Diagnosis and management of acute alcohol withdrawal

Alcohol abuse produces a considerable burden of illness in the Canadian population. The diagnosis of alcohol dependence and withdrawal can be difficult, particularly in the setting of covert intake or comorbidity. Two validated scales, the CAGE questionnaire to screen for alcohol abuse and dependence and the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to assess the severity of withdrawal, are valuable tools for clinicians to use on a regular basis. For the treatment of alcohol withdrawal, compelling anecdotal evidence supports the routine administration of thiamine, but not necessarily other vitamins. Phenytoin has not been shown to be superior to placebo for uncomplicated withdrawal seizures. Neuroleptics are not recommended for routine use. Sedation with benzodiazepines guided by the CIWA-Ar results is recommended. There is good evidence that the management of alcohol withdrawal can be improved with the routine use of the CIWA-Ar scale to assess severity, treatment with adequate doses of benzodiazepines and follow-up monitoring of patients in alcohol withdrawal.

An analysis of the geographic variation in cancer incidence and its determinants in Ontario

Cancer incidence data for the Ontario Public Health Units in 1980-91 were examined to investigate regional patterns and the existence of outlier values after adjustment for known risk factors. Candidate risk factors were derived from the Ontario Health Survey and the census. Weighted regressions were fit to the data, and the spatial pattern of the residuals was analyzed. The number of outlier data points with significant elevations or reductions in risk was close to that expected by chance. They were dispersed geographically, and occurred in a variety of cancer types. We conclude that, in general, most of the geographic variation in cancer risk can be associated with variation in known risk factors, and that there appear to be no broad regional effects remaining after adjustment for these factors. A few cancer sites provide limited evidence of regional effects that may warrant further investigation.

Effect of the framing of questionnaire items regarding satisfaction with training on residents' responses

PURPOSE

To determine whether framing questions positively or negatively influences residents' apparent satisfaction with their training.

METHOD

In 1993-94, 276 residents at five Canadian internal medicine residency programs responded to 53 Likert-scale items designed to determine sources of the residents' satisfaction and stress. Two versions of the questionnaire were randomly distributed: one in which half the items were stated positively and the other half negatively, the other version in which the items were stated in the opposite way.

RESULTS

The residents scored 43 of the 53 items higher when stated positively and scored ten higher when stated negatively (p < .0001). When analyzed using an analysis-of-variance model, the effect of positive versus negative framing was highly significant (F = 129.81, p < .0001). While the interaction between item and framing was also significant, the effect was much less strong (F = 5.56, p < .0001). On a scale where 1 represented the lowest possible level of satisfaction and 7 the highest, the mean score of the positively stated items was 4.1 and that of the negatively stated items, 3.8, an effect of 0.3.

CONCLUSIONS

These results suggest a significant "response acquiescence bias." To minimize this bias, questionnaires assessing attitudes toward educational programs should include a mix of positively and negatively stated items.

Should distal interlocking of tibial nails be performed from a medial or a lateral direction? anatomical and biomechanical considerations

OBJECTIVE

To compare the relative risks of neurovascular injury from perforation during distal interlocking and the biomechanical stability of two approaches to distal interlocking of tibial nails.

DESIGN

In vitro anatomical and biomechanical study.

SETTING

All mechanical testing was performed in a servohydraulic test frame with a customized motion transducer.

INTERVENTION

Tibial nails were interlocked distally with a medial-to-lateral (ML) or a lateral-to-medial (LM) approach.

MAIN OUTCOME MEASURE

The distances from the nearest end of each distal locking screw to four neurovascular structures were measured manually with calipers, and two-dimensional motion under simulated stance load across the fracture site was recorded.

RESULTS

There were greater distances from the posterior tibial neurovascular bundle and the superficial peroneal nerve with distal targeting from the LM direction compared with targeting from the ML direction. Biomechanically, the ML nail configuration demonstrated slightly greater resistance to bending than the LM configuration.

CONCLUSIONS

Distal tibial interlocking from the LM direction appears to be safer than interlocking from the ML direction with regard to relative distances from the neurovascular structures. This small anatomical advantage must be considered in light of slightly greater resistance to bending of the ML interlocking configuration compared with the LM interlocking configuration.

Human growth hormone transgene expression increases the biomechanical structural properties of mouse vertebrae

STUDY DESIGN

Caudal vertebrae were obtained from male and female mice from two transgenic lines expressing an erythroid-specific human growth hormone transgene construct, and gender-matched, age-matched, non-transgenic control mice.

OBJECTIVE

To characterize the effect of human growth hormone transgene expression on the biomechanical structural properties of caudal vertebrae in compression.

