Demographic and Clinical Predictors of Pharmacist-Administered Pediatric Influenza Immunization

Background: Pediatricians' offices are primary locations for pediatric influenza vaccination; however, pharmacists are also well-positioned as immunizers. Considering the current COVID-19 pandemic and Public Readiness and Emergency Preparedness (PREP) Act, pharmacists' authority to vaccinate children has been recently expanded. Methods: We used the de-identified Optum ClinformaticsTM Data Mart database to identify demographic and clinical predictors of pharmacist-administered pediatric influenza vaccination compared with influenza vaccination in pediatricians' offices. Procedures codes for influenza vaccinations among children were captured for the 2016-2017 influenza season. Logistic regression was used to identify significant predictors. Results: We included 336 841 children receiving influenza vaccines by a pharmacist (5.2%) or in pediatricians' offices (94.8%). The following significant predictors were identified: older pediatric age groups (13-17 years odds ratio [OR] 91.51, 5-12 years OR 35.41), states allowing pharmacist-administered influenza vaccination at younger ages (no age restrictions OR, 26.68, minimum age 2-4 years old OR, 33.76), influenza vaccination outside of pediatricians' offices in the previous year (pharmacist-administered OR, 22.18, convenience care OR 4.15, emergency care OR 1.69), geographic region (South OR, 2.02, Midwest OR 1.60, and West OR 1.38), and routine health exam or follow-up in the prior 6-months (OR, 1.59). Conclusions: The strongest drivers of pharmacist-administered pediatric influenza vaccination were older pediatric age, more lenient minimum age restrictions, and previous influenza vaccination in a pharmacy. Due to the COVID-19 pandemic, the PREP Act, and forthcoming pediatric COVID-19 vaccines for children, pharmacists may play a greater role in pediatric vaccination resulting in sustained changes in pediatric vaccination practices.

Assessing pharmacist and clinician perspectives on pharmacist-prescribed hormonal contraceptives

BACKGROUND

After the Dobbs et al. ruling in June 2022 by the U.S. Supreme Court eliminated the federal right to abortion care, concerns about access to reproductive health have been elevated. Barriers to contraception use consist of knowledge deficits, unfavorable legal rulings, cost and insurance coverage, unnecessary medical practices, and health care inequities. Pharmacists are the most accessible health care providers who are positioned to mitigate these barriers and expand reproductive health access through scope of practice expansion. The American College of Obstetricians and Gynecologists has expressed their support for pharmacists prescribing hormonal contraceptives. As of October 2022, 22 states and jurisdictions have a protocol in place to allow for autonomous prescribing of hormonal contraceptives by pharmacists.

OBJECTIVE

The objective of this study was to simultaneously assess pharmacist and clinician perspectives of all ages and sexual identities, on pharmacist-prescribed hormonal contraceptives and barriers faced in accessing contraception.

METHODS

The researchers conducted an institutional review board-approved observational study via a cross-sectional survey distributed to licensed pharmacists and clinicians from October 2022 to February 2023. The survey population included those who were 18 years or older, English speaking, and recruited both in person and through e-mail listservs. The survey assessed barriers to contraception access, perspectives toward pharmacist-prescribed hormonal contraception, likelihood of receiving pharmacist-prescribed hormonal contraception, and pharmacist comfort with prescribing hormonal contraceptives.

RESULTS

Nearly 38% of respondents reported having ever experienced ≥ 1 barrier in accessing contraception, which were having a time barrier or delay in appointment, a cost or copay barrier, and/or lacking an obstetrician/gynecologist. Eighty-one percent of all respondents agreed or strongly agreed with pharmacist-prescribed hormonal contraception. Sixty-one percent of pharmacists said they are either very or somewhat comfortable prescribing hormonal contraception. Pharmacists' most commonly reported concerns were payment for services, lack of access to patient medical records, and patient safety.

CONCLUSIONS

After Dobbs et al., most pharmacists and clinicians in Rhode Island support pharmacist-prescribed hormonal contraceptives and the most frequently reported barriers faced in accessing contraception may be overcome through pharmacist prescribing. The information and data gathered from this study supported legislation for pharmacist prescriptive authority for hormonal contraception in Rhode Island.

