ASHP and ASHP Foundation Pharmacy Forecast 2024: Strategic Planning Guidance for Pharmacy Departments in Hospitals and Health Systems

Purpose: The 2024 ASHP Pharmacy Forecast identifies and contextualizes emerging issues and trends that will influence healthcare, health systems, and the pharmacy profession and provides recommendations to inform long-term strategic planning that should prompt action by pharmacists and health-system leaders. Methods: Drawing on the “wisdom of crowds” concept, a survey was constructed with 6 general themes, each with 6 to 9 focused statements and a seventh theme on preparedness (58 survey items in total). The size of and representation within the survey panel were intended to capture opinions from a wide range of pharmacy leaders. The survey instructed panelists to consider the likelihood of the events/scenarios described in the statements occurring in the next 5 years as being likely, somewhat likely, somewhat unlikely, or very unlikely. Then, survey panelists assessed the preparedness (from very unprepared to very prepared) for 12 of the statements. Results: The 6 survey themes identified were Urgent Public Health Priorities, Responding to the Mental Health Crisis, Achieving Care Equity, New Disease Paradigms and Treatment Innovations, Workforce: Focus on Culture for the Future, and Artificial Intelligence: Can Ethics and Regulators Catch Up? The survey was completed by 250 respondents, yielding an 88% response rate. Analysis of survey results was provided by chapter authors along with strategic recommendations to guide actions for each theme. Conclusion: The focus of the Pharmacy Forecast is on large-scale, long-term trends that will influence healthcare and the pharmacy profession over months and years and not on day-to-day situational dynamics. The report provides insight to stimulate thinking and discussion and provides a starting point to proactively position leaders, their teams, and departments for potential future events and trends.

Counseling Adults in Career Transition: Reflections of a Counselor-in-Training

The following is a description of the experiences of a counselor-in-training at the University of Missouri-Columbia Career Center. The Career Center at the University of Missouri-Columbia serves a wide variety of clients ranging from 16-year-old high school students needing help on deciding on a college major to sixty-year-old adults seeking to make a major career transition. This diversity of clients and their needs is illustrated through case examples and it is suggested that the holistic model of career counseling that is taught at the University of Missouri Career Center is appropriate for these clients. What is also described through case examples is how counselors-in-training in settings such as career centers may benefit from additional training outside of what is normally taught in graduate level career development courses.

Coats disease in a 3-week-old boy

Coats disease is a rare, idiopathic retinal vasculopathy that predominantly affects males in the first decade of life. We report the case of a 3-week-old boy who presented with atypical rapidly progressing disease suggestive of Coats exudative vasculopathy. The eye developed retinal fibrosis and phthisis bulbi within 4 weeks. Retinoblastoma could not be ruled out, although histopathology after enucleation revealed no retinoblastoma. To our knowledge, this is the youngest case of Coats disease to be reported in the literature. This case highlights the wide variation in the clinical presentation of Coats disease and the difficulty in differentiating it from diffuse infiltrative retinoblastoma.

Comparing laparoscopic and open inguinal hernia repair in octogenarians

PURPOSE

To compare outcomes of laparoscopic and open inguinal hernia repair in elderly patients.

METHODS

We retrospectively reviewed patients ≥80 years old undergoing laparoscopic or open inguinal hernia repair from October 2006 to July 2009 at our medical center. Descriptive statistics were calculated, and outcomes were compared using Fisher's exact test, Wilcoxon rank-sum test, and Student's t test; a p value <0.05 was considered significant.

RESULTS

Open inguinal hernia repairs were performed in 58 patients, and laparoscopic repairs in 23 patients. There was no significant difference in average age (81 vs. 83 years, p = 0.09) or gender (91 % male vs. 74 % male, p = 0.1) for the laparoscopic versus open groups. Resident involvement (55 vs. 26 %, p = 0.02) was more common in the open group, and there was no difference in number of cases done for incarcerated hernias (17 vs. 13 %, p = 0.8) in the open versus laparoscopic groups. We observed a significant difference in hernia laterality and anesthesia type, with significantly more bilateral hernias (48 vs. 2 %, p ≤ 0.001) and more general anesthesia (100 vs. 31 %, p ≤ 0.001) in the laparoscopic compared with the open group. There were no significant differences in ASA score (p = 0.1), operating-room time (p = 0.6), urine output (p = 0.1), morbidity (p = 1), or mortality unrelated to the hernia surgery (13 vs. 22 %, p = 0.5) between the laparoscopic and open groups. At an average follow-up of 31 months (laparoscopic) and 19 months (open), only one recurrence occurred (open group).

CONCLUSIONS

Despite subtle differences between the laparoscopic and open approaches to inguinal hernia repairs in octogenarians, both procedures are safe with similar outcomes.

Autofluorescence imaging - a useful adjunct in imaging macular trauma

Autofluorescence imaging is a rapid, noninvasive technique, with several applications becoming slowly integrated into ophthalmic clinical practice. We describe its use as a valuable tool for predicting the function of the retinal pigment epithelium following damage from blunt ocular trauma.

Skin problems related to the occupation of commercial fishing in North Carolina

OBJECTIVE

Commercial fishing is one of the most dangerous professions with many of the occupational health problems related to the skin. This study elucidates the types of occupational skin disorders that occur in commercial fishermen in North Carolina. STUDY DESIGN/SETTINGS: Booths were set up offering free skin cancer screenings at various seafood festivals, a "blessing of the fleet" event and commercial fishing shows, which were located throughout eastern North Carolina from 2002-2004. When commercial fishermen were screened, they were asked about significant skin problems that they had experienced and were related to their occupation. They were specifically asked about their history of (1) cancerous and precancerous skin lesions, (2) eczemas, (3) superficial fungal infections, (4) bacterial infections of the skin, (5) traumatic injuries related to the skin, (6) bites and stings, (7) shocks from fish, and (8) skin problems related to environmental extremes.

RESULTS

Eighty-one North Carolina watermen were screened: seven of the fishermen (9%) had at least one basal cell carcinoma, five (6%) had at least one squamous cell carcinoma, and no melanomas were detected. Many occupationally related skin disorders were noted on the historical survey, and some of the more dangerous of these included traumatic injuries related to fishing equipment, cutaneous cancers, fish bites, infections, stingray injuries, and man-of-war stings.

LIMITATIONS

The sample population was comprised of volunteers, which limits generalizability, and some diagnoses were established retrospectively.

CONCLUSIONS

There are a wide variety of skin disorders among commercial fishermen in North Carolina and healthcare professionals should be aware of these when working with watermen.

