Relationship between Anterior Pituitary Volume and IGF-1 Serum Levels in Soldiers with Mild Traumatic Brain Injury History

PURPOSE

A high mild traumatic brain injury (mTBI) incidence rate exists in military and sport. Hypopituitarism is an mTBI sequela; however, few studies have examined this phenomenon in those with an mTBI history. This cross-sectional study of Special Operations Forces combat soldiers aimed 1) to relate anterior pituitary gland volumes (actual and normalized) to insulin-like growth factor 1 (IGF-1) concentrations, 2) to examine the effect of mTBI history on anterior pituitary gland volumes (actual and normalized) and IGF-1 concentrations, and 3) to measure the odds of demonstrating lower anterior pituitary gland volumes (actual and normalized) or IGF-1 concentrations if self-reporting mTBI history.

METHODS

Anterior pituitary gland volumes were manually segmented from T1-weighted 3D brain MRI sequences; IGF-1 serum concentrations were quantified using commercial enzyme-linked immunosorbent assays. Correlations and linear regression were used to determine the association between IGF-1 serum concentration and anterior pituitary gland volume (n = 74). Independent samples t-tests were used to compare outcomes between mTBI groups and logistic regression models were fit to test the odds of demonstrating IGF-1 concentration or anterior pituitary volume less than sample median based on mTBI group (n = 54).

RESULTS

A significant linear relationship between the subjects' anterior pituitary gland volumes and IGF-1 concentrations (r72 = 0.35, P = 0.002) was observed. Soldiers with mTBI history had lower IGF-1 concentrations (P < 0.001) and lower anterior pituitary gland volumes (P = 0.037) and were at greater odds for IGF-1 serum concentrations less than the sample median (odds ratio = 5.73; 95% confidence interval = 1.77-18.55).

CONCLUSIONS

Anterior pituitary gland volume was associated with IGF-1 serum concentrations. Mild TBI history may be adversely associated with anterior pituitary gland volumes and IGF-1 concentrations. Longitudinal IGF-1 and anterior pituitary gland monitoring may be indicated in those who report one or more mTBI.

Pathology-based staging for HPV-positive squamous carcinoma of the oropharynx

OBJECTIVE

The rapid worldwide rise in incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has generated studies confirming this disease as an entity distinct from traditional OPSCC. Based on pathology, surgical studies have revealed prognosticators specific to HPV-positive OPSCC. The current AJCC/UICC staging and pathologic nodal (pN)-classification do not differentiate for survival, demonstrating the need for new, HPV-specific OPSCC staging. The objective of this study was to define a pathologic staging system specific to HPV-positive OPSCC.

METHODS

Data were assembled from a surgically-managed, p16-positive OPSCC cohort (any T, any N, M0) of 704 patients from five cancer centers. Analysis was performed for (a) the AJCC/UICC pathologic staging, (b) newly published clinical staging for non-surgically managed HPV-positive OPSCC, and (c) a novel, pathology-based, "HPVpath" staging system that combines features of the primary tumor and nodal metastases.

RESULTS

A combination of AJCC/UICC pT-classification and pathology-confirmed metastatic node count (⩽4 versus ⩾5) yielded three groups: stages I (pT1-T2, ⩽4 nodes), II (pT1-T2, ⩾5 nodes; pT3-T4, ⩽4 nodes), and III (pT3-T4, ⩾5 nodes), with incrementally worse prognosis (Kaplan-Meier overall survival of 90%, 84% and 48% respectively). Existing AJCC/UICC pathologic staging lacked prognostic definition. Newly published HPV-specific clinical stagings from non-surgically managed patients, although prognostic, showed lower precision for this surgically managed cohort.

CONCLUSIONS

Three loco-regional "HPVpath" stages are identifiable for HPV-positive OPSCC, based on a combination of AJCC/UICC primary tumor pT-classification and metastatic node count. A workable, pathologic staging system is feasible to establish prognosis and guide adjuvant therapy decisions in surgically-managed HPV-positive OPSCC.

Chondrocyte culture and assay

Chondrocytes constitute the sole cell type found within cartilage, and control the formation and composition of cartilage. Cellular, biochemical and pharmacological studies of arthritis and other cartilage disorders have increasingly focused on chondrocyte function. Three methods are presented in this unit for culturing chondrocytes, and two assays are described that characterize proteoglycan synthesis, a key measure of chondrocyte function.Chondrocytes constitute the sole cell type found within cartilage, and control the formation and composition of cartilage.

Identification of dipeptidyl nitriles as potent and selective inhibitors of cathepsin B through structure-based drug design

Cathepsin B is a member of the papain superfamily of cysteine proteases and has been implicated in the pathology of numerous diseases, including arthritis and cancer. As part of an effort to identify potent, reversible inhibitors of this protease, we examined a series of dipeptidyl nitriles, starting with the previously reported Cbz-Phe-NH-CH(2)CN (19, IC(50) = 62 microM). High-resolution X-ray crystallographic data and molecular modeling were used to optimize the P(1), P(2), and P(3) substituents of this template. Cathepsin B is unique in its class in that it contains a carboxylate recognition site in the S(2)' pocket of the active site. Inhibitor potency and selectivity were enhanced by tethering a carboxylate functionality from the carbon alpha to the nitrile to interact with this region of the enzyme. This resulted in the identification of compound 10, a 7 nM inhibitor of cathepsin B, with excellent selectivity over other cysteine cathepsins.

