Effect of inspiratory rise time on sputum movement during ventilator hyperinflation in a test lung model

OBJECTIVES

Physiotherapists may use ventilator hyperinflation to enhance secretion clearance for intubated patients. This study investigated the effects of altering percentage inspiratory rise time (IRT) on sputum movement, ratio of peak inspiratory to expiratory flow rate (PIF:PEF ratio) and net peak expiratory flow (PEF) during ventilator hyperinflation in a test lung model.

DESIGN

Laboratory-based bench study.

INTERVENTIONS

Simulated sputum (two viscosities) was inserted into clean, clear tubing and connected between a ventilator and a resuscitation bag. Thirty-six ventilator hyperinflation breaths were applied for each 5% incremental increase in IRT between 0% and 20%.

MAIN OUTCOME MEASURES

The primary outcome was sputum displacement (cm). Secondary outcomes included PIF:PEF ratio and net PEF.

RESULTS

Significant cephalad sputum movement of 2.42cm (1.59 to 3.94) occurred with IRT between 5% and 20%, compared with caudad movement of 0.53 cm (0.31 to 1.53) at 0% IRT (median sputum movement difference 3.7cm, 95% confidence interval 2.2 to 4.8, P<0.001). Incremental increases in IRT percentage produced linear enhancements in PIF:PEF ratio and net PEF for both sputum concentrations (P<0.001). However, once the critical threshold for PIF:PEF ratio of 0.9 was achieved, the distance of sputum movement remained consistent for all IRT values exceeding 5%.

CONCLUSIONS

Significant increases in sputum movement occurred when IRT percentage was lengthened to achieve the optimal PIF:PEF ratio, irrespective of sputum viscosity. This provides a theoretical rationale for therapists to consider this technique when treating mechanically ventilated patients. As no additional sputum movement was seen beyond the critical PIF:PEF ratio threshold, a low IRT percentage may potentially be used to achieve effective sputum movement.

DVD Versus Physiotherapist-Led Inhaler Education: A Randomised Controlled Trial

Correct technique with inhalers is vital for therapeutic effect. Efficacy of DVD inhaler instruction was investigated. Secondary aims were to examine feasibility of an inhaler technique outcome measure, and to compare knowledge and self-efficacy after DVD or individual education. This was a randomised controlled trial conducted in a regional hospital paediatric ward, involving new or existing paediatric inhaler users. Inhaler technique was assessed pre-education in existing inhaler users. Participants were then randomised to message equivalent education by DVD or individually with a physiotherapist. Inhaler technique, self-efficacy and knowledge were assessed immediately post- and three months after education. Twenty one participants received DVD or individual education. There were no significant differences between groups for technique, self-efficacy or knowledge at any time. The outcome measure was feasible for use in a research study. DVD education was equivalent to individual instruction to teach parents how to use inhalers with their child.

Elbow kinematics after radiocapitellar arthroplasty

PURPOSE

Radiocapitellar arthroplasty has been proposed as a reconstructive option for combined radial head and capitellar deficiency. The purpose of this study was to assess the impact of radiocapitellar replacement on elbow kinematics. We hypothesized that with the medial collateral ligament (MCL) intact, radiocapitellar arthroplasty would replicate normal kinematics, and that a radiocapitellar arthroplasty would more closely approximate normal kinematics than an elbow with a deficient lateral column or with a deficient MCL.

METHODS

We tested 7 cadaveric arms in an upper extremity joint simulator. Each arm underwent computed tomographic scanning to aid implant size selection and computer-assisted implant insertion. We obtained kinematic data using an electromagnetic tracking system during elbow flexion. The capitellar and radial head implants were placed through an extended lateral epicondylar osteotomy. We sectioned the anterior bundle of the MCL, leaving the flexor-pronator mass intact. Outcomes of interest were varus-valgus and rotational kinematics of the ulnohumeral joint.

RESULTS

The radiocapitellar arthroplasty showed no difference in kinematics compared with the postosteotomy control. The MCL-deficient elbow showed more valgus angulation and more external ulnar rotation than the control or radiocapitellar arthroplasty in the pronated, valgus loaded position. The deficient lateral column demonstrated increased external ulnar rotation kinematics during active elbow flexion.

CONCLUSIONS

Radiocapitellar arthroplasty can restore normal elbow kinematics with the MCL intact. If the MCL is deficient, radiocapitellar arthroplasty does not restore normal kinematics.

CLINICAL RELEVANCE

Radiocapitellar arthroplasty should be considered in cases of lateral column deficiency because it maintains normal elbow kinematics during active motion. Whereas radiocapitellar arthroplasty improves the stability of the MCL-deficient elbow with deficiency of the lateral column, reconstruction of the MCL may further improve normal kinematics.

CT Guided Lung Biopsies: An Audit Cycle

Aim

To re-audit the practice of CT guided lung biopsies

Standard

British Thoracic Society guidelines

Methods

The present audit of CT guided lung biopsies has been undertaken to assess if changes in practice instituted following an initial audit in 2003/2004 has improved the diagnostic yield and impacted on the complication rate.

