Defining capabilities in deployed UK military prehospital emergency care

The UK military prehospital emergency care (PHEC) operational clinical capability framework must be updated in order that it retains its use as a valid operational planning tool. Specific requirements include accurately defining the PHEC levels and the 'Medical Emergency Response Team' (MERT), while reinforcing PHEC as a specialist area of clinical practice that requires an assured set of competencies at all levels and mandatory clinical currency for vocational providers.A military PHEC review panel was convened by the Defence Consultant Advisor (DCA) for PHEC. Each PHEC level was reviewed and all issues which had, or could have arisen from the existing framework were discussed until agreement between the six members of this panel was established.An updated military PHEC framework has been produced by DCA PHEC, which defines the minimum requirements for each operational PHEC level. These definitions cover all PHEC providers, irrespective of professional background. The mandatory requirement for appropriate clinical exposure for vocational and specialist providers is emphasised. An updated definition of MERT has been agreed.This update provides clarity to the continually evolving domain of UK military PHEC. It sets out the PHEC provider requirements in order to be considered operationally deployable in a PHEC role. There are implications for training, manning and recruitment to meet these requirements, but the processes required to address these are already underway and well described elsewhere.

Integrated analysis of proteomics, epigenomics and metabolomics data revealed divergent pathway activation patterns in the recent versus chronic post-traumatic stress disorder

Metabolomics, proteomics and DNA methylome assays, when done in tandem from the same blood sample and analyzed together, offer an opportunity to evaluate the molecular basis of post-traumatic stress disorder (PTSD) course and pathogenesis. We performed separate metabolomics, proteomics, and DNA methylome assays on blood samples from two well-characterized cohorts of 159 active duty male participants with relatively recent onset PTSD (<1.5 years) and 300 male veterans with chronic PTSD (>7 years). Analyses of the multi-omics datasets from these two independent cohorts were used to identify convergent and distinct molecular profiles that might constitute potential signatures of severity and progression of PTSD and its comorbid conditions. Molecular signatures indicative of homeostatic processes such as signaling and metabolic pathways involved in cellular remodeling, neurogenesis, molecular safeguards against oxidative stress, metabolism of polyunsaturated fatty acids, regulation of normal immune response, post-transcriptional regulation, cellular maintenance and markers of longevity were significantly activated in the active duty participants with recent PTSD. In contrast, we observed significantly altered multimodal molecular signatures associated with chronic inflammation, neurodegeneration, cardiovascular and metabolic disorders, and cellular attritions in the veterans with chronic PTSD. Activation status of signaling and metabolic pathways at the early and late timepoints of PTSD demonstrated the differential molecular changes related to homeostatic processes at its recent and multi-system syndromes at its chronic phase. Molecular alterations in the recent PTSD seem to indicate some sort of recalibration or compensatory response, possibly directed in mitigating the pathological trajectory of the disorder.

Outpatient Pharmacogenomic Screenings to Prevent Addiction, Overdose, and Suicide

Point-of-care genetic testing for single nucleotide polymorphisms (SNPs) to improve psychiatric treatment in outpatient settings remains a challenge. The presence or absence of certain genomic alleles determines the activity of the encoded enzymes, which ultimately defines the individual's drug metabolism rate. Classification of poor metabolizers (PMs) and rapid/ultrarapid metabolizers (RMs/UMs) would facilitate personalization and precision of treatment. However, current pharmacogenomic (PGx) testing of multiple genes is comprehensive and requires quantitative analyses for interpretations. We recommend qualitative, fast-track, point-of-care screenings, which are one- or-two gene-based analyses, as a quick initial screening tool to potentially eliminate the need for an expensive quantitative send-out test, which is a costly and lengthy process. We speculate that these tests will be relevant in two major scenarios: 1) clinical psychiatry for treating disease states such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), where trial and error is still the mainstay of drug selection and symptom management, a process that is associated with significant delay in optimizing individualized treatment and dose, and thus response; and 2) pain management, where quickly determining an effective level of analgesia while avoiding a toxic level can cause a drastic improvement in mental health.

Development of an Animal Model of Military-Relevant Traumatic Stress

INTRODUCTION

Acute Stress Reactions (ASRs) affect a subgroup of individuals who experience traumatic stress. In the context of military operations, such reactions are often termed Combat and Operational Stress Reactions (COSRs). COSRs not only encompass all symptoms of ASRs but also include additional symptoms related to military combat and may develop at a rate higher than the general public experiences ASRs. Despite an obvious need, there are currently no approved pharmacologic treatments or guidelines for ASR and/or COSR. Preclinical rodent stress models and behavioral assessments are used to evaluate pharmacotherapies and elucidate underlying mechanisms. Here, we combined established traumatic stress models to develop a model of traumatic stress relevant to military trauma exposure and measured behavioral outcomes that reflect outcomes observed in ASRs and COSRs.