Orbital wall approach with preoperative orbital imaging for identification and retrieval of lost or transected extraocular muscles

PURPOSE

To report the results of an anterior approach along the orbital wall to recover a lost or transected extraocular muscle.

METHODS

This is a retrospective review of lost or transected muscles retrieved by an anterior orbitotomy approach to the adjacent orbital wall because they were unable to be recovered by a standard conjunctival approach. Magnetic resonance imaging or computed tomography was performed on all subjects before surgery.

RESULTS

Six patients underwent anterior orbitotomy via an orbital wall approach; all had undergone an attempted retrieval from a standard transconjunctival approach that failed. Five muscles had been lost from surgical or traumatic transection, and 1 muscle had been lost during strabismus surgery. The muscle location at retrieval ranged from 20 to 25 mm (mean, 23 mm) posterior to the limbus. The duration that these muscles were disinserted ranged from 7 days to 7.5 years (mean, 24 months). Preoperative deviation in primary gaze ranged from 15 to 50 PD, whereas first day postretrieval deviations all measured less than 8 PD. After a mean follow-up of 162 weeks, the mean deviation in primary gaze was 2 PD (range, orthotropia to 7 PD of esotropia).

CONCLUSIONS

Anterior orbitotomy along the orbital wall with preoperative orbital imaging of extraocular muscle anatomy and function combine to create a valuable approach for retrieval of a lost or transected muscle. This technique may successfully retrieve lost or transected muscles that previously were irretrievable when using a standard transconjunctival approach.

Serum calcitonin precursors in sepsis and systemic inflammation

High serum levels of the calcitonin (CT) prohormone, procalcitonin (pro-CT), and its component peptides occur in systemic inflammation and sepsis. Using two different assays, we undertook a prospective study to determine the utility of serum precalcitonin peptides (pre-CT) as markers in this condition. Twenty-nine patients meeting criteria for the systemic inflammatory response syndrome were studied daily in two intensive care units. Sera were collected, and APACHE II scores were determined until recovery or death. All patients had markedly elevated serum pre-CT. Prognostically, peak values were the most important. The highest values portended mortality, and a lower level could be ascertained below which all patients survived. Peak pre-CT levels were significantly higher in patients with infection documented by blood cultures than in those patients with no documented infection from any source (P < 0.05). Mature CT remained normal or only moderately elevated. Compared with the serum pre-CT levels, receiver operating characteristic curve analysis revealed that the APACHE II scores, although more cumbersome, were better overall predictors of mortality. Thus, pre-CT is an important serum marker for systemic inflammatory response syndrome and is predictive of outcome. It also provides data concerning the presence of severe infection and may prove to be clinically useful for proactive patient care.

Changes in cochlear mechanics during vocalization: evidence for a phasic medial efferent effect

The mustached bat, Pteronotus p. parnellii, has a finely tuned cochlea that rings at its resonant frequency in response to an acoustic tone pip. The decay time (DT) and frequency of these damped oscillations can be measured from the cochlear microphonic potential (CM) to study changes in cochlear mechanics. In this report, we describe phasic changes that occur in synchrony with communication sound vocalizations of the bat. Three animals with chronically implanted electrodes were studied. During the experiments, 1-2 ms tone pips were emitted from a speaker every 200 ms. This triggered a computer analysis of the resulting CM to determine the DT and cochlear resonance frequency (CRF) of the ringing. The time relative to vocalizations was determined by monitoring the output of a microphone placed near a bat's mouth. Similar results were obtained from all three bats tested. In a representative case, the average DT was 2.33 +/- 0.25 ms while the bat was quiet, but it decreased by 46% to 1.26 +/- 0.75 during vocalizations, which indicates a greater damping of the cochlear partition. Sometimes, DT started decreasing immediately before the bat vocalized. After the end of a vocalization, the return to baseline values varied from rapid (milliseconds) to gradual (1-2 seconds). The CRF also changed from baseline values during vocalization, although the amount and direction of change were not predictable. When gentamicin was administered to block the action of medial olivocochlear (MOC) efferents, DT reduction was still evident during vocalization but less pronounced. We conclude that phasic changes in damping occur in synchrony with vocalization, and that the MOC system plays a role in causing suppression. Since suppression can begin prior to vocalization, this may be a synkinetic effect, mediated by neural outflow to the ear in synchrony with neural outflow to the middle ear muscles and the muscles used for vocalization.

Autogenous fascia augmentation of a partially extirpated muscle with a subperiosteal medial orbitotomy approach

INTRODUCTION

Endoscopic sinus surgery can result in serious extraocular muscle dysfunction. The medial rectus muscle is more frequently affected than other extraocular muscles.

