Survey of a domiciliary stroke rehabilitation service

A previous randomized controlled comparison of hospital-based and domiciliary rehabilitation for stroke patients discharged from hospital (the DOMINO study) found home therapy to be beneficial in a subgroup who had been in hospital on a stroke unit before entering the trial, whereas no benefit was seen in patients who had been on ordinary geriatric or general medical wards. In this study, to explain the findings of the DOMINO study further, the therapy records kept during the DOMINO study of the amount and type of rehabilitation provided by the domiciliary rehabilitation team were examined.

More patients who had been on the stroke unit before entering the trial received therapy and they received more and longer visits than those who had been on geriatric or medical wards. The group from the stroke unit were more likely to receive practice in activities of daily living (ADL), assessment for and instruction in the use of aids and appliances, gait re-education, mobility practice and facilitation of normal muscle tone.

One possible deduction is that home rehabilitation services should aim to deliver an average of 15-20 visits in six months, since only this amount of therapy was associated with a measurable benefit. The active components of home therapy may be ADL practice, assessment for and instruction in the use of aids and appliances, gait re-education, mobility, mobility practice and facilitation of normal muscle tone.

The unreliability of sensory assessments

The intra- and inter-rater reliability of a standardized assessment of sensory impairment were investigated. Twenty stroke patients were assessed at home by the same physiotherapist on two occasions. There was good consistency overtime on most items. Twenty patients in hospital were assessed by two physiotherapists. The results indicate poor agreement between assessors. Twenty-five patients were assessed by a physiotherapist and a doctor. Results indicate low agreement between these assessors. Results indicate poor inter-rater reliability on a standardized assessment. It is suggested that this may also be a problem for clinical assessments of sensory impairment after stroke.

Treatment of facial erythema in patients with rosacea with topical brimonidine tartrate: correlation of patient satisfaction with standard clinical endpoints of improvement of facial erythema

BACKGROUND

Once-daily brimonidine tartrate (BT) 0.5% gel was shown to provide significantly greater efficacy vs. vehicle for the treatment of facial erythema in patients with rosacea.

OBJECTIVES

To demonstrate that patient satisfaction with overall appearance is correlated with reduction in facial erythema, as measured by clinician and patient assessments.

METHODS

Data from two identical phase III, multicentre, randomized, controlled trials of moderate facial erythema of rosacea (study A: n = 260; study B: n = 293) with topical BT 0.5% compared to vehicle gel once-daily for 4 weeks were analysed. Correlations of Patient's Assessment of Appearance (PAA) with Clinician's Erythema Assessment (CEA) and Patient's Self-Assessment (PSA) of erythema were evaluated by calculation of gamma statistics.

RESULTS

PAA correlated with CEA post-application on Days 1, 15 and 29 for the intent-to-treat population and provided a median gamma value of 0.57 (min = 0.28, max = 0.61). PAA and PSA was also highly correlated post-application on Days 1, 15 and 29; with a median gamma value of 0.87 (min = 0.66, max = 0.89). Subjects who achieved a clinically meaningful improvement in both CEA and PSA scales were more likely to report satisfaction with the overall appearance of their skin (P < 0.001).

CONCLUSIONS

Both one- and two-grade improvements in facial erythema assessed by subjects (PSA) and clinicians (CEA) correlate well with PAA, a patient-centered representation of meaningful change.

Frequency of prenatal cytogenetic diagnosis and pregnancy outcomes by maternal race-ethnicity, and the effect on the prevalence of trisomy 21, Metropolitan Atlanta, 1996-2005

The prevalence of trisomy 21 has been reported to differ by race-ethnicity, however, the results are inconsistent and the cause of the differences is unknown. Using data from 1996 to 2005 from the Metropolitan Atlanta Congenital Defects Program (MACDP), we analyzed the use of prenatal cytogenetic testing and the subsequent use of elective termination among pregnancies affected with any MACDP-eligible birth defect and trisomy 21, by maternal race-ethnicity. We then examined whether these factors could explain the observed differences in the prevalence of trisomy 21 among race-ethnicity groups. Among all pregnancies with birth defects, prenatal cytogenetic testing as well as elective terminations after an abnormal prenatal cytogenetic test result were observed less frequently among Hispanic women than among non-Hispanic white women (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.56-0.78, respectively). In pregnancies affected by trisomy 21, both the Hispanic and the non-Hispanic black populations had more live births (89.5% and 77.8%, respectively) and fewer elective terminations (5.7% and 15.2%, respectively) compared to the non-Hispanic white population (63.0% live births, 32.3% elective terminations). After adjusting for elective terminations, non-Hispanic white mothers had a higher live birth prevalence of trisomy 21 compared to non-Hispanic black (OR 0.64, 95% CI 0.54-0.76) or Hispanic mothers (OR 0.69, 95% CI 0.55-0.86). Overall, our data suggest that factors associated with decisions made about the use of prenatal testing, and about pregnancy management after testing, might play a large role in the race-ethnicity differences observed in the live birth prevalence of trisomy 21.

Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors?

Immunizations are crucial to the prevention of disease, thus, having an accurate measure of vaccination status for a population is an important guide in targeting prevention efforts. In order to comprehensively assess the validity of self-reported adult vaccination status for the eight most common adult vaccines we conducted a survey of vaccination receipt and compared it to the electronic medical record (EMR), which was used as the criterion standard, in a population of community-dwelling patients in a large healthcare system. In addition, we assessed whether validity varied by demographic factors. The vaccines included: pneumococcal (PPSV), influenza (Flu), tetanus diphtheria (Td), tetanus diphtheria pertussis (Tdap), Human Papilloma Virus (HPV), hepatitis A (HepA), hepatitis B (HepB) and herpes zoster (shingles). Telephone surveys were conducted with 11,760 individuals, ≥18, half with documented receipt of vaccination and half without. We measured sensitivity, specificity, positive and negative predictive value, net bias and over- and under-reporting of vaccination. Variation was found across vaccines, however, sensitivity and specificity did not vary substantially by either age or race/ethnicity. Sensitivity ranged between 63% for HepA to over 90% (tetanus, HPV, shingles and Flu). Hispanics were 2.7 times more likely to claim receipt of vaccination compared to whites. For PPSV and Flu those 65+ had low specificity compared to patients of younger ages while those in the youngest age group had lowest specificity for HepA and HepB. In addition to racial/ethnic differences, over-reporting was more frequent in those retired and those with household income less than $75,000. Accurate information for vaccination surveillance is important to estimate progress toward vaccination coverage goals and ensure appropriate policy decisions and allocation of resources for public health. It was clear from our findings that EMR and self-report do not always agree. Finding approaches to improve both EMR data capture and patient awareness would be beneficial.

Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors?

Immunizations are crucial to the prevention of disease, thus, having an accurate measure of vaccination status for a population is an important guide in targeting prevention efforts. In order to comprehensively assess the validity of self-reported adult vaccination status for the eight most common adult vaccines we conducted a survey of vaccination receipt and compared it to the electronic medical record (EMR), which was used as the criterion standard, in a population of community-dwelling patients in a large healthcare system. In addition, we assessed whether validity varied by demographic factors. The vaccines included: pneumococcal (PPSV), influenza (Flu), tetanus diphtheria (Td), tetanus diphtheria pertussis (Tdap), Human Papilloma Virus (HPV), hepatitis A (HepA), hepatitis B (HepB) and herpes zoster (shingles). Telephone surveys were conducted with 11,760 individuals, ≥18, half with documented receipt of vaccination and half without. We measured sensitivity, specificity, positive and negative predictive value, net bias and over- and under-reporting of vaccination. Variation was found across vaccines, however, sensitivity and specificity did not vary substantially by either age or race/ethnicity. Sensitivity ranged between 63% for HepA to over 90% (tetanus, HPV, shingles and Flu). Hispanics were 2.7 times more likely to claim receipt of vaccination compared to whites. For PPSV and Flu those 65+ had low specificity compared to patients of younger ages while those in the youngest age group had lowest specificity for HepA and HepB. In addition to racial/ethnic differences, over-reporting was more frequent in those retired and those with household income less than $75,000. Accurate information for vaccination surveillance is important to estimate progress toward vaccination coverage goals and ensure appropriate policy decisions and allocation of resources for public health. It was clear from our findings that EMR and self-report do not always agree. Finding approaches to improve both EMR data capture and patient awareness would be beneficial.

Trends in cytogenetic testing and identification of chromosomal abnormalities among pregnancies and children with birth defects, metropolitan Atlanta, 1968-2005

The purpose of this study was to examine changes in the use of cytogenetic testing and identification of chromosomal abnormalities among pregnancies and children with birth defects. Utilizing data from 1968 to 2005 from the Metropolitan Atlanta Congenital Defects Program, we analyzed trends in the frequency and timing (prenatal or postnatal) of cytogenetic testing and the prevalence of recognized chromosome abnormalities among pregnancies and children with birth defects (n = 51,424). Cytogenetic testing of pregnancies and children with birth defects increased from 7.2% in 1968 to 25.0% in 2005, as did the identification of chromosomal abnormalities (2.2% in 1968 to 6.8% in 2005). The use of prenatal cytogenetic testing decreased from 1996 to 2005 among women aged ≥35 years. Identification of chromosomal abnormalities in pregnancies and children with birth defects increased from 1968 to 2005, possibly due to increased testing, improved diagnostic techniques, or increasing maternal age. The decline in prenatal cytogenetic testing observed among mothers aged ≥35 years may be related to the availability of improved prenatal screening techniques, resulting in a reduction in the utilization of invasive diagnostic tests.

