Primary intra-articular epithelioid sarcoma of the knee: Unusual presentation of a rare entity

We report a case of a 60-year-old female with severe and progressive pain of her right knee. Physical therapy, pain medication, and arthroscopic debridement were unsuccessful. Finally, pathological examination revealed an intra-articular epithelioid sarcoma, a rare tumor in an atypical location. Patient died within 5 months after initial admission. Despite this unusual clinical course and presentation, we would like to share the valuable clinical lessons we learned from this case. Introduction of a coordinating physician in combination with a multidisciplinary treatment regarding optimal pain management should optimize treatment results in future patients.

Subtypes of Psychosis Among Difficult-to-treat Patients – A Cluster Analytical Replication Study Among Chronically Psychotic, Institutionalized Dual Diagnosis Patients

Background

Research is lacking on possible subtypes of psychosis in difficult-to-treat patients that require long-term institutionalisation due to a combination of psychosis, substance abuse and problem behaviours after multiple failed treatments.

Aim

The aim of this study is to increase our knowledge of this group of patients in order to apply more targeted interventions.

Objective

To identify subtypes of psychosis among this group by cluster analysis and compare these subtypes on different clinical variables.

Methods

PANSS data was acquired for 117 patients. Separate clusters were identified by using Ward's method of hierarchical cluster analysis, replicating Dolffus et al., 1996 [1], who used this method in a cohort of schizophrenia patients. Subtypes of psychosis were identified using PANSS items. Clusters were compared on several clinical variables, f.e. course of admission.

Results

Four distinct clusters were identified (Fig. 1): (1) a ‘positive cluster’, (2) a ‘mild cluster’, (3) a ‘negative cluster’, and (4) a ‘mixed group’. These clusters are similar to those found by Dolffus et al.

There was a significant association between cluster and co-morbid personality disorder, P < 0.05. No significant association was found between clusters and other clinical variables.

Conclusions

Among difficult-to-treat institutionalised patients four distinct subtypes of psychosis could be identified, comparable to those found in a cohort of schizophrenia patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial

Objective

To determine if a neuroplasticity educational explanation for a manual therapy technique will produce a different outcome compared to a traditional mechanical explanation.

Methods

Sixty-two patients with chronic low back pain (CLBP) were recruited for the study. Following consent, demographic data were obtained as well as pain ratings for low back pain (LBP) and leg pain (Numeric Pain Rating Scale), disability (Oswestry Disability Index), fear-avoidance (Fear-Avoidance-Beliefs Questionnaire), forward flexion (fingertips-to-floor), and straight leg raise (SLR) (inclinometer). Patients were then randomly allocated to receive one of two explanations (neuroplasticity or mechanical), a manual therapy technique to their lumbar spine, followed by post-intervention measurements of LBP, leg pain, forward flexion, and SLR.

Results

Sixty-two patients (female 35 [56.5%]), with a mean age of 60.1 years and mean duration of 9.26 years of CLBP participated in the study. There were no statistically significant interactions for LBP (p = .325), leg pain (p = .172), and trunk flexion (p = .818) between the groups, but SLR showed a significant difference in favor of the neuroplasticity explanation (p = .041). Additionally, the neuroplasticity group were 7.2 times (95% confidence interval = 1.8-28.6) more likely to improve beyond the MDC on the SLR than participants in the mechanical group.

Discussion

The results of this study show that a neuroplasticity explanation, compared to a traditional biomechanical explanation, resulted in a measureable difference in SLR in patients with CLBP when receiving manual therapy. Future studies need to explore if the increase in SLR correlated to changes in cortical maps of the low back.

Prevalence and determinants of medication non-adherence in chronic pain patients: a systematic review

BACKGROUND

Chronic pain is commonly treated with analgesic medication. Non-adherence to prescribed pain medication is very common and may result in sub-optimal treatment outcome. The aim of this review was to investigate the prevalence of medication non-adherence and to present determinants that may help identify patients at risk for non-adherence to analgesic medication.

