AB1397 WORK SMARTER NOT HARDER

Background

In 2014 we were a small team with only 1 WTE (Whole Time Equivalent) CNS (Clinical Nurse Specialist) and 2 WTE consultants for a population of 220,000. Most CNS clinic appointments were taken up for drug counselling. Waiting times were approx. 6 weeks for drug counselling. Consultants would often counsel for DMARDs.

That year at a national meeting a virtual group MDT (multidisciplinary) was presented by the team at Manchester Royal infirmary (MRI). They used a good quality presentation for patients starting bDMARDs as a tool for drug counselling.

After having to put on an extra clinic to counsel 5 patients, all for rituximab, frustratingly I asked why can’t I get them all in the same room to save time? We needed to work smarter, not harder, utilise time & space to ensure best practice but also ensure gold standard, patient centered care continued. We modified the format used at MRI to a face to face group education and counselling of patients to improve waiting times and patient flow.

Objectives

Reduce the amount of clinic appointments used to counsel patients for sDMARDs (synthetic disease modifying anti-rheumatic drugs) and bDMARDs (biologic).

Free up clinic appointments for follow up/ review and flares.

Standardise information given out to ensure they are all given the same gold standard information and education.

Methods

We visited the team at MRI to view the format of their virtual clinic. It didn’t meet the needs of our service so we modified and adapted the presentation.

Set up a group education session to discuss the most common sDMARDs and bDMARDs used for Inflammatory Arthritis.

I developed a power point presentation and booklet that can be used by CNS- ensuring the same information is given to every patient, both attending the group session and those not suitable for group session (ie Language barriers) who would be seen individually. We use a screening proforma to ensure safety of commencement for the individual prior to attending clinics which has a tick list for screening requirements.

The session is undertaken in our education centre. Pre Covid the session could accommodate up to 10 patients per session per week, uptake on average 8-10 patients for sDMARDs and 5-6 for bDMARDs. We alternated biologic and sDMARD sessions, if demand required, we changed a session to accommodate. The room is booked for 1½ hours every week, the sDMARD presentation lasts approximately ½ an hour & bDMARD session 50 minutes, time is allowed for group & individual questions if required at the end. This contrasts with 25 minute appointment for sDMARD & 50 minute for bDMARD counselling 1:1.

The booklet, along with information pack, is given at the group session to all patients. This includes all the information the patient requires (advice line information, blood forms). Prior to the group clinic admin team prepare the patient packs for the CNS to give to patients.

Results

We received 102 anonymous responses back from 136 patients asked. (75% response)

Following these sessions we found less calls to the advice line regarding medication queries, able to add in further cDMARDs or switch to alternate due to S/Es over the telephone

Feedback from patients.-120 comments received.

Clear simple information about a number of possible drugs used to treat my condition not just the 1 I am prescribed. If my medication needs changing I already know about it.

The lecture aspect of the types/contra-indications of meds was very useful & removed the ‘fear’ attached to these specialist drugs.

The session with other patients present stopped me from feeling alone in this position. The booklet is brilliant as it includes everything that was in the session. Also it took away the ‘fear’ of the side effects.

Conclusion

7 years on we feel that Group Counselling has been a huge success, we noticed how successful this was once we had to deal with the pandemic and cancel the group sessions. Patients feedback proves that they like the session and find them valuable. Whilst being beneficial and impoving work productivity and streamling the service.

Acknowledgements

The Rheumatology Team at The Kellgren Centre Manchester Royal Infirmary

Disclosure of Interests

Kelly Tempest Speakers bureau: Abbvie

Sanofi

Galapogos, Hanu Reddy: None declared, Samantha Johns: None declared, Kathryn Wright: None declared, Shabina Sultan Speakers bureau: Amgen, Grant/research support from: lilly

Successful treatment of Aureobasidium pullulans central catheter-related fungemia and septic pulmonary emboli

INTRODUCTION

Aureobasidium pullulans is a saprophytic fungus that is widely distributed in the environment, and in the right host can be an opportunistic human pathogen.

