Red cell exchange for rapid leukoreduction in adults with hyperleukocytosis and leukostasis

ABSTRACT

We show that red cell exchange (RCE) treats hyperleukocytosis in acute leukemia. RCE provided similar leukoreduction to standard therapeutic leukoreduction and could be superior in patients with severe anemia or monocytic leukemias or when requiring rapid treatment.

Buccal Mucosal Grafts as a Novel Treatment for the Repair of Rectovaginal Fistulas: Protocol for an Upcoming Prospective Single-Surgeon Case Series

Background

Rectovaginal fistulas (RVFs) are abnormal communications between the rectum/anus and the vagina. They are most frequently formed a result of obstetric injury and have deleterious effects on patients’ quality of life. Despite several treatment modalities, RVFs remain difficult problems to manage, and many patients fail multiple attempts at surgical repair. Buccal mucosal grafts (BMGs) may be a solution to this problem. A BMG is an oral mucosal tissue harvested from the inner cheek. There are 2 case reports that describe the successful use of BMGs in the repair of RVFs.

Objective

Our objective is to validate these findings with a prospective case series while also addressing the key issues of indication, technical details, procedure safety, and short-term outcomes.

Methods

A prospective single-surgeon case series will be undertaken at a university-affiliated academic tertiary care hospital in Calgary, Alberta (Canada). The estimated recruitment is between 3 and 5 patients. Patients will undergo surgical repair of their RVFs with an autologous BMG. Data on patient characteristics, fistula characteristics, and surgical variables will be collected and analyzed prospectively. The primary outcome is fistula closure. This study has been approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB20-1123).

Results

Two previous case reports have described the successful use of BMGs in the repair of RVFs. We have received ethics approval to attempt to validate these findings through a prospective case series.

Conclusions

RVFs cause significant patient morbidity and are difficult problems to manage. Bolstered by the successful use of BMGs in urologic surgery and the previously published case reports demonstrating success in RVFs, we believe that BMGs may be a solution to RVFs.

International Registered Report Identifier (IRRID)

PRR1-10.2196/31003

ISIS Penning source extraction studies reveal the 3-dimensional Child-Langmuir effect

The standard 1X ISIS negative Penning surface plasma source has reliably produced an H^- beam for ISIS operations for 35 years. In order to meet the 60 mA, 2 ms, and 50 Hz beam current and duty cycle required for the front end test stand (Letchford et al., in Proceedings of IPAC2015, Richmond, VA, USA, 2015), a 2X scaled source has been developed [Faircloth et al., AIP Conf. Proc. 2052, 050004 (2018)]. The 2X source has a plasma chamber twice the linear dimensions of the 1X source. This paper investigates the comparison between different emission areas (plasma electrode aperture dimensions) for both the 1X and 2X sources. Slit and circular extraction schemes are studied. A 3D Child-Langmuir relationship is observed where the space charge limited current density depends on the aspect ratio of the extraction aperture.

P951The factors influencing total ischaemic time in patients presenting with STEMI in an Irish tertiary referral centre

Background

Despite highly functioning primary percutaneous coronary intervention (PPCI) programmes, STEMI is still associated with significant morbidity and mortality. The European Society of Cardiology STEMI guidelines in 2017 introduced a novel metric relating to STEMI patients: “total ischaemic time”. This time-period starts at the onset of chest pain and ends at wire cross, and it is thought to accurately reflect burden of myocardial destruction.

Aims

To assess the total ischaemic time of patients presenting with STEMI in an Irish tertiary referral centre and the factors influencing delays in presentation and treatment.

Methods

Prospective cohort analysis was conducted on all patients presenting with STEMI from October 2017 to January 2019. Patients were included if they had a culprit lesion that was successfully revascularized. All information was recorded at time of presentation. Bayesian statistics were employed to conduct the analysis.

