FEASIBILITY OF THE ACTPLAN PROGRAM FOR AFRICAN-AMERICAN DEMENTIA CAREGIVERS: A SELF-DIRECTED MULTIMEDIA DELIVERY

African Americans (AA) are less likely than White Americans to complete advance care plans or end-of-life treatment documents. They face significantly greater risk of Alzheimer’s Disease, a silent epidemic for this population, and other dementias. The healthcare system’s lack of dementia support for AAs contributes to disparate care. A four-session caregiver group education program was conducted on advance care planning for AA dementia family providers. The program was based on Kolb’s Experiential Learning Model and initially found effective in an R01 study using in-person delivery by a professional. The present pilot assessed feasibility of delivering the program in a self-directed multimedia format without professional facilitation, using Session 1 on tube feeding decisions as the test session. Twenty-six AA dementia caregivers completed the session in groups of 5 to 8 at a church equipped with a large TV screen. On-screen prompts guided navigation through the program which included recorded lecture, slides, short videos on decision-making, and group discussions. Using quantitative and qualitative methods, pre-and post-survey instruments were administered and interviews conducted. Usability ratings averaged 84%. Knowledge and self-efficacy gains exceeded those of the R01, with a 35% increase in correct responses on knowledge items, versus 18% for the R01 subjects; and increase in perceived decisional self-efficacy of 31% versus 30% for the R01 subjects. Qualitative feedback was universally positive. These findings confirm the feasibility of the self-guided multimedia approach to delivery of the program. A large RCT is planned which, if successful, will support wide dissemination to AA caregivers in need.

Feasibility of the ACTPlan Program for African American Dementia Caregivers: A Self-Directed Multimedia Delivery

African Americans (AA) are less likely than White Americans to complete advance care plans or end-of-life treatment documents. They face significantly greater risk of Alzheimer’s Disease, a silent epidemic for this population, and other dementias. The healthcare system’s lack of dementia support for AAs contributes to disparate care. A four-session caregiver group education program was conducted on advance care planning for AA dementia family providers. The program was based on Kolb’s Experiential Learning Model and initially found effective in an R01 study using in-person delivery by a professional. The present pilot assessed feasibility of delivering the program in a self-directed multimedia format without professional facilitation, using Session 1 on tube feeding decisions as the test session. Twenty-six AA dementia caregivers completed the session in groups of 5 to 8 at a church equipped with a large TV screen. On-screen prompts guided navigation through the program which included recorded lecture, slides, short videos on decision-making, and group discussions. Using quantitative and qualitative methods, pre-and post-survey instruments were administered and interviews conducted. Usability ratings averaged 84%. Knowledge and self-efficacy gains exceeded those of the R01, with a 35% increase in correct responses on knowledge items, versus 18% for the R01 subjects; and increase in perceived decisional self-efficacy of 31% versus 30% for the R01 subjects. Qualitative feedback was universally positive. These findings confirm the feasibility of the self-guided multimedia approach to delivery of the program. A large RCT is planned which, if successful, will support wide dissemination to AA caregivers in need.

Trust Building Recruitment Strategies for Researchers Conducting Studies in African American (AA) Churches: Lessons Learned

BACKGROUND

An initial and vital important step in recruiting participants for church-based hospice and palliative care research is the establishment of trust and credibility within the church community. Mistrust of medical research is an extremely important barrier hindering recruitment in African American (AA) communities. A church-based EOL dementia education project is currently being conducted at four large urban AA churches. Church leaders voiced mistrust concerns of previous researchers who conducted investigations in their faith-based institutions. We explored strategies to ameliorate the mistrust concerns. Specific aim: To identify trust-rebuilding elements for researchers following others who violated trust of AA church leaders.

METHODS

Face-to-face, in-depth interviews were conducted from a convenient sample of four established AA church leaders. Interviews were held in the informants' churches to promote candor and comfort in revealing sensitive information about trust /mistrust. Content analysis framework was used to analyze the data. Elements identified from the analysis were then used to create themes.