PRESENTATION OF CASE

A 66-year-old man with Crohn's disease with a single kidney, and requiring total parenteral nutrition via a Hickman catheter, was admitted with a 10-week history of progressive shortness of breath, fevers and weight loss. Chest imaging demonstrated new multifocal lung parenchymal opacities compatible with septic pulmonary emboli. Blood culture grew a yeast-like organism that transformed into a black mold on subculture, eventually identified as A. pullulans. Due to triazole resistance, the patient was treated with liposomal amphotericin and micafungin. Serum (1,3)-β-d-glucan level was used to monitor therapy, initially measured at >500 pg/mL and decreasing to 66 pg/mL after one year of therapy.

DISCUSSION

We describe the successful treatment of a case of catheter related fungemia and septic pulmonary emboli due A. pullulans. While initially appearing as an oval yeast on blood culture, subsequent growth as a black mold led to identification of the fungus as A. pullulans. The infection was cured with a combination of antifungal agents, even though the foreign body could not be safely removed. Nephrotoxicity required dosing adjustment of the amphotericin to biweekly during the maintenance phase of treatment. The serum (1,3)-β-d-glucan level proved to be useful in monitoring response to therapy.

CONCLUSION

We report here successful treatment of a disseminated A. pullulans infection with an induction and maintenance approach to liposomal amphotericin dosing, and monitoring response to therapy with serum (1,3)-β-d-glucan levels.

Antimicrobial salvage therapy for persistent staphylococcal bacteremia using daptomycin plus ceftaroline

PURPOSE

Guidelines recommend daptomycin combination therapy as an option for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia after vancomycin failure. Recent data suggest that combining daptomycin with a β-lactam may have unique benefits; however, there are very limited clinical data regarding the use of ceftaroline with daptomycin.

METHODS

All 26 cases from the 10 medical centers in which ceftaroline plus daptomycin was used for treatment of documented refractory staphylococcal bacteremia from March 2011 to November 2012 were included. In vitro (synergy studies, binding assays, cathelicidin LL-37 killing assays), and in vivo (virulence assays using a murine subcutaneous infection model) studies examining the effects of ceftaroline with daptomycin were also performed.

FINDINGS

Daptomycin plus ceftaroline was used in 26 cases of staphylococcal bacteremia (20 MRSA, 2 vancomycin-intermediate S aureus, 2 methicillin-susceptible S aureus [MSSA], 2 methicillin-resistant S epidermidis). Bacteremia persisted for a median of 10 days (range, 3-23 days) on previous antimicrobial therapy. After daptomycin plus ceftaroline was started, the median time to bacteremia clearance was 2 days (range, 1-6 days). In vitro studies showed ceftaroline synergy against MRSA and enhanced MRSA killing by cathelicidin LL-37 and neutrophils. Ceftaroline also induced daptomycin binding in MSSA and MRSA to a comparable degree as nafcillin. MRSA grown in subinhibitory concentrations of ceftaroline showed attenuated virulence in a murine subcutaneous infection model.

IMPLICATIONS

Ceftaroline plus daptomycin may be an option to hasten clearance of refractory staphylococcal bacteremia. Ceftaroline offers dual benefit via synergy with both daptomycin and sensitization to innate host defense peptide cathelicidin LL37, which could attenuate virulence of the pathogen.

The use of ceftaroline fosamil in methicillin-resistant Staphylococcus aureus endocarditis and deep-seated MRSA infections: a retrospective case series of 10 patients

There are many limitations to the current antibiotics used for the treatment of severe methicillin-resistant Staphylococcus aureus (MRSA) infections. Ceftaroline is a new fifth-generation cephalosporin approved for the treatment of skin and soft tissue infections caused by MRSA and community-acquired pneumonia. We propose that ceftaroline can also be used successfully in more severe MRSA infections, including endocarditis. We conducted a retrospective chart review in a university-affiliated Department of Veterans Affairs hospital in San Diego, California (USA) of ten inpatients treated with ceftaroline for severe MRSA infection, including five cases of probable endocarditis (including two endocardial pacemaker infections), one case of pyomyositis with possible endocarditis, two cases of pneumonia (including one case of empyema), two cases of septic arthritis (including one case of prosthetic joint infection), and two cases of osteomyelitis. Seven of the 10 patients achieved microbiological cure. Six of the 10 patients achieved clinical cure. Seven patients were discharged from the hospital. Three patients were placed on comfort care and expired in the hospital; one achieved microbiological cure before death, and two remained bacteremic at time of death. In most patients, ceftaroline was effective for treatment of MRSA bacteremia and other severe MRSA infections. Adverse effects seen included rash, eosinophilia, pruritus, and Clostridium difficile infection. Ceftaroline can be a safe and effective drug for treatment of severe MRSA infections, and further comparative studies are warranted.