Diverse mutational mechanisms cause pathogenic subtelomeric rearrangements

Chromosome rearrangements are a significant cause of intellectual disability and birth defects. Subtelomeric rearrangements, including deletions, duplications and translocations of chromosome ends, were first discovered over 40 years ago and are now recognized as being responsible for several genetic syndromes. Unlike the deletions and duplications that cause some genomic disorders, subtelomeric rearrangements do not typically have recurrent breakpoints and involve many different chromosome ends. To capture the molecular mechanisms responsible for this heterogeneous class of chromosome abnormality, we coupled high-resolution array CGH with breakpoint junction sequencing of a diverse collection of subtelomeric rearrangements. We analyzed 102 breakpoints corresponding to 78 rearrangements involving 28 chromosome ends. Sequencing 21 breakpoint junctions revealed signatures of non-homologous end-joining, non-allelic homologous recombination between interspersed repeats and DNA replication processes. Thus, subtelomeric rearrangements arise from diverse mutational mechanisms. In addition, we find hotspots of subtelomeric breakage at the end of chromosomes 9q and 22q; these sites may correspond to genomic regions that are particularly susceptible to double-strand breaks. Finally, fine-mapping the smallest subtelomeric rearrangements has narrowed the critical regions for some chromosomal disorders.

The mouse A/HeJ Y chromosome: another good Y gone bad

In both humans and mice there are numerous reports of Y chromosome abnormalities that interfere with sex determination. Recent studies in the mouse of one such mutation have identified Y chromosome nondisjunction during preimplantation development as the cause of abnormal testis determination that results in a high frequency of true hermaphroditism. We report here that the mouse Y chromosome from the A/HeJ inbred strain induces similar aberrations in sex determination. Our analyses provide evidence, however, that the mechanism underlying these aberrations is not Y chromosome nondisjunction. On the basis of our findings, we postulate that a mutation at or near the centromere affects both the segregation and sex-determining properties of the A/HeJ Y chromosome. This Y chromosome adds to the growing list of Y chromosome aberrations in humans and mice. In both species, the centromere of the Y is structurally and morphologically distinct from the centromeres of all other chromosomes. We conclude that these centromeric features make the human and mouse Y chromosomes extremely sensitive to minor structural alterations, and that our studies provide yet another example of a good Y chromosome gone 'bad.'

Reduced antibody response to streptavidin through site-directed mutagenesis

Streptavidin provides an effective receptor for biotinylated tumoricidal molecules, including radionuclides, when conjugated to an antitumor antibody and administered systemically. Ideally, one would like to administer this bacterial protein to patients repeatedly, so as to maximize the antitumor effect without eliciting an immune response. Therefore, we attempted to reduce the antigenicity of streptavidin by mutating surface residues capable of forming high energy ionic or hydrophobic interactions. A crystallographic image of streptavidin was examined to identify residues with solvent-exposed side chains and residues critical to streptavidin's structure or function, and to define loops. Mutations were incorporated cumulatively into the protein sequence. Mutants were screened for tetramer formation, biotin dissociation, and reduced immunoreactivity with pooled patient sera. Patient antisera recognized one minor continuous epitope with binding locus at residue E101 and one major discontinuous epitope involving amino acid residues E51 and Y83. Mutation of residues E51, Y83, R53, and E116 reduced reactivity with patient sera to <10% that of streptavidin, but these mutations were no less antigenic in rabbits. Mutant 37, with 10 amino acid substitutions, was only 20% as antigenic as streptavidin. Rabbits immunized with either streptavidin or mutant 37 failed to recognize the alternative antigen. Biotin dissociated from mutant 37 four to five times faster than from streptavidin. Residues were identified with previously undescribed impact on biotin binding and protein folding. Thus, substitution of charged, aromatic, or large hydrophobic residues on the surface of streptavidin with smaller neutral residues reduced the molecule's ability to elicit an immune response in rabbits.

Impact of birthweight on healthcare charges within a managed care organization

OBJECTIVE

To determine the rate of low-birthweight (LBW) births and the association of LBW with utilization and healthcare charges in a managed care organization.

DESIGN

Observational study of computerized and medical record data.

PATIENTS AND METHODS

We assessed the rate of LBW (weight < 2500 g) for singleton infants born during 1993 and 1995 at 2 hospitals (1993, N = 3212; 1995, N = 3073). For a subset of infants born during 1995 (n = 1273), we examined differences in utilization and medical charges, by birthweight category (moderately LBW [MLBW; 1500 to 2499 g] vs normal birthweight [NBW]), at 1 year postdischarge.

