Osteopontin: an effector and an effect of tumor metastasis

Osteopontin (OPN) is a matricellular protein that is produced by multiple tissues in our body and is most abundant in bone. It is also produced by cancer cells and plays a determinative role in the growth, progression and metastasis of cancer. Clinically, OPN has been reported to be upregulated in tumor cells per se; this is also reflected by increased levels of OPN in the circulation. Thus, increased OPN levels the plasma are an effect of tumor growth and progression. Functionally, high OPN levels are determinative of higher incidence of bone metastases in mouse models and are clinically correlated with metastatic bone disease and bone resorption in advanced breast cancer patients. Several research efforts have been made to therapeutically target and inhibit the activities of OPN. In this article we have reviewed OPN in its role as an effector of critical steps in tumor progression and metastasis, with a particular emphasis on its role in facilitating bone metastasis of breast cancer. We have also addressed the role of the host-derived OPN in influencing the malignant behavior of the tumor cells.

Hydroxyapatite-ceramic-coated femoral components in young patients followed-up for 16 to 19 years: an update of a previous report

In 2004 we described the ten-year prospective results of 38 total hip replacements using the Furlong hydroxyapatite-ceramic-coated femoral component in 35 patients < 50 years old. We have now reviewed the surviving 35 arthroplasties in 33 patients at a mean of 16 years (10.3 to 19.9). The mean age of the surviving patients at the time of operation was 41.3 years (26.0 to 49.0). Of these, eight have undergone revision of their acetabular component for aseptic loosening. None of the femoral components has had revision for aseptic loosening giving a survival rate of 100% at 16 years (95% confidence interval 89% to 100%). The Furlong hydroxyapatite-ceramic-coated femoral component gives excellent long-term survival in young and active patients.

Focal femoral osteolysis after revision hip replacement with a cannulated, hydroxyapatite-coated long-stemmed femoral component

We describe a case of symptomatic focal femoral osteolysis around a screw hole distal to the hydroxyapatite-coated portion of a cannulated femoral component in a revision hip replacement. No locking screw had been inserted into this, the most proximal of the three distal holes for locking screws. The presence of polyethylene wear debris in the tissue excised from the lesion suggested that it had passed through the cannulated portion of the stem and out of the proximal unfilled distal locking hole, initiating an osteolytic reaction in an otherwise well-fixed stem. This case highlights an important design characteristic of such cannulated, uncemented femoral components. We recommend that the proximal aperture of these cannulated stems be occluded at implantation.

The utility of the general practice research database to examine selected congenital heart defects: a validation study

OBJECTIVE

The purpose of this research was (1) to validate that ventricular septal defect (VSD), tetralogy of Fallot (TOF), and coarctation of the aorta (COA) can be studied in the UK General practice research database (GPRD) and (2) to understand which of the available GPRD components (computerized medical records, questionnaires, and maternal/infant free text) provide maximal information about these heart defects.

METHODS

Using a practitioner questionnaire, the positive predictive value (PPV) of the computerized medical record for VSD, TOF, and COA were determined. Both infant and maternal free text was examined. Concordance between the infant free text information and questionnaires was calculated. The proportion of infant information captured in the maternal free text was determined.

RESULTS

A 93% response rate was achieved. Based on questionnaire responses, an overall PPV of 93.5% was achieved (VSD = 95%, TOF = 90%, COA = 100%). Approximately half of the records contained infant free text information including information on the type and size of VSD, echocardiogram findings, and surgery. Concordance between the infant's free text and questionnaire information occurred in most of the cases (92-100%). The proportion of infant information in the maternal free text was low (4-19%).

CONCLUSION

The GPRD computerized medical records are sufficient to assess VSD, TOF, and COA. This study confirms that maternal free text provides a low yield of limited information pertaining to the infants' defect, while the infant free text may provide an additional information usually obtainable from practitioner questionnaires. The information provided by an infant free text may limit the need for practitioner questionnaire validation.

Profiles of hepatic and dysrhythmic cardiovascular events following use of fluoroquinolone antibacterials: experience from large cohorts from the Drug Safety Research Unit Prescription-Event Monitoring database

OBJECTIVE

To investigate how frequently serious dysrhythmic cardiovascular, and hepatotoxic events are reported during routine clinical use of fluoroquinolones (quinolones) in general practice.

DESIGN

Cohorts prescribed quinolones (cohort sizes: ciprofloxacin 11 477; enoxacin 2790; ofloxacin 11 033 and norfloxacin 11 110; mean age in each cohort of 48.6 to 57.0 years) were selected from the Drug Safety Research Unit's Prescription-Event Monitoring (PEM) database. The monitoring periods were November 1988 to January 1989 for ciprofloxacin; April 1989 to January 1991 for enoxacin; May 1991 to December 1991 for ofloxacin and October 1990 to October 1991 for norfloxacin. Data collected over the total PEM surveillance period on selected gastrointestinal events were extracted and reviewed to identify possible hepatic events, together with selected cardiovascular events associated with dysrhythmias. For each quinolone, times to onset of the event and patient-months of observation (denominator values) were calculated. The analysis was based on two observation periods: rate of event during the first 7 days following dispensing of a prescription for each drug (W(1)), and rate of event during the second to sixth week inclusive (W(2)).

