Addressing Insulin Injection Technique: A Follow-up Study of Canadian Patients with Diabetes

INTRODUCTION

Proper insulin injection technique is important for optimal glycaemic control, yet patients with diabetes often inject insulin incorrectly. Previous studies identified common errors in insulin injection in Canada, and this article seeks to evaluate the current insulin injection technique practices among patients and explore the effectiveness of feedback and education in improving their technique.

METHODS

The study recruited 147 patients and 16 physicians across Canada to gather insights into current insulin injection practices and education gaps. Eligible patients were people living with diabetes who inject insulin using an insulin pen and pen needles. Eligible physicians, who were unsupported by diabetes educators, completed a practice assessment survey and selected 10 eligible patients to complete a baseline assessment survey. During the patient visit, if an error in the patient's technique was identified, a pop-up knowledge transfer (KT) prompt would appear, providing feedback and information on best practices at the point of care. Follow-up surveys were completed 1-3 months later.

RESULTS

Physicians reported facing barriers to providing education and feedback, including lack of time and personnel, and lack of effective educational material. Patients demonstrated modest improvements in some injection technique domains at their follow-up visit, including injection force factors, time the needle was held in the skin, pen needle reuse, injection area size, and injection angle. The most common initial mistakes by patients were selecting an area smaller than recommended and not paying attention to the injection force. At the second visit, patients reduced an average of one error in their injection technique.

CONCLUSION

Results showed that basic feedback by their physician during one visit could exert moderate improvements on patients' injection technique. Proper injection technique is critical for diabetes management, and incorporating targeted ongoing education and support can significantly enhance physician practices, ultimately reducing risks and improving outcomes.

Insulin Injection Practices in a Population of Canadians with Diabetes: An Observational Study

INTRODUCTION

Proper insulin injection technique has demonstrated positive clinical outcomes in patients with diabetes. A Canadian-based practice reflective was undertaken to evaluate the current state of understanding of injection technique practices by patients administering insulin, and the importance physicians place on proper injection technique.

METHODS

Twenty-four sites across Canada completed a practice profile survey and enrolled adult non-pregnant patients with either type 1 or type 2 diabetes injecting insulin using an insulin pen. Seven areas of proper injection technique to be evaluated were identified by the study steering committee: size of injection site, use of a skin lift, needle reuse, length of the needle, duration of the needle in the skin, injection into lipohypertrophic tissue, and applied injection force. During a scheduled visit, each patient filled out the Injection Technique Survey and the physician documented the answers via an electronic database.

RESULTS

Almost all physicians surveyed agreed (96%) that proper insulin injection technique is important or very important and 80% indicated they were either completely confident or fairly confident in discussing overall insulin injection technique. All patients surveyed were making at least one insulin injection technique error within the following categories: applied injection force (76%), area size of injection site (64%), duration of pen needle in skin (61%), pen needle reuse (39%), performs a skin lift with a 4 or 5 mm needle (38%), uses a longer pen needle than required (34%), and injection of insulin into lipohypertrophic tissue (37%).

CONCLUSION

Patients commonly make insulin injection errors. Patient and physician education on optimal insulin injection technique continues to be an unmet medical need for the treatment of patients with diabetes. Prospective trials examining the impact of new technology, diabetes educational teams, and e-learning as educational interventions are potential avenues to explore in future studies to support improved insulin injection technique.

Differential Pharmacokinetic Interaction of Tacrolimus and Cyclosporine on Everolimus

OBJECTIVE

We characterized the pharmacokinetics of tacrolimus and everolimus in a combined immunosuppressive regimen.

METHODS

This was an open-label exploratory trial in eight maintenance renal transplant patients with calcineurin inhibitor intolerance initially receiving mycophenolate mofetil (MMF) and tacrolimus. At enrollment, MMF was discontinued and replaced with everolimus 1.5 mg twice a day in study period 1 (days 1 to 10). In period 2 (day 11 to month 3), tacrolimus dose was reduced by half.