RESULTS

In both 1993 and 1995, 3% of singleton infants were LBW infants, and 2% to 3% were macrosomic (> or = 4500 g). Complete data for analyses of utilization and healthcare charges were available on 1273 infants who were enrolled for the entire postdischarge year. The use of outpatient, emergency department (ED), and subspecialty care by MLBW infants and by NBW infants was similar. However, MLBW was associated with an increased rate of rehospitalization during the first year of birth (P < .01). MLBW infants' medical care charges were 46% higher than those of NBW infants (P = .0125).

CONCLUSIONS

MLBW infants and NBW infants had similar outpatient and ED service use during the first year after hospital discharge. Excess charges incurred by MLBW infants were primarily due to higher rates of rehospitalization. Of the 38 admissions, 21 were related to infection or fear of infection, and 4 were due to congenital malformations.

Clinical features and treatment of peristomal pyoderma gangrenosum

CONTEXT

Peristomal pyoderma gangrenosum (PPG), an unusual variant of pyoderma gangrenosum, has been reported almost exclusively in patients with inflammatory bowel disease (IBD) and is frequently misdiagnosed.

OBJECTIVE

To better characterize the clinical manifestations, diagnosis, and management of PPG.

DESIGN, SETTING, AND PATIENTS

Retrospective analysis of 7 patients with PPG observed in a university-affiliated community setting between 1988 and December 1999.

MAIN OUTCOME MEASURES

Clinical and histopathologic features, associated disorders, and microbiologic findings.

RESULTS

Two patients had Crohn disease, 2 had ulcerative colitis, and 3 had abdominal cancer. Five patients had at least 1 relapse of PPG after initial healing. Although 3 of 4 patients with IBD had active bowel disease, a parallel course with PPG occurred in only 1 patient. Both patients whose stoma was relocated developed an ulcer at the new site. Effective therapies included topical superpotent corticosteroids; intralesional injection of triamcinolone acetonide at the ulcer margin; topical cromolyn sodium; oral dapsone, prednisone, cyclosporine, mycophenolate mofetil; and intravenous infliximab.

CONCLUSION

Our experiences demonstrate that although PPG has been most often reported in patients with IBD, it may occur in the absence of IBD. Biopsy of the skin lesion is not diagnostic but excludes other causes. Relocation of the stoma may be associated with a new ulceration and should be avoided. Trauma to the skin of a predisposed patient may elicit the pustules or ulcerations associated with pathergy. JAMA. 2000;284:1546-1548.

Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions

Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative disease of undetermined cause. The diagnosis is based on clinical and pathologic features and requires exclusion of conditions that produce ulcerations. An atypical bullous variant (atypical pyoderma gangrenosum, APG) exists with clinical features similar to those of Sweet syndrome. Because PG is a rare disease, few large case series have been reported. Pyoderma gangrenosum was first recognized as a unique disease entity in the first half of the 20th century. Cumulative knowledge of PG is based on a handful of case series and multiple individual case reports. To augment that knowledge, we present our experience with a large number of patients over a significant time. We performed a retrospective analysis of the medical records of 86 patients with PG who were evaluated and treated over 12 years at 2 university-based dermatology departments. The mean (+/- standard deviation) age of onset of PG and APG, respectively, was 44.6 +/- 19.7 years and 52.2 +/- 15.3 years. Lower extremity involvement was most common in PG, whereas upper extremity involvement was most common in APG. Associated relevant systemic diseases were seen in 50% of patients. Inflammatory bowel disease was the most common association in patients with PG, whereas hematologic disease or malignancy was most common in those with APG. Although a few patients were managed with local measures or nonimmunosuppressive treatment, the majority required oral corticosteroid therapy, often with systemic immunosuppressive treatment. PG patients required a mean 11.5 +/- 11.1 months of treatment to achieve remission compared with 9.0 +/- 13.7 months for patients with APG. Five patients (5.8%) had disease that was extremely refractory to multiple intensive therapies. The prognosis and disease associations for PG and APG appear to be different. Compared with PG, APG is more often associated with hematologic disease or malignancy, and remits more quickly.

Pacifier use and otitis media in infants twelve months of age or younger

PURPOSE

The purpose of this study was two fold: to determine if within a selected population of infants the prevalence of otitis media was greater in pacifier users than in non-pacifier users, and to reveal if an association existed between otitis media and pacifier use.

METHODS

The study consisted of 200 children, 12 months of age or younger. Parents were surveyed regarding children's pacifier habits, day care attendance, feeding habits, thumb sucking habits, exposure to parental smoking, and parental education level.

RESULTS

The prevalence of otitis media in pacifier users (36%) was larger than that of non-pacifier users (23%), P < 0.05. A logistic regression analysis determined an association existed between otitis media and pacifier use, bottle feeding, thumb sucking, and day care utilization, P < or = 0.05. No association was discovered between otitis media and breast feeding, parental smoking and parental education level.