RESULTS

Multidimensional overarching themes emerged from the analysis included: Experience with researchers (positive and extremely negative), violation of trust and trust building strategies.

CONCLUSIONS

Findings suggest that researchers who wish to conduct successful studies in the AA religious institutions must implement trust rebuilding strategies that include mutual respect, collaboration and partnership building. If general moral practices continue to be violated, threat to future hospice and palliative care research within the institutions may prevail. Thus, potential benefits are thwarted for the church members, AA community, and advancement of EOL care scholarship.

'If you listen to me properly, I feel good': a qualitative examination of patient experiences of dietetic consultations

BACKGROUND

There is considerable interest in healthcare research regarding communication skills and some debate surrounding the effectiveness of a patient-centred approach to care. Understanding patient experiences of consultations can help indicate how consultations can be modified to improve effectiveness. At present, there is little research exploring patient experience of dietetic consultations. The present study aimed to achieve a better understanding of patients' experiences of dietetic consultations using qualitative analysis.

METHODS

Patients undergoing consultations with a dietitian were invited to discuss their experience of the consultation with a research dietitian who was not involved in their care. Individual interviews and focus groups were conducted and analysed using the Framework approach.

RESULTS

Seventeen patients participated and described their experiences of consultations, which were varied and influenced by factors such as information given (resources, explanation, repetition, consistency); their dietitian's approach (prescriptive or nonprescriptive, use of behaviour change skills), behaviour (listening skills, body language) and appointment (expectations, involvement of the multidisciplinary team, length of time); and their own internal experience (confidence, guilt, frustration). Patients agreed that certain factors, such as good communication and rapport, receiving effective and reliable information and resources, and nonjudgmental, regular support, were important factors in creating a positive experience of their consultation. However, they differed in what they believed constituted these factors.

CONCLUSIONS

 Patients like dietitians to adopt a patient-centred approach, which might be either patient- or practitioner-led, and to take account of what they wanted from consultations, adapting these to meet their individual requirements.

Model for the First NIH-funded Center of Excellence in End-of-Life Research

Centers of excellence are widely acknowledged as a mechanism to promote scientific advances in a particular field of science, but until recently there have been no end-of-life or palliative care research centers funded by the National Institutes of Health (NIH). The purpose of this article is to describe aims, framework, and organizational structure of the first NIH-funded Center of Excellence on end-of-life research, the Center for End-of-Life Transition Research (CEoLTR), and the advances in end-of-life research that the CEoLTR will facilitate. The teams of researchers involved in the CEoLTR have grown impressively since it was funded in 2007. Collectively, the teams are on target to accomplish all of the original goals for this five year award.

Vascular and Alzheimer-type pathology in an autopsy study of African-Americans

The authors studied 13 autopsy brains from a larger cohort of 270 African-Americans with a clinical diagnosis of Alzheimer disease (AD), vascular dementia (VaD), or stroke without dementia. Two subjects exhibited changes of pure VaD, 5 had pure AD, and 6 showed a mixture of AD pathology and strokes. Overall, there was good agreement between the pathologic diagnoses and the clinical diagnoses.

Community-based research: barriers to recruitment of African Americans

The elimination of health disparities for African Americans requires culturally relevant, empirical knowledge, which in turn requires including African Americans in research studies. However, power-difference barriers and conceptual barriers continue to inhibit the recruitment of African Americans. The purpose of this article is to define and discuss certain barriers to the recruitment of African Americans into research studies and to present culturally and contextually sensitive strategies to overcoming these barriers. Power-difference barriers reflect unequal authority and often generate mistrust. Conceptual barriers reflect researchers' need for better understanding about African Americans. Effective strategies include collaboration with the community through a community advisory board and conducting community-based participatory action research. Also, integrating alternative conceptual frameworks with mainstream frameworks may reduce researchers' ideological assumptions about African Americans. To promote optimal recruitment of African Americans, researchers must be aware of power-difference barriers and conceptual barriers and move toward active collaboration with African American communities.

Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK

Violence and aggression is common in psychiatric inpatient units. Despite the near universal prevalence of restraint, there is very little published research on either the efficacy or the subjective effects of restraint on staff or patients. In this pilot study, semistructured interviews were given to the patients and staff involved in six untoward incidents in which the patient participant had been subject to manual physical restraint. Participants were interviewed as soon as possible after the occurrence of the incidents. The interviews asked the patient and staff participants to identify and discuss the factors that they found helpful and unhelpful during and in the immediate aftermath of these incidents. The incidents generated strong emotions for all concerned. The patients valued staff time and attention but felt that they received too little attention. Both nurses and patients discriminated between permanent and temporary staff. Patients reported feeling upset, distressed and ignored prior to the incidents and isolated and ashamed afterwards. Postincident debriefing was valued by all but was patchy for staff and rarer still for patients. Patients feared the possibility of being restrained. Half of the patients and several staff members reported that the incidents had reawakened distressing memories of previous traumatic events. Further research on the subjective effects of restraint is urgently needed.

Renal fibrosis: collagen composition and assembly regulates epithelial-mesenchymal transdifferentiation

Type IV collagen is a major component of basement membranes and it provides structural and functional support to various cell types. Type IV collagen exists in a highly complex suprastructure form and recent studies implicate that protomer (the trimeric building unit of type IV collagen) assembly is mediated by the NC1 domain present in the C-terminus of each collagen alpha-chain polypeptide. Here we show that type IV collagen contributes to the maintenance of the epithelial phenotype of proximal tubular epithelial cells, whereas type I collagen promotes epithelial-to-mesenchymal transdifferentiation (EMT). In addition, the recombinant human alpha1NC1 domain inhibits assembly of type IV collagen NC1 hexamers and potentially disrupts the deposition of type IV collagen, facilitating EMT in vitro. Inhibition of type IV collagen assembly by the alpha1NC1 domain up-regulates the production of transforming growth factor-beta1 in proximal tubular epithelial cells, an inducer of EMT. These results strongly suggest that basement membrane architecture is pivotal for the maintenance of epithelial phenotype and that changes in basement membrane architecture potentially lead to up-regulation of transforming growth factor-beta1, which contributes to EMT during renal fibrosis.

Decision making for health care professionals: use of decision trees within the community mental health setting

AIM OF THE PAPER

To examine the application of the decision tree approach to collaborative clinical decision-making in mental health care in the United Kingdom (UK).

BACKGROUND

While this approach to decision-making has been examined in the acute care setting, there is little published evidence of its use in clinical decision-making within the mental health setting. The complexities of dual diagnosis (schizophrenia and substance misuse in this case example) and the varied viewpoints of different professionals often hamper the decision-making process. This paper highlights how the approach was used successfully as a multiprofessional collaborative approach to decision-making in the context of British community mental health care.

DESIGN

A selective review of the relevant literature and a case study application of the decision tree framework.

CONCLUSIONS

The process of applying the decision tree framework to clinical decision-making in mental health practice can be time consuming and client inclusion within the process is not always appropriate. The approach offers a method of assigning numerical values to support complex multiprofessional decision-making as well as considering underpinning literature to inform the final decision. Use of the decision tree offers a common framework that can assist professionals to examine the options available to them in depth, while considering the complex variables that influence decision-making in collaborative mental health practice. Use of the decision tree warrants further consideration in mental health care in terms of practice and education.

