Four buildings and a flush: Lessons from degraded water quality and recommendations on building water management

A reduction in building occupancy can lead to stagnant water in plumbing, and the potential consequences for water quality have gained increasing attention. To investigate this, a study was conducted during the COVID-19 pandemic, focusing on water quality in four institutional buildings. Two of these buildings were old (>58 years) and large (>19,000 m2), while the other two were new (>13 years) and small (<11,000 m2). The study revealed significant decreases in water usage in the small buildings, whereas usage remained unchanged in the large buildings. Initial analysis found that residual chlorine was rarely detectable in cold/drinking water samples. Furthermore, the pH, dissolved oxygen, total organic carbon, and total cell count levels in the first draw of cold water samples were similar across all buildings. However, the ranges of heavy metal concentrations in large buildings were greater than observed in small buildings. Copper (Cu), lead (Pb), and manganese (Mn) sporadically exceeded drinking water limits at cold water fixtures, with maximum concentrations of 2.7 mg Cu L-1, 45.4 μg Pb L-1, 1.9 mg Mn L-1. Flushing the plumbing for 5 min resulted in detectable residual at fixtures in three buildings, but even after 125 min of flushing in largest and oldest building, no residual chlorine was detected at the fixture closest to the building's point of entry. During the pandemic, the building owner conducted fixture flushing, where one to a few fixtures were operated per visit in buildings with hundreds of fixtures and multiple floors. However, further research is needed to understand the fundamental processes that control faucet water quality from the service line to the faucet. In the absence of this knowledge, building owners should create and use as-built drawings to develop flushing plans and conduct periodic water testing.

A Critical Review on the Factors that Influence Opportunistic Premise Plumbing Pathogens: From Building Entry to Fixtures in Residences

Residential buildings provide unique conditions for opportunistic premise plumbing pathogen (OPPP) exposure via aerosolized water droplets produced by showerheads, faucets, and tubs. The objective of this review was to critically evaluate the existing literature that assessed the impact of potentially enhancing conditions to OPPP occurrence associated with residential plumbing and to point out knowledge gaps. Comprehensive studies on the topic were found to be lacking. Major knowledge gaps identified include the assessment of OPPP growth in the residential plumbing, from building entry to fixtures, and evaluation of the extent of the impact of typical residential plumbing design (e.g., trunk and branch and manifold), components (e.g., valves and fixtures), water heater types and temperature setting of operation, and common pipe materials (copper, PEX, and PVC/CPVC). In addition, impacts of the current plumbing code requirements on OPPP responses have not been assessed by any study and a lack of guidelines for OPPP risk management in residences was identified. Finally, the research required to expand knowledge on OPPP amplification in residences was discussed.

Tenets of a holistic approach to drinking water-associated pathogen research, management, and communication

In recent years, drinking water-associated pathogens that can cause infections in immunocompromised or otherwise susceptible individuals (henceforth referred to as DWPI), sometimes referred to as opportunistic pathogens or opportunistic premise plumbing pathogens, have received considerable attention. DWPI research has largely been conducted by experts focusing on specific microorganisms or within silos of expertise. The resulting mitigation approaches optimized for a single microorganism may have unintended consequences and trade-offs for other DWPI or other interests (e.g., energy costs and conservation). For example, the ecological and epidemiological issues characteristic of Legionella pneumophila diverge from those relevant for Mycobacterium avium and other nontuberculous mycobacteria. Recent advances in understanding DWPI as part of a complex microbial ecosystem inhabiting drinking water systems continues to reveal additional challenges: namely, how can all microorganisms of concern be managed simultaneously? In order to protect public health, we must take a more holistic approach in all aspects of the field, including basic research, monitoring methods, risk-based mitigation techniques, and policy. A holistic approach will (i) target multiple microorganisms simultaneously, (ii) involve experts across several disciplines, and (iii) communicate results across disciplines and more broadly, proactively addressing source water-to-customer system management.