CONCLUSION

The risk of developing otitis media in an infant is two times greater if a pacifier is used and five times greater if bottle fed or attending a day care facility.

Early- and late-stage breast cancer in a managed care setting in relation to mammography screening

A case-control study was conducted to ascertain occurrence of advanced- and early-stage breast cancer, use of mammography, and the relationship between the two. All women with stage III/IV breast cancer (N = 46) were matched to two controls (stage 0/I and stage II) by year of diagnosis and age. Matched-pair analyses assessed antecedent use of screening mammography. Results indicated that advanced-stage patients were significantly less likely than their stage 0/I counterparts to have had antecedent screening within 13 months of diagnosis [chi2: 5.78; OR: 6.0; p < 0.05]. Cases compared with stage II controls did not differ statistically. Efforts should focus on increasing mammography in currently targeted age groups. Considerations might be toward extending regular screening for women 40 to 49 and over 75.

Scarring alopecia and sclerodermatous changes of the scalp in a patient with hepatitis C infection

Hepatitis C virus (HCV) is a common cause of chronic hepatitis and is frequently associated with extrahepatic disease. Recently, cutaneous disorders have been a presenting manifestation of HCV infection. Porphyria cutanea tarda (PCT) is one of the cutaneous diseases associated with hepatitis C. PCT manifests in an acute form with tense bullae and erosions and in a chronic form with milia, scarring, and sclerodermatous changes. HCV has also been implicated as a cause of vasculitis through immune complex deposition. We report a patient in whom HCV was associated with sclerodermoid PCT and a medium vessel vasculitis. This case underscores the importance of HCV and its potential cutaneous manifestations, as well as the importance of recognizing cutaneous manifestations of internal disease that may be the first clue to diagnosis of HCV.

Morning vs evening light treatment of patients with winter depression

BACKGROUND

According to the phase-shift hypothesis for winter depression, morning light (which causes a circadian phase advance) should be more antidepressant than evening light (which causes a delay). Although no studies have shown evening light to be more antidepressant than morning light, investigations have shown either no difference or morning light to be superior. The present study assesses these light-exposure schedules in both crossover and parallel-group comparisons.

METHODS

Fifty-one patients and 49 matched controls were studied for 6 weeks. After a prebaseline assessment and a light/dark and sleep/wake adaptation baseline week, subjects were exposed to bright light at either 6 to 8 AM or 7 to 9 PM for 2 weeks. After a week of withdrawal from light treatment, they were crossed over to the other light schedule. Dim-light melatonin onsets were obtained 7 times during the study to assess circadian phase position.

RESULTS

Morning light phase-advanced the dim-light melatonin onset and was more antidepressant than evening light, which phase-delayed it. These findings were statistically significant for both crossover and parallel-group comparisons. Dim-light melatonin onsets were generally delayed in the patients compared with the controls.

CONCLUSIONS

These results should help establish the importance of circadian (morning or evening) time of light exposure in the treatment of winter depression. We recommend that bright-light exposure be scheduled immediately on awakening in the treatment of most patients with seasonal affective disorder.

Methyldibromoglutaronitrile (Euxyl K400): a new and important sensitizer in the United States?

BACKGROUND

Methyldibromoglutaronitrile (MDGN) is a component of Euxyl K400, a preservative used in many skin care products in Europe. MDGN has been used in skin care products in the United States for the last 5 years. Contact allergy from MDGN has been reported from Europe.

OBJECTIVE

The purpose of this study was to determine the frequency of MDGN as a sensitizer in patients undergoing routine patch testing.

METHODS

We reviewed the results in 163 patients who underwent patch testing during a 4-month period to determine the number who had any reaction to MDGN at two different concentrations (0.2% and 0.5%). Tests were graded with the use of the North American Contact Dermatitis Group criteria (0 to 3+), and readings were performed at 48 and 96 hours (all positive reactions were evaluated at a follow-up visit or by telephone interview).

RESULTS

In the 4-month period, 45 of the 163 patients showed some reaction (+/- to 3+) at one or more readings. Of these, the results for 23 patients were considered to be irritant false-positive reactions; for 3 patients, the results were classified as uncertain; and for 19 patients, the results were classified as allergic. Of these, the results for eight patients were of definite relevance; the results for five patients were of probable relevance, and the results for six patients were of doubtful relevance to the problem condition. Other positive patch tests to a variety of allergens were frequently seen in persons positive to MDGN.

CONCLUSION

MDGN is a sensitizer in skin products and, with the increase of its use, should be considered in the patch test evaluation of patients with persistent dermatitis. Optimum patch test concentrations are yet to be determined.

