Trihexyphenidyl treatment of clozapine-induced hypersalivation

The objective of this study was to investigate the efficacy of the anticholinergic agent trihexyphenidyl in the treatment of clozapine-induced hypersalivation. Fourteen chronic schizophrenic patients who exhibited nocturnal hypersalivation during clozapine treatment were coadministered trihexyphenidyl (5-15 mg/day, at bedtime) for 15 days. Salivation was assessed by a single-item 5-point scale. A reduction of 44% in the reported nocturnal hypersalivation was observed after trihexyphenidyl treatment. These results indicate that at least some chronic schizophrenic patients with clozapine-induced nocturnal hypersalivation may benefit from anticholinergic treatment.

The tax gene sequences form two divergent monophyletic lineages corresponding to types I and II of simian and human T-cell leukemia/lymphotropic viruses

Evolutionary associations of human and simian T-cell leukemia/lymphotropic viruses I and II (HTLV-I/II and STLV-I/II) are inferred from phylogenetic analysis of tax gene sequences. Samples studied consisted of a geographically diverse assemblage of viral strains obtained from 10 human subjects and 20 individuals representing 12 species of nonhuman primates. Sequence analyses identified distinct substitutions, which distinguished between viral types I and II, irrespective of host species. Phylogenetic reconstruction of nucleotide sequences strongly supported two major evolutionary groups corresponding to viral types I and II. With the type I lineage, clusters were composed of strains from multiple host species. A genetically diverse, monophyletic lineage consisting of eight new viral strains from several species of Asian macaques was identified. The second lineage consisted of a monophyletic assemblage of HTLV-II/STLV-II strains from Africa and the New World, including an isolate from a pygmy chimp (Pan paniscus) as an early divergence within the lineage. High levels of genetic variation among strains from Asian STLV-I macaque suggest the virus arose in Asia. Evidence of the origin of the type II virus is less clear, but diversity among HTLV-II variants from a single isolated population of Mbati villagers is suggestive but not proof of an African origin.

Pharmacokinetics of pamidronate disodium in patients with cancer with normal or impaired renal function

Pamidronate is a second-generation bisphosphonate that undergoes negligible biodegradation and is eliminated exclusively by renal excretions. Nineteen cancer patients were stratified according to baseline creatinine clearance (Clcr): group I, Clcr > 90 mL/min (n = 6); group II, Clcr 61 mL/min to 90 mL/min (n = 6); group III, Clcr 30 mL/min to 60 mL/min (n = 3); group IV, Clcr < 30 mL/min (n = 4). All patients received a single, 90-mg dose of pamidronate disodium administered in a 4-hour intravenous infusion. Plasma and urine samples were collected at intervals up to 36 and 120 hours, respectively, after the start of infusion and were assayed for pamidronate, using validated high-performance liquid chromatography. Pamidronate's pharmacokinetics were characterized by a short distribution phase (2-3 hours) followed by rapid elimination of the drug in urine. Elimination of pamidronate was slower in patients in group IV with a mean +/- standard deviation area under the plasma concentration-time curve (AUC0-36) of 19.0 +/- 4.60 micrograms.hr/mL compared with 8.1 +/- 3.13 micrograms.hr/mL in patients in group I. A linear relationship in Clcr was observed for AUC0-36 (r = 0.67), urinary excretion (r = 0.69), and renal clearance (r = 0.81). Renal clearance was proportional to Clcr for patients in all four renal-function groups. In the treatment of bone metastases of malignancy, successive doses of pamidronate are generally separated by weeks; thus, plasma accumulation in patients with renal impairment is not expected to be clinically relevant. A reduction in dose of pamidronate disodium should not be necessary in cancer patients with renal impairment.

Value of carcinoembryonic antigen monitoring in curative surgery for recurrent colorectal carcinoma

PURPOSE

This study is designed to review a carcinoembryonic antigen (CEA)-driven postoperative protocol designed to identify patients suitable for curative reresection when recurrent colorectal cancer is identified.

METHODS

A total of 285 patients who were operated on for colon or rectal carcinoma between 1981 and 1985 were evaluated (with CEA levels) every two months for the first two years, every three months for the third year, every six months for years 4 and 5, and annually thereafter. CEA levels above 5 microg were considered abnormal and were evaluated with diagnostic imaging and/or endoscopy.

