Barriers and solutions to developing and maintaining research networks during a pandemic: An example from the iELEVATE perinatal network

Introduction

To improve maternal health outcomes, increased diversity is needed among pregnant people in research studies and community surveillance. To expand the pool, we sought to develop a network encompassing academic and community obstetrics clinics. Typical challenges in developing a network include site identification, contracting, onboarding sites, staff engagement, participant recruitment, funding, and institutional review board approvals. While not insurmountable, these challenges became magnified as we built a research network during a global pandemic. Our objective is to describe the framework utilized to resolve pandemic-related issues.

Methods

We developed a framework for site-specific adaptation of the generalized study protocol. Twice monthly video meetings were held between the lead academic sites to identify local challenges and to generate ideas for solutions. We identified site and participant recruitment challenges and then implemented solutions tailored to the local workflow. These solutions included the use of an electronic consent and videoconferences with local clinic leadership and staff. The processes for network development and maintenance changed to address issues related to the COVID-19 pandemic. However, aspects of the sample processing/storage and data collection elements were held constant between sites.

Results

Adapting our consenting approach enabled maintaining study enrollment during the pandemic. The pandemic amplified issues related to contracting, onboarding, and IRB approval. Maintaining continuity in sample management and clinical data collection allowed for pooling of information between sites.

Conclusions

Adaptability is key to maintaining network sites. Rapidly changing guidelines for beginning and continuing research during the pandemic required frequent intra- and inter-institutional communication to navigate.

Achieving Educational Change through Technical Assistance

This article reports on a survey of recipients of 51 technical assistance projects in 18 states and territories provided by the Teaching Research Assistance to Children Experiencing Sensory Impairments project. On the basis of the respondents’ assessments of factors that result in the most effective provision of technical assistance by consultants in educational settings, the authors present a systematic approach to the achievement of desired individual, programmatic, and systemwide changes through technical assistance.

The European TREatment of ATopic eczema (TREAT) Registry Taskforce survey: prescribing practices in Europe for phototherapy and systemic therapy in adult patients with moderate-to-severe atopic eczema

Background

For many years dermatologists have had access to few therapies for patients with moderate‐to‐severe atopic eczema (AE). New promising therapies are entering the market but conventional phototherapies and systemic therapies have more well‐known safety profiles, lower costs and wider availability.

Objectives

To provide insight into current prescribing practices of conventional phototherapy and systemic immunomodulatory therapies for adults with chronic AE, and the factors influencing these prescribing practices, before biologics and other novel therapeutics become routine clinical practice.

Methods

In this exploratory study dermatologists were invited to participate in an online survey via a mailing list of the European Academy of Dermatology and Venereology and national societies. Data were collected on participant characteristics (including clinical practice data), the use of phototherapies and systemic therapies, and factors influencing their use.

Results

From 30 European countries, 238 out of 361 dermatologists willing to participate (65·9%) completed the survey, with 229 meeting the inclusion criteria. For phototherapy (prescribed by 84·7%), most preferred narrowband ultraviolet B as first line (80·9%) and psoralen plus ultraviolet A as second (21·6%). For systemic therapy (prescribed by 95·2%) ciclosporin (54·1%), oral corticosteroids (32·6%) and methotrexate (30·7%) were used first line. Dermatologists relied mostly on personal experience for prescribing phototherapy and systemic therapy. Azathioprine and mycophenolic acid were prescribed by only 135 (59·0%) and 85 (37·1%) participants in total, mostly due to a lack of personal experience.

Conclusions

This study provides insight into prescribing practices for conventional phototherapy and systemic therapy in Europe and shows that off‐label therapies are also preferred as first‐line choice of systemic therapy.

What is already known about this topic?

Varying prescribing practices were found for adult (in the UK) and paediatric (in Northern America and Europe) patients with moderate‐to-severe atopic eczema (AE).

Not much is known about the prescription of phototherapy and (off‐label) systemic therapy for adult patients in Europe.

