The evolution of diverse antimicrobial responses in vancomycin-intermediate Staphylococcus aureus and its therapeutic implications

Staphylococcus aureus causes endocarditis, osteomyelitis, and bacteremia. Clinicians often prescribe vancomycin as an empiric therapy to account for methicillin-resistant S. aureus (MRSA) and narrow treatment based on culture susceptibility results. However, these results reflect a single time point before empiric treatment and represent a limited subset of the total bacterial population within the patient. Thus, while they may indicate that the infection is susceptible to a particular drug, this recommendation may no longer be accurate during therapy. Here, we addressed how antibiotic susceptibility changes over time by accounting for evolution. We evolved 18 methicillin-susceptible S. aureus (MSSA) populations under increasing vancomycin concentrations until they reached intermediate resistance levels. Sequencing revealed parallel mutations that affect cell membrane stress response and cell-wall biosynthesis. The populations exhibited repeated cross-resistance to daptomycin and varied responses to meropenem, gentamicin, and nafcillin. We accounted for this variability by deriving likelihood estimates that express a population's probability of exhibiting a drug response following vancomycin treatment. Our results suggest antistaphylococcal penicillins are preferable first-line treatments for MSSA infections but also highlight the inherent uncertainty that evolution poses to effective therapies. Infections may take varied evolutionary paths; therefore, considering evolution as a probabilistic process should inform our therapeutic choices.

Maintaining, masking, and mimicking selection: the interplay of cell-intrinsic and cell-extrinsic effects upon eco-evolutionary dynamics

Evolution is a stochastic yet inevitable process that lies at the heart of biology yet in the multi-cellular environments within patients, ecological complexities arise via heterogeneity and microenvironments. The interplay of ecology and mutation is thus fundamental to predicting the evolution of complex diseases and engineering optimal treatment solutions. As experimental evidence of ecological interactions between disease agents continues to grow, so does the need for evolutionary theory and modeling that incorporates these interaction effects. Inspired by experimental cell biology, we transform the variables in the interaction payoff matrix to encode cell-cell interactions in our mathematical approach as growth-rate modifying, frequency-dependent interactions. In this way, we can show the extent to which the presence of these cell-extrinsic ecological interactions can modify the evolutionary trajectories that would be predicted from cell-intrinsic properties alone. To do this we form a Fokker-Planck equation for a genetic population undergoing diffusion, drift, and interactions and generate a novel, analytic solution for the stationary distribution. We use this solution to determine when these interactions can modify evolution in such ways as to maintain, mask, or mimic mono-culture fitness differences. This work has implications for the interpretation and understanding of experimental and patient evolution and is a result that may help to explain the abundance of apparently neutral evolution in cancer systems and heterogeneous populations in general. In addition, the derivation of an analytical result for stochastic, ecologically dependent evolution paves the way for treatment approaches requiring knowledge of a stationary solution for the development of control protocols.

Deficient adolescent social behavior following early-life inflammation is ameliorated by augmentation of anandamide signaling

Early-life inflammation has been shown to exert profound effects on brain development and behavior, including altered emotional behavior, stress responsivity and neurochemical/neuropeptide receptor expression and function. The current study extends this research by examining the impact of inflammation, triggered with the bacterial compound lipopolysaccharide (LPS) on postnatal day (P) 14, on social behavior during adolescence. We investigated the role that the endocannabinoid (eCB) system plays in sociability after early-life LPS. To test this, multiple cohorts of Sprague Dawley rats were injected with LPS on P14. In adolescence, rats were subjected to behavioral testing in a reciprocal social interaction paradigm as well as the open field. We quantified eCB levels in the amygdala of P14 and adolescent animals (anandamide and 2-arachidonoylglycerol) as well as adolescent amygdaloid cannabinoid receptor 1 (CB1) binding site density and the hydrolytic activity of the enzyme fatty acid amide hydrolase (FAAH), which metabolizes the eCB anandamide. Additionally, we examined the impact of FAAH inhibition on alterations in social behavior. Our results indicate that P14 LPS decreases adolescent social behavior (play and social non-play) in males and females at P40. This behavioral alteration is accompanied by decreased CB1 binding, increased anandamide levels and increased FAAH activity. Oral administration of the FAAH inhibitor PF-04457845 (1mg/kg) prior to the social interaction task normalizes LPS-induced alterations in social behavior, while not affecting social behavior in the control group. Infusion of 10ng PF-04457845 into the basolateral amygdala normalized social behavior in LPS injected females. These data suggest that alterations in eCB signaling following postnatal inflammation contribute to impairments in social behavior during adolescence and that inhibition of FAAH could be a novel target for disorders involving social deficits such as social anxiety disorders or autism.

Burden and coping among the relatives and carers of brain-injured survivors

The relatives/carers of 23 traumatic brain injury patients were interviewed around one year after patients' discharge from postacute rehabilitation to determine the nature of the residual problems, the nature of the relatives' and carers' responses, and the strain on relatives and carers. Relatives were under very considerable strain. Some response styles were associated with increased stress, but there was little evidence for the effectiveness of positive coping strategies in reducing stress.

Fractionation of visuo-spatial memory processes in bipolar depression: a cognitive scaffolding account

BACKGROUND

Previous studies of neurocognitive performance in bipolar disorder (BD) have demonstrated impairments in visuo-spatial memory. The aim of the present study was to use an object-location memory (OLM) paradigm to assess specific, dissociable processes in visuo-spatial memory and examine their relationship with broader neurocognitive performance.