SUMMARY OF BACKGROUND DATA

An increase in trabecular and cortical bone deposition caused by erythroid-specific human growth hormone transgene expression was demonstrated previously.

METHODS

Compression tests were performed on individual caudal vertebrae (Ca4, Ca5, Ca6) obtained from male and female mice from two transgenic lines (TG420 and TG450) and nontransgenic control mice. Two age groups were evaluated: 12 weeks old and 6 months old. The data were used to obtain axial stiffness, maximum load, and energy to failure.

RESULTS

Vertebrae from male TG420 transgenic mice produced significantly larger values for maximum load, energy to failure, and axial stiffness at both 12 weeks and 6 months in comparison with their age-matched non-transgenic male controls. Vertebrae from female TG420 transgenic mice produced similar responses at 6 months. Vertebrae from male TG450 transgenic mice showed significant increases in maximum load and energy to failure at 6 months. In general, the biomechanical properties of vertebrae were significantly larger in the 6-month age group than in the 12-week age group, and this increase was significantly greater in the transgenic mice than in the gender-matched control mice during the same time span. This process was also influenced by transgenic genotype and gender.

CONCLUSIONS

Erythroid-specific production of human growth hormone in transgenic mice resulted in significant increases in biomechanical properties of their caudal vertebrae in compression. The changes in the biomechanical properties were influenced by genotype, age, and gender.

Laparoscopic resection of a benign true cyst of the spleen with the harmonic scalpel producing high levels of CA 19-9 and carcinoembryonic antigen

Primary true cysts of the spleen constitute 10 per cent of all nonparasitic cysts of the spleen. These cysts have been managed with total or partial splenectomy or marsupialization. Previous series reported elevated serum levels of CA 19-9 and carcinoembryonic antigen (CEA). A 16-year-old male presented with left upper quadrant pain and was found to have a mass on palpation. An ultrasound and a CT scan of the abdomen showed a 20-cm cystic lesion in the spleen. The CA 19-9 and CEA serum levels were 1264 units/ml (nl <33 units/ml) and 7.5 ng/ml (nl <3.1 ng/ml), respectively. Laparoscopic resection of the cyst using the harmonic scalpel was performed. The pathology showed a benign true epithelial cyst of the spleen, with strongly immunoperoxidase stains for keratin, CA 19-9, and CEA. Levels of CA 19-9 and CEA in the cystic fluid were 48,275 units/ml and 96.6 ng/ml, respectively. This is the first case reported in the literature of a true benign splenic cyst producing high levels of CEA and CA 19-9 in serum and cystic fluid. The patient was discharged home on the 1st postoperative day without problems and returned to his normal daily activities with the 1st week after surgery. The CA 19-9 and CEA serum levels returned to normal levels.

Confirmation of FWT1 as a Wilms' tumour susceptibility gene and phenotypic characteristics of Wilms' tumour attributable to FWT1

A susceptibility gene for Wilms' tumour (WT), designated FWT1, was previously mapped to chromosome 17q12-q21 by linkage analysis of a single family. We now confirm the existence of this gene by analysis of additional cases in the original family (3-point LOD score=5.69), and by detecting strong evidence of linkage to this region in an unrelated pedigree with seven cases of WT (3-point LOD score=2.56). Analysis of 11 smaller WT families confirms that there is genetic heterogeneity in familial WT, as three families exhibit strong evidence against linkage to FWT1. One of these was subsequently found to have a predisposing WT1 mutation. However, the other two families show evidence against both FWT1 and WT1, suggesting that at least one further familial WT gene exists. Analysis of the phenotype of 16 WT cases from the families linked to FWT1 demonstrates that they present at a significantly older age and a significantly later stage than both sporadic WT and the six cases from two families unlinked to either FWT1 or WT1. The results confirm the role of FWT1 in susceptibility to WT, provide strong evidence for genetic heterogeneity in familial WT and suggest there are phenotypic differences between familial WT due to FWT1, familial WT due to other genes and non-familial WT.

The puzzle of Fran: home healthcare in a hurricane

A natural disaster in the form of Hurricane Fran resulted not only in stories of ingenuity and compassion, but in a major performance improvement (PI) process for the entire agency. Through this PI process we learned about ourselves as a home health agency and discovered ways to improve our performance. More importantly we discovered ways to improve patient tracking and care during a disaster.