Results

158 patients were recruited. Mean age was 61 (range29–96). Male:female ratio 5:1 in this cohort. Average total ischaemic time was 409.4mins ±501.4. The average time from chest pain to “call for help” (i.e. patient delay) was 208.3mins ±397.8, which represented 50.89% of the total ischaemic time (see Figure 1). The average time from “call for help” to first medical contact (FMC) was 18.4mins ±30.07. Average time from FMC to ECG was 44.9mins ±151.16, and was dependent upon type of FMC (Primary care 127mins vs paramedic 25mins p=0.030932). After FMC, 48.7% of patients had an ECG performed in under 10mins as per guidelines. After ECG was performed, 46.4% of patients had ECG to “wire cross” time under 90mins as per guidelines; 65.8% were within 120 mins and 91.4% were within 180mins. Those presenting to their general practitioner as FMC were significantly less likely to have both an ECG <10mins (NNH 2.84 95% CI 1.79–6.91) and ECG to wire time of <90mins (NNH 6.13 95% CI 2.88–48.70).

As age increased, so too did total ischaemic time (Pearson R=0.164, p=0.043), which was dependent on increasing patient delay with age (Pearson R=0.2181, p=0.0066). Women had a higher total ischaemic time than men (546 vs 382mins p=0.0233). This was determined to be as a result of: a numerically higher patient delay (220 vs 206 mins, p=0.214) and women having a longer time from FMC to ECG (104mins vs 34mins, p=0.0021).

Conclusion

Over 50% of the total ischaemic time was due to patient delay, suggesting a role for cardiovascular awareness programmes. Increasing age was associated with longer patient delay, indicating a need for directed awareness in this demographic. Women had a higher total ischaemic time, and waited a significantly longer time for ECG following FMC; highlighting the need for awareness amongst healthcare professionals of atypical clinical features associated with STEMI in women. Patients who attended their GP waited longer for an ECG and, once performed, were less likely to be revascularised within 90mins.

Influence of adjuvant antibiotics on fistula formation following incision and drainage of anorectal abscesses: a systematic review protocol

BACKGROUND

Development of fistula-in-ano following incision and drainage (I&D) of anorectal abscesses occurs in over 30% of patients. It is associated with significant patient morbidity and societal cost. The use of antibiotics following drainage is controversial, with randomized controlled trials reporting opposing conclusions regarding their influence on the rate of fistula formation. Given the significant burden associated with their development, it is imperative to determine strategies to minimize their occurrence. The objective of this review is to summarize the available evidence on the role of antibiotics following I&D of anorectal abscesses on fistula formation. Secondary objectives include determining if antibiotics are associated with morbidity, repeat presentation to the emergency department, and requirement for reoperation.

METHODS/DESIGN

MEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials, http://apps.who.int/trialsearch , and clinicaltrials.gov will be searched to identify published and ongoing unpublished interventional and observational studies evaluating the role of antibiotics post I&D on the incidence of fistula formation. There will be no restriction on language, date, or journal. Title and abstracts as well as full texts will be screened in duplicate based on inclusion and exclusion criteria. The Cochrane Risk of Bias tool and ROBINS-I will be used to assess risk of bias in randomized and non-randomized studies, respectively. Our primary outcome is the incidence of fistula formation; secondary outcomes include morbidity, representation to ED, and reoperation. Study heterogeneity will be calculated with Cochran's Q test, P value, and I 2 index. SASS (version 9.4) will be used for meta-analysis.

DISCUSSION

This is the first study to review the available evidence on adjuvant antibiotics and incidence of fistula formation following I&D of anorectal abscesses.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018092044.

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

Small bowel adenocarcinoma and Crohn's disease: Any further ahead than 50 years ago?

This review of the literature on small bowel carcinoma associated with Crohn’s disease specifically addresses the incidence, risk factors, and protective factors which have been identified. It also reviews the clinical presentation, the current modalities of diagnosis, the pathology, treatment, and surveillance. Finally, the prognosis and future direction are addressed. Our experience with small bowel adenocarcinoma in Crohn’s disease is reported. Readers will be provided with a better understanding of this rare and often poorly recognized complication of Crohn’s disease.

Augmenting cognitive behaviour therapy for post-traumatic stress disorder with emotion tolerance training: a randomized controlled trial

BACKGROUND

Many patients do not adhere to or benefit from cognitive behaviour therapy (CBT) for post-traumatic stress disorder (PTSD). This randomized controlled trial evaluates the extent to which preparing patients with emotion regulation skills prior to CBT enhances treatment outcome.

METHOD

A total of 70 adult civilian patients with PTSD were randomized to 12 sessions of either supportive counselling followed by CBT (Support/CBT) or emotion regulation training followed by CBT (Skills/CBT).