METHOD

Fifty participants (25 patients with BD in a current depressive episode and 25 matched healthy controls) completed the OLM paradigm which assessed three different aspects of visuo-spatial memory: positional memory, object-location binding, and a combined process. Secondary neurocognitive measures of visuo-spatial memory, verbal memory, attention and executive function were also administered.

RESULTS

BD patients were significantly impaired on all three OLM processes, with the largest effect in exact positional memory (d = 1.18, p < 0.0001). General deficits were also found across the secondary neurocognitive measures. Using hierarchical regression, verbal learning was found to explain significant variance on the OLM measures where object-identity was present (the object-location binding and combined processes) and accounted for the group difference. The group difference in precise positional memory remained intact.

CONCLUSIONS

This study demonstrates that patients with bipolar depression manifest deficits in visuo-spatial memory, with substantial impairment in fine-grain, positional memory. The differential profile of processes underpinning the visuo-spatial memory impairment suggests a form of 'cognitive scaffolding', whereby performance on some measures can be supported by verbal memory. These results have important implications for our understanding of the functional cognitive architecture of mood disorder.

Neurocognitive functioning in bipolar depression: a component structure analysis

BACKGROUND

Previous studies of neurocognitive performance in bipolar disorder (BD) have focused predominantly on euthymia. In this study we aimed to compare the neurocognitive profile of BD patients when depressed with healthy controls and explore the component structure of neurocognitive processes in these populations.

METHOD

Cognitive tests of attention and executive function, immediate memory, verbal and visuospatial learning and memory and psychomotor speed were administered to 53 patients with a SCID-verified diagnosis of BD depression and 47 healthy controls. Test performance was assessed in terms of statistical significance, effect size and percentile standing. Principal component analysis (PCA) was used to explore underlying cognitive factor structure.

RESULTS

Multivariate analysis revealed an overall group effect, depressed BD patients performing significantly worse than controls. Patients performed significantly worse on 18/26 measures examined, with large effect sizes (d > 0.8) on tests of speed of processing, verbal learning and specific executive/working memory processes. Almost all tests produced at least one outcome measure on which ∼25-50% of the BD sample performed at more than 1 standard deviation (s.d.) below the control mean. Between 20% and 34% of patients performed at or below the fifth percentile of the control group in working memory, verbal learning and memory, and psychomotor/processing speed. PCA highlighted overall differences between groups, with fewer extracted components and less specificity in patients.

CONCLUSIONS

Overall, neurocognitive test performance is significantly reduced in BD patients when depressed. The use of different methods of analysing cognitive performance is highlighted, along with the relationship between processes, indicating important directions for future research.

Large arrays and properties of 3-terminal graphene nanoelectromechanical switches

Large arrays of 3-terminal nanoelectromechanical graphene switches are fabricated. The switch is designed with a novel geometry that leads to low actuation voltages and improved mechanical integrity, while reducing adhesion forces, which improves the reliability of the switch. A finite element model including non-linear electromechanics is used to simulate the switching behavior and to deduce a scaling relation between the switching voltage and device dimensions.

On-chip optical interconnects made with gallium nitride nanowires

In this Letter we report on the fabrication, device characteristics, and optical coupling of a two-nanowire device comprising GaN nanowires with light-emitting and photoconductive capabilities. Axial p-n junction GaN nanowires were grown by molecular beam epitaxy, transferred to a non-native substrate, and selectively contacted to form discrete optical source or detector nanowire components. The optical coupling demonstrated for this device may provide new opportunities for integration of optical interconnects between on-chip electrical subsystems.

Adverse life event reporting and worst illness episodes in unipolar and bipolar affective disorders: measuring environmental risk for genetic research

BACKGROUND

Studies exploring gene-environment interplay in affective disorders now include very large numbers of participants. Methods for evaluating the role of adversity in such studies need to be developed that do not rely on lengthy and labour-intensive interviews. In the present study, a brief questionnaire method for measuring 11 adverse events reported before interview and before their worst illness episodes by bipolar, unipolar and healthy control participants, participating in genetic association studies, was evaluated.

METHOD

Five hundred and twelve bipolar disorder (BD) participants, 1447 participants with recurrent unipolar depression (UPD) and 1346 psychiatrically healthy control participants underwent the researcher-administered version of the List of Threatening Experiences Questionnaire (LTE-Q) for the 6 months before their worst affective episodes for UPD and BD participants, and for the 6 months before interview for the UPD participants and controls.

RESULTS

UPD and BD cases were significantly more likely to report at least one event, as well as more events in the 6 months before interview and before their worst illness episodes, than healthy controls. Both manic and depressive episodes were significantly associated with adverse events in the BD cases. Depressed mood at the time of interview influenced event reporting in UPD and control participants but not the BD cases. Age was negatively correlated with the number of events reported by controls.

CONCLUSIONS

The researcher-administered LTE-Q provides a measure of case-control differences for adversity that is applicable in large genetic association studies. Confounding factors for event reporting include present mood and age.

Incidence and correlates of radiation dermatitis in children and adolescents receiving radiation therapy for the treatment of paediatric sarcomas

AIMS

To investigate the relationship between the maximum grade of skin toxicity, radiation dose and clinical variables in children receiving treatment for sarcomas involving the bone and soft tissue.

MATERIALS AND METHODS

Between January 2003 and July 2006, 82 patients with musculoskeletal tumours on an Institutional Review Board (IRB)-approved prospective study at St. Jude Children's Research Hospital received three-dimensional conformal or intensity-modulated radiation therapy for local tumour control. Radiation dermatitis was graded according to the National Cancer Institute's Common Toxicity Criteria version 2.0 during and after radiation therapy. The dose to the skin was calculated for each patient from the radiation treatment plan.