Digital tomosynthesis--a new lease of life for the intravenous urogram?

OBJECTIVES

Digital tomosynthesis is a new digital technique based on conventional X-ray tomography. It acquires multiple low-dose projections during a single sweep of the X-ray tube, which are reassembled to provide high-resolution slices at different depths. Suggested uses include visualisation of pulmonary nodules, mammography, angiography, dental imaging and delineation of fractures. This study aims to evaluate its potential role as part of an intravenous urogram (IVU) by assessing the diagnostic quality in imaging the kidneys in clinical practice.

METHODS

100 renal units from consecutive traditional IVU studies were retrospectively compared with 101 renal units imaged using digital tomosynthesis. These were scored for visualisation of the renal outline and collecting system, presence of a renal cyst or mass and overall diagnostic quality. Radiation doses were calculated.

RESULTS

46.5% of traditional IVUs were found to be of diagnostic quality. The IVUs with digital tomosynthesis were of diagnostic quality in 95.5%. This represents a highly statistically significant difference (p<0.0001). There was also a statistically significant dose reduction, with a mean reduction of 56%, for the samples studied.

CONCLUSION

Digital tomosynthesis offers a significant increase in the percentage of diagnostic quality tests for assessing renal pathology, compared with traditional IVU, and significantly reduces radiation. It also offers considerable advantages in ease and speed of imaging. For these reasons, in any situation where IVU is still being used to assess the kidneys, digital tomosynthesis is likely to be of considerable benefit in improving diagnostic quality.

Screening for unmet psycho-social needs in cancer care

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Background: Persons receiving cancer care are at risk for undiagnosed depression, but the burden of anxiety symptoms and social work needs is not well described. The objectives of the clinical intervention were: 1) to describe the burden of depression, anxiety and social distress; and 2) to determine whether an unmet need for psycho-social services existed in a sample of cancer patients at a university cancer center with an active psycho-social referral program. Methods: We developed a survey composed of the Memorial Distress Thermometer (MDT), specific social work needs, and the depression and anxiety modules from the Patient Health Questionnaire (PHQ). The clinical survey was administered to a convenience sample presenting for either referral visits or ongoing cancer treatment at the Indiana University Cancer Center for a four month period. Patient request for services, indicated need, and standardized threshold scores were used to determine need for referral (MDT ≥ 4; PHQ depression ≥ 10; PHQ anxiety ≥ 10). Descriptive statistics were calculated. Results: 184 patients (70% male) completed the survey. One-third of those screened met criteria for social work referral. 78% reported at least some distress (mean score 3.6) on the MDT, with 46% (n=81) scoring 4 or above. Social work needs included helping children cope with parental illness (11%), pharmaceutical expenses (11%), insurance assistance (6%), discussing illness with spouse (6%), and lodging during treatment (5%). Mental health distress was common. 34% met criteria for referral to psychological or psychiatric services. The mean PHQ depression score was 4.7, with moderate to severe depression (score ≥ 10) in 13%. Symptoms of generalized anxiety were also common, with a mean score of (5.0) and 11% scoring ≥ 10. Conclusions: In persons receiving cancer care, previously unknown distress, social work needs, depression, and anxiety were common. The burden of symptoms resulted in a markedly increased need for psycho-social services. These data reflect upon the significant need for regular screening and integration of psycho-social services with cancer treatment.

No significant financial relationships to disclose.

Use of inhaled nitrous oxide for minor eyelid surgery: a placebo-controlled study

BACKGROUND

Pain from local anaesthetic injection for minor eyelid surgery can often be severe enough to be the most unpleasant part of the procedure. This study was aimed at assessing the efficacy of 50 : 50 N(2)O/O( 2) (Entonox) in relieving such pain.