METHODS

A search was performed in PubMed and Embase with systematic approach including PRISMA recommendations. Individual risk of bias was assessed and systematic data extraction was performed.

RESULTS

Twenty-five studies were included. Non-adherence rates to pain prescriptions ranged from 8% to 62% with a weighted mean of 40%. Underuse of pain medication was more common than overuse in most studies. Factors that were commonly positively associated with non-adherence were dosing frequency, polymedication, pain intensity, and concerns about pain medication. Factors negatively associated with non-adherence were age, again pain intensity and quality of the patient-caregiver relationship. Underuse was positively associated with active coping strategies and self-medication, and negatively associated with perceived need for analgesic medication. Overuse was positively associated with perceived need, pain intensity, opioid use, number of prescribed analgesics, a history of drug abuse, and smoking.

CONCLUSION

Non-adherence to analgesic medication use is very common in the chronic pain population. The choice for pharmacological therapy should not only be based upon pain diagnosis but should also take the risks of non-adherence into account. The value of adherence monitoring or adherence enhancing interventions has to be investigated in future studies.

Mental health among living kidney donors: a prospective comparison with matched controls from the general population

The impact of living kidney donation on donors' mental health has not been sufficiently nor comprehensively studied. Earlier studies demonstrated that mental health did not change in the majority of donors, however they often lacked a suitable control group and/or had other methodological limitations. Consequently, it remains unclear whether changes in mental health found among a minority of donors reflect normal fluctuations. In this study we matched 135 donors with individuals from the general Dutch population on gender and baseline mental health and compared changes in mental health over time. Mental health was measured using the Brief Symptom Inventory and Mental Health Continuum Short Form. Primary analyses compared baseline and 6 months follow-up. Secondary analyses compared baseline and 9 (controls) or 15 months (donors) follow-up. Primary multilevel regression analyses showed that there was no change in psychological complaints (p = 0.20) and wellbeing (p = 0.10) over time and donors and controls did not differ from one another in changes in psychological complaints (p = 0.48) and wellbeing (p = 0.85). Secondary analyses also revealed no difference in changes between the groups. We concluded that changes in mental health in the short term after donation do not significantly differ from normal fluctuations found in the Dutch general population.

Pleural effusion as a complication of clozapine treatment

Introduction

Clozapine treatment has been recognized as a superior treatment in schizophrenia. Clozapine treatment has also be accompanied with several rare but severe adverse events, like neutropenia, agranulocytosis, myocarditis, pericarditis and polyperositis. We report a patient that suffers from hyperleucocytemia, eosinophilia and pleuritis, due to clozapine treatment, the adverse events disappeared after a switch to aripiprazole.

Objectives

To review the literature on reports on pleuritis and polyserositis in order searching for guidance in these clinical situation, like the need tot interrupt the medication, the prognosis and if rechallenges are reported. Another objective was to discover if something is known about the underlying mechanism.

Methods

To review the literature, we used the following terms: clozapine, treatment, immunological reaction, neutropenia, leucopenia, epicarditis, polyserositis, pleuritis, pleural effusion, underlying mechanisms, risk factors.

A literature search was performed in Pubmed® and Embase Psychiatry® in the period longing from 1972 till October 2010

Results

Risk factors as well as the underlying mechanisms offer no guidance for dealing with the clinical critical situations.

There are only a few reports on pleural effusion, there are some reports on pleural effusion in combination with epicarditis, there are some reports on polyserositis including pleural effusion.

No rechallenges are reported of clozapine on pleural effusion.

There is no information in the literature on the risk that a pleuritis will extend to other organs, like the heart and the liver, when continuing the clozapine treatment.

Conclusion

Hypotheses about the underlying mechanism will be presented. A program of additional diagnostics will be described

[Neurosyphilis: unexpected reunion with an old acquaintance]

A 45-year-old man was admitted to a psychiatric hospital with confusion and disorientation; he was suspected of having Korsakoff syndrome. He was known to have a history of alcohol abuse, complicated by epileptic fits, and to have had a recent ischaemic cerebrovascular attack. Unexpectedly, screening for syphilis turned out to be positive. Examination of the cerebrospinal fluid led to the diagnosis of neurosyphilis. Most neurological and psychiatric symptoms disappeared after treatment with antibiotics.