Noncrop Host Plant Associations for Oversummering of Diuraphis noxia in the State of South Australia

Diuraphis noxia, Russian wheat aphid (Hemiptera: Aphididae), established in Australia since 2016, is dependent on grasses (Poales: Poaceae) to persist in the low-rainfall Australian wheat belt, where no crops are present during summer. To identify grasses as D. noxia hosts in Australia, plants were tested in greenhouse conditions as either whole plants collected from roadsides or grown from collected seed in 2017 and 2018. To determine actual field refugia, direct grass sampling and Berlese extraction of aphids were conducted from October 2018 to May 2020 throughout Southern Australia (2,285 samples). One hundred and twenty-six grass species were collected, 54 showed presence of D. noxia, of which 24 were considered host plants, including 16 species (9 Australian natives) not recorded as host plants previously. Hordeum leporinum (Link) Arcang. Poales:Poaceae and several Bromus species (Poales: Poaceae) showed the highest D. noxia detection frequency and aphid numbers, but these introduced grass species are not summer active in most of South Australia. The native Enneapogon nigricans (Poales: Poaceae) (R.Br.) is the most important summer refuge species because of its widespread distribution, summer growth, and an intermediate level of positive detections with low D. noxia populations. The late summer represents the main bottleneck for D. noxia with very few hosts available and very low D. noxia detections overall. Late summer rainfall (February) seems essential to have the main host grasses germinate for D. noxia populations to build up and potentially invade crops sown in autumn.

The Chemical Complexity of e-Cigarette Aerosols Compared With the Smoke From a Tobacco Burning Cigarette

Background: As e-cigarette popularity has increased, there is growing evidence to suggest that while they are highly likely to be considerably less harmful than cigarettes, their use is not free of risk to the user. There is therefore an ongoing need to characterise the chemical composition of e-cigarette aerosols, as a starting point in characterising risks associated with their use. This study examined the chemical complexity of aerosols generated by an e-cigarette containing one unflavored and three flavored e-liquids. A combination of targeted and untargeted chemical analysis approaches was used to examine the number of compounds comprising the aerosol. Contributions of e-liquid flavors to aerosol complexity were investigated, and the sources of other aerosol constituents sought. Emissions of 98 aerosol toxicants were quantified and compared to those in smoke from a reference tobacco cigarette generated under two different smoking regimes. Results: Combined untargeted and targeted aerosol analyses identified between 94 and 139 compounds in the flavored aerosols, compared with an estimated 72-79 in the unflavored aerosol. This is significantly less complex (by 1-2 orders of magnitude) than the reported composition of cigarette smoke. Combining both types of analysis identified 5-12 compounds over and above those found by untargeted analysis alone. Gravimetrically, 89-99% of the e-cigarette aerosol composition was composed of glycerol, propylene glycol, water and nicotine, and around 3% comprised other, more minor, constituents. Comparable data for the Ky3R4F reference tobacco cigarette pointed to 58-76% of cigarette smoke "tar" being composed of minor constituents. Levels of the targeted toxicants in the e-cigarette aerosols were significantly lower than those in cigarette smoke, with 68.5->99% reductions under ISO 3308 puffing conditions and 88.4->99% reductions under ISO 20778 (intense) conditions; reductions against the WHO TobReg 9 priority list were around 99%. Conclusion: These analyses showed that the e-cigarette aerosols contain fewer compounds and at significantly lower concentrations than cigarette smoke. The chemical diversity of an e-cigarette aerosol is strongly impacted by the choice of e-liquid ingredients.

Glyphosate exposure in pregnancy and shortened gestational length: a prospective Indiana birth cohort study

BACKGROUND

Glyphosate (GLY) is the most heavily used herbicide worldwide but the extent of exposure in human pregnancy remains unknown. Its residues are found in the environment, major crops, and food items that humans, including pregnant women, consume daily. Since GLY exposure in pregnancy may also increase fetal exposure risk, we designed a birth-cohort study to determine exposure frequency, potential exposure pathways, and associations with fetal growth indicators and pregnancy length.

METHOD

Urine and residential drinking water samples were obtained from 71 women with singleton pregnancies living in Central Indiana while they received routine prenatal care. GLY measurements were performed using liquid chromatography-tandem mass spectrometry. Demographic and survey information relating to food and water consumption, stress, and residence were obtained by questionnaire. Maternal risk factors and neonatal outcomes were abstracted from medical records. Correlation analyses were used to assess relationships of urine GLY levels with fetal growth indicators and gestational length.