RESULTS

The radiation doses delivered to the primary tumour ranged from 4140 to 7020cGy, with a mean dose of 5040cGy. The maximum recorded grade of skin toxicity was: grade 0: seven patients (8.6%); grade 1: 26 patients (31.7%); grade 2: 37 patients (45.1%); grade 3: 10 patients (12.2%); grade 4: two patients (2.4%). A significant association for increased grade of skin toxicity was observed between dose (P<0.01), volume of skin treated above 4000cGy (P=0.03), use of a bolus (P<0.01), Caucasian race (P<0.01) and related pain (P<0.01).

CONCLUSIONS

These findings suggest that the delivered dose, use of a bolus, the volume treated, and race may be used in the clinical setting to predict patients at risk for skin toxicity. Alterations in treatment technique and early therapeutic intervention may help to reduce or eliminate radiation-induced skin side-effects and associated pain.

The changing natural history of spinal muscular atrophy type 1

BACKGROUND

Noninvasive ventilation has become increasingly available to spinal muscular atrophy (SMA) patients since the early 1990 s. This is expected to have improved survival for SMA type 1 patients.

OBJECTIVE

To assess whether there has been a change in survival in patients with SMA type 1 between 1980 and 2006.

METHODS

We used deidentified, family-reported data from participants in the International Spinal Muscular Atrophy Patient Registry and obtained additional clinical information through a mail-in questionnaire. One hundred forty-three patients with SMA type 1 were included in the analysis. Survival of patients born in 1995-2006 (n = 78) was compared with that of patients born in 1980-1994 (n = 65), using the Kaplan-Meier method and Cox proportional hazards models with age at death as the outcome.

RESULTS

Patients born in 1995 though 2006 had significantly increased survival compared with those born in 1980-1994 (log-rank test, p < 0.001). In a Cox model, patients born in 1995-2006 had a 70% reduction in the risk of death compared with those born in 1980-1994 (hazard ratio [HR] 0.3, 95% CI 0.2-0.5, p < 0.001) over a mean follow-up of 49.9 months (SD 61.1, median 22.0). However, when controlling for demographic and clinical care variables, year of birth was no longer significantly associated with age at death (HR 1.0, 95% CI 0.6-1.8, p = 0.9), whereas ventilation for more than 16 h/d, use of a mechanical insufflation-exsufflation device, and gastrostomy tube feeding showed a significant effect in reducing the risk of death.

CONCLUSION

Survival in spinal muscular atrophy type 1 patients has increased in recent years, in relation to the growing trend toward more proactive clinical care.

Occurrence of proteolytic activity and N-acyl-homoserine lactone signals in the spoilage of aerobically chill-stored proteinaceous raw foods

Proteolytic pseudomonads dominate the spoilage flora of aerobically chill-stored proteinaceous raw foods. Proteolysis during spoilage of these food systems affects both food quality and the dynamics of the bacterial community because it increases the availability of nutrients to the community as a whole. Quorum sensing, or cell-cell signaling, is associated closely with ecological interactions among bacteria in mixed communities. The potential role of quorum sensing in proteolytic food spoilage was examined, based on the evaluation of N-acyl-homoserine lactone (AHL) signal molecules. The occurrence of proteolytic activity and AHL signals was studied during spoilage of aerobically chill-stored ground beef, fish, chicken, and raw milk. Pseudomonads dominated the psychrotrophic flora, followed distantly by members of the Enterobacteriaceae. The growth of pseudomonads was correlated with the occurrence of proteolytic activity in all food systems. AHL concentration began increasing significantly only after the onset of proteolytic activity. Widely divergent AHL profiles were revealed by thin-layer chromatography analysis of the different food samples, and these profiles were likely determined by the undefined bacterial flora in these systems and by the characterized pseudomonads and Enterobacteriaceae. Although Hafnia alvei was a major component of the Enterobacteriaceae flora in all foods tested and a strong AHL producer, the signal molecules produced by H. alvei strain EB1 did not influence protease production by Pseudomonas fluorescens strain 395 in vitro. These results do not indicate any clear correlation between the overall detectable AHL signal molecules accumulated in the food samples and proteolytic activity.

Management of the giant-cell tumours of the distal radius

BACKGROUND

Giant-cell tumour of the distal radius is a rare neoplasm that affects the peri-articular metaphysial region of the bone. Curettage alone or with bone grafting has been reported to be associated with high incidence of local recurrence in these tumours. In the present series, we report the results of curettage only as the treatment for primary giant-cell tumour of the distal radius carried out at a single centre.

PATIENTS AND RESULTS

A total of 287 patients with giant-cell tumour have been referred to us for treatment over the last 28 years; 24 of these were found to have lesion in the distal radius. One patient underwent endoprosthetic replacement of the distal radius. The remaining 23 patients underwent curettage of the primary neoplasm. Four out of the 23 (17%) patients developed local recurrence of disease, The mean time to local recurrence was 17 months (range, 9-27 months). Complications such as collapse of the articular cartilage are more common in patients with an extensive soft tissue component of the tumour.

CONCLUSIONS

Curettage alone is adequate treatment for the majority of patients with giant-cell tumours of the distal radius but some form of stabilisation may be required in the presence of extensive bone destruction.

Peroneal tenosynovitis following ankle sprains

Peroneal tenosynovitis has a variety of causes which include inversion injury of the ankle. It is rarely reported and frequently misdiagnosed. We report the operative findings and outcome of surgical decompression in 19 patients who clinically presented following inversion injury with features suggestive of peroneal tenosynovitis. A review of the literature of this pathology is presented.