[Myocarditis and cardiomyopathy: underestimated complications resulting from clozapine therapy]

BACKGROUND

Treatment with clozapine can affect the heart, leading to serious complications such as myocarditis and cardiomyopathy. When in their early stages both illnesses are difficult to diagnose; this can have serious consequences. Recent analyses of clozapine data suggest that particularly myocarditis is possibly more common than has been assumed hitherto.

AIM

To determine the frequency of these complications and to find out what diagnostic tests are available and whether it is necessary or possible to adjust current guidelines on these complications.

METHOD

The relevant literature was consulted via PubMed, Embase Psychiatry and Psycinfo on the basis of the keywords 'clozapine' and 'myocarditis', 'cardiomyopathy' and 'heart failure'.

RESULTS

Studies showed that the incidence of myocarditis varied from 0.015 to 1.3%. Cardiomyopathy was the subject of fewer studies, one study reported an incidence of 0.022%. More than 50% of the cases of myocarditis developed during the first few weeks of treatment, the average time being about 15 days. For an early diagnosis it is important to monitor the patient's symptoms carefully, especially during the first four weeks following the start of medication. Monitoring should include laboratory tests and electrocardiography. Echocardiography and MRI can be useful additions to the diagnostic process.

CONCLUSIONS

Early diagnosis of myocarditis is important because it is a serious condition. Timely recognition of subclinical myocarditis could possibly prevent later complications such as cardiomyopathy. Clinical guidelines are proposed on the basis of the literature.

[Galactorrhoea and the use of selective serotonin reuptake inhibitors]

The subject of this case study is a female patient who was treated with a selective serotonin reuptake inhibitor (SSRI), citalopram, because of a depressive episode. She developed symptoms of galactorrhea; there was a time relationship between suspension of the treatment with citalopram and a reduction of the galactorrhea symptoms. The consulting internist assumed that the symptoms were due to hyperprolactinemia arising from under-supplementation of thyroid hormone and resultant hypothyroidism. Psychiatrists usually see galactorrhea in patients who are taking antipsychotics. However, few psychiatrists know that galactorrhea can also be caused by SSRIs. When a patient has symptoms of bilateral galactorrhea and has used an SSRI and when hyperprolactinemia has been found in laboratory tests it is probably advisable to stop the SSRI medication. The article mentions what additional research is needed.

Panic disorder and depression: relationship between psychological and biochemical aspects

In a group of medication-free out-patients suffering from depression and/or panic disorder we investigated the interdependence between psychological parameters such as aggression and biochemical parameters such as serotonin and tryptophan. We compared the findings in the patient group with a reference group. In the group of patients as a whole negative correlations were observed between the concentration of serotonin in platelets and depression and with hostility and aggression against others. Serotonin in plasma and tryptophan correlated negatively with hostility. The findings support the suggested link between aggression and depression with a low functioning serotonergic system.

Mirtazapine versus venlafaxine in hospitalized severely depressed patients with melancholic features