RESULTS

Skills/CBT resulted in fewer treatment drop-outs, less PTSD and anxiety, and fewer negative appraisals at 6 months follow-up than Support/CBT. Between-condition effect size was moderate for PTSD severity (0.43, 95% confidence interval x0.04 to 0.90). More Skills/CBT (31%) patients achieved high end-state functioning at follow-up than patients in Support/CBT (12%) [Χ2(n=70)=3.67, p<0.05].

CONCLUSIONS

This evidence suggests that response to CBT may be enhanced in PTSD patients by preparing them with emotion regulation skills. High attrition of participants during the study limits conclusions from this study.

A computerized system for reporting medication events in psychiatry: the first two years of operation

The aim of this paper is to describe the first 2 years of operation of an electronic system for reporting medication events in psychiatry (Medi-Event system). We have carried out a descriptive analysis of all medication events (errors, near misses and adverse drug reactions) reported between 1 March 2008 and 28 February 2010 at a large, specialist UK psychiatric hospital. A total of 406 medication errors, 40 near misses and no adverse drug reactions were reported in the study period, representing a very large increase in reporting frequency with respect to the previous paper system. The majority (88.8%) of incidents were medication administration errors. The most common error types were failure to sign for a drug and omission of a drug without valid clinical reason. Although most errors were of minor severity, 6.3% were rated as moderate or serious. Distraction was cited as the most common contributory factor, also poor communication and being unfamiliar with the ward. In conclusion, use of the Medi-Event system increased the reporting of medication errors. Analysis of the pattern of errors, as well as of contributory factors and suggestions for error prevention, may help reduce the frequency of medication events and hence improve patient care.

Examples of Hydrothermal Titration and Real Time X-Ray Diffraction in the Synthesis of Open Frameworks

Hydrothermal titration (HTT) techniques represent a new synthetic strategy for the production of open frameworks. As an example, initial digestion of amorphous GeS2 in the presence of tetraethyl ammonium hydroxide (TEAOH) at 100°C is followed by injection of Ag+ into this mixture to condense the [Ge4S10]4− clusters and form a framework consisting of 8-ring channels bounded by alternating GeS-clusters and Ag+. The rational use of this apparatus depends upon determining the timing of injection. Insight into the changes occurring during reactant digestion is provided by real time synchrotron X-ray powder diffraction. Changes in the the system dimethylamine-Sb-S have been followed in real time at different temperatures. The transformation from mixtures of DMA, Sb and S to the known open phase DMA-SbS-SB8 was followed by observing monochromatic X-ray scattering detected on an imaging plates over a 8 hr period with one continuous exposure.

Joint physical custody and neighborhood friendships in middle childhood

Almost half of first marriages end in divorce, which in turn may produce joint physical custody arrangements. Seen by many states to be in the best interest of the child, joint physical custody is increasingly common. Yet much is unknown about its consequences for children. This article considers how joint physical custody arrangements affect children’s neighborhood friendships, an important component of child well-being because of their contributions to social and cognitive development. Thirteen parents and 17 children (aged 5–11) in 10 families, selected via convenience and snowball sampling, participated in semistructured interviews. The findings suggest that joint physical custody arrangements do not imperil children’s neighborhood friendships; indeed, most children and parents interviewed voiced contentment in this area.

Interactions of poly(amino acids) in aqueous solution with charged model surfaces—analysis by colloidal probe

Biomolecules in a confined solution environment may be subject to electrostatic forces with a range up to 100 nm, while van der Waals interaction will account for shorter-range forces. The response of two model poly(amino acids)--poly-L-lysine and poly-L-glutamic acid--has been investigated for a silica/Si-oxide surface at pH 6. The model amino acids were adsorbed, or covalently coupled, to colloidal probes consisting of a microsphere attached to a force-sensing lever. The methodology was based on sensing interaction between the probe and a flat surface through carrying out force versus distance analysis with a scanning force microscope. The results were analyzed within the framework of the conventional DLVO theory. The outcomes illustrate both repulsive and attractive long-range interactions that will hinder, or promote, colloidal biospecies in solution entering the region of attractive short-range interactions at the physical interface. Large 'snap-on' distances were observed for some systems and have been ascribed to compression of the 'soft' functionalized layers. Those observations and measurements of adhesion provided insight into conformation of the adsorbed species and strength of attachment. The results have implications for the efficacy of methods and devices that seek to exploit the properties of micro/nano-fluidic systems.