Cognitive deficit induced by acute tryptophan depletion in patients with Alzheimer's disease

OBJECTIVE

The study assessed the effects on global cognitive function and mood of a reduction of brain serotonin by means of acute tryptophan depletion in 16 patients with dementia of the Alzheimer type and in 16 cognitively intact comparison subjects.

METHOD

In a double-blind, crossover design, subjects received a tryptophan-free amino acid drink to induce acute tryptophan depletion and, on a separate occasion, a placebo drink containing a balanced mixture of amino acids. On each occasion, ratings of depressed mood were made at baseline and 4 and 7 hours later, and the Modified Mini-Mental State was administered at baseline and 4 hours later.

RESULTS

Patients with dementia of the Alzheimer type had a significantly lower mean score on the Modified Mini-Mental State after acute tryptophan depletion than after receiving placebo. The comparison group showed no difference in mean score on the Modified Mini-Mental State after acute tryptophan depletion and after receiving placebo. No significant changes in mood were found in either group.

CONCLUSIONS

Acute tryptophan depletion significantly impaired cognitive function in patients with dementia of the Alzheimer type. Compromised serotonergic function, in combination with cholinergic deficit, may make an important contribution to cognitive decline in dementia of the Alzheimer type.

The standardized family: an innovation in primary care education at the University of Massachusetts

In 1995 as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative, the University of Massachusetts (UMass) Medical School developed the "standardized family" as a new model for teaching the essential elements of primary care in a core curriculum format outside of the clinical setting. Using this model, a hypothetical family unit (the "McQ Family") serves as the focus for case-based clinical problem solving. This paper describes the standardized family model and provides two years of evaluation outcomes such as curriculum assessments, student performance outcomes, and correlation with external measures of clinical performance to support the effectiveness of this educational model. It discusses the transferability of the standardized family model from UMass Medical School to Pennsylvania State University College of Medicine and uses Pennsylvania State's adaptation (the "Hershey-Penn Family") to illustrate how the standardized family can be customized to integrate a core curriculum into a three-year longitudinal primary care program. The authors suggest that the standardized family model has the potential to meet a broad range of primary care teaching needs at other institutions.

Effects of tamoxifen, fluphenazine and estradiol on ATP levels in preoptic area and hypothalamic slices from ovariectomized rats

Tamoxifen, the major adjuvant drug treatment for estrogen-dependent breast cancer, has been shown previously to affect both estrogen-dependent and calcium/calmodulin-dependent pathways. In the current study, we developed an in vitro slice system to study the effects of tamoxifen on ATP levels in hypothalamic (HTH) and preoptic areas (POA) of the rat brain. Baseline data showed that, following a 2-h incubation, HTH and POA slices had comparable ATP levels to hippocampal slices, a system used extensively by researchers examining the metabolic responsiveness of the hippocampal region (HPC) of the brain. HTH-POA slice ATP levels remained steady for 2, 4 and 6 h, but fell to 11% of initial levels by 12 h. Neurons from HTH-POA slices incubated for 4 h appeared healthy and demonstrated robust protein synthesis as measured autoradiographically by incorporation of [3H]leucine. We explored the effects of tamoxifen (TAM), fluphenazine (FLU) and estradiol (E2) on ATP levels in HTH and POA slices. The effects of TAM were complex: a 4-h incubation with 10-6 M TAM led to decreased ATP levels in HTH (but not POA), and a 4-h incubation with 10-8 M led to increased ATP levels in POA (but not HTH); a 15-min exposure to 10-6 M TAM decreased ATP levels in POA (but not HTH) slices, while the exposure of slices to the lower concentration of TAM was without effect in either area. As with higher concentrations of TAM, 4-h incubation with 10-6 M FLU decreased ATP levels in HTH (but not POA), while incubation with E2 did not affect slice ATP levels. These data are consistent with the hypothesis that both TAM and FLU alter ATP levels in HTH slices via calmodulin- or calcium-mediated processes.

Putting occupation into practice: occupation as ends, occupation as means

This article addresses a difficulty that many occupational therapists experience: maintaining occupation as the core of their therapeutic intervention. This difficulty not only results from but also contributes to occupational therapy's struggle with professional identity. Current manifestations of the problem are described as component-driven practice and the narrowing of occupation to basic activities of daily living. The concepts of occupation as ends and occupation as means are proposed as a practical solution to guide treatment planning and merge remediation and adaptation within a single occupational session. Each concept is investigated in terms of its history within the profession and its usefulness for analyzing and solving therapeutic problems. These concepts are discussed as useful guidelines to help occupational therapists not only in their clinical decision making but also in their understanding and expression of the field's unique expertise. A case example, applying occupation as ends and occupation as means to evaluation and treatment, is presented.

Development of the technology for 'Diprifusor' TCI systems

The availability of fast-acting intravenous drugs for anaesthesia has encouraged anaesthetists to gain a practical understanding of the pharmacodynamics and pharmacokinetics of these drugs to optimise their administration. 'Diprifusor' technology uses pharmacokinetic modelling to control the infusion rate of a pump, providing the anaesthetist with direct control of the blood concentration rather than indirect control by the infusion rate. The 'Diprifusor' electronics module is a dual microprocessor component that can be incorporated into an infusion pump to provide this mode of administration. This paper describes the module's infusion control system, prefilled syringe recognition system and the safety aspects addressed by the design.