Results

97 biopsies were carried out in 90 patients. The overall diagnostic rate was 85.6 % (66 true positive and 17 true negatives). There were 14 (14.4%) false negatives. 28 (28.9%) patients developed a pneumothorax and 6 patients (6.2%) required insertion of chest drain.

Conclusion

The overall diagnostic rate is within the BTS standard and is higher than the previous audit (85.6 % compared to 81 % in the previous audit). The number of biopsies performed has increased significantly. The complication rate for pneumothorax is higher than the BTS standard. The technique of biopsy has also changed with most biopsies now being core biopsies rather than fine needle aspiration (FNA).

Effect of chest wall vibration timing on peak expiratory flow and inspiratory pressure in a mechanically ventilated lung model

OBJECTIVE

To investigate the effects of chest wall vibration timing on air flow and pressure in a ventilated lung model.

DESIGN

Laboratory-based bench study.

PARTICIPANTS

Thirty physiotherapists with experience in intensive care.

INTERVENTION

Physiotherapists applied three sets of eight chest wall vibrations to an intubated, mechanically ventilated mannequin. Vibrations were applied at the start of expiration (optimal), mid to late inspiration (early) and early to mid expiration (late). Air flow, peak pressure and volume were measured continuously. Forces applied during vibrations were recorded using a force-sensing mat, placed under the physiotherapists' hands.

RESULTS

During optimal and early vibrations, peak expiratory flow increased significantly compared with baseline ventilation [mean difference for optimal vibrations 8.8l/minute, 95% confidence interval (CI) 6.0 to 11.6; mean difference for early vibrations 7.0l/minute, 95% CI 4.3 to 9.9]. Late vibrations did not enhance expiratory flow. Peak inspiratory pressure was significantly higher during early vibrations compared with baseline values (mean difference 5.6cmH(2)O, 95% CI 2.9 to 8.2). Peak inspiratory pressure generated during early vibrations was, on average, 8.4cmH(2)O greater than with optimal timing.

CONCLUSION

The safety and effectiveness of respiratory physiotherapy treatments are likely to be influenced by the timing of vibrations within the breath cycle. Early vibrations generate potentially dangerous peak inspiratory pressures. Late vibrations, although not harmful, are not effective at increasing peak expiratory flow. This is an important consideration when training physiotherapists and evaluating outcomes of treatments in intensive care.

Simultaneous measurement of force and respiratory profiles during chest physiotherapy in ventilated children

There are currently no objective means of quantifying chest wall vibrations during manual physiotherapy. The aims of the study were to (i) develop a method to quantify physiotherapy-applied forces and simultaneous changes in respiratory flow and pressure, (ii) assess the feasibility of using this method in ventilated children and (iii) characterize treatment profiles delivered by physiotherapists in the paediatric intensive care unit. Customized sensing mats were designed and used in combination with a respiratory profile monitor. Software was developed to align force and flow data streams. Force and respiratory data were successfully collected in 55 children (median age 1.6 years (range 0.02-13.7 years)). Physiotherapists demonstrated distinctive variations in the pattern of force applied and manual lung inflations. The maximum applied force ranged from 15 to 172 N, and was correlated with the child's age (r = 0.76). Peak expiratory flow increased significantly during manual inflations both with and without chest wall vibrations (p < 0.05). This method provides the basis for objective assessments of the direct and independent effects of vibration forces and manual lung inflations as an essential precursor to developing evidence-based practice.

Opportunities and challenges for collaboration in research and practice in injury prevention across work and other settings

Even though injuries at work and in other settings (homes, roads, etc) commonly involve similar mechanisms, research and prevention are usually specific to each setting. The potential benefits of addressing common features of injury prevention are noted across setting, while some unique features of the work environment are acknowledged. Further integration is recommended using the following approaches: (i) organization of research questions by injury mechanisms and (ii) support of comparative research across settings by funding agencies.

Anxiolytic-like activity of the mGLU2/3 receptor agonist LY354740 in the elevated plus maze test is disrupted in metabotropic glutamate receptor 2 and 3 knock-out mice

RATIONALE

(1S,2S,5R,6S)-2-Aminobicyclo[3.1.0]hexane-2,6-dicarboxylic acid (LY354740) is a potent and selective agonist for group II metabotropic glutamate (mGlu2 and mGlu3) receptors, with anxiolytic-like activity in animal and human models, and efficacy in anxiety patients. However, the lack of mGlu2 or mGlu3 receptor specific agonists has prevented in vivo characterization of individual functions of these two receptors in mediating the anxiolytic-like effects of LY354740.

OBJECTIVE

To utilize mGlu2 receptor and mGlu3 receptor knockout animals and the mGlu2/3 selective antagonist (2S,1'S,2'S)-2-(9-xanthylmethyl)-2-(2'-carboxycyclopropyl)glycine (LY341495) to further investigate the roles of mGlu2 and mGlu3 receptors in mediating the anxiolytic-like actions of LY354740 in a mouse model of anxiety [elevated plus maze (EPM) test].