RESULTS

Scrutiny of original green forms revealed no evidence of drug-induced hepatic dysfunction within 42 days of drug administration for any of the quinolones monitored. No evidence was found of drug-induced dysrhythmic events associated with enoxacin within 42 days of drug administration. Of the other quinolones, 'atrial fibrillation' was reported most often within 42 days following ciprofloxacin administration, with no change in event rate over that time, crude relative risk (CRR)[W(1)/W(2)] 1.0 [95% confidence interval (CI) 0.02 to 8.92]. Other less serious events associated with dysrhythmia were reported with varying incidence within 42 days of quinolone administration. The crude rate of palpitation did not change significantly over that time for ciprofloxacin, ofloxacin and norfloxacin: CRR 0.83 (95% CI 0.02 to 6.86), 2.00 (95% CI 0.19 to 12.20) and 4.99 (95% CI 0.06 to 391.94), respectively. Syncope and tachycardia were also reported for ofloxacin [CRR 9.99 (95% CI 0.52 to 589.49 for both events)] and ciprofloxacin [1.0 (95% CI 0.02, 8.92)] and 2.50 (95% CI 0.04, 47.96) for syncope and tachycardia, respectively].

CONCLUSION

It cannot be ruled out that some rare hepatic and dysrhythmic events associated with quinolones may be drug related. The primary purpose of PEM is signal generation. Compared with the other quinolones, ciprofloxacin was associated with the highest number of reports of dysrhythmic cardiovascular events occurring within 42 days of administration. This requires further investigation by other types of epidemiological study.

Domestic violence screening, policies, and procedures in Indian health service facilities

BACKGROUND

Research shows that domestic violence against women in the United States is common, and the prevalence of domestic violence is high among Native American women. Victims of domestic violence can benefit from appropriate office intervention and referral. This study examined the effect of administrative and legal requirements on screening for domestic violence in Indian Health Service (IHS) hospitals and clinics.

METHODS

A questionnaire was mailed using the total design method to all IHS hospitals and clinics regarding activities related to domestic violence: screening; policies and procedures; presence of committees; staff training; and state and tribal mandatory reporting requirements.

RESULTS

The response rate was 65%. Eighty-eight (62%) of 142 facilities screen for domestic violence. A facility was more likely to screen if it had policies and procedures for domestic violence. Ninety-one (64%) of sites had policies and procedures for domestic violence. Less than one half these sites evaluated the use of these policies and procedures. Hospitals were more likely to have policies and procedures than clinics, as were sites administered by the IHS, rather than those administered by tribal contract. Fifty-eight (40.8%) facilities indicated 18 states have mandatory domestic violence reporting requirements. Thirty-three (23.2%) facilities indicated 31 different tribes mandate reporting of domestic violence. Forty-two (29.6%) facilities reported mandatory staff training in at least one topic related to domestic violence in the past year.

CONCLUSIONS

Domestic violence policies and procedures promote screening for this important health care problem.

Is there an association between selective serotonin reuptake inhibitors and risk of abnormal bleeding? Results from a cohort study based on prescription event monitoring in England

OBJECTIVE

To investigate whether an association between the use of selective serotonin reuptake inhibitor (SSRI) antidepressants and abnormal bleeding is demonstrated in a large population study.

METHODS

An observational cohort study using cohorts from the Drug Safety Research Unit's prescription event monitoring database was performed.

RESULTS

Analysis of combined haemorrhagic event rates calculated for the first 6 months of treatment for four SSRIs showed no significant difference between the rate for abnormal bleeding in the first month after starting treatment compared with months 2-6 [difference in rates 0.63 per 1000 patient months of treatment, 99% confidence interval (CI) -0.4, 1.67]. Comparison of the rates for the exposed combined SSRI cohort with the unexposed non-psychiatric drug cohort for the first month [relative risk (RR) 1.38, 95% CI 0.82, 2.34] and months 2-6 (RR 1.17, 95% CI 0.81, 1.68) showed no significant differences after adjustment for age and gender. However, there was a tendency towards highest risk with the combined SSRI cohort and lowest with the baseline cohort.

CONCLUSION

This study provides weak evidence to support the hypothesis of a link between SSRIs and precipitation of bleeding events at a population level. The 95% CI is consistent with a possible risk of bleeding associated with SSRI users versus non-psychiatric drug users in the first month. Fuller consideration of confounding would be possible using follow-up of identified cases in a nested case-control study.

A comparison of the use, effectiveness and safety of bezafibrate, gemfibrozil and simvastatin in normal clinical practice using the New Zealand Intensive Medicines Monitoring Programme (IMMP)

AIMS

Because of the importance of treating dyslipidaemia in the prevention of ischaemic heart disease and because patient selection criteria and outcomes in clinical trials do not necessarily reflect what happens in normal clinical practice, we compared outcomes from bezafibrate, gemfibrozil and simvastatin therapy under conditions of normal use.

