Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute

Of the 400,000-500,000 permanent pacemaker leads implanted worldwide each year, around 10% may eventually fail or become infected, becoming potential candidates for removal. Intravascular techniques for removing problematic or infected leads evolved over a 5-year period (1989-1993). This article analyzes results from January 1994 through April 1996, a period during which techniques were fairly stable. Extraction of 3,540 leads from 2,338 patients was attempted at 226 centers. Indications were: infection (27%), nonfunctional or incompatible leads (25%), Accufix or Encore leads (46%), or other causes (2%). Patients were 64+/-17 years of age (range 5-96); 59% were men, 41% women. Leads were implanted 47+/-41 months (maximum 26 years), in the atrium (53%), ventricle (46%), or SVC (1%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths, and/or transfemorally using snares, retrieval baskets, and sheaths. Complete removal was achieved for 93% of leads, partial for 5%, and 2% were not removed. Risk of incomplete or failed extraction increased with implant duration (P<0.0001), less experienced physicians (P<0.0001), ventricular leads (P<0.005), noninfected patients (P<0.0005), and younger patients (P<0.0001). Major complications were reported for 1.4% of patients (<1% at centers with >300 cases), minor for 1.7%. Risk of complications increased with number of leads removed (P<0.005) and with less experienced physicians (P<0.005); risk of major complications was higher for women (P<0.01). Given physician experience, appropriate precautions, and appropriate patient selection, contemporary lead removal techniques allow success with low complication rates.

Identification of endocrine-disrupting effects in aquatic vertebrates and invertebrates: report from the European IDEA project

The EU-funded project IDEA aimed to evaluate (a) what parameters and endpoints allow the detection of endocrine-mediated developmental and reproductive effects of (xeno)estrogens in life cycle- and life stage-specific toxicity tests with the zebrafish Danio rerio, a small laboratory fish used in many ecotoxicity test guidelines, and (b) whether substances that act as estrogens in vertebrates may also adversely affect the development, differentiation, and reproduction of aquatic invertebrates. The invertebrate species investigated included Hydra vulgaris, Gammarus pulex, Chironomus riparius, Hyalella azteca, and Lymnaea stagnalis. The animals were exposed to the model estrogenic chemicals ethynylestradiol (EE2), bisphenol A (BPA), and octylphenol (OP), which exert their endocrine activity in vertebrates through the estrogen receptor. As endpoints, developmental and reproductive parameters at the organism level as well as molecular and cellular parameters were measured. Life cycle exposure of zebrafish to (xeno)estrogens induced a specific, partly irreversible response pattern, consisting mainly of (a) induction of vitellogenin (VTG), (b) alterations of gonad differentiation, (c) delay of first spawning, and (d) reduced fertilization success. The effects of EE2 on zebrafish were expressed at environmentally realistic concentrations, while BPA and OP became effective at concentrations higher than those usually found in the environment. The vitellogenic response was equally sensitive as the reproductive parameters in the case of EE2, but VTG was more sensitive in the case of BPA. Partial life cycle exposure of zebrafish had lasting effects on fish development and reproduction only when the fish were exposed during the stage of juvenile bisexual gonad differentiation. In (partial) life cycle and multigeneration studies with invertebrates, (xeno)estrogenic impact was assessed by a range of developmental and reproductive parameters including hatching, growth, moulting, mating behavior, and egg number. Several parameters were found to be responsive to (xeno)estrogens; however, most effects were induced only at higher, probably nonphysiological concentrations. Low-dose effects were observed in full life cycle experiments, particularly in the second generation. It remains to be established whether the estrogen-induced alterations in the invertebrate species indeed do result from disturbances of the endocrine system. The findings of the present research project support the development of appropriate testing methodologies for substances with estrogenic activity.

Crude Fat, Diethyl Ether Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with diethyl ether by the Randall method, also called the Soxtec method or the submersion method. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 12 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.09 to 9.26% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.0 to 21.0%. The method is recommended for Official First Action.