Oral syphilis—re-emergence of an old disease with oral manifestations

Three representative cases of oral primary syphilis are presented. We wish to highlight the resurgence of this disease, which has occurred recently in the western world, particularly in Europe and the United States of America. Since the initial presentation may be oral, it is important to include syphilis in the differential diagnosis of patients presenting to oral diagnostic clinics with atypical oral ulceration. Recent developments in the serological diagnostic tests and treatment are reviewed. Early diagnosis and treatment has significant implications, not only for the patient, but also for previous and future transmission to contacts. Early syphilis is a highly infectious disease in which the lesions heal spontaneously, despite inappropriate treatment which may appear curative, and yet the patient remains infectious. It is therefore important that clinicians maintain a high clinical index of suspicion and crucial that an accurate diagnosis be made at presentation.

Methylene Blue Enhancement of Resuscitation After Refractory Hemorrhagic Shock

BACKGROUND

Methylene blue has been used to treat hypovolemic states. This study evaluated prehospital resuscitation after refractory hemorrhagic shock with a combination of methylene blue and limited-volume lactated Ringer's solution.

METHODS

After blood loss to a mean arterial pressure of 50 mm Hg in canines, refractory hemorrhagic shock was defined as minimal hemodynamic response to phenylephrine. Differential protocols included no treatment (control), methylene blue bolus, limited-volume lactated Ringer's solution, and combined methylene blue/lactated Ringer's solution therapies. Hemodynamic parameters were collected at baseline, during shock, during refractory hemorrhagic shock, and 30, 60, 90, and 120 minutes after treatment. Radiolabeled microspheres were used to measure end-organ perfusion and oxygen delivery.

RESULTS

Methylene blue/lactated Ringer's resuscitation improved prehospital survival (p < 0.05), mean arterial pressure and cardiac output (p < 0.05), vital end-organ blood flow and oxygen delivery (p < 0.05), and decreased serum lactate levels (p < 0.05), as compared with the methylene blue and lactated Ringer's single therapies.

CONCLUSIONS

Resuscitation after refractory hemorrhagic shock using a combination of methylene blue and limited-volume lactated Ringer's solution improves prehospital survival and hemodynamic stability and reduces ischemic damage in an acute setting. This form of therapy has been proved useful as a temporizing measure for resuscitation after refractory hemorrhagic shock in a canine model and warrants further study for its application to the hemorrhagic trauma patient.

Inflammatory bowel disease patients' decisions to use complementary therapies: links to existing models of care

OBJECTIVE

In this paper we present emergent categories of factors that influence inflammatory bowel disease patients' decisions to use complementary therapies and discuss similarities between this work and existing models of care.

METHODS

This combined methods study consisted of a quantitative survey followed by qualitative interviews. The results of the qualitative interviews are reported in this article.

RESULTS

Major categories that emerged during qualitative analysis were the personal context (i.e. contextual issues that influenced the individual's experience of illness), impact (i.e. the impact that the experience of illness had on the individual), and action (i.e. actions taken to manage the individual's illness).

DISCUSSION

Research in the areas if complementary therapy, biopsychosocial models, and patient-centered care, point to the importance of patient-physician communication. Our findings with people who have inflammatory bowel disease are in alignment with this previous body of work. By investigating the reasons for using complementary therapies among people who have a chronic illness, we make a substantive contribution to a growing body of literature that supports the need for continued emphasis on strengthening patient-physician relationships.

Development of healthy public policy: feminist analysis of conflict, collaboration and social change

In the past two decades, the need for economic restructuring has served as a rationale for dismantling social programs in Canada. As it has been enacted, such social restructuring has disproportionately affected marginalized people, particularly women. In this article we explore the schism between the principles that underlie the development of healthy public policy and those that are driving current social policy development. Through this analysis we discuss the implications of policy development that is based upon principles of inequity, and we suggest that implementation of healthy public policy requires transformational change in the underlying principles of the social system. A policy shift based upon principles of equity and social justice has been espoused throughout the health promotion literature. We suggest that such a shift will be facilitated by strengthening collaborative relations among points of conflict within society and among policy makers and women's organizations.

Quantification of the response of equine apocrine sweat glands to beta2-adrenergic stimulation

The aim of the present study was to characterise the quantitative sweating response of the horse to beta2-adrenergic stimulation. The sweating responses of 6 horses to the randomised infusion of 8 different adrenaline concentrations (0.025, 0.05, 0.075, 0.1, 0.2, 0.4, 1.0 or 2.0 microg/kg bwt/min), was investigated. Sweating rate (SR) and skin temperature (TSK) on the neck (N) and gluteal region (G), and plasma adrenaline and noradrenaline concentrations were measured. Peak SR was approximately 15 (N) and approximately 9 g/m2/min (G) during infusion of both 1.0 and 2.0 microg/kg bwt/min adrenaline. Sweat produced per nmol/l plasma adrenaline peaked during the infusion of 0.075 microg/kg bwt/min adrenaline. Higher adrenaline infusion concentrations resulted in a progressive decrease in the amount of sweat produced per nmol/l plasma adrenaline and a plateau of 6 g/m2/(nmol/l) plasma adrenaline was reached for infusions between 1.0 and 2.0 microg/kg bwt/min. Peak SR were far lower than we have previously reported during exercise. There was no evidence of sweat gland fatigue or vasoconstriction during infusion, suggesting saturation of sweat gland beta2 receptors. We conclude that sweating in the horse is under dual control from a combination of hormonal and neural mechanisms.

Spelling and the speech-language pathologist: there's more than meets the eye

Interest in spelling and spelling difficulties has increased in recent years. Like reading, spelling is no longer viewed as a strictly visual process. Rather, the language basis of spelling is evident in the phonological, orthographic, morphological, and even syntactic knowledge required to be a good speller. Speech-language pathologists (SLPs) have expertise in basic language processes that enable them to play an important role in assessment and intervention for spelling problems. Underscoring the importance of this effort are the serious social and vocational consequences attached to poor spelling and the intractable nature of spelling problems. This article reviews information about spelling-language connections, the nature of spelling problems, and assessment and intervention principles or procedures that represent best practices based on current spelling research. Implications for SLPs working with students who have spelling difficulties are suggested throughout.

Undiagnosed alcoholism & prescription drug misuse among the elderly. Special considerations for home assessment

Elderly patients are living longer than ever. Often, health care providers perceive this longevity as a measure of professional success. These patients don't always share this cheerful perspective. Living to a "ripe old age" can impose tremendous stress. An alarming number of these patients turn to alcohol and prescription drugs to escape the physical, emotional, spiritual, social and financial losses associated with aging.