METHODS

To confirm that mGlu2/3 receptors are responsible for anxiolytic-like activity in the EPM under these test conditions, mice were pretreated with LY341495 at 30 min prior to s.c. administered LY354740. Subsequently, saline vehicle or LY354740 was administered (s.c.) 30 min before the EPM testing in wild-type, mGlu2 receptor knockout, and mGlu3 receptor knockout mice.

RESULTS

LY354740 reduced in a dose-dependent manner anxiety-related behavior on the EPM in wild-type mice with a maximally effective dose of 10--20 mg/kg s.c. Pretreatment with LY341495 potently prevented the anxiolytic-like effects of LY354740 (20 mg/kg, s.c.) in mice. Although the mGlu2 receptor knockout and mGlu3 receptor knockout mice were grossly normal, the anxiolytic-like activity of LY354740 (20 mg/kg, s.c.) was not evident in either mGlu2 or mGlu3 receptor knockout mice, when compared to their wild-type controls.

CONCLUSIONS

The activation of both mGlu2 and mGlu3 receptors by LY354740 appears to be required for anxiolytic-like activity in the EPM test in mice. These studies serve as a foundation for additional studies on underlying circuits, brain structures, and receptor subtypes involved in the anxiolytic-like actions of mGlu receptor active agents, and the design of future drugs for anxiety disorders in humans.

A novel approach to a patient with Crohn disease and a high stoma output: a missed opportunity?

The development of stricturing or penetrating behaviour in Crohn disease is influenced by disease location, clinical activity of the disease and smoking habit. The management of inflammatory bowel disease remains unsatisfactory, and the influence of current therapies--immunosuppressants, and especially the novel biological treatment now commonly used in Crohn disease--remains largely unknown. A relatively smaller number of patients receive dietary treatment as well. Physicians' scepticism, under-resourced dietetic departments and patient compliance are the main concerns in considering enteral nutrition. The management of high stomal output in Crohn disease is even more challenging. We report a case of active Crohn disease with high stoma output treated successfully solely with enteral feeding without the need for surgical intervention or administration of potent pharmacotherapy.

Generation and pharmacological analysis of M2 and M4 muscarinic receptor knockout mice

Muscarinic acetylcholine receptors (M1-M5) play important roles in the modulation of many key functions of the central and peripheral nervous system. To explore the physiological roles of the two Gi-coupled muscarinic receptors, we disrupted the M2 and M4 receptor genes in mice by using a gene targeting strategy. Pharmacological and behavioral analysis of the resulting mutant mice showed that the M2 receptor subtype is critically involved in mediating three of the most striking central muscarinic effects, tremor, hypothermia, and analgesia. These studies also indicated that M4 receptors are not critically involved in these central muscarinic responses. However, M4 receptor-deficient mice showed an increase in basal locomotor activity and greatly enhanced locomotor responses following drug-induced activation of D1 dopamine receptors. This observation is consistent with the concept that M4 receptors exert inhibitory control over D1 receptor-mediated locomotor stimulation, probably at the level of striatal projection neurons where the two receptors are known to be coexpressed. These findings emphasize the usefulness of gene targeting approaches to shed light on the physiological and pathophysiological roles of the individual muscarinic receptor subtypes.

An examination of the role of clinical psychology in meeting the needs of young disabled clients and their families/carers

This paper examines the views of clients with a physical disability, general practitioners and staff working in health and social work physical disability services about the needs of young disabled people. The most common area of disability seen by GPs was respiratory, followed by cardiac problems and stroke. With the exception of cardiac patients a third to over half of GPs felt that the needs of the identified groups were not being adequately met, in particular the needs of individuals with progressive neuromuscular problems. Over a quarter of clients felt that their needs were not being adequately met. Ninety-five percent of GPs and 100% of staff identified psychological needs of clients. For clients themselves, physical needs are ranked highest, with over 33 percent identifying psychological problems, 50 percent neuropsychological problems and 25 percent psychosexual difficulties as priority needs. In relation to carers, over 90 percent of GPs, 100% of staff and 50 percent of clients highlighted psychological needs. The majority of participants felt that clinical psychology had an important role to play in physical disability services. There was broad agreement on the areas of need which psychology would be seen to address. These were psychological needs, behavioural problems, neuropsychological problems and relationship/psychosexual difficulties. A high percentage of both staff and GPs also saw a role for clinical psychology in meeting the psychological, relationship and psychosexual needs of carers.

Central muscarinic inhibition of lower urinary tract nociception

Previous studies indicate cholinergic systems suppress somatic nociception. The present studies determined if cholinergic muscarinic systems suppress visceral nociception, specifically, chemical irritation of the lower urinary tract. Bladders of urethane-anesthetized rats were cannulated through the dome for continuous-infusion cystometrogram recordings. EMG electrodes recorded anal sphincter activity. Infusion of 0.5% acetic acid into the bladder to produce irritation increased bladder activity and anal sphincter activity (i.e. activation of a nociceptive vesicoanal reflex). Oxotremorine (a muscarinic agonist) and (-)butylthio[2.2.2] (a mixed muscarinic agonist/antagonist) dose-dependently inhibited vesicoanal reflex activity. This inhibition was antagonized by atropine (a centrally active muscarinic antagonist) but not by scopolamine methylbromide (a peripherally restricted muscarinic antagonist). Physostigmine (a centrally active cholinesterase inhibitor) also dose-dependently inhibited vesicoanal reflex activity in an atropine-sensitive manner, while neostigmine (a peripherally restricted cholinesterase inhibitor) did not. Atropine alone (i.e. administered without prior administration of muscarinic agonist or cholinesterase inhibitor) produced robust but transient (15 min) increases in vesicoanal activity and bladder activity under conditions of acetic acid infusion into the bladder. Under conditions of saline infusion into the bladder, atropine had the opposite effect on bladder activity (i.e. inhibition). These studies indicate that an endogenous cholinergic muscarinic system can be activated by lower urinary tract irritation to suppress visceral nociception through central nervous system mechanisms.

