Insufficient Impact: Limited Implementation of Federal Regulatory Changes to Methadone and Buprenorphine Access in Arizona During COVID-19

Introduction

This study examined the impact of federal regulatory changes on methadone and buprenorphine treatment during COVID-19 in Arizona.

Methods

A cohort study of methadone and buprenorphine providers from September 14, 2021 to April 15, 2022 measured the proportion of 6 treatment accommodations implemented at 3 time periods: before COVID-19, during Arizona's COVID-19 shutdown, and at the time of the survey completion. Accommodations included (1) telehealth, (2) telehealth buprenorphine induction, (3) increased multiday dosing, (4) license reciprocity, (5) home medications delivery, and (6) off-site dispensing. A multilevel model assessed the association of treatment setting, rurality, and treatment with accommodation implementation time.

Results

Over half (62.2%) of the 74-provider sample practiced in healthcare settings not primarily focused on addiction treatment, 19% practiced in methadone clinics, and 19% practiced in treatment clinics not offering methadone. Almost half (43%) were unaware of the regulatory changes allowing treatment accommodation. Telehealth was most frequently reported, increasing from 30% before COVID-19 to 80% at the time of the survey. Multiday dosing was the only accommodation substantially retracted after COVID-19 shutdown: from 41% to 23% at the time of the survey. Providers with higher patient limits were 2.5-3.2 times as likely to implement telehealth services, 4.4 times as likely to implement buprenorphine induction through telehealth, and 15.2-20.9 times as likely to implement license reciprocity as providers with lower patient limits. Providers of methadone implemented 12% more accommodations and maintained a higher average proportion of implemented accommodations during the COVID-19 shutdown period but were more likely to reduce the proportion of implemented accommodations (a 17-percentage point gap by the time of the survey).

Conclusions

Federal regulatory changes are not sufficient to produce a substantive or sustained impact on provider accommodations, especially in methadone medical treatment settings. Practice change interventions specific to treatment settings should be implemented and studied for their impact.

Come back when you're infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023

BACKGROUND

Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort.

METHODS

A mixed methods "secret shopper" syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was "to protect myself from HIV and hepatitis C." A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer's subjective experience.

RESULTS

Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions.

CONCLUSIONS

Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

"As safe as possible": a qualitative study of opioid withdrawal and risk behavior among people who use illegal opioids

BACKGROUND

Opioid withdrawal is a regular occurrence among many people who use illicit opioids (PWUIO) that has also been shown to increase their willingness to engage in risk-involved behavior. The proliferation of fentanyl in the illicit opioid market may have amplified this relationship, potentially putting PWUIO at greater risk of negative health outcomes. Understanding the relationship between withdrawal and risk-involved behavior may also have important implications for the ways that problematic drug use is conceptualized, particularly in disease models of addiction, which position risk behavior as evidence of pathology that helps to justify ontological distinctions between addicts and non-addicts. Examining withdrawal, and its role in PWUIO's willingness to engage in risk, may aid in the development of alternative theories of risk involvement and create discursive spaces for de-medicalizing and de-othering people who use illegal drugs.

METHODS

This article is based on 32 semi-structured interviews with PWUIO in the New York City area who also reported recent withdrawal experience. Interviews were conducted remotely between April and August 2022 and recorded for later transcription. Data were then coded and analyzed based on a combination of inductive and deductive coding strategies and informed by the literature.

RESULTS

Participants described a strong relationship between withdrawal and their willingness to engage in risk-involved behavior that was exacerbated by the proliferation of fentanyl. Yet, their descriptions did not align with narratives of risk as a product of bad decisions made by individuals. Rather, data demonstrated the substantial role of social and structural context, particularly drug policies like prohibition and criminalization, in the kinds of risks that PWUIO faced and their ability to respond to them.

CONCLUSIONS

Withdrawal should be taken more seriously both from an ethical perspective and as an important catalyst of risk behavior. However, theories that position activities taken to avoid withdrawal as irrational and as evidence of pathology are poorly aligned with the complexity of PWUIO's actual lives. We recommend the use of less deterministic and less medicalized theories of risk that better account for differences between how people view the world, and for the role of socio-structural forces in the production of risk.

SI-CBPAR: Towards structural indicators of community-based participatory action research

INTRODUCTION

Structural aspects of community-engaged research are not well measured yet have critical implications for community research empowerment. This is particularly so with people who use drugs. We introduce the Structural Indicators of Community-Based Participatory Action Research (SI-CBPAR) to measure structural indicators of community-research entity relationships.

METHODS

A three-phased process of iterative development, feasibility and applicability assessment was used to examine the instrument with community-engaged studies as a first stage of instrument development. The development team included people with university, non-government organisation and lived/ing drug use experience. Four studies on the health of people who use drugs were reviewed for indicator evidence followed by iterative discussion about construct and item discrepancies. Indicators were measured for the degree to which they were observed using a three-point scale.

RESULTS

All but two constructs were confirmed for meaning. Constructs of 'community' and 'coalition' required revision and explanation. The need for further exploration of power differentials between community and community-based organisations was identified. Indicator evidence was found for all six categories across studies. The instrument was deemed applicable and easy to use. It was observed that categories could apply to studies with various degrees of community engagement and to other research focal areas.

DISCUSSION AND CONCLUSIONS

SI-CBPAR applicability testing and initial category confirmation indicate its potential utility for community research collaboratives. The next phase of development involves cognitive interviewing with researchers from across community engaged research orientations, and with communities engaged in research beyond drug user health.

Opportunities and Challenges: Hepatitis C Testing and Treatment Access Experiences Among People in Methadone and Buprenorphine Treatment During COVID-19, Arizona, 2021

Introduction

The purpose of this study was to characterize hepatitis C virus screening and treatment access experiences among people in treatment for opioid use disorder in Arizona during COVID-19.

Methods

Arizonans receiving treatment for opioid use disorder from methadone clinics and buprenorphine providers during COVID-19 were interviewed about hepatitis C virus testing, curative treatment, and knowledge about screening recommendations. Interviews were conducted with 121 people from August 4, 2021 to October 10, 2021. Qualitative data were coded using the categories of hepatitis C virus testing, knowledge of screening recommendations, diagnosis, and experiences seeking curative treatment. Data were also quantitated for bivariate testing with outcome variables of last hepatitis C virus test, diagnosis, and curative treatment process. Findings were arrayed along an adapted hepatitis C virus cascade framework to inform program and policy improvements.