METHODS

A random sample of 200 patients was selected from the New Zealand Intensive Medicines Monitoring Programme's (IMMP) patient cohorts for each drug. Questionnaires sent to prescribers requested information on indications, risk factors for ischaemic heart disease, lipid profiles with changes during treatment and reasons for stopping therapy.

RESULTS

80% of prescribers replied and 83% of these contained useful information. The three groups were similar for age, sex and geographical region, but significantly more patients on bezafibrate had diabetes and/or hypertension than those on gemfibrozil or simvastatin. After treatment and taking the initial measure into account, the changes in serum lipid values were consistent with those generally observed, but with gemfibrozil being significantly less effective than expected. More patients (15.8%S) stopped gemfibrozil because of an inadequate response compared with bezafibrate (5.4%) and simvastatin (1.6%). Gemfibrozil treatment was also withdrawn significantly more frequently due to a possible adverse reaction compared with the other two drugs.

CONCLUSIONS

In normal clinical practice in New Zealand gemfibrozil appears less effective and more frequently causes adverse effects leading to withdrawal of treatment than either bezafibrate or simvastatin.

Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies

BACKGROUND & AIMS

The miss rate of colonoscopy for neoplasms is poorly understood. The aim of this study was to determine the miss rate of colonoscopy by same day back-to-back colonoscopy.

METHODS

Two consecutive same day colonoscopies were performed in 183 patients. The patients were randomized to undergo the second colonoscopy by the same or a different endoscopist and in the same or different position.

RESULTS

The overall miss rate for adenomas was 24%, 27% for adenomas < or = 5 mm, 13% for adenomas 6-9 mm, and 6% for adenomas > or = 1 cm. Patients with two or more adenomas at the first examination were more likely than patients with no or one adenoma detected at the first examination to have one or more adenomas at the second examination (odds ratio, 3.3; 95% confidence interval, 1.69-6.46). Right colon adenomas were missed more often (27%) than left colon adenomas (21%), but the difference was not significant. There was evidence of variation in sensitivity between endoscopists, but significant miss rates for small adenomas were found among essentially all endoscopists.

CONCLUSIONS

Using current colonoscopic technology, there are significant miss rates for adenomas < 1 cm even with meticulous colonoscopy. Miss rates are low for adenomas > or = 1 cm. The results suggest the need for improvements in colonoscopic technology.

Motivational orientations of urban- and rural-based RNs: implications for staff development educators

Part of professional development is influencing RNs to return for an undergraduate degree, a challenge for the staff development educator. Expanding on earlier research using Boshier's Educational Participation Scale to reveal motivational orientations, the authors queried 5 groups of RNs who were enrolled in BSN education between 1990 and 1992 (N = 235) and living in rural and urban areas of Texas. There were no significant differences of overall motivational orientations, yet RN students living in rural areas scored higher in professional knowledge (P = 0.03) whereas urban-based RN students scored higher in compliance with authority (P = 0.02). Specific marketing and educational strategies are discussed.

The prescribing and adverse reactions of nonsteroidal antiinflammatory drugs in general practice: a Dunedin study

AIMS

The aims of this study were to describe the prescribing of nonsteroidal antiinflammatory drugs (NSAIDs) by some general practitioners and to assess the information recorded on computer records on their use in individual patients so that techniques could be developed for a broader investigation of the topic in general practice.

METHODS

All prescribing and consulting data from five Dunedin practices was reviewed for a 6 month period. From all consultations generating a prescription for NSAIDs, data was collected relating to the name of the drug, dosage, strength and length of treatment and patient demographic and morbidity details. Recorded adverse drug reactions were classified into six groups and four age groups were used for the analysis.

RESULTS

Prescriptions for NSAIDs accounted for 2.6% of all items prescribed. Diclofenac was the most commonly prescribed NSAID, for most conditions, but menstrual problems were more likely to be treated with mefenamic acid. Coprescription of possibly contraindicated medications (usually antihypertensive medicines) occurred for 20.8% of patients. Gastric adverse reactions were reported in 3% of cases while 0.9% of prescriptions resulted in no change in condition, leading to a change in therapy. Aspirin, fenbufen, ketoprofen, sulindac and flurbiprofen were never prescribed for patients under 20 years old.

CONCLUSION

Routinely recorded patient and prescribing information from general practice permits an assessment of the use of NSAIDs which includes the conditions for which they are prescribed, the total numbers prescribed, concurrent medications prescribed and their recorded adverse effects. This is not possible from any other source. Data from clinical trials provides an incomplete assessment of the use of these medications in general practice.

Diabetic gastroparesis. What to do when gastric emptying is delayed

Diagnostic evidence or symptoms of gastroparesis develop in about 20% to 30% of patients with long-standing diabetes. Diabetic gastroparesis is likely caused by autonomic neuropathy involving the nerves that regulate gastric motor function. The following are necessary for diagnosis: thorough history taking and physical examination to eliminate factors that might further delay gastric emptying; esophagogastroduodenoscopy or barium contrast studies to exclude structural abnormalities; and a radionuclide gastric emptying study. The three main agents available for therapy in the United States are metoclopramide (Maxolon, Octamide, Reglan), erythromycin, and cisapride (Propulsid). All have been shown to offer benefit in improving gastric emptying and symptoms, although use of metoclopramide is limited by a significant incidence of side effects. Surgical intervention should be avoided if possible.