The aim of this multicenter, randomized, double-blind, 8-week study was to compare the antidepressant efficacy and tolerability of mirtazapine and venlafaxine in the treatment of hospitalized patients with DSM-IV diagnosis of severe depressive episode with melancholic features. Patients with a baseline score of > or = 25 on the 17-item Hamilton Rating Scale for Depression (HAM-D-17) were randomly assigned to receive treatment with either mirtazapine (N = 78, 15-60 mg/day) or venlafaxine (N = 79, 75-375 mg/day, twice a day) in a rapid up-titration schedule. Efficacy was assessed with the Montgomery-Asberg Depression Rating Scale (MADRS), HAM-D-17, and Clinical Global Impression scale, and quality of life was assessed with the Quality of Life, Enjoyment, and Satisfaction Questionnaire and Quality of Life in Depression Scale. Tolerability was assessed with the Utvalg for Kliniske Undersogelser (UKU) side effect scale and by reporting adverse events. Both drugs were effective in reducing overall symptoms of depression, showing substantial reductions in group mean MADRS scores (-20.1 for mirtazapine and -17.5 for venlafaxine) and HAM-D-17 scores (-17.1 for mirtazapine and -14.6 for venlafaxine) at the end of the treatment. Although not statistically significant, at all assessment times higher percentages of patients treated with mirtazapine were classified as responders (> or =50% reduction) on the HAM-D (at endpoint, 62% vs. 52%) and MADRS (at endpoint: 64% vs. 58%). Likewise were the percentages of remitters (HAM-D score < or =7; MADRS score < or =12) also higher in the mirtazapine group. A statistically significant difference favoring mirtazapine was found on the HAM-D Sleep Disturbance factor at all assessment points (p < or = 0.03). Both treatments were well tolerated. Although slightly more subjects treated with mirtazapine reported at least one adverse event, a statistically significantly higher percentage of patients treated with venlafaxine (15.3%) than mirtazapine (5.1%) dropped out because of adverse events (p = 0.037). Quality of life improved in both treatment groups. In this study, treatment with mirtazapine resulted in a trend toward more responders and remitters than treatment with venlafaxine and in significantly fewer dropouts as a result of adverse events.

[Impact of demographic changes on drug utilization related to diabetes in Aquitaine]

Diabetes is a chronic disease highly correlated to age. In 1998, the Sickness Find of the Aquitaine region has reimbursed 273 million French Francs for expenditures related to diabetes pharmaceuticals. The amount would increase to 300 million French Francs in 2005, a growth of nearly 10%, whereas the Aquitaine population would increase only 4%, from 2,909,000 in 1998 to 3,024,000 seven years later. The difference comes from population aging, as the calculations are undertaken "other things being equal": the insurance coverage rate, the disease prevalence rate, the consumption of pharmaceuticals per patient are supposed unchanged during the period.

Mirtazapine: efficacy and tolerability in comparison with fluoxetine in patients with moderate to severe major depressive disorder. Mirtazapine-Fluoxetine Study Group

OBJECTIVE

To compare the efficacy and tolerability of mirtazapine and fluoxetine in depressed inpatients and outpatients.

METHOD

Patients with a major depressive episode (DSM-III-R), a baseline score of > or=21 on the 17-item Hamilton Rating Scale for Depression (HAM-D), and > or=2 on HAM-D Item 1 (depressed mood) were randomly assigned to a 6-week treatment with either mirtazapine (N=66, 15-60 mg/day) or fluoxetine (N=67, 20-40 mg/day). The upper limit of the mirtazapine dose range was above the dose range approved in the United States (15-45 mg/day). Efficacy was evaluated by the HAM-D, Clinical Global Impressions, the Visual Analogue Mood Rating Scale (VAMRS), and the Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ). The efficacy analyses were performed on the intent-to-treat group using the last-observation-carried-forward method.

RESULTS

Mean total 17-item HAM-D scores at baseline were 26.0 for the mirtazapine- and 26.1 for the fluoxetine-treated group. The decrease from baseline on the HAM-D was larger in the mirtazapine than in the fluoxetine group throughout the treatment period, reaching statistical significance at days 21 and 28. At assessments from day 21 and onward, the absolute difference between the 2 study groups favoring mirtazapine ranged from 3.7 to 4.2 points, the magnitude of difference usually seen between an efficacious antidepressant drug and placebo. Mean dosages at weeks 1-4 were 36.5 mg/day for mirtazapine and 19.6 mg/day for fluoxetine; the respective dosages at weeks 5-6 were 56.3 mg and 35.8 mg. Similar numbers of patients dropped out due to adverse events; tolerability profiles were comparable except for changes in body weight from baseline which were statistically significantly more pronounced in the mirtazapine group compared to the fluoxetine group.

