Endo-histologic Normalization Is Achievable with Tofacitinib and Is Associated with Improved Clinical Outcomes

BACKGROUND

Recent real-world effectiveness studies investigating tofacitinib have been encouraging. Questions remain regarding the long-term effectiveness and safety of tofacitinib, effect on endoscopic remission rates, histologic changes, and alterations in fecal calprotectin levels.

METHODS

This retrospective study includes consecutive patients with inflammatory bowel disease (IBD) who initiated tofacitinib therapy. We reviewed electronic medical records for demographic and clinical data, as well as all adverse events and hospitalizations. All patients receiving tofacitinib were included in the safety analysis and only patients with ulcerative colitis (UC) were included in the effectiveness analysis.

RESULTS

119 patients with IBD (97 UC, 12 CD, and 10 pouchitis) seen at our center between 2014 and 2020 were included in this study. Median follow-up was 32 weeks (interquartile range (IQR) 3-252). Clinical response and remission were observed in 70% and 21%, 59% and 33%, and 49%, and 37% at weeks 8, 24, and 52, respectively. Endo-histologic healing was achieved by 11%, 25%, and 37.5% of patients at weeks 8, 24, and 52, respectively. Histologic normalization occurred as early as 24 weeks in this cohort and was achieved by 26% of patients in endoscopic remission. Overall, there were 27 (25%) adverse events with 6 (5%) resulting in treatment discontinuation. There were 11 (10%) infections, none required treatment discontinuation. Ten (10.3%) patients underwent colectomy during the follow-up period. There were no cardiovascular adverse events in the cohort during follow-up.

CONCLUSION

This study demonstrates the effectiveness and long-term safety of tofacitinib in patients with UC. Importantly, we show that the endpoint of endo-histologic healing is achievable with tofacitinib and can occur as early as week 8 of therapy.

Using Wearable Biosensors to Predict Length of Stay for Patients with IBD After Bowel Surgery

BACKGROUND AND AIMS

It remains unknown whether ambulation or sleep predicts postoperative length of stay for patients with IBD. We aim to identify the utility of wearable biosensors in predicting postoperative length of stay for patients with IBD.

METHODS

Associations of postoperative length of stay with step count/sleep duration/sleep efficiency measured by wearable biosensors were examined. The best-fitting multivariable linear regression model predicting length of stay was constructed using stepwise model selection.

RESULTS

Final sample included 37 patients. Shorter sleep duration on postoperative day 4 (r = 0.51, p = 0.043) or 5 (r = 0.81, p = 0.0045) or higher sleep efficiency on postoperative day 5 (r = - 0.77, p = 0.0098) was associated with a shorter length of stay. Additionally, a more positive change in sleep efficiency from postoperative day 4-5 was associated with a shorter length of stay (r = - 0.77, p = 0.024). The best-fitting multivariable linear regression model revealed Clavien-Dindo grade 1 (p = 0.045) and interaction between Clavien-Dindo grade 2/3a and mean daily steps (p = 0.00038) are significant predictors of length of stay. The following variables were not significantly associated with length of stay: mean daily steps/sleep duration/sleep efficiency, average rate of change in these three variables, and changes in step count between successive postoperative days 1-5, sleep duration between successive postoperative days 2-5, and sleep efficiency between successive postoperative days 2-4.

CONCLUSION

We demonstrated the utility of activity and sleep data from wearable biosensors in predicting length of stay. Patients with more severe complications may benefit more (i.e., reduced postoperative length of stay) from increased ambulation. However, overall, sleep duration/efficiency did not predict length of stay.

Implementation of tailored interventions in a statewide programme to reduce central line-associated bloodstream infections

BACKGROUND

There have been few studies exploring implementation strategies to central line-associated bloodstream infections (CLABSIs) in low- or middle-income countries.

AIM

To implement tailored interventions to reduce CLABSI rates in adult intensive care units.

METHODS

The implementation strategy of the State Health Department was performed in São Paulo State, Brazil, over two cycles. Cycle 1 (56 hospitals) was exploratory and cycle 2 (77 hospitals) was designed to confirm the hypothesis generated by the first cycle, with three phases each (pre-intervention, intervention, post-intervention). Cycles included: evaluation of healthcare workers' knowledge, observation of practices, and CLABSI rates monthly report. In cycle 1, a log-normal mixed model was used to select variables significantly associated with the reduction of CLABSI. In cycle 2, CLABSI rates were evaluated.

FINDINGS

Healthcare workers' practices improved after intervention. In cycle 1, reduction of CLABSI rates was more pronounced in hospitals with initial CLABSI rates >7.4 per 1000 catheter-days (P < 0.001) and those that introduced the use of peripherally inserted central catheters (P = 0.01). For hospitals with high CLABSI initial rates, simulation demonstrated that the rates were expected to decrease by 36% (95% CI: 9-63), no matter the type of intervention. In cycle 2, there was an overall decrease in CLABSI rates during the intervention period; whereas the mean rate fell further post-intervention, rates at the 90^th percentile increased.

CONCLUSION

The implementation strategy may have had an effect on infection rates independently of the specific interventions implemented; however, the sustainability of reduction in the post-intervention period remains a challenge.

Use of hyaluronidase for cervical ripening: a randomized trial

OBJECTIVE

To investigate the action of intracervical administration of hyaluronidase (HAase) as an inductor of cervical ripening on an outpatient basis.

METHODS

A randomized double-blind trial was conducted with 168 pregnant women at term, Bishop score (BS)<5, normal fetal vitality and no uterine contractions. An evaluation was performed at the first visit, when either 20,000 UI of lyophilized HAase (5 ml) or placebo was administered via cervical injection. After 48 h, if the BS remained<5, a second dose was administered. The primary outcome was the BS after 48 h or 96 h. The outcome was considered positive when BS>/=5.