Rationalizing radio medical advice for maritime emergencies

The provision of radio medical advice by the National Health Service for British coastal waters has developed in an ad hoc fashion. In 1999, the closure of one of the two centres providing such advice led to unexpected problems. The demographic characteristics of the offshore population covered by each centre were markedly different and this resulted in a different spectrum of medical emergencies presenting to the sole remaining centre. Subsequent data collection of the details of medical emergencies presenting from offshore allowed an audit to inform the development of training packages for both base and remote practitioners. This has led to an ongoing national rationalization of ship-to-shore radio medical advice for the UK.

Imaging and force-distance analysis of human fibroblasts in vitro by atomic force microscopy

The structure of human fibroblasts have been characterised in vitro by atomic force microscopy (AFM) operated in the imaging or in the force versus distance (F-d) modes. The choice of cell substrate is important to ensure good adhesion. Of greater significance in the context of AFM analysis, is the observation that the substrate affects the imaging conditions for in vitro analysis of live cells. For instance, very rarely will glass coverslips lead to acceptable outcomes (i.e., resolved cytoskeletal structure). Activated tissue culture dishes, on the other hand, promote conditions that routinely result in good quality images. Those conditions are then unaffected by adoption of relatively high force loadings (more than 10 nN), large fields of view (100 x 100 microm2) and high scan speeds (up to ca. 200 microm/sec), all of which exceed values recommended in the literature. Plasma membranes are fragile in the context of AFM analysis (F-d analysis gives an equivalent Young's Modulus of ca. 5 kPa). However, the present work suggests that fragility per se need not be a problem, rather it is the adhesive interactions with the tip, which under some circumstances may exceed 20 nN, that are the source of poor imaging conditions. The present results, being supported by a qualitative model, suggest that the activated substrate acts as a preferential scavenger of cellular debris thus preventing the tip from biofouling, and will therefore promote low adhesion between tip and membrane. Good imaging conditions provide non-destructive in vitro information about cytoskeletal structure and dynamics, as shown in two examples concerned with cytochalasin treatment and with the MTT assay.

Improving management of anemia using CQI techniques

During the last two years, the National Kidney Foundation's Dialysis Outcomes Quality Initiative (NKF-DOQI) Anemia Work Group has been developing clinical practice guidelines for the management of anemia in patients with chronic renal failure. After an in-depth critical analysis of the scientific literature, with a consensus of "expert opinion" used to support recommendations in areas with inadequate published data, evidence-based guidelines were developed. These clinical practice guidelines, regardless of how well-founded in scientific evidence, are likely to be disregarded if they are not applicable in the day-to-day care of patients. Thus, they must be practical, clearly stated, and usable, given available resources and constraints. The purpose of this article is to describe our experiences in implementing some of these guidelines over the last two years, as they were being developed, for the care of patients in our hemodialysis unit.

The appreciation of visual jokes in people with schizophrenia: a study of 'mentalizing' ability

It has been suggested that certain characteristic symptoms of schizophrenia reflect a specific deficit in the ability to attribute mental states to others ('mentalizing'). Patients with negative features, particularly social withdrawal and blunted affect, those with thought disorder and patients with paranoid symptoms have difficulties when they try to infer what is going on in the minds of other people. This study examines this notion using two sets of cartoon jokes. While the first set can be understood purely using physical and semantic analysis, the second set requires that the viewer appreciates the mental state of the main character in order to 'get' the joke. For control subjects there was no difference in the ability to understand the two types of joke, while the schizophrenic patients found the mental state jokes significantly more difficult to understand. This effect was most marked in patients with behavioural disorders and those reporting passivity experiences. Those with paranoid delusions also showed a selective comprehension deficit with the mental state stimuli. Patients who were symptom free at the time of testing showed normal performance.