Magnetic resonance imaging and temporal lobe epilepsy

Surgical treatment is a well established option for patients with medically refractory temporal lobe epilepsy. Magnetic resonance imaging (MRI) has revolutionized the evaluation of these patients. New techniques can identify structural, metabolic and functional abnormalities associated with the epileptogenic zone. Mesial temporal sclerosis is the most common pathological finding and presents as hippocampal atrophy, which can be detected by visual inspection in most cases. Volumetric analysis of medial temporal structures offers the advantage of detecting bilateral abnormalities. Magnetic resonance spectroscopy can detect metabolic abnormalities associated with the epileptogenic focus. Functional MRI allows for the non-invasive evaluation of cognitive function, allowing for the localization of the neuroanatomic substrate of motor, sensory and cognitive functions. Intraoperative MRI-based image guided systems are a useful adjunct in the surgical treatment of this epileptic syndrome.

Processing/activation of caspases, -3 and -7 and -8 but not caspase-2, in the induction of apoptosis in B-chronic lymphocytic leukemia cells

Chlorambucil and prednisolone, two commonly used drugs in the treatment of chronic lymphocytic leukemia (CLL), induce apoptosis in CLL cells. We have investigated the involvement in this apoptotic cell death of caspases, which cleave critical cellular substrates thereby acting as the executioners of the apoptotic process. Induction of spontaneous or chlorambucil/prednisolone-induced apoptosis of freshly isolated B-CLL cells in culture resulted in the activation of the 'effector' caspases, -3 and -7, but generally not of caspase-2. Activation of caspases-3 and -7 was accompanied by the proteolysis of the DNA repair enzyme, poly (ADP-ribose) polymerase. Induction of apoptosis was also accompanied by the processing of caspase-8, the extent of which varied between patients. Induction of apoptosis and processing of all the caspases was inhibited by the cell permeable caspase inhibitor, benzyloxycarbonyl-Val-Ala-Asp (OMe) fluoromethyl ketone (Z-VAD.fmk). Our results demonstrate a key role for the activation and processing of caspases in the execution phase of apoptosis in CLL cells. Apoptosis of CLL cells resulted in the selective activation of some but not all caspases. Our results suggest that the dysregulation of apoptosis observed in CLL may be due to the signalling leading to the activation of caspases rather than a deletion of pro-caspases. High levels of caspase-8 in CLL cells in conjunction with low levels of CD95 receptor may offer new therapeutic opportunities for the treatment of CLL.

Shingles: a review of diagnosis and management

Herpes zoster or shingles results from reactivation of varicella zoster virus previously dormant in cells of the dorsal root ganglion. The incidence of shingles increases with age and immunosuppression. Guidelines for managing shingles are now available and implementation, with the emphasis on early treatment, may reduce the severity of a shingles attack and reduce the incidence of complications.

The natural history of untreated lower urinary tract symptoms in middle-aged and elderly men over a period of five years

OBJECTIVES

To describe changes in untreated lower urinary tract symptoms (LUTS), levels of bothersomeness and interference in selected living activities arising from LUTS in a cohort of men followed up for a period of 5 years.

METHODS

1,994 men aged 40-79 years registered in four health centres in Scotland completed a urinary symptom questionnaire in the community. 1,177 (71% of original eligible participants) were followed up at 5 years.

RESULTS

The mean level of LUTS and the level of bothersomeness they caused increased universally between baseline and 5 years. The largest increases in mean symptom levels occurred for straining, hesitancy, incomplete emptying, weak stream and nocturia, and for mean levels of bothersomeness, i.e. dribbling, incomplete emptying, weak stream, frequency, nocturia and intermittency. The increase in mean interference level in selected living activities arising from LUTS was less marked. The progression of LUTS over time in individual men was very variable; however, the overall trend was one of continuing deterioration.

CONCLUSION

If left untreated, overall levels of middle-aged and elderly mens' LUTS, bothersomeness and interference in selected activities caused by these symptoms will increase over time.

Depletion of dopamine in the prefrontal cortex decreases the basal electrophysiological activity of mesolimbic dopamine neurons

One hypothesis regarding the etiology of schizophrenia proposes that disruption of the dopaminergic innervation of the prefrontal cortex leads to an increase in dopamine (DA) transmission in subcortical regions. In the present study, we examined the effect of 6-hydroxydopamine lesions of the medial prefrontal cortex (mPFC) dopamine innervation on the spontaneous electrophysiological activity of ventral tegmental DA neurons recorded in vivo. DA cell activity was assessed along three dimensions: (1) the relative proportion of DA neurons exhibiting spontaneous activity, (2) their basal firing rate, and (3) the mean percentage of spikes fired in bursts. In lesioned rats, DA neurons in the ventral tegmental area (VTA) exhibited a significantly slower mean firing rate, as well as a significant reduction in the percentage of spikes fired in bursts relative to controls. In contrast, depletion of DA in the mPFC did not have a significant effect on the relative proportion of VTA DA neurons exhibiting spontaneous activity. We suggest that by reducing the basal electrophysiological activity of VTA DA neurons, mPFC DA depletion may lead to an increase in the level of responsivity of the system to excitatory stimuli. Thus, the magnitude of increase in action potential-dependent DA release that occurs in response to a challenge may be augmented in lesioned rats.