Although therapies like dupilumab are promising new treatment modalities, better‐known safety profiles, lower costs and better availability are reasons to improve the evidence profile of conventional systemic therapies like ciclosporin.

What does this study add?

Prescribing practices of European dermatologists treating adult patients with moderate‐to-severe AE show diversity.

Most dermatologists prefer narrowband ultraviolet B as first‐line phototherapy, followed by psoralen plus ultraviolet A as second line.

Next to ciclosporin, which is most commonly prescribed, (off‐label) methotrexate and oral corticosteroids are also frequently used as first‐line systemic agents in chronic AE.

Lack of personal experience with azathioprine and mycophenolic acid was the most important reason against their prescription.

What are the clinical implications of the work?

The results from this study might help to improve the experience with, and prescribing of, all available conventional phototherapies and (off‐label) systemic therapies.

Guidelines developers might use these results to develop and implement treatment algorithms.

Linked Comment:Bruin‐Weller. Br J Dermatol 2020; 183:987–988.

Plain language summary available online

Overview of systematic reviews in allergy epidemiology

BACKGROUND

There is a substantial body of evidence on the epidemiology of allergic conditions, which has advanced the understanding of these conditions. We aimed to systematically identify systematic reviews and meta-analyses on the epidemiology of allergic diseases to assess what has been studied comprehensively and what areas might benefit from further research.

METHODS

We searched PubMed and EMBASE up to 12/2014 for systematic reviews on epidemiological research on allergic diseases. We indexed diseases and topics covered and extracted data on the search characteristics of each systematic review.

RESULTS

The search resulted in 3991 entries after removing duplicates, plus 20 other items found via references and conference abstracts; 421 systematic reviews were relevant and included in this overview. The majority contained some evidence on asthma (72.9%). Allergic rhinitis, atopic eczema and food hypersensitivity were covered in 15.7%, 24.5% and 9.0%, respectively. Commonly studied risk factors for atopic eczema included dietary and microbial factors, while for asthma, pollution and genetic factors were often investigated in systematic reviews. There was some indication of differing search characteristics across topics.

CONCLUSION

We present a comprehensive overview with an indexed database of published systematic reviews in allergy epidemiology. We believe that this clarifies where most research interest has focussed and which areas could benefit from further research. We propose that this effort is updated every few years to include the most recently published evidence and to extend the search to an even broader list of hypersensitivity/allergic disorders.

Severity scoring in carpal tunnel syndrome helps predict the value of conservative therapy

A prospective study was performed to assess the outcome of conservative treatment of carpal tunnel syndrome and to establish the predictive value of preoperative Boston carpal tunnel questionnaire scores. Sixty-seven patients with 101 symptomatic hands underwent an evidence-based education and conservative therapy regime prior to surgery. All patients were scored using the Boston carpal tunnel questionnaire at presentation and at 3 months. Fifty-eight of 67 patients completed both assessments providing a complete assessment of 89 symptomatic hands. The mean Boston carpal tunnel questionnaire scores improved significantly from 2.45 to 2.12 and throughout the duration of the study 73% of patients improved with conservative treatment and 14% did not require surgery. Severity scoring at presentation was predictive of outcome with conservative therapy. This work suggests that the Boston carpal tunnel questionnaire can be used to identify patients who are likely to respond to conservative treatment.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study

BACKGROUND

We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.

METHOD

Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.

RESULTS

Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20).

CONCLUSION

Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Audit of advice provided on pelvic floor exercises

Stress incontinence is often seen as an inevitable consequence of childbirth rather than a condition that is both preventable and treatable. Pelvic floor exercises can reduce the symptoms of urinary incontinence. An audit of provision of pelvic floor exercise-related advice revealed that more high-quality information was needed.