RESULTS

At study entry tacrolimus trough level (C0) was 7.9 +/- 3.9 ng/mL and area under the curve over a dosing interval (AUC) was 132 +/- 56 ng x h/mL. The addition of everolimus in period 1 did not change tacrolimus exposure: C0 8.4 +/- 4.0 ng/mL, AUC 134 +/- 70 ng x h/mL. Everolimus pharmacokinetics in the presence of tacrolimus in period 1 were: C0 3.3 +/- 1.2 ng/mL, Cmax 10.4 +/- 5.1 ng/mL, AUC 58 +/- 20 ng x h/mL. When compared to pharmacokinetic data from a previous study in 47 renal transplant patients receiving everolimus at the same fixed dose (1.5 mg twice a day) with cyclosporine, everolimus exposure was 2.5-fold higher with cyclosporine relative to the data in this study with tacrolimus. After tacrolimus dose reduction in period 2, there was no clinically relevant change in everolimus exposure: C0 3.0 +/- 1.1 ng/mL, Cmax 8.2 +/- 1.3 ng/mL, AUC 49 +/- 10 ng x h/mL.

CONCLUSIONS

Tacrolimus appears to have a minimal effect on everolimus blood levels compared with the influence of cyclosporine. The dose of everolimus when combined with tacrolimus needs to be higher than when combined with cyclosporine in order to reach a given everolimus blood level.

A Multicenter, Prospective, Randomized, Double-Blind Trial of Basiliximab in Heart Transplantation

BACKGROUND

The role and pharmacokinetics of interleukin-2 (IL-2) monoclonal antibodies (mAbs) in heart transplantation remain unclear. This 1-year double-blind, randomized, placebo-controlled study evaluated safety, tolerability, and pharmacokinetics of the IL-2 mAb basiliximab with cyclosporine, mycophenolate mofetil, and steroids in adult de novo heart transplant recipients.

METHODS

Fifty-six patients received either basiliximab (20 mg) or placebo on Days 0 and 4 post-transplantation. Safety assessments included adverse events, serious adverse events, and infections. The time to and severity of biopsy-proven acute rejection (BPAR) were also assessed.

RESULTS

Basiliximab was generally well tolerated. There were no significant differences between treatment groups with respect to adverse event profiles, serious adverse events (84.0% vs 61.3%), or infections (84% vs 74.2%). The mean number of days to first BPAR was longer with basiliximab (73.7 +/- 59.68) than placebo (40.6 +/- 53.30) at 6 months, but not statistically significant (trend). The duration that basiliximab concentrations exceeded the CD25 saturation threshold averaged 38 +/- 13 days. Patients with rejection did not clear basiliximab faster or have shorter durations of saturation than rejection-free patients. None of the patients screened had detectable anti-idiotype antibodies.

CONCLUSIONS

These pilot results describe the pharmacokinetics of basiliximab and show that basiliximab appears to be tolerated with a similar safety profile to placebo in adult de novo heart transplant recipients. Larger scale clinical trials are feasible and warranted.

Bacterial vaginosis - a microbiological and immunological enigma. Review article

The development of bacterial vaginosis (BV) among women of childbearing age and the resulting quantitative and qualitative shift from normally occurring lactobacilli in the vagina to a mixture of mainly anaerobic bacteria is a microbiological and immunological enigma that so far has precluded the formulation of a unifying generally accepted theory on the aetiology and clinical course of BV. This critical review highlights some of the more important aspects of BV research that could help in formulating new basic ideas respecting the biology of BV, not least the importance of the interleukin mediators of local inflammatory responses and the bacterial shift from the normally occurring lactobacilli species: L. crispatus, L. gasseri, L. jensenii, and L. iners to a mixed flora dominated by anaerobic bacteria.

Nail alterations secondary to pactitaxel [corrected] therapy

Docetaxel and pactitaxel [corrected] are the main drugs pertaining to the taxanes family. Nail alterations associated with docetaxel therapy are not a rare event, but they have rarely been reported secondary to paclitaxel therapy, probably because of its more recent use. We present two cases of onycholysis and nail discoloration secondary to paclitaxel therapy.