RESULTS

The mean age of participants was 29 years, and the majority were Caucasian. Ninety three percent of the pregnant women had GLY levels above the limit of detection (0.1 ng/mL). Mean urinary GLY was 3.40 ng/mL (range 0.5-7.20 ng/mL). Higher GLY levels were found in women who lived in rural areas (p = 0.02), and in those who consumed > 24 oz. of caffeinated beverages per day (p = 0.004). None of the drinking water samples had detectable GLY levels. We observed no correlations with fetal growth indicators such as birth weight percentile and head circumference. However, higher GLY urine levels were significantly correlated with shortened gestational lengths (r = - 0.28, p = 0.02).

CONCLUSIONS

This is the first study of GLY exposure in US pregnant women using urine specimens as a direct measure of exposure. We found that > 90% of pregnant women had detectable GLY levels and that these levels correlated significantly with shortened pregnancy lengths. Although our study cohort was small and regional and had limited racial/ethnic diversity, it provides direct evidence of maternal GLY exposure and a significant correlation with shortened pregnancy. Further investigations in a more geographically and racially diverse cohort would be necessary before these findings could be generalized.

The burden of chronic spontaneous urticaria is substantial: Real-world evidence from ASSURE-CSU

BACKGROUND

Chronic spontaneous urticaria (CSU) can be debilitating, difficult to treat, and frustrating for patients and physicians. Real-world evidence for the burden of CSU is limited. The objective of this study was to document disease duration, treatment history, and disease activity, as well as impact on health-related quality of life (HRQoL) and work among patients with inadequately controlled CSU, and to describe its humanistic, societal, and economic burden.

METHODS

This international observational study assessed a cohort of 673 adult patients with CSU whose symptoms persisted for ≥12 months despite treatment. Demographics, disease characteristics, and healthcare resource use in the previous 12 months were collected from medical records. Patient-reported data on urticaria and angioedema symptoms, HRQoL, and work productivity and activity impairment were collected from a survey and a diary.

RESULTS

Almost 50% of patients had moderate-to-severe disease activity as reported by Urticaria Activity Score. Mean (SD) Dermatology Life Quality Index and Chronic Urticaria Quality of Life Questionnaire scores were 9.1 (6.62) and 33.6 (20.99), respectively. Chronic spontaneous urticaria markedly interfered with sleep and daily activities. Angioedema in the previous 12 months was reported by 66% of enrolled patients and significantly affected HRQoL. More than 20% of patients reported ≥1 hour per week of missed work; productivity impairment was 27%. These effects increased with increasing disease activity. Significant healthcare resources and costs were incurred to treat CSU.

CONCLUSIONS

Chronic spontaneous urticaria has considerable humanistic and economic impacts. Patients with greater disease activity and with angioedema experience greater HRQoL impairments.

Age-related changes in mesenchymal stem cells identified using a multi-omics approach

Mesenchymal stem cells (MSC) are capable of multipotent differentiation into connective tissues and as such are an attractive source for autologous cell-based treatments for many clinical diseases and injuries. Ageing is associated with various altered cellular phenotypes coupled with a variety of transcriptional, epigenetic and translational changes. Furthermore, the regeneration potential of MSCs is reduced with increasing age and is correlated with changes in cellular functions. This study used a systems biology approach to investigate the transcriptomic (RNASeq), epigenetic (miRNASeq and DNA methylation) and protein alterations in ageing MSCs in order to understand the age-related functional and biological variations, which may affect their applications to regenerative medicine. We identified no change in expression of the cellular senescence markers. Alterations were evident at both the transcriptional and post-transcriptional level in a number of transcription factors. There was enrichment in genes involved in developmental disorders at mRNA and differential methylated loci (DML) level. Alterations in energy metabolism were apparent at the DML and protein level. The microRNA miR-199b-5p, whose expression was reduced in old MSCs, had predicted gene targets involved in energy metabolism and cell survival. Additionally, enrichment of DML and proteins in cell survival was evident. Enrichment in metabolic processes was revealed at the protein level and in genes identified as undergoing alternate splicing. Overall, an altered phenotype in MSC ageing at a number of levels implicated roles for inflamm-ageing and mitochondrial ageing. Identified changes represent novel insights into the ageing process, with implications for stem cell therapies in older patients.