Isolation and characterization of an avian isolate of Encephalitozoon hellem

Members of the phylum Microspora are a group of unusual, obligate intracellular eukaryotic parasites that infect a wide range of hosts. However, there are a limited number of microsporidial infections reported in avian hosts, and no parasite species has been defined as an avian pathogen. A microsporidian organism was recovered from the droppings of a clinically normal peach-faced lovebird (Agapornis roseicollis) and established in in vitro culture. Intermittent parasite spore shedding was documented over a 2-month period using calcofluor M2R staining of cloacal swabs. The organism was identified as Encephalitozoon hellem based on protein and antigenic profiles and molecular sequencing of the small subunit and internal transcribed spacer regions of the ribosomal RNA gene.

Restriction-fragment-length polymorphism analysis of small-subunit rRNA genes of Blastocystis hominis isolates from geographically diverse human hosts

Genomic diversity among 14 isolates of Blastocystis hominis from 4 different geographic locations was examined by small-subunit rRNA (ssu rRNA) restriction-fragment-length polymorphisms (RFLP) using 5 different restriction endonucleases. On the basis of the observed RFLP patterns among the isolates, a total of 12 genotypes were identified, with 7 isolates exhibiting mixed RFLP genotypes. There was no correlation between B. hominis geographic origin and RFLP banding pattern or genotype.

Antipyretic measures for treating fever in malaria

OBJECTIVES

Fever control measures are commonly used in treating malaria. Some researchers have suggested that fever reduction may prolong malaria illness. We aim to assess whether antipyretic measures in malaria influences outcome, measured by length of illness, parasitaemia, and occurrence of convulsions.

SEARCH STRATEGY

We searched the Cochrane infectious Diseases Group Trial Register, the Cochrane Controlled Trial Register, and other electronic bibliographies, and contacted researchers and organizations working in this field.

SELECTION CRITERIA

Randomised or pseudo-randomised trials which compared antipyretic drugs with mechanical or no antipyretic measures in patients with slide-confirmed malaria.

DATA COLLECTION AND ANALYSIS

Inclusion criteria were independently applied by two reviewers. We extracted data from selected trials using a standard form. Weighted mean difference with 95% confidence interval was calculated for continuous data.

MAIN RESULTS

Three randomised trials with pooled 128 adults and children with falciparum malaria; all unblinded; allocation concealment unclear in two. Inconsistent pattern of fever clearance between trials, but malaria cure rate reported to be similar between intervention and control in all trials. Mean parasite clearance time reported to be similar in one trial but longer in paracetamol group in two trials: sample size in one trial was too small to conclude anything (n=7), while the other trial was difficult to evaluate.

REVIEWER'S CONCLUSIONS

There is no statistically significant data to draw any conclusions. The clinical significance of preliminary report suggesting that antipyretic drugs prolong malaria parasitaemia was not confirmed.

Restriction-fragment-length polymorphism analysis of small-subunit rRNA genes of Blastocystis isolates from animal hosts

The anaerobic enteric protozoan organism Blastocystis sp. has been identified from mammalian, avian, reptilian, and arthropod hosts. Eight Blastocystis isolates from five animal host species (cow, goat, sheep, guinea pig, and rhea) were compared by small-subunit ribosomal RNA (ssu rRNA) restriction-fragment-length polymorphism (RFLP) analyses using five restriction endonucleases. The isolates sorted into five genotypes. Multiple genotypes were found in isolates from a single animal host species, and multiple host species shared a single genotype. A molecular method such as RFLP analysis of ssu rRNA genes facilitates the characterization of Blastocystis isolates from various host species.

Encephalitozoon cuniculi strain III is a cause of encephalitozoonosis in both humans and dogs

Microsporidia are obligate intracellular eukaryotic organisms found in a wide range of vertebrate and invertebrate hosts. Encephalitozoon cuniculi is commonly found in domestic rabbits and rodents and also occurs in dogs, other canids, and primates, including humans. DNA sequencing of the ribosomal RNA genes has been used to identify these parasites to a species level and to define E. cuniculi strains I, II, and III. Eight new dog isolates were characterized as E. cuniculi strain III by use of molecular methods. This strain has also been identified in isolates from immunocompromised humans, suggesting the zoonotic potential of this parasite species. Prolonged microsporidial spore shedding from asymptomatic dogs is also reported.