The polymerase chain reaction in the demonstration of monoclonality in T cell lymphomas

AIMS

To evaluate polymerase chain reaction (PCR) amplification of T cell receptor (TCR) beta and gamma chain genes as a means of demonstrating monoclonality in T cell lymphomas using histological samples; to compare the performance of PCR with Southern blot analysis.

METHODS

TCR-beta, TCR-gamma and immunoglobulin heavy chain (IGH) genes were analysed using PCR in 55 cases of T cell lymphoma (28 frozen tissue and 27 paraffin wax embedded samples), diagnosed using morphological and immunohistochemical criteria. The 28 frozen samples were subjected to Southern blot analysis using TCR-beta, TCR-gamma and IGH gene probes. Twenty five B cell lymphomas and 21 non-neoplastic lymphoid tissue samples were used as controls.

RESULTS

Using TCR-beta PCR, monoclonality was detected in 24 (44%) of 55 T cell lymphomas compared with 43 (78%) of 55 using TCR-gamma PCR and in 82% with both techniques. Five (9%) of 55 T cell lymphomas were IGH PCR positive. None of the non-neoplastic lymphoid control samples were PCR positive. All B cell lymphomas showed a polyclonal pattern with TCR-beta PCR while a single B cell lymphoma was positive using TCR-gamma primers. With TCR-beta PCR, a monoclonal result was seen in 12 (43%) of 28 frozen samples of T cell lymphoma, compared with 23 (82%) of 28 using Southern blot analysis. With TCR-gamma PCR, 19 (68%) of 28 frozen tissue samples were positive, compared with 26 (93%) of 28 using Southern blot analysis. A single case showed IGH rearrangement by Southern blot analysis.

CONCLUSION

TCR-gamma PCR should be the method of choice for analysis of clonality in paraffin wax embedded sections of lymphoproliferative lesions, as TCR-beta PCR has a high false negative rate. Southern blot analysis remains the most successful technique when sufficient fresh tissue samples and resources are available.

Informing etiologic research priorities for squamous cell esophageal cancer in Africa: A review of setting-specific exposures to known and putative risk factors

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in most Eastern and Southern African countries, but its etiology has been understudied to date. To inform its research agenda, we undertook a review to identify, of the ESCC risk factors which have been established or strongly suggested worldwide, those with a high prevalence or high exposure levels in any ESCC-affected African setting and the sources thereof. We found that for almost all ESCC risk factors known to date, including tobacco, alcohol, hot beverage consumption, nitrosamines and both inhaled and ingested PAHs, there is evidence of population groups with raised exposures, the sources of which vary greatly between cultures across the ESCC corridor. Research encompassing these risk factors is warranted and is likely to identify primary prevention strategies.

Immune responses of teleost fish

In fish all the pre-requisites to mount a specific immune response are present, but the main differences from the mammalian system are that the secondary response is relatively minor and IgG is not present. In teleosts mainly IgM is present, and IgD has been recently described but its function is, as yet, unknown. However, different forms of fish IgM and its observed flexibility of structure may compensate for a lack of Ig class diversity. The innate immune response of teleosts is highly developed. Multiple forms of key constitutive and inducible components, such as lysozyme, C3, alpha2-macroglobulin and C-reactive protein, are present, and may enhance immune recognition. Low ambient temperature appears to have an impact on all aspects of the immune response, particularly the T-dependent specific immune response due to the non-adaptive lipid composition of T-cell membranes. Temperature effects on the nonspecific immune system are less well characterised, but there is evidence that low temperatures are also suppressive. Knowledge of immune system function becomes essential for disease prevention strategies such as the development of vaccines, selection for increased disease resistance and identification of genes suitable for trangenesis.

Delayed seizure-like activity following analytically confirmed use of previously unreported synthetic cannabinoid analogues

Synthetic cannabinoid use has become widespread, leading to increased burdens on health care providers. Symptoms range from agitation and psychosis to seizures and acute kidney injury. We report a case where a patient was assessed and treated twice within 12 h for seizures following synthetic cannabinoid intoxication. Blood sample determinations showed low concentrations of analogues not previously reported, some of which are legal. Clinicians should be aware that synthetic cannabinoids may cause an array of severe health consequences. Given the ever evolving structure of available analogues, clinicians must also be prepared for other unexpected adverse effects.