RESULTS

The results indicate that the proportion of positive response for the HAase group (55%) after 48 h is significantly higher (p<0.0001) than the corresponding proportion for the placebo group (7%) with an absolute risk reduction (ARR) of 48%=55-7% (95%CI=40-56%). After 96 h, these proportions are 93% in the Haase group and 22% in the placebo group (p<0.0001, ARR=71%, 95%CI=61-81%). The average duration of labour for the nulliparae in the HAase group (6.5h) is significantly smaller (p<0.0001) than for those under placebo (12.0 h) with an absolute difference of 5.5h (95%CI=4.6-6.4h). For the multiparae, the results are 4.3h for the HAase patients versus 9.5h for the placebo patients (p<0.0001) with an absolute difference of 5.2h (95%CI=4.1-6.3h). The proportion of vaginal deliveries for women who received HAase was 82% versus 51% for the placebo group (p=0.0007, ARR=31%, 95%CI=19-44%). The proportion of vaginal deliveries for patients with prior cesareans in the HAase group (69%) was also significantly higher (p<0.0001) than that corresponding to the placebo group (13%) with ARR=56% (95%CI=26-86%). No uterine hyper stimulation occurred in the study.

CONCLUSION

We detected significant associations between intracervical injection of HAase and ripening of the cervix, as well as with shorter duration of labour and larger chance of vaginal delivery, suggesting that this is a simple, effective and safe method even for women with prior cesarean.

Holistic processing unites face parts across time

When complementary halves of different familiar faces are combined into a new face, there is interference in the identification of either half. This "composite face effect" has been taken as strong evidence that faces are processed holistically. Here, we demonstrate that this effect can persist when the two parts of a face are separated by up to 80 ms of visual noise, showing that the parts of a face interact not only spatially but also temporally. We suggest that the processing underlying robust identification accepts an accumulation of evidence over time.

Air pollution and child mortality: a time-series study in São Paulo, Brazil

Although most available evidence relating air pollution and mortality was obtained for adults, pollution has been also associated with increased mortality in children, but in a significantly smaller number of studies. This study was designed to evaluate the association between child mortality and air pollution in the city of São Paulo, Brazil, from 1994 to 1997. Daily records of mortality due to respiratory diseases for children under 5 years of age were obtained from the municipal mortality information improvement program. Daily concentrations of sulfur dioxide (SO(2)), carbon monoxide (CO), inhalable particulate matter less than 10 microm in diameter (PM(10)), and ozone were obtained from the state air pollution controlling agency. Information on minimum daily temperature and on relative humidity were obtained from the Institute of Astronomy and Geophysics of the University of São Paulo. Statistical analysis was performed through generalized additive models considering a Poisson response distribution and a log link. Explanatory variables were time, temperature, humidity, and pollutant concentrations. The loess smoother was applied to time (in order to model seasonality) and temperature. Significant associations between mortality and concentrations of CO, SO(2), and PM(10) were detected. The coefficients (and standard errors) of these three pollutants were 0.0306 (0.0076), 0.0055 (0.0016), and 0.0014 (0.0006), respectively. The observed associations were dose dependent and quite evident after a short period of exposure (2 days). According to the proposed model and considering the mean of the pollutant concentration during the period of the study, the estimated proportions of respiratory deaths attributed to CO, SO(2), and PM(10), when considered individually, are around 15, 13, and 7%, respectively.

Air pollution and child mortality: a time-series study in São Paulo, Brazil

Although most available evidence relating air pollution and mortality was obtained for adults, pollution has been also associated with increased mortality in children, but in a significantly smaller number of studies. This study was designed to evaluate the association between child mortality and air pollution in the city of São Paulo, Brazil, from 1994 to 1997. Daily records of mortality due to respiratory diseases for children under 5 years of age were obtained from the municipal mortality information improvement program. Daily concentrations of sulfur dioxide (SO(2)), carbon monoxide (CO), inhalable particulate matter less than 10 microm in diameter (PM(10)), and ozone were obtained from the state air pollution controlling agency. Information on minimum daily temperature and on relative humidity were obtained from the Institute of Astronomy and Geophysics of the University of São Paulo. Statistical analysis was performed through generalized additive models considering a Poisson response distribution and a log link. Explanatory variables were time, temperature, humidity, and pollutant concentrations. The loess smoother was applied to time (in order to model seasonality) and temperature. Significant associations between mortality and concentrations of CO, SO(2), and PM(10) were detected. The coefficients (and standard errors) of these three pollutants were 0.0306 (0.0076), 0.0055 (0.0016), and 0.0014 (0.0006), respectively. The observed associations were dose dependent and quite evident after a short period of exposure (2 days). According to the proposed model and considering the mean of the pollutant concentration during the period of the study, the estimated proportions of respiratory deaths attributed to CO, SO(2), and PM(10), when considered individually, are around 15, 13, and 7%, respectively.

Suppressors of mdm20 in yeast identify new alleles of ACT1 and TPM1 predicted to enhance actin-tropomyosin interactions

The actin cytoskeleton is required for many aspects of cell division in yeast, including mitochondrial partitioning into growing buds (mitochondrial inheritance). Yeast cells lacking MDM20 function display defects in both mitochondrial inheritance and actin organization, specifically, a lack of visible actin cables and enhanced sensitivity to Latrunculin A. mdm20 mutants also exhibit a temperature-sensitive growth phenotype, which we exploited to isolate second-site suppressor mutations. Nine dominant suppressors selected in an mdm20/mdm20 background rescue temperature-sensitive growth defects and mitochondrial inheritance defects and partially restore actin cables in haploid and diploid mdm20 strains. The suppressor mutations define new alleles of ACT1 and TPM1, which encode actin and the major form of tropomyosin in yeast, respectively. The ACT1 mutations cluster in a region of the actin protein predicted to contact tropomyosin, suggesting that they stabilize actin cables by enhancing actin-tropomyosin interactions. The characteristics of the mutant ACT1 and TPM1 alleles and their potential effects on protein structure and binding are discussed.