RESULTS

Follow-up was available for 280 patients (98.2 percent). Distribution of patients by Astler-Coller was: A, 14 percent; B1, 20 percent; B2, 39 percent; C1, 5 percent; C2, 21 percent. There were 62 of 280 patients (22 percent) who developed elevated CEA levels, with 44 patients who demonstrated clinical or radiographic evidence of recurrence. Eleven patients were selected for surgery with curative intent (4 hepatic resections, 1 pulmonary wedge resection, 2 abdominoperineal resections, 2 segmental bowel resections, and 2 cranial metastasectomies). Three of 11 patients (27 percent) benefited and have disease-free survivals greater than 60 months. Of the 223 patients without elevated CEA, 22 (9.9 percent) had recurrent cancer without any survivors. Overall, 3 of 285 patients (1.1 percent) were cured as a result of CEA follow-up.

CONCLUSION

CEA-driven surgery is useful in selected patients and can produce long-term survivors.

Endorectal repair of rectocele revisited

BACKGROUND

Transanal repair of rectocele involving the suprasphincteric portion of the rectovaginal septum has been shown to provide excellent results in up to 90 per cent of cases. Selection of patients suitable for repair is important. Rectocele with concomitant cystocele is best repaired transvaginally. An alternative approach is recommended for enterocele.

METHODS

With the patient in the prone position and using local anaesthesia, a mucomuscular endorectal flap is raised and the underlying tissues are plicated. The excessive flap is excised, and the cut edges are approximated. A retrospective review of 123 consecutive cases of transanal repair of rectocele was conducted. Patient satisfaction and complications were compared with those in a previously reported study.

RESULTS

Overall patient satisfaction improved from 63 per cent of 59 patients in an earlier study to 82 per cent in this report. The overall complication rate decreased from 7 to 3 per cent.

CONCLUSION

This study demonstrates the validity of a simple technique of transanal repair of rectocele in an ambulatory setting. Minimal morbidity and successful outcome can be achieved with this procedure.

Multiple myeloma and chronic lymphocytic leukemia

Much progress has been made in delineating the pathogenesis of multiple myeloma and chronic lymphocytic leukemia. The cell of origin in both diseases has been better defined, which has led to important clinical treatments. For myeloma, reduction of tumor burden in autografts has been accomplished and been associated with favorable outcome. The importance of interleukin-6 in maintaining this tumor and causing skeletal disease has been more clearly defined and has led to treatment with antibodies that block this cytokine's action. The bisphosphonate pamidronate decreases skeletal complications and improves quality of life for these patients. For chronic lymphocytic leukemia, further definition of common cytogenetic and gene abnormalities have been made and associated with patient outcome. The nucleoside analogues continue to produce excellent responses and the use of myeloablative chemotherapy with hematopoietic support shows promise in early studies.

The effect of topical fluoride agents on saliva secretion

The aim of this study was to assess the possible influence of various topical fluoride agents on the rate of saliva secretion. Fifteen healthy volunteers, both males and females, aged 20-60 years, participated in this study. Aminfluorides and monofluorophosphate products in gel, toothpaste and rinse states were used. Each subject brushed or rinsed the teeth and mouth for 2 minutes. Secreted saliva was collected for 5 minutes. Salivary secretion was significantly greater after toothbrushing with aminfluoride compounds as compared to toothbrushing with monofluorophosphate. There was a tendency for an increased saliva flow rate with higher fluoride concentration of the aminfluoride.

Factors predicting the outcome of intraarterial thrombolysis in peripheral arterial and graft occlusions

PURPOSE

To determine the association between successful intraarterial thrombolysis and the following factors: sex, age, symptoms, duration of symptoms, length of occlusion, conduit type, runoff, and catheter localization.

MATERIAL AND METHODS

Forty-six patients with acute or subacute occlusions of peripheral native arteries and grafts were treated with continuous intraarterial infusion of streptokinase or urokinase. A univariate chi-square test and logistic regression analysis were used.

RESULTS

Successful lysis was achieved in 27 of 46 patients (59%). The logistic regression analysis revealed a significant association between successful thrombolysis and good runoff (p < 0.01). A catheter position above the occlusion resulted in lysis in only one of 11 patients. The variables rest pain and claudication were slightly significant (p = 0.07). None of the other variables were significant, but a trend toward a separate effect of duration of occlusion was found.