Results

Just over half of the sample reported ever having tested for hepatitis C virus (51.2%, n=62) and of this group, 58.1% were tested in the past 12 months. Among those who were ever tested, 54.8% reported a hepatitis C virus diagnosis and 16.1% reported either being in treatment or having been declared cured of the hepatitis C virus. Among those who were diagnosed with hepatitis C, 14.7% indicated that they unsuccessfully tried to access curative treatment and would not attempt to again. Reasons cited for not accessing or receiving curative treatment included beliefs about treatment safety, barriers created by access requirements, natural resolution of the infection, and issues with healthcare coverage and authorization.

Conclusions

Structural barriers continue to prevent curative hepatitis C virus treatment access. Given that methadone and buprenorphine treatment providers serve patients who are largely undiagnosed or treated for hepatitis C virus, opportunities exist for them to screen their patients regularly and provide support for and/or navigation to hepatitis C virus curative treatment.

Upper body accelerations during walking are altered in adults with ACL reconstruction

This study was designed to assess and compare the pattern of acceleration from the lower trunk, neck and head regions for individuals with reconstructed ACL compared to healthy controls during walking. Participants with unilateral ACL reconstruction and matched control persons participated in the study. Accelerations were collected using three triaxial accelerometers attached to the head, neck, and lower trunk. Measures of amplitude and signal regularity of the acceleration data were performed. Similarities were seen between both groups with regards to the general acceleration patterns in all three axes. However, the results also revealed that the individuals with ACL reconstruction had significantly greater peak power in the AP direction at higher frequencies, indicating a reduced ability to attenuate frequency signals. Further, the ACL group had a reduced ability to control head motion during gait, as indicated by reduced regularity in VT. Both groups demonstrated a similar pattern of gait-related oscillations across the head, neck and trunk segments. However, adults with a reconstructed ACL demonstrated a reduced capacity to compensate for the higher frequency components of the gait signal, which may have led to a decline in head control. Overall, these findings indicate that previous damage to the ACL is not simply localized to the knee joint, but influences upper body control, too.

Bracing of the trunk and neck has a differential effect on head control during gait

During gait, the trunk and neck are believed to play an important role in dissipating the transmission of forces from the ground to the head. This attenuation process is important to ensure head control is maintained. The aim of the present study was to assess the impact of externally restricting the motion of the trunk and/or neck segments on acceleration patterns of the upper body and head and related trunk muscle activity. Twelve healthy adults performed three walking trials on a flat, straight 65-m walkway, under four different bracing conditions: 1) control-no brace; 2) neck-braced; 3) trunk-braced; and 4) neck-trunk braced. Three-dimensional acceleration from the head, neck (C7) and lower trunk (L3) were collected, as was muscle activity from trunk. Results revealed that, when the neck and/or trunk were singularly braced, an overall decrease in the ability of the trunk to attenuate gait-related oscillations was observed, which led to increases in the amplitude of vertical acceleration for all segments. However, when the trunk and neck were braced together, acceleration amplitude across all segments decreased in line with increased attenuation from the neck to the head. Bracing was also reflected by increased activity in erector spinae, decreased abdominal muscle activity and lower trunk muscle coactivation. Overall, it would appear that the neuromuscular system of young, healthy individuals was able to maintain a consistent pattern of head acceleration, irrespective of the level of bracing, and that priority was placed over the control of vertical head accelerations during these gait tasks.

Evidence-based guide to perioperative medicine

The discipline of perioperative medicine is assuming greater importance as increasing numbers of older patients with medical comorbidity undergo complex surgical procedures. If patient outcomes and use of limited hospital resources are to be optimized, physicians with skills and interest in perioperative risk assessment and therapeutic intervention are needed. This systematic review attempts to provide an evidence-based update in several key areas in the management of the perioperative patient.

Vitamin D deficiency in general medical inpatients in summer and winter

BACKGROUND

Vitamin D deficiency is common in various populations worldwide. Adverse effects of vitamin D deficiency are the development of bone disorders; however, other diseases such as multiple sclerosis, type 1 diabetes, rheumatoid arthritis and certain cancers have also been linked to vitamin D deficiency. The general medical inpatient population is a group at increased risk of vitamin D deficiency. These patients often have coexistent risk factors for its consequences. This study aims to document a point prevalence of vitamin D deficiency in this population.

METHODS

Two cross-sectional audits of patients admitted to general medicine units were carried out--the first in mid-November at the end of winter and the second in mid-April and May at the end of summer. Information regarding patients' comorbidities, medication usage, previous falls and fractures was obtained and serum 25-hydroxyvitamin D, parathyroid hormone and calcium levels were measured.

RESULTS

A total of 129 patients was studied (65 in winter and 64 in summer). Ninety-four patients (74%) had 25-hydroxyvitamin D levels < or = 50 nmol/L. Seven patients had severe deficiency (levels < or = 12.5 nmol/L). Average vitamin D levels were lower at the end of winter (35 vs 43 nmol/L, P = 0.007). Of the 37 patients receiving vitamin D supplements, 20 (54%) had 25-hydroxyvitamin D levels < or = 50 nmol/L.

CONCLUSION

Low vitamin D levels were common in this general medical inpatient population. The average vitamin D level was lower in the patient group tested in November following winter. Supplementation of vitamin D did not uniformly prevent deficiency.

Sinusoidal visuomotor tracking: intermittent servo-control or coupled oscillations?

In visuomotor tasks that involve accuracy demands, small directional changes in the trajectories have been taken as evidence of feedback-based error corrections. In the present study variability, or intermittency, in visuomanual tracking of sinusoidal targets was investigated. Two lines of analyses were pursued: First, the hypothesis that humans fundamentally act as intermittent servo-controllers was re-examined, probing the question of whether discontinuities in the movement trajectory directly imply intermittent control. Second, an alternative hypothesis was evaluated: that rhythmic tracking movements are generated by entrainment between the oscillations of the target and the actor, such that intermittency expresses the degree of stability. In 2 experiments, participants (N = 6 in each experiment) swung 1 of 2 different hand-held pendulums, tracking a rhythmic target that oscillated at different frequencies with a constant amplitude. In 1 line of analyses, the authors tested the intermittency hypothesis by using the typical kinematic error measures and spectral analysis. In a 2nd line, they examined relative phase and its variability, following analyses of rhythmic interlimb coordination. The results showed that visually guided corrective processes play a role, especially for slow movements. Intermittency, assessed as frequency and power components of the movement trajectory, was found to change as a function of both target frequency and the manipulandum's inertia. Support for entrainment was found in conditions in which task frequency was identical to or higher than the effector's eigenfrequency. The results suggest that it is the symmetry between task and effector that determines which behavioral regime is dominant.