L-carnitine and acetyl-L-carnitine status during hemodialysis with acetate in humans: a kinetic analysis

The effects of the acetate content of hemodialysis fluids on the relation between L-carnitine (free carnitine, cr FC) and acetyl-L-carnitine (AC) have not previously been examined in detail. The net fluxes of FC, AC, and acetate between intra- and extracellular pools during hemodialysis were calculated using a kinetic model with dialysates containing three concentrations of FC (0, 40, and 80 mumol/L) and either 40 or 3 mmol acetate/L. Radioenzymatic assays of FC and AC were optimized for use with samples taken during hemodialysis. Acetate stimulated a tissue uptake of FC (P < 0.05) that could exceed the rate of FC delivery and was related to the dialysate FC composition (P < 0.02). There were associated changes in tissue AC output. With dialysate containing 40 mmol acetate/L, AC tissue output was directly related to the dialysate FC composition (P < 0.05). The AC tissue output was less with dialysate containing 3 mmol acetate/L (P < 0.05) but the significant increase with the provision of FC in the dialysate was retained (P < 0.05). Hemodialysis may therefore represent an acute period of relative carnitine deficiency when regeneration of free coenzyme A from acetyl coenzyme A consequent to metabolism of acetate is limited.

Plasma non-esterified fatty acid response to dialysate acetate concentration during haemodialysis in humans

We have inhibited the in vitro generation of non-esterified fatty acids in plasma samples taken during haemodialysis by cooling the samples rapidly, centrifuging and freezing within 5 min of sampling and completing the assay on the same day. The relationship of non-esterified fatty acid concentrations during haemodialysis to the acetate concentration of the dialysate and the profile of circulating lipase activities was studied. With this sample-handling protocol we found lower non-esterified fatty acid concentrations than reported in many other studies and the results suggest that, under normal conditions of haemodialysis, the circulating non-esterified fatty acid concentrations and the associated risk of unwanted side-effects may have been previously over-estimated due to artefactual in vitro sample lipolysis. We also showed that, at the end of dialysis, when circulating lipase activities were least, the non-esterified fatty acid concentrations were lower (P < 0.05) with an acetate dialysate containing 37 mmol/l acetate than with a bicarbonate dialysate containing 3 mmol/l acetate.

Distance and pairing effects on the brownDominant heterochromatic element in Drosophila

We examined the behavior of the brownDominant (bwD) heterochromatic insertion moved to different locations relative to centric heterochromatin. Effects were measured as the degree of silencing of a wild-type brown eye pigment gene by bwD across a tandem duplication. A series of X-ray-induced effects were recovered at high frequency. Cis-acting enhancers were obtained by relocation of the duplication closer to autosomal heterochromatin. Enhancers were also recovered on the homologous chromosome when it was similarly rearranged, revealing a novel interhomologue effect whereby interactions occur between genetic elements near opposite ends of a chromosome arm rather than between paired alleles. Cis-acting suppressors were obtained as secondary rearrangements in which the duplication was moved farther away from heterochromatin. Suppression was correlated with loss of cytological association between bwD and the polytene chromocenter. Surprisingly, the distance from bwD to the chromocenter was not correlated with the strength of enhancement or suppression. We propose that bwD fails to coalesce with the chromocenter when its position along the chromosome places it beyond a threshold distance from heterochromatin, and this threshold depends upon the configuration of both the chromosome carrying bwD and its paired homologue.

Immunophenotyping of acute leukemia at King Faisal Specialist Hospital and Research Centre

During a 20 month period, 133 bone marrow samples from an equal number of patients with acute leukemia were immunophenotyped. Patients ranged in age from two to 68 years with a mean of 23 years. Eighty-four (63.2%) were classified as acute lymphocytic leukemia (ALL) with the following immunologic subclassification: common ALL 83.3%, T-cell ALL 11.9%, null-cell ALL 2.4% and 2.4% differentiated B-cell ALL. Twenty-eight cases (21%) were classified as acute myeloid leukemia (AML) and 16 cases (12%) demonstrated biphenotypic features. Concordance with morphology and cytochemistry was observed in 129 cases (97%). Four cases (3%) manifested discrepancy between immunophenotyping, morphology and cytochemistry. We conclude that immunophenotyping by flow cytometry is a useful and reliable method for classification of acute leukemia, especially when interpreted in the light of morphology and cytochemistry.

Immunophenotyping of childhood acute lymphoblastic leukemia in Saudi Arabia: second look

Geographical variations in the incidence of disease are of considerable theoretical and practical importance. It has been claimed that the distribution of acute lymphoblastic leukemia (ALL) phenotypes in Saudi Arabia is different from that recorded in the Western literature. One hundred and twelve (112) patients under 15 years of age, diagnosed as ALL between January 1992 and May 1994 had immunophenotypes performed on their blast cells. Common ALL (cALL) together with pre-B-ALL, formed 86.5% of the total; B-cell 3%, T-cell 6% and null cell 4.5%. These figures are not significantly different from the Western literature. A previous claim from this institution in 1990, that both null and B-cell ALL were significantly increased compared with elsewhere, is not supported by the present figures. Age and sex distribution, and FAB classification, L1 77%, L2 20% and L3 3%, were also of the same order as described elsewhere and, in particular, there was no increase in the frequency of L3 subtype.