Radiobiological prediction of normal tissue toxicities and tumour response in the radiotherapy of advanced non-small-cell lung cancer

A number of randomized studies have been carried out in the UK and USA to determine the optimal radiotherapy dose schedule for advanced non-small-cell lung cancer (NSCLC). We have examined eight radiotherapy regimens from data taken from four randomized phase III studies carried out in the UK (1264 patients): 10 Gy single fraction; 17 Gy in two fractions over 8 days; 30 Gy in ten fractions over 14 days; 22.5 Gy in five fractions in 5 days; 27 Gy in six fractions over 11 days; 30 Gy in six fractions over 11 days; 36 Gy in 12 fractions over 16 days; and 39 Gy in 13 fractions over 17 days. We compared the clinical results in palliation, toxicity and survival with four regimens taken from one randomized study from the USA (365 patients): 40 Gy in 20 fractions over 4 weeks; 40 Gy 'split course' in ten fractions in 4 weeks; 50 Gy in 25 fractions over 5 weeks; and 60 Gy in 30 fractions over 6 weeks. Using the linear-quadratic (LQ) radiobiological model, we have calculated the radiobiological equivalent dose (BED) for acute-reacting tissues (BED10), late-reacting tissues (BED1.7) and tumour (BED25), and related the predicted response to the observed response in each tissue. There was a good correlation between the predicted response and the reported response in the case of late-reacting tissue toxicity and tumour response. The model confirmed that, in good performance status patients, a higher value for BED25 correlated with a higher degree of local control and survival and that radiotherapy regimens with a higher value for BED1.7 were associated with five cases of cord myelopathy, if the spinal cord was not shielded. In poor performance status patients the model suggested that the optimal regimen was a single fraction of 10 Gy because this resulted in an equivalent degree of symptom control as other regimens, needed only one hospital visit and was less likely to result in cord damage, thus, allowing for the possibility of retreatment at a later date.

Association between air pollution and intrauterine mortality in São Paulo, Brazil

The associations among daily counts of intrauterine mortality and pollutant concentrations (NO2, SO2, CO, O3, and particulate matter (3/4)10 microm) were investigated for the period ranging from January 1991 to December 1992 in the city of São Paulo, Brazil. We used Poisson regression techniques, adjusted for season and weather. The association between intrauterine mortality and air pollution was strong for NO2 (coefficient = 0.0013/ microg/m3; p<0.01) but lesser for SO2 (coefficient = 0.0005/ microg/m3; p<0.10) and CO (coefficient = 0.0223/ppm; p<0.10). A significant association was observed when an index that combined these three pollutants was considered in the models instead of considering each pollutant individually (p<0.01). These associations exhibited a short time lag, not over 5 days. In addition, some evidence of fetal exposure to air pollution was obtained by disclosing a significant association between the levels of carboxyhemoglobin of blood sampled from the umbilical cord and ambient CO levels in children delivered by nonsmoking pregnant women in the period from May to July 1995. Our results suggest that air pollution in São Paulo may promote adverse health effects on fetuses.

Association between air pollution and intrauterine mortality in São Paulo, Brazil

The associations among daily counts of intrauterine mortality and pollutant concentrations (NO2, SO2, CO, O3, and particulate matter (3/4)10 microm) were investigated for the period ranging from January 1991 to December 1992 in the city of São Paulo, Brazil. We used Poisson regression techniques, adjusted for season and weather. The association between intrauterine mortality and air pollution was strong for NO2 (coefficient = 0.0013/ microg/m3; p<0.01) but lesser for SO2 (coefficient = 0.0005/ microg/m3; p<0.10) and CO (coefficient = 0.0223/ppm; p<0.10). A significant association was observed when an index that combined these three pollutants was considered in the models instead of considering each pollutant individually (p<0.01). These associations exhibited a short time lag, not over 5 days. In addition, some evidence of fetal exposure to air pollution was obtained by disclosing a significant association between the levels of carboxyhemoglobin of blood sampled from the umbilical cord and ambient CO levels in children delivered by nonsmoking pregnant women in the period from May to July 1995. Our results suggest that air pollution in São Paulo may promote adverse health effects on fetuses.

The influence of a mineralizing mouthrinse on the mineral contents and on the pH of dental plaque

The main objective of this study was to evaluate the effects of a single use of a mineralizing mouthrinse on dental plaque pH and on its mineral contents: an additional objective was to examine the effects of an oral prophylaxis and scaling on the same response variables. A total of 22 volunteer dental students (14 female and 8 male) participated in the study. The mineralizing mouthrinse contained calcium, phosphate, strontium and fluoride ions. Following a 48-hour period without oral hygiene and 2 hours after breakfast, dental plaque was collected twice from each participant for the evaluation of the effects of the oral prophylaxis and scaling, and twice more for the evaluation of the effects of the mineralizing mouthrinse. The pH was measured in vitro with a microelectrode and the mineral contents were determined by atomic emission spectrometry. The results demonstrate that the average post-prophylaxis pH was higher than the average pre-prophylaxis pH, and that a variation of the average contents of some minerals in the dental plaque was also observed after prophylaxis compared to the contents prior to prophylaxis. Although there was a significant reduction in the Fe content after the rinse with the mineralizing solution, no significant variation on the average pH was detected.

The pharmacokinetics and metabolism of ifosfamide during bolus and infusional administration: a randomized cross-over study

In a randomized cross-over trial, 11 patients received ifosfamide (IFOS) in 21-day cycles, which alternated between 3 g m(-2) x (2 or 3) days given as a 1-h bolus doses, or the same total dose as a continuous infusion. Patients who received four or more cycles also alternated between two cycles on dexamethasone 4 mg 8 hourly for 3 days starting 8 h before IFOS, and two cycles off dexamethasone. A total of 34 patient cycles were studied and serum and urinary levels of IFOS, 2 dechloroethylifosfamide (2DC), 3 dechloroethylifosfamide (3DC), carboxyifosfamide (CX) and isophosphoramide mustard (IPM) were measured by thin-layer chromatography. No significant differences could be detected in the areas under the curve (AUCs) of serum concentration, nor in the proportion of IFOS or its metabolites found in the urine. There was no significant effect of dexamethasone on IFOS metabolism. These results indicate that there is no identifiable pharmacokinetic basis for insistence on either bolus or infusional methods of IFOS administration.