Neuropsychiatric reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). The New Zealand experience

The New Zealand Medicines Adverse Reactions Committee has been monitoring reports of adverse drug reactions (ADRs) since 1965. We wished to determine the numbers of voluntary reports of different types of ADR to all nonsteroidal anti-inflammatory drugs (NSAIDs) over a long time period and relate these to age. As the elderly are known to suffer from neuropsychiatric adverse effects of many drugs, we investigated neuropsychiatric reactions to NSAIDs to determine whether these were more commonly reported in the elderly. We counted all reported ADRs suspected to be associated with NSAIDs as well as selected types of ADRs reported from 1970 to 1989. These were divided into 5-year periods and 10-year age groupings. In each consecutive 5-year period there was a progressive increase in the numbers of all ADRs reported for all NSAIDs. This was particularly marked above 50 years of age, but the numbers were reduced above 80 years. Reports for females accounted for about two-thirds of all reactions. Not unexpectedly, alimentary and dermatological ADRs accounted for most reactions and were more common in the group above 50 years. Overall, neuropsychiatric reactions were the third most common ADR type reported. Their numbers increased with age and peaked in the 50 to 59 age group, with a sharp decline after 69 years. This age distribution paralleled that for all ADRs to NSAIDs. Although neuropsychiatric reactions to NSAIDs were reported in all age groups, they were not reported more commonly in the elderly. This study suggests that neuropsychiatric reactions to NSAIDs may be more frequent than is commonly believed.

General practitioners' views on the role of the community pharmacist

AIM

to determine the views of general practitioners on the roles and activities of community pharmacists.

METHOD

the views of 137 general practitioners in Otago and Southland were canvassed by postal questionnaire.

RESULTS

one hundred and three completed questionnaires were returned. All of the general practitioners reported that their professional contact with pharmacists was useful. Seventy-five percent expressed a desire for greater cooperation. Nearly all respondents (99%) accepted that pharmacists have a role in screening prescriptions for possible problems and preparing and dispensing medicines. They also accepted that pharmacists were capable of treating and advising in the management of minor illnesses. Providing drug information to general practitioners, information about previously diagnosed conditions to patients, and advice on personal and home hygiene were less widely accepted activities. The majority indicated that they considered it inappropriate for pharmacists to undertake screening programmes (blood pressure (70.6%), cholesterol (70.6%), glucose (60.8%), haemoglobin (72.5%)). Younger general practitioners objected more often than older general practitioners to reclassification of Acetopt eye drops from prescription only to availability through pharmacies (p < 0.05). Female general practitioners were more often in favour of reclassification of Gyno-Daktarin than their male colleagues (p < 0.05).

CONCLUSION

this study shows that general practitioners accept several aspects of the current role of pharmacists in providing primary health care. However, there is room for improved communication between general practitioners and pharmacists to ensure optimum patient care.

Knowledgeable non-compliance with prescribed drugs in elderly subjects--a study with particular reference to non-steroidal anti-inflammatory and antidepressant drugs

Knowledgeable non-compliance with non-steroidal anti-inflammatory drugs (NSAIDs) and antidepressant drugs was investigated in a community-based sample of elderly people. Everyone 70 years and over living in a defined area and taking one of the above drugs, and at least one other prophylactic or symptomatic drug, was studied. Non-steroidal anti-inflammatory drugs and antidepressant drugs are commonly regarded as symptomatic only and knowledgeable non-compliance is consequently high. They are also regarded as less important than drugs which produce no immediate relief of symptoms but which the patient recognizes as needing to be taken regularly to maintain health. In our study, compliance with non-steroidal anti-inflammatory drugs and antidepressant drugs was highest in those who were compliant with a prophylactic drug and were also taking a symptomatic drug. The greater the number of tablets the patient was taking the more likely he or she was to be compliant with the NSAID. Compliance with NSAIDs and antidepressant drugs requires clear label instructions and the patient knowing the purpose of the medication.

Technical aspects of the use of the Russell-Taylor reconstruction nail

The introduction of the reconstruction nail has broadened the indications for the intramedullary fixation of difficult femoral fractures. The operative technique is, however, complicated. Some technical difficulties encountered during its use are presented, together with guidance to allow these problems to be avoided.

Nurse practitioners develop leadership in community problem-solving

If nurse practitioners are to become agents of change within the community, a shift in focus from the individual/family/caseload to one that includes population/community will be required. The nurse practitioner will need to develop the skills of community coalition building and grantsmanship. Graduate preparation in primary care nursing can provide an opportunity to develop the necessary knowledge and skills for leadership in community problem-solving by incorporating reality-based learning experiences into the curriculum. A model for guiding graduate study is presented.