Laminar inflammatory gene expression in the carbohydrate overload model of equine laminitis

REASONS FOR PERFORMING STUDY

There is a need to assess the laminar inflammatory response in a laminitis model that more closely resembles clinical cases of sepsis-related laminitis than the black walnut extract (BWE) model.

OBJECTIVES

To determine if a similar pattern of laminar inflammation, characterised by proinflammatory cytokine expression, occurs in the CHO model of laminitis as has been previously reported for the BWE model.

METHODS

Sixteen horses administered 17.6 g of starch (85% corn starch/15% wood flour)/kg bwt via nasogastric (NG) tube were anaesthetised either after developing a temperature>38.9°C (DEV group, n=8) or at onset of Obel grade 1 lameness (OG1 group, n=8). Control horses (CON group, n=8) were anaesthetised 24 h after NG administration of 6 l of deionised water. Laminar tissue was collected from horses while under anaesthesia, followed by humane euthanasia. Real time-quantitative PCR was used to assess laminar mRNA concentrations of genes involved in inflammatory signalling.

RESULTS

Increased mRNA concentrations (P<0.05) for IL-1β, IL-6, IL-12p35, COX-2, E-selectin and ICAM-1 were present in laminae from horses with OG1 lameness but not at the DEV time, when compared to the CON horses. No differences between the groups were found for IL-2, IL-4, IL-10, TNF-α, IFN-γ or COX-1 at either the DEV or OG1 time points.

CONCLUSIONS

There was a notable difference in the temporal pattern of inflammatory events between the BWE and CHO models, with the majority of laminar inflammatory events appearing to occur at or near the onset of lameness in the CHO model, whereas many of these events peak earlier in the developmental stages in the BWE model. This suggests that, in addition to circulating inflammatory molecules, there may be a local phenomenon in the CHO model resulting in the simultaneous onset of multiple laminar events including endothelial activation, leucocyte emigration and proinflammatory cytokine expression.

POTENTIAL RELEVANCE

The similar (although somewhat delayed) inflammatory response in the CHO model of laminitis indicates that inflammatory signalling is a consistent entity in the pathophysiology of laminitis.

Crude Fat, Hexanes Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with hexanes by the Randall method, also called the Soxtec method or the submersion method. The use of hexanes provides for an alternative to diethyl ether for fat extractions. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples compared to Soxhlet. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 14 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.23 to 5.80% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.88 to 14.1%. The method is recommended for Official First Action.

Conserving biodiversity in production landscapes

Alternative land uses make different contributions to the conservation of biodiversity and have different implementation and management costs. Conservation planning analyses to date have generally assumed that land is either protected or unprotected, and that the unprotected portion does not contribute to conservation goals. We develop and apply a new planning approach that explicitly accounts for the contribution of a diverse range of land uses to achieving conservation goals. Using East Kalimantan (Indonesian Borneo) as a case study, we prioritize investments in alternative conservation strategies and account for the relative contribution of land uses ranging from production forest to well-managed protected areas. We employ data on the distribution of mammals and assign species-specific conservation targets to achieve equitable protection by accounting for life history characteristics and home range sizes. The relative sensitivity of each species to forest degradation determines the contribution of each land use to achieving targets. We compare the cost effectiveness of our approach to a plan that considers only the contribution of protected areas to biodiversity conservation, and to a plan that assumes that the cost of conservation is represented by only the opportunity costs of conservation to the timber industry. Our preliminary results will require further development and substantial stakeholder engagement prior to implementation; nonetheless we reveal that, by accounting for the contribution of unprotected land, we can obtain more refined estimates of the costs of conservation. Using traditional planning approaches would overestimate the cost of achieving the conservation targets by an order of magnitude. Our approach reveals not only where to invest, but which strategies to invest in, in order to effectively and efficiently conserve biodiversity.