Enhancement of D1 dopamine receptor-mediated locomotor stimulation in M(4) muscarinic acetylcholine receptor knockout mice

Muscarinic acetylcholine receptors (M(1)-M(5)) regulate many key functions of the central and peripheral nervous system. Primarily because of the lack of receptor subtype-selective ligands, the precise physiological roles of the individual muscarinic receptor subtypes remain to be elucidated. Interestingly, the M(4) receptor subtype is expressed abundantly in the striatum and various other forebrain regions. To study its potential role in the regulation of locomotor activity and other central functions, we used gene-targeting technology to create mice that lack functional M(4) receptors. Pharmacologic analysis of M(4) receptor-deficient mice indicated that M(4) receptors are not required for muscarinic receptor-mediated analgesia, tremor, hypothermia, and salivation. Strikingly, M(4) receptor-deficient mice showed an increase in basal locomotor activity and greatly enhanced locomotor responses (as compared with their wild-type littermates) after activation of D1 dopamine receptors. These results indicate that M(4) receptors exert inhibitory control on D1 receptor-mediated locomotor stimulation, probably at the level of striatal projection neurons where the two receptors are coexpressed at high levels. Our findings offer new perspectives for the treatment of Parkinson's disease and other movement disorders that are characterized by an imbalance between muscarinic cholinergic and dopaminergic neurotransmission.

Performance of open-fronted microbiological safety cabinets: the value of operator protection tests during routine servicing

The performance of class I and II microbiological safety cabinets over 7 years, employed in a force-ventilated containment level 3 (CL-3) laboratory, is described. Operator Protection (OP) provided by the cabinets, assessed by still and latterly limited 'in-use' KI-Discus tests, showed no overall deterioration during the review period. Comparisons show that a selected class II unit, but not a second, and a new class II MSC in a recently commissioned, similar CL-3 facility, provide the same order of OP as a class I cabinet. From the experiences described, it is strongly recommended that OP tests (OPTs) should be part of the routine servicing regime to ensure that cabinets meet required performance levels, and additionally to allow detection and rectification of poor containment, particularly where induced by environmental factors. The value of OPTs is discussed with reference to certain national standards.

Are risk factors for atherothrombotic disease associated with back pain sickness absence? The Whitehall II Study

STUDY OBJECTIVE

To explore the previously stated hypothesis that risk factors for atherothrombotic disease are associated with back pain.

DESIGN

Prospective (mean of four years of follow up) and retrospective analyses using two main outcome measures: (a) short (< or = 7 days) and long (> 7 days) spells of sickness absence because of back pain reported separately in men and women; (b) consistency of effect across the resulting four duration of spell and sex cells.

SETTING

14 civil service departments in London.

PARTICIPANTS

3506 male and 1380 female white office-based civil servants, aged 35-55 years at baseline.

MAIN RESULTS

In age adjusted models, low apo AI was associated with back pain across all four duration-sex cells and smoking was associated across three cells. Six factors were associated with back pain in two cells: low exercise and high BMI, waist-hip ratio, triglycerides, insulin and Lp(a). On full adjustment (for age, BMI, employment grade and back pain at baseline), each of these factors retained a statistically significant effect in at least one duration-sex cell. Triglycerides were associated with short and long spells of sickness absence because of back pain in men in fully adjusted models with rate ratios (95% confidence intervals) of 1.53 (1.1, 2.1) and 1.75 (1.0, 3.2) respectively. There was little or no evidence of association in age adjusted models with: fibrinogen, glucose tolerance, total cholesterol, apoB, hypertension, factor VII, von Willebrand factor, electrocardiographic evidence of coronary heart disease and reported angina.

CONCLUSIONS

In this population of office workers, only modest support was found for an atherothrombotic component to back pain sickness absence. However, the young age of participants at baseline and the lack of distinction between different types of back pain are likely to bias the findings toward null. Further research is required to ascertain whether a population sub-group of atherothrombotic back pain can be identified.