Medication use in nine year olds: types of medicines used and recall of advice given

Use of medications was investigated in 819 nine year old children living in Dunedin. Twenty-four percent of the cohort (199 children) were given medications during the week prior to interview, mainly on prescription (68%). The majority of medicines used were said to be for respiratory illnesses and oral antibiotics represented a high proportion of prescribed medicines. Most medicines were obtained through a pharmacy (91%), and side effects were noted by nine percent of those taking medications. Some counselling was recalled with 70% of items although, as recalled by the parent, less than 25% of medicines obtained from pharmacies were dispensed or sold with any advice or instruction. The prescriber must ensure that adequate information is provided for the patient. Pharmacists may reinforce this information and provide additional advice on optimum methods of administration. It is debatable whether antibiotics should be used to the extent indicated by this study.

Treatment of unstable intertrochanteric fractures of the femur: a prospective trial comparing anatomical reduction and valgus osteotomy

A series of 100 consecutive patients with unstable intertrochanteric fractures were treated by compression hip screw fixation; 55 patients had an anatomical reduction (Group 1) and 45 patients a Sarmiento osteotomy and valgus reduction (Group 2). Group 1 spent an average of 10 days less in hospital than Group 2 (21 days compared with 31 days) (P less than 0.02). They also had a greater chance of returning to their pre-injury accommodation and of achieving their pre-injury walking capability. Radiological failure of fracture fixation, with varus angulation of the femoral head by cutting out of the screw, was seen seven times in Group 1 but only once in Group 2. Anatomical reduction provides better clinical results than valgus osteotomy in the patient with an unstable intertrochanteric fracture stabilized by a compression hip screw. The capacity for failure of fracture fixation is greater, however, in the former. Valgus osteotomy provides a simple means of securing a stable reduction of the fracture which cannot be satisfactorily reduced by closed means.

Treatment of Periscaphoid Osteoarthritis by Silastic Scaphoid Implant

Periscaphoid osteoarthritis may arise de novo or as a sequel of an established non-union of a scaphoid fracture. The treatment of resultant pain and disability often presents a difficult problem since internal fixation and/or bone grafting of the pseudoarthrosis may fail to relieve the symptoms due to degenerative change. Many methods of alleviating these symptoms have been suggested in the past. We have reviewed the experience of the Windsor Orthopaedic group in the use of Silastic scaphoid implants.

Variability in the elimination of mianserin in elderly patients

1. Two studies of the elimination of mianserin are reported. 2. In the first study, the oral clearance of mianserin was measured in 15 elderly patients at steady state. In a sub-group of eight patients who completed studies at two different doses there was evidence of enhanced oral clearance at the higher dose. 3. In the second study, the elimination half-life was estimated in 12 patients who were observed to have disproportionately high mianserin concentrations with respect to dose. All had half-lives greater than or equal to 2.5 days with a mean of 6 +/- 2.8 (s.d.) days. In six of the patients the profile of elimination was suggestive of saturable elimination. 4. The sparteine oxidation status was measured in seven of the patients showing slow mianserin elimination. Only one was a 'poor oxidiser' of sparteine, suggesting no concordance with this phenotype. 5. It is concluded that there is marked variability in the elimination of mianserin in elderly patients.

Adverse drug reaction reporting and retrospective phenotyping for oxidation polymorphism

A genetically determined impairment in the ability to oxidase sparteine and debrisoquine also affects the oxidation of several other drugs. This impairment in oxidation may result in accumulation of the associated drugs and in an increased susceptibility to adverse reactions from these drugs. Dunedin houses the New Zealand national centre for the collation and study of adverse drug reactions. Included among the reporting schemes is an intensified monitoring system for newly released drugs, in which physicians report all clinical events occurring during treatment with the drugs under surveillance. The centre thus has available extensive records of names and addresses of prescribers and patients who have been reported as experiencing an adverse event while receiving drug therapy. We investigated the association between genetically poor oxidation of sparteine and adverse reactions to drugs selected as possibly sharing the sparteine/debrisoquine oxidation pathway; these included perhexiline, metoprolol, debrisoquine, piroxicam, mianserin and nifedipine. A kit containing instructions, a sparteine capsule and a container for urine collection was sent to physicians who reported adverse reactions or events to one of the above drugs for forwarding to the patient. It appeared possible, after assays of returned urine for sparteine and its metabolites, that adverse reactions to nifedipine were associated with genetically poor oxidation.(ABSTRACT TRUNCATED AT 250 WORDS)

Disposition of ethanol and its proximate metabolite, acetaldehyde, in the near-term pregnant ewe for short term maternal administration of moderate-dose ethanol

The effect of short term maternal ethanol administration on the disposition of ethanol in the ovine maternal-fetal unit was determined. Eleven conscious instrumented near-term pregnant ewes (between 125 and 134 days of gestation; term, 147 days) received 1-hr iv infusion of 1 g of ethanol.kg of maternal body weight-1.day-1 for six days (N = 6 ewes) or an equivalent volume of saline for six days (N = 5 ewes). On the seventh day, the ethanol- and saline-pretreated animals were administered 1 g of ethanol.kg of maternal body weight-1. Ethanol and acetaldehyde concentrations were determined by headspace GLC in maternal blood, fetal blood, and amniotic fluid samples obtained at selected times during the 14-hr study. The data demonstrated that short term maternal administration of once-daily moderate dose ethanol did not produce major changes in the disposition of ethanol and its proximate metabolite, acetaldehyde, in the maternal, fetal, and amniotic fluid compartments during near-term ovine pregnancy.