MEKK2 gene disruption causes loss of cytokine production in response to IgE and c-Kit ligand stimulation of ES cell-derived mast cells

Ligation of the high-affinity IgE receptor (FcepsilonRI) or of c-Kit stimulates cytokine production in mast cells. We show that MEK kinase 2 (MEKK2), a MAPK kinase kinase (MAP3K) that regulates the JNK and ERK5 pathways, is required for cytokine production in embryonic stem (ES) cell-derived mast cells (ESMC). Targeted disruption of the MEKK2 or MEKK1 gene was used to abolish expression of the respective kinases in ESMC. Transcription of specific cytokines in response to IgE or c-Kit ligand was markedly reduced in MEKK2(-/-) ESMC relative to wild-type ESMC. Cytokine production in MEKK1(-/-) ESMC was similar to that of wild-type ESMC, demonstrating the specificity of MEKK2 in signaling cytokine gene regulation. MEKK2(-/-) ESMC also lost receptor-mediated stimulation of JNK. In contrast, JNK activation in response to UV irradiation was normal, showing that MEKK2 is required for receptor signaling but not for cellular stress responses. MEKK2 is the first MAP3K shown to be required for mast cell tyrosine kinase receptor signaling controlling cytokine gene expression.

Aberrant wound healing and TGF-beta production in the autoimmune-prone MRL/+ mouse

Wound healing is a complex process that involves inflammation, apoptosis, growth, and tissue remodeling. The autoimmune-prone inbred mouse strain MRL/+ manifests accelerated and extensive healing to ear punch wounds, suggesting a link between immune defects and wound healing. Prior studies with lupus-prone mice have shown that hematopoietic cells of lupus-prone strains can transfer disease to otherwise non-autoimmune-prone recipients. In this study we performed reciprocal bone marrow transfers between MRL and the control strain B10.BR and found that radioresistant MRL/+ host cells, rather than hematopoietic cells, are required for the healing response. We have also made the novel observations that, compared to normal controls, MRL/+ hematopoietic cells overproduce TGF-beta1 and manifest impaired inflammatory responses to lipopolysaccharide challenge. These features suggest that the aberrant wound healing phenotype of MRL mice is independent of their propensity to develop autoimmunity.

Efficient peripheral clonal elimination of B lymphocytes in MRL/lpr mice bearing autoantibody transgenes

Peripheral B cell tolerance was studied in mice of the autoimmune-prone, Fas-deficient MRL/ lpr.H-2(d) genetic background by introducing a transgene that directs expression of membrane-bound H-2Kb antigen to liver and kidney (MT-Kb) and a second transgene encoding antibody reactive with this antigen (3-83mu delta, anti-Kk,b). Control immunoglobulin transgenic (Ig-Tg) MRL/lpr.H-2(d) mice lacking the Kb antigen had large numbers of splenic and lymph node B cells bearing the transgene-encoded specificity, whereas B cells of the double transgenic (Dbl-Tg) MRL/lpr.H-2(d) mice were deleted as efficiently as in Dbl-Tg mice of a nonautoimmune B10.D2 genetic background. In spite of the severely restricted peripheral B cell repertoire of the Ig-Tg MRL/lpr.H-2(d) mice, and notwithstanding deletion of the autospecific B cell population in the Dbl-Tg MRL/lpr.H-2(d) mice, both types of mice developed lymphoproliferation and exhibited elevated levels of IgG anti-chromatin autoantibodies. Interestingly, Dbl-Tg MRL/lpr.H-2(d) mice had a shorter lifespan than Ig-Tg MRL/lpr.H-2(d) mice, apparently as an indirect result of their relative B cell lymphopenia. These data suggest that in MRL/lpr mice peripheral B cell tolerance is not globally defective, but that certain B cells with receptors specific for nuclear antigens are regulated differently than are cells reactive to membrane autoantigens.

Enhancement of 1,25-dihydroxyvitamin D3-mediated antitumor activity with dexamethasone

BACKGROUND

The active metabolite of vitamin D, i.e., 1,25-dihydroxycholecalciferol (1,25-D3), inhibits the growth of murine SCCVII/SF squamous cell carcinoma cells, both in vitro and in vivo. However, in vivo use of 1,25-D3 is hampered as a result of hypercalcemia (i.e., elevated levels of calcium in the blood). Glucocorticoids, such as dexamethasone, affect calcium absorption and modulate vitamin D receptor binding and have been used to treat hypercalcemia. In this study, we examined the effect of dexamethasone on tumor growth inhibition by 1,25-D3.

METHODS

The effects of 1,25-D3 and dexamethasone, alone and in combination, on the growth of SCCVII/SF cells in in vitro culture or in vivo in female C3H/HeJ mice were determined by clonogenic tumor cell assay and/or by actual changes in tumor volume. Vitamin D receptor-ligand-binding activities in whole-cell extracts from cells (in culture), tumors, and normal tissues were assayed by single-point saturation analysis and equilibrium binding.

RESULTS

Treatment of cultured SCCVII/SF cells with 500 nM dexamethasone for 24 hours before addition of 1,25-D3 reduced their survival. The growth of SCCVII/SF tumors was inhibited in mice treated simultaneously with dexamethasone and 1,25-D3 (as compared with no treatment or single-agent treatment); hypercalcemia was also reduced. Total vitamin D receptor content in SCCVII/SF cells was increased after treatment with dexamethasone. Treatment of tumor-bearing animals with dexamethasone (9 microg/day) for 7 days led to increased vitamin D receptor-ligand-binding activities in whole-cell extracts from tumor or kidneys and decreased activity in intestinal mucosa.

CONCLUSIONS

Dexamethasone may enhance the antitumor effect of 1,25-D3 by increasing vitamin D receptor-ligand-binding activity.