METHODS

A transconjunctival subperiosteal medial orbitotomy was successful in retrieving a partially extirpated medial rectus muscle after endoscopic sinus surgery.

RESULTS

A previous attempt to localize this muscle by conventional surgery with extensive exploration was unsuccessful. A Hummelsheim procedure was also abandoned after a rupture of the nasal aspect of the inferior rectus muscle occurred.

CONCLUSION

The approach we describe allowed adequate visualization of the posterior orbital content, as well as adequate space for suture placement.

Discovery of CGS 27023A, a non-peptidic, potent, and orally active stromelysin inhibitor that blocks cartilage degradation in rabbits

Structure-activity relationships of a lead hydroxamic acid inhibitor of recombinant human stromelysin were systematically defined by taking advantage of a concise synthesis that allowed diverse functionality to be explored at each position in a template. An ex vivo rat model and an in vivo rabbit model of stromelysin-induced cartilage degradation were used to further optimize these analogs for oral activity and duration of action. The culmination of these modifications resulted in CGS 27023A, a potent, orally active stromelysin inhibitor that blocks the erosion of cartilage matrix.

Hybrid multi/single layer array transducers for increased signal-to-noise ratio

In medical ultrasound imaging, two-dimensional (2-D) array transducers are necessary to implement dynamic focusing in two dimensions, phase correction in two dimensions and high speed volumetric imaging. However, the small size of a 2-D array element results in a small clamped capacitance and a large electrical impedance, which decreases the transducer signal-to-noise ratio (SNR). We have previously shown that SNR is improved using transducers made from multi-layer PZT, due to their lower electrical impedance. In this work, we hypothesize that SNR is further increased using a hybrid array configuration: in the transmit mode, a 10 Omega electronic transmitter excites a 10 Omega multi-layer array element; in the receive mode, a single layer element drives a high impedance preamplifier located in the transducer handle. The preamplifier drives the coaxial cable connected to the ultrasound scanner. For comparison, the following control configuration was used: in the transmit mode, a 50 Omega source excites a single layer element, and in the receive mode, a single layer element drives a coaxial cable load. For a 5x102 hybrid array operating at 7.5 MHz, maximum transmit output power was obtained with 9 PZT layers according to the KLM transmission line model. In this case, the simulated pulse-echo SNR was improved by 23.7 dB for the hybrid configuration compared to the control. With such dramatic improvement in pulse-echo SNR, low voltage transmitters can be used. These can be fabricated on integrated circuits and incorporated into the transducer handle.

Practice patterns in the diagnosis and treatment of anxiety and depression in the medically ill. A survey of psychiatrists

By use of a survey that assessed practice patterns and responses to case vignettes of anxiety and depression in the medically ill, 38 psychiatrists were compared with 10 national leaders in consultation-liaison psychiatry. On the case vignettes, percentage agreement with the experts varied significantly by case and by question. Fifty-eight percent of the time the psychiatrists agreed with the experts on whether to order laboratory tests as compared with an 81% agreement level on whether to use psychotherapy. Multiple regression analysis revealed that the best model to predict lower agreement with the experts was years in practice plus percentage of time spent in solo (vs. group) practice (r2 = 0.40). This study extended previous data-based pharmacoepidemiology by assessing multiple aspects of psychiatrists' practice patterns. Psychiatrists who are more distant from training years and more isolated from the current stimulation of colleagues may be particularly appropriate targets for continuing education.

Optimization of signal-to-noise ratio for multilayer PZT transducers

In medical ultrasound imaging, two-dimensional (2-D) array transducers are desirable to implement dynamic focusing and phase aberration correction in two dimensions as well as volumetric imaging. Unfortunately, the small size of a 2-D array element results in a small clamped capacitance and a large electrical impedance near the resonance frequency. This results in poor signal-to-noise ratio (SNR) of the array elements. It has previously been demonstrated that transducers made from multilayer PZT ceramics have lower electrical impedance and greater SNR than comparable single layer elements. A simplified circuit model has been developed to optimize the SNR for multilayer ceramic (MLC) transducers. In this model, an electronic transmitter excites the array element and in the receive mode, the element drives a coaxial cable load terminated by a high impedance preamplifier. The transducer impedance is Zt/N2, where N is the number of piezoelectric layers. Maximum transmit signal is obtained when N = Ntx such that the transducer impedance, Zt/Ntx2, is matched to the source impedance. Maximum receive signal is obtained when N = Nrx such that the transducer impedance, Zt/Nrx2, is matched to the coaxial cable reactance. For maximum pulse-echo signal, the transducer should be designed with N = square root of Ntx Nrx, the geometric mean of Ntx and Nrx. Using this optimization technique, a 1.5-D array was designed with 3 layers for maximum pulse-echo SNR. Results of simulations from the simplified circuit analysis were consistent with those of the KLM model. The 3 layer array was fabricated as well as a single layer control array. The measured transmit signal and receive signal agreed with the simulation results.