The effect of a novel tobacco process on the in vitro cytotoxicity and genotoxicity of cigarette smoke particulate matter

Some of the toxic effects of smoking have been attributed to the combustion of nitrogenous protein in tobacco. The effects of a treatment which reduces tobacco's protein nitrogen level, on the in vitro cytotoxicity and genotoxicity of cigarette smoke particulate matter (PM), were measured. PMs were tested in the Neutral Red Uptake (NRU) test; the Salmonella mutagenicity assay (SAL); the mouse lymphoma mammalian cell mutation assay (MLA) and the in vitro micronucleus test (IVMNT). PMs from all of the cigarettes were cytotoxic and genotoxic. PM obtained from smoking treated tobacco, showed a small, consistent and statistically significant reduced mutagenicity (revertants/μg) in TA98 with post-mitochondrial supernatant (S9). No consistent quantitative or qualitative differences were detected in the other tests. The data are discussed in relation to published information on smoke chemistry obtained from cigarettes made of tobacco treated using this technique. The observations confirm that the method did not give rise to any new qualitative or quantitative cytotoxic or genotoxic effects, and may have reduced PM's bacterial mutagenicity in TA98 with S9. Further toxicity testing is warranted, to investigate the effects of the tobacco treatment in more detail and add to the data already obtained.

Effects of doxycycline on human prostate cancer cells in vitro

Prostate cancer is the most common form of cancer in older men and the major cause of death from prostate cancer is metastatic disease. The matrix metalloproteinases (MMPs) play a significant role in the growth, invasion and metastasis of many tumors, including those of the prostate. We previously demonstrated that doxycycline, a synthetic tetracycline, inhibits MMPs and cell proliferation and induces apoptosis in several cancer cell lines. We also demonstrated that in an in vivo model of metastatic breast cancer in athymic mice doxycycline inhibits tumor size and regrowth after resection. In the present study, gelatinolytic activity in the human prostate cancer cell line, LNCaP, was suppressed and significant inhibition of cell growth occurred after exposure to 5 or 10 microg/ml of doxycycline, while cell growth was normal in untreated cells. Radioisotope incorporation into proteins was reduced by doxycycline. DNA fragmentation, consistent with apoptosis, was demonstrated in cells treated with doxycycline. These data suggest that doxycycline may have potential utility in the management of prostate cancer.

Effects of vitamin D3 on proliferation of cancer cells in vitro

The principal cause of death from most forms of cancer is metastatic disease. Cancer cells appear to grow quickly out of the control of the normal host regulatory mechanisms. Many factors contribute to this unrestrained proliferation, including increased metalloproteinase activity causing degradation of the extracellular matrix surrounding cancer cells, angiogenesis permitting easy access of the cells to the bloodstream and decrease or loss of programmed cell death, or apoptosis, an important mechanism for removal of abnormal or senescent cells. Treatment modalities targeted towards arresting cancer cell proliferation and spread are needed to improve the survival of patients with cancer. Vitamin D3, 1,25-dihydroxychole-calciferol D3, has been shown to induce apoptosis in the human breast cancer cell line, MCF-7. We have studied the effects of three concentrations of vitamin D3 on the human breast cancer cell line, MDA-MB-435, the human prostate cancer cell line, LNCaP, and a human osteosarcoma cell line, U20S. We report here that vitamin D3 strikingly inhibits cell proliferation and induces apoptosis in all three cell lines.

Inhibition of proliferation and induction of apoptosis by doxycycline in cultured human osteosarcoma cells

Matrix metalloproteinases (MMPs) play a major role in the phenomena of growth, invasion, and metastasis of malignant disease. We studied the effects of doxycycline, a synthetic tetracycline that has been shown to suppress MMP activity in other solid tumors, on osteosarcoma (OSA) cell proliferation and MMP activity in vitro. OSA cells from 6 patients and from one established human tumor cell line (U2OS) (American Type Culture Collection) were cultured in the presence or absence of doxycycline. Doxycycline (10 microg/ml) suppressed OSA cell proliferation threefold to sevenfold in all cultures. MMP activity was assessed by gelatin zymography and was diminished by approximately 50% in all cultures. We examined the hypothesis that induction of apoptosis is one of the mechanisms by which doxycycline inhibits OSA cell proliferation. Ethidium bromide-stained gels of DNA from cells grown in the presence of 5 microg/ml and 10 microg/ml of doxycycline revealed laddering consistent with apoptosis after 24 hours in culture. The demonstration that doxycycline suppresses cell proliferation and MMP activity and induces apoptosis in human OSA cells in vitro suggests that this well-tolerated oral agent may be effective in the in vivo treatment of OSA.