MATERIALS AND METHODS

Adult male rats underwent exposure to either a combination of two or three traumatic stress exposures (e.g., predator exposure, underwater trauma (UWT), and/or inescapable shock) or control procedures. Behavioral performance on the open field, elevated plus maze, and acoustic startle response (SR) was then assessed 24- and 48-hours following stress/control procedures.

RESULTS

In Experiment 1, rats were exposed to a two-stressor model, where predator exposure was coupled with UWT. Minor behavioral deficits were observed in SR for stress-exposed rats as compared to controls. In Experiment 2, inescapable shock was added to predator exposure and UWT. Behavioral performance deficits were observed across all behavioral tests. In Experiment 3, procedures from Experiment 2 were repeated with the only major modification being a shortened predator exposure duration, which resulted in performance deficits in SR only.

CONCLUSIONS

We found that the three-stressor model of Experiment 2 resulted in the greatest overall behavioral disturbance (both in the number of variables and magnitude of stress effects). Interestingly, behavioral deficits elicited from the shorter predator exposure were distinct from those observed with longer predator exposure times. Together, these results generally suggest that combined preclinical stressors with military-relevant elements result in behavioral performance deficits reflective of post-trauma phenotypes in Soldiers. The present findings support the use of both physical and psychological stressors to model operationally relevant traumatic stress exposure.

Consistency of denominator data in electronic health records in Australian primary healthcare services: enhancing data quality

The quality of data derived from primary healthcare electronic systems has been subjected to little critical systematic analysis, especially in relation to the purported benefits and substantial investment in electronic information systems in primary care. Many indicators of quality of care are based on numbers of certain types of patients as denominators. Consistency of denominator data is vital for comparison of indicators over time and between services. This paper examines the consistency of denominator data extracted from electronic health records (EHRs) for monitoring of access and quality of primary health care. Data collection and analysis were conducted as part of a prospective mixed-methods formative evaluation of the Commonwealth Government's Indigenous Chronic Disease Package. Twenty-six general practices and 14 Aboriginal Health Services (AHSs) located in all Australian States and Territories and in urban, regional and remote locations were purposively selected within geographically defined locations. Percentage change in reported number of regular patients in general practices ranged between -50% and 453% (average 37%). The corresponding figure for AHSs was 1% to 217% (average 31%). In approximately half of general practices and AHSs, the change was ≥ 20%. There were similarly large changes in reported numbers of patients with a diagnosis of diabetes or coronary heart disease (CHD), and Indigenous patients. Inconsistencies in reported numbers were due primarily to limited capability of staff in many general practices and AHSs to accurately enter, manage, and extract data from EHRs. The inconsistencies in data required for the calculation of many key indicators of access and quality of care places serious constraints on the meaningful use of data extracted from EHRs. There is a need for greater attention to quality of denominator data in order to realise the potential benefits of EHRs for patient care, service planning, improvement, and policy. We propose a quality improvement approach for enhancing data quality.

Allograft theory: transmission of devil facial-tumour disease

The Tasmanian devil, a large carnivorous Australian marsupial, is under threat from a widespread fatal disease in which a malignant oral-facial tumour obstructs the animal's ability to feed. Here we show that the chromosomes in these tumours have undergone a complex rearrangement that is identical for every animal studied. In light of this remarkable finding and of the known fighting behaviour of the devils, we propose that the disease is transmitted by allograft, whereby an infectious cell line is passed directly between the animals through bites they inflict on one another.