Apoliprotein B polymorphism: Application to monitoring early bone marrow transplantation in Saudi population

Seventy-three unrelated Saudi individuals and seven consecutive bone marrow transplant donor-recipient pairs were studied to characterize and determine the frequency of 3' apolipoprotein B alleles by polymerase chain reaction. The samples analyzed were either peripheral blood or bone marrow aspirates. Eleven different alleles were detected. The index of heterozygosity was 0.66. Apolipoprotein B analysis was informative in 57% of the studied donor-recipient pairs. Engraftment was detected as early as day three post-transplantation. The threshold of detection of this allele was up to 0.01x106/ml. Mixed chimerism of the order of 1% could be detected. We concluded that apolipoprotein B is a highly polymorphic allele among the Saudi population and this makes the region a useful marker for monitoring engraftment following allogeneic bone marrow transplantation.

Melatonin shifts human circadian rhythms according to a phase-response curve

A physiological dose of orally administered melatonin shifts circadian rhythms in humans according to a phase-response curve (PRC) that is nearly opposite in phase with the PRCs for light exposure: melatonin delays circadian rhythms when administered in the morning and advances them when administered in the afternoon or early evening. The human melatonin PRC provides critical information for using melatonin to treat circadian phase sleep and mood disorders, as well as maladaptation to shift work and transmeridional air travel. The human melatonin PRC also provides the strongest evidence to date for a function of endogenous melatonin and its suppression by light in augmenting entrainment of circadian rhythms by the light-dark cycle.

Management of segmental defects by the Ilizarov intercalary bone transport method

Seventeen patients with segmental skeletal defects were managed with the Ilizarov intercalary bone transport method, whereby an osseous defect is eliminated by elongating one fragment. On average, the regenerate new bone length measured 5.14 cm, corresponding to the creation of new osseous tissue equaling 13.7% of the bone's original length (range, 4.2%-35%). The average time in fixation was 9.6 months, including 4.8 months to transport the bone fragment throughout the limb. Numerous complications were encountered, most commonly wire-site sepsis and fixator instability. No serous nerve or vessel complications occurred. All but one patient eventually healed, although six patients required bone grafts, five at the target site and one at the level of the regenerate. Most of the difficulties encountered were due to a lack of technical knowledge with the method.

Serological survey for canine cutaneous and visceral leishmaniasis in areas at risk for transmission in Rio de Janeiro where prophylactic measures had been adopted

A serological survey for canine visceral (VL) and American cutaneous leishmaniasis (ACL) has been carried out during 1984-1989, to assess the effects of the prophylactic measures adopted in areas where there was a risk of transmission of the diseases in Rio de Janeiro. A previous serological survey (1982/83) had detected serum positive dogs as well as the human disease in these same areas. A total of 22,828 dogs have been examined in this last survey, 7,807 of which came from Campo Grande (VL and ACL area), 4,110 from Jacarepaguá (ACL area), 4,146 from Realengo, 3,879 from Bangu and 2,886 from Senador Camará, (three VL areas). The analysis of these results showed a notable reduction in the number of serum positive dogs, compared to those of the first survey of 1982/83 as follows: (a) in Campo Grande (VL and ACL) the infection rate of the first survey was 12.7%, against 0.62% of the second; (b) in Jacarepaguá (ACL) it decreased from 8.6% to 1.8% (c) in Bangu, Realengo and Senador Camará (VL) the rate decreased from 4.3% to 0.38%. The results indicate that this decrease was due to the prophylactic measures adopted in those areas.

ICI D7114 a novel selective beta-adrenoceptor agonist selectively stimulates brown fat and increases whole-body oxygen consumption

1. ICI D7114 is a novel, beta-adrenoceptor agonist which stimulates whole body oxygen consumption in conscious rats, cats and dogs and brown adipose tissue (BAT) activity in conscious rats. Treatment of rats with ICI D7114 stimulated oxygen consumption (ED50, 0.04 mg kg-1, p.o.) and BAT mitochondrial guanosine diphosphate (GDP)-binding (ED50, 0.15 mg kg-1, p.o.) with no chronotropic effects on the heart at these doses. 2. Reference beta-adrenoceptor agonists, isoprenaline and clenbuterol, also stimulated oxygen consumption and BAT activity but were less selective because they also produced effects on heart rate at these doses. 3. Treatment of conscious rats with ICI D7114 did not attenuate the chronotropic effects on the heart of a subsequent isoprenaline challenge. 4. Administration of ICI D7114 or of its acid metabolite had no effect in a cat soleus muscle model of tremor or on blood potassium levels in the conscious dog, indicating lack of effects at beta 2-adrenoceptors. 5. The results indicate that ICI D7114 may have activity at atypical beta-adrenoceptors in brown adipose tissue leading to increased whole body oxygen consumption.