Verb and noun morphology in the spoken and written language of children with language learning disabilities

The purpose of this study was to investigate the use of verb and noun morphology in school-age children's spoken and written language. Sixty children, with and without language learning disabilities (LLD), each produced 2 spoken and 2 written language samples. The children's accuracy in using morphemes that mark verb finiteness (regular past tense, 3rd person singular present tense, copula, and auxiliary BE) was compared with their accuracy in using noun morphology (regular plural, possessive, articles). As would be expected, the typically achieving children, who were aged 7 to 12 years, had mastered the verb and noun morphology in spoken and written samples. The children with LLD, aged 10 to 12 years, also showed high accuracy in the spoken samples. On the other hand, they showed substantial difficulty in the written samples with the regular past tense, with errors in 26% of obligatory contexts. However, the children with LLD also had difficulty with the regular plural, with errors in 12% of obligatory contexts. For both the regular past tense and plural, all errors were errors of omission. These results indicate that finiteness marking remains an area of relative difficulty, but perhaps not the only grammatical difficulty, for children with language impairments in the school years.

General language performance measures in spoken and written narrative and expository discourse of school-age children with language learning disabilities

Language performance in naturalistic contexts can be characterized by general measures of productivity, fluency, lexical diversity, and grammatical complexity and accuracy. The use of such measures as indices of language impairment in older children is open to questions of method and interpretation. This study evaluated the extent to which 10 general language performance measures (GLPM) differentiated school-age children with language learning disabilities (LLD) from chronological-age (CA) and language-age (LA) peers. Children produced both spoken and written summaries of two educational videotapes that provided models of either narrative or expository (informational) discourse. Productivity measures, including total T-units, total words, and words per minute, were significantly lower for children with LLD than for CA children. Fluency (percent T-units with mazes) and lexical diversity (number of different words) measures were similar for all children. Grammatical complexity as measured by words per T-unit was significantly lower for LLD children. However, there was no difference among groups for clauses per T-unit. The only measure that distinguished children with LLD from both CA and LA peers was the extent of grammatical error. Effects of discourse genre and modality were consistent across groups. Compared to narratives, expository summaries were shorter, less fluent (spoken versions), more complex (words per T-unit), and more error prone. Written summaries were shorter and had more errors than spoken versions. For many LLD and LA children, expository writing was exceedingly difficult. Implications for accounts of language impairment in older children are discussed.

Thermoregulatory strategies during short-term exercise at different intensities

Previously we have observed a decline in sweating rate (SR) during high intensity exercise in an incremental test protocol. In man, the sweating sensitivity (SR/degree C) has been shown to vary with exercise intensity. The aim of the present study was to determine if thermoregulatory responses in the horse, a prolific sweater with a high rate of metabolic heat production, were modified by exercise intensity. The effect of 3 separate exercise intensities (50 (S), 70 (M) and 90% (F) VO2peak on neck (SRN) and gluteal sweating rate (SRG), pulmonary artery (TPA), rectal (TREC) and skin temperatures on the neck (TSK-N) and gluteal region (TSK-G) were investigated. Horses were exercised for approximately 2 min at each exercise intensity in a randomised order. The rate of increase in TPA increased with exercise intensity (P < 0.05) (0.27 +/- 0.05, 0.43 +/- 0.04 and 0.77 +/- 0.05 degree C/min during S, M and F, respectively. The TPA and TSK temperatures at the onset of sweating were not different between exercise intensities (P > 0.05). Despite the increased rate of heat production with increasing exercise intensity, sweating sensitivity decreased on both the neck (P < 0.05) (18.2 +/- 3.4 (S), 12.0 +/- 3.5 (M) and 2.9 +/- 0.7 (g/m2/min)/degree C (F)[ and gluteal region (P < 0.05) (8.9 +/- 2.0 (S), 5.1 +/- 1.7 (M) and 0.8 +/- 0.3 (g/m2/min)/degree C (F)[. During exercise at 90% VO2peak sweating sensitivity and the rate of increase in skin temperature were markedly reduced compared to at 70% VO2peak. The present investigation demonstrates that the drive to thermoregulate is overridden during short-term, high-intensity exercise, resulting in greater heat storage (TPA) as a result of a lower SR sensitivity.

Sweating and skin temperature responses of normal and anhidrotic horses to intravenous adrenaline

Anhidrosis has been recognised for over half a century, but despite some excellent epidemiological studies, there has been little progress in understanding the aetiology of the condition. Using a modified ventilated capsule, we obtained dynamic, quantitative data on sweating responses in anhidrotic horses and normal sweating controls from the same environment. Ten horses with current seasonal anhidrosis and 10 matched normal sweating controls were selected. Each horse was given two 10 min infusions of 1 and 2 micrograms/kg/min adrenaline, separated by at least 6 h. Sweating responses and skin temperatures on the neck and gluteal region were measured. Plasma and sweat for analysis of total protein and electrolytes and plasma for analysis of adrenaline were collected. Anhidrotic horses produced significantly less sweat, had lower initial and peak sweat rates and a greater neck:gluteal ratio for sweat production. Plasma adrenaline at rest or at the time of peak sweating rate was not different between groups. In nearly three-quarters of the anhidrotic horses, the shape of the sweat rate against time curve was different compared to controls. Volume of sweat produced was significantly correlated with skin temperature on the neck of controls and anhidrotic horses and on the gluteal region of controls, but not anhidrotic horses. Plasma total protein and electrolyte concentrations were not different between groups. There were significant differences in sweat electrolyte concentrations between controls and anhidrotic horses. These differences were reduced when sweat electrolytes were expressed per g of total protein, and no differences existed when expressed as g/m2. This study has provided insight into the response of anhidrotic horses to beta 2 adrenergic stimulation and may be a useful technique to investigate this condition.

SB-236057, a selective 5-HT1B receptor inverse agonist, blocks the 5-HT human terminal autoreceptor

A novel compound, SB-236057 (1'-ethyl-5-(2'-methyl-4'-(5-methyl-1,3,4-oxadiazol-2-yl)biphenyl- 4-carbonyl)-2,3,6,7-tetrahydrospiro[furo[2,3-f]indole-3,4'-piperid ine]) has been shown to have high affinity for human 5-hydroxytryptamine1B (5-HT1B) receptors (pKi = 8.2) and displays over 75 or more-fold selectivity for the human 5-HT1B receptor over other 5-HT receptors, including the human 5-HT1D receptor, and a range of other receptors, ion channels and enzymes. In functional studies using [35S]GTPgammaS binding, SB-236057 displayed negative intrinsic activity (pEC50 = 8.0) at human 5-HT1B receptors stably expressed in Chinese Hamster Ovary (CHO) cells and caused a rightward shift of agonist concentration response curves consistent with competitive antagonism (pA2 = 8.9). SB-236057 potentiated [3H]5-HT release from electrically stimulated guinea pig or human cortical slices. SB-236057 also abolished the inhibitory effect of exogenously superfused 5-HT on electrically-stimulated release from slices of the guinea pig cortex. These studies using SB-236057 confirm that, in both the guinea pig and human cerebral cortex, the terminal 5-HT autoreceptor is of the 5-HT1B subtype.