Potentiation of cisplatin antitumor activity using a vitamin D analogue in a murine squamous cell carcinoma model system

In a murine squamous cell carcinoma (SCC) model, we have demonstrated that both 1,25-dihydroxycholecalciferol (1,25-D3) and the analogue 1,25-dihydroxy-16-ene-23-yne-cholecalciferol (Ro23-7553) have significant in vitro and in vivo antitumor activity. We have examined here the cell cycle effect of 1,25-D3 and Ro23-7553 on SCCVII/SF tumor cells by quantitating nuclear DNA using a detergent-trypsin method via flow cytometry analysis. Both 1,25-D3 and Ro23-7553 resulted in a significant increase of cells in G0-G1, with an accompanying decrease of cells in S phase. The ability to arrest cells in G0-G1 has been exploited by combining Ro23-7553 with the cytotoxic agent cisplatin (cis-diamminodichloroplatinum; cDDP). Using the in vitro clonogenic assay, pretreatment with Ro23-7553 for 24-48 h significantly enhanced cDDP-mediated tumor cell kill as compared to concurrent treatment with Ro23-7553 and cDDP or cDDP alone. To examine the effect of Ro23-7553 and cDDP in vivo, C3H/HeJ mice with 9-14-day SCC tumors were treated either for 3 days with varying i.p. doses of Ro23-7553 or for 7 days continuously through the use of Alzet pumps, and on the last day of Ro23-7553 treatment, cDDP (1-6 mg/kg) was administered. Using the in vivo excision tumor cell clonogenic assay, in which tumors were removed from animals 24 h after cDDP treatment and plated in a clonogenic assay, pretreatment with Ro23-7553 markedly enhanced cDDP-mediated clonogenic tumor cell kill, even at low doses of cDDP as compared to cDDP treatment alone. Similarly, a significant decrease in fractional tumor volume and increase in tumor regrowth delay was observed when animals were pretreated before cDDP with Ro23-7553 as compared to either agent alone. These results demonstrate a significant enhanced antitumor effect with Ro23-7553 pretreatment before cDDP both in vitro and in vivo and suggest that Ro23-7553 may potentiate cDDP cytotoxicity through effects on cell cycle progression.

Thermographic assessment of dentine pin placement

OBJECTIVE

This in-vitro study aimed to examine the change in surface temperature induced by the actions of drills for the placement of dentine pins.

METHODS

Ten decoronated extracted premolar teeth were embedded by the apical tip of their roots in orthoresin. They were held in a bench vice and allowed to reach the ambient temperature of 24 degrees C. A thermal imaging camera, Agema Thermovision 900 series, was positioned 0.05 m perpendicular to the decoronated surface. Sequential recording of a series of images was stored at a rate of three per second during each stage of the pin placement procedure. This included a pilot drill, a channel cutting drill and the pin placement. All pins were 0.675 mm diameter x 2 mm in length and were placed 1 mm from the amelo-dentinal junction using a Kavo handpiece rotating at 4000 rpm.

RESULTS

The mean baseline temperature for the thermally stabilized teeth was 23.9 degrees C. The action of the round pilot drill changed the temperature from baseline by 25 degrees C. The action of the channel drill generated the greatest heat, with a mean maximum temperature recorded during these procedures of 94 degrees C +/- 9 degrees C. The pilot drill produced a mean change from baseline of 31.3 degrees C +/- 17.7 degrees C during pin placement.

CONCLUSIONS

The placement of dentine pins produced a high temperature increase on the surface of the dentine. All stages of pin placement gave rise to an increased temperature, but this was maximal with the channel drill. Further studies are required to determine whether these surfaces temperatures are transferred to the pulpal chamber.

Analysis of central B cell tolerance in autoimmune-prone MRL/lpr mice bearing autoantibody transgenes

The effect of the autoimmune prone MRL/lpr (H-2k) genetic background on central B cell tolerance was studied in mice bearing 3-83 (anti-H-2Kk) Ig heavy and light chain transgenes. B cells bearing the dominant, transgene-encoded anti-H-2Kk specificity were tolerized appropriately on the MRL/lpr genetic background. Nevertheless, mice developed disease traits characteristic of the MRL/lpr strain, including lymphadenopathy and elevated levels of IgG dsDNA autoantibodies. Two transgenic lines were examined in this analysis: 3-83 mu delta, which expresses IgM and IgD forms of the 3-83 Ab, and Tol 1, which expresses only the IgM form of 3-83. The results obtained differed somewhat between the two transgenic lines. Crosses using 3-83 mu(delta) mice never demonstrated any defects in B cell self-tolerance to H-2Kk. Similarly, no Kk autoantibody production was seen in Tol 1 mice that were backcrossed onto the MRL/lpr genetic background and maintained in a specific pathogen-free facility. However, a subset of Tol 1/MRL/lpr mice that were housed in a conventional mouse facility demonstrated significant transgene-derived anti-Kk autoantibodies. Overall, these results suggest that there is no general defect in central B cell tolerance in MRL/lpr mice, despite their defect in the fas gene. These findings suggest similarities between the MRL/lpr T and B cell systems, because both fail to manifest clear central tolerance defects, but they nevertheless promote hyperplasia and autoimmunity in the peripheral immune system.

Analysis of central B cell tolerance in autoimmune-prone MRL/lpr mice bearing autoantibody transgenes

The effect of the autoimmune prone MRL/lpr (H-2k) genetic background on central B cell tolerance was studied in mice bearing 3-83 (anti-H-2Kk) Ig heavy and light chain transgenes. B cells bearing the dominant, transgene-encoded anti-H-2Kk specificity were tolerized appropriately on the MRL/lpr genetic background. Nevertheless, mice developed disease traits characteristic of the MRL/lpr strain, including lymphadenopathy and elevated levels of IgG dsDNA autoantibodies. Two transgenic lines were examined in this analysis: 3-83 mu delta, which expresses IgM and IgD forms of the 3-83 Ab, and Tol 1, which expresses only the IgM form of 3-83. The results obtained differed somewhat between the two transgenic lines. Crosses using 3-83 mu(delta) mice never demonstrated any defects in B cell self-tolerance to H-2Kk. Similarly, no Kk autoantibody production was seen in Tol 1 mice that were backcrossed onto the MRL/lpr genetic background and maintained in a specific pathogen-free facility. However, a subset of Tol 1/MRL/lpr mice that were housed in a conventional mouse facility demonstrated significant transgene-derived anti-Kk autoantibodies. Overall, these results suggest that there is no general defect in central B cell tolerance in MRL/lpr mice, despite their defect in the fas gene. These findings suggest similarities between the MRL/lpr T and B cell systems, because both fail to manifest clear central tolerance defects, but they nevertheless promote hyperplasia and autoimmunity in the peripheral immune system.