Molecular identification of encephalitozoon hellem in an ostrich

Microsporidia are obligate, intracellular, eukaryotic parasites found in a wide variety of vertebrate and invertebrate hosts. Scientific literature contains a small number of reports of these parasites in psittacine hosts, and recently microsporidiosis was reported in the first nonpsittacine host, an ostrich. DNA was extracted from formalin-fixed, paraffin-embedded ostrich tissues, and a portion of the small subunit ribosomal RNA gene was sequenced to identify the microsporidian species. The organisms were identified as Encephalitozoon hellem, a parasite species that was first described in immunocompromised humans and recently reported in three psittacine species.

Pancreas divisum: implications for diagnostic and therapeutic pancreatography

OBJECTIVE

The purpose of our study was to determine the prevalence, distribution, and clinical significance of pancreatic ductal changes due to pancreatitis on ERCP in patients with pancreas divisum.

MATERIALS AND METHODS

From January 1993 through December 1997, 1714 patients underwent 2469 ERCP studies. Ninety-four patients (5.5%) had pancreas divisum. Retrospective review of the spot radiographs was performed to establish the presence and location of pancreatitis. Clinical indications for and therapy during ERCP were correlated with radiographic findings.

RESULTS

Of the 94 patients with pancreas divisum, 54 (57%) had radiographic evidence of pancreatitis. Of these 54 patients, 44 had at least one episode of clinically documented pancreatitis, seven had recurrent abdominal pain, and three underwent ERCP for biliary indications. In 76% of the 54 patients with radiographic evidence of pancreatitis, only the dorsal system showed irreversible inflammatory change (p < .0001). Acute recurrent pancreatitis was the most common indication for ERCP in divisum patients and was statistically more common than in pancreatitis patients with normal anatomy (p < .0001). Sixty-two (66%) of the 94 patients with pancreas divisum underwent endoscopic pancreatic intervention, most commonly minor papilla sphincterotomy or stenting or both. Eleven patients with clinically documented pancreatitis had no abnormalities revealed by ERCP.

CONCLUSION

In our population of patients referred for ERCP and found to have pancreas divisum, the prevalence of pancreatitis was very high and usually was limited to a dorsal distribution.

Distribution of parthenogenetic cells in the mouse brain and their influence on brain development and behavior

A systematic analysis of parthenogenetic (PG) cell fate within the central nervous system (CNS) was made throughout fetal development and neonatal and adult life. Chimeras were made between PG embryos carrying a ubiquitously expressed lacZ transgene and normal fertilized embryos. After detailed histological analysis, we find that the developmental potential of PG cells is spatially restricted to certain parts of the brain. PG cells are prevalent in telencephalic structures and are largely excluded from diencephalic structures, especially the hypothalamus. These spatial restrictions are established early in development. Behavioral studies with chimeras identified an increase in male aggression when the proportion of PG cells in the brain was high. These studies demonstrate that imprinted genes play key roles in development of the CNS and may be involved in behavior.

Tropisetron compared with a metoclopramide-based regimen in the prevention of chemotherapy-induced nausea and vomiting

This randomised, open, parallel group study compared the antiemetic efficacy and tolerability of tropisetron with metoclopramide plus lorazepam in 102 patients receiving a first course of non-cisplatin-containing chemotherapy. Control of acute vomiting by tropisetron was significantly superior to that of the metoclopramide regimen, with total control (no vomiting) in 45% of 51 patients in the tropisetron group compared with 22% of 51 patients in the metoclopramide group (P = 0.013); total and partial control (< 5 vomits) occurred in 67 and 47% of patients, respectively (P = 0.044). The incidences of acute nausea and of delayed nausea and emesis were similar in the two treatment groups. Both tropisetron and metoclopramide were well tolerated; no adverse effects were attributed to tropisetron administration with the exception of headache. One patient in the metoclopramide group reported confusion and tremor thought to be related to the antiemetic therapy. Tropisetron is an effective and well-tolerated agent in the prevention of chemotherapy-induced vomiting. The control of acute nausea was similar in the two treatment groups, but tropisetron was superior to a metoclopramide-based regimen in the control of acute vomiting.