Improving biomaterial properties of collagen films by chemical modification

Films of bovine collagen were chemically modified with the goal of improving their biomaterial properties. The modified films were investigated with respect to their affinity to fibroblast and endothelial cells, as well as their antibacterial properties tested by adhesion of Staphylococcus aureus. Modifications that only change the net charge of collagen, such as acetylation, succinylation, and treatment with glutaraldehyde (all increase the negative charge), and amination with ethylenediamine (EDA), N,N-dimethyl-EDA (DMEDA), or butylamine (all increase the positive charge), did not dramatically alter the mammalian cell attachment to the film. In contrast, derivatization of collagen using methoxypoly(ethylene glycol) (PEG) diminished the attachment of fibroblasts by 98 +/- 1% and of endothelial cells by more than 99% compared to unmodified collagen. Moreover, the rate of growth of fibroblasts dropped by 97 +/- 1% and that of endothelial cells by 88 +/- 3% as a result of PEGylation of collagen. Adhesion of S. aureus cells also plummeted by 93 +/- 2% as a result of this PEGylation. With these antifouling properties, PEG-collagen may be a promising coating material for coronary stents. Subsequent derivatization of PEG-collagen with EDA or DMEDA abolished its mammalian cell-repelling ability, whereas bacterial cell repulsion was partially retained: for example, DMEDA-modified PEG-collagen exhibits up to a 5-fold lower bacterial adhesion than collagen. It is worth noting that a material that allows mammalian cell attachment but reduces bacterial adhesion could be useful as an implant or coating.

The concept of priority as it relates to a community mental health team

This article illustrates how a concept clarification exercise can provide evidence to inform local policy development. Based on the framework developed in Walker and Avant's (1995) concept clarification theory, the concept of priority is examined in the context of a team of community mental health nurses. Themes of risk, multidisciplinary working, resources, and nursing role are identified as key areas for consideration, and the difficulties existing between government policy directives towards the severely mentally ill and health promotion are discussed. The article highlights how nursing theory can integrate the concept analysis of priority in planning client care. This is presented using Peplau's (1952) model as a guide to further enhance meaning of generated priorities to nursing practice.

Selectivity of mu-opioid receptor determined by interfacial residues near third extracellular loop

We hypothesized that the selectivity profile of the rat mu-opioid receptor for opioid receptor-selective ligands is determined by the nature of the amino acid residues at highly divergent sites in the ligand-binding pocket. To determine which characteristics of these residues contribute to opioid receptor ligand selectivity, we made various mutant receptors that replaced the Lys(303) and Trp(318) residues near the extracellular interface of transmembrane domains VI and VII, respectively. Ligand binding determinations using transiently transfected monkey kidney epithelial (COS-1) cells show that Lys(303) mutations cause little change in the receptor binding profile, whereas the Trp(318) mutant receptors have considerably lower affinity for micro-opioid receptor-selective ligands and greatly increased affinity for delta-opioid receptor-selective ligands. The nature of these mutations show that this effect is not due to sterics or charge alone. [35S]guanosine-5'-O-(3-thio)-triphosphate ([35S]GTPgammaS) activity assays show that these residues may influence functional, as well as binding selection. We conclude that a primary role for Trp(318) is to form a basis for ligand selectivity.

Hospitals do not inform GPs about medication that should be monitored

BACKGROUND

General practitioners are now asked to prescribe drugs that, due to possible risks and side effects, had previously been prescribed almost exclusively at hospital.

OBJECTIVE

To assess the quality of hospital letters as the key communication between hospitals and GPs.

METHOD

Hospital letters examined using a predetermined protocol.

RESULTS

Of 224 patients identified who were taking drugs that required regular monitoring, 173 were commenced in hospital. Fewer than one in five (30; 17%) hospital letters indicated that there was a risk associated with the drug or that it should be routinely monitored. Monitoring frequency was identified on only 14 occasions and the majority of letters (129; 74. 6%) did not state who was to be responsible for ongoing monitoring (either GP or hospital). Information was slow to arrive at the practice and, in 12% of cases, the hospital letter had not arrived within 14 days of commencement of medication.

CONCLUSION

The information provided in hospital letters is insufficient to allow GPs to put structures in place to monitor drug therapy.