Psychotic experiences induced in deluded patients using distorted auditory feedback

The effect of hearing immediate auditory feedback of their own voice distorted in pitch was examined in 21 patients with a diagnosis of schizophrenia. Patients frequently reported that they heard a voice "speaking when I speak" and often attributed this "other" voice to an external agent: "I think it's an evil spirit speaking when I speak." The frequency of making these ''other''attributions was significantly related to degree of pitch distortion (rho = 0.62, P <.01) and to current severity of delusions (rho = 0.62, P <.01). However, the relationship with hallucinations was not significant (rho = 0.40) and there was no relationship with negative features such as psychomotor retardation. We conclude that the "hallucination-like" reports elicited by our paradigm resulted from an interaction between an unusual perceptual experience (distorted auditory feedback) and an abnormal mechanism for belief formation present in deluded patients. This formulation suggests a close relationship between delusions and hallucinations.

A functional neuroanatomy of hallucinations in schizophrenia

Hallucinations, perceptions in the absence of external stimuli, are prominent among the core symptoms of schizophrenia. The neural correlates of these brief, involuntary experiences are not well understood, and have not been imaged selectively. We have used new positron emission tomography (PET) methods to study the brain state associated with the occurrence of hallucinations in six schizophrenic patients. Here we present a group study of five patients with classic auditory verbal hallucinations despite medication, demonstrating activations in subcortical nuclei (thalamic, striatal), limbic structures (especially hippocampus), and paralimbic regions (parahippocampal and cingulate gyri, as well as orbitofrontal cortex). We also present a case study of a unique, drug-naive patient with visual as well as auditory verbal hallucinations, demonstrating activations in visual and auditory/linguistic association cortices as part of a distributed cortical-subcortical network. Activity in deep brain structures, identified with group analysis, may generate or modulate hallucinations, and the particular neocortical regions entrained in individual patients may affect their specific perceptual content. The interaction of these distributed neural systems provides a biological basis for the bizarre reports of schizophrenic patients.

Regional brain activity in chronic schizophrenic patients during the performance of a verbal fluency task

BACKGROUND

This study examined the pattern of cerebral blood flow observed in chronic schizophrenic patients while they performed a paced verbal fluency task. Such tasks engage a distributed brain system associated with willed action. Since willed action is impaired in many chronic schizophrenic patients we hypothesised that task performance would be associated with an abnormal pattern of blood flow.

METHOD

Positron emission tomography (PET) was applied to 18 chronic schizophrenic patients stratified into three groups on the basis of verbal fluency performance and current symptoms. Regional cerebral blood flow (rCBF) was measured while the patients performed (a) verbal fluency, (b) word categorisation, and (c) word repetition. Results were compared with six normal controls matched for age, sex and premorbid IQ. Analysis was restricted to six brain regions previously identified in studies of normal volunteers.

RESULTS

In five brain areas, including the left dorsolateral prefrontal cortex, the patients showed the same pattern of activation as control subjects. However, in the left superior temporal cortex, all patient groups failed to show the normal decrease in blood flow when verbal fluency was compared with word repetition.

CONCLUSION

These observations suggest that (a) chronic schizophrenic patients can show a normal magnitude of frontal activation when matched for performance with controls, and (b) they fail to show the expected reductions of activity in the superior temporal cortex. This latter result may reflect abnormal functional connectivity between frontal and temporal cortex.

Transmission electron microscopic demonstration of vimentin in rat osteoblast and osteocyte cell bodies and processes using the immunogold technique

BACKGROUND

The immunogold labeling technique and transmission electron microscopy were used to demonstrate the expression and position of the intermediate filament vimentin in rat osteoblast and osteocyte cell bodies and cell processes. Conventional light and transmission electron microscopic studies of bone cells demonstrated adjacent cell linkage to be mediated by osteoblast and osteocyte processes present within the canalicular system traversing the bone matrix. The cell processes were filled with densely packed filaments, many of which have been shown previously to be actin microfilaments. The appearance, however, of 10 nm diameter filaments in some cell processes and the fact the intermediate filament vimentin has been defined in many cells of mesenchymal origin raised the possibility that some of these filaments might be vimentin. The ultrastructural colloidal gold immunochemical technique allowed for demonstration in situ of the expression of vimentin filaments plus accurate definition of their position.