Metabolic effects of nitric oxide synthase inhibition during exercise in the horse

The effect of nitric oxide synthase (NOS) inhibition during exercise on lactate production was investigated in five Thoroughbred horses. A standard exercise test (SET), consisting of three canters (approximately 55 per cent VO2max), with walking and trotting between each canter, was performed twice (control and test, in random order) by each horse. Nphi-nitro-L-arginine methyl ester (L-NAME; 20 mg kg-1), a competitive inhibitor of NOS, induced a significant increase (P < 0.05) in plasma lactate [5.7 (2.9) vs 11.8 (3.8) mmol L-1], which continued to increase despite administration of L-arginine, the substrate for NOS. There were no differences in cardiac output (Q) or the total body oxygen consumption (VO) between each SET. The results show that non-specific inhibition of NOS isoforms during exercise in the horse increases plasma lactate concentration, although the mechanism/s remain uncertain.

Physiological responses of horses to a treadmill simulated speed and endurance test in high heat and humidity before and after humid heat acclimation

To investigate whether horses were able to acclimate to conditions of high temperature and humidity, 5 horses of different breeds were trained for 80 min on 15 consecutive days on a treadmill at 30 degrees C and 80%RH. Training consisted of a combination of long duration low-intensity exercise, medium duration medium intensity exercise and short duration high intensity exercise. Between training sessions the horses were maintained at 11+/-3 degrees C and 74+/-2%RH. Before (PRE-ACC) and after acclimation (POST-ACC) the horses undertook a simulated Competition Exercise Test (CET), designed to represent the Speed and Endurance Test of a 3-day event, at 30 degrees C/80%RH. Maximal oxygen uptake (VO2PEAK) was not changed following acclimation (PRE-ACC 141+/-8 ml/min/kg bwt vs. POST-ACC 145+/-9 ml/min/kg bwt [STPD], P>0.05). Following acclimation, 4 of the 5 horses were able to complete a significantly greater amount of Phase D in the CET (PRE-ACC 6.3+/-0.3 min vs. POST-ACC 7.3+/-0.3 min, P<0.05; target time = 8 min). Resting body temperatures (pulmonary artery [TPA], rectal [TREC] and tail-skin [TTSK] temperatures) were all significantly lower following acclimation. During exercise, metabolic heat production (M) and heat dissipation (HD), for the same exercise duration, were both significantly lower following acclimation (P<0.05), although heat storage (HS) was significantly higher (P<0.05). The higher heat storage following acclimation was associated with a lower TTSK for a given TPA and a decreased total fluid loss (% bodyweight, P<0.05). Plasma volume was not changed following acclimation. The relationship of sweating rate (SR) to TPA or TTSK on either the neck or the gluteal region was not significantly altered by acclimation, although the onset of sweating occurred at a lower TPA or TTSK following acclimation (P<0.05). The horses in the present study showed a number of physiological adaptations to a period of 15 days of exposure to high heat and humidity consistent with a humid heat acclimation response. These changes were mostly similar to those reported to occur in man and other species and were consistent with thermal acclimation and an increased thermotolerance, leading to an improved exercise tolerance. It is concluded that a 15 day period of acclimation is beneficial for horses from cooler and or drier climates, that have to compete in hot humid conditions and that this may redress, to some extent, the decrement in exercise tolerance seen in nonacclimated horses and reduce the risk of heat related disorders, such as heat exhaustion.

Rehydration following exercise: effects of administration of water versus an isotonic oral rehydration solution (ORS)

The effects of administering (1) 6L isotonic oral rehydration solution (ORS), similar in composition to plasma (except for an elevated potassium concentration) and with an osmotic skeleton and (2) 6L water (no osmotic skeleton), were evaluated in five thoroughbred horses following exercise-induced dehydration. The horses were exercised on a treadmill for 10 min at walk (1.7 m.s-1; approximately 15% VO2max), 40 min at trot (3.7 m.s-1; approximately 25% VO2max) and 10 min at walk (1.7 m.s-1; approximately 15% VO2max). Exercise was undertaken on a 3 degrees incline at 30 degrees C/80% RH. Solutions of water or ORS at 20 degrees C were administered by nasogastric tube over 60s 5 min following exercise. Mean weight loss following exercise was 9.2 +/- 1.7 kg (2.0 +/- 0.4% body weight; mean +/- SEM) with water and 9.2 +/- 1.1 kg (2.0 +/- 0.2% body weight) with ORS and was not different between treatments (P > 0.05). Water treatment resulted in a fall in plasma [Na+] (approximately 3 mmol.L-1) and C1- (1-2 mmol.L-1) concentrations by 30 min after administration and the effect persisted until the end of the study (300 min post fluids). There was little change in plasma total protein (TP) from that at the end of exercise, suggesting a failure of water to restore or maintain PV. In contrast, ORS administration resulted in a small increase in plasma [Na+] (1-2 mmol.L-1) and [Cl-] (2-3 mmol.L-1) with a corresponding decrease in plasma TP. By 120 min post ORS, plasma TP and PV were no longer significantly different from rest or pre-exercise (P > 0.05), whilst with water, TP was elevated (approximately 3-4 g.L-1) and PV reduced (approximately 4-5 mL.kg-1). Total urine output was not significantly different between water (1096 +/- 135 mL) and ORS (750 +/- 215 mL, P > 0.05). Estimates of expected plasma volume and electrolyte concentration changes as a result of either treatment compared well with measured changes of TP and PV. On the basis of calculated or measured changes, it was estimated that only 1L of water contributed to rehydration following exercise compared to 4L isotonic, plasma-like ORS. The administration of 6L ORS restored the PV deficit induced by exercise with minimal or no disturbance of plasma electrolyte concentrations. In contrast, water alone resulted in minimal improvement in PV. When fluid intake after periods of fluid loss, such as induced by exercise or transport, is not accompanied by food intake, the present study has clearly demonstrated that water alone is ineffective in promoting rehydration compared with an isotonic, plasma-like ORS.

A multimethod research study on the use of complementary therapies among patients with inflammatory bowel disease

CONTEXT

The purpose of this study was to gain a better understanding of the use of complementary therapies among patients with inflammatory bowel disease.

OBJECTIVE

To examine factors influencing the use of complementary therapies, to explore patient-physician communication concerning those therapies, and to assess the effect of combining qualitative with quantitative research.

DESIGN

In-depth qualitative interviews.

PARTICIPANTS

Fourteen patients were selected from a quantitative study in which the use of complementary therapies among patients with inflammatory bowel disease was assessed.

RESULTS

Patients reported using complementary therapies because of the serious side effects of medical treatment, because they felt conventional treatments did not help, and because complementary therapies were thought to be safe. Psychological and social factors for using complementary therapies must be considered and understood. Patients cited many reasons for not discussing the use of complementary therapies with their doctors. Adding qualitative data to quantitative research greatly increased the authors' understanding of factors that contribute to complementary therapy use.