How well do New Zealand patients understand and manage their asthma? A community study

Patient understanding of the nature of asthma and of its management was assessed using an interviewer administered questionnaire in a community sample of asthmatics identified through prescriptions at randomly selected Dunedin city pharmacies. Of 135 subjects whose histories, and lung function data where available, were consistent with asthma, 20 did not know they had asthma. Only half could give a simple explanation of asthma, and many were confused about therapies, especially the use of corticosteroids. Only half demonstrated satisfactory aerosol inhalation technique. Deficiencies in medical management including lack of lung function monitoring, regular followup and provision of a crisis plan for severe attacks were noted. Patients previously hospitalised more often had a crisis plan and recalled advice on management of asthma, but had little knowledge about the nature of the condition. The continuing high asthma mortality rate in New Zealand may in part reflect management deficiencies both in long term care and in recognition and management of severe attacks. These may be compounded by poor patient understanding of asthma.

Use of anti-asthma drugs in New Zealand

Increased sales of anti-asthma drugs, and a second "epidemic" of asthma mortality, raised concerns about the management of asthma in New Zealand. To study this, prescriptions were obtained from randomly selected pharmacies to identify 235 patients receiving one common anti-asthma drug, 175 of whom were willing to be interviewed. The authors considered that 80% had asthma, and only 20% suffered primarily from chronic bronchitis or emphysema. The increased sales of anti-asthma drugs could not therefore be explained by their increasing use in treatment of other respiratory disorders. One third of the identified asthmatic subjects experienced daily symptoms despite regular drug treatment. Inhaled corticosteroids were used by only 42% of this group with persistent symptoms. Regular or short course oral corticosteroids, with or without inhaled steroids, had been required by 49%. All patients with domiciliary nebulisers appeared to use these appropriately, and most had peak expiratory flow meters. Despite the increased sales of anti-asthma drugs, corticosteroids appear to be as much underused in patients with chronic asthma in the community as in those who die of their disease.

Orthopaedic problems in the elderly

Orthopaedic problems affecting the elderly are discussed and related to basic bone and joint pathology. The treatment of these problems is outlined with a special call for the highest standards of medical and surgical care, by a multidisciplinary team. Early internal fixation of pathological fractures is recommended to allow early mobilisation. Total replacement arthroplasty similarly allows an early return to normal mobility in patients disabled by osteoarthrosis of a major weight bearing joint. Some aspects of the medical treatment of metabolic bone disease are also discussed.

Diminished hepatic triiodothyronine production in Gunn rats

The liver is a major site of conversion of thyroxine (T4) to the more active thyroid hormone 3,5,3'-triiodothyronine (T3). Hepatic T4 to T3 conversion is altered by a variety of pathological processes and pharmacological agents. We studied T4 to T3 conversion in glucuronyl transferase deficient homozygous Gunn rats because they have a hepatic enzyme abnormality which leads to hyperbilirubinaemia, and also because they have been reported to have alterations in thyroid hormone metabolism. An in vitro incubation system employing the 10,000 X g supernatant of liver homogenate was used, and T3 production was measured by radioimmunoassay. Experiments were done using substrate concentrations ranging from 0.56 to 20 microM, tissue protein in concentrations ranging from 0.625 to 20 mg and incubation times of 15 to 60 min. T3 production by liver homogenates from homozygous Gunn rats in these studies ranged from 29 to 70% of that produced by liver homogenates from phenotypically normal heterozygous Gunn rats. The deficit in hepatic T3 production by homozygous rats could not be overcome by increasing cofactor concentrations. After ultracentrifugation at 100,000 X g, T4-5'-deiodinase activity was found primarily in the 100,000 X g sediment fraction. Homozygous rat liver 100,000 X g sediment T3 production was 55% of that of the heterozygous rat liver 100,000 X g sediment. Liver cytosol from both homozygous and heterozygous rats inhibited microsomal T4-5'-deiodinase activity similarly. Addition of unconjugated bilirubin to liver homogenates resulted in reduction of T3 production in livers from both homozygous and heterozygous rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychological preparation influences nitrous oxide analgesia: replication of laboratory findings in a clinical setting

In an earlier laboratory study, administration of 33% nitrous oxide yielded lower, not higher, pain thresholds when combined with appropriately altered expectations of enhanced creativity and sensitivity. The present study was undertaken in an attempt to replicate this finding in a group of clinical dental patients. It was expected that anxiety would play a significant role in our findings. The present study experimentally confirms that controlled psychological preparation of the clinical subject prior to administration of conventional dental dosages of nitrous oxide can significantly modify the perception of tooth pulp pain, neutralizing and even reversing its analgesic efficacy without increasing anxiety.

Retired executives link purchasers and providers in Greater Philadelphia

A three-year project funded by the John A. Hartford Foundation of New York used retired executives and physicians to overcome Philadelphia area employers' coolness to HMOs. Acting as evaluators, facilitators, educators and advisors, the participants achieved improved understanding and helped raise HMO enrollment from 3.5% to 11.6% of the target population. The President of the Executive Service Corps of the Delaware Valley tells how.