CONCLUSION

We found that mirtazapine was as well tolerated as fluoxetine and significantly more effective after 3 and 4 weeks of therapy.

Effects of clomipramine on plasma amino acids and serotonergic parameters in panic disorder and depression

We examined the effects of long-term (six months) treatment with the serotonin potentiating tricyclic antidepressant clomipramine on several serotonergic parameters in panic disorder and depressive patients. Serotonin (5-HT) levels in blood, platelets and plasma were significantly reduced to 4%, 3% and 28% of their respective baseline values. In addition, the plasma level of tryptophan was also significantly reduced, although the decrease was only 16%. Three months after discontinuation of clomipramine treatment, 5-HT in blood and platelets reached baseline values again, while the plasma 5-HT level was still reduced to 68% of pretreatment values. Unexpectedly, the plasma tryptophan concentration was even lower at this time-point than after six months of treatment. These results show that clomipramine not only has an effect on 5-HT levels in blood, platelets and plasma, but also on plasma tryptophan concentration. We speculate that low plasma tryptophan after treatment may constitute a risk for the recurrence of psychopathology.

Trait anxiety, coping with stress, and norharman

Plasma levels of the beta-carboline norharman, concentration of platelet 5-HT, trait measures of anxiety, and measures of coping and defense mechanisms were compared for 15 patients with panic disorder and 24 healthy volunteers. Patients indicated that they made less use of the defense mechanism of principalization than control subjects. No other differences between patients and controls were significant. Platelet 5-HT concentration was positively correlated with the subjectively reported anxiety. Plasma norharman concentration was negatively correlated with the defense mechanisms of principalization and repression and positively correlated with coping strategies involving palliation. The positive correlations of norharman levels with projection and self-comforting fell short of significance and existed in the patient group only. No correlation was apparent between levels of plasma norharman and scores on anxiety. It was concluded that norharman is not a marker for panic disorder or trait anxiety, but that it might reflect intrapsychic and coping processes.

Efficacy and tolerability of citalopram in comparison with fluvoxamine in depressed outpatients: a double-blind, multicentre study. The LUCIFER Group

In 16 depression clinics in hospitals and outpatient facilities in the Netherlands, a study was performed to evaluate and compare the efficacy and tolerability of citalopram and fluvoxamine and to determine the difference in the incidence of gastrointestinal side-effects. A total of 217 patients with a depressive disorder (DSM-III-R criteria) and a score of at least 16 on the Hamilton rating scale for depression were randomized to treatment. The results of this study indicate that the two drugs are equally effective. The adverse events occurring during treatment show a similar pattern between the two drugs, but citalopram is better tolerated than fluvoxamine. Citalopram induces fewer gastrointestinal adverse events compared with fluvoxamine. However, this did not affect the drop-out rates.

Better discrimination of hip fracture using bone density, geometry and architecture

Bone density predicts the risk of hip fracture. Because hip strength is determined by bone geometry and architecture as well as density, we tested which variables in geometry and architecture were independent discriminators of hip fracture and, if combined with density, improved the discrimination of fracture from non-fracture over bone density alone. The design was a case-control study. The subjects were Caucasian women over the age of 60 years who had sustained a hip fracture after the age of 58 years (n = 22), and controls matched for age and weight (n = 43) and unmatched controls (n = 317) with no history of hip fracture. Variables in density, geometry and architecture were obtained from dual-energy X-ray absorptiometry images and from radiographs of the upper end of the femur. In a univariate model, of the measures of bone mass, the best discriminator of hip fracture was bone mineral density of the neck of femur; of the geometric measurements, it was hip axis length; and of the measurements of bone architecture, it was Singh grade. In a multivariate model, these three variables were shown to be independent discriminators of hip fracture. When hip axis length was combined with bone mineral density, there was significant improvement in discrimination of hip fracture (p = 0.014), and when Singh grade was combined with hip axis length and bone mineral density there was a further significant improvement (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Calcaneal ultrasonic measurements discriminate hip fracture independently of bone mass