Interleukin 1 alpha and gamma-interferon induction of nitric oxide production from murine tumor-derived endothelial cells

The role of nitric oxide (NO) in vascular function, host tumoricidal activity, and antiinflammatory effects is well documented. A number of cytokines induce NO from a variety of cell types. We have demonstrated in murine models that interleukin 1 alpha (IL-1 alpha) induces acute hemorrhagic necrosis, microvascular injury, and enhanced clonogenic tumor cell kill. Effects on the vasculature are observed only in tumor and not in normal tissues. Using methods established previously in our laboratory, murine tumor-derived and normal endothelial cells were cultured with IL-1 alpha, IFN-gamma, or IL-1 alpha/IFN-gamma at various doses with NO production quantitated through the measurement of nitrite by the Griess reaction. In tumor-derived endothelial cells, we demonstrated that neither cytokine alone was capable of inducing nitrite but that the combination of IL-1 alpha/IFN-gamma induced dose-dependent nitrite, with peak levels observed after 4 days incubation. When tumor-derived, normal yolk sac, mouse brain, or mouse aortic endothelial cells were treated with IL-1 alpha (100 units/ml)/IFN-gamma (10 units/ml), tumor-derived endothelial cells produced significantly more nitrite when compared to the normal endothelial cells. Nitrite production from IL-1 alpha/IFN-gamma was sensitive to the nitric oxide synthase inhibitors, NG-methyl-L-arginine or NG-nitro-L-arginine in a dose-dependent manner. In addition, dexamethasone significantly inhibited nitrite production from IL-1 alpha/IFN-gamma-treated, tumor-derived endothelial cells. These studies suggest that the antitumor activity of IL-1 alpha may be mediated through the production of NO from tumor-derived endothelial cells.

Extractions in support of orthodontic treatment

Extractions in support of orthodontic therapy may be done in any combination of teeth. The more common extraction patterns are: 1. Maxillary and mandibular first premolars; 2. Maxillary first and mandibular second premolars; 3. Maxillary and mandibular second premolars; 4. Maxillary first premolar; 5. Maxillary second permanent molar; 6. Maxillary first permanent molars; 7. Maxillary permanent lateral incisors; 8. Mandibular permanent incisors; or 9. Any possible combination and variation for other considerations. Extractions have been proven to support changes in the profile, helping in the alignment of teeth and in reducing lower facial height. The decision as to whether or not to extract requires a great deal of thoughtful application of diagnostic skills.

Activities associated with drownings in Imperial County, CA, 1980-90: implications for prevention

Statewide surveillance in California determined that the highest drowning rate from 1980 through 1989 was for the rural, desert county of Imperial (21.9 drownings per 100,000 population). To identify activities associated with drowning in this county, the authors abstracted data from the county sheriff-coroner's reports. From 1980 through 1990, there were 317 unintentional drownings; 85 percent occurred in irrigation canals. The activity prior to drowning was known for 262 persons (83 percent), and the most common activity was illegal entry into the United States. Overall, 140 persons (53 percent) were illegal entrants. Ninety-three percent of illegal entrants drowned in the All American Canal; the monthly drowning rate increased as the monthly average water velocity in the canal increased (r = 0.36; P < 0.001). Forty-eight persons (18 percent) drowned while riding in or on a land vehicle (automobile, pick-up truck, motorcycle, dune buggy, or tractor), the second most common activity associated with drowning. Seventy percent of the 23 drivers had an alcohol concentration of 100 milligrams per deciliter or more, California's limit for intoxication. To reduce drownings in Imperial County, prevention strategies should target persons engaged in at-risk activities near bodies of water. These strategies should include the identification and use of effective canal safety devices.

Receptor editing in self-reactive bone marrow B cells

A central paradigm of immunology is clonal selection: lymphocytes displaying clonally distributed antigen receptors are generated and subsequently selected by antigen for growth or elimination. Here we show that in mice transgenic for anti-H-2Kk,b antibody genes, in which a homogeneous clone of developing B cells can be analyzed for the outcome of autoantigen encounter, surface immunoglobulin M+/idiotype+ immature B cells binding to self-antigens in the bone marrow are induced to alter the specificity of their antigen receptors. Transgenic bone marrow B cells encountering membrane-bound Kb or Kk proteins modify their receptors by expressing the V(D)J recombinase activator genes and assembling endogenously encoded immunoglobulin light chain variable genes. This (auto)antigen-directed change in the specificity of newly generated lymphocytes is termed receptor editing.

Peripheral deletion of self-reactive B cells

B LYMPHOCYTES are key participants in the immune response because of their specificity, their ability to take up and present antigens to T cells, and their capacity to differentiate into antibody-secreting cells. To limit reactivity to self antigens, autospecific B cells can be functionally inactivated or deleted. Developing B cells that react with membrane antigens expressed in the bone marrow are deleted from the peripheral lymphocyte pool. It is important to ascertain the fate of B cells that recognize membrane autoantigens expressed exclusively on peripheral tissues because B cells in the peripheral lymphoid organs are phenotypically and functionally distinct from bone-marrow B cells. Here we show that in immunoglobulin-transgenic mice, B cells specific for major histocompatibility complex class I antigen can be deleted if they encounter membrane-bound antigen at a post-bone-marrow stage of development. This deletion may be necessary to prevent organ-specific autoimmunity.

Pneumatosis intestinalis and pneumoperitoneum complicating mixed connective tissue disease

A case of a young woman with a 3-year history of mixed connective tissue disease who developed secondary pneumatosis intestinalis and pneumoperitoneum and died shortly after of rapidly progressive disease is reported. The pathogenesis, treatment and prognosis of this unusual complication in mixed connective tissue disease are discussed.