Activation and inhibition of bovine carbonic anhydrase III by dianions

We have found that many dianionic species, at millimolar concentrations, significantly activate or inhibit the bovine carbonic anhydrase III-catalyzed hydration of CO2. Dianionic species such as HPO2-4 and SO2-3, with pKb values near 7, are activators, whereas weakly basis species such as SO2-4 act as inhibitors. Both activation and inhibition are partial hyperbolic in nature and do not appear to compete with monoanionic linear inhibitors like N-3. Our kinetic data are consistent with a formal mechanism of action for carbonic anhydrase III that is directly analogous to that of carbonic anhydrase II, in which Lys-64 of carbonic anhydrase III can act as an intramolecular H+ transfer group during CO2 hydration. Our data suggest that dianionic inhibitors depress the rate of H+ transfer during turnover by stabilizing the protonated form of Lys-64. We postulate that dianionic activators enhance the rate of a rate-limiting H+ transfer step in the mechanism, probably by acting directly as H+ acceptors.

The accuracy of predictions about progress of patients on a stroke unit

The aim of the study was to check the accuracy of predictions about the factors which affect the progress, in physical abilities and activities of daily living, of patients admitted to a stroke unit. A series of 60 patients admitted consecutively to a stroke unit were assessed on tests of motor, functional and cognitive abilities at admission. On the basis of these assessments predictions were made about the abilities of the patients at discharge. Patients were assessed for level of motor abilities and activities of daily living at discharge and the accuracy of the predictions checked. Predictions were found to be significantly correlated with outcome but the relationships were not so close as to be useful for the clinical management of individual patients.

Unilateral duplication of the cerebellar hemisphere and internal, middle, and external ear: a clinical case study

This article presents the unique congenital anomaly complex of ipsilateral cerebellar hemisphere duplication and internal, middle, and external ear duplication. Diagnostic techniques included a head CT scan, a three-dimensional head CT scan, and a head MRI. An aberrant notochordal split was proposed as the embryologic mechanism leading to the development of such anomalies.

The effect of surgery and nutritional regimen on plasma lipoproteins and fat metabolites in man

Plasma lipoproteins and fat metabolites were measured before and during the first five post-operative days in patients undergoing elective abdominal surgery of moderate severity. They received nutrition as total parenteral nutrition (TPN) or 4% dextrose saline (D S ) or isotonic aminoacids (IAA). Surgery caused an immediate fall in total and very low density lipoprotein triglyceride and total high density lipoprotein cholesterol but a rise in the high density lipoprotein subfraction 2 cholesterol. The increase in total triglyceride after 5 post-operative days was due principally to changes in triglyceride not carried by very low density lipoprotein and was related to the type of nutrition provided. There was no evidence of impaired intra-vascular lipolysis.

The timing of menarche in juvenile rheumatoid arthritis

A study of the age of menarche in juvenile rheumatoid arthritis (JRA) patients was undertaken to determine what factors affect the timing of menarche. There was a significant difference between the mean age of menarche for the 68 JRA patients and 46 controls (p = 0.015). No clear etiology for this difference was elucidated. Polyarticular-onset JRA patients had the oldest age of menarche, but this finding was of marginal statistical significance (p less than 0.05,pcorr less than 0.25). The multivariate model that included onset type, steroid use, and duration of disease weakly predicted age of menarche in the JRA group. This model suggests that, exclusive of height and weight parameters, duration of disease was the most important predictor of menarche in JRA.

Star Formation in W49A: Gravitational Collapse of the Molecular Cloud Core Toward a Ring of Massive Stars

High-resolution molecular line and continuum radio images from the Hat Creek Radio Observatory and the Very Large Array suggest that the core of the W49A star-forming region is undergoing gravitational collapse. The radio continuum shows a 2-parsec ring of at least ten distinct ultracompact H-II regions, each associated with at least one O star. The ring is a region of large-scale, organized massive star formation. Recombination line velocities and HCO(+) excitation requirements indicate that the ring is rotating around 50,000 solar masses of material. Because the HCO(+) (1-0) line shows red-shifted absorption but blue-shifted emission, the molecular cloud core is believed to be collapsing toward the center of the ring. The HCO(+) radial velocities, as well as H-I, H(2)CO, and magnetic-field measurements, fit a simple model of inside-out gravitational collapse of a once magnetically supported cloud.