METHODS

In this randomised placebo-controlled double blind trial, 100 patients were randomised to receive either Entonox or air. Questions regarding pain during the administration of local anaesthetic, discomfort during the procedure and side effects experienced were asked by an investigator who was blinded to the type of gas inhaled.

RESULTS

The difference in pain score between the Entonox and control groups was not statistically significant (p = 0.474). The difference in discomfort score between the two groups was also not statistically significant (p = 0.948). More side effects were noted with Entonox than with air (p = 0.003, statistically significant). However, this was not clinically significant.

CONCLUSION

Entonox has been used effectively in different specialties for pain relief. However, our study was unable to show this beneficial effect in relieving pain from local anaesthetic injections for minor eyelid surgery.

Intrapulmonary arteriovenous shunting may be a universal phenomenon in patients with the superior cavopulmonary anastomosis: a radionuclide study

OBJECTIVE

To evaluate the extent of intrapulmonary right to left shunting in children after bidirectional cavopulmonary anastomosis (BCPA).

DESIGN

Prospective study of patients who underwent BCPA in a single centre.

PATIENTS

17 patients with complex cyanotic congenital cardiac malformations who underwent BCPA at 1-45 months of age (median 21 months) were evaluated 15-64 months postoperatively (median 32 months). Five children between 1 and 10 years (median 5 years) with normal or surgically corrected intracardiac anatomy and peripheral pulmonary circulation who required V/Q scanning for other reasons were used as controls.

INTERVENTIONS

All patients underwent cardiac catheterisation to exclude angiographically demonstrable venovenous collaterals followed by pulmonary perfusion scanning using (99m)technetium ((99m)Tc) labelled albumen microspheres to quantify the intrapulmonary right to left shunt.

MAIN OUTCOME MEASURE

Percentage of intrapulmonary right to left shunt.

RESULTS

The mean (SD) level of physiological right to left shunting found in the control group was 5.4 (2.3)%. All patients with BCPA showed the presence of a significantly higher level of intrapulmonary shunting (26.8 (16.9)%, p < 0.001). The degree of shunting was significantly increased in the subgroup of 11 patients with BCPA as the only source of pulmonary blood flow (34.9 (15.8)%), when compared to the six remaining patients with an additional source of pulmonary blood supply (12.0 (2.6)%, p < 0.001). There was a negative correlation between age at BCPA and the shunt percentage found in the patients with a competitive source of pulmonary blood flow (r = -0.63, p < 0. 01).

CONCLUSIONS

Intrapulmonary right to left shunting develops in all patients following BCPA. This may be caused by a sustained and inappropriate vasodilatation resulting from absence or decreased levels of a substance that inhibits pulmonary vasodilatation. Augmenting BCPA with an additional source of blood flow containing hepatic factor limits the degree of intrapulmonary arteriovenous shunting and may help provide successful longer term palliation.

StuAp is a sequence-specific transcription factor that regulates developmental complexity in Aspergillus nidulans

The Aspergillus nidulans Stunted protein (StuAp) regulates multicellular complexity during asexual reproduction by moderating the core developmental program that directs differentiation of uninucleate, terminally differentiated spores from multinucleate, vegetative hyphae. StuAp is also required for ascosporogenesis and multicellular development during sexual reproduction. StuAp is a member of a family of fungal transcription factors that regulate development or cell cycle progression. Further, StuAp characterizes a sub-family possessing the conserved APSES domain. We demonstrate for the first time that the APSES domain is a sequence-specific DNA-binding domain that can be modeled as a basic helix-loop-helix (bHLH)-like structure. We have found that StuAp response elements (A/TCGCGT/ANA/C) are located upstream of both critical developmental regulatory genes and cell cycle genes in A.nidulans. StuAp is shown to act as a transcriptional repressor in A.nidulans, but as a weak activator in budding yeast. Our data suggest that the differentiation of pseudohyphal-like sterigmatal cells during multicellular conidiophore development requires correct StuAp-regulated expression of both developmental and cell cycle genes in A.nidulans. The budding pattern of sterigmata may involve processes related to those controlling pseudohyphal growth in budding yeast.

Corneal tissue levels of topically applied ofloxacin

PURPOSE

To evaluate the levels of ofloxacin (Ocuflox) in human corneal tissue in patients exposed to various dosing regimens and application methods.