Pronounced pharmacologic deficits in M2 muscarinic acetylcholine receptor knockout mice

Members of the muscarinic acetylcholine receptor family (M1-M5) are known to be involved in a great number of important central and peripheral physiological and pathophysiological processes. Because of the overlapping expression patterns of the M1-M5 muscarinic receptor subtypes and the lack of ligands endowed with sufficient subtype selectivity, the precise physiological functions of the individual receptor subtypes remain to be elucidated. To explore the physiological roles of the M2 muscarinic receptor, we have generated mice lacking functional M2 receptors by using targeted mutagenesis in mouse embryonic stem cells. The resulting mutant mice were analyzed in several behavioral and pharmacologic tests. These studies showed that the M2 muscarinic receptor subtype, besides its well documented involvement in the regulation of heart rate, plays a key role in mediating muscarinic receptor-dependent movement and temperature control as well as antinociceptive responses, three of the most prominent central muscarinic effects. These results offer a rational basis for the development of novel muscarinic drugs.

A comparison of peak vs cumulative physical work exposure risk factors for the reporting of low back pain in the automotive industry

OBJECTIVE: To determine the relative importance of modelled peak spine loads, hand loads, trunk kinematics and cumulative spine loads as predictors of reported low back pain (LBP). BACKGROUND: The authors have recently shown that both biomechemical and psychosocial variables are important in the reporting of LBP. In previous studies, peak spinal load risk factors have been identified and while there is in vitro evidence for adverse effects of excessive cumulative load on tissue, there is little epidemiological evidence. METHODS: Physical exposures to peak and cumulative lumbar spine moment, compression and shear forces, trunk kinematics, and forces on hands were analyzed on 130 randomly selected controls and 104 cases. Univariable and multivariable odds ratios of the risk of reporting were calculated from a backwards logistic regression analysis. Interrelationships among variables were examined by factor analysis. RESULTS: Cases showed significantly higher loading on all biomechanical variables. Four independent risk factors were identified: integrated lumbar moment (over a shift), 'usual' hand force, peak shear force at the level of L(4)/L(5) and peak trunk velocity. Substituting lumbar compression or moment for shear did not appreciably alter odds ratios because of high correlations among these variables. CONCLUSIONS: Cumulative biomechanical variables are important risk factors in the reporting of LBP. Spinal tissue loading estimates from a biomechanical model provide information not included in the trunk kinematics and hand force inputs to the model alone. Workers in the top 25% of loading exposure on all risk factors are at about six times the risk of reporting LBP when compared with those in the bottom 25%. RELEVANCE: Primary prevention, treatment, and return to work efforts for individuals reporting LBP all require understanding of risk factors. The results suggest that cumulative loading of the low back is important etiologically and highlight the need for better information on the response of spinal tissues to cumulative loading.

Determinants of disability after a work related musculetal injury

OBJECTIVE

Musculoskeletal soft tissue injuries consume considerable resources in personal suffering, medical care, work absenteeism, and compensation benefits. Our aim was to determine specific clinical and behavioral factors that prognostically influence return to work following musculoskeletal work related injuries.

METHODS

A longitudinal cohort study was conducted on 148 randomly selected workers who had not returned to work in 3 months following musculoskeletal soft tissue injury. The cohort was identified from the files of the Workers' Compensation Board of Ontario, Canada. The workers were interviewed and assessed at 3, 9, 15, and 21 months after injury. The WHO Classification of Impairment, Disabilities and Handicap was used as the conceptual framework. The analysis employed a proportional hazards regression model with allowance for time dependent covariates.

RESULTS

The rate of return to work for men was 1.5 times that for women, and 20% less for every 10 year increase in age. Controlling for sex and age, psychological distress and functional disability were associated with a slower rate of return to work. The rate of return to work for workers who were provided with modified jobs was 2 times higher than for those with no such accommodation in employment.

CONCLUSION

The negative effect of psychological distress and functional disability on return to work rates must be considered in the design and delivery of rehabilitation programming for workers with musculoskeletal soft tissue injuries. The employer's provision of a "modified job" is important in the prevention of continued disability.

Preventing disability from work-related low-back pain. New evidence gives new hope--if we can just get all the players onside

Despite the publication in the mid-1990s of comprehensive practice guidelines for the management of acute low-back pain, both in the United States and elsewhere, this ubiquitous health problem continues to be the main cause of workers' compensation claims in much of the Western world. This paper represents a synthesis of the intervention studies published in the last 4 years and is based on a new approach to categorizing these studies that emphasizes the stage or phase of back pain at the time of intervention and the site or agent of the intervention. Current thinking suggests that medical management in the first 3-4 weeks after the onset of pain should be generally conservative. Several studies of rather heterogeneous interventions focusing on return to work and implemented in the subacute stage (3-4 to 12 weeks after the onset of pain) have shown important reductions in time lost from work (by 30% to 50%). There is substantial evidence indicating that employers who promptly offer appropriately modified duties can reduce time lost per episode of back pain by at least 30%, with frequent spin-off effects on the incidence of new back-pain claims as well. Finally, newer studies of guidelines-based approaches to back pain in the workplace suggest that a combination of all these approaches, in a coordinated workplace-linked care system, can achieve a reduction of 50% in time lost due to back pain, at no extra cost and, in some settings, with significant savings.