Pharmacist-Administered Influenza Vaccination in Children and Corresponding Regulations

In our retrospective cohort study, we evaluated trends in pharmacist-administered pediatric influenza vaccination rates in the United States and corresponding state-level pharmacist pediatric vaccination authorization models, including minimum age requirements, vaccination protocols, and/or prescription requirements. An administrative health claims database was used to capture influenza vaccinations in children less than 18 years old with 1 year of continuous enrollment and joinpoint regression was used to assess trends. Of the 3,937,376 pediatric influenza vaccinations identified over the study period, only 3.2% were pharmacist-administered (87.7% pediatrician offices, 2.3% convenience care clinics, 0.8% emergency care, and 6.0% other locations). Pharmacist-administered pediatric influenza vaccination was more commonly observed in older children (mean age 12.65 ± 3.26 years) and increased significantly by 19.2% annually over the study period (95% confidence interval 9.2%-30.2%, p < 0.05). The Northeast, with more restrictive authorization models, represented only 2.2% (n = 2816) of all pharmacist-administered pediatric influenza vaccinations. Utilization of pharmacist-administered pediatric influenza vaccination remains low. Providing children with greater access to vaccination with less restrictions may increase overall vaccination rates. Due to the COVID-19 pandemic and the Public Readiness and Emergency Preparedness Act, pharmacists will play a major role in vaccinating children.

Leadership Lessons and Career Advice From the Musical Hamilton

The musical Hamilton, written by Lin-Manuel Miranda, creatively depicts the life and career of founding father Alexander Hamilton. While Hamilton is the primary focus, highlights of the career and personal journeys of other leaders, such as George Washington, Thomas Jefferson, and Aaron Burr, are interjected throughout the production. Often the musical numbers in Hamilton focus on aspects of leadership and career development that Hamilton and his contemporaries were learning or needed to learn. These lessons are applicable to the challenges that faculty members in academic pharmacy face today at different stages of a career. These include the importance of maximizing opportunities, listening, self-reflection, compromise, patience, empathy, prioritizing, tending relationships, making difficult decisions, knowing when to say goodbye, and managing a legacy.

Minor physical anomalies across ethnic groups in a first episode psychosis sample

Minor physical anomalies (MPAs) are more prevalent amongst individuals with psychosis, supporting a neurodevelopmental model for psychotic disorders. The aim of this study was to investigate the possibility that neurodevelopmental adversity contributes to the excess of psychosis found in some ethnic groups in the UK. Subjects with first onset psychosis and healthy neighbourhood controls were enrolled in the AESOP study in South East London and Nottingham between 1997 and 1999. MPA rates were estimated in four broad ethnic groupings (White, African Caribbean, Black African and Other). Patients (n=245) had a higher mean total MPA score than healthy controls (n=158). This held true across each of the four ethnic groupings. The results of this study suggest that neurodevelopmental factors play a role in the aetiology of psychosis across all ethnic groups.

Individual-based approach to modeling hyphal growth of a biocontrol fungus in soil

ABSTRACT Fungi in soil perform beneficial roles that include biological control of soilborne plant pathogens. However, relatively little predictive information is available about the growth and activity of fungal hyphae in soil habitats. A stochastic computer simulation model ("Fungmod") was developed to predict hyphal growth of the biocontrol fungus Trichoderma harzianum ThzID1 in soil. The model simulates a fungal colony as a population of spatially referenced hyphal segments, and is individual-based, in that records of spatial location and branching hierarchy are maintained for individual hyphal nodes. In this way, the entire spatial structure of the fungal colony (hyphal network) can be explicitly reconstructed at any point in time. Also, the soil habitat is modeled as a population of spatially referenced 1-mm(3) soil cells, allowing for the simulation of a spatially heterogeneous environment. Initial hyphal growth parameters were derived from previously published results, and the model was tested against new data derived from image analysis of hyphal biomass accumulation in soil. The ability to predict fungal growth in natural habitats will help to improve the predictability of successful myco-parasitic events in biological control systems.

Grey matter correlates of minor physical anomalies in the AeSOP first-episode psychosis study

BACKGROUND

Minor physical anomalies are more prevalent among people with psychosis. This supports a neurodevelopmental aetiology for psychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association.

AIMS

To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis.

METHOD

Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients.

RESULTS

The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus.

CONCLUSIONS

Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regional grey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Development of an assay for antibodies to Saccharomyces cerevisiae: Easy, cheap and specific for Crohn's disease

OBJECTIVE

To develop a serological test to measure antibodies to Saccharomyces cerevisiae in patients with inflammatory bowel disease.