METHODS

The studies were performed in newborn rat femoral and tibial diaphyseal cortical bone and in 1-week-old repair bone from 2.4 mm diameter defects made through the lateral cortex in 6-week-old rat femurs and tibias. The bone tissues for the immunochemical study were fixed in 1% glutaraldehyde, 4% paraformaldehyde, and 0.1 M phosphate buffer (pH 7.4) for 2 days. Decalcification was performed in 6% EDTA for 2-3 days. Infiltration involved use of Lowicryl resin K4M, and the embedding and curing processes were performed in a cryostat with temperatures -30 degrees C. An antivimentin monoclonal antibody was used for labeling using the postembedding technique. Effective antibody dilutions ranged from 1:10 to 1:200, with the dilutions of 1:25 and 1:100 showing the best combination of filament labeling with the least matrix background. The grids were exposed to 10 nanometer gold colloid conjugated goat anti-mouse IgM for demonstration of binding.

RESULTS

Vimentin immunolabeling was defined clearly in relation to filaments within the osteoblast and osteocyte cell body cytoplasm, throughout the entire length of the osteoblast and osteocyte cell processes, and in close relationship to the intracellular gap junctions which were present within the cell processes both close to the cell bodies and within the canaliculi well away from them.

CONCLUSIONS

Immunogold labeling demonstrates the presence of the intermediate filament vimentin in osteoblast and osteocyte cell bodies and processes of rat bone. Vimentin distribution is not concentrated to specific areas, is present throughout the extent of the bodies and processes, and is seen immediately adjacent to gap junctions.

Imaging transient, randomly occurring neuropsychological events in single subjects with positron emission tomography: an event-related count rate correlational analysis

Many neuropsychiatric symptom states are idiosyncratic, involuntary, randomly occurring, subjective, and transient. The brain states associated with these clinically important mental states cannot be imaged directly with existing positron emission tomography (PET) techniques. A new PET method that brings such mental/brain states under experimental control for analysis in single subjects is described. It utilizes a slow bolus H2 15O three-dimensional (3D) regional CBF imaging technique. The analysis focuses upon natural or experimentally induced variance in the temporal distribution of specific neuropsychological events over the course of a study session. For each scan, the amount of radioactivity entering the brain during these events is calculated to derive a score reflecting the contribution of the events to the image. A statistical analysis is then performed to identify those pixels in which the intensity covaries with the scan scores over the subject's scans. This permits the identification of the brain areas associated with the mental state of interest. The method is validated using an auditory sentence-monitoring task. The detection in single subjects of cerebral activations associated with recurrent events as brief as 2 s in duration is demonstrated. This method may be used as a means of imaging ephemeral neurologic or neuropsychiatric symptom states or as an alternative to a subtraction design for activation studies.

Implementing an inpatient eating disorders program

Inpatient treatment can be quite effective for clients with severe or persistent eating disorders. A successful treatment program, however, requires extensive nursing participation. The author addresses specific clinical problems and system issues related to this population of clients. She stresses the importance of clinical expertise among nursing staff and coordination with interdisciplinary staff members.

Detection of thirty-second cognitive activations in single subjects with positron emission tomography: a new low-dose H2(15)O regional cerebral blood flow three-dimensional imaging technique

Positron emission tomography regional CBF (rCBF) studies of cognitive processes have traditionally required 30-60 mCi of H2(15)O per scan and intersubject averaging to achieve statistical significance. However, intersubject anatomical, functional, and disease variability can make such an approach problematic. A new method that produces significant results in single subjects is presented. It is based upon high-sensitivity three-dimensional imaging and a "slow" bolus administration of < 15 mCi of H2(15)O per scan. The method is validated in four normal volunteers using control and auditory-language activation tasks with four scans per condition and statistical parametric mapping analysis. It is demonstrated that the rCBF distribution associated with the cognitive state is detected during the arrival of radiotracer in the brain. This occurs over 30 s and constitutes a critical temporal window during which stimulation should be performed. A 90-s acquisition time is found to produce results of greater significance than a 60-s acquisition time. The implications of the results and the functional neuroanatomical findings are discussed. This method is suitable for the study of individual functional neuroanatomy in many neuropsychological, pharmacologic, and symptom states in normal subjects and in patients with psychiatric and neurologic disorders.

Extracorporeal photochemotherapy in progressive systemic sclerosis

BACKGROUND

Extracorporeal photochemotherapy, an immune-modulating form of therapy, has been shown to be effective in the treatment of autoimmune diseases. We evaluated the effects of extracorporeal photochemotherapy in the treatment of patients with progressive systemic sclerosis (PSS).