Patient Self-Determination Act: advocating for the patient's wishes

The United States has a long tradition of protecting an individual's rights. A recent example is the Patient Self-Determination Act (PSDA), federal law (1992, P.L. 101-508). It specifically allows competent individuals to communicate their preferences for life-sustaining medical treatment before they become incapacitated and are unable to make them known. It requires health care agencies, including home health agencies, receiving funds through Medicaid or Medicare programs to provide information and education about advance directives (ADs) to their patients, staff, and the community. Home health care agencies need to have protocols in place to be in compliance with the law. Agencies have to inform patients about their rights to make health care decisions and must maintain written policies about the implementation of those rights. The federal law prohibits home care providers from making the patient's care conditional on the existence of an AD or in any way altering the quality of care provided because of his or her wishes.

Assessment of donor cell and matrix survival in fresh articular cartilage allografts in a goat model

The long-term survival of allografts of articular cartilage has been proposed to be dependent on the survival of the cells that maintain the unique structural and material properties of the allograft. In this study, we assessed cell survival in 24 fresh articular cartilage allografts of the medial plateau in a Spanish-goat model. A DNA-probe technique was used to distinguish clearly between DNA from donor (allograft) and host cells. The intraarticular survival of viable allograft chondrocytes in the transplanted articular cartilage started to diminish as early as 3 weeks after transplantation; however, there was considerable variation in the amount of donor cell DNA detected in the allografts at 6 and 12 months following transplantation. This contrasts with our experience with fresh allografts of ligament, tendon, and meniscus, in which no donor DNA was detected 4 weeks after transplantation. DNA from host cells was present in all articular cartilage allografts, as evidenced by detectable unique host DNA patterns. Histological and histochemical assays showed that none of the transplants demonstrated normal structure and composition at 1 year after transplantation. The grafts in which large quantities of donor DNA were present appeared grossly superior to those with no or reduced remaining demonstrable donor DNA.

Studies of copper transport in cultured bovine chondrocytes

Copper serves as the cofactor for a number of important enzymes in cartilage, as well as in other tissues, including lysyl oxidase, superoxide dismutase, and cytochrome oxidase. Ceruloplasmin is responsible for the transport of approx. 95% of the copper in serum, but the mechanisms for intracellular copper transport are unknown. We have demonstrated recently that a high-molecular-weight cartilage glycoprotein, referred to as CMGP, has regions of sequence homology with ceruloplasmin. CMGP also binds copper and has at least some oxidase activity similar to that of ceruloplasmin. Other tissues synthesize intracellular ceruloplasmin-like proteins. The present report represents part of an effort to examine the hypothesis that CMGP is a copper transport protein in chondrocytes and to characterize the enzymatic activities of CMGP. These studies demonstrate that CMGP is the principal chondrocyte protein labeled by 67Cu in vitro and that the label is localized to the mitochondria, cytosol, and membrane fractions of sucrose gradients, suggesting copper transport through the cell. In parallel experiments, [3H]leucine was incorporated into proteins corresponding to the subunits and fragments of CMGP, as described previously, and in a similar distribution among the subcellular fractions as labeled copper. Additionally, CMGP has oxidase and ferroxidase activities similar to those of ceruloplasmin.

Evidence that a 550,000-dalton cartilage matrix glycoprotein is a chondrocyte membrane-associated protein closely related to ceruloplasmin

Cartilage matrix glycoprotein (CMGP) is a disulfide-bonded 550,000-dalton protein that is synthesized by chondrocytes and ciliary epithelial cells. We have purified the protein from bovine and porcine articular cartilage and have sequenced two peptides, which both have significant homology with human ceruloplasmin, a copper-binding oxidase. Immunolocation analysis indicates that a commercial polyclonal antiserum to human ceruloplasmin reacts with bovine cartilage CMGP. Chelating columns made with copper bind CMGP from bovine cartilage extracts. CMGP is present in bovine chondrocyte membrane preparations purified from sucrose density gradients. Oligonucleotide probes have been synthesized based on the published sequence of the 3'-untranslated region and a portion of the C terminus of human ceruloplasmin and have been used to amplify a cDNA fragment from bovine cartilage and human liver libraries. CMGP demonstrates oxidase activity towards p-phenylenediamine similar to that of ceruloplasmin. These studies suggest that CMGP is closely related to, if not identical with, ceruloplasmin. It is possible that CMGP may be involved in metal transport into and/or within the chondrocyte.