High-dose chemotherapy with busulphan and cyclophosphamide and bone-marrow transplantation for drug-sensitive malignancies in adults: a preliminary report

The technique of high-dose chemotherapy and bone-marrow transplantation takes advantage of any potential dose-response effect in the treatment of cancer and the ability of infused marrow to circumvent severe myelotoxicity. We report our initial experience of 20 high-dose chemotherapy procedures with busulphan and cyclophosphamide as the treatment regimen. Autologous (14 patients), human leukocyte antigen-matched, sibling-allogeneic (five patients) and identical-twin (one patient) transplantations were performed in patients with leukaemias (12 patients), lymphomas (seven patients) or a germ-cell tumour (one patient). One in-hospital and one late death occurred as a result of the toxicity of high-dose chemotherapy. All evaluable patients demonstrated bone-marrow engraftment and became independent of blood transfusions. Five of six patients who were treated in partial remission or relapse obtained a complete remission. Seven patients have relapsed. Eleven patients currently are alive and disease-free and nine patients have returned to their full-time occupations. High-dose chemotherapy can be undertaken with an over-all morbidity that is similar to that which is experienced during the induction chemotherapy of acute leukaemia.

Episodic confusion and tremor associated with extrahepatic portacaval shunting in cirrhotic liver disease

In an elderly male patient with alcohol-related liver disease, who developed episodic confusion and tremor, we found a large extrahepatic portacaval shunt. He had no clinical or laboratory evidence of liver dysfunction except for an elevated serum ammonia level that increased further in response to an ammonium chloride challenge test. Extrahepatic portacaval shunting causing episodic confusion and tremor may occur with alcoholic liver disease without overt liver failure and may require abdominal angiography or a transhepatic portogram to demonstrate the shunt.

Field susceptibility of Japanese-type plums to Xanthomonas campestris pv. pruni

Fifty-five cultivars and 9 breeding selections of Japanese-type plum (Prunus salicina and hybrids) were evaluated from 1985 to 1988 for their susceptibility in the field to Xanthomonas campestris pv. pruni in a cultivar screening trial at the Granite Belt Horticultural Research Station (GBHRS), Applethorpe, Queensland. Laroda, Friar and Beauty were the most susceptible cultivars and showed severe leaf shothole, summer twig cankers and twig death. October Purple, Eldorado, Santa Rosa and Blackamber were also susceptible, displaying leaf shothole and twig cankers in the worst years. The locally established cultivars Doris, Queensland Red Ace, Shiro and Santa Rosa have been considered our most susceptible cultivars but were not as susceptible as many of the recent Californian introductions. Californian cultivars were more susceptible to bacterial spot than the selections from the GBHRS plum breeding program. The incidence of bacterial spot was higher in the years of high summer rainfall. Seventeen genotypes including 5 GBHRS selections did not display symptoms of bacterial spot. Wilson (P. salicina x P. cerasifera) is considered a good source of bacterial spot resistance for use in breeding.

Catheter sepsis during parenteral nutrition: the safety of long-term OpSite dressings

A prospective controlled study of the safety of various catheter dressing protocols was carried out in 168 patients receiving parenteral nutrition via an infraclavicular central venous catheter. Four protocols were compared: 36 patients received gauze dressings changed three times per week; 31 received OpSite dressings changed every 7th day (OpS-7), 32 received OpSite changed every 10th day (OpS-10), and 69 received OpSite changed twice weekly (OpS-ICU). Mean duration of parenteral nutrition was approximately 2 weeks and all groups were well matched except that OpS-ICU patients suffered more frequently from an acute illness. Catheter-related sepsis was identified by clinical signs of systemic sepsis, positive peripheral venous blood and catheter-tip cultures and/or defervescence of fever after catheter removal. Catheter-related sepsis rates were low in all groups: 1/36 for Gauze, 0/31 for OpS-7, 1/32 for OpS-10, and 2/69 for OpS-ICU. Septicemia attributable to causes apart from catheter sepsis occurred in two, two, three, and four patients, respectively. Bacterial colonization of skin beneath OpSite was no more common in the OpS-10 than in the other groups. Signs of inflammation at catheter insertion sites were common in all groups but did not relate closely to skin colonization. OpSite can be safely applied to central venous catheters inserted under strict aseptic conditions, even in patients with open septic drainage. Dressings can be left in place for 7 days with a margin of safety lasting to 10 days, thus saving on cost of materials and nursing time.

"Open-access" endoscopy for general practitioners. Experience of a private gastrointestinal clinic

Previous authors have questioned the value of an "open-access" upper gastrointestinal endoscopy service, its increased usage and its low useful diagnostic yield. We have analysed the results of 8270 consecutive endoscopies that were performed in one private outpatient gastrointestinal clinic from 1977 to 1984. Of these, 1409 endoscopies were performed as part of an open-access service for referring doctors. The remainder were performed after referral for a gastrointestinal consultation. No deaths or major complications occurred in either group. A steady increase in referrals to both groups was noted over the years, with an increasing proportion of normal results. A positive endoscopic finding was found significantly more frequently in the open-access group (61%) compared with those patients that were referred for a gastrointestinal consultation (52.6%). Individual endoscopists varied significantly in their tendency to report mucosal inflammatory lesions. We believe that outpatient open-access endoscopy that is performed by experienced clinicians with trained staff and appropriate facilities is a safe and acceptable alternative to barium meal examinations.

Effects of peritoneovenous shunting on body composition

The effect of peritoneovenous shunting on body composition has been studied in 7 cirrhotic patients undergoing a successful shunt and 3 patients in whom the shunt was unsuccessful. In the 7 patients with functioning shunts, their weight had decreased by a mean of 9 kg (p less than 0.001) by 6 wk after initial diuresis, natriuresis, and kaliuresis, and was associated with a decrease in total body potassium (TBK) but not total body nitrogen (TBN). This resulted in a significant decrease in the TBK/TBN ratio from 2.12 +/- 0.74 to 1.66 +/- 0.20 (p less than 0.01). By a mean of 14 mo, in these 7 patients there was a significant increase in mean TBN (from 1.54 +/- 0.10 to 1.84 +/- 0.10, p less than 0.005) associated with an improvement in the mean nitrogen index (from 0.74 +/- 0.04 to 0.88 +/- 0.04, p less than 0.005). These changes were associated with a significant increase in nonalcoholic calories, a nonsignificant increase in protein consumption, and a positive nitrogen balance. After the initial kaliuresis, mean potassium balance remained constantly positive (+22.7 +/- 3.4 mmol/day), serum aldosterone levels normalized, and TBK increased. In contrast, 3 patients with failed peritoneovenous shunting continued to lose weight significantly despite the presence of ascites; TBN and nitrogen index also decreased. In conclusion, body composition studies appear to have confirmed the clinical observation that cirrhotic patients with massive ascites have depleted body protein which is gradually repleted only after successful shunting. In this situation TBK, long used as a measure of lean body mass, is less satisfactory than TBN and nitrogen index. This improvement in body protein appears to be explained by an increased dietary intake associated with improved nitrogen balance, but these changes are not found in patients in whom the shunt failed.