Structural stability of DNA in nonaqueous solvents

One of the defining physicochemical features of DNA in aqueous solution is its ability to maintain a double-helical structure and for this structure to undergo a cooperative, heat-induced denaturation (melting). Herein we show that a 21-mer synthetic DNA can form and maintain such a duplex structure not only in water but even in 99% glycerol; moreover, this double-helical structure reversibly and cooperatively melts in that solvent, with a T(m) value of some 30 degrees lower than in water. Two much larger, natural DNAs, from calf thymus and salmon testes, exhibit similar behavior in glycerol. All three DNAs can also sustain a double-helical structure in 99% ethylene glycol, although its thermostability (as reflected by the melting temperature) is some 20 degrees lower than in glycerol. In contrast, no duplex structure of any of the DNAs was detected in 99% formamide, methanol, or DMSO. This solvent trend resembles that previously observed in studies of protein structure and folding and underscores the importance of hydrophobic interactions in both protein and DNA structure and stability. Our findings suggest that water may not be unique as a suitable medium not only for protein structure but also for that of nucleic acids.

Coil embolization of coronary supply to a cardiac metastasis

Coil embolization of tumor-related coronary arteries was successful in interrupting coronary supply to a cardiac metastasis from uterine leiomyosarcoma. In patients with cardiac metastases of highly malignant tumors this may be a palliative therapeutic approach.

Effects of mindfulness-based stress reduction on medical and premedical students

The inability to cope successfully with the enormous stress of medical education may lead to a cascade of consequences at both a personal and professional level. The present study examined the short-term effects of an 8-week meditation-based stress reduction intervention on premedical and medical students using a well-controlled statistical design. Findings indicate that participation in the intervention can effectively (1) reduce self-reported state and trait anxiety, (2) reduce reports of overall psychological distress including depression, (3) increase scores on overall empathy levels, and (4) increase scores on a measure of spiritual experiences assessed at termination of intervention. These results (5) replicated in the wait-list control group, (6) held across different experiments, and (7) were observed during the exam period. Future research should address potential long-term effects of mindfulness training for medical and premedical students.

Arterial saccular aneurysm model in the rabbit

Saccular aneurysms arising from the common carotid artery in the neck at the origin of the internal carotid artery were created in male rabbits using the stump of a ligated external carotid artery. These stumps were intraluminally perfused with varying concentrations of porcine pancreatic elastase for 45 minutes via a microcatheter introduced into the femoral artery. The aneurysms were allowed to mature for 2 to 12 weeks. Gross examination and histologic studies confirmed the presence of an aneurysm in all 15 experiments. Ninety-two percent (12 of 13) of the aneurysms studied by postoperative angiography were shown to be angiographically patent: 40% of all aneurysms were noted to be patent at harvest; and the remainder showed evidence of intraluminal thrombus. On histologic examination, all aneurysms showed complete loss of elastic lamina without evidence of fibrosis or scarring.

Yolk sac concentration of prostaglandin E2 in diabetic pregnancy: further clues to the etiology of diabetic embryopathy

Fetal malformation associated with maternal diabetes occurs before the seventh week of pregnancy. Current hypotheses suggest that the diabetic milieu causes a reduction in phosphatidylinositol turnover, leading to a disruption in the arachidonic acid cascade and resulting in a deficiency of prostaglandins, particularly prostaglandin E2. This in turn results in a wide variety of congenital anomalies. This hypothesis has not been tested experimentally in humans. The yolk sac is thought to be the most important source of nutrition in early pregnancy. We sought to compare yolk sac prostaglandin levels in normal and diabetic women. Under ultrasonographic guidance, yolk sacs were aspirated form 8 normal and 12 diabetic women ranging from 8 to 10 weeks gestational age prior to elective abortion. Prostaglandin E2 levels were determined using RIA. The mean prostaglandin E2 level in normal controls was 3605 pg/mL, and was undetected in all of the yolk sacs aspirated from diabetic women (P < 0.001). Yolk sac diameter in diabetic pregnancies was 1.2 mm larger than that of normal pregnancies. The functional and morphological changes demonstrated in this study may increase our understanding of the pathophysiology of diabetic embryopathy.