METHODS

Nine patients with active progressive systemic sclerosis were treated with extracorporeal photochemotherapy on 2 successive days monthly. The duration of therapy ranged from 6 to 21 months.

RESULTS

A significant improvement was noted in the skin, musculoskeletal system, functional index, and symptoms including Raynaud's phenomenon, dyspnea, fatigue, dysphagia, and arthralgias, as well as improvement of cutaneous ulcers. Stabilization of the pulmonary function studies was also noted in the majority of patients over the course of therapy. No serious side effects were noted throughout the course of therapy in the 9 patients.

CONCLUSIONS

The results suggest that photopheresis may be beneficial in selected early cases of progressive systemic sclerosis.

Photopheresis for ARC: a nursing perspective

Photopheresis, an approved treatment for cutaneous T-cell lymphoma (CTCL), is the basis of a trial involving patients with AIDS-related complex (ARC). This study has provided the opportunity to identify unique nursing challenges along with satisfaction from innovative nursing interventions.

Memory for what it is and memory for what it means: a single case of Korsakoff's amnesia

A single case of Korsakoff's syndrome, showing classic circumscribed amnesia on traditional neuropsychological tests, performed a number of learning tasks previously used in primates to demonstrate the different anatomical basis of memory systems used to learn about the properties of objects or to learn about rules of responding. The patient (CJ) performed in a manner very similar to lesioned monkeys in that he could learn evaluative tasks (e.g. a red object is nice), but not rule based tasks (e.g. a red object means go left). In consequence CJ learned an object discrimination task in a manner qualitatively different from a group of non-amnesic controls. Although he could not learn rule based tasks, CJ could perform them once he had been given the rule. Detailed analysis of learning showed that CJ could choose the object he had chosen previously, but could not say where it had been or whether he had been rewarded. Furthermore he could recognise a word as familiar, while not remembering its source. We propose that he has a specific impairment in a memory system concerned with the representation of the signification of objects in particular contexts, while representation of the properties of objects remains intact.

Viral-specific immunization in AIDS-related complex by photopheresis

The potential for therapeutic intervention in 7 patients with AIDS-related complex (ARC) was evaluated through the use of photopheresis. The rationale for the study was based on: 1. the demonstration that psoralen and UVA could inactivate HIV/virus in vitro; 2. CD4 cells are the primary target population effected by HIV and photopheresis; and 3. reinfusion of inactivated virus and cell-associated virus might serve to engender an immune response. Preliminary results in 7 patients with ARC over 6 to 18 months revealed a virus-specific response with an elevation of HIV antibodies, while EBV and CMV titers remained unchanged. The immunologic results revealed an increase in the CD8 lymphocyte population, stable activation markers (B2 microglobulin neopterin), a decrease in p24 antigen titers and inability to culture HIV virus in 3 patients. All of these results were in the context of a stable or increasing CD4+ percent. Six patients did not reveal a generalized inhibition of other immune responses as demonstrated by recovery of DTH. In addition, the resolution of lymphadenopathy, night sweats, fever and weight loss, paralleled the immunologic response.

Infection of a polarized epithelial cell line with wild-type reovirus leads to virus persistence and altered cellular function

The mechanisms and consequences of persistence of non-transforming viruses are poorly understood. Reovirus infections are usually regarded as cytocidal and infection is associated with inhibition of cellular protein and DNA synthesis. Reovirus infection of the polarized epithelial MDCK cell line is not associated with inhibition of protein synthesis, and cells become persistently infected and continue to grow without c.p.e. after infection. After several passages, virus persistence is associated with profound morphological and functional changes. The cells lose their usual cobblestone appearance and acquire a fibroblastic, undifferentiated morphology. This is associated with an inability to form tight junctions. In addition, expression of epidermal growth factor receptors and one adhesion protein is altered in the persistently infected cells. These results demonstrate that reovirus persistence will occur readily, and that infection of differentiated cells with a non-transforming virus can lead to loss of differentiation and abnormal protein expression.

Detection of major group rhinoviruses by soluble intercellular adhesion molecule-1 (sICAM-1)

Soluble intercellular adhesion molecule-1 (sICAM-1) was shown to be the receptor for the major subgroup of rhinoviruses. It was demonstrated that this molecule can inhibit the binding and subsequent infection of target cells by rhinoviruses belonging to the major but not the minor subgroup. The data reported now describe an ELISA-based system utilizing biotinylated sICAM-1 as a means of detecting rhinoviruses belonging to the major subgroup.