TLR2 sensing of F. nucleatum and S. sanguinis distinctly triggered gingival innate response

Gingival tissue faces constant exposure to micro-organisms. It functions as part of the host response, an anti-microbial barrier that recognizes and discriminates between commensal and pathogenic bacteria. This study aimed to evaluate and compare the effects of cell wall extracts from different periodontal bacteria, commensals Streptococcus sanguinis and Fusobacterium nucleatum and the pathogen Porphyromonas gingivalis, on the innate immune response of gingival keratinocytes and the role of TLR2 in regulating this. We assayed mRNA levels to determine the expression of human beta-defensins (hbetaD2, hbetaD3), interleukin-1alpha, -1beta, 6 and 8 and matrix metalloproteinase-9. F. nucleatum extracts induced beta-defensin and inflammatory marker mRNA expression at higher levels than P. gingivalis. Extracts from the Gram-positive commensal S. sanguinis did not upregulate the host response. TLR2 extinction inhibited the upregulation of beta-defensin and cytokine transcripts by F. nucleatum extracts but, in contrast, led to a weak induction of hbetaD3 after challenge with S. sanguinis extracts. Although F. nucleatum strongly induces innate immune and inflammatory mediators, S. sanguinis limits their expression through TLR2. Together, our data demonstrate that gingival keratinocytes recognize and discriminate between Gram-positive and Gram-negative commensal extracts, in part through TLR2, to activate different signaling pathways of the innate immune host response.

A comparative study of Chironomus riparius Meigen and Chironomus tentans Fabricius (diptera:chironomidae) in aquatic toxicity tests

Chironomus riparius Meigen and Chironomus tentans Fabricius were examined under controlled conditions and exposed to the reference toxicants cadmium and lindane (gamma-hexachlorocyclohexane) to identify any differences that could have implications for their use in aquatic toxicity testing. Preliminary studies showed that both species could be cultured in the laboratory using similar methodology, resulting in the typical bimodal emergence of adult males prior to females. However, adults of C. riparius emerged earlier and in greater numbers than C. tentans. Comparative measurements of head capsule width and body length for the four larval instars revealed similar dimensions for each species up to and including the third instar. Fourth-instar larvae of C. tentans were considerably larger than those of C. riparius. Median lethal concentrations (LC50) determined over a 10-day exposure period suggested no difference in species response to cadmium; however, with increasing exposure time, C. tentans was significantly more sensitive to lindane. The investigations showed that the pattern of response was similar for the two species, and that both C. riparius and C. tentans are suitable test organisms for acute exposure assays.

Imprecision of counting CFU-GM colonies and CD34-expressing cells

Determinations of committed haemopoietic progenitor cells, namely CFU-GM (colony-forming unit-granulocyte/macrophage) and of CD34-expression haemopoietic cells as assessed by multiparameter flow cytometry are routine diagnostic tools in haemopoietic cell therapy. Generally, the tests are used to optimise the timing and management of cytapheresis and to assess the engraftment potential of the harvested cells. Both measurements, however, are at best surrogate markers, as an adequate routine test which effectively assesses the short- and long-term repopulating haemopoietic cell is not available. Nonetheless, cell threshold doses have been established. Above these thresholds rapid engraftment is almost invariable but below these thresholds the outcome is variable. In this study we have focussed on the imprecision in counting haemopoietic cells, as assessed as CFU-GM and as CD34-expressing cells. The data on both tests have been analysed from six European institutions. The coefficient of variation in CFU-GM colony counting was about 30%, whereas the coefficient of variation in flow cytometric counting of CD34-expressing cells was about 10%. These data suggest that the technical imprecision in enumerating progenitor cells, particularly CFU-GM, at low levels, might make a major contribution to the clinical variability observed after transplantation of sub-threshold progenitor cell dose.