Conferment of honorary fellowship on Sir Theodore Fox

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Genetically determined variability in acetylation and oxidation. Therapeutic implications

The clinical significance of two separate genetic polymorphisms which alter drug metabolism, acetylation and oxidation is discussed, and methods of phenotyping for both acetylator and polymorphic oxidation status are reviewed. Particular reference is made to the dapsone method, which provides a simple means of distinguishing fast and slow - and possibly intermediate - acetylators, and to the sparteine method which allows a clear separation of oxidation phenotypes. Although acetylation polymorphism has been known for some time, definite indications for phenotyping are few. It is doubtful whether acetylator phenotype makes a significant difference to the outcome in most isoniazid treatment regimens, and peripheral neuropathy from isoniazid in slow acetylators is easily overcome by pyridoxine administration. However, in comparison with rapid acetylators, slow acetylators receiving isoniazid have an increased susceptibility to phenytoin toxicity, and perhaps also to carbamazepine toxicity. It is also possible that rapid acetylators receiving isoniazid attain higher serum fluoride concentrations from enflurane and similar anaesthetics than do similarly treated slow acetylators. Thus, when drug interactions of these types are suspected, phenotyping for acetylator status may be advisable. If routine monitoring of serum procainamide and N-acetylprocainamide concentrations is practised, phenotyping of subjects prior to therapy with these agents should not be necessary. Although acetylator phenotype influences serum concentrations of hydralazine, when this drug is given in combination with other drugs acetylator phenotype has not been shown to influence the therapeutic response. Slow acetylator phenotype along with female gender and the presence of HLA-DR antigens appear to be risk factors in the development of hydralazine-induced systemic lupus erythematosus (SLE). Determination of acetylator phenotype may therefore help determine susceptibility to this adverse reaction. In the case of sulphasalazine, adult slow acetylators require a lower daily dose of the drug than fast acetylators in order to maintain ulcerative colitis in remission without significant side effects. It is therefore advisable to determine acetylator phenotype prior to sulphasalazine therapy. Work on the association of acetylation polymorphism with various disease states is also reviewed. It is possible that a higher incidence of bladder cancer is associated with slow acetylation phenotype - especially in individuals exposed to high levels of arylamines. The question as to whether idiopathic SLE is more common in slow acetylators remains unresolved. There appears to be no difference between fa

Presentation of The Academy Plaque to August H. Groeschel, M. D

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Cognitive modification of pain: information in combination with N2O

The present study sought to discover whether information clarifying how the analgesic/sedative drug nitrous oxide (N2O) works would result in increased analgesic responses to painful stimuli when various concentrations of N2O were administered. Subjects were provided with high and low levels of information regarding the action and use of N2O as an analgesic and sedative. Absolute sensation threshold (AST), pain threshold (PTh), and pain tolerance (PTo) to tooth pulp shock were measured in microamperes during administration of each of 3 concentrations of N2O (15%, 30%, and 45%, with oxygen). Subjects rated stimulus intensity and stimulus aversiveness in response to a fixed painful stimulus, and completed questionnaires regarding the perceived efficacy of N2O and their subjective mood state throughout the session. The marked differences observed in pain reports between the high information group and the control group confirm that providing information to people receiving a drug for pain relief yields higher sensation thresholds, pain thresholds, and tolerance of pain. In addition, we observed that in the presence of N2O an equivalent fixed painful stimulus will be perceived as less painful after appropriate information is provided. These findings suggest that experimentally influencing thought processes, in combination with an analgesic, can have the effect of increasing analgesia.

A pain microcomputer system for clinical and laboratory investigation

This report describes the design and use of a mobile "Pain Microcomputer System" (PMS). As a mobile clinical and laboratory research tool the PMS integrates four functions: (1) psychophysical measurement of behavioral pain responses; (2) psychophysiologic recording, including brain evoked potentials, cortical power spectrum analysis, EKG and EMG; (3) data acquisition, analysis and display; (4) peripheral communications via modem allows interaction with larger computers for more complex data analyses, extensive graphics, etc. A word processor disk facilitates writing of scientific and clinical reports. Present and future capabilities of the system for comprehensive pain research and patient care are discussed.

Cognitive reversal of expected nitrous oxide analgesia for acute pain

In a laboratory experiment, the expected analgesic action of 33% nitrous oxide was reversed by creating the expectancy of heightened awareness of bodily sensations. Pain threshold and tolerance of electrical tooth-pulp stimulation were significantly reduced. Results from a control study gave us a basis for comparison of changes in the verbal expression of pain when nitrous oxide was administered without introducing expectancies beyond those already held by the subjects. Contrasting results from the experimental and control studies confirm the powerful role of mental processes in mediating pain experience.