Psychiatric aspects of the eosinophilia-myalgia syndrome

The eosinophilia-myalgia syndrome (EMS) is a rare systemic disease caused by presumably contaminated L-tryptophan. Thirteen outpatients with EMS were found to have a high degree of depression, anxiety, and difficulty adjusting to illness. Pre-EMS history of major depression but not EMS severity predicted poor adjustment to illness.

Escalation of a fetish: coprophagia in a nonpsychotic adult of normal intelligence

A 47-year-old man is described whose fetish of fecal smearing, coprophilia, escalated to coprophagia in a setting of depression and alcohol abuse. The case is the first described in a nonpsychotic adult of normal intelligence. Treatment focused upon the depression and substance abuse as well as on the psychodynamic issues that fostered his despair and allowed the fetish to evolve into coprophagia.

A program to develop residents as teachers

Residents are recognized as important and influential teachers of medical students. Although they are expected to teach and evaluate students, few residents have been taught how, and most would like to receive training to develop and improve their skills as teachers. We developed a "Residents as Teachers" retreat based on our faculty development program for clinical preceptors. We focused on clinical precepting skills, including evaluation/feedback, and the ability to prepare and deliver a brief presentation. The program increased knowledge and skills and improved attitudes about teaching, as reflected in self-reports, observed performance, and medical student ratings. The retreat also provided a valuable social experience for residents. The program has been considered beneficial by residents, program faculty members, medical students, the student clerkship director, and the residents' primary care preceptors. The retreats form the centerpiece of our curriculum for residents as teachers and have become an annual tradition in the residency program.

Multilayer piezoelectric ceramics for two-dimensional array transducers

In medical ultrasound imaging, 2-D array transducers have become essential to implement dynamic focusing and phase-correction in the elevation dimension as well as real-time volumetric scanning. Unfortunately, the small size of a 2-D array element results in a small clamped capacitance and a large electrical impedance near resonance. These elements have poor sensitivity because their impedance is much higher than the electrical impedance of the transmit and receive circuitry. Sensitivity can be improved by using an N layer structure of PZT ceramic with the layers connected acoustically in series and electrically in parallel. For the multilayer ceramic (MLC), the damped capacitance is multiplied by a factor of N(2) and the electrical impedance by 1/N(2) compared to a single layer element of the same dimensions. A 3x43 phased-array transducer has been fabricated using 3 layer PZT-5H material. Each element had a thickness of 0.66 mm and an area of 0.37x3.5 mm. The MLC was manufactured using thick film technology with plated-through vias to electrically interconnect the electrode layers. The completed transducer was compared to a single layer control array of similar dimensions. With a light epoxy backing and a lambda/4 matching layer, the MLC array elements had an impedance of 100 Omega at series resonance of 2.25 MHz, compared to 800 Omega for the control elements. The lower impedance of the MLC elements resulted in a minimum round-trip insertion loss of 24.0 dB, compared to an 34.1 dB for the control array elements. These results were consistent with KLM modeling. B-scan images were made of cysts in a tissue-mimicking phantom and of the left kidney in vivo. The images clearly showed a higher signal-to-noise ratio for the MLC array compared to the control. As a result, 2-D arrays made of multilayer ceramics can be used to form images at a higher frequency and greater range than single layer arrays.

Comparison of magnetic resonance imaging (MRI) and histopathology in rabbit models of osteoarthritis and immune arthritis

Osteoarthritis was surgically induced in mature male Dutch Belted rabbits by sectioning the fibular collateral and sesamoid ligaments and removal of the anterior horn of the lateral meniscus. The site of surgical intervention was detectable by MRI. Histopathologic analysis revealed severe focal cartilage lesions on opposing surfaces of the tibia and femur. Histology of cartilage adjacent to the osteoarthritic lesions appeared normal. In another animal model, arthritis was induced by immunization against ovalbumin followed by intra-articular injection of ovalbumin. MRI of immune arthritic rabbit knees showed accumulation of synovial fluid and cartilage degradation. Histopathology was characterized by vascular necrosis of the synovium and depletion of cartilage proteoglycan. MRI can be used to non-invasively follow the therapeutic effects of drug treatment on synovial inflammation and cartilage degradation in rabbit knees.

A comparison of chondrocyte proteoglycan metabolism in monolayer and agarose cultures

Bovine chondrocyte cultures were established in agarose and in monolayers to compare the effects of cytokines and drugs on matrix metabolism. The production of sulfated glycosaminoglycans (S-GAG) from the medium and cell surface compartments were measured by a dimethylmethylene blue assay. In the agarose cultures most of the proteoglycan remained in the agar, but was continuously released into the medium for more than 50 days. In the monolayers, the cell surface compartment became saturated with S-GAG in 5-6 days. Then a time-dependent decrease of accumulation occurred in the medium after 8-10 days. The anabolic effects of insulin-like growth factor (IGF) and a protein kinase C activator (PMA) were measured in these cultures. IGF and PMA increased S-GAG accumulation in the medium from monolayers but not from agarose cultures. In the agarose cultures, S-GAG was released into the medium after these cultures were changed to serum-free test conditions. This release overshadowed any increase in S-GAG synthesis. The catabolic effect of IL-1 was more evident in the monolayers than in the agarose cultures. Agarose cultures maintain the chondrocyte phenotype longer than monolayers but for initial drug studies monolayer cultures appear to be more appropriate.