CONCLUSIONS

Multiple factors contribute to the decision to use complementary therapies among those with inflammatory bowel disease. Identifying these factors is important for educating physicians regarding their patients' use of complementary therapies and may contribute to improved patient-physician communication.

Complementary medicine use by patients with inflammatory bowel disease

OBJECTIVE

The purpose of this study was to establish the degree and determinants of the use of complementary therapies by patients with inflammatory bowel disease (IBD) and their reasons for seeking them.

METHODS

The first phase was a cross-sectional survey of 134 patients with IBD (98 with Crohn's disease, 34 with ulcerative colitis, and two indeterminate) using a mailed, structured questionnaire (response rate 70%). Determinants of complementary medicine use were examined using logistic regression. The second phase was an in-depth exploration using personal interviews of the beliefs and perceptions of 14 complementary medicine users about the management of their disease. Analysis was performed using standard qualitative techniques and the identification of important, patient-identified themes about the management of IBD.

RESULTS

Complementary therapies had been used by 51% of patients in the previous 2 yr. Current use was reported by 33%, of whom one-half were using it for their IBD. Vitamins and herbal products were the most commonly reported therapies. In multivariate analysis, duration of disease > 10 yr and a history of hospitalization were independent predictors of complementary medicine use. The side effects and lack of effectiveness of standard therapies were the most commonly cited reasons for seeking complementary medicine. Sixty-two percent had told their doctor about their use of complementary medicine.

CONCLUSION

Complementary medicine use is common in patients with IBD, especially among those with a longer duration of disease or a history of hospitalization.

A framework for the development of community health agency partnerships

The purpose of the study reported in this paper was to generate substantive theory regarding the development of effective partnerships among community agencies working with vulnerable populations. Ethnographic interviews were conducted and analyzed by applying the constant comparative method of qualitative analysis. This information was supplemented with data from the participants in two workshops, three manuscript reviewers, and relevant literature. Analysis of the data resulted in the emergence of a framework that outlines elements of partnerships. This framework furnishes the foundation for discussions of partnership configuration and partnership development. The results of this study provide basic guidelines for the formation of effective partnerships, and show that there is no single way to develop and structure such collaborative initiatives. Further studies are required in other substantive areas to advance the emergence of a formal theory of partnerships.

Building a feminist theoretical framework for screening of wife-battering: key issues to be addressed

The purpose of this paper is to identify key questions which must be addressed in developing a woman-centred, that is feminist, theoretical framework for screening for wife battering in health settings. The health sector has not had a positive history in addressing women's health holistically or in terms of the social context of women's lives. This is notable in relation to the issue of wife battering, where attention is recent but growing and responses have been varied. On the other hand, violence against women is one of the greatest threats to their health and, therefore, it can be argued that the health sector has a major role to play in ending this violence. With the recent efforts within the health sector, a great deal has been accomplished; we have some consensus on what is an appropriate protocol for and the roles of health care providers. We are also making progress in developing training programs. Several things are still lacking an understanding of the systemic barriers to promotion of and participation in screening; sufficient program evaluations; sufficient attention to issues of diversity among women; and, a theoretical framework for practice which links these together.

Post exercise changes in compartmental body temperature accompanying intermittent cold water cooling in the hyperthermic horse

Whereas the efficacy of cold water cooling of horses has been demonstrated by several studies, the dynamics of temperature changes within and between compartments (primarily muscle, blood [core], skin and deep core [rectal]) have not been investigated. Changes in body temperature associated with cold water cooling were investigated in the hyperthermic horse. Muscle (TMU), pulmonary artery (TPA), rectal (TREC), tail-skin (TTSK) and coat surface (TCOAT) temperatures, were monitored continuously in 5 Thoroughbred horses during and after exercise in hot humid (30 degrees C and 80% RH) conditions on a treadmill. Horses were cooled in the hot humid environment with cold water (approximately 6 degrees C) for 6 30 s periods. Between each 30 s cooling period the horses stood for 30 s. A total of 180 l of cold water was applied. Horses were monitored for a further 4 min following the final cooling period. From the end of exercise to the end of the final cooling (6.5 min), mean (+/- s.e.) rates of decrease for TTSK and TPA were similar (0.8 +/- 0.1 and 0.8 +/- 0.1 degrees C/min, respectively). The effects on TMU and TREC were less marked, with average rates of 0.2 +/- 0.1 and 0.0 +/- 0.1 degrees C/min, respectively. During the first 4 min of cooling, TPA fell during the 30 s period of water application and rose during each 30 s period of standing. When TPA fell below approximately 36.5 degrees C, these variations were suppressed and TPA rose steadily, despite continued applications; TREC and TMU continued to fall, although less rapidly than before. These observations are consistent with the onset of skin vasoconstriction at low TPA. The mechanism is mediated through a cooling of circulating blood volume providing a greater capacity for heat transfer between muscle and circulation. Intermittent application of cold water (approximately 6 degrees C) improves heat removal without apparent deleterious effects and is well tolerated. Even when hypothermia develops (based on TPA), muscle and rectal temperatures continue to fall.

Effects of administration of water versus an isotonic oral rehydration solution (ORS) at rest and changes during exercise and recovery

The administration of 41 of an isotonic, plasma-like oral rehydration solution (ORS) with an osmotic skeleton and 41 of water (water; no osmotic skeleton), were evaluated in five thoroughbred horses. Solutions were administered by nasogastric tube 4 h after feeding. Uptake of deuterium, concentrations of plasma sodium, potassium, chloride, glucose, total protein and packed cell volume, pH, PCO2, HCO3-, total CO2, actual base excess, standard base excess, plasma volume and weight loss were assessed both at rest, and during and after exercise on a treadmill. Each horse underwent four experimental sessions (water-resting; ORS-resting; water-exercise; ORS-exercise). There was an indication of uptake of both water and ORS by 10 min post-administration. Based on the appearance of deuterium in plasma, there was no significant difference in the rate of uptake of water or ORS at rest, although there was a trend for the uptake of ORS to be slower than water during the exercise session. The mean decrease in total protein (TP, 3.0 g l-1) and the increase in plasma volume (PV, 4.6 ml kg-1) after administration of ORS at rest was greater (P < 0.05) than that of water (TP, 1.3 g l-1 and PV, -1.2 ml kg-1). There was no significant difference in TP or PV following administration of water or ORS during the exercise treatment. Exercise had little effect on plasma sodium concentration. The results confirmed that administration of 41 of isotonic, plasma-like ORS provided a much more distinct and durable contribution to the maintenance of plasma volume and circulation than administration of an equal amount of water at rest. Subsequent exercise may, however, mask some of the effects observed at rest.