Transurethral prostatectomy: practice aspects of the dominant operation in American urology

In a national survey of all American urologists transurethral prostatectomy accounted for 38 per cent of the major surgical procedures performed by the respondents. They regarded the operation as complex and they believe achievement of proficiency requires that more be performed during residency training than any other urological operation. Furthermore, they assigned transurethral prostatectomy a significantly higher relative value than have medical economists doing research in the field of physician reimbursement. The effect of recent legislated congressional reductions in the allowable Medicare fees for transurethral prostatectomy is discussed along with the impact of these reductions on urological patient care and the American urologist. Practice patterns and geographic variations in the costs of transurethral prostatectomy also are considered.

A study of the atmosphere in London underground trains before and after the ban on smoking

Measurements of the ambient atmosphere in London Underground train compartments were made before and after a ban on smoking. Levels of nicotine and carbon monoxide and estimates of airborne particulates are given. This paper describes the analytical techniques used in measuring constituents of tobacco smoke in the ambient air of public environments. Levels observed were all found to be far lower than recommended OSHA limits for safe exposure.

Cocaine-sensitive O-methylation of noradrenaline in dental pulp of the rabbit: comparison with the rabbit ear artery

Incisor pulp from the rabbit metabolises exogenous noradrenaline in concentrations between 0.12 and 1.2 mumol/l mainly to NMN. Effects of chronic sympathetic denervation indicated that in incisor pulp the NMN is extraneuronal in origin, and that DOPEG and DOMA formation, as well as a major part of the noradrenaline which accumulates in the tissue, are associated with the sympathetic nerves. NMN formation was unaffected by hydrocortisone 210 mumol/l, but was strongly inhibited by cocaine 30 mumol/l. These effects contrasted with those in the rabbit ear artery, where NMN formation was increased by cocaine 30 mumol/l and decreased by hydrocortisone 210 mumol/l. In COMT-inhibited denervated pulp, cocaine inhibited the accumulation of noradrenaline. Monoamine fluorescence histochemistry of pulp exposed to noradrenaline 50 mumol/l indicated that cocaine-sensitive uptake occurred in fibroblasts. It is concluded that O-methylation of noradrenaline in dental pulp involves prior uptake of the amine by a process resembling uptake1 but which is distinguished from uptake1 by its extraneuronal location.

Role of sympathetic nerves in the metabolism of exogenous noradrenaline in rabbit gingival tissue and ear artery

Uptake and metabolism of 3H-noradrenaline 0.18 mumol/l was examined in rabbit gingival slices and ear artery segments. The tissues were incubated with the 3H-amine for 30 min. The artery accumulated approximately ten times more of the 3H-amine and generated four times more 3H-metabolites than the gingiva. In both tissues, chronic sympathetic denervation resulted in marked decreases in 3H-noradrenaline accumulation and deamination. An inhibitor of sympathetic neuronal uptake, cocaine 30 mumol/l, strongly inhibited the firmly-bound component of 3H-noradrenaline accumulation by the tissues and strongly decreased the accumulation of deaminated metabolites in the incubating medium. It is concluded that the sympathetic nerve terminals play an important role in the accumulation and deamination of noradrenaline in the gingiva and in the artery. Chronic sympathetic denervation resulted in increased 3H-normetanephrine (NMN) formation by the gingiva and the artery, indicating that in both tissues the noradrenaline was O-methylated at sites extraneuronal to the sympathetic nerves. Differences between the effects of cocaine in the gingiva and artery, with respect to 3H-NMN accumulation in the incubating medium, are interpreted as evidence that in the gingiva, but not in the artery, cocaine inhibits extraneuronal O-methylation, as well as neuronal uptake, of noradrenaline.