We studied 336 elderly white women, of whom 22 had previously suffered a hip fracture and 22 had previously suffered a vertebral fracture. All subjects were 60 years old or older with a mean age of 73:7 years. Measurements of ultrasonic transmission velocity (UTV), broad-band ultrasonic attenuation (BUA) and stiffness (STF) were made at the os calcis using a Lunar Achilles ultrasound device. Measurements of lumbar spine bone mineral density (L2-4 BMD) and femoral neck BMD were made using dual-energy X-ray absorptiometry. The fracture groups were significantly older and had more years since menopause than the control groups. Logistic regression showed that measurements of UTV, STF and BUA discriminated between fracture and non-fracture subjects for both the hip (p < 0.001) and spine (p < 0.05). Femoral neck BMD discriminated both hip and vertebral fractures from controls (p < 0.001 and p < 0.01, respectively). Spinal BMD discriminated between subjects with vertebral fractures and those without (p < 0.01), but not hip fractures (p = 0.64). For hip fracture, areas under receiver-operating characteristic (ROC) curves were 0.85 for UTV, 0.83 for STF, 0.79 for BUA, 0.78 for femoral neck BMD and 0.53 for spinal BMD. For vertebral fracture, areas under the ROC curve were 0.68 for UTV, 0.70 for STF, 0.66 for BUA, 0.66 for femoral neck BMD and 0.67 for spinal BMD.(ABSTRACT TRUNCATED AT 250 WORDS)

Increasing occupational therapy research: is it time to try something new?

Lack of substantial occupational therapy research is a recognized and persistent problem; which is often discussed throughout the literature but not truly addressed. Action must be taken to involve clinicians in the effort to substantiate the efficacy of treatments through outcome studies. We offered several proactive recommendations that could be implemented on a national level to encourage hesitant practitioners to conduct research. Past recommendations have not tapped the expertise of a large segment of our profession. Our recommendations will enhance the accessibility of research to a greater percentage of occupational therapy professionals by specifically targeting problems related to money, education, and time.

Cloning and characterization of NF-ATc and NF-ATp: the cytoplasmic components of NF-AT

Present evidence indicates a pathway of signal transmission in T cells that is outlined in figure 1. The elevation in intracellular calcium that is induced by interactions at the antigen receptor leads to the activation of the calcium-dependent phosphatase calcineurin. This in turn leads to the nuclear association of the cytosolic component of NF-ATc. The activation of calcineurin and the nuclear import of NF-ATc can both be blocked by cyclosporin A or FK506 in complex with their respective immunophilins. Once in the nucleus, NF-ATc interacts with NF-ATn to form an active transcriptional complex. NF-ATn is a ubiquitous protein, can be synthesized in response to PMA, and has many similarities to AP-1. The mechanism by which NF-ATc enters the nucleus is unknown, and although it appears to require calcineurin, NF-ATc has not yet been shown to be an in vivo substrate of calcineurin. Alternative mechanisms include the possibility that NF-ATc operates on some cytoplasmic anchor or that other proteins that are controlled by calcineurin carry out the nuclear import of NF-ATc. Although NF-ATp copurifies with NF-ATc, there is as yet no understanding of how NF-ATp is functioning in vivo. Now that these proteins are purified and cloned, the major goals will be to understand their role and the roles of other family members in thymic development.

Positive associations between anticipatory anxiety and needle pain for subjective but not for physiological measures of anxiety

So far, the association between anxiety and pain has not been studied with measures tapping a physiological dimension of anxiety. Therefore, during a blood extraction procedure, we recorded subjective anxiety, electrodermal activity, heart rate, and intensity of pain. Subjects were 15 patients with panic disorder and 24 healthy subjects. Positive associations between subjective anxiety and pain were found in each group. The physiological activity preceding the venipuncture, however, was not significantly related to the intensity of the pain.