Nitric oxide and thermoregulation during exercise in the horse

The effect of inhibition of nitric oxide production on sweating rate (SR) and on core, rectal, and tail skin temperatures was measured in five Thoroughbred horses during exercise of variable intensity on a high-speed treadmill. A standard exercise test consisting of three canters [approximately 55% maximum O2 uptake (VO2max)], with walking (approximately 9% VO2max) and trotting (approximately 22% VO2max) between each canter, was performed twice (control or test), in random order, by each horse. N(G)-nitro-L-arginine methyl ester (L-NAME; 20 mg/kg), a competitive inhibitor of nitric oxide synthase, was infused into the central circulation and induced a significant reduction in the SR measured on the neck (31.6 +/- 6.4 vs. 9.7 +/- 4.2 g x min(1) x m(-2); 69%) and rump (14.7 +/- 5.2 vs. 4.8 +/- 1.6 g x min(-1) x m(-2); 67%) of the horses during canter (P < 0.05). Significant increases in core, rectal, and tail skin temperatures were also measured (P < 0.05). L-Arginine (200 mg/kg iv) partially reversed the inhibitory effects of L-NAME on SR, but core, rectal, and tail skin temperatures continued to increase (P < 0.05), suggesting a cumulation of body heat. The results support the contention that nitric oxide synthase inhibition diminishes SR, resulting in elevated core and peripheral temperatures leading to deranged thermoregulation during exercise. The inhibition of sweating by L-NAME may be related to peripheral vasoconstriction but may also involve the neurogenic control of sweating.

Effects of nitric oxide inhibition on thermoregulation during exercise in the horse

We investigated the role of NO in the control of thermoregulation. We measured sweating rate and body temperatures (core, rectal and skin) in five thoroughbred horses during exercise of variable intensity on a high-speed treadmill. A standard exercise test (SET) consisting of three canters (8 m s-1), with walking and trotting between each canter, was performed twice, in random order, by each horse and N omega-nitro-L-arginine methyl ester (L-NAME; 20 mg ml-1), a competitive inhibitor of nitric oxide synthase (NOS), was infused into the central circulation after the first canter in the test SET only. L-Arginine (200 mg ml-1), a substrate of NOS, was injected after the second canter in both control and test SETs. L-NAME significantly (p < 0.05) reduced the sweating rate measured on the neck (31.6 +/- 6.4 versus 9.7 +/- 4.2 g/min/m2) and rump (14.7 +/- 5.2 versus 4.8 +/- 1.6 g/min/m2) while raising the core temperature (39.7 +/- 0.2 versus 40.6 +/- 0.7 degrees C, p < 0.05) during the second canter. In the third canter, sweating rate had increased after giving L-arginine during the test SET, but had not returned to levels measured at similar times during the control SET. Core, rectal and skin temperatures continued to rise and were significantly higher than control levels, despite giving L-arginine. The results show that inhibition of NO production reduces sweating rate in the horse during exercise thereby inducing a rise in body temperatures.

Modified ventilated capsule for the measurement of sweating rate in the exercising horse

Modification of a ventilated capsule technique for the measurement of sweating rate (SR) is described for application in an exercising horse. The plastic capsule was sealed against the coat of the horse. Dry air was blown through the capsule over the skin and the change in absolute humidity (g/m3) between air entering and leaving the capsule was used to calculate SR. The effect of flow rate on the response characteristics of the system was investigated and measured over a range of sweating rates in a group of horses completing a short exercise test. Repeatability of SR measurements made at 2 sites, one 10 cm distal to the tuber sacrale (SRS) and the other approximately overlying C4 in the neck (SRN), were compared. To encourage the rapid and complete evaporation of moisture from the area of coat enclosed by the SR capsule, it was demonstrated that the degree of saturation of the air leaving the capsule should be maintained below 15% relative humidity (RH). This was best achieved at flow rates exceeding 35 l/min. No significant difference was found between the 2 repeated tests separated by 3 days, with respect to right atrial temperature (TRA) and SR. The modified system for the measurement of SR in the exercising horse used in this study was shown to be fast responding and capable of measuring a wide range of sweating rates. A good seal was maintained throughout and the capsule was removed without causing damage to the coat.

Physiological responses in nonheat acclimated horses performing treadmill exercise in cool (20 degrees C/40% RH), hot dry (30 degrees C/40% RH) and hot humid (30 degrees C/80% RH) conditions

The aim of the present study was to determine the effect of different environmental conditions on physiological response to exercise. Four winter acclimatised, nonheat acclimated horses of different breeds were exercised at 20 degrees C/40% RH (CD), 30 degrees C/40% RH (HD) and 30 degrees C/80% RH (HH). The exercise test was designed to represent the structure and intensity of a One star Speed and Endurance test (competition exercise test [CET]). All 4 horses were able to complete the full CET (60 min + 30 min active recovery) in CD and HD, but only one horse completed the CET in HH. Two horses were stopped because of pronounced general fatigue and one because of a right atrial temperature (TRA) of 43 degrees C. Oxygen uptake on each phase was not different between CD and HD, but was higher during Phases B, C and D in HH. Mean peak TRA at the end of Phase D was 40.3 +/- 0.2, 41.6 +/- 0.4 and 42 +/- 0.3 degrees C for CD, HD and HH, respectively. Corresponding, mean peak rectal temperatures (TREC) following Phase D were 39.5 +/- 0.1, 40.6 +/- 0.1 and 41.5 +/- 0.1 degree C for CD, HD and HH, respectively. Mean time to peak TREC was 9.3 +/- 1.1 (CD), 7.3 +/- 1.8 (HD) and 10.8 +/- 2.3 (HH) min and was not significantly different between conditions (P > 0.05). Heat dissipation amounted to 83 +/- 1, 73 +/- 2 and 70 +/- 1% of heat production in CD, HD and HH, respectively. Weight loss was significantly correlated with both body surface area (CD r = 0.85; HD r = 0.87; HH r = 0.81) and bodyweight (CD r = 0.97; HD r = 0.93; HH r = 0.94). The greatest weight loss recorded was 4.6% bodyweight in one horse in HD. The mean increase in exercise intensity over the whole CET (in terms of VO2) of HD and HH and HH compared with CD was 5 +/- 3 and 14 +/- 3% higher, respectively. The exercise induced hyperthermia and the reduced capacity for heat dissipation produced partial compensatory responses in minute ventilation (VE), particularly during Phase C, when the horses were trotting. In HD, the increase in VE was achieved mainly through an increase in frequency, whilst in HH it was achieved through an increase in tidal volume (VT). The horses demonstrated a high degree of tolerance to environmental heat load, suggesting a high thermoregulatory capacity. However, for unacclimatised animals exercising in severely hot and humid conditions, performance may be limited.