Effects of the M1 agonist xanomeline on processing of human beta-amyloid precursor protein (FAD, Swedish mutant) transfected into Chinese hamster ovary-m1 cells

Complementary DNA (cDNA) encoding human beta-amyloid precursor protein familial Alzheimer's disease (FAD) Swedish mutant (beta APPSM) form was cloned into a mammalian expression vector (PK255) containing the CMV promoter. The vector was transfected into Chinese hamster ovary cells containing human muscarinic m1 receptors (CHO-m1), and clonal cells stably expressing beta APPSM were isolated. The effects of m1-receptor activation by the selective m1 agonist xanomeline and the non-selective muscarinic agonist carbachol on processing of beta APPSM to release soluble APP (APPs) and beta-amyloid peptide (A beta) were compared. Xanomeline stimulated APP release with a potency 1000-fold greater than that observed for carbachol. Concentrations of carbachol and xanomeline producing maximal effects on APPs release reduced the secretion of A beta by 28 and 46%, respectively. These results extend previous studies with xanomeline and suggest that cholinergic replacement therapy for Alzheimer's disease may reduce amyloid deposition.

Behavioral pharmacology of olanzapine: a novel antipsychotic drug

BACKGROUND

In this paper, we review the behavioral pharmacology of olanzapine and compare it to its in vitro profile and to clozapine and a number of other antipsychotic agents, and we estimate the likelihood that olanzapine will be an effective and safe antipsychotic with fewer side effects.

METHOD

Since there is no model of schizophrenia, per se, a battery of behavioral assays was used.

RESULTS

Behavioral assays confirmed the in vitro results that olanzapine interacts with dopamine, serotonin, and muscarinic receptor subtypes. Moreover, olanzapine appears to have a clozapine-like atypical profile based on (1) mesolimbic selectivity, (2) blocking 5-HT receptors at a lower dose than dopamine receptors, and (3) inhibiting the conditioned avoidance response (indicative of antipsychotic efficacy) at doses that are lower than those required to induce catalepsy (indicative of extrapyramidal side effects). No only is this profile similar to that of clozapine, but olanzapine has other similarities: olanzapine substitutes for clozapine in a drug discrimination assay; like clozapine and unlike "typical" antipsychotics, olanzapine increases responding in a conflict procedure; and olanzapine, like clozapine, reverses changes induced by antagonists of the NMDA receptor.

CONCLUSION

On the basis of these findings, we predict that olanzapine will be an efficacious antipsychotic, active against both positive and negative symptoms, while producing fewer extrapyramidal symptoms than existing treatments.

Assessment of physical work load in epidemiologic studies: common measurement metrics for exposure assessment

There are many possible means of determining exposure ranging from self-reports of physical exposure to measures of muscle activations and estimated spinal loads. In epidemiologic studies, issues of validity make instrumented measures preferable, however issues of cost and practicability tend to force investigators to less costly but less valid and less reliable measures of exposure, such as self-report questionnaires. This paper presents a method by which estimates of exposure from self-report questionnaires, expert observers, work sampling, video analysis and electromyograms can be reported in a common metric, Newtons of force on a tissue, and show, as an example of its application, estimation of spinal compression on auto workers. A common metric allows a flexible approach to selection of measurement methods in occupational settings: no matter which instrument is used the results can be combined to provide an overall picture of exposure. This approach to exposure assessment for the low back allows for comparability across studies and settings.

Effects of electroconvulsive therapy on peripheral adrenoceptors, plasma, noradrenaline, MHPG and cortisol in depressed patients

BACKGROUND

The mechanism of the antidepressant action of electroconvulsive therapy (ECT) remains unknown. Based on previous work with antidepressant drugs and their effects on the noradrenergic system, we undertook this study to further determine the effects of ECT on selected indices of peripheral adrenoceptor function in depressed patients.

METHODS

Binding parameters (Bmax and Kd) of platelet alpha 2- and leukocyte beta 2-adrenoceptors, plasma noradrenaline (NA), 3-methoxy-4-hydroxy-phenylglycol (MHPG) and cortisol levels were determined in 18 patients, prior to treatment and 14 days after the last of a series of ECTs, and compared with samples obtained from 18 matched control subjects.

RESULTS

Platelet alpha 2-adrenoceptor sites were significantly elevated in untreated patients compared with controls (P < 0.03), but leukocyte beta 2-adrenoceptor numbers did not differ. Treatment with ECT led to a significant reduction in platelet alpha 2-adrenoceptor numbers, whereas leukocyte beta 2-adrenoceptor densities increased. Pre-ECT plasma NA, MHPG, and cortisol levels were elevated in patients, compared with controls, and decreased following ECT, but these differences were not statistically significant. Post-ECT plasma NA and beta 2-adrenoceptor numbers were significantly, negatively correlated (P < 0.05).

CONCLUSIONS

These results suggest that platelet alpha 2-adrenoceptors are supersensitive in depressed patients and treatment with ECT results in down-regulation of these receptors, which may be interpreted as a primary therapeutic, "normalising' effect. The post-ECT changes in leukocyte beta 2-adrenoceptors are probably only secondary to the lower circulating plasma NA levels.

Effects of prehospital care on outcome in patients with cardiac illness

STUDY OBJECTIVE

To compare outcomes of patients with acute cardiac illness transported by ambulance for whom prehospital care was provided by emergency medical technician-paramedics (EMT-Ps) or EMTs trained in defibrillation (EMT-Ds).