Early events of RNA polymerase II transcription initiation

We have investigated the earliest stages of assembly of an RNA polymerase II transcription complex. General transcription factors from HeLa cells were partially purified and assayed using the adenovirus-2 major late promoter. Preincubation of either all the transcription factors (TF) with the DNA or only the subset consisting of TFIIA, TFIID, and DNA overcame the 15-20 min lag normally observed. The kinetics demonstrate that TFIIA first interacts with the template over a 5 min. period, and then TFIID interacts with the IIA:DNA complex over a 2 min. period. The remainder of the necessary transcription factors then interact with the IIA:IID:DNA complex. There are apparently interactions between IIA and IID, as a pre-incubation of these factors (without DNA) overcomes the lag period. Both IIA:DNA and IIA:DNA:IID interactions are temperature sensitive, resulting in slower kinetics at 0 degree C. Thus, the kinetics of transcription involve activation processes in addition to DNA binding.

Drug inhibitors of RNA polymerase II transcription

Transcription by RNA polymerase II occurs after formation of a transcription complex. This complex is assembled in stages by the interaction of transcription factors with the template and/or with each other. We report on the ability of six drugs to inhibit the assembly of the RNA polymerase II transcription complex. Assembly of the complex on the adenovirus major late promoter requires several transcription factors. The normal assembly process requires that the DNA first interact with TFIIA, then with TFIID, and finally with at least four additional transcription factors (one of which is RNA polymerase II). We observed that streptolydigin (10 micrograms/ml) inhibits association of ILA and IID, and at higher concentrations (100 micrograms/ml) inhibits that IIA/IID complex from binding to DNA. Streptovaricin (100 micrograms/ml) appears to inhibit the IIA/IID interaction with DNA and prevents reinitiation (at 500 micrograms/ml). Adriamycin (1 microgram/ml) inhibits the interaction of TFIID with the IIA/DNA complex and inhibits an additional event immediately prior to, or during, elongation. Daunorubicin may be an elongation inhibitor. Heparin at 10 micrograms/ml inhibits further assembly after the IIA/IID/DNA complex has formed, and at 100 micrograms/ml also inhibits a late event in the assembly process and blocks reinitiation. Rifamycin AF/013 (100 micrograms/ml) inhibits the early events necessary to form the IIA/IID/DNA complex and (at 10 micrograms/ml) an assembly event following formation of the IIA/IID/DNA complex. Therefore, these compounds should be useful as probes for further examination of the assembly process.

Arterial oxygen desaturation following intravenous injection of midazolam

The water soluble benzodiazepine derivative, midazolam, is used almost exclusively at our institution to produce sedation for numerous surgical procedures. Mild arterial oxygen desaturation has been reported in patients who have received as little as .04 mg/kg. A time series design study was undertaken to determine if there was any correlation between the decline in arterial oxygen percent saturation (SaO2) and the time at which sedation occurred and to establish the presence of any statistical significance in this decline. Thirty-one ASA I and II patients consisting of 8 females and 23 males requiring various minor orthopedic and general surgical procedures were studied. The total mean age of the population was 32.29 +/- 12.43 years (mean +/- SD). Fourteen patients had a smoking history, while 15 patients did not (2 patients were eliminated from the study for failure to demonstrate sedation, as characterized by either Verrill's sign or thickened speech following intravenous administration of midazolam). All patients arrived in the operating room unpremedicated and were administered .04 mg/kg midazolam intravenously. Arterial oxygen saturation was measured over a 10-minute period using pulse oximetry. Results were analyzed using regression analysis, a t-test for independent groups, and a one-way analysis of variance. There was no statistically significant difference in the decline in SaO2 between smokers and nonsmokers. Our study has shown that the mean onset of sedation using a dose of .04 mg/kg occurred between 3 and 4 minutes, with the peak fall in SaO2 occurring at the 3-minute interval irrespective of smoking history. The greatest mean drop in SaO2 was 95.84%. Midazolam, like its parent drug, diazepam, alters ventilatory mechanics.(ABSTRACT TRUNCATED AT 250 WORDS)