CONCLUSION

Good runoff and intrathrombotic infusion are virtual necessities in obtaining a positive immediate outcome in peripheral arterial and graft occlusions. In our study, other factors were less important.

Variations in colon and rectal surgical mortality. Comparison of specialties with a state-legislated database

PURPOSE

This study was designed to examine variations in operative mortality among surgical specialists who perform colorectal surgery.

METHODS

Mortality rates were compared between six board-certified colorectal surgeons and 33 other institutional surgeons using comparable colorectal procedure codes and a validated database indicating patient severity of illness. Thirty-five ICD-9-CM procedure codes were used to identify 2,805 patients who underwent colorectal surgery as their principal procedure between July 1986 and April 1994. Atlas, a state-legislated outcome database, was used by the hospital's Quality Assurance Department to rank the Admission Severity Group (ASG) of 1,753 patients from January 1989 to April 1994 (higher ASG, 0 to 4, indicates increasing medical instability).

RESULTS

Colorectal surgeons had an eight-year mean in-hospital mortality rate of 1.4 percent compared with 7.3 percent by other institutional surgeons (P = 0.0001). There was a significantly lower mortality rate for colorectal surgeons compared with other institutional surgeons in ASG 2 (0.8 and 3.8 percent, respectively; P = 0.026) and ASG 3 (5.7 and 16.4 percent, respectively; P = 0.001).

CONCLUSIONS

Board-certified colorectal surgeons had a lower in-hospital mortality rate than other institutional surgeons as patients' severity of illness increased.

Production of anti-erythrocyte antibodies by leukemic and nonleukemic B cells in chronic lymphocytic leukemia patients

We have assessed the specificity of antibodies from the leukemic B cells of five patients with both chronic lymphocytic leukemia and autoimmune hemolytic anemia (CLL-AHA). Leukemic cells from one patient displayed surface immunoglobulin with heavy and light chain isotypes identical to that of the patient's anti-red blood cell (RBC) antibodies, and the leukemic cells secreted antibodies in vitro with anti-RBC activity. However, in the remaining patients, the leukemic cells displayed surface immunoglobulin with light chain isotypes different from that of the patient's anti-RBC antibodies and secreted antibodies in vitro with no detectable anti-RBC activity. Thus, there are two distinct classes of CLL-AHA patients, differentiated by the presence or absence of an anti-RBC antibody-producing leukemic B cell clone. The apparent heterogeneity in the source of pathogenic anti-RBC antibodies may impact the treatment response of the two classes of CLL-AHA patients.

Spiroplasma diminutum sp. nov., from Culex annulus mosquitoes collected in Taiwan

Initially, strain CUAS-1T (T = type strain), which was isolated from a frozen triturate of Culex annulus mosquitoes collected in Taiwan, was thought to be a member of spiroplasma group VII. This placement was based on the spiroplasma deformation test titer observed when strain CUAS-1T spiroplasmas were tested with Spiroplasma monobiae MQ-1T antiserum. The results of subsequent reciprocal spiroplasma deformation, metabolism inhibition, and growth inhibition tests clearly revealed that strain CUAS-1T is not serologically related to previously described spiroplasma groups (groups I to XXIV) and thus is a representative of a new group, group XXV. Strain CUAS-1T was characterized by using the minimal standards for mollicute species descriptions. During logarithmic-phase growth, strain CUAS-1T cells are characteristically very short helices with 1.5 to 2 helical turns (1 to 2 microns), highly motile, and bounded by a single trilaminar membrane and form granular colonies with satellites when the organism is grown aerobically on MID medium containing 1.6% agar. Growth in MID broth occurs at temperatures ranging from 10 to 37 degrees C, and the optimum temperature is 30 degrees C. Substrate utilization tests revealed that cholesterol is required for growth, that glucose is hydrolyzed, and that arginine is not hydrolyzed both in the presence and in the absence of glucose. The genome of strain CUAS-1T is 1,080 kbp long, and the guanine-plus-cytosine content is 26 +/- 1 mol%. On the basis of the results of our studies we propose that strain CUAS-1T (group XXV) should be placed in a new species, Spiroplasma diminutum. Strain CUAS-1 (= ATCC 49235) is the type strain of S. diminutum.