Urinary proton magnetic resonance studies of early ifosfamide-induced nephrotoxicity and encephalopathy

Ifosfamide is an oxazophosphorine widely used in the treatment of cancer in children and adults. Nephrotoxicity and neurotoxicity are major side effects. The aim of this study was to use high-resolution proton nuclear magnetic resonance (1H NMR) spectroscopy of urine to identify novel biochemical markers of ifosfamide-induced toxicity. Urine samples were collected from 10 nonencephalopathic patients (who had not previously received nephrotoxic chemotherapy) immediately prior to the first ifosfamide dose and at timed intervals for up to four treatment cycles. The findings were compared with those for urine samples collected from five patients during acute encephalopathic episodes. 1H NMR urinalysis identified a series of characteristic time-related changes in the excretion profiles of low molecular weight endogenous metabolites during ifosfamide therapy. These changes included a decreased excretion of hippurate and an increased excretion of glycine, histidine, glucose, lactate, and trimethylamine-N-oxide. Two nonencephalopathic patients had marked but transient glutaric or adipic aciduria during the second cycle of ifosfamide treatment. Urinary retinol-binding protein rose acutely after each treatment cycle but usually returned to baseline levels. Maximum renal toxicity was observed by the fourth treatment cycle. The ratio of the urinary excretion of the uroprotectant mesna (active form) to dimesna (inactive form) correlated with the degree of renal toxicity. For the encephalopathic patients, the ifosfamide-induced changes in the urinary low molecular weight metabolite profile were similar to those for the nonencephalopathic group. In contrast to previous reports, none of the encephalopathic group developed glutaric aciduria, and i.v. methylene blue did not reverse neurotoxicity in the two patients who received it. The results suggest that ifosfamide nephrotoxicity involves both cortical and medullary regions of the nephron and that the urinary mesna:dimesna ratio may be important in assessing the degree of cytoprotection. This study demonstrates that 1H NMR can provide novel biochemical information on ifosfamide-induced toxicity and will be of value in the optimization of ifosfamide therapy.

Effect of gustatory stimulation on flow rate and protein content of human parotid saliva according to the side of preferential mastication

Unstimulated and citric acid-stimulated parotid saliva from the left- and right-hand sides of 20 females, was collected separately to compare the corresponding flow rates, total protein and electrophoretic protein profiles. Individuals having the left-hand side as the preferential side of mastication presented significantly greater flow rates for the ipsilateral glands than for the contralateral ones. Although the data suggested that the left-hand side average protein concentrations were greater for the group with the right-hand side of preferential mastication, the results were not statistically significant. Some minor differences in electrophoretic protein profiles were detected by scanning densitometry.

The effect of training on the ability of children to use dental floss

The effect of training on the ability to use dental floss was evaluated in a study involving forty-eight children in the 6.5 to 7.5 age-group. Using a dental plaque index for the proximal surfaces, we observed significantly superior average results for the trained group (five weekly sessions) relative to the group with no training. We also observed a significant average difference favoring the male trained group relative to the female trained group.

Supratentorial low grade gliomas in adults. A retrospective analysis of 43 cases treated with surgery and radiotherapy

Forty-three adults with histologically verified low grade gliomas, treated with post-operative radiotherapy between 1983 and 1991, were reviewed. Previous studies have identified age and extent of surgery as prognostic factors for survival. In this series, there was no significant difference between patients under 40 years of age and those 40 and over, nor was there a survival difference between those who had open biopsy and those who underwent subtotal/total resection. Patients with seizures preoperatively showed improvement in epileptic control at one year post-radiation. Clinical performance status and neurological deficit scoring indicated good preservation of function one year after radiation.

VAPEC-B chemotherapy in the treatment of aggressive non-Hodgkin's lymphoma: a retrospective analysis of 45 patients

We performed a retrospective analysis on 45 patients who, between January 1989 and October 1993, received VAPEC-B chemotherapy for high and intermediate grade non-Hodgkin's lymphoma. The aim was to assess response and tolerance to treatment. The weekly regimen consisted of: doxorubicin 35 mg/m2 i.v. weeks 1,3,5,7,9,11; cyclophosphamide 350 mg/m2 i.v. weeks 1, 5, 9; etoposide 100 mg/m2 p.o. daily for 5 days, weeks 3, 7, 11; vincristine 1.4 mg/m2 i.v. (2 mg max.) weeks 2, 4, 6, 8, 10; bleomycin 10 mg/m2 i.v. weeks 2, 6, 10; methotrexate 12.5 mg i.t. weeks 1, 5, 9; prednisolone 50 mg p.o. daily for 6 weeks, reduced to 25 mg daily for 6 weeks. The patients treated were aged 22-71 years, 34 (75%) had high grade (Working Formulation) non-Hodgkin's lymphoma (NHL); 11 (24%) had intermediate grade NHL; 25 had Stage III/IV disease; and 14 (31%) had marrow involvement. The majority of patients (76%) received VAPEC-B as first line chemotherapy; the remainder received it for relapsing disease. Follow-up time from completion of VAPEC-B chemotherapy ranged from 6 months to 50 months (median 25). VAPEC-B, as first line therapy, induced a complete response (CR) and partial response (PR) in 79% and 18% respectively, whilst 3% had no response to treatment. VAPEC-B used for relapsing disease produced CR and PR in 64% and 27% respectively, whilst 9% failed to respond. Six patients in PR and five patients in CR have subsequently undergone an autologous bone marrow transplant or a peripheral blood stem cell transplant. In the group who received VAPEC-B first line but did not proceed to transplant (27 patients), five relapsed (three with CNS disease who had not had CNS prophylaxis). Tolerance to treatment was measured by WHO toxicity scores. The haemoglobin (Hb) toxicity median score for all patients was grade 1 (Hb 9.5-10.9 g/dl), and the white cell count (WCC), toxicity score was grade 2 (WCC 2.0-2.9 x 10(9)/l). No platelet toxicity was observed. Ten per cent of patients suffered grade 3 severity infections requiring antibiotics and there was one treatment related death. The majority of patients received VAPEC-B on time, however, 24% patients had a 2-week delay. VAPEC-B chemotherapy is an effective regimen for malignant lymphoma, either as a first line or as a salvage treatment. Although chemotherapy was given weekly, the tolerance to treatment was acceptable, thus making this short regimen a good alternative to CHOP chemotherapy.