A new use for M-mode echocardiography in detecting left ventricular diastolic dysfunction in coronary artery disease

Regional left ventricular (LV) diastolic function affects the global rate and pattern of LV filling. These changes may be detected by changes in the magnitude and timing of the increase in LV basal diameter during diastole. Because M-mode echocardiography possesses the high temporal and spatial resolution to detect such abnormalities, a group of 8 normal control subjects were compared with a group of 12 patients with coronary artery disease (CAD) to determine differences in the rate and timing of ventricular filling. The CAD patients had lower rates of fast filling expansion than the control subjects. The proportion of LV diastolic expansion during fast filling was lower. During atrial systole the increased rate of LV expansion was not significantly higher in the CAD patients, but the proportion of diastolic expansion occurring with atrial systole was increased. These changes may reflect a decrease in the rate and magnitude of early diastolic filling in the noncompliant ventricle and an increased reliance on active atrial transport. Thus, CAD alters the rate and pattern of LV filling. Changes in LV diameter as measured by M-mode echocardiography may be useful in detecting altered patterns of LV diastolic filling and identifying patients with CAD.

Purulent meningococcal pericarditis: chronic percutaneous drainage with a modified catheter aided by echocardiography

A 7-month-old infant presented with suspected sepsis. On the third day of illness signs of cardiac tamponade developed. Tamponade was relieved by pericardiocentesis, and countercurrent immunoelectrophoresis (CIE) analysis of the fluid was positive for meningococcus group B. Antibiotic treatment was changed to penicillin G. After echocardiography demonstrated reaccumulation of fluid, a modified #16 gauge angiocatheter was placed percutaneously in the pericardial space. When drainage slowed it was repositioned using two-dimensional echocardiography. After 24 h the catheter was removed and no further accumulation occurred. The antibiotics were continued an additional 10 days and the infant recovered uneventfully. Modification of the catheter and echographic repositioning may decrease the need for surgical drainage in such patients.

Prior hot plate exposure enhances morphine analgesia in tolerant and drug-naive rats

The associative model of morphine tolerance predicts that established tolerance should be attenuated, i.e., extinguished, by placebo injections in the former morphine injection environment. The present study examined the effect of placebo sessions, with and without accompanying nociceptive stimulation, on the extinction of analgesic tolerance. In Experiment 1, rats rendered tolerant to morphine displayed recovery of morphine's analgesic action only following placebo sessions including exposure to a painful hot plate surface (52.5 degrees C); placebo sessions on a cool plate (23-24 degrees C) failed to attenuate tolerance even though these placebo sessions more closely matched the stimulus conditions of tolerance acquisition. In Experiment 2, repeated hot plate exposures were similarly found to enhance morphine analgesia in drug-naive rats. These results question an extinction account of the effect of hot plate placebo sessions observed in Experiment 1. Instead, they suggest that nociceptive hot plate exposures, per se, are sufficient to enhance subsequent morphine analgesia.

Metabolic management in Menière's disease

Pollution in the bloodstream by abnormal amounts of metabolites (sugar, insulin, triglycerides and cholesterol) over an extended period of time will have an adverse effect upon the small blood vessels: the arterioles, capillaries and venules. If the microcirculation of the inner ear becomes afflicted, it may produce endolymphatic hydrops. Control of blood pollution can usually be achieved by intelligent dietary management; and, in the case of Menière's disease, the clinical relief is gratifying. Carbohydrate and lipid metabolism is complicated. If the new insulin-glucose tolerance test is used, it will detect many more cases of glucose intolerance. Fifty consecutive cases of Menière's disease were studied for abnormal levels of metabolites. Thirty-eight (76 %) of these cases had either an abnormal glucose tolerance test (using the Wilkerson point system) or at least borderline insulin levels: a) abnormal insulin levels, 35 cases; b) borderline insulin values, 3 cases; c) abnormal glucose tolerance with normal insulin values, no cases; d) both normal glucose tolerance and normal insulin production, 12 cases.

Petrosquamosal suture and lamina

The junction of the petrosal and squamosal portions of the temporal lobe has important relationships that are of interest to the otologist. The resultant suture extends from the glaserian fissure across the top of the middle ear cleft and into the mastoid portion of the temporal bone. It may permit quick passage of infection from the middle ear to the middle cranial fossa. The petrosa may override the squama, forcing it down into the tympanum, where it could cause malleus fixation and a conductive type hearing loss. In the mastoid the suture is identifiable on the surface, but in the interior it is represented by the petrosquamosal lamina. The deeper portion in the petrosal portion of the mastoid may be easily overlooked in surgery of the mastoid and may lead to facial nerve injury.