Impaired recognition of disgust in Huntington's disease gene carriers

Face processing and facial expression recognition were investigated in the earliest stages of Huntington's disease, by studying 40 people who presented for genetic testing. Twenty-three of these 'at risk' individuals turned out not to carry the gene for Huntington's disease (the AR- group). Seventeen were found to be gene carriers (the AR+ group); 15 from genetic testing, and two who showed signs of early stages of Huntington's disease. A number of standard tasks were used to provide background information, including recognition memory for words, picture naming, verbal fluency, and figure copying; none revealed significant differences between the AR+ and AR- groups. Face processing abilities were investigated using tests of identification of familiar (famous) faces, unfamiliar face matching, recognition memory for faces, and recognition of facial expressions of emotion. No statistically significant differences between the AR+ and AR- groups were found for any of these tests, but the AR+ group showed a borderline overall impairment in recognizing facial expressions of emotion (0.05 < P < 0.1). When recognition of each of the six basic emotions used was examined separately, only disgust was found to be significantly impaired. This highly selective deficit in the recognition of disgust was confirmed in the subgroup of 15 individuals shown by genetic testing to be Huntington's gene carriers; it was therefore found in people who were free from clinical symptoms and did not perform significantly more poorly than non-carriers on any of the background tests, on any of the other face processing tasks, and even for recognition of any other basic emotion. This points strongly to the importance of the basal ganglia in the emotion of disgust.

Late rehabilitation for closed head injury: a follow-up study of patients 1 year from time of discharge

Subsequent to the setting up of an outpatient psychological service for head-injured patients, 50 patients were interviewed a year from the time of their discharge from our neurorehabilitation unit. The problems which persisted at this stage are presented and discussed. Some of the difficulties encountered in the evaluation of rehabilitation effects are identified. We conclude that: (1) there is a desperate need in the UK for more long-term support and rehabilitation services for this group of patients and (2) it is essential that such services are carefully monitored and evaluated despite the difficulties involved.

Differing mechanisms of action of angiotensin-converting enzyme inhibition in black and white hypertensive patients. The Trandolapril Multicenter Study Group

The antihypertensive effect of the angiotensin-converting enzyme inhibitor trandolapril administered in doses of 1, 2, and 4 mg/d was compared in 207 white patients and 91 black patients with mild to moderate hypertension following a double-blind, randomized, placebo-controlled, parallel study design. Trandolapril is a prodrug that is rapidly hydrolyzed to its active diacid metabolite, trandolaprilat. After 6 weeks of double-blind treatment, trandolapril lowered baseline sitting diastolic pressure in both white and black patients. A comparison of the antihypertensive response of the two populations revealed that the black patients required between two and four times the dose of trandolapril to obtain a response similar to that observed in the white patients. A dose of 1 mg/d trandolapril resulted in a 6.1 mm Hg mean decrease in baseline sitting diastolic pressure for white patients; a similar response (-6.5 mm Hg) was observed in the black patients at 4 mg/d. In contrast to the population differences in blood pressure, the decreases in angiotensin-converting enzyme activity were similar for both populations. An evaluation of trandolaprilat levels revealed that there were no racial differences in the trandolaprilat concentrations required to achieve a given degree of angiotensin-converting enzyme inhibition. Therefore, it appears that the antihypertensive response of black patients is not completely explained by a reduction in angiotensin-converting enzyme activity. The lack of response at a lower dose but increasing response at a higher dose could reflect another vasodepressor activity of trandolapril or just be evidence of reduced sensitivity of high blood pressure in blacks to angiotensin-converting enzyme inhibition.

State association-sponsored program for SBB candidates

Concern about the closure of the only Specialist in Blood Banking (SBB) School in the State of Michigan prompted the Michigan Association of Blood Banks (MABB) to develop and administer a comprehensive series of lectures to meet the needs of technologists seeking SBB certification via the experiential route. The program consisted of more than 60 1(1/2)-hour lectures covering all aspects of blood banking (genetics, coagulation, immunology, blood group serology, blood collection and administration, and transfusion medicine) except infectious disease testing and management issues. The latter were presented during two free-standing one-day seminars (for which a fee was charged for those not registered for the lecture series). Educational techniques were covered in a self-study module. Two lectures were presented one morning each week from March through December, with no presentations during July. Lecturers were local volunteer experts, and detailed learning objectives were established for each topic. Each registrant was charged a nominal fee ($100 for MABB members; $150 for nonmembers). There were 32 registrants for the lecture series, with additional registrants for the seminars. Total revenue was $5,100, and expenses amounted to approximately $2,400, mostly for faculty honoraria and catering for the two seminars. The popularity of our program reflects the need for alternatives to formal SBB schools.

ICI 182,780: a pure antiestrogen that affects behaviors and energy balance in rats without acting in the brain

ICI 182,780 is one of a new class of steroidal antiestrogens that differs from nonsteroidal antiestrogens, such as tamoxifen, in a number of respects. 1) It is bound by estrogen receptors with a high affinity, similar to that for estradiol. 2) It is a "pure" antiestrogen in that it does not mimic any of the effects of estradiol. 3) This class of antiestrogens does not seem to be bound by antiestrogen binding sites. 4) ICI 182,780 may not be active in the brain after peripheral administration. Indeed, ICI 182,780 blocked in vivo cell nuclear binding of [3H]estradiol in uterus, pituitary, and adipose tissue but not in hypothalamus-preoptic area. In vitro, ICI 182,780 competed for binding by neural estrogen receptors with an affinity comparable with that for estradiol. When given to ovariectomized rats, ICI 182,780 did not mimic any of the actions of estradiol. Instead, ICI 182,780 treatment completely blocked the uterotrophic effects of estradiol and attenuated the actions of estradiol on linear growth, carcass fat content, fat pad weight, and sexual receptivity. Treatment with ICI 182,780 also attenuated the estrogenic effects of tamoxifen on food intake, body weight and composition, linear growth, and uterine weight. These findings support the concept that, in addition to its actions in the brain, estradiol can act peripherally to modulate regulatory behaviors, energy balance, and estrous behavior. They are also consistent with the hypothesis that nonsteroidal antiestrogens, such as tamoxifen, affect energy balance via estrogen receptors, rather than antiestrogen binding sites.