Toxicity of 17alpha-ethinylestradiol and bisphenol A to the freshwater Cnidarian Hydra vulgaris

Estrogens and estrogen mimics that enter the environment are known to present a serious threat to the development and reproduction of vertebrates by disrupting their normal endocrine function. There is also concern that such chemicals may be damaging to invertebrates. In this study, Hydra vulgaris, a member of the Cnidaria, an evolutionarily primitive group of invertebrates present before the divergence of the protostomes and deuterostomes, was exposed to the synthetic estrogen 17alpha-ethinylestradiol (EE2) and bisphenol A (BPA), both of which are known to be estrogenic in fish. Effects on polyp survival, structure, and regeneration (and sexual reproduction for EE2) were examined and mortality was recorded at high concentrations, with 96-h LC(50)s of 3.8 mg/L and 6.9 mg/L for EE2 and BPA, respectively. The structure and physiology of polyps was adversely affected at concentrations greater than 58 microg/L EE2 and 42 microg/L BPA. There was a concentration-related inhibition of regeneration above 150 microg/L EE2 and 460 microg/L BPA. Sexual reproduction was only impaired at 500 microg/L EE2. These results clearly suggest that the signaling processes necessary for the control and regulation of cell movement and differentiation during normal development, regeneration, and sexual reproduction in H. vulgaris are not disrupted by estrogenic pollutants at low environmentally relevant concentrations.

Transport of long-chain native fatty acids across human erythrocyte ghost membranes

Evidence from a number of laboratories suggests that membrane proteins may meditate the transport of physiologic fatty acids (FA) across cell membranes. However, actual transport of unbound free fatty acids (unbound FFA) from the aqueous phase on one side of a cell membrane to the aqueous phase on the other side has not been measured previously. In this study, we have used the fluorescent probe of unbound FFA, ADIFAB, to monitor the time course of FA movement from the outer to the inner aqueous compartments, and from the lipid membrane to the outer aqueous compartment of red cell ghosts. These two measurements, together with measurements of the lipid/aqueous partition coefficients, allowed the determination of the rate constants for binding (kon), flip-flop (kff), and dissociation (koff) for the transport of long-chain natural FA across red cell ghosts. Measurements done using palmitate, oleate, and linoleate at temperatures between 20 and 37 degreesC revealed that the overall transport times ranged from about 0.5 to more than 10 s, depending upon FA type and temperature. Analysis of these time courses yielded kff values between 0.3 and 3.0 s-1, and these values were consistent with those obtained using ghosts containing pyranine to detect intracellular acidification by the translocating FA. The measured koff values ranged from about 0.3 to 5 s-1, while the rate of binding, for the ghost concentrations used in this study (>50 microM phospholipid), exceed both kff and koff. Thus, long-chain FA transport across red cell ghost membranes is rate-limited by a combination of flip-flop and dissociation rates. Binding of FA to ghost membranes was well described by simple, nonsaturable, aqueous/membrane partition, and that partition appears to be governed by the aqueous solubility of the FA. Transport rates did not reveal any evidence of saturation and were not affected by a variety of protein-specific reagents. These FA binding and transport characteristics are similar to those observed previously for lipid vesicles, although the rate constants are generally about 2-3 fold larger for ghosts as compared to the lipid vesicles. We suggest, therefore, that FA transport across red cell ghosts is reasonably well described by transport across the lipid phase of the membrane.

Vitellogenin isolation, purification and antigenic cross-reactivity in three teleost species

Vitellogenin (Vtg) was isolated from male greenback flounder (Rhombosolea tapirina), rainbow trout (Oncorhynchus mykiss) and Atlantic salmon (Salmo salar) plasma, following induction by estradiol (E(2)) inoculation. The molecular weight of each native molecule, as determined by gel filtration, was 540, 383 and 557 kDa, respectively. With sodium dodecyl sulphate polyacrylamide gel electrophoresis under reducing conditions, Atlantic salmon and greenback flounder Vtg appeared as three major bands (approximately 159, 117, 86 kDa and 155, 104, 79 kDa, respectively), whereas rainbow trout Vtg appeared as one major band (approximately 154 kDa). Several minor bands were also present in each Vtg isolate. Polyclonal antisera, produced against only the highest molecular weight band from each species following excision from reducing gels, were reactive with all major bands in Western blots. In competition ELISA, parallel binding slopes were demonstrated between purified Vtg and plasma from vitellogenic females of the same species, but there was no reaction with plasma from untreated males. These antisera were highly species-specific and little cross-reactivity was noted, even between the two salmonid species. These data suggest that excision of bands from gels is a simple procedure for the preparation of species-specific antisera, and confirm that cross-species assays give highly variable results.