Biliary obstruction after cholecystectomy: diagnosis with quantitative cholescintigraphy

Fifty patients with recurrent post-cholecystectomy pain underwent hepatobiliary scintigraphy. Time-activity curves were generated from regions of interest over the liver, bile duct, duodenum, and bowel. Patients were divided into obstructed and unobstructed groups with endoscopic retrograde cholangiopancreatography criteria. Measurements from the liver, duodenum, and bowel curves contributed little to the analysis. The washout phase of the bile duct curve showed intermittent emptying in both obstructed and unobstructed groups. Less than one-third of peak activity remained in both groups at 90 minutes. Retention fell more rapidly in the later portion of the sequence in patients with obstruction. Quantification was essential, since differences were subtle and could not be appreciated visually. In the absence of hepatocellular disease, the most reliable criterion was the time at which maximal bile duct activity occurred. A cutoff level of 29 minutes or more was used in the diagnosis of obstruction. A sensitivity of 93% with an adequate specificity of 64% and an overall accuracy of 80% was achieved in the prediction of obstruction.

Effects of antibiotics on RNA polymerase III transcription

We investigated the effects of six drugs on an RNA polymerase III in vitro transcription system. Adriamycin, daunorubicin, heparin, rifamycin AF/013, streptolydigin, and streptovaricin all inhibit RNA synthesis from a tRNA gene or the adenovirus 2 (AD2) VA1 RNA gene. The completed RNA polymerase III transcription complex is formed by the sequential, ordered addition of protein factors. Although both genes reportedly use the same transcription fractions for in vitro RNA synthesis, some of these drugs interfere differentially with these genes. A drug concentration that inhibits transcription from one gene may not inhibit transcription from the other gene. Adriamycin seems to block transcription if added between the binding of the individual transcription fractions. Daunorubicin appears to inhibit VA transcription only if added prior to both transcription fractions, but inhibits tRNA synthesis before and during transcription factor binding. Heparin blocks both genes between factors binding to DNA and after factor binding. Rifamycin blocks VA synthesis more effectively than tRNA synthesis. Streptolydigin blocks transcription of both genes. Streptovaricin probably blocks transcription by inhibiting early transcription complex assembly events. These drugs appear useful as appropriate probes to investigate transcription complexes since several discriminate between complexes formed on different genes during the assembly process.

Relationship of parasagittal bands of acetylcholinesterase activity to the climbing fiber representation

The organization of the somatosensory representation by the climbing fiber system was correlated to parasagittal zones in the vermis, which were demarcated by the parasagittal banding pattern of acetylcholinesterase (AChE) activity. Extracellular recordings were made of climbing fiber responses that were elicited by tactile stimulation in anesthetized cats. After the climbing fiber representation was mapped physiologically, the cerebellum was histologically processed for AChE activity. The lateral edge of the lateral AChE banding coincided with the junction between a medial vermis (zones A and X) where 82% of the units were unresponsive and the lateral vermis (zone B) where 72% of the climbing fiber responses represented areas of the body surface.

