described. Three thousand rad of external beam irradiation was administered three weeks after the implant. Twenty-five patients with clinically localized adenocarcinoma of the prostate were treated with excellent normal tissue tolerance and no major complications. This technique offers excellent control over the implant volume, dose distribution, and radiation exposure to personnel.

Chromosomal location of genes for gliadin polypeptides in durum wheat Triticum turgidum L

The chromosomal location of genes was determined for 19 of 30 gliadin bands extracted from seeds of a set of durum wheat (Triticum turgidum L. var. 'durum') aneuploids and durum cultivars. Individual bands were identified by their relative mobility on polyacrylamide gels. The gene(s) for gliadin band 45, which has been associated with strong gluten by several authors, was shown to be controlled by chromosome 1 B. A band with similar mobility (band 46) was controlled by 'Chinese Spring' chromosome 1D. Conventional breeding procedures coupled with the use of electrophoresis of gliadin polypeptides should result in rapid conversion of current weaker gluten durum cultivars to strong gluten cultivars.

Gray-scale ultrasonography in the evaluation of neoplastic invasion of the base of the tongue

Patients with primary carcinoma of the base of the tongue or direct invasion from contiguous areas were examined clinically and with ultrasound, and in some cases with computed tomography (CT), xerography, and polytomography. In all cases, multiple biopsy specimens were obtained. Utrasonography was better than the other imaging methods in delineating disease extent in the tongue itself, while CT and tomography were more useful in evaluating the retropharyngeal and lateral pharyngeal regions. It is suggested that ultrasound be used in the initial evaluation of such patients.

Intestinal parasites in University of Dacca students

Nine hundred and thirty three students of Dacca University were examined: mean haemoglobin levels were 80.5 per cent for men and 70.0 per cent for women. Five hundred and thirty three (57.3%) of the students had single or multiple intestinal parasitic infections, of which Ascaris lumbricoides (366), Entamoeba histolytica (113) and Trichuris trichiura (99) were the commonest. It is suggested that chronic nutritional deficiencies are compounded by these parasites, leading to low weights, and low haemoglobins.