DESIGN

A prospective chart review carried out over 3.5 years.

SETTING

The Hamilton-Wentworth region of Ontario, Canada, which covers 1,136 km2 and includes five receiving hospitals.

PARTICIPANTS

We prospectively identified 8,720 potentially eligible patients from approximately 30,000 who presented to the ambulance service. We reviewed hospital charts to confirm eligibility. The group of 8,720 patients yielded 3,066 patients with acute cardiac illness who met all other eligibility requirements. We excluded patients in cardiac arrest.

RESULTS

Incidence of myocardial infarction (MI), length of hospital stay, and mortality were evaluated. Analysis was performed with chi 2 tests for association, linear regression, and logistic regression. Of the eligible patients who received prehospital EMS care, 783 sustained MIs. The proportions of people discharged alive with the diagnosis of MI did not differ between crew types (P = .16). Average hospital stay was 13 days in both groups for patients with the discharge diagnosis of MI; hospital stay ranged from 9 (EMT-D) to 11 days (EMT-P) for any patient with a discharge diagnosis other than MI. These values were statistically similar. The odds ratio of having had an MI after treatment by an EMT-D crew was 1.02 (95% confidence interval, .86 to 1.21) compared with that for treatment by an EMT-P crew.

CONCLUSIONS

In an urban setting with short (less than 10 minutes) average transport times, the availability of prehospital paramedic care does not affect occurrence of MI, length of hospital stay, or mortality of patients presenting to the EMS system with cardiac illness.

Basic statistics for clinicians: 4. Correlation and regression

Correlation and regression help us to understand the relation between variables and to predict patients' status in regard to a particular variable of interest. Correlation examines the strength of the relation between two variables, neither of which is considered the variable one is trying to predict (the target variable). Regression analysis examines the ability of one or more factors, called independent variables, to predict a patient's status in regard to the target or dependent variable. Independent and dependent variables may be continuous (taking a wide range of values) or binary (dichotomous, yielding yes-or-no results). Regression models can be used to construct clinical prediction rules that help to guide clinical decisions. In considering regression and correlation, clinicians should pay more attention to the magnitude of the correlation or the predictive power of the regression than to whether the relation is statistically significant.

Basic statistics for clinicians: 3. Assessing the effects of treatment: measures of association

In the third of a series of four articles the authors show the calculation of measures of association and discuss their usefulness in clinical decision making. From the rates of death or other "events" in experimental and control groups in a clinical trial, we can calculate the relative risk (RR) of the event after the experimental treatment, expressed as a percentage of the risk without such treatment. The absolute risk reduction (ARR) is the difference in the risk of an event between the groups. The relative risk reduction is the percentage of the baseline risk (the risk of an event in the control patients) removed as a result of therapy. The odds ratio (OR), which is the measure of choice in case-control studies, gives the ratio of the odds of an event in the experimental group to those in the control group. The OR and the RR provide limited information in reporting the results of prospective trials because they do not reflect changes in the baseline risk. The ARR and the number needed to treat, which tells the clinician how many patients need to be treated to prevent one event, reflect both the baseline risk and the relative risk reduction. If the timing of events is important--to determine whether treatment extends life, for example--survival curves are used to show when events occur over time.

Basic statistics for clinicians: 2. Interpreting study results: confidence intervals

In the second of four articles, the authors discuss the "estimation" approach to interpreting study results. Whereas, in hypothesis testing, study results lead the reader to reject or accept a null hypothesis, in estimation the reader can assess whether a result is strong or weak, definitive or not. A confidence interval, based on the observed result and the size of the sample, is calculated. It provides a range of probabilities within which the true probability would lie 95% or 90% of the time, depending on the precision desired. It also provides a way of determining whether the sample is large enough to make the trial definitive. If the lower boundary of a confidence interval is above the threshold considered clinically significant, then the trial is positive and definitive, if the lower boundary is somewhat below the threshold, the trial is positive, but studies with larger samples are needed. Similarly, if the upper boundary of a confidence interval is below the threshold considered significant, the trial is negative and definitive. However, a negative result with a confidence interval that crosses the threshold means that trials with larger samples are needed to make a definitive determination of clinical importance.

Basic statistics for clinicians: 1. Hypothesis testing

In the first of a series of four articles the authors explain the statistical concepts of hypothesis testing and p values. In many clinical trials investigators test a null hypothesis that there is no difference between a new treatment and a placebo or between two treatments. The result of a single experiment will almost always show some difference between the experimental and the control groups. Is the difference due to chance, or is it large enough to reject the null hypothesis and conclude that there is a true difference in treatment effects? Statistical tests yield a p value: the probability that the experiment would show a difference as great or greater than that observed if the null hypothesis were true. By convention, p values of less than 0.05 are considered statistically significant, and investigators conclude that there is a real difference. However, the smaller the sample size, the greater the chance of erroneously concluding that the experimental treatment does not differ from the control--in statistical terms, the power of the test may be inadequate. Tests of several outcomes from one set of data may lead to an erroneous conclusion that an outcome is significant if the joint probability of the outcomes is not taken into account. Hypothesis testing has limitations, which will be discussed in the next article in the series.