Resynchronization of ovulation and timed insemination in lactating dairy cows

The objective was to compare pregnancy rates to resynchronization and timed AI (TAI) protocols in lactating dairy cows that received GnRH at 23 d and were diagnosed not pregnant at 30 d after the pre-enrollment AI. Nonpregnant cows (624) at ultrasonography on day 30 (study day 0) were classified as diestrus (74.8%), metestrus (5.6%) and without a CL (19.5%). Cows in diestrus were assigned either to the GnRH group (PGF2alpha on day 0, GnRH on day 2 and TAI 16 h later, n = 238) or the estradiol cypionate (ECP) group (PGF2alpha on day 0, ECP on day 1, and TAI 36 h later, n = 229). Cows in metestrus were assigned to the Modified Heatsynch Group (GnRH on day 0, PGF(2alpha) on day 7, ECP on day 8 and TAI on day 9, n = 35). Cows without a CL (n = 122) were classified either as proestrus (10.6%), ovarian cysts (7.5%) or anestrus (1.4%), and assigned to factorial treatments (i.e., use of GnRH versus CIDR) to either the GnRH group (GnRH on day 0, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28), the CIDR group (CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 34), the GnRH + CIDR group (GnRH on day 0, CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16h later, n = 32), and the control group (PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28). For cows without a CL, plasma P4 concentrations were determined on days 0, 7, 10 and 17 and ovarian structures determined on days 0, 7 and 17. Pregnancy rates were evaluated at 30, 55 and 90 d after the resynchronized AI. For cows in diestrus, there were no differences in pregnancy rates on days 30, 55 and 90 for cows in the GnRH (27.5, 26.5 and 24.2%) or ECP (29.1, 25.5 and 24.1%) groups. In addition, there were no differences in pregnancy losses between days 30 and 55 and 55 and 90 between the GnRH (7.0 and 8.6%) and ECP (9.8 and 5.4%) groups. For cows without a CL, GnRH on day 0 increased the proportion of cows with a CL on days 7 and 17 and plasma P4 concentration on day 17 in cows with ovarian cysts but not for cows in proestrus. The CIDR insert increased pregnancy rate in cows with ovarian cysts but reduced pregnancy rate for cows in proestrus.

Resynchronization of ovulation and timed insemination in lactating dairy cows

The objective was to compare pregnancy rates and pregnancy losses in lactating dairy cows that were diagnosed not pregnant and re-inseminated following either the Ovsynch or Heatsynch protocols. Also evaluated were the effects of stages of the estrous cycle, ovarian cysts and anestrus on pregnancy rates for both treatments. Non-pregnant cows (n = 332) as determined by ultrasonography on day 27 post-AI (study day 0) were divided into two groups. Cows in the Ovsynch group (n = 166) received GnRH on day 0, PGF2alpha on day 7, GnRH on day 9, and timed AI (TAI) 16 h later (day 10). Cows in the Heatsynch group (n = 166) received GnRH on day 0, PGF2alpha on day 7, estradiol cypionate (ECP) on day 8, and TAI 48 h later (day 10). Cows detected in estrus on days 8 and 9 were inseminated and included in the study. On day 0, cows were classified according to different stages of the estrous cycle, or presence of ovarian cysts or anestrus. Pregnancy rates were evaluated 27, 45 and 90 days after resynchronized AI. Overall, there was no difference in pregnancy rates on days 27, 45 and 90 between cows in the Ovsynch (25.2, 17.5, and 13.9%) and Heatsynch (25.8, 19.9, and 16.1%) groups. There was no difference in pregnancy losses from days 27 to 45 and days 45 to 90 for cows in the Ovsynch (25.0 and 17.9%) and Heatsynch (14.7 and 10.3%) groups. However, pregnancy rates were increased when cows in metestrus were subjected to the Heatsynch protocol and cows with ovarian cysts were subjected to the Ovsynch protocol.

Resynchronization of ovulation and timed insemination in lactating dairy cows, II: assigning protocols according to stages of the estrous cycle, or presence of ovarian cysts or anestrus