Streptococcus pneumoniae bacteremia in a community hospital

We reviewed 71 consecutive patients with Streptococcus pneumoniae bacteremia. The patients were analyzed by age, sex, ethnic background, and clinical presentation. Laboratory data reviewed included a CBC count, electrolyte levels, liver function studies, chest radiograph, HIV status, a sputum culture and Gram's stain, and sensitivities for the S pneumoniae isolated. Modalities of therapy, response to treatment, and ultimate outcome were examined. Many of the patients with pneumococcal bacteremia did not have cough, fever, or chills. HIV positivity was a risk factor for pneumococcal infection although it was not associated with increased mortality. Mortality correlated with elderly status, leukopenia, and lack of fever. Many patients had symptoms suggestive of atypical pneumonia including myalgia and mental status change. Hyponatremia and hyperbilirubinemia were commonly noted.

Activation signals regulate heat shock transcription factor 1 in human B lymphocytes

We previously showed that the ability of human B lymphocytes to elicit a cytoprotective heat shock response when confronted by heat or other stresses was dependent upon the state of cell activation. This was unexpected, considering the highly conserved nature of the heat shock response and the widely held belief that all nonmutated mature cells were capable of eliciting a heat shock response when stressed. To elucidate the mechanism by which activation primes B cells to respond to stresses, we examined heat shock transcription factor 1 (hHSF1) in B cells since this factor appears to be solely responsible for stress-induced transcription of heat shock genes in human cells. In the current report, we show that hHSF1-DNA binding complexes are undetectable in extracts of unactivated B cells. In fact, hHSF1 protein is not constitutively expressed in unactivated B cells, nor is its synthesis stress-inducible. However, following activation, hHSF1 can be found in either a transcriptionally active or an inactive state, depending upon whether the cell has been stressed or not. Thus, activation pathways play an important role in enabling B cells to survive and function properly in the context of physiologic stresses by regulating hHSF1.

Metronidazole and clarithromycin resistance in Helicobacter pylori determined by measuring MICs of antimicrobial agents in color indicator egg yolk agar in a miniwell format. The Gastrointestinal Physiology Working Group of Universidad Peruana Cayetano Heredia and the Johns Hopkins University

Resistance of Helicobacter pylori to metronidazole often causes failure of commonly used combination drug treatment regimens. We determined the MICs of metronidazole and clarithromycin against 18 H. pylori strains from Peru using tetrazolium egg yolk (TEY) agar. The MIC results obtained by agar dilution with petri dishes were compared with the results found through a miniwell format. The results of the two protocols for measuring drug susceptibility differed by no more than 1 dilution in all cases. On TEY agar, bright-red H. pylori colonies were easy to identify against a yellow background. Sixty-one percent (11 of 18) of the strains were resistant to metronidazole (MIC, > or = 4 micrograms/ml) and 50% (9 of 18) were resistant to clarithromycin (MIC, > or = 0.125 micrograms/ml), whereas none (0 of 5) of the strains tested were resistant to tetracycline (MIC, > or = 1 micrograms/ml). Thus, the prevalence of metronidazole and clarithromycin resistance in Peru is higher than that in developed regions of the world. The miniwell plate with TEY agar allows easy H. pylori colony identification, requires about one-third less of the costly medium necessary for petri dish assaying, conserves space, and yields MICs equivalent to those with agar dilution in petri dishes.

Sensitization of Lewis rats with sulfoglucuronosyl paragloboside: electrophysiological and immunological studies of an animal model of peripheral neuropathy

Antibodies against sulfoglucuronosyl glycosphingolipids (SGGLs) are known to be present in sera of patients with chronic polyneuropathy associated with IgM paraproteinemia. We recently studied rats sensitized with sulfoglucuronosyl paragloboside (SGPG), a major SGGL species, emulsified with keyhold limpet hemocyanin and Freund's adjuvant. The titer of the IgM class antibodies against SGPG increased up to 1:1,600, while that of the IgG class increased up to 1:800 2 weeks after sensitization. The antibodies showed a high degree of antigenic specificity; no cross-reactivity with other brain glycolipids could be detected. They, however, reacted with human myelin-associated glycoprotein (MAG) by Western blot analysis, but not with rat MAG. These animal models showed minor but clear clinical signs of neuropathy, consisting of mild tail muscle tone loss and walking disabilities. Electrophysiological examination of the sciatic nerves revealed nerve conduction abnormalities which consisted of conduction block and mild decrease in conduction velocity. Thus, our results support the concept that anti-SGPG antibodies may play an important pathogenetic role in this type of chronic neuropathy.