SETTING

Corneal Consultants of Indiana, Indianapolis, Indiana, USA.

METHODS

Forty patients meeting inclusion criteria were recruited from persons scheduled to have penetrating keratoplasty (PKP). Patients were placed into one of two study groups of 20 each based on dosing regimen and application method. The SAS GLM (General Linear Models) procedure was used to test for differences in mean Ocuflox tissue concentration among study groups and for interaction effects of preoperative diagnosis, trephine size, dosing regimen, and corneal integrity.

RESULTS

Corneal tissue concentrations of Ocuflox were elevated significantly by varying drug application methods and dosing schedules before PKP. Eyes receiving medication every 15 minutes for 4 hours had significantly higher levels of Ocuflox than those receiving the drug in six doses over 24 hours before surgery. Ocuflox concentrations exceeded the MIC90 (minimum inhibitory concentration) for key ocular pathogens in essentially all cornea specimens studied.

CONCLUSION

Ocuflox penetration was improved by administering it in a controlled setting at 15 minute intervals over 4 hours. The drug provided high tissue levels in both the cornea and aqueous humor, which together with its broad range of antibacterial coverage, should make it a good choice for prophylactic treatment.

Risk Factors for Corneal Graft Failure/Comment/Comments/Response

BACKGROUND

Penetrating keratoplasty is one of the most common and successful ophthalmic procedures. However, controversy and uncertainty still call to question the significance of certain risk factors for graft failure.

METHODS

A consecutive series of 1819 penetrating keratoplasties at a single center was studied to determine donor and recipient risk factors for graft failure. Mean follow up was 2.3 years (range, 1 to 96 months) with 139 (7.7%) eyes lost to follow up.

RESULTS

Previous graft failure was the most significant risk factor for secondary failure (P = .0013). The risk of failure significantly decreased with increased postoperative time. Significant patient risk factors for secondary failures in initial grafts included race (P = .01), age (P = .004), iris color (P = .02), use of preoperative glaucoma medications (P = .0008), deep stromal vascularization (P = .002), and host horizontal diameter (P = 0.007). Significant risk factors for failures associated with immunologic allograft reactions in initial grafts included horizontal corneal diameter (P = .002), donor size (P = .05), differences between horizontal corneal diameter, and both donor size (P = .02) and recipient trephination size (P = .01). However, deep stromal vascularization was only marginally significant (P = .09). A history of preoperative glaucoma medication usage was not a significant risk factor.

CONCLUSIONS

The relationship of the recipient's horizontal corneal diameter to immunologic graft rejection is a new risk factor that surgeons can directly control and thereby help avoid graft failure.

The effect of PHA stimulation on lymphocyte sub-populations in whole-blood cultures

Although lymphocytes in phytohaemagglutinin (PHA)-stimulated whole blood cultures are routinely used to assess genotoxin-induced chromosome damage, very little information is available on the effect of PHA on the various cell populations present, and there appear to be no data for the protocols used in routine genotoxicity assays. In this study, we used flow cytometric analysis to examine the size/complexity of the white blood cell (WBC) population and the expression of key antigenic markers by the lymphocytes over a 96-h period following PHA stimulation. The changes in the WBC population are complex, and would seem to represent different populations dying out, remaining static or starting to divide. The initial decrease seen in overall cell numbers probably reflects death of the neutrophil and monocyte populations. The subsequent increase in cell numbers appears to be due to division of the lymphocytes and, by 96 h post-stimulation, they comprise about half the total cell number and, as expected, > 90% are activated T-cells; it seems reasonable to assume that these represent the target cells in genotoxicity assays. Although we do not suggest that these findings should alter the routine conduct of clastogenicity assays using PHA-stimulated whole-blood cultures, they indicate that such tests are empirical and that closer investigation will only confirm their relatively imprecise nature.

Explantation of posterior chamber lenses

A consecutive series of 119 explanted posterior chamber lenses is reviewed. Seventy (58.8%) were removed because of dislocation or improper fixation, 15 (12.6%) because of anisometropia, and 18 (15.1%) because of chronic inflammation. Sixty-two (52.1%) of these explantations probably occurred for reasons that can be avoided by changes in preoperative, operative, or postoperative techniques. The rate of posterior chamber lens explantations is quite low considering the large number of lenses implanted; with changing surgical techniques, we anticipate that the number of lenses requiring removal will decrease.