Pregnancy rates were compared in lactating dairy cows (n = 1083) assigned to protocols for resynchronization of ovulation based on stages of the estrous cycle, or presence of ovarian cysts or anestrus. Cows were detected not pregnant by ultrasonography 30 d after a previous AI (study day 0) and classified as diestrus, metestrus, proestrus, with ovarian cysts or anestrus. Cows in diestrus (January-May) were assigned to either Ovsynch (GnRH day 0, PGF2alpha day 7, GnRH day 9, and timed-AI [TAI] 16 h later; n = 96), or Quicksynch (PGF2alpha day 0, estradiol cypionate [ECP] day 1, AI at detected estrus [AIDE] on day 2, or TAI on day 3; n = 96). Cows in diestrus (June-December) were assigned to either Ovsynch (n = 156) or Modified Quicksynch (PGF2alpha day 0, ECP day 1, AIDE days 2 and 3, and to Ovsynch on day 4 if not detected in estrus; n = 142). Cows in metestrus were assigned either to Ovsynch (n = 68), Heatsynch (GnRH day 0, PGF2alpha day 7, ECP day 8, AIDE day 9, or TAI day 10; n = 62), or GnRH + Ovsynch (GnRH on day 0, followed by Ovsynch on day 8; n = 64). Cows in proestrus, with ovarian cysts, or anestrus were assigned to either Ovsynch (proestrus n = 89, ovarian cysts n = 97, anestrus n = 8) or GnRH + Ovsynch (proestrus n = 87, ovarian cysts n = 109, anestrus n = 9). Pregnancy rate was evaluated 30, 55 and 90 d after resynchronized AI. For cows in diestrus (January-May), pregnancy rates were higher for Ovsynch (35.9, 29.2 and 26.0%) than for Quicksynch (21.7, 16.7 and 15.6%). For cows in diestrus (June-December), pregnancy rates were similar for Ovsynch (34.4, 24.0 and 23.6%) and Modified Quicksynch (27.1, 26.2 and 21.6%). For cows in metestrus, pregnancy rates were higher for GnRH + Ovsynch (33.3, 24.5 and 20.3%) than for Heatsynch (20.3, 12.9 and 9.8%). For cows with ovarian cysts, pregnancy rates were higher for GnRH + Ovsynch (30.3, 26.6 and 22.9%) than for Ovsynch (20.2, 18.5 and 14.7%). Assignment to resynchronization protocols based on the stages of the estrous cycle, or presence of ovarian cysts improved pregnancy rates.

Strategic use of gonadotrophin-releasing hormone (GnRH) to increase pregnancy rate and reduce pregnancy loss in lactating dairy cows subjected to synchronization of ovulation and timed insemination

The objective of this study was to determine the effect of GnRH (100 microg i.m.) treatment 5 and 15 days after timed insemination (TAI) on pregnancy rate and pregnancy loss in lactating dairy cows subjected to synchronization of ovulation. The study included 831 lactating dairy cows subjected to a Presynch-Ovsynch protocol for first service. On the day of TAI (Day 0), cows were randomly assigned to one of four experimental groups. Cows in Group 1 (n = 214) were treated with GnRH on Day 5; cows in Group 2 (n = 209) were treated with GnRH on Day 15; cows in Group 3 (n = 212) were treated with GnRH on both Day 5 and Day 15; cows in Group 4 (n = 196) were not treated. Pregnancy rate was evaluated at Day 27 and Day 45 after TAI. The interestrus interval and the proportion of cows diagnosed not pregnant based on expression of estrus and insemination before pregnancy diagnosis on Day 27 were determined. The results of this study are: (1) GnRH treatment on Day 5 or Day 15 did not increase pregnancy rate, or reduce pregnancy loss between Day 27 and Day 55 after TAI; (2) cows treated with GnRH on both Day 5 and Day 15 had a lower (P < 0.01) proportion of cows diagnosed not pregnant based on expression of estrus before ultrasonography on Day 27 (26.5%) compared to control cows (52.9%), and these cows had an extended (P = 0.05) interestrus interval (23.4 days vs. 21.5 days); and (3) GnRH treatment on both Day 5 and Day 15 after TAI reduced pregnancy rate on Day 27 (36.8% vs. 44.4% for control cows; P < 0.03) and Day 55 (28.3% vs. 36.2% for control cows; P < 0.01). Therefore, strategies to stimulate CL function using multiple doses of GnRH during the luteal phase need to consider potential negative effects.

8RESYNCHRONIZATION OF OVULATION AND TIMED INSEMINATION IN LACTATING DAIRY COWS USING THE OVSYNCH AND HEATSYNCH PROTOCOLS INITIATED 7 DAYS BEFORE PREGNANCY DIAGNOSIS ON DAY 30 BY ULTRASONOGRAPHY