Deletion of genetic material from a poly(ADP-ribose) polymerase-like gene on chromosome 13 occurs frequently in patients with monoclonal gammopathies

Recently, by using a probe for the nuclear DNA repair enzyme poly(ADP-ribose) polymerase gene, a pseudogene was found on the long arm of chromosome 13. RFLP analysis demonstrates the presence of a common "A" allele and a rare "B" allele, which has a deletion of approximately 200 bp. This deletion occurs more frequently in blacks than in whites in the United States. In two B-cell malignancies, Burkitt's and follicular lymphomas, there is a marked increased frequency of the expression of the B allele. Thus, we have analyzed the frequency of this allele in another B-cell malignancy, multiple myeloma (MM), which is also more frequently observed in blacks. We studied 97 patients with MM (41 black and 56 white patients) and 30 patients with the related disorder monoclonal gammopathy of undetermined significance (MGUS; 13 black and 17 white patients). The results demonstrate that the overall frequency of B allele expression (37%) is higher than in a noncancer control population (23%; P < 0.01). This difference is mainly due to the much higher frequency of B expression in black patients (52 versus 35% in black controls; P < 0.01), whereas there is no significant difference in white patients (18 versus 14% in white controls). Overall, B allelic frequency is similar in patients with MM and MGUS. Matched germline and tumor DNA show identical patterns of expression of these alleles. These results suggest germline B allelic expression predisposes one to MM and MGUS.

Multiple myeloma and chronic lymphocytic leukemia

New insights into the molecular biology of both multiple myeloma and chronic lymphocytic leukemia can potentially lead to new treatment modalities. For myeloma, its lack of CD34 expression can lead to a functional but less contaminated autograft for stem cell transplantation. Single or even double transplants are being used to treat high-risk or even relapsed disease. Cytokines, such as interleukin-6, appear to play a role in tumor growth and bony complications as well. The bisphosphonate drugs are now known to decrease skeletal complications. For chronic lymphocytic leukemia, the nucleoside analogues have produced impressive response rates in many patients. Cell surface markers and cytogenetic abnormalities continue to identify patients with poor prognoses. Myeloablative therapy remains controversial for this disease.

Molecular epidemiology of dengue-1 and dengue-4 viruses

Genetic variation between geographically and temporally distinct isolates of dengue-1 (DEN-1) and dengue-4 (DEN-4) viruses was investigated. The nucleotide sequences of a fragment of the envelope protein gene encoding amino acids 28 to 87 of 35 DEN-1 isolates and 28 DEN-4 isolates were determined. Maximum nucleotide sequence variation was 6.9% and 4.9% for DEN-1 and DEN-4 viruses, respectively. Taking a divergence of 6% between the nucleotide sequences as the cut-off value, three genotype groups were defined for DEN-1 viruses, whereas only one was observed for DEN-4 viruses. Molecular analysis of isolates from the South Pacific permits the classification of the recent strains of DEN-1 (1988-1989 epidemics) into a genotype distinct from the genotype which comprises earlier strains. This observation suggests that the recent epidemics were due to the introduction of a new genotype rather than to the re-emergence of the earlier strain.

The relationship between alveolar bone height and age in the primary dentition. A retrospective longitudinal radiographic study

The natural history of changes in attachment level in the primary dentition should be determined before considering diagnostic criteria for periodontal diseases in children. The present study was designed to describe longitudinal changes in the distance between the alveolar bone crest and the cementoenamel junction (ABC-CEJ) determined radiographically. Bite-wing radiographs were obtained from 33 children as part of a routine annual dental examination in a rural community. The ABC-CEJ distance of 1500 sites located at the mesial and distal aspects of primary molars and distal aspect of primary cuspids were measured. An analysis of variance model was used to assess the effect of age, sex, tooth, side of the mouth, jaw, site and patient on the ABC-CEJ measurements. The side of the mouth (left, right) and the site (mesial, distal) had no significant effect on the ABC-CEJ distance. ABC-CEJ distances in the upper jaw were greater than in the lower jaw, and different teeth exhibited different ABC-CEJ distances. Canines had the greatest distance and second molars the smallest. The most interesting relationship was between alveolar bone height and age. The overall ABC-CEJ distance seemed to increase with age; however, this was not a linear relationship but followed the pattern of facial growth, with two spurts separated by a period of minimal increase. The results indicate that different levels of ABC-CEJ distance might be considered as a cut-off value for radiographic diagnosis of alveolar bone loss at different ages, for different primary teeth and for different jaws.