Sacroiliac joint pyarthrosis

Sacroiliac (SI) joint infection is rare, and symptoms are idiosyncratic and often confusing. This paper reviews six cases of SI joint infection with regard to their clinical manifestations, diagnostic imaging, and treatment. The six patients were seen over a 15-year period and had a mean age of 16.2 years and a mean follow-up of 44.2 months. The most common presenting symptom was fever (71.4%). The most common physical findings were elevated temperature and limited ipsilateral hip motion. In most cases the white blood cell count and erythrocyte sedimentation rate were elevated, and 71% of the cases had positive blood cultures. The most specific imaging study was the technetium bone scan. All patients were treated with 3 to 6 weeks of appropriate antibiotics and were asymptomatic and had a normal physical examination on follow-up. Routine anteroposterior roentgenograms of the pelvis demonstrated sclerosis of the affected SI joint in one third of the cases. There appeared to be no long-term sequelae in this group of patients.

Estrogens and antiestrogens: actions and interactions with fluphenazine on food intake and body weight in rats

Treatment of ovariectomized rats for 3 days with 2 micrograms estradiol benzoate (E2B), 6 micrograms ethinyl estradiol, or 1-2 mg of either of the antiestrogens nafoxidine or tamoxifen led to similar decreases in food intake, body weight gain, adipose tissue lipoprotein lipase activity, and hepatic fatty acid synthetase activity, despite their different effects on uterine growth and induction of progestin receptors in pituitary and adipose tissue. Longer-term (2 wk) treatment with tamoxifen resulted in similar transient changes in food intake and body weight gain, as did treatment with E2B. Daily administration of 50 micrograms fluphenazine (FLU) led to significant decreases in body weight, although there was no change in food intake. Concurrent administration of FLU with either E2B or tamoxifen led to additive effects on body weight and food intake change. None of the treatments had any effect on in vitro binding of [3H]tamoxifen to antiestrogen binding sites in pooled hypothalamic-preoptic area samples.

Complex balance reactions in different sensory conditions: adolescents with and without idiopathic scoliosis

We measured simple and complex balance responses with a force plate stabiliometer in 70 adolescents: 50 with idiopathic scoliosis (IS) and 20 controls. In stable static balance positions, the two groups performed similarly, but when the visual and somatosensory systems were challenged simultaneously, the IS group had a significantly higher mean body sway than the controls. Within the IS group, children with mild, nonprogressive curves that had not been operated on were significantly more likely to maintain their balance when the visual and somatosensory systems were challenged simultaneously than those with curves > or = 40 degrees, who had had surgery, and who had more rapid progression of the curve. These findings suggest that adolescents with IS have normal balance in static, stable positions but are not able to perform as well as normal adolescents in sensory-challenged positions, particularly if they have a severe, progressive curve. Longitudinal studies are needed to determine whether balance dysfunction can be used to predict progression of the curve.

Antiestrogen binding sites in brain and pituitary of ovariectomized rats

In addition to interacting with estrogen binding sites in a number of tissues, antiestrogens have recently been shown to interact with a separate, estrogen-non-compatible, antiestrogen-specific binding site (AEBS). In order to better understand possible mechanisms by which the antiestrogens may effect behavioral and physiological changes, we have examined AEBS in several areas of the brain and pituitary in adult, ovariectomized rats. Single point binding assays with 2 nM [3H]tamoxifen (TAM) in the presence of saturating amounts (1 microM) E and +/- 1 microM TAM indicated the existence of specific binding to AEBS throughout the brain and pituitary. In most areas of the brain (cortex, cerebellum, amygdala, area postrema/nucleus of the solitary tract region) as well as pituitary. Scatchard analyses revealed the presence of a single AEBS with a dissociation constant (Kd = 1-4 x 10(-9) M) similar to that previously reported for other tissues. However, in both hypothalamus and preoptic area, an additional, higher affinity site (Kd = 6-9 x 10(-11) M) was found. Competitive inhibition studies revealed that there was little competition by the potent estrogen agonist, diethylstilbesterol, for AEBS binding. Antiestrogens competed in the following order: tamoxifen greater than or equal to nafoxidine much greater than keoxifene. Additional competitive inhibition studies were run using neurotransmitter antagonists. The phenothiazines, chlorpromazine and fluphenazine, bind to both D1 and D2 dopamine receptors and effectively compete with [3H]TAM for binding at the AEBS. Other pharmacological substances, including specific antagonists of the D2 sites, as well as antagonists of the norepinephrine, opiate, histamine, GABA and acetylcholine systems, were ineffective competitors for [3H]TAM binding.

Derotational analysis of Cotrel-Dubousset instrumentation in idiopathic scoliosis

Ten patients with idiopathic scoliosis were treated with posterior spinal fusion and Cotrel-Dubousset instrumentation. Computed tomographic scans and intraoperative photographs were used to evaluate the derotational effect of the Cotrel-Dubousset instrumentation. The frontal deformity was corrected from an average of 51 degrees to 15 degrees and the kyphosis from 9.5 degrees to 18 degrees. The amount of preoperative vertebral rotation was variable, however, and insignificant postoperative changes were documented in the majority of cases.