METHODS

An ELISA to the mannan of S cerevisiae that is commercially available was developed. Sera were tested from randomly chosen sera specimens kept frozen at the University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba. Clinical diagnoses were kept blinded until the assay results were finalized. One hundred thirty-six sera were tested, including 51 with Crohn's disease, 32 with ulcerative colitis, one with indeterminate colitis and 16 other control subjects. Thirty-six samples were duplicates from patients already studied but were either run on separate days or drawn on different days.

RESULTS

Using a cutoff of 15 binding units as a positive result, Crohn's disease was found to have a sensitivity of 53% but a specificity of 100% compared with ulcerative colitis. Compared with all other diagnoses (including ulcerative colitis), Crohn's disease had a sensitivity of 53% and a specificity of 96%. For patients with Crohn's disease only, those who were anti-S cerevisiae antibody (ASCA) positive (n=27) were significantly more likely to have proximal gastrointestinal disease and significantly less likely to have colonic or inflammatory type disease than those who were ASCA negative (n=24). The direct cost of this assay was $6.00 per positive test, and the total charge was set at $38.15.

CONCLUSIONS

A reasonably inexpensive, easy and reproducible assay to assess for antibodies to S cerevisiae has been developed. Using a cutoff for positivity of 15 binding units, this test had a specificity of 100% for ruling out Crohn's disease and a lower (60%) sensitivity compared with ulcerative colitis. This test could identify a specific phenotype of patients with Crohn's disease as being more likely to have small bowel Crohn's disease and less likely to have colonic (isolated) or inflammatory disease, as opposed to fibrostenotic disease or penetrating disease. The test proved reliable when assaying samples drawn or assayed on different days.

Enterotoxigenic Escherichia coli infection in captive black-footed ferrets

Enterotoxigenic Escherichia coli with genes for heat stabile toxins Sta and STb was isolated from the gastrointestinal tract and multiple visceral organs of three adult and three juvenile black-footed ferrets (Mustela nigripes) that died in a captive breeding colony between 24 May 1998 and 2 July 1998. Similar isolates were obtained from rectal swabs of one adult and one juvenile that were clinically ill. All were fed a diet composed of mink chow, raw rabbit meat, beef liver powder, blood meal and lard. Escherichia coli of the same toxin genotype was isolated from the mixed ration. Clinical signs included sudden death, dehydration, anorexia and diarrhea. Necropsy lesions included acute enteritis with large numbers of rod shaped bacteria microscopically visible on intestinal villi.

Psychiatric treatment and operational readiness: clinical guidelines for Air Force practice

Clinical criteria for psychiatric illnesses that are career limiting to active duty Air Force personnel are defined in Air Force Instruction (AFI) 48-123. The terms used in the AFI are not sufficiently specific to the standards of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The authors review AFI 48-123 for conditions commonly seen in Air Force mental health practice and offer clinical interpretation of this AFI to bring it into line with DSM-IV. As a result of this synthesis, decisions regarding which mental health conditions warrant medical evaluation board disposition are clearer and more uniform. Clinicians and administrators are encouraged to refer to this paper for assistance in making decisions on mental health patients.

The Massachusetts forensic transition program for mentally ill offenders re-entering the community

On April 1, 1998, the Massachusetts Department of Mental Health established the forensic transition program for mentally ill offenders. The primary goal of the statewide program, which follows clients for three months after their release from correctional facilities, is to coordinate services and assist in community reintegration. In the first year of the program, 233 mentally ill offenders received services. Seventy-four clients had been discharged as of April 1, 1999. At discharge 42 of the 74 clients (57 percent) were living in the community and were receiving mental health services. The other clients were hospitalized immediately after release (20 percent), reincarcerated (10 percent), hospitalized after a brief stay in the community (3 percent), or lost to follow-up (11 percent).

The use of amplified fragment length polymorphism (AFLP) in the isolation of sex-specific markers

Sex identification is a problem in research and conservation. It can often be solved using a DNA test but this is only an option if a sex-specific marker is available. Such markers can be identified using the amplified fragment length polymorphism (AFLP) technique. This is usually a taxonomic method, as it produces a DNA fingerprint of 50-100 PCR bands. However, if male and female AFLP products are compared, sex-specific markers are confined to the heterogametic sex and can rapidly be identified. Once a marker is found, AFLP can be used to sex organisms directly or the marker can be sequenced and a standard PCR test designed.