A survey to evaluate the management of orthodontic patients with a history of rheumatic fever or congenital heart disease

A survey concerning the orthodontic management of patients with a history of rheumatic fever or congenital heart disease was mailed to a random sample of 500 orthodontists throughout the United States. Two hundred thirty-two surveys were completed and returned. Analysis revealed that 88% of the respondents were aware that they should screen for patients with a history of rheumatic fever or congenital heart disease, only 11% used the antibiotic regimen recommended in 1977 by the American Heart Association (see Fig. 2), one half of the respondents thought it was necessary to provide antibiotic coverage during banding, and 38% deemed it necessary for debanding procedures which were likely to cause some degree of bleeding from the gingival sulcus. Only one half of the respondents would discontinue treatment if a condition of gingivitis developed which did not show signs of improvement, and only 70% provided medication for orthodontic procedures that could result in bacteremia. Furthermore, the results of this survey indicated that there was a great variation in the antibiotic regimen of orthodontic treatment for patients at risk of developing endocarditis and that there was a need to make the orthodontist more aware of the 1977 recommendations of the American Heart Association. Finally, a comparison between the year of graduation from an orthodontic program and the number of respondents who did not screen for or did not premedicate at-risk patients revealed a direct relationship. The earlier the education, the smaller the number of respondents who screened or premedicated.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of fasting and hypocaloric diets on the functional and metabolic characteristics of rat gastrocnemius muscle

Previous observations have shown that in human subjects with malnutrition and after prolonged fasting, there are characteristic changes in the force-frequency response, relaxation rate and power of muscle during a 30 s stimulus (fatigue). In order to characterize these findings under carefully controlled conditions, in different types of muscle and to correlate them with changes in muscle structure, composition and biochemical status, we developed an animal model in rats. In this model, nutrient restriction, both after an acute fast and after chronic hypocaloric feeding, resulted in: (a) loss of force during high frequency stimulation but preservation of contraction-relaxation characteristics during low frequency stimulation; (b) slower muscle relaxation rate at high frequency stimulation; (c) increased muscle fatiguability at high frequency stimulation. Measurements of muscle enzymes showed that acute fasting resulted in a reduced content of glycolytic enzymes, but preservation of oxidative enzymes, while chronic hypocaloric dieting resulted in a reduction in both classes of enzyme. There was no significant change in ATP, AMP or energy charge, or in intracellular sodium, potassium and magnesium levels. Creatine phosphate was normal in acutely fasted animals but low in those fed hypocalorically. By contrast, increased intracellular calcium and ADP levels were seen in both fasted and hypocalorically fed animals. These findings suggest that subtle disturbances of intracellular energy states with altered calcium flux may be of importance in the genesis of muscle dysfunction caused by malnutrition.

Effects of total parenteral nutrition and chemotherapy on the metabolic derangements in small cell lung cancer

Changes in energy metabolism, substrate use, and hormone profiles were prospectively studied in 31 patients with small cell lung cancer receiving chemotherapy. Patients were randomized to receive either 4 weeks of total parenteral nutrition (n = 15) or to continue self-regulated p.o. diet (control group; n = 16). The initial actual resting energy expenditure measured by indirect calorimetry was 31% higher than the predicted resting energy expenditure determined by the Harris-Benedict formula. The p.o. calorie intake was inappropriately low for these hypermetabolic patients. Total parenteral nutrition resulted in a significant positive net energy balance, but in follow-up was associated with prolonged anorexia and a negative energy balance. Complete response to therapy reduced resting energy expenditure and increased calorie intake, whereas the contrary was true in nonresponders. Elevated plasma-free fatty acids (800 +/- 62 microM; S.E.) and a low respiratory quotient (0.74 +/- 0.02) indicate that the dominant energy source in patients with small cell lung cancer is fat, and that increased fat oxidation continues despite tumor response. Elevated fasting plasma catecholamines and insulin resistance may contribute to continued fat mobilization. Initially, there was a significant increase in blood lactate (1118 +/- 95 microM) suggesting either increased tumor or tumor-mediated glycolytic activity. Response to therapy was associated with a fall in blood lactate levels. The most effective way of improving the metabolic derangements in patients with small cell lung cancer was to achieve tumor response to therapy.

Metabolic and structural changes in skeletal muscle during hypocaloric dieting

Hypocaloric dieting and fasting alter the contraction-relaxation characteristics of skeletal muscle and result in low frequency fatigue. We report the metabolic and structural changes in skeletal muscle in five morbidly obese female subjects who had biopsies of the gastrocnemius muscle on a base-line diet (2500 kcal/day) followed by a repeat biopsy after 2 wk of a 400-kcal/day carbohydrate diet. Hypocaloric dieting resulted in a significant increase in the intracellular muscle calcium content (p less than 0.05), which may account for the observed changes in muscle function. There were no significant changes in muscle glycogen, lactate, pyruvate, or free energy stores. There was a significant decrease in muscle enzymes [phosphofructokinase (p less than 0.05), succinate dehydrogenase (p less than 0.02)] and some muscle amino acid levels [glutamine (p less than 0.025), glycine (p less than 0.01), and alanine (p less than 0.02)], while muscle histochemistry showed type II fiber atrophy (p less than 0.025). However, these changes reflect a generalized response to hypocaloric dieting and probably do not explain the specific functional changes. Change in the muscle calcium content is probably an important mediator of the adverse functional effects of malnutrition.

Delayed gastric emptying and improvement with domperidone in a patient with anorexia nervosa

A woman with anorexia nervosa who displayed severe bloating after eating was treated with domperidone, a novel compound with prokinetic properties. Both subjective ratings of satiety and assessment of gastric emptying documented improvement.