Trace element intakes and dietary phytate/Zn and Ca x phytate/Zn millimolar ratios of periurban Guatemalan women during the third trimester of pregnancy

Repeated 24-h recalls (9-14/subject) were conducted on 52 periurban Guatemalan pregnant women aged 25 +/- 5 y (means +/- SD). Intakes of energy, protein, calcium, zinc, copper, manganese, nonstarch polysaccharide (NSP), phytate, and millimolar ratios of phytate to zinc and (calcium x phytate) to zinc were calculated from food-composition values on the basis of chemical analysis and the literature. Mean (+/- SD) daily intakes were as follows: energy 8694 +/- 1674 kJ, protein 63.0 +/- 13.3 g, calcium 727 +/- 163, zinc 11.3 +/- 2.7, copper 1.3 +/- 0.3, manganese 2.8 +/- 0.6, phytate 2254 +/- 773 mg/d, NSP 26.6 +/- 6.9 g, phytate/zinc 18.8 +/- 4.2, (calcium x phytate)/zinc 706 +/- 21 mmol/MJ. Ninety-four percent had zinc intakes below the recommendations (15 mg) of WHO and the US recommended dietary allowances, assuming 20% absorption. Tortillas were a major source of zinc (46%), copper (20%), manganese (23%), calcium (39%), phytate (68%), and NSP (50%); 19% zinc from flesh foods. Thirty-eight percent had phytate-zinc ratios > 20; 94% had millimolar ratios of (calcium x phytate) to zinc per MJ > or = 22. The high prevalence of millimolar ratios of phytate to zinc and (calcium x phytate) to zinc per MJ above 20 and 22, respectively, may compromise zinc nutriture.

Corticosteroid therapy and respiratory muscle function in humans

We examined the effects of prednisone administration on respiratory muscle function in humans using a double-blind study with a placebo control group. A total of 16 normal subjects were randomized to receive 20 mg prednisone daily (n = 8) or placebo daily (n = 8) for 2 wk. Inspiratory muscle strength (Pimax), expiratory muscle strength (PEmax), diaphragmatic strength (Pdimax), and inspiratory muscle endurance were measured at the beginning and end of the study. There was no significant change with treatment for Pimax (-145 +/- 7 to -138 +/- 6 cm H2O), PEmax (171 +/- 17 to 169 +/- 14 cm H2O), Pdimax (194 +/- 11 to 196 +/- 12 cm H2O), or endurance (76 +/- 3 to 77 +/- 4%) for the prednisone group and no significant difference between the two groups. We conclude that prednisone in moderate dosage has no significant effect on respiratory muscle function in humans, at least in the short term.

Platelet-activating factor in porcine Pseudomonas acute lung injury

We investigated the role of platelet-activating factor (PAF) in acute septic lung injury by examining the effects of the selective PAF antagonist SRI 63-675 and by measuring PAF in lung tissue in the porcine model. Four groups of pigs (15-25 kg) were studied: saline control (C, n = 5); Pseudomonas (Ps, n = 9), given 5 x 10(8) CFU/ml at 0.3 ml/20 kg/min intravenously over 1 hr; SRI (n = 3), given SRI 63-675 in a 40 mg/kg bolus; and SRI + Ps (n = 5). Ps infusion produced a fulminant lung injury characterized by a threefold increase in pulmonary arterial pressure at 30 min and persistent pulmonary hypertension (P less than 0.05 vs C), a significant (P less than 0.05 vs C) decrease in arterial oxygen tension (PaO2) from 60 min, a significant (P less than 0.05 vs C) increase in extravascular lung water (EVLW) from 120 min, and a significant (P less than 0.05 vs C) increase in albumin flux determined scintigraphically as slope index at 150-180 min. Systemic arterial pressure and cardiac index (CI) decreased significantly (P less than 0.05) in the Ps group vs C at 60 and 180 min, respectively. Bolus injection of SRI 63-675 at the time of Ps infusion blocked the early pulmonary hypertension, attenuated the early and late fall in PaO2, ameliorated the increase in EVLW, and prevented the late (150-180 min) increase in albumin flux. SRI 63-675 had minimal effects on Ps-induced hypotension or alterations in CI.(ABSTRACT TRUNCATED AT 250 WORDS)