Treatment of experimental aneurysms using collagen-coated microcoils

Endovascular treatment of certain surgically difficult aneurysms is currently performed using fibered microcoils or electrolytically detachable microcoils to obliterate these lesions by forming an intra-aneurysmal thrombus. Unfortunately, this treatment option results in a significant incidence of incomplete obliteration of treated aneurysms. A thrombus can recanalize, resulting in further aneurysm growth and subsequent rupture. Nineteen aneurysms were surgically created in 10 pigs using jugular venous pouches. The aneurysms were allowed to mature for periods of 7 days to as long as 11 weeks prior to embolization. Fourteen remained patent for embolization. The aneurysms were then embolized (9 with collagen-coated microcoils, 5 with dacron-fibered platinum microcoils). Follow-up angiograms were obtained prior to sacrifice at 1, 3, 6, 9, and 12 weeks postembolization, and the embolized aneurysms and parent vessels were harvested for histopathological studies. The current study was designed to evaluate the potential efficacy of collagen-coated microcoils in providing an enduring therapy for aneurysms by comparing this new embolic device with the standard dacron-fibered platinum microcoils in a swine common carotid artery side wall aneurysm model. The aneurysms treated with collagen microcoils were completely obliterated with a collagen-rich fibrous scar with no histological evidence of residual thrombus or recanalization. Additionally, after treatment of experimental aneurysms with collagen microcoils, re-endothelialization across the former aneurysm neck was seen. In contrast, aneurysms embolized with dacron-fibered microcoils contained persistent thrombus surrounded by a relatively immature scar with residual aneurysmal lumen and lack of endothelium.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of a set of T7 RNA polymerase active site mutants

We have evaluated the elongation rates, processivities, and abortive transcription characteristics of a set of T7 RNA polymerase mutants that map to the polymerase active site. The effects of these mutations on transcription are complex: they cause decreases in activity and processivity during both the processive and abortive phases of transcription and exhibit disproportionate decreases in activity and processivity on poly(dA).poly(dT) or poly(dT) versus poly(dG).poly(dC) templates. They also exhibit an increase in the proportion of slippage dependent poly(G) transcript synthesis during the initial stages of transcription. It is shown that these multiple, distinct effects on transcription can be attributed to decreases in the mutant enzymes' phosphodiester bond formation rates. Estimates of the decreases in these rates are derived from the measured transcript elongation rates and processivities of the mutant enzymes.

The thumb subdomain of T7 RNA polymerase functions to stabilize the ternary complex during processive transcription

To examine the function of the thumb subdomain in bacteriophage T7 RNA polymerase we constructed a set of deletion mutants within this subdomain. These mutants exhibited reduced processivity during the processive, but not the abortive, stage of transcription. Reduced processivity was found to be due primarily to an increase in the processive ternary complex dissociation rate (destabilization of the processive ternary complex). The destabilization of the ternary complex does not appear to be due to a decrease in the affinity of the polymerase for the nascent RNA. These observations support the proposal that the thumb subdomain functions to stabilize the processive ternary complex during the processive (but not the abortive) stage of transcription, probably by wrapping around the template to prevent polymerase dissociation.