Somatosensory representation of the cerebellar climbing fiber system in the rat

The climbing fiber responses of 542 Purkinje cells were isolated in the vermal and intermediate zones of lobules II to VI of the rat cerebellum. Mechanical stimulation successfully elicited 53% of the isolated climbing fiber responses, whereas the remaining units were unresponsive to any stimulation employed. Of the units elicited by the stimulation, 34% required cutaneous and 66% required deep stimulation. Some proportion of the representation of each body region required either cutaneous or deep stimulation. The hind-limb had the largest representation and accounted for 55% (160/288) of the units. In contrast, the forelimb was only represented by 10% of the units, the tail by 16%, the face by 11% and the remaining 6% of the units by surface regions of the spine, chest and abdomen. On the basis of their proportional representation of body regions, 3 different cortical areas were distinguished: (1) a medial vermis, which consisted predominantly of unresponsive units; (2) a lateral vermis, which included representations of the extremities, trunk and tail; and (3) the intermediate zone, where the only representation of the face was evident. Within each area, the representations formed a disjunctive pattern of irregularly shaped patches and areas of overlap. In comparison with the climbing fiber organization of the cat, the medial vermal unresponsive zone and the patch-like representations of various body surfaces in the rat were similar to the cat, but the proportional representation of various body surfaces and effective stimulus modality were different, which may reflect morphological and behavioral differences between the species.

Cholescintigraphic detection of functional obstruction of the sphincter of Oddi. Effect of papillotomy

Unexplained abdominal pain after cholecystectomy has been attributed to sphincter of Oddi dysfunction, but no objective diagnostic criteria exist. Biliary excretion was quantitated by computer-assisted cholescintigraphy in 35 postcholecystectomy controls without symptoms, 9 patients with suspected sphincter of Oddi dysfunction (studied before and after sphincterotomy), and 18 patients with overt cholestasis from other causes (6 with extrahepatic obstruction and 12 with parenchymal liver disease). In patients with sphincter of Oddi dysfunction or with cholestasis, the time to attain maximal activity in the biliary system was significantly (p less than 0.05) longer, the percent of radiotracer excreted at 45, 60, and 90 min was less, and the emptying rate was slower compared with the controls. Cholecystokinin (0.02 U/kg X min) did not abolish biliary output, excluding a paradoxical response of the sphincter. After sphincterotomy, biliary activity peaked earlier and the percent excreted at 45 min increased but did not revert to normal. Relief of symptoms occurred in 8 of 9 patients. The one failure had normal emptying characteristics before sphincterotomy, and did not change after surgery. Another developed recurrent pain and a corresponding deterioration in biliary emptying on serial scans. Thus, functional obstruction at the sphincter of Oddi exists, is not due to any paradoxical response to cholecystokinin, and in the absence of overt cholestasis, can be detected by quantitative cholescintigraphy. Successful sphincterotomy may not completely restore biliary emptying to normal.

The effect of a progestin on gallbladder function in young women

Female sex hormones have been considered to be a risk factor for the development of cholesterol gallstone disease, because of increased cholesterol saturation of bile. Impaired gallbladder function is an additional factor which is suspect but unproved. We investigated gallbladder function in 10 young women on two occasions: first during the follicular phase of the menstrual cycle, when endogenous progesterone is low, and again after the ingestion of medroxyprogesterone acetate, 10 mg/day for 10 days, just prior to the next menstrual period. Another group, 15 young women, was studied during their luteal phase, when endogenous progesterone is high. Gallbladder filling and emptying in response to cholecystokinin (0.02 U/kg-min) was quantitated by 99mTc-HIDA cholescintigraphy. Gallbladder filling and emptying were no different in women in the follicular phase than in women in the luteal phase of the menstrual cycle. In both menstrual phases, the administration of the exogenous progestin significantly (p less than 0.05) reduced the fraction of hepatic bile entering the gallbladder. Gallbladder emptying was also depressed: the total amount ejected was less, the time to empty half the contents was prolonged, and the rate was slower (p less than 0.05). Thus, different phases of the normal menstrual cycle do not appear to have any effect on gallbladder function. Administration of an exogenous progestin, however, significantly impairs both gallbladder filling and emptying, factors which could predispose to the formation of cholesterol gallstones.

Response of malignant hypertension with refractory cardiac failure to captopril: A case report

A convincing response to the orally administered angiotensin I-converting enzyme inhibitor captopril (SQ 14225) in a severe hyper-reninaemic hypertensive patient resistant to other forms of treatment is described. The use of this drug in accelerated severe hypertension with impending organ damage is suggested during the early phase of treatment.