Association between air pollution and mortality due to respiratory diseases in children in São Paulo, Brazil: a preliminary report

This work presents the results of a time series study relating air pollution and respiratory mortality in children under 5 years of age in the metropolitan area of São Paulo, Brazil. Daily records of mortality (excluding neonatal mortality) for the period May 1990 to April 1991 were collected along with daily records of relative humidity, temperature, SO2, CO, particulates (PM10), O3, and NOx concentrations. Using multiple regression methods we demonstrated a significant association between mortality due to respiratory diseases and the NOx levels. After controlling for weather and season effects, the odds of dying due to respiratory diseases, considering the mean levels of NOx in São Paulo, was estimated at 1.3 (+/- 0.13). This result is in accord with previous animal studies conducted by our group and indicates that air pollution in São Paulo has reached levels high enough to have adverse health effects on the exposed population.

The successful use of radiotherapy for osteoblastoma

We report a case of osteoblastoma arising in the petrous temporal bone of a 16-year-old boy. Attempts at surgical resection were unsuccessful. The patient was treated with radiotherapy and is now well 10 years later. A review of the literature indicates that radiotherapy has been used rarely for this tumour and some have felt it to be detrimental. Our report illustrates a case where planned radiotherapy has been successful when full surgical resection had not been possible.

Effectiveness of three mouthrinses to inhibit acid formation by dental plaque under home-use conditions

A study was conducted to assess the effectiveness of three mouthrinses (Plax, Cepacol and Fluordent) to inhibit acid formation from plaque collected from 21 volunteer dental students. Plaque was collected on each side of the mouth, two hours after breakfast, once-a-week, after a period of 48 hours without any oral hygiene other than the use of the mouthrinses. Initial pH and the change in pH of plaque incubated with sucrose were recorded up to 120 min. Excepting Cepacol for the first week only, no inhibitory effect on acid formation was observed.

A single-dose study of the efficacy and safety of FS 205-397 (250 mg or 500 mg) versus aspirin and placebo in the treatment of postsurgery dental pain

The efficacy and safety of two dose levels of FS 205-397 (either 250 or 500 mg) were compared with the efficacy and safety of aspirin 650 mg and placebo in a 6-hour, single-dose, double-blind study in 161 patients who had undergone extraction of third molars. Each of the doses of FS 205-397, as well as aspirin, produced analgesia. However, the analgesic effects of both the 500 mg dose of FS 205-397 and aspirin were at times significantly better and more prolonged than those produced by the lower dose of FS 205-397. On the other hand, both doses of FS 205-397 had a significantly faster onset of action than aspirin. Side effects, reported by 17% of the 161 patients, did not differ significantly among the four treatment groups with respect to frequency, type, or severity. The most commonly reported side effects were nausea (7%) and drowsiness (6%). The results indicated that FS 205-397, administered in single doses of either 500 or 250 mg, is a safe and effective analgesic for the relief of pain following dental surgery, and may offer particular advantages in terms of onset of effects.

Effects of flunitrazepam on memory and their reversal by two antagonists

The amnestic effects of flunitrazepam (2 mg intravenously) were studied in normal volunteers with emphasis on their relationship to sleep and their reversal by two specific benzodiazepine receptor antagonists (Ro 15-1788 and Ro 15-3505). The test battery was based on available clinical tests to assess various aspects of encoding and recall. The results suggest that flunitrazepam impairs acquisition of new information by interfering with encoding, and that these effects are clearly independent of sleep. Flunitrazepam effects on memory were fully reversed by both antagonists, as were the subjective and objective signs of sedation. This speaks against the hypothesis of different receptors for sedative and amnestic effects. Ro 15-3505 had shorter lasting effects than Ro 15-1788 and interfered with some tests; this is discussed in relation to its inverse agonistic effects.

Infant temperament and subject loss due to crying during operant conditioning

Infants who failed to complete a 2-day operant-conditioning task were compared with a stratified random sample of those who did on measures of infant temperament and several demographic characteristics. A discriminant-function analysis revealed that female infants who cried differed from female infants who did not cry on measures of duration of orienting and latency to approach sudden or novel stimuli. Reliable prediction of crying and noncrying could not, however, be made for males. No sex differences emerged in the incidence of crying or in the number of sessions completed. Partially successful females (i.e., those completing 1 of the 2 sessions) could reliably be discriminated from those who cried during the first session on measures of age at testing and maternal ratings of smiling behavior. The results of this study suggest that, as with habituation studies, subject loss in operant-conditioning studies is influenced by individual differences among the infants which may or may not adversely affect external validity.

Limitation of impedance plethysmography in assessing efficacy of dihydroergotamine-heparin prophylaxis of deep vein thrombosis

The sensitivity of impedance plethysmography (IPG) for diagnosing deep vein thrombosis was evaluated in the presence of dihydroergotamine, an agent with significant venoconstrictor activity. In a prospective, randomized, controlled clinical trial, 105 patients undergoing total hip replacement surgery were investigated to evaluate the thromboprophylactic efficacy of DHE-Heparin using IPG and 125I-Fibrinogen Leg Scanning to monitor the incidence of DVT. Retrospective analysis of the IPG data indicated that DHE-Heparin impaired the sensitivity of impedance plethysmography by decreasing venous capacitance and venous outflow. Although the patient sample size was relatively small, the results showed trends which suggested that the utility of impedance plethysmography for diagnosing DVT was limited in the presence of a vasoactive agent. Alternate noninvasive diagnostic methods may need to be considered in select patients receiving concomitant medications possessing venoconstrictor activity.