Changing trends in explanted intraocular lenses: a single center study

Over a nine-year period, our practice removed 1,091 intraocular lenses. The most common type of lens requiring explantation was the closed-loop anterior chamber lens (58.6%). The Stableflex lens represented the largest percentage of all removed lens types (28.8%). The number of closed-loop anterior chamber lenses requiring removal peaked in 1988 and then gradually declined. All other lens styles have shown gradually increasing removal rates. Older style iris-fixated lenses and rigid anterior chamber lenses, which have not been implanted for several years, have increasing removal rates. Late breakage of fixational polypropylene sutures with pupil-supported iris-fixated lenses have occurred in five cases; the average time from implantation to suture breakage was 112 months.

Day hospital therapeutic community treatment for patients with personality disorders. An empirical evaluation of the containment function

Does a day hospital format represent an adequate level of treatment for decompensated patients with personality disorders? The study concerns 97 consecutive patients, 50 of whom belonged to cluster A and B personality disorders. The patients were referred partly from an acute admission ward and partly from outpatient departments. The mean treatment time was approximately 6 months. The dropout rate for schizotypal and borderline patients was 38%. No patient committed suicide. Two patients made suicidal attempts during treatment. The level of medication was moderate, and 58% of the patients were drug-free at discharge. Treatment results at discharge, measured by SCL-90 and Health Sickness Rating Scale, were very good for patients with axis I disorders only, good for cluster C personality disorders, modest for borderline patients, and very modest for schizotypal patients. In general, the results indicate that the containing capacity of a day hospital therapeutic community is substantial and that it may reduce the need for long-term inpatient treatment.

Personality disorders 2-5 years after treatment: a prospective follow-up study

Ninety-seven patients consecutively admitted to a day unit specializing in the treatment of personality disorders were included in a prospective follow-up study. At follow-up an average of 3 years after index admission, patients with borderline personality disorder (BPD) displayed a moderate symptom reduction and a fair global outcome. Patients with schizotypal personality disorder (STP) showed a similar reduction in symptoms but retained relatively poor global functioning. Individuals with cluster C personality disorders, in contrast, showed both a good global outcome and a marked symptom reduction. STP individuals were the least socially adjusted, employed and self-supporting of all diagnostic subgroups. STP and BPD individuals had far more inpatient treatment in the follow-up period than other groups. The overall suicide rate was low compared with most similar studies.

Transient post-partum thyroid dysfunction and postnatal depression

In the course of a population study of thyroid dysfunction in pregnancy and the post-partum period, 65 women, considered to be antibody-positive (microsomal and thyroglobulin), and 82 antibody-negative women were assessed for postnatal depression at 6-8 weeks post partum. The women were also assessed for the development of post-partum thyroid dysfunction. Of the 147 women, 22 met DSM-III criteria for major depression. The presence of autoantibodies showed little association with depressed mood but there was a minor association of postnatal depression with actual thyroid dysfunction in that incidence of the latter condition was higher in depressed women (Raskin scale P less than 0.01; Edinburgh scale P less than 0.05; Montgomery-Asberg scale P less than 0.1). Three of eight mothers with thyroid dysfunction had major depression and were depressed on all three scales.

The use of rating scales to identify post-natal depression

One hundred and forty-seven mothers were screened for major depression at six to eight weeks post-partum. Using predetermined cut-off points, the Edinburgh Postnatal Depression Scale and the Beck scale were compared in their abilities to identify the 15% of subjects who had major depression according to DSM-III criteria. The sensitivity of Edinburgh scale was 95% and its specificity 93%. The performance of the Beck scale was markedly inferior, with a sensitivity of 68% and specificity of 88%.