Cardiopulmonary resuscitation training: where are we now?

The aim of this study was to assess the current situation with regard to cardiopulmonary resuscitation training and organisation 10 years after guidelines were published by the Royal College of Physicians. Questionnaires were sent to 100 UK hospital trusts (88 responses) and 200 general practitioners on Wirral, Merseyside (92 responses). Most trusts gave their staff annual training in CPR, but only 80% trained all staff who came into contact with patients. Not all trusts employed resuscitation training officers, carried out routine audit or had formal CPR policies. The majority of GPs had had no training in CPR for more than five years. Only one practice had a defibrillator, yet 14% had needed to carry out CPR in the past 12 months. Less than half the GPs ever discussed CPR with appropriate patients. The resuscitation service in this country is fragmented, and certain areas--particularly in the training of GPs--need attention.

Using the SARs to add policy value to household projections

"Household projections are at the centre of the debate about future housing requirements in England. The Census of Population Sample of Anonymised Records offers actual and potential opportunities to ¿add value' to traditional projections. This article gives examples of such added value, including testing definitional sensitivity of projection outcomes, assisting further detailed disaggregation of projected components, assisting the matching of household projections to dwelling supply, and offering scope to explore via data linkage the relationships between household projections and ¿backlog' housing needs, affordability, dwelling size, and tenure."

Functional MRI lateralization of memory in temporal lobe epilepsy

OBJECTIVE

To determine the feasibility of using functional magnetic resonance imaging (fMRI) to detect asymmetries in the lateralization of memory activation in patients with temporal lobe epilepsy (TLE).

BACKGROUND

Assessment of mesial temporal lobe function is a critical aspect of the preoperative evaluation for epilepsy surgery, both for predicting postoperative memory deficits and for seizure lateralization. fMRI offers several potential advantages over the current gold standard, intracarotid amobarbital testing (IAT). fMRI has already been successfully applied to language lateralization in TLE.

METHODS

fMRI was carried out in eight normal subjects and 10 consecutively recruited patients with TLE undergoing preoperative evaluation for epilepsy surgery. A complex visual scene encoding task known to activate mesial temporal structures was used during fMRI. Asymmetry ratios for mesial temporal activation were calculated, using regions of interest defined in normals. Patient findings were compared with the results of IAT performed as part of routine clinical evaluation.

RESULTS

Task activation was nearly symmetric in normal subjects, whereas in patients with TLE, significant asymmetries were observed. In all nine patients in whom the IAT result was interpretable, memory asymmetry by fMRI concurred with the findings of IAT including two patients with paradoxical IAT memory lateralization ipsilateral to seizure focus.

CONCLUSIONS

fMRI can be used to detect asymmetries in memory activation in patients with TLE. Because fMRI studies are noninvasive and provide excellent spatial resolution for functional activation, these preliminary results suggest a promising role for fMRI in improving the preoperative evaluation for epilepsy surgery.

Biogeographic origins of goannas (Varanidae): a molecular perspective

This project aims to clarify the phylogenetic relationships among the extant species of Varanus in order to elucidate the origins of Varanidae, using DNA sequences. Results obtained for a minimum of 662 nucleotides of 12S rRNA sequence data from each of 21 extant species of Varanus indicate that the Australian varanids form a single monophyletic clade and also suggest that within the Australian varanids, members of the subgenus Odatria (pygmy monitors) may from a clade separate from those in the subgenus Varanus (large monitors). The Asian species appear to be sister taxa to the Australian species, while the two African species investigated were most divergent, suggesting that the Varanidae are not Gondwanic in origin. Hypothesis testing analyses were performed and involved constraining the 12S sequence data according to previously described topologies and testing the difference using parametric and nonparametric statistics. The phylogeny generated using 12S sequence data was statistically different from previously described morphological trees, while there was some support for topologies based on chomosomal and immunological datasets. Overall, our results suggest that the Australian species may be derived from an Asian source and are, therefore, in agreement with the hypothesis based on the fossil record suggesting that Varanidae may be Asian in origin.

Asthma diagnosis by spirometry. Sensitive or specific?

Spirometry is the recommended first-line investigation for diagnosing asthma, with greater than 15% improvement in FEV1 considered diagnostic. However, evidence suggests a majority of asthmatics may go undetected at 15%, thus a lower diagnostic value may be preferred.