Practical considerations for the use of the pedobarograph

The pedobarograph functions as a device for the dynamic, quantitative measurement of pedal pressures. To date, little attention has been paid to various practical questions concerning its operation. For example, the number and timing of trials sufficient to provide meaningful information upon which to reliably base investigational or management decisions has yet to be addressed. Twenty volunteers were used for the measurement of pedal pressures for 15 trials during three separate sessions. Statistical analysis for the determination of MIVQUE(0) estimates and maximum likelihood estimates were used to determine the individual variability, the variability of the specific area of the foot, the daily variability, and the trial-to-trial variability. This analysis indicated that for the assessment of pedal pressures in a clinical setting, the variance factors were sufficiently minimized by obtaining multiple measurements. The improvement in the estimate of error by obtaining trials on different days was overshadowed by the potential benefit of doing extra trials on a single day. Three trials on 1 day should sufficiently reduce estimates of error for both clinical and investigational purposes.

A quantitative assessment of the effect of metatarsal pads on plantar pressures

The treatment of metatarsalgia secondary to the plantar prominence of the metatarsal heads has lead to the development of numerous orthotic devices designed to decrease pressures in these areas. In spite of the considerable cost of some of these devices, there has yet to be much objective evidence of their efficacy. This study assessed the effect of a simple metatarsal pad on pressures transmitted to the metatarsal heads. Quantitative measurements of dynamic peak pressures for 10 asymptomatic subjects with and without metatarsal pads were made using the pedobarograph. Female volunteers had a reduction in peak metatarsal pressures from 12% to 60% when a small metatarsal pad was appropriately applied to the foot. In two of five males there was a decrease in metatarsal pressure of 14% to 44%. One male had no change in pressure, while two others had an increase in pressure from 8% to 28%. When properly positioned and appropriately monitored, metatarsal pads can be an inexpensive and effective means of reducing metatarsal pressures.

Molecular characterization of MHC class II antigens (beta 1 domain) in the BB diabetes-prone and -resistant rat

The BB or BB/Worcester (BB/W) rat is widely recognized as a model for human insulin-dependent diabetes mellitus (IDDM). Of at least three genes implicated in genetic susceptibility to IDDM in this strain, one is clearly linked to the major histocompatibility complex (MHC). In an attempt to define the diabetogenic gene(s) linked to the MHC of the BB rat, cDNA clones encoding the class II MHC gene products of the BB diabetes-prone and diabetes-resistant sublines have been isolated and sequenced. For comparison, the beta 1 domain of class II genes of the Lewis rat (RT1L) were sequenced. Analysis of the sequence data reveals that the first domain of RT1.D beta and RT1.B beta chain of the BB rat are different from other rat or mouse class II sequences. However, these sequences were identical in both the BB diabetes-prone and BB diabetes-resistant sublines. The significance of these findings is discussed in relation to MHC class II sequence data in IDDM patients and in the nonobese diabetic (NOD) mouse strain.

A molecular basis for MHC class II--associated autoimmunity

Class II major histocompatibility (MHC) molecules have an immunoregulatory role. These cell-surface glycoproteins present fragments of protein antigens (or peptides) to thymus-derived lymphocytes (T cells). Nucleotide sequence polymorphism in the genes that encode the class II MHC products determines the specificity of the immune response and is correlated with the development of autoimmune diseases. This study identifies certain class II polymorphic amino acid residues that are strongly associated with susceptibility to insulin-dependent diabetes mellitus, rheumatoid arthritis, and pemphigus vulgaris. These findings implicate particular class II MHC isotypes in susceptibility to each disease and suggest new prophylactic and therapeutic strategies.

The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison

The displaced femoral neck fracture poses difficult decision-making issues for the orthopedic surgeon. Young patients frequently require a rapid open reduction and rigid internal fixation in the face of multiple associated injuries. Elderly patients present the typical decision dilemma of internal fixation versus arthroplasty. Consecutive, randomized, prospective series of cases for evaluation of alternatives in the treatment of this difficult fracture are lacking. Between 1982 and 1984, 34 elderly patients with displaced femoral neck fractures were randomized to open reduction or hemiarthroplasty study groups. Although the surgical risks are relatively high, two-year observations showed better functional results in the cemented hemiarthroplasty group.