Genetic and environmental risk factors for Parkinson's disease in a Chinese population

An epidemiological study of the environmental and genetic factors as well as the possible interplay between them was conducted among 215 patients with Parkinson's disease and 313 controls in a Chinese population in Hong Kong. In univariate analysis, a regular tea drinking habit was found to be a protective factor, which had not been reported before. Smoking (a protective factor), family history, duration of pesticide exposure (in years) in farming and pesticide exposure during farming in women (both risk factors) have been reported previously. In multivariate analysis, current smoking reached borderline significance at the 5% level and the variables, years exposed to pesticides and family history were significant at the 10% level. By contrast with the common occurrence of polymorphism of the CYP2D6 gene (a gene involved with xenobiotic metabolism) in white people, it is very rare in China and is not thought to be a significant factor contributing to Parkinson's disease in Chinese people.

A DNA test to sex most birds

Birds are difficult to sex. Nestlings rarely show sex-linked morphology and we estimate that adult females appear identical to males in over 50% of the world's bird species. This problem can hinder both evolutionary studies and human-assisted breeding of birds. DNA-based sex identification provides a solution. We describe a test based on two conserved CHD (chromo-helicase-DNA-binding) genes that are located on the avian sex chromosomes of all birds, with the possible exception of the ratites (ostriches, etc.; Struthioniformes). The CHD-W gene is located on the W chromosome; therefore it is unique to females. The other gene, CHD-Z, is found on the Z chromosome and therefore occurs in both sexes (female, ZW; male, ZZ). The test employs PCR with a single set of primers. It amplifies homologous sections of both genes and incorporates introns whose lengths usually differ. When examined on a gel there is a single CHD-Z band in males but females have a second, distinctive CHD-W band.

The effects of oral versus written instructions on parents' recall and satisfaction after pediatric appointments

This study explored the differential effects of written versus oral instructions on parents' recall of information and satisfaction after pediatric appointments. Ninety-six parents completed descriptive information and satisfaction ratings, and four pediatricians completed ratings concerning the complexity level of the appointment. After the appointment, parents were randomly assigned to the Written condition (to receive a transcription of the pediatrician's instructions) or Oral condition (verbal instruction only). Parents were telephoned 5 to 7 days later to report their recall of instructions and satisfaction with the appointment. For the Oral condition parents only, more previous appointments with a given pediatrician were associated with greater parental satisfaction and recall of instructions, and more previous appointments and more time spent with the pediatrician were related to fewer forgotten instructions. Parental characteristics, such as age, number of children, and occupational status, were associated with satisfaction and accurate recall. Implications of these findings are discussed.

Variation in sexual orientations among men who have sex with men, and their current sexual practices

PURPOSE

To explore group variations in sexual risk-taking among different sexual orientations of men who have sex with men (MSM).

METHOD

A convenience sample of men was recruited in gay-identified venues. An analysis was conducted to determine the independence of sexual orientation (gay, gay-previously heterosexual, currently bisexual), age and risk-taking.

RESULTS

Bisexual men were younger, lived outside metropolitan areas and socialized more in bathhouses. In general, bisexuals reported the safest sexual practices and previously heterosexual men the most unprotected.

CONCLUSIONS

Among MSM, variation in sexual orientations was associated with differences in unprotected sex for older age groups. For the youngest age group, a similar level of risk-taking of the different orientation groups suggests uniform sociocultural influences.

Dosimetric considerations in treating mediastinal disease with mantle fields: characterization of the dose under mantle blocks

PURPOSE

While the rationale for using mantle fields is well understood and the prescription of these fields is straightforward, the underlying complexity of the dose distributions that result is not generally appreciated. This is especially true in the choice of lung block design, which affects the dose to both the target volume as well as to the normal lung tissue. The key to the design of optimal lung blocks is the physician's perception of the complex relationship between the geometric and dosimetric aspects of heavily modified fields, as well as how the physical and anatomical properties of the target volume and the shape of the patient's lungs relate to the images visualized on simulator films.

METHODS AND MATERIALS

Depth doses and cross-beam profiles of blocks ranging in width from 1 cm to 10 cm were taken using an automated beam scanning system. These data were then converted to "shadow fields." The results were compared to open fields of the same size using standard methodology.

RESULTS

Shadow fields behave quite similarly to small, open fields in terms of x-ray-light field congruence, flatness, symmetry, and penumbra. There is a 2-3 mm rim between the edge of the block and the point at which it becomes nominally effective. The dose at the center of a block, which gives the normalization of the shadow fields, is given by a block transmission factor (BTF), which produces results in excellent agreement with measurements over a wide variety of block sizes and tissue depths.