Release of cell surface proteoglycan from chondrocytes by interleukin-1

A cell culture model was developed to assess factors that can protect cartilage from recombinant human interleukin-1 alpha (IL-1)-induced breakdown. IL-1 (0.01-10 ng/ml) caused a dose-dependent release of cell surface proteoglycan into the medium of bovine and rabbit articular chondrocytes. Sulfated glycosaminoglycan (S-GAG) was detected in the medium and on the cell surface by a dimethlymethylene blue assay. The redistribution of the cell surface S-GAG to the medium compartment required protein synthesis because it was inhibited by cycloheximide and was time-dependent (> 5 h). Although the release was most likely due to de novo synthesis of proteases, standard protease inhibitors failed to prevent the release even when used in combination. TGF-beta and IGF-I increased the amount of S-GAG in both the medium and cell surface compartments, but did not protect from IL-1-induced release. This method has an advantage over a cartilage model of IL-1-induced matrix release because the drug and cytokine exposure time is reduced and the variability is less.

A stromelysin assay for the assessment of metalloprotease inhibitors on human aggregated proteoglycan

Human proteoglycan was aggregated to an immobilized hyaluronan solid phase on a 96-well ELISA plate. This complex was then degraded by recombinant human stromelysin. The remaining proteoglycan fragments were detected using a monoclonal antibody probe directed against the chondroitin sulfate (CS) region of the core protein. Stromelysin degraded the aggregate in a time and dose dependent manner as reflected by the loss of the CS epitope. Assay sensitivity was 0.125 U/well with total loss of the CS epitope occurring at 4 U/well. o-phenanthroline (IC50 = 52 microM) and U24522 (IC50 = 9 microM) inhibited degradation, while phosphoramidon did not. Serine and cysteine protease inhibitors had no effect. A comparative analysis of this assay with a reference method, substance P assay, gave similar inhibitor profiles. The use of aggregated human proteoglycan (native conformation) as a substrate, may better reflect how stromelysin inhibitors behave in the presence of complex substrates such as cartilage matrix.

Developing community faculty. Principles, practice, and evaluation

Medical education is increasingly emphasizing outpatient experiences in community settings, and, concurrently, the development and assessment of the teaching skills of community faculty. These skills can be addressed through a faculty development program focusing on (1) issues relevant to community education, (2) adult learning principles, and (3) logistics that facilitate the participation of community medical faculty. Using a series of 1- to 3-day seminars, the program described focused on clinical precepting and brief presentations, used interactional teaching and practicums, and actively involved participants in the evaluation and planning fo the seminars. Evaluation of the program suggested that it was successful in increasing participants' knowledge and application of educational principles taught. Such programs can result in the development of an effective and potentially abundant resource of faculty members for the medical education of students and residents.

Professionally-led support groups for cancer patients: an intervention in search of a model

OBJECTIVE

The objective of this review was to evaluate the clinical and research literature on professionally-led support groups for cancer patients and to propose an approach that would address patients' needs from diagnosis through survivorship.

METHOD

Computerized and manual searches, including Medline and Psychlit searches, were completed for reviews of the literature. Twelve research studies were identified that met our criteria for in-depth review. A clinical model emerged from discussions of an oncology study group based on theoretical formulations and clinical experience with oncology patients.

RESULTS

We found that recent research suggests that professionally-led support groups are increasing in number and that participation in such groups seems to enhance patients' quality, and possibly even quantity, of survival. Despite this, little effort has been made to determine what type of group may be appropriate for which patients and when in their course of care.

CONCLUSIONS

If psychosocial intervention, in the form of professionally-led support groups for cancer patients, is to be more effective, it should be guided by a model which takes into consideration the changing needs and concerns of patients over the course of illness and, in many cases, recovery. The authors present an outline delineating what such a model might entail.

Psychiatric affiliations between community hospitals and university programs. Transcending the difficulties

The community-based general hospital is increasingly utilized as a clinical training site for psychiatric education. Are such affiliations taken for granted by university departments? Only by careful review of the governance structure and motivations for such affiliations can a successful program be developed. Such affiliations need not be "taken for granted." Ongoing flexibility and communication will foster mutual respect between the clinical faculty within the community hospital and the university department. A case example is provided to demonstrate such a process.

Seven different assays of hyaluronan compared for clinical utility

To compare six assays of hyaluronan (hyaluronic acid; HYA) in serum, developed in different laboratories, we analyzed 10 samples from each of three groups: healthy persons, patients with primary biliary cirrhosis, and patients with rheumatoid arthritis. All the assays are based on the use of affinity proteins specific for HYA, prepared from cartilage or brain tissue, and are analogous to RIA or enzyme immunoassay techniques. The assay results were of the same magnitude. Although statistical analysis indicated that the methods in some cases deviated significantly from one another, this variation was less than the physiological variation in the healthy population. Therefore, the results of clinical investigations in which the various methods have been used are comparable. The analyses have high specificity and sensitivity for primary biliary cirrhosis but are somewhat less suitable for detecting rheumatoid arthritis. A seventh laboratory, which obtained antibodies to HYA, used these in an RIA to analyze a separate series of serum specimens. Results were in agreement with those obtained by one of the other assays.