Physiological, metabolic and biochemical responses of horses competing in the speed and endurance phase of a CCI*****3-day-event

The present study was undertaken to investigate physiological, metabolic, haematological and biochemical changes in horses competing in the Speed and Endurance test of a Concours Complet International (CCI)*****3-day-event held under FEI rules. A total of 28 horses competing in the Burghley Horse Trials Speed and Endurance test were selected to be monitored: 11 horses in 1993 and 17 horses in 1994. Of the 28 horses selected, 17 completed the Speed and Endurance test and went on to complete the showjumping test. Mean +/- s.d. shade temperature and relative humidity, black globe temperature and wind speed were 13 +/- 1 and 20 +/- 2 degrees C, 54 +/- 3 and 55 +/- 10%, 17 +/- 2 and 29 +/- 4 degrees C and 2.7 +/- 0.7 and 1.2 +/- 0.3 m/s, for 1993 and 1994, respectively. Mean heart rate during Phases A, B and D was not significantly different between years, but mean heart rate during Phase C and X was significantly higher in 1994. Mean (+/- s.d.) heart rate on Phase B and D for all horses in both 1993 and 1994 was 198 +/- 8 and 188 +/- 11 beats/min, respectively. Mean heart rate during Phase D showed a poor correlation with mean speed (r = 0.412). Total mean (+/- s.d.) weight loss from the start of Phase A to the end of Phase D was 15.5 +/- 6.1 kg in 1993 and 16.5 +/- 5 kg in 1994 and did not differ significantly between years. Following 14-18 h completion of Phase D, mean bodyweight was not significantly different from that at the start of Phase A in either year. Mean rectal temperature at the end of Phase D was 41 +/- 0.6 degrees C and 41.1 +/- 0.6 degrees C in 1993 and 1994, respectively (P > 0.05). Both the lowest (39.7 degrees C) and highest (41.8 degrees C) rectal temperatures were recorded at the end of Phase D in 1994. Plasma lactate concentrations at the end of Phase D were 8.5-38.5 mmol/l. The highest lactate concentration also coincided with the highest plasma glucose concentration (11.4 mmol/l) as well as the joint fastest time in either year, although overall lactate showed only weak correlations with mean speed on Phase D (r = 0.12, 1993; r = 0.58, 1994). While the Speed and Endurance test at CCI*****level run in a temperate climate presents a considerable challenge to the fitness and ability of the horses competing, the metabolic and physiological changes are not extreme. The majority of horses that finish the test appear to undergo a rapid and considerable degree of recovery and are able to present sound at the final inspection, take part in the showjumping test and complete the competition.

Electrolyte and total protein changes in nonheat acclimated horses performing treadmill exercise in cool (20 degrees C/40%RH), hot, dry (30 degrees C/40%RH) or hot, humid (30 degrees C/80%RH) conditions

Four horses (H, J, N and M) undertook a simulated competition exercise test (CET), designed to simulate physiological and metabolic stresses of the Speed and Endurance (S & E) test of a 3-day-event, under 3 different environmental conditions: 20 degrees C/40% relative humidity (RH) (cool, dry [CD] 2 sessions); 30 degrees C/40% RH (hot, dry [HD]) and 30 degrees C/80% RH (hot, humid [HH]) (Marlin et al. 1995a). Venous blood samples for electrolyte and total protein (TP) determinations were collected from indwelling catheters at predetermined time points throughout each CET and initial 30 min recovery period. Venous blood samples were collected by jugular venepuncture at 2 h and 24 h after the end of the final 8 min canter (Phase D). The effects of exercise, environmental condition and horse on venous TP, sodium (Na+), potassium (K+), chloride (Cl-), calcium (Ca2+), magnesium (Mg2+) and phosphate (PO4(3-)) plasma concentrations were investigated. In addition, the effect of environmental condition on estimated cation loss was evaluated. All horses completed the full CET under the CD and HD conditions, but only one horse completed the full 8 min of the final canter Phase D under HH conditions. Exercise had a significant (P < 0.05) effect on all parameters similar to those reported previously in field competitions. There was a significant (P < 0.05) interaction between time and horse for TP, Na+ and Cl-. Overall, the environmental condition had a significant (P < 0.05) effect on all parameters, but the differences were not considered to be of any physiological relevance, other than for Cl- and TP. There was a significant (P < 0.05) interaction between time and environmental condition for Cl- and TP only. During much of the CET and recovery period, mean Cl- values were higher with the first CD session than the second CD session or under the HH or HD conditions. For TP after 2 min of Phase D and during the initial recovery period, concentrations were higher under the HH conditions and returned to the Pre- values less quickly. There were marked individual variations in the estimated cation losses and no consistent effect of environmental condition was found. Although estimated fluid loss was similar following both HD and HH sessions, restoration of bodyweight was slower following the CET studies under HH conditions.

Clinical observations made in nonheat acclimated horses performing treadmill exercise in cool (20 degrees C/40%RH), hot, dry (30 degrees C/40%RH) or hot, humid (30 degrees C/80%RH) conditions

Four horses (H, J, N and M) undertook a treadmill competition exercise test (CET), designed to simulate the physiological and metabolic stresses of the Speed and Endurance phase of a 3-day-event, under 3 different environmental conditions: 20 degrees C/40% relative humidity (RH) (cool, dry [CD]: 2 sessions); 30 degrees C/40%RH (hot, dry [HD]) and 30 degrees C/80%RH (hot, humid [HH]) (Marlin et al. 1995). A number of subjective clinical observations were made at designated time points throughout the exercise test and initial recovery period including buccal mucous membrane colouration, capillary refill time, neck and point of shoulder skin pinch recovery time, grade of abdominal sounds; anal sphincter tone as well as the presence or absence of fatigue and ataxia. The aim was to investigate their value in predicting performance in the final canter phase of the CET equivalent to the cross-country or Phase D of a field competition. In addition, the use of a more objective assessment, the cardiac recovery index (CRI), was investigated together with the heart rate, rectal temperature and respiratory frequency at the end of Phase C and at the 8 min point of the 10 Minute Box (8'X). The CRI was calculated according to the formula CRI = P2-P1 where P2 = the heart rate in beats/min at the 8 min point of the '10 Minute Box' (Phase X) of the CET. P1 = the heart rate (beats/min) at the 7 min point just before the horse was made to trot over a distance of 80 m at a speed of 3.7 m/s (at a 3 degrees incline) before returning to a walk. The study suggested that the subjective tests carried out at the 'End-C' and/or '8'X' time points were not useful in predicting subsequent performance in the final canter phase (Phase D) and neither were heart rate, rectal temperature or respiratory frequency. However, the only horse (Horse H) to complete the full CET under HH conditions was the only animal to show a decrease in respiratory frequency between the End-C and 8'X time points. All others showed an obvious increase. Under HH conditions, Horse H also had the lowest CRI. For 3 of the horses the highest CRI value was found under the HH conditions, for the fourth horse an equally high CRI value was found with one of the CD sessions. However, under the HH conditions, both P1 and P2 values were > 100. The study suggested that it could be beneficial if a suitably modified CRI test, as well as a procedure to monitor the change in respiratory frequency during the 10 Minute Box, were evaluated further on the treadmill and in the field with respect to their potential usefulness as additional aids to the assessment of a horse's suitability to proceed to Phase D.