CONCLUSION

The radiation dose under shielding blocks can be considerably higher than expected, and care must be exercised when drawing blocks close to critical structures. The effects of blocks can be described in terms of normalized shadow fields, which behave similar to narrow, open fields, but with a divergence characteristic of their position relative to the radiation source. The normalization value for these fields, which gives the relative dose under the block, can be obtained from a straightforward analytical expression, the BTF.

Serologic testing for reactive arthritis

The objective of the study was to determine the sensitivity and specificity of quantitative serum antibody response to Salmonella enteritidis lipopolysaccharide (LPS) as a diagnostic test for post-Salmonella reactive arthritis (ReA). In a single food-source outbreak of Salmonella enteritidis, serum was collected from dysenteric individuals with and without ReA at 6, 12, and 24 months post infection. Serum was also collected from control patients with no prior exposure to Salmonella infection. Quantitative measurements of isotypic antibodies to Salmonella enteritidis LPS were performed by an ELISA. Sensitivity and specificity of quantitative isotypic antibody levels over time were plotted on receiver operator characteristic (ROC) curves. Serum IgG and IgA anti-LPS were found to be present in higher levels in the ReA patients than in controls. Using the optimal cutoff of 0.10 selected from an ROC curve, IgG anti-LPS is 88% sensitive and 94% specific, and IgA anti-LPS is 75% sensitive and 100% specific. We conclude that IgA anti-LPS is both sensitive and specific in distinguishing prior exposure to Salmonella LPS in ReA patients compared to unexposed controls.

Utilization of commercial antisera and flow cytometry in HLA-B27 typing

The study of large groups of individuals (from reactive arthritis epidemics, for example) for epidemiologic and genetic data has been hampered by the techniques by which HLA typing is performed. Microlymphocytotoxicity is costly not only in materials but also in the time required to perform a given assay and thus does not lend itself to large scale testing. To study such epidemics, in the best way, one must be able to respond as soon as possible after the epidemic is recognized and on a large scale. We thus examined HLA-B27 typing by flow cytometry and commercially available monoclonal antibodies. Two commercially available monoclonal HLA-B27 antibodies were compared. We conclude that the utilization of monospecific HLA-B27 antibodies and flow cytometry allows for the determination of HLA-B27 and HLA-B7 phenotype of a large number of individuals over a short period of time, thereby making the study of a large group both economical and feasible.

Secretory immune response and clinical sequelae of Salmonella infection in a point source cohort

OBJECTIVE

To determine the kinetic isotypic serum and secretory immune response to Salmonella enteritidis in a cohort of individuals exposed to the organism in a single food source outbreak of dysentery. To determine the clinical outcome and immunogenetics of the exposed cohort and to correlate these features with the immune response.

METHODS

Following a single point source outbreak of Salmonella enteritidis, a cohort of dysenteric individuals were ascertained using a reactive arthritis screening questionnaire (QUEST). Serum and stimulated saliva samples were obtained at 6, 12, and 24 months following the outbreak of dysentery; examinations were conducted at the same time. Two unexposed control groups were ascertained: (1) general rheumatology clinic patients and (2) well nonarthritic family practice patients. An ELISA to determine quantitative IgA responses to Salmonella enteritidis lipopolysaccharide (LPS) was performed.

RESULTS

Eleven of the 84 exposed individuals with dysentery developed reactive arthritis (ReA) of reactive enthesitis (ReE). There was a prolonged salivary IgA anti-LPS response in both the ReA/ReE and DYS (dysentery alone) patients compared with unexposed controls. A ratio of salivary IgA anti-LPS/serum IgA anti-LPS > 1 was associated with a good outcome (remission) of ReA, whereas a ratio < 1 was associated with chronic disease.

CONCLUSIONS

There is a more prolonged humoral immune response to Salmonella LPS in exposed individuals than hitherto described. A risk factor in the prolongation of ReA is the inability to mount an appropriate specific salivary (secretory) immune response.

Nosocomial infection with Clostridium difficile investigated by pyrolysis mass spectrometry

Fifty-eight isolates of Clostridium difficile from two distinct outbreaks were examined for inter-strain similarity by pyrolysis mass spectrometry (PMS). The first outbreak began on a geriatric acute unit and spread to a long stay geriatric facility. PMS analysis showed that most isolates from both sites were indistinguishable. Isolates obtained in the preceding year from the long stay facility were found to be closely similar to these outbreak isolates. In the second, smaller outbreak on a female medical ward in another general hospital, PMS again showed that a single strain was probably responsible. Representative isolates from these two different outbreaks were shown to be distinct. The ability to compare rapidly large numbers of isolates of C. difficile makes PMS attractive for initial screening in suspected outbreaks, providing important information for outbreak management and allowing conventional typing methods to be concentrated on relevant isolates.