Feasibility of multidrug resistance (MDR-1) gene transfer in patients undergoing high-dose therapy and peripheral blood stem cell transplantation for lymphoma

We have performed a pilot study of MDR-1 gene transfer in patients receiving CD34-selected peripheral blood stem cell (PBSC) transplant for lymphoma. To ensure minimum engraftment thresholds and facilitate CD34 purification, mobilisation of > 2 x 10(6) CD34 cells/kg was a condition for recruitment. Of 11 patients counselled for study entry, only five achieved this target in a single apheresis. In three consenting patients, purified CD34 cells were exposed to A12M1 MDR-1 retroviral supernatant for 6 h, cryopreserved then thawed and readministered following ablative chemotherapy. No delay in engraftment was observed, although one patient received additional back-up cells. Gene transfer was demonstrated by polymerase chain reaction (PCR) for vector-derived MDR-1 cDNA sequence in all cases. Analysis of peripheral blood and bone marrow cells after transplant has, however, shown no evidence of in vivo gene transfer with a follow-up of 12, 15 and 18 months. The effect of MDR-1 substrate drugs has not yet been tested as all patients remain in clinical and radiological remission of their lymphoma. These results confirm the difficulty of achieving in vivo gene transfer in human haemopoietic cells and indicate major logistical constraints in PBSC mobilisation in patients with relapsed and resistant disease in whom initial studies are appropriate.

Chronic exposure to 17 alpha-ethinylestradiol and bisphenol A-effects on development and reproduction in the freshwater invertebrate Chironomus riparius (Diptera: Chironomidae)

The effect of 17 alpha-ethinylestradiol (EE) and bisphenol A (BPA) on development and reproduction in Chironomus riparius was determined over two generations in chronic sediment exposure assays. A number of response criteria were examined in order to identify any chemical-related effects including median emergence times (EmT50), the number and sex ratio of emerged adults, egg production and egg viability. The results showed that emergence time and percentage adult emergence were affected by EE and BPA exposure. These effects were primarily associated with the second generation of test animals, most notably in the BPA study, where the emergence of male and female adults was significantly (P<0.05) delayed at concentrations ranging from 78 ng/l to 0.75 mg/l. At very low concentrations (1 ng/l) of EE, both the first and second generation of adults emerged significantly earlier than control animals. No effect on the percentage emergence of first generation adults was evident with either chemical or in the second generation with BPA. The number of egg-ropes produced by the first generation females varied between treatments but no dose-response pattern was evident. Although certain responses were significantly affected, results in general do not suggest that the criteria examined, although validated as indicators of general sediment toxicity, could be used to detect the oestrogenic effects of EE and BPA on C. riparius.

Complement-fixing antibodies to sympathetic and parasympathetic tissues in IDDM. Autonomic brake index and heart-rate variation

We describe herein complement-fixing anti-adrenal medullary (CF-ADM) and anti-sympathetic ganglia (CF-SG) antibodies in insulin-dependent diabetes mellitus (IDDM). This study describes complement-fixing anti-vagus (CF-V) nerve antibodies and their relationship to the cardiovascular autonomic brake index (a measure of transient decrease in heart rate during the 1st min after a tilt), and R-R interval variation with deep breathing. CF-V was detectable in 7 of 83 (8.4%) subjects with IDDM aged 1.5-65.5 yr (mean +/- SE 28.7 +/- 1.8 yr) and duration of diabetes 0-47 yr (11.8 +/- 1.4 yr). Seventy-six nondiabetic subjects (aged 10-65 yr) all had negative CF-V scores. CF-V scores correlated with CF-ADM (0-16 yr of IDDM, r = 0.61, P less than 0.0001) and CF-SG (r = 0.39, P less than 0.05). Seventy IDDM subjects (aged 28 +/- 5 yr, duration of diabetes 17 +/- 3 yr) without proteinuria or proliferative retinopathy were screened for CF-ADM, CF-SG, and CF-V antibodies. Five of 70 (7.1%) had CF-SG only (negative for CF-ADM and CF-V). Brake indices ranged from 14.7 to 51.3 (37.3 +/- 6.9). Three of 70 (4.2%) had CF-ADM only, with brake indices from 26.9 to 45.1 (32.9 +/- 6.1). Four of 70 (5.7%) had CF-V antibodies only, with brake indices of 12.7-17.3 (15.1 +/- 1.1). Subjects with CF-SG or CF-ADM (anti-sympathetic) had higher brake indices than subjects with CF-V (anti-parasympathetic) antibodies (P less than 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Interpersonal learning in groups: an investigation