The blood supply of the intracavernous cranial nerves: an anatomic study

Cranial nerve deficits are the most common complications of cavernous sinus surgery. Often the deficit occurs despite anatomic preservation of the nerve, and ischemic injury is thought to be the cause. A better understanding of the blood supply of these nerves may help to prevent such complications. The authors performed a cadaveric microsurgical study of the intracavernous cranial nerves and their blood supply in 20 cavernous sinuses. The oculomotor nerve received branches from the inferolateral trunk or its equivalent in all specimens (100%). The proximal trochlear nerve received branches from the inferolateral trunk in 80% of the specimens and from the tentorial artery of the meningohypophyseal trunk in 20%. The distal half was supplied by the branches from the inferolateral trunk only. In the region of Dorello's canal, the proximal third of the abducens nerve received branches from the dorsal clival artery of the meningohypophyseal trunk. The middle and distal thirds received branches from the inferolateral trunk. The ophthalmic and proximal maxillary segments of the trigeminal nerve received branches from the inferolateral trunk. The distal maxillary segment was supplied by the artery of the foramen rotundum. In the majority of cases, the medial third of the Gasserian ganglion received branches from both the inferolateral trunk and the tentorial artery. The middle third of the ganglion received branches from either the inferolateral trunk or the middle meningeal artery. Our findings indicate the important role the intracavernous branches of the internal carotid artery play in the blood supply of the intracavernous cranial nerves, and stress the need to preserve these branches to prevent or minimize postoperative deficits.

Mutations in T7 RNA polymerase that support the proposal for a common polymerase active site structure

In order to test the proposal that most nucleotide polymerases share a common active site structure and folding topology, we have generated 22 mutations of residues within motifs A, B and C of T7 RNA polymerase (RNAP). Characterization of these T7 RNAP mutants showed the following: (i) most of the mutations resulted in moderate to drastic reductions in T7 RNAP transcriptional activity supporting the idea that motifs A, B and C identify part of the polymerase active site; (ii) the degree of conservation of an amino acid within these motifs correlated with the degree to which mutation of that amino acid reduced transcriptional activity, supporting the predictive ability of this alignment in identifying the most functionally critical residues; (iii) a comparison of DNAP I and T7 RNAP mutants revealed similarities (as well as differences) between corresponding mutant phenotypes; (iv) the Klenow fragment structure is shown to provide a reasonable basis for interpretation of the differential effects of mutating different amino acids within motifs A, B and C in T7 RNAP. These observations support the proposal that these polymerase active sites have similar three-dimensional structures.

Transcranial Doppler monitoring during percutaneous transluminal aortic valvuloplasty

Cerebral blood flow was studied in 12 elderly patients with severe calcific aortic stenosis by means of transcranial Doppler sonography (TCD) during percutaneous transluminal aortic valvuloplasty (PTAV). In 8 of these 12 patients duplex sonography revealed a stenosis of the internal carotid artery (ICA) exceeding 50%. Frequency spectra of 10 patients showed a satisfactory quality and were analyzed. In 7 subjects balloon inflation was well tolerated and systolic blood pressure did not drop below 75 mmHg. In these patients, whether they had a stenosis of the ICA or not, blood flow velocity in the middle cerebral artery (MCA) did not decrease to a critical level. The authors defined "critical" as a reduction of mean blood flow velocity in the MCA exceeding 50% or a decrease below 35 cm/sec. Three patients showed a rapid decrease of systolic aortic pressure below 75 mmHg. In these subjects mean blood flow velocity in the MCA dropped to levels below 35 cm/sec. Deflation and retraction of the balloon resulted in a rapid increase of systemic blood pressure and flow velocity in the MCA. This report demonstrates TCD to be a useful monitoring method of determining residual perfusion in patients with aortic stenosis during PTAV.

Evidence for a direct inhibitory effect of ethanol upon gonadotropin secretion at the pituitary level

Mixed rat pituitary cells harvested from pituitaries obtained from adult male rats were maintained in tissue culture for periods up to 240 hr. Viability determined by trypan blue exclusion at the end of each experiment was greater than 90%. Basal secretory rats of luteinizing hormone (LH) into the culture medium were determined before and after the addition of ethanol (30 mg/100 ml) to the incubation medium. Ethanol-reduced (p less than .01) LH secretion of treated cultures were compared to control cultures. Based upon this preliminary in vitro study with rat tissue and on prior studies performed in man and animals, we suggest that ethanol inhibits LH secretion at the pituitary level.