Rapid re-synchronization of ovulation and insemination in cows found nonpregnant to a previous service is important to maintain high reproductive efficiency. The objective was to compare pregnancy rate (PR) and pregnancy losses (PL) in cows subjected to Ovsynch or Heatsynch protocols 7 days before pregnancy diagnosis by ultrasonography (U/S) on Day 30. Initiation of both protocols included administration of GnRH on Day 23, which was considered the optimal time according to the distribution of interestrus intervals in cows previously inseminated. The study was conducted in a large dairy herd located in north central Florida from March to May, 2003. Of 593 cows treated with GnRH on Day 23 (±1) after insemination and found nonpregnant at U/S on Day 30 (±1; experimental Day 0), 75% (445) had a CL (diestrus) and were sequentially assigned to the two experimental groups. Cows in the Ovsynch Group (n=225) received 25mg (i.m.) PGF2α (Lutalyse, Pharmacia, Kalamazoo, MI, USA) on Day 0, 100μg (i.m.) GnRH (Cystorelin, Merial Limited, Iselin, NJ, USA) on Day 2, and were timed inseminated 16h later. Cows in Heatsynch Group (n=220) received 25mg (i.m.) PGF2α on Day 0, and 1mg (i.m.) estradiol cypionate (ECP, Pharmacia, Kalamazoo, MI, USA) on Day 1, and were timed-inseminated 36h later. Pregnancy at Day 30 was determined by U/S and at Day 55 by rectal examination of the genital tract. Pregnancy rate and PL were evaluated using multiple logistic regression. Pregnancy rate at Day 30 for Ovsynch (64/225, 28.4%) and Heatsynch (63/220, 28.6%) and PR at Day 55 for Ovsynch (58/225, 25.8%) and Heatsynch (54/220, 24.5%) were not different. In addition, PL between Days 30 and 55 for Ovsynch (6/64, 9.4%) and Heatsynch (9/63, 14.3%) were not different. There were no effects of parity, inseminator and days in milk on PR. However, PR at day 30 was higher in lots with cooling systems (46/141, 32.6%) and lots of first calf heifers (41/135, 30.4%) compared to lots of multiparous cows late in lactation without cooling systems (32/148, 21.6%). In conclusion, Heatsynch and Ovsynch initiated 7 days before pregnancy diagnosis on Day 30 had comparable PR of 25% at Day 55 in lactating dairy cows during the period of March–May.

Probing inhibitors binding to human urokinase crystals by Raman microscopy: implications for compound screening

Inhibition of urokinase activity represents a promising target for antimetastatic therapy for several types of tumor. The present study sets out to investigate the potential of Raman spectroscopy for defining the molecular details of inhibitor binding to this enzyme, with emphasis on single crystal studies. It is demonstrated that high quality Raman spectra from a series of five inhibitors bound individually to the active site of human urokinase can be obtained in situ from urokinase single crystals in hanging drops by using a Raman microscope. After recording the spectrum of the free crystal, a solution of inhibitor containing an amidine functional group on a naphthalene ring was added, and the spectrum of the crystal-inhibitor complex was obtained. The resulting difference Raman spectrum contained only vibrational modes due to bound inhibitor, originating from the protonated group, i.e., the amidinium moiety, as well as naphthalene ring modes and features from other functionalities that made up each inhibitor. The identification of the amidinium modes was placed on a quantitative basis by experimental and theoretical work on naphthamidine compounds. For the protonated group, -C-(NH2)(2)(+), the symmetric stretch occurs near 1520 cm(-1), and a less intense antisymmetric mode appears in the Raman spectra near 1680 cm(-1). The presence of vibrational modes near 1520 cm(-1) in each of the Raman difference spectra of the five complexes examined unambiguously identifies the protonated form of the amidinium group in the active site. Several advantages were found for single crystal experiments over solution studies of inhibitor-enzyme complexes, and these are discussed. The use of single crystals permits competitive binding experiments that cannot be undertaken in solution in any kind of homogeneous assay format. The Raman difference spectrum for a single crystal that had been exposed to equimolar amounts of all five inhibitors in the hanging drop showed only the Raman signature of the compound with the lowest K(i). These findings suggest that the Raman approach may offer a route in the screening of compounds in drug design applications as well as an adjunct to crystallographic analysis.

Solution structure of the antiapoptotic protein bcl-2

The structures of two isoforms of Bcl-2 that differ by two amino acids have been determined by NMR spectroscopy. Because wild-type Bcl-2 behaved poorly in solution, the structures were determined by using Bcl-2/Bcl-x(L) chimeras in which part of the putative unstructured loop of Bcl-2 was replaced with a shortened loop from Bcl-x(L). These chimeric proteins have a low pI compared with the wild-type protein and are soluble. The structures of the two Bcl-2 isoforms consist of 6 alpha-helices with a hydrophobic groove on the surface similar to that observed for the homologous protein, Bcl-x(L). Comparison of the Bcl-2 structures to that of Bcl-x(L) shows that although the overall fold is the same, there are differences in the structural topology and electrostatic potential of the binding groove. Although the structures of the two isoforms of Bcl-2 are virtually identical, differences were observed in the ability of the proteins to bind to a 25-residue peptide from the proapoptotic Bad protein and a 16-residue peptide from the proapoptotic Bak protein. These results suggest that there are subtle differences in the hydrophobic binding groove in Bcl-2 that may translate into differences in antiapoptotic activity for the two isoforms.