Growth-restricted dengue virus mutants containing deletions in the 5' noncoding region of the RNA genome

The dengue type 4 virus (DEN4) RNA genome contains a 101-nt 5' noncoding (NC) sequence which is predicted to form a stable secondary structure. DEN4 cDNA from which infectious RNA can be transcribed was used to engineer deletions in the 5' NC region for functional analysis of RNA structure and for isolation of DEN4 mutants that could be evaluated as candidates for use in a live attenuated vaccine. Eleven distinct deletions in the region of the DEN4 genome between nts 18 and 98 were constructed; each mutation was predicted to alter or disrupt the local base-parings in the 5' NC RNA structure. An infectious virus was not recovered from the RNA transcripts of five of these deletion mutants. Significantly, four of the five apparently lethal deletions were located in a 5- to 6-nt base-paired region of a predicted long stem or adjacent to it. In contrast, with one exception, mutants which yielded infectious virus had deletions which were located in a loop or short stem region. The effect of the deletions on the efficiency of translation of viral RNA transcripts was examined in vitro. The RNA transcripts of deletion constructs which did not yield viable virus were translated at an efficiency ranging from 40 to 160% that of wild-type virus transcripts. The translation efficiency of infectious RNA transcripts also varied. Deletion mutants recovered from RNA transcripts that exhibited low to moderate efficiency of translation had a small plaque morphology and exhibited reduced growth in simian LLC-MK2 and mosquito C6/36 cells compared to the wild-type virus. Among the 11 mutant constructs, deletion of nts 82-87 caused the greatest reduction in translation efficiency. Nevertheless, an infectious virus was recovered from LLC-MK2 cells transfected with the RNA transcripts of mutant d(82-87). The progeny of this mutant produced small plaques on LLC-MK2 cells and grew to low titer in these cells. Unlike wild-type DEN4 or other DEN4 deletion mutants tested, mutant d(82-87) failed to produce plaques on C6/36 cells and was also replication-defective in Aedes aegypti and Aedes albopictus following intrathoracic inoculation.

Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Exercise training and severe caloric restriction: effect on lean body mass in the obese

The purpose of this study was to investigate the effects of exercise intensity on the body composition of obese subjects during severe caloric restriction. Forty obese subjects (33 women, 7 men; 41 +/- 7.7 years; 106 +/- 26kg; body fat > 25% men, > 30% women) on a commercially prepared OPTIFAST 420kcal/day supplemented fast were randomized into groups that exercised at target heart rates corresponding to 40% and 60% of the heart rate reserve (HRR) at the start of the program. Training volume was similar for both groups at approximately 300kcal per session three times per week for 12 weeks. Body weight, body fat, and lean weight were similar for both exercise intensity groups at week one. Overall, body weight decreased by 15.3 +/- 6.7 kg (p < or = .05), and body fat decreased by 14.9 +/- 5.0 kg (p < or = .05) for the 40 subjects, whereas lean weight remained unchanged. No significant differences in body weight, body fat, or lean weight were observed between the two groups. The results of the current study indicated that while on a supplemented 420-kcal/day fast, exercise at 40% and 60% of the HRR affected body composition similarly when total training volume was held constant at 900kcal/week. Lean weight remained unchanged and accompanied a 14.9 +/- 5.0-kg decrease in body fat, which may have resulted when the volume of exercise (ie, 900kcals/wk) was factored into the exercise prescriptions. These results suggest that exercising at 60% of the HRR offers no advantages for body composition changes over those obtained from exercising at 40% of HRR when the total volume of exercise training is controlled.

Anorectal abscess-fistulae

Anal abscess-fistulae have a tendency to recur based on variations in anatomic configuration and complexities of operative treatment and problematic postoperative healing. A classification of superficial, simple, complex, and recurrent fistulae was used to track outcome. Recurrence rates are substantially higher for those fistulae classified as complex. The reasons for this are discussed in this article.