Long-term effects of sexual abuse which occurred in childhood: a review

The psychological problems and difficulties experienced by adults who report having been sexually abused in childhood are reviewed. These long-term effects include damage to the victims' emotional reactions and self-perceptions, relationship problems, problems with sexuality and difficulties in social functioning. Common presenting problems of victims of childhood sexual abuse (CSA) are described. Also discussed are the characteristics of incestuous abuse in terms of the victim, the abusive relationship and its termination; the contributions of the various aspects of CSA to the psychological impact of such abuse; and psychodynamic explanations of the development of long-term effects. The bulk of the published material regarding the long-term effects of CSA refers to female victims only, and this 'bias' is reflected in the review.

Treatment of sexual abuse which occurred in childhood: a review

This review is concerned with the individual and group treatment of clients who present with a history of sexual abuse in childhood. Almost all of the literature regarding the individual treatment of these clients is based on clinical reports; very little is experimentally based. Most of the reports of group treatment are of a similar nature, although some outcome research data are included. The clinical consensus, in terms of the issues, stages, goals and techniques of therapy, is described. In addition, an overview is provided of the identification of clients who may have a history of CSA, which includes guidelines for assisting disclosure. Finally, the issues raised for therapists in treating these clients are addressed. Much of the material reviewed in this article refers to the treatment of female, and in particular incestuously abused, victims; at the time of writing, very little information was available regarding the treatment of male victims.

Photopheresis for the treatment of cutaneous T cell lymphoma

We investigated the use of extracorporeal chemotherapy (photopheresis) in eight patients with cutaneous T cell lymphoma. Initially described by Edelson et al. for the treatment of erythrodermic cutaneous T cell lymphoma, we have expanded the treatment to include patients with extensive patch/plaque disease as well as tumor-stage disease. Four of five patients with erythrodermic stage disease had either a complete or a partial clinical remission with photopheresis alone. One patient with extensive patch/plaque disease continued to have a partial clinical remission of 7 months' duration with photopheresis alone. Of the two patients with tumor-stage disease, one remained without evidence of clinical disease at 10 months with photopheresis alone, whereas the second patient had a partial clinical remission of 5 months with a combination of local radiation therapy followed by monthly photopheresis. The skin biopsy specimen obtained from the patient with tumor-stage disease in complete clinical remission did not show cutaneous T cell lymphoma. We conclude that photopheresis is an effective modality alone or in combination with adjunctive therapy for erythroderma, extensive patch/plaque disease, and some tumor-stage disease.

POMC in rhesus anterior pituitary and plasma: evidence of N-acetylated beta-endorphin and alpha-MSH

Pro-opiomelanocortin (POMC) related peptides have been studied in rat tissue and plasma, but they have not been well characterized in the rhesus monkey. Since monkey pituitary may be more similar to the human pituitary than the rat, we have characterized POMC related peptides by immunocytochemical, multiple radioimmunoassays (RIA's) and molecular sieving chromatography. Immunocytochemical staining demonstrated N-acetylated- beta-endorphin (N-Ac- beta-End) and alpha-MSH in a few corticotrophs. RIA's of crude anterior pituitary extract and molecular sieving chromatography demonstrates that the major portion is beta-End sized with a significant proportion being N-acetylated and an alpha-MSH peak. Molecular sieving chromatography of extracted plasma demonstrated a similar pattern to that seen in the anterior pituitary. These data suggest that rhesus monkey processes POMC differently than rat or man.

Plasma beta-endorphin-like immunoreactivity, self reported pain perception and anxiety levels in women during pregnancy and labor

Plasma Beta-endorphin (B-END) immunoreactivity was measured in 19 men, 16 women at midcycle, and ten pregnant women at various points in their pregnancies. There is a significant difference between the levels measured in males and females (t = 3.74, df = 31, p = .0007). Pregnant women demonstrated a steady increase in plasma Beta-End-like immunoreactivity between second and third trimester and through labor. The levels dropped rapidly postpartum. The material being measured is predominantly B-end-sized. Psychological studies indicate that these changes are not strongly correlated with pain perception or self-reported anxiety levels.