Rationale for Bcl-xL/Bad peptide complex formation from structure, mutagenesis, and biophysical studies

The three-dimensional structure of the anti-apoptotic protein Bcl-xL complexed to a 25-residue peptide from the death promoting region of Bad was determined using NMR spectroscopy. Although the overall structure is similar to Bcl-xL bound to a 16-residue peptide from the Bak protein (Sattler et al., 1997), the Bad peptide forms additional interactions with Bcl-xL. However, based upon site-directed mutagenesis experiments, these additional contacts do not account for the increased affinity of the Bad 25-mer for Bcl-xL compared to the Bad 16-mer. Rather, the increased helix propensity of the Bad 25-mer is primarily responsible for its greater affinity for Bcl-xL. Based on this observation, a pair of 16-residue peptides were designed and synthesized that were predicted to have a high helix propensity while maintaining the interactions important for complexation with Bcl-xL. Both peptides showed an increase in helix propensity compared to the wild-type and exhibited an enhanced affinity for Bcl-xL.

Sequential single doses of cisapride, erythromycin, and metoclopramide in critically ill patients intolerant to enteral nutrition: a randomized, placebo-controlled, crossover study

OBJECTIVE

To evaluate the comparative efficacy of enteral cisapride, metoclopramide, erythromycin, and placebo for promoting gastric emptying in critically ill patients with intolerance to gastric enteral nutrition (EN).

DESIGN

A randomized, crossover study.

SETTING

Adult medical intensive care unit at a university-affiliated private hospital and trauma intensive care unit at a university teaching hospital.

PATIENTS

Ten adult, critically ill, mechanically ventilated patients not tolerating a fiber-containing EN product defined as a single aspirated gastric residual volume >150 mL or two aspirated gastric residual volumes >120 mL during a 12-hr period.

INTERVENTIONS

Patients received 10 mg of cisapride, 200 mg of erythromycin ethylsuccinate, 10 mg of metoclopramide, and placebo as 20 mL of sterile water every 12 hrs over 48 hrs. Acetaminophen solution (1000 mg) was administered concurrently. Gastric residual volumes were assessed, and plasma acetaminophen concentrations were serially determined by TDx between 0 and 12 hrs to evaluate gastric emptying.

MEASUREMENTS AND MAIN RESULTS

Gastric residual volumes during the study were not significantly different between agents. No differences in area under the concentration vs. time curve or elimination rate constant were identified between agents. Metoclopramide and cisapride had a significantly shorter mean residence time of absorption than erythromycin (6.3+/-4.5 [SEM] mins and 10.9+/-5.8 vs. 30.1+/-4.5 mins, respectively [p<.05]). Metoclopramide (9.7+/-15.3 mins) had a significantly shorter time to peak concentration compared with erythromycin and placebo (60.7+/-8.1 and 50.9+/-13.5 mins, respectively [p<.05]). The time to onset of absorption was significantly shorter for metoclopramide vs. cisapride (5.7+/-4.5 vs. 22.9+/-5.7 mins [p<.05]).

CONCLUSION

In critically ill patients intolerant to EN, single enteral doses of metoclopramide or cisapride are effective for promoting gastric emptying in critically ill patients with gastric motility dysfunction. Additionally, metoclopramide may provide a quicker onset than cisapride.

Psychotherapy with phobic patients: the marriage relationship as the source of symptoms and focus of treatment

Four patients demonstrating phobic symptoms occurring in the context of maladaptive marriages are presented. Thorough historical data collection is stressed. Similarities in family backgrounds and personality styles emerge in these cases and are discussed in relation to genesis of symptoms within the marital relationships. A psychotherapeutic approach is described and results of treatment examined.

Cell-mediated immunoselection against cell-surface antigens of somatic cell hybrids

Cytotoxic lymphoid cells derived from in vivo immunization of mice across H2 barriers were utilized in in vitro cytotoxicity assays. The target cells were somatic cell hybrids derived from parental cells differing at the H2 locus. The hybrid cells surviving cytotoxicity were grown to confluent populations and the H2 antigens selected against were no longer demonstrable by indirect immunofluorescence. Comparative karyology of hybrid cells expressing both parental H2 types before immunoselection with hybrid cells surviving immunoselection revealed a decrease in the number of murine chromosomes number 17, suggesting that those cells surviving cytotoxicity had spontaneously lost these chromosomes prior to the selection event. The possibility of immunoconstruction of somatic cell hybrids on the basis of their cell-surface antigens is discussed.