A double-blind comparative clinical trial of citalopram vs maprotiline in hospitalized depressed patients

In a double-blind clinical trial comprising 29 depressed patients citalopram, a highly selective 5-HT re-uptake inhibitor and maprotiline, a specific NA re-uptake inhibitor, were compared. Allowing for the small sample and taking into consideration that both groups consisted of severely ill, hospitalized patients, it is notable that half of them appeared to respond to treatment. Comparison of the clinical efficacy of the two drugs showed no significant difference, but the profiles of the side-effects appeared to be different. The patients treated with citalopram showed increased sweating, drowsiness, restlessness and headache. These side-effects were almost entirely reported by the non-responders. The maprotiline patients had anticholinergic symptoms, such as dryness of mouth and constipation, side-effects which were also reported by the responders. No correlation was found between plasma steady-state levels of either drug and clinical outcome. The Dexamethasone Suppression Test (DST) appeared to show some predictive value as regards treatment response. There was a tendency towards better overall treatment results in the non-suppressor group. Determination of post-probenecid 5-HIAA, HVA and MHPG concentrations in lumbar-CSF was made in 22 patients. There was a significant negative correlation between HVA and the severity of depression, as well as a significant negative correlation of MHPG with the Newcastle score. The 5-HIAA concentration was found to be correlated with HVA, but not with MHPG. Rather surprisingly significant negative correlation between 5-HIAA and treatment results with maprotiline was found, but no correlation with MHPG. The lumbar-CSF MHPG and HVA values did not appear to have any predictive value as regards treatment response to citalopram or maprotiline. As expected the serotonin (5-HT) concentration in blood and thrombocytes in patients treated with citalopram showed a highly significant reduction after 2 and 4 weeks of treatment.

Plasma tryptophan and tyrosine ratios to competing amino acids in relation to antidepressant response to citalopram and maprotiline. A preliminary study

Pretreatment plasma ratios of tryptophan (Trp) and tyrosine (Tyr) to other large neutral amino acids were determined in 27 depressed patients who completed a double-blind trial of citalopram, a selective serotonin uptake inhibitor, against maprotiline, a selective noradrenaline uptake inhibitor. The Trp ratio and the Tyr ratio were decreased in the total patient sample as compared with healthy controls. Plasma Tyr ratio was normal in the endogenous, but significantly decreased in the non-endogenous depressives. There was no significant relationship between the plasma Trp ratio and the probenecid-induced accumulation of 5-HIAA in the CSF, or between the plasma Tyr ratio and HVA level in CSF, whereas the CSF level of MHPG correlated significantly with the plasma Tyr ratio. There was a significantly positive correlation between the Trp ratio, the Tyr ratio, their sum and the final Hamilton depression score in 14 patients treated with citalopram; on the whole, this association was evident also in the endogenous and non-endogenous subgroups. In 13 patients on maprotiline there was a significantly positive correlation between the plasma Tyr ratio and the percent reduction of Hamilton depression score; this association was poor in the endogenous, whereas a trend towards a correlation remained in the non-endogenous subgroup. The results suggest that the plasma Trp and Tyr ratios may be determinants of clinical improvement in depressed patients to treatment with citalopram and maprotiline. However, further studies are needed on larger patient samples to allow a firm conclusion.

Cost of orthopedic injuries sustained in motorcycle accidents

Fifty-one serial admissions to the orthopedic services at the University of California, Davis, Medical Center, Sacramento, for motorcycle accident trauma with open fractures were reviewed. Fifty-five percent of those tested were alcohol intoxicated at the time of admission. Seventy-five percent carried no insurance of any kind, and for the total group, 72% of the cost of acute hospitalization (+17,704 per patient) was paid by the state of California, with an additional 10% paid by other tax-based sources. Care of motorcycle trauma consumes a substantial portion of public health care funds in California. This could be reduced by legislative action concerning helmet use, licensing, and rigid enforcement of compulsory insurance.