Using mortality data to describe geographic variations in health status at sub-district level

OBJECTIVE

To describe sub-district variations in health status, using mortality data that are processed locally.

DESIGN

A descriptive study of routinely collected death registration data, using multicause coding.

SETTING

The London Borough of Croydon, with a population of 319,200 divided into 27 electoral wards.

SUBJECTS

Deaths of Croydon residents, registered with the Registrar of Births and Deaths, which occurred between January 1990 and December 1992 inclusive.

MAIN OUTCOME MEASURES

Variations in life expectancy, all-cause standardised mortality ratios (SMRs), and disease-specific mortality ratios between selected wards. Deaths in nursing homes were excluded to avoid bias.

RESULTS

Data from 8,930 death registrations, of which 852 occurred in nursing homes, were analysed by electoral ward. The range for all-cause SMRs, including nursing home deaths, was 153 (139-168) to 66 (58-75). When nursing home deaths were excluded, the SMRs for two wards that were significantly higher than the Croydon average fell into the average range. The range, excluding nursing home deaths, was 133 (113-153) to 71 (62-80). Life expectancy at birth varied from 79.8 years to 74.4 years, and life expectancy at age 65 by three years between wards at the two ends of the spectrum. The geographic distribution of ischaemic heart disease and diabetes showed significant differences.

CONCLUSIONS

We contend that death registration data are a useful tool for describing sub-district variations in health status. Deaths of nursing home residents are a source of bias and should be excluded from the analysis. Multicause coding allows a more accurate description of geographic variations in specific diseases, such as ischaemic heart disease and diabetes.

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Investigation of the 5-hydroxytryptamine receptor mediating the 'maintained' short-circuit current response in guinea-pig ileal mucosa

1. 5-Hydroxytryptamine (5-HT) stimulated a biphasic increase in short-circuit current (SCC) in guinea-pig isolated ileal mucosa. The initial 'spike' response to 5-HT was inhibited by tetrodotoxin (0.3 microM). We have investigated the 5-HT receptor mechanism(s) controlling the second 'maintained' component of the response which remained after treatment with tetrodotoxin. 2. 5-HT stimulated concentration-related increases in SCC with an EC50 value of 5.4 microM. Isobutyl-methylxanthine (IBMX, 10 microM) produced a six fold leftward shift of this concentration-response curve, suggesting the involvement of a cyclic nucleotide(s) in these responses. 3. In the presence of IBMX, 5-HT stimulated reproducible increases in SCC with an EC50 value of 0.9 microM. The rank order of potency of indole agonists in these tests was 5-HT greater than or equal to 5-methoxytryptamine greater than 5-carboxamidotryptamine = alpha-methyl-5-HT much greater than 2-methyl-5-HT. 4. The substituted benzamides were partial agonists. Metoclopramide and cisapride produced approximately 20% of the 5-HT maximum, and renzapride and R,S-zacopride produced approximately 50% of the 5-HT maximum. Metoclopramide and cisapride inhibited the SCC responses to 5-HT with apparent pKB values of 4.8 and 7.0 respectively. 5. The SCC responses to 5-HT were not inhibited by antagonists selective for 5-HT1 (methysergide, methiothepin), 5-HT2 (ketanserin) or 5-HT3 (ondansetron, ICS205-930) receptors. 6. The SCC responses to 5-methoxytryptamine, 5-carboxamidotryptamine, alpha-methyl-5-HT and R,S-zacopride, but not 5-HT, were selectively inhibited by high concentrations of ICS205-930 with apparent pKB values of approximately 6.7. A possible interpretation of these results is that the 'maintained' SCC response to 5-HT is mediated by a heterogeneous population of 5-HT receptors. One of these receptors exhibits the characteristics of the putative 5-HT4 receptor.

Intraabdominal sepsis after hepatic trauma

In a review of 58 patients who survived liver trauma seen at Boston City Hospital, 10 patients had 13 intraabdominal abscesses and 1 died from overwhelming sepsis. Multivariate analysis of risk factors revealed that the number of units of perioperative, postoperative, and total blood transfused were each highly significant (p less than 0.0001). Mode of injury, hepatic resection, gastrointestinal tract perforation, and the number of associated injuries were not significant risk factors when transfusion requirements were accounted for. Fever and leukocytosis were unreliable predictors of abscess formation. The available literature suggests a strong relationship between intraperitoneal bleeding and septic complications.

Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections

Four treatment regimens for patients with specified combinations of low back pain and sciatica were evaluated. The largest group studied had low back pain with limited straight-leg raising (SLR) and in them the beneficial effect of manipulation in hastening pain relief was highly significant. In similar patients without limitation of SLR, the effect was of borderline significance. In all the other groups, treated patients also recovered more quickly than their controls. Traction, for patients with low back pain and sciatica, and epidural injections when a root palsy was present also produced some significant pain relief. The effect of sclerosants for back pain was less clear.

Enzyme polymorphism and the identity of Trypanosoma brucei gambiense

Thirty-two isolates from man in known areas of Gambian trypanosomiasis, in the Sudan, Kenya, Zaire, Nigeria, Ivory Coast, Burkina Faso, Liberia and Senegal, were examined by isoenzyme electrophoresis of 11 enzymes. Comparisons were also made with our previously published results on 23 other stocks of similar origins, which had been examined in the same manner. All those stocks of low initial virulence to laboratory rodents, which thus conform to the accepted view of the behaviour of Trypanosoma brucei gambiense can be identified by characteristic combinations of enzyme patterns, especially certain aminotransferase markers. A limited study of superoxide dismutase polymorphism suggested a further marker of value. The isolates of high initial virulence to rodents, which are thus behaviourally akin to T. b. rhodesiense, did not share these characteristics. We conclude that there exists a homogeneous group of trypanosomes of wide dispersion throughout tropical Africa, characterized by certain isoenzyme combinations and low initial virulence to rodents, which corresponds to the classical concept of T. b. gambiense. The features of limited antigenic repertoire, high resistance to normal human serum and restriction fragment length polymorphisms of the genes for certain variant surface glycoproteins also appear to be characteristic of this group.

Effect of prednisolone on theophylline pharmacokinetics in patients with chronic airflow obstruction

The effect of prednisolone on the elimination kinetics of theophylline was studied in a group of nine patients with chronic airflow obstruction. Volume of distribution, plasma half life, and clearance after a single intravenous dose of aminophylline (5.6 mg/kg) were unchanged by prednisolone treatment (20 mg daily for three weeks). The metabolism of an intravenous bolus of theophylline is not influenced by oral prednisolone.