The Assessment Unit of the Epilepsy Centre, Quarriers Homes

The work of the Assessment Unit in the Epilepsy Centre, Quarriers Homes, Scotland is described. One hundred and thirty patients with severe epilepsy were admitted over a three year period for investigation of seizures and rationalisation of therapy. The degree of psychomotor impairment due to epilepsy itself, or to anti-epileptic drugs was estimated. Cognitive functioning and levels of ability with interpersonal relationships were measured and plans were drawn up for rehabilitation. A plea is made for NHS funding to support the provision of this service for people with epilepsy.

Lithotripsy as an outpatient service

A lithotripsy outpatient service was introduced in Hamilton in April 1989 and between then and July 1990 452 patients with renal calculi were treated. The patients came from throughout New Zealand. A three month follow up showed that with stones less than 20 mm in diameter there was total clearance of residual fragments of less than 2 mm in 70% of patients. With stones of diameter greater than 20 mm the clearance rate was 50%. Posttreatment complications needing medical assistance occurred in 7% (31 patients). In 21 patients the stone either could not be found or did not disintegrate.

Flexible cystoscopy as an adjunct to extracorporeal shockwave lithotripsy

Ancillary procedures associated with extracorporeal shockwave lithotripsy (ESWL) include placement and subsequent removal of double pigtail ureteric stents. A simple new technique has been developed for the insertion of these stents. Using the flexible cystoscope, the procedure is performed on an out-patient basis under local anaesthesia. Placement of the stents was successful in 30/34 patients and removal was successful in 14/14 patients.

Corticosterone, foraging behavior, and metabolism in dark-eyed juncos, Junco hyemalis

Male, dark-eyed juncos, Junco hyemalis, were held in captivity under conditions simulating winter temperature and photoperiod. Birds were administered corticosterone (B), metapyrone (MET), or control (empty) implants in silastic tubing. B implants resulted in higher plasma levels of B, especially on the first day following implantation. After 4 days, B-implanted birds had significant atrophy of the flight muscles and increased storage of fat in the furcular and abdominal adipose depots. Despite the increased fat deposition, no differences in adipose tissue lipoprotein lipase (LPL) activity or plasma levels of glycerol or free fatty acid were observed after 4 days of treatment. There were no differences in muscle LPL activity when enzyme activity was expressed per tissue. However, when enzyme activity was expressed per gram of tissue, muscle LPL was significantly greater in the B-treated birds. Therefore, despite the atrophy of muscle tissue, the LPL enzyme had been preserved. No differences were observed in either foraging behavior or food consumption, even in light of the dramatic changes in fat and muscle masses in B-treated birds. These data are discussed in light of the chronic effects of B which may be applicable to the advanced stage of stress in birds.

Microcomputer-based rehabilitation for unilateral left visual neglect: a randomized controlled trial

Microcomputers are widely used in cognitive rehabilitation of brain damage. Unilateral neglect is commonly a target of cognitive rehabilitation, both computer-based and non-computer-based. This study reports the results of a randomized controlled trial of computer-based rehabilitation with blind follow-up for six months. Thirty-six patients with unilateral neglect, as defined by the behavioral subtests of the Behavioural Inattention Test, were randomized into two groups. One group of 20 subjects received a mean of 15.5 (SD = 1.8) hours of computerized scanning and attentional training; the second group of 16 subjects received a mean of 11.4 (SD = 5.2) hours of recreational computing (selected to minimize scanning and timed attentional tasks). Blind follow-up at the end of training and six months after revealed no statistically or clinically significant results between groups. These findings argue against routine clinical use of this type of computerized training until further studies establish what type, frequency, and duration of training produces clinically significant changes in unilateral visual neglect if, indeed, computerized training can have an effect with this type of disorder.

Non-verbal cues in the self-presentation of parkinsonian patients

Parkinson's disease (PD) patients are seen as cold, withdrawn, unintelligent and moody, and appear to relate poorly to the interviewer (Pentland, Pitcairn, & Gray & Riddle, 1987). The cues responsible for this are shown to be related not only to the type of limb and body movements made, but also particularly to the facial expressions. The expressions seen are not only reduced in frequency but are also qualitatively different, particularly in the smiles which are seen to be 'false' smiles. The implications of this for a treatment regime are discussed in relation to the neurology of the disease. It would seem that non-verbal training methods may not produce the required effects because of the shift in neural pathway used from that which normally controls spontaneous expressive movements (via the basal ganglia) to that used in voluntary movements.

Tracheobronchial and pulmonary histopathology following conventional and high-frequency jet ventilation

The advent of high-frequency jet ventilation (HFJV) as an alternative method of respiratory support for newborns has been implicated as a causative agent of necrotizing tracheobronchitis (NTB). We conducted a controlled trial of prolonged HFJV and conventional mechanical ventilation (CMV) in adult cats to determine effects on airway injury related to mode of ventilation and placement of the jet injector (proximal vs distal trachea). Fifteen cats were randomly assigned to either high-frequency positive pressure ventilation, proximal injection jet ventilation, or distal injection jet ventilation. The animals were ventilated for more than 33 hours. Post mortem, the trachea and respiratory tree were removed en bloc and fixed in formalin. A pathologist, unaware of the mode of ventilation, examined tracheobronchial histology and assigned scores using a technique previously described. Lung parenchymal tissue was also assessed using a similar grading system. Statistical analysis (Kruskal-Wallis analysis of variance) demonstrated no significant differences between tracheobronchial or lung parenchymal histopathology regardless of the mode of ventilation. We conclude that (1) the adult cat serves as a useful model for evaluating histopathologic effects of prolonged ventilation, (2) the etiology and pathogenesis of airway injury appears to be multifactorial, and the mode of ventilation is only one of many contributing variables, and (3) previously demonstrated differences between CMV and HFJV may be related to a much shorter duration of ventilation.