The cerebral radioprotective effect of alternative barbiturates to pentobarbital

The potential for normal brain tissue injury is one of the limiting factors in the use of radiotherapy for brain tumors. As attempts to enhance brain tumor radiation sensitivity have been unsuccessful, the use of cerebral radioprotectants provides an attractive alternative. Pentobarbital has recently been shown to be a cerebral radioprotectant in the rodent and primate models of single fraction radiation injury. Because daily high doses of pentobarbital bring certain significant risks, the potential usefulness of alternative barbiturates was explored. Seven groups of rats received 70 Gy of whole-brain-only irradiation in the single fraction. Group 1 was treated while awake. Groups 2, 3, and 4 received pentobarbital, thiopental, and methohexital, respectively. Groups 5, 6, and 7 received increasing doses of phenobarbital. Mean group survival at 30 days after treatment was determined and compared with the survival of animals treated while awake. Thiopental enhanced survival, similar to pentobarbital. Methohexital and phenobarbital were of no radioprotective value. The differences in the hypnotic effects of these barbiturates is based on dissimilar effects on the kinetics of chloride ion channel patency. We propose that these differences also influence their radioprotective properties. Thiopental is a shorter acting alternative to pentobarbital for cerebral radioprotection. Use of it should permit safer and easier investigation of this radioprotective effect in human trials.

A simple CT aperture emulator for use with a radiotherapy simulator

Tumor localization in radiation treatment planning often involves the generation of quantitative anatomical data from multiple imaging modalities. It is desirable to take all of the images in the selected treatment position, which is usually decided upon during the initial simulator session. The different scanning modalities are often operated by different staff, at different times and in different locations; thus, it is difficult to ensure consistency in the position of the patient's body, and its documentation, at various times and places. Also, devices such as CT and MR scanners frequently pose restrictions due to their limited apertures. Failure to consider the physical limitations of such scanning equipment at the time of simulation or localization may result in placing the patient in a treatment position which will not fit through the aperture of the CT (or MRI) scanner, or which will result in a clinically important portion of the anatomy being "cut off" in the resulting scans. This can lead to re-simulation of the patient or result in a lack of accurate coordination of simulator and CT scan data. To minimize problems such as these, we have developed a CT Aperture Emulator which can be used at the time of the initial simulation. This is a lightweight "halo" easily attached to the simulator, which mimics the size and shape of the CT aperture. It permits reproducible adjustment of the patient's position, while allowing technologists and physicians to set up the patient with respect to potential CT constraints, in particular with regard to the use of immobilization and support devices. The emulator device also facilitates reproducing a patient's treatment position on the CT scanner. The concept has been found to have additional clinical uses and can be extended to a variety of imaging equipment.

Rapid inter-strain comparison by pyrolysis mass spectrometry in nosocomial infection with Xanthomonas maltophilia

Seventeen strains of Xanthomonas maltophilia and one strain of Pseudomonas cepacia were examined by pyrolysis mass spectrometry (PYMS). The Xanthomonas strains comprised 11 clinical and environmental isolates from a suspected outbreak of colonization and infection on a heart-lung transplant intensive care unit, two strains from patients elsewhere in the same hospital and four strains from a national reference collection. The single isolate of Pseudomonas cepacia was from a sink in the same affected intensive care unit. A series of discriminant analyses performed on the PYMS-derived data showed that, whereas six strains of Xanthomonas from the respiratory tract, blood and ventilatory equipment of one of the affected patients were indistinguishable, all the other isolates were distinct. The results of PYMS rapid inter-strain comparison were in accord with those of an epidemiological investigation which suggested that the episode was due to unauthorized reuse of disposable nebulizers and not to cross-infection between patients. Pyrolysis mass spectrometry with rapid data analysis is a potentially useful technique for the investigation of nosocomial infections due to organisms such as X. maltophilia.

Neoplastic invasion in experimental carcinoma of the colon: abnormal differentiation and release of mucus

Carcinomas of the colon were induced in F344 rats with dimethylhydrazine (20 mg/kg for 12 weeks). The invasive edges of the lesions were examined with the electron microscope. As in human colorectal cancer, the invasive edges show neoplastic cells with abnormal differentiation of apical cytoplasmic rootlets and processes at the basal or invasive edge of the cell, 'apical reversal'. Mucous carcinoma cells release material into the interstitial connective tissue matrix. The features may contribute to the complex phenomenon of neoplastic invasion.