Test-retest reproducibility of the relative dose response for vitamin A status in Guatemalan adults: issues of diagnostic sensitivity

The relative dose response (RDR) test has been used as a functional measure of whole-body stores of vitamin A in humans. We have examined the reproducibility of the RDR procedure in a population of Guatemalan adult subjects who would be expected to show a moderate prevalence of hypovitaminosis A. Fifty-one subjects were administered a standard RDR test, and the plasma samples were analyzed for retinol, tocopherol, retinol binding protein (RBP) and prealbumin (PAL). Thirty-four of the subjects underwent repeat RDR tests 7 d later. Plasma levels in fasted subjects were as follows: retinol, 1.35 +/- 0.30 mumol/L; RBP, 37.8 +/- 7.7 mg/L; PAL, 187.0 +/- 39.0 mg/L; and tocopherol, 16.6 +/- 6.2 mumol/L. RDRs ranged from -35.2% to +63.1%, with a mean of 2.6 +/- 10.4%. Overall, we observed poor within-subject reproducibility of the RDR procedure whether expressed numerically or by diagnostic classification. Moreover, in contrast to previous studies in children, we observed fewer positive RDR tests than would be expected for the population studied. Nevertheless, the mean RDR was inversely proportional to fasting retinol levels, thus confirming the validity of the biological basis of the RDR procedure in humans. Because of high intra-individual variability with this test, investigators should be cautious when using the RDR procedure in serial studies to monitor the efficacy of therapeutic interventions or subject compliance to dietary regimens.

Human BCGF-12kD functions as an autocrine growth factor in transformed B cells

In case of lymphoid malignancies of B cell origin and Epstein-Barr Virus (EBV) transformed B cells, it is invariably found that these cells proliferate in the apparent absence of signals from T cells. Many of transformed B cells tested appear to be refractory to the proliferative effects of a number of defined cytokines including IL-1, IL-2, IL-4, IL-5, IL-6, IL-7, TNF alpha, lymphotoxin and IFN gamma. We have recently reported on the molecular cloning of a T cell derived human B cell growth factor, BCGF-12kD. In this study, we show that recombinant BCGF-12kD induces proliferation in EBV negative undifferentiated lymphoma B cell line, MC116 and Burkitt's lymphoma B cell line, P3HR1. A mouse monoclonal antibody produced against a BCGF-12kD synthetic peptide neutralizes the BCGF activity present in the MC116 conditioned media as well as inhibits the in vitro growth of MC116. The PCR analysis of the BCGF-12kD gene transcription provides further evidence that MC116 cells express the BCGF-12kD gene, whereas this gene is silent in resting and anti-IgM activated normal human B cells. These data clearly suggest an immunoregulatory role of BCGF-12kD in transformed human B cells.