Self-hypnosis, sensory cuing, and response prevention: decreasing anxiety and improving written output of a preadolescent with learning disabilities

In this case study we describe a hypnobehavioral procedure used in the successful treatment of a 10 1/2-year-old boy who suffered from an adjustment disorder with academic inhibition, manifested by an anxiety reaction secondary to learning disabilities that affected his written-language output. Treatment consisted of three self-management techniques: self-monitoring and charting of conditions that preceded anxiety-related behaviors; self-hypnosis and a progressive-muscle-relaxation induction technique; and response-prevention training. The hypnobehavioral procedure decreased anxiety and increased written-language output. We discuss the results in relation to the specific benefits obtained by the preadolescent studied, the advantages of the hypnobehavioral procedure over previous methods to resolve anxiety, the role of self-hypnosis in problem resolution, and future research directions.

Elevation of synovial plasminogen activator activity after injection of interleukin-1 alpha into rabbit knee joint

We investigated production of plasminogen activator (PA) and cartilage degradation induced by injection of recombinant human interleukin-1 (rhIL-1 alpha) in rabbit knees. Rabbits were injected intra-articularly (i.a.) with 100 ng rhIL-1 alpha and necropsied at 0, 3, 6, 18 and 54 h and synovial lavage and articular cartilage were collected. PA activity in the joint lavage was measured using Z-Lys-thiobenzyl ester as a substrate. Cartilage degradation was assessed by quantitating sulfated glycosaminoglycan (S-GAG) to hydroxyproline (Hyp) and appearance of keratan sulfate (KS) in synovial lavage by and ELISA. The PA activity in the lavage of IL-1 injected knees at 3, 6, and 18 h was elevated 8 to 10 fold compared to vehicle controls. At 54 h the activity declined to approximately one third of that seen at the earlier time points. KS in the joint lavage was highest at 18 h, suggesting proteoglycan degradation. The maximal loss of cartilage proteoglycan (S-GAG/Hyp) occurred by 54 h. These observations demonstrate that i.a. injection of IL-1 stimulated the production of PA activity within the rabbit joint. Since elevation of PA activity is followed by cartilage degradation, we investigated effect of anti-inflammatory agents on PA activity and cartilage degradation in this model. We found that triamcinolone, indomethacin and dexamethasone were able to suppress PA activity but not the cartilage degradation. These observations suggest that in this model of cartilage degradation suppression of PA is not sufficient to inhibit cartilage degradation.

Relationship of blood markers to disease severity and drug efficacy in rat adjuvant arthritis

Rat adjuvant arthritis (AA) was used as a model to evaluate several blood markers as possible predictive indicators of drug efficacy. AA was induced in Sprague-Dawley rats by the injection of complete Freund's adjuvant into the right hind foot pad. The rats were dosed p.o. from day 18 to day 31 with levamisole (10 mg/kg), indomethacin (1 mg/kg), diclofenac sodium (0.5 & 1 mg/kg), and prinomide (10 & 20 mg/kg). Disease severity was assessed by paw circumference on day 31. The following blood markers were analyzed: hyaluronate by ELISA, prostaglandin E2 by RIA, ESR by micro-dispette, total PMN by Technicon H-1, and albumin by BCG dye. Blood marker correlation (r) to disease severity was: hyaluronate (0.71), prostaglandin E2 (0.58), ESR (0.52), PMN (0.58), and albumin (-0.71). The relative rank order of drug efficacy (indomethacin, diclofenac sodium, and prinomide) did not differ using the change in paw circumference (day 31-day 17) or blood markers. Levamisole exacerbated the disease as measured by all the above parameters. Thus, these blood markers provide additional information for the statistical evaluation of drugs in rat adjuvant arthritis.

Interleukin-1-induced cartilage degradation is independent of substance P level in rabbit knees

The effect of SP on recombinant human IL-1 alpha-induced cartilage degradation in rabbit knees was investigated. Co-injection of 10 ng IL-1 and 1 micrograms SP did not increase cartilage degradation above the level observed after injection of 10 ng IL-1 alone. Co-injection of 100 ng IL-1 and 150 micrograms Spantide, a potent SP antagonist, did not reduce the level of cartilage degradation. Infusion of 100 ng SP/day for two weeks did not induce cartilage degradation. These observations suggest that cartilage degradation induced by IL-1 is independent of SP concentrations in rabbit knees.