The hormonal environment of post-natal depression

The incidence of post-natal depression is high, and dramatic changes in steroid hormones and prolactin occur in the post-partum period. In an attempt to correlate these events, 147 mothers, six to eight weeks after delivery of a healthy infant, completed standard psychological tests, including the Edinburgh, Montgomery-Asberg, and Raskin scales. They also provided matched samples of plasma for assay of cortisol, oestradiol, progesterone and prolactin, and saliva for assay of cortisol and progesterone. All steroid concentrations were within the appropriate normal ranges. Of the mothers, 14.9% were depressed on all three scales. Significant correlations were seen between depression ratings and salivary progesterone and prolactin. In bottle-feeders, salivary progesterone was positively associated with depression, whereas in breast-feeders it was negatively associated. Plasma prolactin levels were inappropriately low in depressed breast-feeders. These data indicate that differing therapies may be appropriate for depression in breast- and bottle-feeders.

Clinical utility of the dexamethasone suppression test assessed by plasma and salivary cortisol determinations

Concentrations of cortisol in saliva and plasma were compared in matched samples during a standard 1 mg dexamethasone suppression test. The study involved 185 routine psychiatric admissions, all of whom were classified according to DSM-III criteria. In a group of 122 matched samples of saliva and plasma, there was a Pearson correlation coefficient of 0.867 and a Spearman rank correlation coefficient of 0.869. Medication with anticholinergic side effects had little effect on the correlation and was not associated with major difficulties in salivary sampling due to "dry mouth." In a group of 178 diagnoses where both saliva and plasma were obtained, results were almost identical. Although nonsuppression was found in all psychiatric conditions, there was a very significant association with major depressive episode with melancholia.

Evidence that trypsin digestion exposes a channel in the sarcoplasmic reticulum membrane

We present evidence that proteolytic digestion of sarcoplasmic reticulum membranes with trypsin exposes an ionophore that is capable of translocating calcium across the membrane of preloaded vesicles. Net transport of calcium appears to stop when the chemical potential of the ion on both sides of the membrane is equal. The temperature coefficient of steady-state leakage suggests that the ionophore is of the channel or pore type. We suggest that tryptic digestion exposes a channel in sarcoplasmic reticulum membranes through which calcium, and perhaps other ions as well, can diffuse down concentration gradients.

Activation of classical complement pathway by naturally occurring heteroantibodies in normal rabbit serum. Effect on subpopulations of human lymphoid cells

Heteroantibodies present in normal rabbit serum (NRS) are toxic to human B lymphocytes, T lymphocytes, and monocytes. Even NRS, which exhibits little back ground cytotoxicity for human lymphoid cells in conventional HLA or B-cell lymphocytotoxic assays, can be shown to contain considerable activity by making two modifications in usual procedures: by washing cells in saline or balanced salt solutions devoid of protein or sugar substances, and by increasing incubation time for 1 h to 3--4 h. Using such modifications, the cytotoxic activity of NRS towards human lymphoid cells was investigated and was found to involve activation of the classical complement pathway rather than activation of the alternate complement pathway. Residual unwanted background cytotoxicity of NRS toward human lymphoid cells can be decreased without loss of desired complement activity either by heating NRS for 15 min at 50 degrees C or by mixing NRS with small amounts of normal human serum.

Studies on Chloroplast Membranes. I. 13C Chemical Shifts and Longitudinal Relaxation Times of Carboxylic Acids

The 13C chemical shift and longitudinal relaxation time (T1) of the individual carbon atoms in a series of carboxylic acids in CDCl3 solution have been determined. Substituent shift parameters have been derived from the chemical shift data. The relaxation times have been interpreted in terms of increasing segmental motion along the methylene chains of the carboxylic acid molecules which are associated at the carboxylic acid groups in the form of inverted micelles. Differences in the segmental motion between saturated and unsaturated carboxylic acids are rationalized on the grounds of intermolecular interactions between adjacent molecules in the inverted micelle structures.