Increased survival time after delayed histamine and prostaglandin blockade in a porcine model of severe sepsis-induced lung injury

A combination of cimetidine, diphenhydramine, and ibuprofen has been shown to be an effective treatment in a porcine model of septic acute lung injury. The present study was designed to evaluate this therapy in a delayed treatment survival model. Three groups of animals were studied: a control group (C, n = 6) received a sham infusion of 0.9% saline; a septic group (Ps, n = 5) received a continuous infusion of live Pseudomonas aeruginosa organisms; and a treatment group (CID, n = 6) received P. aeruginosa plus cimetidine 150 mg, ibuprofen 12.5 mg/kg, and diphenhydramine 10 mg/kg given at 90 min after P. aeruginosa infusion, and hourly thereafter. Group Ps developed fulminant acute lung injury and hypodynamic septic shock. CID therapy ameliorated temporarily the progressive course of hypoxemia and increased extravascular lung water (EVLW), delayed the onset of cardiovascular deterioration, and improved significantly survival time. It was concluded that CID therapy given at 90 min after the onset of lethal continuous P. aeruginosa infusion improved significantly animal survival time by improving temporarily hypoxemia and increase in EVLW and delaying cardiovascular collapse.

Ranitidine compared to cimetidine in multiagent pharmacological treatment of porcine Pseudomonas ARDS

The effects of two pharmacologically distinct histamine H2 receptor antagonists were studied in combination with ibuprofen (I) and diphenhydramine (D) in a porcine model of septic ARDS. Cimetidine (C) is reported as having direct oxygen radical scavenging abilities and is an inhibitor of cytochrome P-450, whereas ranitidine (R) acts solely by H2 receptor blockade. Four groups were studied: Group Ps (n = 8) received a continuous infusion of live Pseudomonas aeruginosa 5 x 10(8) CFU/ml at 0.3 ml/20kg/min, Group C (n = 6) received a control saline infusion, and the treatment groups received I (12.5 mg/kg) and D (10 mg/kg) in combination with either C (150 mg, CID, n = 6) or R (25 mg, RID, n = 5) given at 20 and 120 minutes after the onset of Ps. Pulmonary (PAP) and systemic (SAP) arterial pressures, cardiac index (CI), PaO2, thermal cardiogreen extravascular lung water (EVLW) and scintigraphically determined pulmonary albumin flux (slope index, SI) were measured. Ps infusion produced significant (p less than 0.05) cardiovascular collapse, hypoxemia and increased EVLW and SI. Both CID and RID temporarily reversed pulmonary arterial hypertension and maintained PaO2, EVLW, SAP and CI at control levels throughout the study, and significantly improved SI at 180 min. These results suggest that cimetidine and ranitidine act in this combination therapy primarily as H2 receptor antagonists.

Serodiagnosis of New World leishmaniasis by using a genus-specific antigen in enzyme linked immunosorbent assays

A genus-specific monoclonal antibody (83L-5G9), generated against promastigotes of Leishmania braziliensis panamensis (WRAIR-470), has been used as a ligand in immunochromatography columns for the recovery and purification of the genus-specific antigen. When the purified polypeptide, actually a doublet comprised of a 58 kd and a 31 kd moiety, was used as the antigen in enzyme linked immunosorbent assays (ELISA), it was reactive with 36 of 85 sera from Leishmania patients and with 1 of 49 sera from confirmed cases of Chagas' disease. An additional 25 sera from an unexposed population and five specimens from individuals seropositive for Toxoplasma gondii were nonreactive.

Presence of preactivated T cells in hemodialyzed patients: their possible role in altered immunity

Interleukin 2 (IL-2) and B-cell growth factors I and II (BCGF I and BCGF II) are lymphokines produced by T cells that play a major role in T- and B-cell cooperation. Peripheral blood lymphocytes from 12 uremic patients undergoing intermittent hemodialysis were tested for their capacity to produce IL-2 and BCGFs and to respond to these soluble mediators. IL-2 and BCGF activities were determined by means of two biological assays (proliferation of IL-2-dependent cytotoxic T-cell line CTLL-2 and of anti-human IgM (mu chain)-stimulated normal B cells, respectively) in the supernatants of phytohemagglutinin A-stimulated T-cell cultures. IL-2 activity was significantly decreased in patients as compared to normal controls (mean +/- SEM, 0.28 +/- 0.09 unit per ml) in hemodialyzed patients versus 1.02 +/- 0.16 units per ml in normal controls). This profound abnormality contrasted with the normal activity of the BCGFs that was invariably observed in the same supernatants. A similar dissociation was detected when analyzing the sensitivity of uremic B and T cells to exogenous purified lymphokines. Anti-IgM (mu chain)-stimulated uremic B cells exhibited a normal response to recombinant IL-2 and to chromatography-purified BCGF I and BCGF II. Resting B cells did not show any increased reactivity to these lymphokines. In contrast, whereas in normal controls recombinant IL-2 exclusively induced the proliferation of T cells that had been previously activated by a mitogen, resting T cells from uremic patients were highly responsive to exogenous IL-2. This abnormal response was paralleled by significantly increased proportions of peripheral T cells recognized by the anti-Tac monoclonal antibody that specifically binds to the IL-2 receptor. These data clearly show the existence in hemodialyzed patients of abnormally high proportions of T cells presenting phenotypic and functional signs of preactivation. This increased T-cell IL-2 receptor expression may offer an explanation to the deficient IL-2 activity observed in patients' supernatants (by inducing increased absorption of the lymphokine). The potential relevance of these preactivated T cells to the depressed cell-mediated immunity observed in hemodialyzed patients is outlined.

Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position

Because venous air embolism (VAE) has been considered to be a major deterrent to use of the sitting position, records of 255 patients undergoing neurosurgery in the sitting position from 1975 to 1982 were reviewed to determine the nature of morbidity and mortality in relation to the surgical procedure as well as to the occurrence of VAE. Complications were classified as surgical or anesthetic during joint review by a neurosurgeon and two neuroanesthesiologists. Outcome was classified on the basis of postoperative hospital course and discharge examination. The incidence of VAE was 30%. Although there was a variety of perioperative complications in patients with and without VAE, most of the complications were related to the operative procedure, not the sitting position or VAE. The episodes of VAE did not seem to be significant factors in the perioperative morbidity and mortality in our series of patients operated upon in the sitting position. Two case reports are discussed in detail.

Hemodynamic effects of molsidomine vasodilatory therapy in acute myocardial infarction

The hemodynamic effects and duration of action of 4 mg of intravenous molsidomine (M), a new peripheral vasodilator antianginal agent, were evaluated and compared to those of 10 mg sublingual isosorbide dinitrate (ISDN) in 12 patients with uncomplicated acute myocardial infarction (AMI). Both M and ISDN produced marked decreases in mean right atrial pressure (RAP), mean pulmonary capillary wedge pressure (WP), and mean pulmonary arterial pressure. The maximal decreases in RAP (-56%) and WP (-35%) with intravenous M intended to be more pronounced than with sublingual ISDN (RAP-35% and WP-29%). Physiologic modest declines in systemic vascular resistance, cardiac output, and arterial pressure were similar with the both drugs. The duration of action of M was longer (average 5 hours) than that of ISDN (2 hours). No patient experienced hypotension, tachycardia, or other adverse responses following M, suggesting that M is well isolated by patients with normotensive AMI.

The immunoperoxidase technique for rapid human cytomegalovirus identification

Sixteen cytomegalovirus (CMV) isolates from both ill and healthy patients were identified by the immunoperoxidase technique (IP). CMV detection was accomplished by direct examination of the primary isolate using either direct (DIP) or indirect immunoperoxidase (IIP) techniques. In thirteen of the isolates, confirmation of identification was achieved by indirect immunofluorescence (IFA) and by demonstration of herpes particles by electron microscopy (EM). Further, in four cases of non-CMV alterations in the tissue culture which might be confused with actual infection, the IP test was negative as were the confirmatory tests. The IIP is preferred over the DIP test since the latter shows a certain amount of background stain of uninfected cells. Tissue culture cells showing focal CMV cytopathic effect contained both nuclear and cytoplasmic inclusions stained by IP technique. Nonspecific staining was associated with cytoplasmic inclusion bodies. The IP technique can detect individual cell CMV infection at 24 hours when EM reveals only unenveloped viral particles. It is sensitive, specific, and allows direct identification of infected cells in the primary isolate in as little as 90 minutes. Furthermore, it can be performed in standard isolation tissue culture tubes, whereas IFA requires the transfer of the infected cells onto slides or the routine use of Leighton tubes.