A comparison between muscle function and body composition in anorexia nervosa: the effect of refeeding

Skeletal muscle function, body composition (total body nitrogen and total body potassium) and standard parameters of nutritional assessment were measured in six severely depleted patients with primary anorexia nervosa, both on admission and during oral refeeding. The function of the adductor pollicis muscle was assessed by electrical stimulation of the ulnar nerve. On admission muscle function was markedly abnormal in the patients with anorexia nervosa (n = 6) compared with normal subjects (n = 22), with a significant increase in the force of contraction at 10 Hz, with a mean +/- SEM of 48.0 +/- 3.7% and 28.8 +/- 1.2%, respectively (p less than 0.001). There was slowing of the maximal relaxation rate, 6.6 +/- 0.6% and 9.6 +/- 0.2%, respectively (p less than 0.001) and increased muscle fatigue 18.6 +/- 5.9% and 3.5 +/- 0.8%, respectively (p less than 0.01). Initially, the mean serum albumin was normal (4.0 +/- 0.1 g/dl), although there was evidence of severe depletion of somatic protein stores, with a low total body nitrogen and creatinine-height index. Within 4 wk of oral refeeding, maximal relaxation rate and muscle fatigability were restored to normal, and within 8 wk all parameters of muscle function were normal. During the study total body nitrogen increased by only 13% and was still 19.4% below the predicted normal total body nitrogen, whereas total body potassium increased by 32% and body fat by 46%. Normalization of muscle function may be related to restoration of muscle electrolytes rather than repletion of body nitrogen.

Complete remission in Cronkhite-Canada syndrome

A case of Cronkhite-Canada syndrome, where there was complete remission confirmed by radiology, endoscopy, and histology, is reported. On presentation, there was generalized gastrointestinal polyposis, hypoalbuminemia, skin pigmentation, onycho-dystrophy, and alopecia. Enteral nutrition alone was administered for 10 wk, with resolution of the ectodermal features and disappearance of the polyps within 4 mo of commencement of the treatment. This report of complete remission supports the generally accepted nonneoplastic and essentially inflammatory nature of the polyps in Cronkhite-Canada syndrome. Consideration needs to be given to nutritional deficiency as a cause of the syndrome.

Skeletal muscle function during hypocaloric diets and fasting: a comparison with standard nutritional assessment parameters

Skeletal muscle function and standard nutritional assessment parameters were measured in six obese patients. Base-line measurements were made on a weight-maintaining diet, and further measurements after 2 wk of a 400-cal diet, followed by 2 wk of fasting and then after 2 wk of refeeding. The function of the adductor pollicis muscle was assessed by electrical stimulation of the ulnar nerve. The objective parameters of muscle function measured were: 1) force of contraction expressed as a percentage of the maximal force obtained with electrical stimulation at 10, 20, 30, 50, and 100 Hz. 2) Maximal relaxation rate expressed as percentage force loss/10 ms. 3) Endurance expressed as percentage force loss/30 s. Standard nutritional assessment parameters (serum albumin and transferrin, creatinine height index, anthropometry and total body nitrogen and potassium) were also measured. There was a significant increase in the force of contraction at 10 Hz from a base-line of 29.6 +/- 1.0% to 49.0 +/- 2.8% (mean +/- SEM) after 2 wk of a 400-cal diet (p less than 0.01). These was a significant slowing of the maximal relaxation rate from a base-line of 9.8 +/- 0.03% force loss/10 ms to 8.2 +/0 0.3% force loss/10 ms (mean +/- SEM) (p less than 0.01) after 2 wk of a 400-cal diet. After a further 2 wk of fasting these abnormalities in muscle function persisted. There was a significant increase in muscle force loss from a base-line of 3.9 +/- 0.8% force loss/30 s to 13.7 +/- 3.4% force loss/30 s (mean +/- SEM) after fasting (P less than 0.01). After 2 wk of refeeding all aspects of muscle function measured were normal. During the study the standard nutritional assessment parameters did not change significantly.

Skeletal muscle function in malnutrition

Skeletal muscle function was studied in 10 malnourished patients with various gastrointestinal disorders and in 22 normal subjects. The function of the adductor pollicis muscle was assessed by electrical stimulation of the ulnar nerve. The objective parameters of muscle function measured were: 1) Force of contraction expressed as a percentage of the maximal force obtained with electrical stimulation at 10, 20, 30, 50 and 100 Hz. 2) Maximal relaxation rate expressed as percentage force loss/!10 ms. 3) Endurance expressed as percentage force loss/30 s. The force of contraction at 10 Hz was higher in malnourished patients compared with normal subjects, with a mean +/- SEM (n) of 43.0 +/- 4.2% (n = 10) and 28.8 +/- 1.2% (n = 22), respectively, (p less than 0.001). The maximal relaxation rate was slower in patients compared with normals with a mean +/- SEM (n) of 7.2 +/- 0.4% (n = 9) ad 9.6 +/- 0.2% (n = 22), respectively, (p less than 0.001). Muscle endurance testing showed an increased force loss with prolonged tetanic stimulation in patients compared with normals, with a mean +/- SEM (n) of 29.1 +/- 4.0% (n = 7) and 3.5 +/- 0.8% (n = 22), respectively, (p less than 0.001). Four patients were restudied after a 4-wk period of total parenteral nutrition, with a significant improvement in muscle function parameters. Malnutrition results in both increased muscle fatiguability and an altered pattern of muscle contraction and relaxation which are reversible by nutritional supplementation. This technique promises to be valuable in assessing the functional effects of malnutrition and the response to nutritional support.

Carcinoma of the papilla of Vater

Carcinoma of the papilla of Vater was diagnosed in 18 patients during the period 1970 to 1980. In ten patients, surgical treatment was facilitated by a preoperative diagnosis based on duodenal endoscopy, biopsy, cytology and retrograde cholangiopancreatography. Of 16 patients with apparently localised disease at laparotomy, nine had pancreatoduodenectomy (Whipple's operation), three had local resection and four had biliary bypass. Six of nine patients treated by pancreatoduodenectomy are surviving for periods ranging from one to ten years, mean four years, whereas the four patients treated by biliary bypass survived for 0 to 18 months. Tumour recurred in the region of the papilla in two of three patients treated by local resection. Carcinoma of the papilla of Vater is usually localised at the time of diagnosis and prolonged survival can be achieved by pancreatoduodenectomy.