Pharmacological modulation of rat monocytes: in vivo effects on Ia expression and interleukin-1 production

We have shown that during the developing phase of adjuvant disease (AD) in rats the expression of MHC class II (Ia) antigens on blood monocytes (BM) was enhanced. The results of a study in established AD are reported now. Four agents were tested: indomethacin and diclofenac-sodium (1 mg/kg/day); levamisole and prinomide (10 mg/kg/day), administered orally from day 18-31 after induction of AD. We assessed the following BM parameters: Ia expression, interleukin-1 (sIL-1) production, and membrane bound IL-1 (mIL-1). In AD Ia expression was enhanced, no changes occurred in mIL-1 or sIL-1. Indomethacin treatment reduced sIL-1 production, levamisole Ia expression and mIL-1 activity, prinomide all three parameters measured and diclofenac, though clinically effective, none.

Elevated plasma levels of hyaluronate in patients with osteoarthritis and rheumatoid arthritis

Plasma levels of hyaluronate (HA) in patients with rheumatoid arthritis (RA) and patients with osteoarthritis (OA), measured by enzyme-linked immunosorbent assay, were compared with levels in a healthy, age-matched non-arthritic control group, in a retrospective study. Compared with the controls, the mean level of plasma HA was sevenfold higher in the RA group and twofold higher in the OA group. There was no statistically significant correlation between HA levels and 7 other clinical and biochemical parameters in patients with RA. In the OA group, however, plasma HA levels were found to correlate with an objective functional capacity score and with an articular index based on the total amount of cartilage in involved joints. In a retrospective longitudinal study of 6 patients with RA, plasma levels of HA did not show a significant correlation with plasma levels of elastase or with the erythrocyte sedimentation rate. These data support in part the contention that plasma HA may be unique as a marker, in that it may be a reflection of synovial involvement and inflammation, rather than only of inflammation, in arthritis.

Subtype diagnosis in schizophrenia and its relation to neuropsychological and computerized tomography measures

We compared schizophrenic patients with a subtype diagnosis of paranoia (n = 14) to those with nonparanoid subtype diagnoses (n = 18) on the Wisconsin Card Sorting Test (WCST) and multiple computed tomography (CT) scan measures. The results showed that patients with nonparanoid diagnoses sorted fewer categories and made more perseverative errors on the WCST than did patients with the paranoid diagnosis. However, patients in the nonparanoid group could not be distinguished from those in the paranoid group on CT scan measures of brain structure. Additionally, a significant correlation was found between right frontal sulcal enlargement on CT scans and the number of perseverative errors made on the WCST.

Lead exposure at uncovered outdoor firing ranges

Excessive lead exposure in shooting instructors at indoor firing ranges and covered outdoor firing ranges has been documented. The City of Los Angeles assessed exposure of its full-time shooting instructors at uncovered outdoor ranges via air monitoring and blood lead-level measurements. Results of these tests revealed that significant lead exposure and absorption can occur at outdoor firing ranges. The use of copper-jacketed ammunition may decrease air lead levels and decrease lead absorption by range instructors.

An improved method for determining proteoglycans synthesized by chondrocytes in culture

An improved micro method for measuring sulfated glycosaminoglycans (S-GAG) in chondrocyte cultures using 1,9-Dimethylmethylene Blue (DMB) has been developed. By increasing the protein concentration in the DMB assay a soluble GAG-DMB complex is prolonged. Without bovine serum albumin (BSA) in the phosphate-buffered saline (PBS) medium, the half time for loss of absorbance was 18 min; with 1% BSA-PBS there was no loss of absorbance over this time period. The limit of detection in a 96 well microtiter plate assay was 2 micrograms/ml; for a cuvette assay it was 1 microgram/ml. Collagen, DNA and RNA did not interfere with this assay. Hyaluronate caused an increase in absorbance at 530 nm that was lost by preincubating with Streptomyces hyaluronidase. The increase in absorbance was due to a turbidity change because there was no color shift from 600 to 530 nm but rather a uniform increase in absorbance between 400 to 700 nm. To validate the assay, the S-GAG was measured in conditioned medium from primary bovine articular chondrocyte monolayer cultures. A protein synthesis inhibitor, cycloheximide, blocked proteoglycan synthesis by greater than 90%. A cytokine, Interleukin-1 alpha, caused a dose-dependent decrease in proteoglycan accumulation. Chondroitinase ABC digestion of the chondrocyte conditioned medium completely prevented reactivity with the DMB. By preincubating samples with specific enzymes, different types of S-GAG can be measured with this assay. This assay can be used to measure changes in proteoglycans synthesized by chondrocytes.

Nonpsychiatric consultations within a general hospital psychiatric unit: characteristics and concordance

Nonpsychiatric consultations to a general hospital psychiatric unit were investigated for concordance with diagnostic testing advice, drug recommendations, and representation of the medical diagnoses in the discharge summary. Those patients who received consultations were older and had less social support but did not have more severe medical illnesses. The level of concordance with medical consultants' recommendations was far greater than previous reports of psychiatric consultants' advice to nonpsychiatric colleagues.

The concurrent use of lithium and methylphenidate in a child

The case of a young boy with symptoms of both attention deficit and affective disorders is presented. The patient was successfully treated with a combination of lithium and methylphenidate. Issues about comorbidity and polypharmacy in children are raised, and the concommitant use of lithium and methylphenidate in a child is discussed.