Reduction in radiation-induced brain injury by use of pentobarbital or lidocaine protection

To determine if barbiturates would protect brain at high doses of radiation, survival rates in rats that received whole-brain x-irradiation during pentobarbital- or lidocaine-induced anesthesia were compared with those of control animals that received no medication and of animals anesthetized with ketamine. The animals were shielded so that respiratory and digestive tissues would not be damaged by the radiation. Survival rates in rats that received whole-brain irradiation as a single 7500-rad dose under pentobarbital- or lidocaine-induced anesthesia was increased from between from 0% and 20% to between 45% and 69% over the 40 days of observation compared with the other two groups (p less than 0.007). Ketamine anesthesia provided no protection. There were no notable differential effects upon non-neural tissues, suggesting that pentobarbital afforded protection through modulation of ambient neural activity during radiation exposure. Neural suppression during high-dose cranial irradiation protects brain from acute and early delayed radiation injury. Further development and application of this knowledge may reduce the incidence of radiation toxicity of the central nervous system (CNS) and may permit the safe use of otherwise "unsafe" doses of radiation in patients with CNS neoplasms.

Cerebral radioprotection by pentobarbital: dose-response characteristics and association with GABA agonist activity

Pentobarbital reduces cerebral radiation toxicity; however, the mechanism of this phenomenon remains unknown. As an anesthetic and depressant of cerebral metabolism, pentobarbital induces its effects on the central nervous system by stimulating the binding of gamma-aminobutyric acid (GABA) to its receptor and by inhibiting postsynaptic excitatory amino acid activity. The purpose of this study is to investigate the role of these actions as well as other aspects of the radioprotective activity of pentobarbital. Fischer 344 rats were separated into multiple groups and underwent two dose-response evaluations. In one set of experiments to examine the relationship of radioprotection to pentobarbital dose, a range of pentobarbital doses (0 to 75 mg/kg) were given intraperitoneally prior to a constant-level radiation dose (70 Gy). In a second series of experiments to determine the dose-response relationship of radiation protection to radiation dose, a range of radiation doses (10 to 90 Gy) were given with a single pentobarbital dose (60 mg/kg intraperitoneally). Further groups of animals were used to evaluate the importance of the timing of pentobarbital administration, the function of the (+) and (-) isomers of pentobarbital, and the role of an alternative GABA agonist (diazepam). In addition, the potential protective effects of alternative methods of anesthesia (ketamine) and induction of cerebral hypometabolism (hypothermia) were examined. Enhancement of survival time from acute radiation injury due to high-dose single-fraction whole-brain irradiation was maximal with 60 mg/kg of pentobarbital, and occurred over the range of all doses examined between 30 to 90 Gy. Protection was seen only in animals that received the pentobarbital before irradiation. Administration of other compounds that enhance GABA binding (Saffan and diazepam) also significantly enhanced survival time. Ketamine and hypothermia were without protective effect. Protection from acute radiation-induced mortality by pentobarbital in the rat model is a reproducible phenomenon and is associated with the GABA agonistic activity of the compound. This property of GABA agonists offers the potential for a novel approach to enhancement of the efficacy of radiation therapy in the treatment of brain tumors.

Enhancement of the efficacy of x-irradiation by pentobarbital in a rodent brain-tumor model

Radiation therapy is an important component of brain tumor treatment, but its efficacy is limited by its toxicity to the surrounding normal tissue. Pentobarbital acts as a cerebral radioprotectant, but the selectivity of its protection for the central nervous system has not been demonstrated. To determine if pentobarbital also protects tumor against ionizing radiation, five groups of Fischer 344 rats were observed after exposure to varying combinations of the presence or absence of implanted tumor, pentobarbital, and radiation treatment. The first three groups underwent cerebral implantations of a suspension of 9L gliosarcoma cells. Group 1 was left untreated and served as tumor-bearing controls. Group 2 received 30 Gy of whole-brain x-irradiation without anesthesia 8 days after tumor implantation. Group 3 received the same radiation treatment 15 minutes after pretreatment with 60 mg/kg of pentobarbital intraperitoneally. Groups 4 and 5 served as radiation controls, receiving 30 Gy of x-irradiation while awake and 30 Gy of x-irradiation after pentobarbital administration, respectively. Survival was calculated from the death of the last tumor-bearing rat. The mean survival time in tumor-bearing control rats was 20.8 +/- 2.6 days (+/- standard deviation). X-irradiation alone significantly enhanced the period of survival in rats implanted with the 9L tumor (29.7 +/- 5.6 days, p less than 0.03). Further significant prolongation of survival was seen with the addition of pentobarbital to the treatment regimen (39.9 +/- 13.5 days, p less than 0.01). Nontumor-bearing rats irradiated while awake (Group 4) survived 30.9 +/- 2.3 days. All of their pentobarbital-anesthetized counterparts in Group 5 survived. If pentobarbital had offered radioprotection to the tumor, then Group 3 would have had a shorter survival period than Group 2. This implies that the enhancement of survival time after irradiation results from selective protection of normal brain in this model.