Comparison of the metabolic activation of 7, 12-dimethylbenz(a)anthracene by a human hepatoma cell line (HepG2) and low passage hamster embryo cells

Under similar conditions of cell-mediated mutagenesis, secondary hamster embryo (HE) cells were much more effective than were cells of the human hepatoma cell line, HepG2 , in activating 7, 12-dimethylbenz(a)anthracene (DMBA) to metabolites mutagenic for V79 Chinese hamster cells. At the same dose of DMBA (0.1 microgram/ml), mutation induction (6-thioguanine resistance) with HE cells as activators was about ten times greater than with HepG2 cells as activators. Both cell types rapidly metabolized DMBA. HepG2 cells converted DMBA primarily to water-soluble derivatives that were neither sulfates nor glucuronides, whereas HE cells converted DMBA to a variety of organic solvent-soluble and water-soluble metabolites. The major water-soluble metabolites produced by HE cells were phenol-glucuronides. In HepG2 cells, binding of DMBA to DNA reached a maximum value of 12.1 pmol/mg DNA at 12 hr, whereas in HE cells, binding reached a peak value of 180.7 pmol/mg DNA at 24 hr. Despite this difference in total binding between the two cell types, the pattern of DNA adducts formed was nearly identical. The results indicate that the marked difference in the ability of HepG2 and HE cells to activate DMBA in cell-mediated mutation assays is not due to a lower metabolizing capacity of HepG2 cells for DMBA. Rather, significant differences in the metabolic pathways used by the two cell types lead to a marked reduction in DNA-binding metabolites in one cell type ( HepG2 ) compared to the other (HE).

Replicated evidence on the construct validity of the SCAG (Sandoz Clinical Assessment-Geriatric) scale

Factor analysis procedures, applied to a data bank of 1165 senile patients from 21 double-blind studies, yielded 5 factors: cognitive dysfunction (4 items), interpersonal relationships (4 items), apathy (4 items), affect (3 items) and somatic function (3 items). A retrospective review of the 1165 case histories revealed that patients fell into three distinct diagnostic classes: (a) patients whose symptoms of dementia were likely associated with multiple infarcts; (b) patients with other medical disorders such as metabolic imbalances, pulmonary diseases, etc. which may have induced dementia-like symptoms; and (c) primary degenerative dementia for patients with no evidence of other intervening causes. Factor analysis applied independently to the SCAG data of each of the three groups produced similar factor constructs, thereby suggesting that results reported with this instrument are valid across different geriatric diagnostic categories.

Benzo(a)pyrene and 7,12-dimethylbenz(a)anthracene metabolism and DNA adduct formation in primary cultures of hamster epidermal cells

Primary cultures of hamster epidermal cells exposed to hydrocarbon, 1 microgram/ml, rapidly metabolized [3H]benzo(a)pyrene and [14C]7,12-dimethylbenz(a)anthracene to ethyl acetate:acetone- and water-soluble metabolites. By 24 hr, only 13.6% of the organic solvent-soluble radioactivity recovered in the medium was unchanged [3H]benzo(a)pyrene, and only 5.9% was unchanged [14C]7,12-dimethylbenz(a)anthracene. With both hydrocarbons, the major water-soluble metabolites found extracellularly were conjugated with glucuronic acid; these were primarily phenolic derivatives. Metabolites cochromatographing with 7,8-dihydro-7,8-dihydroxybenzo(a)pyrene or trans-3,4-dihydro-3,4-dihydroxy-7,12-dimethylbenz(a)anthracene were not detectable in high-pressure liquid chromatographic profiles of organic solvent-soluble intracellular and extracellular metabolites. However, analysis of [3H]benzo(a)pyrene: and [3H]7,12-dimethylbenz(a)anthracene: DNA adducts indicated that these putative proximate carcinogenic metabolites were formed in these cells and subsequently metabolized to DNA-binding products. The results suggest that metabolic incompetence may not be an explanation for the relative resistance of the hamster to epidermal carcinogenesis by polycyclic hydrocarbons.

Benzo(a)pyrene metabolism in primary cultures of mouse epidermal cells and untransformed and transformed epidermal cell lines

The metabolism of [3H]benzo(a)pyrene [B(a)P] by cultures of primary mouse epidermal cells and untransformed and transformed epidermal cell lines was investigated. All three cell types effectively metabolized [3H]B(a)P. The major organic solvent-extractable metabolites found intracellularly in primary cultures were trans-7,8-dihydro-7,8-dihydroxybenzo(a)pyrene and 3-hydroxybenzo(a)pyrene, although quantities of 9-hydroxybenzo(a)pyrene, trans-9,10-dihydro-9,10-dihydroxybenzo(a)pyrene, and quinones also were present. The major organic solvent-soluble metabolites found in the extracellular medium were trans-9,10-dihydro-9,10-dihydroxybenzo(a)pyrene and trans-7,8-dihydro-7,8-dihydroxybenzo(a)pyrene, with smaller quantities of unconjugated phenols and quinones. The major water-soluble metabolites found in the extracellular medium were conjugated with glucuronic acid [primarily 3-hydroxybenzo(a)pyrene and several quinones]. No sulfate conjugates of [3H]B(a)P metabolites were detected. [3H]B(a)P metabolism was similar in cultures of untransformed and transformed epidermal cell lines but differed from the primary cultures. The major intracellular and extracellular organic solvent-soluble metabolites were diols. Little or no unconjugated phenols were detected. Both the untransformed and transformed epidermal cell lines converted [3H]B(a)P to water-soluble metabolites, primarily glucuronide conjugates. In contrast to the primary cells, a major pathway of trans-7,8-dihydro-7,8-dihydroxybenzo(a)pyrene metabolism in the untransformed and transformed cell lines was a glucuronide conjugate. Primary mouse epidermal cells provide an important model system for studying factors affecting the activation and detoxification of hydrocarbon carcinogens.