Analgesic effects of nitrous oxide with controlled painful stimuli

This study was designed to provide statistical estimates of the effects of N2O on pain and anxiety associated with tooth-pulp shock in a clinical and in a laboratory setting. Amounts of electric stimulation needed to first feel sensation, amounts to feel pain, and pain tolerance were measured. N2O had a significant effect on raising levels of absolute sensation, pain threshold, and pain tolerance in response to increasing electrical stimulation of teeth. These effects were noted when N2O and pulp stimulation were delivered in a clinical dental setting or in a pain-research laboratory. Subjects also decreased their evaluation of the intensity of the same stimulus as N2O was inhaled at various concentrations; their aversion to the same stimulus tended to be influenced by N2O to a greater extent than perceived intensity. Anxiety levels were reduced to a statistically significant degree.

Presentation of Academy plaque to Iago Galdston, M.D

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Microcomputer analysis of cortical power spectrum: calibration and correlates of behavioral artifacts

Cortical power spectrum (CPS) is a quantitative estimate of EEG spectral power density. The CPS provides suitably precise data for quantification and statistical inference compared to the qualitative evaluation of EGG when interpreted by clinicians or researchers. In the past decade, the CPS has been applied to the studies of cognitive functions, memory, psi phenomena, speech laterality, and states of consciousness including coma, sleep, anesthesia, pathophysiology and pain state. However, few systematic evaluations of CPS methodology have been reported, rendering cross-laboratory comparisons difficult and external validity of experimental results uncertain. This report first describes a calibration procedure employing a microcomputer system for measuring the functional relationship between input signals and output cortical powers. Second, we examine controlled behavioral artifact effects on the CPS. The behavioral artifacts observed in the CPS can provide a measurement anchor for less ambiguous interpretation of CPS experiments conducted in clinical or laboratory settings.

Asparagine-linked carbohydrate does not determine the cellular location of yeast vacuolar nonspecific alkaline phosphatase

The nonspecific alkaline phosphatase of Saccharomyces sp. strain 1710 has been shown by phosphatase cytochemistry to be exclusively located in the vacuole, para-Nitrophenyl phosphate-specific alkaline phosphatase is not detected by this procedure because the activity of this enzyme is sensitive to the fixative agent, glutaraldehyde. To determine whether the oligosaccharide of nonspecific alkaline phosphatase is necessary to transport the enzyme into the vacuole, protoplasts were derepressed in the absence or in the presence of tunicamycin, an antibiotic which interferes with the glycosylation of asparagine residues in proteins. The location of the enzyme in the tunicamycin-treated protoplasts, as determined by electron microscopy and subcellular fractionation, was identical to its location in control protoplasts. In addition, carbohydrate-free alkaline phosphatase was found in vacuoles from tunicamycin-treated protoplasts. Our findings indicate that the asparagine-linked carbohydrate moiety does not determine the cellular location of the enzyme.

Peripheral cardiovascular effects in rats after central administration of histamine and antihistamines

1. Vascularly isolated but nervously intact rat right hind limbs were perfused with blood at a constant flow rate and changes in perfusion pressure (proportional to vascular resistance), heart rate and blood pressure were monitored. 2. Histamine administered into the right lateral cerebral ventricle (i.c.v.) through guide cannulae, induced dose-dependent increases in perfusion pressure, heart rate and blood pressure. 3. Prior i.c.v. or i.v. administration of metiamide (an H2-antagonist) did not prevent the cardiovascular responses to i.c.v. histamine but rather prolonged them. Following i.c.v. or i.v. administration of chlorpheniramine (an H1-antagonist), however, changes in vascular resistance, heart rate and blood pressure were not significant. 4. Metiamide administration appeared to have some agonist activity on its own. Thus the role of H2-receptors in cardiovascular responses to centrally administered histamine remains unclear. 5. The work shows that in rats increases in nervous dishcarge to at least the hind limb vascular bed occur following central administration of histamine and conforms that increases occur in heart rate and blood pressure. These responses appear likely to be mediated through stimulation of central H1-receptors.

Blood pressure and vascular resistance in genetically hypertensive rats treated at birth with 6-hydroxydopamine

Genetically hypertensive (GH) rats of the New Zealand strain and normotensive (N) rats were sympathectomized from birth with 6-hydroxydopamine (100 mg/kg,s.c, on alternate days, seven treatments). In adult treated rats from each strain (GHTr and NTr), blood pressure was lower than normal. Functional tests and electron microscopy showed that denervation was virtually complete in mesenteric and hindlimb arteries; the innervation of the renal artery was little affected. Ganglionic blockade still caused a large fall in blood pressure in treated rats. Vascular resistance was higher in blood-perfused hindlimbs and tails of GH rats than in those of N rats; in contrast, resistance was similar in limbs and tails of GHTr and NTr rats and was greater than that found in untreated N rats. Saline-perfused limb vessels had neither neurogenic nor myogenic tone and resistance was higher in GH limbs (whether these were from treated rats or not) than in untreated N limbs. In saline-perfused NTr limbs, there was a paradoxical structural adaptation (probably luminal narrowing) of the hindlimb blood vessels and resistance was higher than in untreated N rats. The resistance of saline-perfused GH and GHTr limbs was similar. A high peripheral resistance appears to be the main mechanism sustaining genetic hypertension, and the integrity of the vasomotor sympathetic nerves is necessary for the development of this form of experimental hypertension.