General pharmacology of gemcitabine hydrochloride in animals

Gemcitabine (2',2'-difluorodeoxycytidine monohydrochloride, LY188011 hydrochloride, CAS 122111-03-9) is a nucleoside analog with a broad spectrum of antitumor activity in murine models and is currently undergoing clinical evaluation. The profile of the pharmacological effects of this agent was assessed in studies evaluating the cardiovascular and respiratory systems, renal function, the gastrointestinal system, the central nervous system, and the autonomic nervous system. In vivo doses ranged from 0.15 to 300 mg/kg given by the intravenous route, while in vitro concentrations up to 1 x 10-3 mol/l were used. Gemcitabine was inactive in the autonomic nervous system, gastrointestinal function, and central nervous system studies. Only minimal changes were seen in the cardiovascular and respiratory study, with a slight decrease in pulmonary arterial pressure at the mid dose and a stroke volume increase at the high dose. In the renal function studies, a slight decrease in the urine pH at the high dose and decreased serum creatinine at the mid dose levels were observed. In summary, gemcitabine had minimal effect in these pharmacodynamic studies. These results indicate that gemcitabine has a low potential to produce adverse pharmacologic effects.

General pharmacology of loracarbef in animals

Loracarbef ((6R, 7S)-7-[(R)-2-amino-2-phenyl-acetamido]-3-chloro-8-oxo-1- azabicyclo [4.2.0]oct-2-ene-2-carboxylic acid, monohydrate, LY 163892, CAS 121961-22-6) is a carbacephem antibiotic targeted for use in the treatment of infectious disease. The potential pharmacological effects of this agent were examined on cardiovascular, respiratory, gastrointestinal, central nervous and autonomic nervous systems. Also examined were local anesthetic activity, effects on platelet aggregation, circulating blood glucose, primary antibody production, renal function, blood coagulation, ocular irritation, and the acute inflammatory response. Doses of 100, 1000, and 2000 mg/kg given by the oral route were selected for most in vivo studies. Concentrations up to 3 x 10(-3) mol/l were used in vitro. Loracarbef was essentially inactive in the tests of central and autonomic nervous system function, platelet aggregation, renal function, blood hemolysis, primary antibody production, blood coagulation, and ocular irritation. It had no local anesthetic activity. At high oral or intravenous doses, representing significant multiples of the therapeutic dose, loracarbef caused changes in gastrointestinal (decrease in gastric acid production and gastric fluid volume; increased biliary output), cardiovascular (increased mean pressure, cardiac output, heart rate, and femoral flow), blood glucose (increased glucose levels), and anti-inflammatory tests (suppressed acute inflammatory response). In summary, loracarbef exhibited minimal activity in these pharmacodynamic studies. These results indicate loracarbef has a low potential to produce adverse effects at therapeutic doses.

Characterization of enamel exposed to 10% carbamide peroxide bleaching agents

The purpose of this investigation was to evaluate the effect of three 10% carbamide peroxide bleaching agents on enamel microhardness and surface morphology. Seventy-two enamel slabs were subjected to one of three carbamide peroxide solutions or an artificial saliva solution for 15 hours a day for 2- and 4-week periods. During the remaining 9 hours, slabs were exposed to human saliva in vivo. Although differences were not statistically significant, microhardness values of all treated specimens 2 weeks after treatment were less than those of control specimens. These trends, however, were not evident at 4 weeks. Scanning electron microscopic evaluation revealed significant surface alterations in enamel topography for slabs treated with the bleaching solutions for 4 weeks. The most severe alterations were found in slabs exposed to the lower-pH solutions.

General pharmacology of nizatidine in animals

Nizatidine (N-[2-[[[2-[(dimethylamino)methyl-4-thiazolyl]- methyl]thio]ethyl]-N'-methyl-2-nitro-1,1-ethenediamine, LY139037, Axid) is a novel, potent, and selective H2-antagonist. The potential secondary pharmacologic effects of this agent on the cardiovascular, respiratory, gastrointestinal, renal, hepatic, autonomic, and central nervous systems as well as effects on circulating blood glucose and the acute inflammatory response were examined. Nizatidine was generally inactive in the tests conducted in mice, rats, guinea pigs, rabbits, and dogs. Nizatidine and the reference H2-antagonist, cimetidine, both produced effects upon the cardiovascular and respiratory systems by intravenous administration in anesthetized dogs at doses in excess of the intended clinical exposure. In summary, these studies confirm the selective pharmacologic activity of nizatidine and indicate a low potential for secondary pharmacologic side effects to be encountered clinically.

Sample size in occupational mortality studies

In 1980, the Occupational Safety and Health Administration asserted that "non-positive human studies" would be considered in reviews of evidence only if in a study the "group of exposed subjects was large enough for an increase in cancer incidence of 50% above that in unexposed controls to have been detected at any of the predicted sites." The concepts of statistical testing and power in occupational mortality studies are reviewed, and studies published in two prominent occupational health journals in 1979 and 1980 are analyzed in terms of their power. A large proportion of standardized mortality ratio studies have a low probability of detection of relative risks of the order of 1.5.