Tumor-initiating activity of 4-fluoro-7,12-dimethylbenz[a]anthracene and 1,2,3,4-tetrahydro-7,12-dimethylbenz[a]anthracene in female SENCAR mice

We have determined the skin tumor-initiating activity in SENCAR mice of two A-ring derivatives of 7,12-dimethylbenz[a]anthracene (DMBA). 4-Fluoro-7,12-dimethylbenz[a]anthracene at a dose of 200 nmol per mouse exhibited weak activity, producing 0.6 papillopmas per mouse; doses of 10 and 20 nmol per mouse had no activity. A derivative of DMBA with the A-ring reduced, 1,2,3,4-tetrahydro-7,12-dimethylbenz[a]anthracene (1,2,3,4,-H-DMBA), had substantial tumor-initiating activity when compared with the parent hydrocarbon. In one experiment, doses of 10 and 100 nmol per mouse gave rise to 1.6 and 9.5 papillomas per mouse, respectively; similar results were obtained in 3 additional experiments. Although the tumor-initiating activity of 1,2,3,4,-H4-DMBA was approximately one-tenth that of DMBA, this derivative was slightly (17%) more active than benzo[a]pyrene. 1,2,3,4-H4-DMBA was tested for the ability to induce mutations to 6-thioguanine-resistance in Chinese hamster V79 cells. In the absence of feeder cells capable of metabolizing polycyclic hydrocarbons, it was not mutagenic. However, in a cell-mediated mutation assay with secondary hamster embryo cells as activators, this derivative produced mutations in a dose-dependent manner and was approximately one-tenth as active as DMBA. These results indicate that metabolism of DMBA at positions 1-, 3-, 2- and 4- is important for biological activity and that for certain derivatives (i.e., 1,2,3,4-H4-DMBA), alternate pathways of metabolic activation may also be important.

A DL-DOPA drop test for the identification of Cryptococcus neoformans

A simple melanin assay using DL.DOPA as the substrate was developed to aid in the identification of Cryptococcus neoformans. The DL-DOPA drop test was simple and efficient. The best results (100% of the C. neoformans isolates were positive) occurred when C. neoformans was grown for two days at room temperature on Sabouraud agar modified. One to three loopfuls of yeast cells were then transferred to a starvation medium for 18-24 hours. Two of three drops of 0.3% DL-DOPA solution was applied to the transferred yeast cells. Only C. neoformans produced a brown or blackgrey pigment within 24 hrs, with 85% of the isolates becoming brown or black-grey within thirty minutes.

Esculin-based medium for isolation and identification of Cryptococcus neoformans

A simple medium was developed, using esculin as the substrate, for the isolation and identification of Cryptococcus neoformans. C. neoformans produced a brown-black pigment on the medium; all other yeasts produced no pigment or were light yellow. Esculin is beta-glucose-6,7-dihydroxycoumarin. C. neoformans produced pigment because the 6,7-dihydroxycoumarin component of the esculin molecule was converted to a melanin-like pigment. We think the reaction was similar to the conversion of diphenols, aminophenols, and diaminobenzenes to melanin. Laboratory studies with isolates of C. neoformans, C. albidus, C. luteolus, and C. terreus and representatives of the genera Candida, Torulopsis, Geotrichum, and Rhodotorula, plus environmental field studies, demonstrated that over 95% of C. neoformans isolates were correctly identified, whereas all other fungi were excluded. Esculin agar was a sensitive, specific medium for the isolation and identification of C. neoformans. It was inexpensive and had a long storage life.

Isodense acute subdural hematoma

An unusual isodense acute subdural hematoma is reported. Its causes may have included dilution with cerebrospinal fluid and a local or disseminated coagulopathy. Detection of such lesions requires a high incidence of suspicion based on subtle abnormalities found on computed tomography and the use of enhancement, particularly with the aid of advanced scanners. When a significant shift of the midline is seen, other alternatives would be angiography or placement of an exploratory burr hole on the "swollen" side.

Rapid biochemical characterization of Haemophilus species by using the micro-ID

Biotyping of Haemophilus influenzae into five type and H. parainfluenzae into three types based on indole production, ornithine decarboxylase, and urease has been reported (M. Kilian, Acta Pathol. Microbiol. Scand. Sect. B 82:835--842, 1976). A commercially available test system designed for the 4-h identification of Enterobacteriaceae. Micro-ID, proved efficacious for the rapid biotyping of these two Haemophilus species. The nitrate reductase, indole production, ornithine decarboxylase, urease, and o-nitrophenyl-beta-D-galactopyranoside hydrolysis tests in Micro-ID correlated over 99% with conventional methodology. By utilizing the indole and o-nitrophenyl-beta-D-galactopyranoside tests it was possible, with 261 of 272 (96.1%) isolates, to distinguish H. influenzae from H. parainfluenzae. Cerebrospinal fluid isolates were over 90% H. influenzae biotype I, and conjunctival isolates were approximately 70% biotype II. Type b H. influenzae were predominantly biotypes I and II; these type b isolates were also overwhelmingly indole producers. Although over 90% of biotypes I and II have been reported to produce beta-lactamase, this was not confirmed by the small number of beta-lactamase producers encountered here. The 4-h Micro-ID should prove a useful mechanism, amenable to the routine clinical laboratory, for the further exploration of the association of Haemophilus with the site of isolation, antigenicity, and antibiotic resistance.

Rapid identification of Enterobacteriaceae from blood cultures with the Micro-ID system

Micro-ID is a new test system designed to identify members of the family Enterobacteriaceae in 4 h. It consists of 15 biochemical tests on reagent-impregnated paper disks; each test is in its own compartment in a molded plastic tray. Based on the pattern of positive and negative biochemical reactions, a five-digit octal code number is calculated. A computer-generated identification manual accompanies the product, and for each octal code listed there is a numerical value that represents the unknown isolate's degree of fit to a typical organism (LFR), a second numerical value that represents its separation from other organisms (PNOR), and a verbal description of the quality of identification. Only one reagent is added to the system. Manufacturer's directions were modified in this laboratory to allow identification from a turbid blood culture bottle within 4 h. Based on 330 routine clinical cultures tested, there was a 96.1% agreement with conventional identification to the genus and species level: 1.2% yielded first two choices possible, with one being the correct choice; 1.2% provided a correct genus, but no species identification; and 1.5% produced an incorrect identification. The Micro-ID is an accurate, facile system for the rapid identification of Enterobacteriaceae from blood cultures.

Quality control of the latex-fixation test

Standardization of the latex-fixation test for the detection of rheumatoid factor may be achieved by the preparation of a standard reference serum. A number of guidelines for the quality control of precision and sensitivity of the test are suggested. In the use of dilution procedures, a 0.1 log10 or a 0.05 log10 difference between tubes is employed. The end point is defined and titer expressed in terms of a final dilution represented by the amount of antigen-antibody added. For statistical purposes all serologic data are geometrically expressed. Commercial kits may be standardized in terms of minimum detectable units and normalized for titer and unit values to enable laboratories to compare results.