Effect of cytokines and anti-arthritic drugs on glycosaminoglycan synthesis by bovine articular chondrocytes

The effect of cytokines (interleukin-1 alpha, interleukin-1 beta, and tumor necrosis factor alpha) and several anti-arthritic drugs on glycosaminoglycan synthesis and secretion into medium by bovine articular chondrocytes was examined. Sulfated glycosaminoglycans (S-GAG) were measured by a modified 1,9-dimethylmethylene blue (DMB) dye binding assay. Hyaluronate (HA) was measured by an inhibition ELISA based on specific binding to a proteoglycan. All three cytokines caused a dose-dependent decrease in S-GAG production and a dose-dependent increase in HA production. Non-steroidal anti-inflammatory drugs (NSAIDs, indomethacin, naproxen, and piroxicam, 1 microM) could not reverse the effect of IL-1 alpha on inhibiting S-GAG and stimulating HA synthesis. The anti-inflammatory steroid (dexamethasone, 1 microM) depressed HA synthesis by 50-70% in the absence or presence of IL-1 alpha. Dexamethasone depressed S-GAG synthesis by 20-30% in the absence or presence of IL-1 alpha. Therefore, none of the tested anti-rheumatic drugs reversed the cytokine mediated changes in glycosaminoglycan synthesis by bovine chondrocytes.

Who gets treated where. A study of patients transferred and not transferred from a consultation-liaison service to a general hospital psychiatry unit

The decision to transfer a patient from a general hospital unit to a psychiatric unit is multifactorial. The most salient patient characteristics include the degree of dysfunctional behavior, the absence of social supports, and the presence of Axis II pathology. Severity of medical illness does not discriminate between the two groups. Awareness of these characteristics could aid physicians in formulating transfer decisions.

Canine serum keratan sulfate and hyaluronate concentrations. Relationship to age and osteoarthritis

Elevated serum levels of keratan sulfate (KS) and hyaluronate (HA) in patients with osteoarthritis (OA) have been reported. We measured KS and HA in dogs to determine if there was an elevation of these serum glycosaminoglycans in a canine model of OA. A single intraarticular injection of 1 mg of chymopapain into a shoulder joint increased serum KS by tenfold, and HA by less than twofold, in 24 hours. Serum KS and HA levels were 3-5-fold higher in dogs younger than 2 months of age than in older dogs. Serum KS and HA concentrations and synovial fluid KS concentrations were unrelated to spontaneous cartilage degeneration in 1-year-old dogs. Higher KS levels in synovial fluid correlated with higher KS levels in serum (r = 0.54, P less than 0.025). The mean KS concentration in sera of older dogs (greater than 3 years old) with OA was 37% higher than that in disease-free controls, but the difference between the groups was not statistically significant. Thus, elevated levels of serum KS and HA do not appear to have clinical significance in this model of OA.

Fatal occupational injuries in California, 1972-1983

Prior reports have indicated that the crude incidence of fatal occupational accidents in California has substantially declined since at least 1972. We tested the hypothesis that this observation was an artifact of demographic shifts in the workforce towards lower-risk age groups and industries. Review of worker's compensation data from 1972 to 1983 identified 2,483 fatal injuries among males. Crude rates declined by an average of 7.0% annually (p less than .005). Age and industry adjustment reduced this decline to 6.7% annually, but the trend was still significant (p less than .005). Thus, the decline in fatal injury rates is not artifactual and will require further study to explain. In a separate analysis, age-specific death rates were found to follow a bimodal pattern in most industries with the highest rates observed at the extremes of age. These results conflict with those of several previous studies. However, these studies did not adjust for the prevalence of part-time work schedules among younger employees.

When is enough enough: the administrative discharge

This paper has described the process of administrative discharge. Indications for its implementation and obstacles to recognizing its appropriateness have been reported. Administrative discharge is a process that has profound effects on the treatment milieu. It deserves further study to document more fully the patients who are subject to it and their eventual clinical outcome.

Serum hyaluronate as a marker for disease severity in the Lactobacillus casei model of arthritis in the rat

Serum concentrations of hyaluronate may provide a clinically relevant, quantitative marker of disease in patients with active rheumatoid arthritis (RA). We studied the utility of serum hyaluronate in an animal model, with features reminiscent of human RA, in which LEW/N female rats were made arthritic by intraperitoneal injection of sonicated Lactobacillus casei. When serum hyaluronate was measured by an inhibition ELISA, a dose dependent correlation was found between the amount of L. casei injected and both joint score and serum hyaluronate in the chronic phase of the disease. A linear correlation between the chronic phase joint score and serum hyaluronate was observed (r = 0.69, p less than 0.001). Two orally administered compounds, flurbiprofen (20 mg/kg) and methotrexate (0.125 mg/kg), were effective in decreasing both variables. Thus, serum hyaluronate may have utility in evaluating the therapeutic efficacy of antirheumatic/antiinflammatory agents in vivo in the chronic phase of RA-like diseases.