81mKr equilibrium radionuclide ventriculography for the assessment of right heart function

Right heart 81mKr equilibrium radionuclide ventriculography was used to derive right ventricular ejection fraction (RVEF) in 12 healthy male volunteers. Anatomical lung subtraction using 99mTc-MAA perfusion scintigraphy was compared with conventional background correction and the effect of imaging projection on the techniques of image analysis evaluated. Both intra and inter observer variability were reduced by anatomical lung subtraction when compared to conventional background correction. In the right anterior oblique (RAO) projection, background corrected RVEF was lower than lung subtracted RVEF - 0.544 +/- 0.05 and 0.612 +/- 0.08 (mean +/- SD) (P less than 0.02). Lung subtracted RVEF in the anterior projection was lower than that with background correction (P less than 0.05) and lower than lung subtracted RVEF in the RAO projection (P less than 0.001). We conclude that optimal separation of right heart structures is achieved in the RAO projection and that reproducibility of the analytical technique is improved by anatomical lung subtraction.

Remediation of attentional difficulties following brain injury: three experimental single case studies

Three young men with attentional problems after severe head injury were given microcomputer based training involving a variety of tasks designed to ameliorate attentional problems. A multiple baseline across function single case experimental design showed these procedures to be effective in producing change specifically in the targetted function.

Percutaneous ablation of canine prostate using transrectal ultrasound guidance. Absolute ethanol and Nd:YAG laser

Percutaneous absolute ethanol injections and Nd:YAG laser ablations were performed bilaterally in canine prostates (N = 13) using transrectal ultrasound guidance. Seventy-one percent (10/14) of the ethanol injections produced an intraglandular focus of hemorrhagic necrosis. Associated morbidity of ethanol injections included necrosis of the external prostatic sphincter and mucosa of the urethra and bladder. Ninety-two percent (11/12) of the laser ablations produced intraglandular foci of thermal tissue damage, which had distinct margins of transition between necrotic and viable cells. The areas of ablation were well visualized by ultrasound and had minimal associated morbidity. The results of this study demonstrate the technical feasibility and low potential morbidity of transrectal ultrasound guided Nd:YAG laser ablations in the canine prostate.

Prostate cancer: comparison of transrectal US and digital rectal examination for screening

The authors examined 784 self-referred men over age 60 years to compare clinical usefulness of transrectal ultrasound (US) and digital rectal examination in a screening program for prostate cancer. Biopsy was performed in 77 cases, 83% (64 of 77) for abnormalities detected with transrectal US and 38% (29 of 77) because of findings at digital examination. Twenty-two cancers were detected, 20 with transrectal US and ten at digital examination. Overall detection rate for prostate cancer with transrectal US was two times higher than that with digital examination (2.6% vs 1.3%). Sensitivity, specificity, and negative predictive value for transrectal US and digital examination were calculated for a range of prevalences (0.028-0.1543). Sensitivity was two times higher for transrectal US than for digital examination. Transrectal US demonstrated 100% (17 of 17) of tumors with the most favorable prognosis (less than or equal to 1.5 cm in diameter) compared with 41% (seven of 17) for digital examination. The authors conclude that transrectal US is more sensitive than digital examination in the detection of prostate cancer, and they advocate broader implementation and evaluation of transrectal US as a tool for early detection.

Factors associated with sexual dysfunction following transurethral resection of the prostate

A retrospective analysis of 62 consecutive potent patients undergoing transurethral resection of the prostate is described. Each patient was interviewed a minimum of six months following surgery. Potency was retained in 89% of patients but 57% of these experienced a decrease from their preoperative level of function. Three factors were found to be significantly associated with a reduction in postoperative potency. These were systemic disease (p less than 0.001), small prostatic resections (p less than 0.001) and a reduced level of potency preoperatively (p less than 0.01). Of those men retaining a degree of potency, 90% achieved their first erection within two months of the procedure. The full extent of sexual dysfunction following transurethral resection of the prostate has not previously been appreciated, nor have the factors associated with this dysfunction.

Intracavernosal injection therapy for impotence: preliminary results

Intracavernosal injection of vasoactive agents is a new technique for inducing penile erection. It has applications in the counselling, diagnosis and treatment of sexual dysfunction. Nineteen patients are reviewed representing our initial experience with this technique. Thirteen men (68%) achieved a full erection with this treatment and a further three (16%) had a partial response. The applications, method and complications are discussed.

Comparison of labetalol and prazosin in hypertensive patients using automated ambulatory monitoring

The differential effects of prazosin and labetalol on blood pressure and heart rate in the clinic and during daily activity were measured in a double-blind study utilizing automatic ambulatory monitors. One hundred five patients with essential hypertension (sitting diastolic blood pressure equal to 101 mm Hg) were randomly assigned to receive prazosin (n = 52) or labetalol (n = 53). Sixty-eight percent of labetalol-treated patients and 50 percent of prazosin-treated patients achieved blood pressure control during clinic visits (sitting diastolic blood pressure less than 90 mm Hg) and were subsequently monitored for 12 hours of normal daily activities. Ambulatory monitoring revealed labetalol-treated patients to have significantly greater decreases in systolic and diastolic blood pressures during daily activity than prazosin-treated patients. Heart rate and rate-pressure product were significantly reduced in the labetalol group but not in the prazosin group. It is concluded that the potential benefits of dual adrenergic blockade, not readily apparent in the non-stressful clinic environment, become more evident during the course of daily activities.