Protection by indomethacin against acute radiation esophagitis

The mechanism of radiation induced damage to the mucosal lining of the gastrointestinal tract, as well as mucositis, is not fully characterized. Prostaglandins may partially mediate the inflammatory response to radiation damage. The effect of the prostaglandin synthetase inhibitor indomethacin on radiation induced esophagitis, pneumonitis, and tumor response was evaluated in the C3H mouse. The effects of indomethacin on radiation induced damage to the esophagus was determined by evaluation of weigh lost, survival, and histologic findings at doses of 28-34 Gy. Although there is a clear difference that supports the use of indomethacin for the prevention of esophagitis, the radiation dose response for esophagitis is steep and likewise, the therapeutic index for the indomethacin amelioration of radiation esophagitis is narrow. Since the tumor response to radiation is unchanged and since indomethacin clearly lessens radiation induced esophagitis in the mouse, this study suggests that indomethacin should be studied in humans for lessening radiation mucositis without jeopardizing the therapy of tumors.

Evolution of acute chest syndrome in sickle cell trait: an ultrastructural and light microscopic study

Light and electron microscopic studies of a patient with sickle cell trait who had an episode of sickling during coronary artery surgery, from which he died, showed fibrin thrombi, focal alveolar wall necrosis, and epithelial cell damage. It is suggested that in cases of sickle trait full precautionary measures should be taken to prevent sickling in these circumstances.

The effect of toluidine blue and methylene blue in immunochemical reactions in vitro

Our observation that the effect of a patient's autoantibody with a potent antithrombin activity could be inhibited by toluidine blue and methylene blue led us to investigate the effect of these dyes in several immunochemical reactions in vitro. Both dyes reduced the titer or prevented the detection of IgG-specific single- and double-stranded DNA-binding antibodies and rheumatoid factors but did not reduce the titer of antinuclear factor and had no effect on detection of microsomal and thyroglobulin antibodies. These dyes did not aggregate or precipitate the immunoglobulins and their inhibitory effect in serum could be removed by dialysis of serum. The possible mechanism of action of these dyes in immunochemical reactions is discussed.

Lymph node metastasis and cell movement: ultrastructural studies on the rat 13762 mammary carcinoma and Walker carcinoma

The aim of this study was to determine whether tumor cells move actively through the linings of lymph node sinuses. Using 13762 carcinoma in F344 rats, and Walker carcinoma in Wistar rats, 20 X 10(6) tumor cells were injected into the footpad, and the ipsilateral popliteal lymph node examined by transmission electron microscopy. The same tumors were examined by making standard cell spots on plastic or glass surfaces, and examining these by phase and reflection contrast microscopy, fluorescent microscopy after anti-actin and phallacidin staining and transmission electron microscopy. The 13762 cells do not migrate through the lining of the lymph node sinusoid, nor move actively in vitro. Ultrastructural appearances of the Walker rat carcinoma cells suggest that they move actively through the sinus lining. After 24 h in vitro the Walker rat carcinoma cells in the centre of the spot are adherent to the surface. There is some movement of the edge of the sheet, and individual tumor cells at the edge of the sheet move actively and independently. We conclude that the Walker rat carcinoma invades the lining of the lymph node sinusoid by active cell movement, and the 13762 carcinoma does not.

IgD kappa plasma cell dyscrasias: extraosseous manifestations including isolated leptomeningitis

IgD kappa plasma cell Dyscrasias are rare. Two cases with unusual presentations and courses area described. One of these patients had myelomatous pleural effusions, and subsequently experienced myelomatous leptomeningitis. The significance of this combination is discussed and the literature reviewed. The value of immunofluorescent techniques in identifying plasma cells in the cerebrospinal fluid and pleural fluid is emphasized.