Performance of latex-fixation kits used for serologic diagnosis of rheumatoid factor in rheumatoid arthritis sera

Ten latex-fixation kits (both slide and tube) were evaluated by use of a reference serum containing 250 IU of rheumatoid factor (Communicable Disease Center). All tests were performed with serial dilution of serum; adjacent tubes differed by a factor of 0.10 log10. Geometric titers, means, standard deviations, and variance analysis were used to evaluate commercial kits. Three levels of variance were applied: (1) 0.18 or less for intralaboratory variation when the same serum is tested with the same kit; (2) 0.18-0.35 when various lots or batches of the same serum were used; (3) 1.0 or less when various commercial kits were tested with the same serum. The sensitivity of each commercial kit was determined by assigning to it a value (the minimum detectable unit) arrived at by dividing the number of units in the standard by the titer obtained. The technic presented could be applicable to other serologic tests, and thus provide a general method for their standardization and quality control.

Clinical evaluation of the MICRO-ID, API 20E, and conventional media systems for identification of Enterobacteriacea

MICRO-ID (General Diagnostics, Morris Plains, N.J.) is a new kit system designed for the identification of Enterobacteriaceae in 4 h. It consists of 15 biochemical tests of paper disks. Each test is in its own compartment in a molded plastic tray. Only one reagent need be added to the system (2 drops of 20% KOH, which is added to the Voges-Proskauer test). Based on the pattern of positive and negative biochemical test results, a five-digit octal code number is calculated. An identification is derived from a computer-generated identification manual. A study was conducted to compare three systems-the MICRO-ID 4-h and the API 20E (Analytab Products Inc., Plainview, N.Y.) 18- to 24-h systems and a conventional media system-to measure the ability of each to identify members of the family Enterobacteriaceae. Comparison tables, rather than simple percentage agreement tables, were generated to define the particular strengths and weaknesses of each system and allow the laboratory to best use the data. The MICRO-ID compared quite favorably with conventional media. MICRO-ID yielded incorrect identifications with 1.5% of the isolates tested (API 20E, 4.7% misidentification rate). Half the MICRO-ID misidentifications occurred when the system identified a Citrobacter diversus as a lysine-negative Escherichia coli; all gave one octal number. A direct comparison of the MICRO-ID and API 20E was of limited value because percentage agreements were merely the sums of the errors of each. The ease of inoculation, the requirement for the addition of only one reagent, and the 4-h capability make the MICRO-ID system an extremely attractive development in the field of bacterial identification.

Three-wavelength light transmission technique to measure smoke particle size and concentration

This paper describes an optical technique and instrumentation for measuring the average particle size and mass concentration of smoke. Transmission through the smoke at three wavelengths (0.45 microm, 0.63 microm, and 1.00 microm) is measured using a white light source and a compact, three-wavelength detector assembly. Sizes and concentrations are then calculated from the transmission data using Mie theory. Graphs of the calculated Mie extinction coefficients are presented for several complex refractive indices. This three-wavelength optical technique was used to study smoke from a wood-tunnel fire, and the results are compared to those of other sizing techniques.

Clobazam versus placebo for anxiety and tension in psychoneurotic outpatients. A multicenter collaborative study

Clobazam, a 1,5-benzodiazepine, was compared with placebo in 190 psychoneurotic outpatients with prominent symptoms of anxiety and tension of at least two weeks of duration. The design was one of double-blind parallel groups treated for one week. Clobazam subjects began on 40 mg daily in divided dosage, which was increased to 80 mg daily be day 3 if the drug was well tolerated. Two patients receiving clobazam had laboratory chemistry abnormalities which were possibly drug related. Adverse effects occurred more frequently in the clobazam group and were typical of those of marketed benzodiazepines. This study indicates that clobazam is an effective anxiolytic agent demonstrating its clinical effects during the first week of treatment.

Esculin hydrolysis by Enterobacteriaceae

Literature reports disagree concerning esculin hydrolysis in the family Enterobacteriaceae. A total of 2,490 strains of the family were investigated for esculin hydrolysis by two methods, the esculin spot test and the PathoTec incubation strip, which measures constitutive enzyme, and five growth-supporting methods, which determine both constitutive and inducible enzymes. The five growth-supporting media studied were: Vaughn-Levine, the standard esculin hydrolysis medium (P. R. Edwards and W. H. Ewing, Identification of Enterobacteriaceae, 3rd ed., 1972); Vaughn-Levine without iron; Vaughn-Levine without Andrade's indicator; and bile-esculin medium. Growth media were incubated at 35 degrees C and checked every 24 h for 120 h. On growth media, 0.3% of Escherichia coli were positive in 24 h, 34% in 48 h, and 61% in 120 h. No strains were positive on the "nongrowth" tests. It appeared that the esculin hydrolysis enzyme(s) of E. coli was inducible rather than constitutive. All esculin hydrolyzers, which yielded positive tests on "constitutive tests" and 24-h tests, were limited to the genera Klebsiella, Enterobacter, and Serratia and species of Proteus vulgaris, Proteus rettgeri, and Citrobacter diversus. When used with standardized inoculum size and incubation time, the esculin hydrolysis test is very useful for differentiation within the family Enterobacteriaceae.

The use of bile - esculin agar for the taxonomic classification of the family Enterobacteriaceae

Bile-esculin medium has been used for many years for the presumptive identification of group D Streptococcus. The test is based on the ability of a bacterium to grow in the presence of 40% bile and produce esculinase. 2935 strains of Enterobacteriaceae were inoculated onto bile-esculin agar slants and incubated at 35 C. Esculin hydrolysis was determined after 24 and 48 hours. At 24 hours of incubation esculin hydrolysis was limited to the genera Klebsiella, Enterobacter, Serratia, and the species P. vulgaris, P. rettgeri, and C. diversus. Not all strains of these species were positive, however. All other members of the family were negative. At 48 hours of incubation 37% of E. coli gave a positive reaction; all other Enterobacteriaceae which were negative at 24 hours remained negative. Esculin hydrolysis is a valuable test for the taxonomic classification of the family Enterobacteriaceae.