Studies on Chloroplast Membranes. II. 13C Chemical Shifts and Longitudinal Relaxation Times of 1,2-Di[(9Z,12Z,15Z)-octadeca-9,12,15-trienoyl]-3-galactosyl-sn-glycerol and 1,2-Di[(9Z,12Z,15Z)-octadeca-9,12,15-trienoyl]-3-digalactosyl-sn-glycerol

The 13C chemical shift and longitudinal relaxation time (T1) of the individual carbon atoms in the two major lipids of chloroplast thylakoids, 1,2-di[(9Z,12Z,15Z)-octadeca-9,12,15-trienoyl]-3- galactosyl-sn-glycerol and 1,2-di[(9Z,12Z,15Z)-octadeca-9,12,15- trienoyl]-3-digalactosyl-sn-glycerol, have been measured in the three solvents: methanol[D4], chloroform[D] and water[D2]. The longitudinal relaxation time data are interpreted in terms of different secondary structures in the different solvents, a monomeric structure in methanol[D4], an inverted micellar structure in chloroform[D] and a bilayer structure in water[D2]. Two possible correlations times can be obtained from the longitudinal relaxation times of the galactosyl and glyceryl carbon atoms in chloroform[D] and water[D2] and nuclear Overhauser enhancement values have been used to assign the correlation times to these carbon atoms.

New Alkaloids of the ent-Kaurene Type From Anopterus Species (Escalloniaceae). I. The Structure and Reactions of Anopterine

Anopterine (1), a major alkaloid from leaf and bark of Anoptevus macleayanus F. Muell. and bark of Anoptevus glandulosus Labill., has an unusual ent-kaurenoid skeleton with a C20-C14 linkage. Hydrolysis of anopterine gives anopteryl alcohol (5), C21H31N05, and two equivalents of tiglic acid. The chemical reactions of anopterine and anopteryl alcohol have been studied in detail, and a number of acetylation products and oxidation products have been obtained. Oxidation of anopteryl alcohol with potassium ferricyanide has given an unusual product (14) which has a C20,C12-oxide bridge and a C5,C6-epoxide group.

New Alkaloids of the ent-Kaurene Type From Anopterus Species. II. The Structure of the Minor Alkaloids

Anopterimine (2) is a new diterpenoid alkaloid, and on the basis of spectroscopic data it is considered to have the same carbon skeleton as anopterine. It is remarkable in having a C19-N azomethine system, while another minor base of A. macleayanus is anopterimine N-oxide (3). Two other new alkaloids, hydroxyanopterine and dihydroxyanopterine, both resemble anopterine, and spectroscopic data indicate that they have an additional hydroxy group at C1 or C3 on the A ring. Dihydroxy- anopterine has tiglic acid and the new acid, (E)-4-hydroxy-2-methylbut-2-enoic acid, as esterifying acids. A biosynthetic route to the Anopterus alkaloids is suggested.

Psychotridine, a C55H62N10 Alkaloid From Psychotria beccarioides (Rubiaceae)

Psychotridine, the major alkaloid from Psychotria beccarioides Wernh. has the molecular composition C55H62N10. It has been shown to be related to hodgkinsine, and a structure (4) derived from five Nb-methyltryptamine units is proposed. Mass spectral evidence for the structure is supported by the conversion of psychotridine through a pentamethiodide into a penta-indolenine base, analogous to the tri-indolenine base derived from hodgkinsine Nb,Nb',Nb?-trimethiodide. The structure is also supported by comparison of the 13C N.M.R. spectra of hodgkinsine and psychotridine.

Elaeocarpus Alkaloids. V. The Alkaloids of Elaeocarpus kaniensis

The leaf alkaloids of Elaeocarpus kalziensis Schltr. are a complex mixture, from which eight new alkaloids have been separated. Spectroscopic evidence has shown that these alkaloids are a closely interrelated group of indolizidines and structures have been assigned to elaeokanine A (1), elaeokanine B (8), elaeokanine C (10), elaeokanine D (12), elaeokanine E (17), and elaeokanidine A (18), Elaeokanidine B and elaeokanidine C are stereoisomers of elaeokanidine A, but the spectroscopic evidence is insufficient for the structures of these alkaloids to be assigned unequivocally. The assigned structures in all cases indicate relative and not absolute stereochemistry. The structures established for elaeokanine A, elaeokanine B, and elaeokanine C by spectroscopic methods have been confirmed by synthesis. Catalytic hydrogenation of synthetic 8-n-butyryl-7-oxoindolizidine (22) over platinum oxide in ethanol afforded (�)elaeokanine C in 30% yield. Under these hydrogenation conditions a major product was 8-n-butyryl-7-oxo-8,9-dehydroindolizidine (23) formed by loss of hydrogen from (22).