The dissatisfaction of patients with communication in health care has largely been addressed by providing more communication skills training. Research into why skills training might be ineffective has identified various factors, which include organizational resistance, personal defences against anxiety and a need for personal reflection and support. In one college of nurse education small group discussion and reflection had become established practice for students in their first and second clinical experience. The groups met once weekly and were facilitated by a nurse teacher. Discussion was unstructured and focused on the nurse's interpersonal relationship with his or her patients. This project examined one such group and sought to examine the use of small group reflective discussion by nurses about their patients as a means of improving interpersonal communication. The research was conducted over a period of 6 months with nine student nurses meeting once weekly during their first two episodes of clinical experience. Kelly's personal construct theory was used and two repertory grids were constructed by the group. One grid examined processes and change in intrapersonal construing, and the other grid examined processes and change in construing about certain patients. These grids were completed by the students at the beginning and at the termination of the groups. Notes were taken after each group meeting, which recorded impressions and processes; these were discussed once weekly with supervision. The notes were analysed using a grounded theory methodology. The results show some changes in patterns of constructing in relation to self which indicate an increase in anxiety and reluctance to self-reflect.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-sympathetic ganglia antibodies and postural blood pressure in IDDM subjects of varying duration and patients at high risk of developing IDDM

We examined the sera of 94 subjects with insulin-dependent diabetes mellitus (IDDM) for the presence of complement-fixing sympathetic ganglia (CF-SG) antibodies. In a cross-sectional analysis (duration 0-43 yr), 22% had detectable CF-SG antibodies. Subjects at high risk for IDDM were also studied. Four groups were studied: group 1 (aged 4-64 yr) islet cell antibody-positive (ICA+) prediabetic subjects, 10 of 19 (53%) were CF-SG+; group 2 (aged 6-14 yr) ICA- prediabetic subjects (first-degree relatives of IDDM subjects with either transient hyperglycemia, impaired oral glucose tolerance, and/or first-phase insulin release after intravenous glucose tolerance testing), 4 of 9 (44%) were CF-SG+ (2 of the 4 ICA- CF-SG+ subjects have progressed to IDDM); group 3 (aged 1.5-43 yr) ICA+ IDDM subjects (less than or equal to 1 yr duration) 6 of 10 (60%) were CF-SG+; and group 4 (aged 8-59 yr) ICA- IDDM subjects (less than or equal to 1 yr duration), 2 of 11 (18%) were CF-SG+. All groups had increased CF-SG compared with controls. Postural blood pressure and simultaneous CF-SG antibody measurements were performed in 28 IDDM subjects. The drop in systolic blood pressure was greater in the CF-SG+ subjects (P less than .05), and the frequency of CF-SG was greater in the mean to -2SD group (P less than .03) when data were analyzed within mean +/- 2SD of the normal blood pressure response.

Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management

Vascular interventional radiology procedures are relatively safe compared with analogous surgical procedures, with overall major complication rates of less than 1%. However, major vascular injuries resulting from these procedures may lead to significant morbidity and mortality. This review will discuss the etiology, clinical presentation, diagnosis, and management of vascular complications related to percutaneous vascular interventions. Early recognition of these complications and familiarity with treatment options are essential skills for the interventional radiologist.

Abnormal haemoglobin levels in acute coronary syndromes

BACKGROUND

Anaemia is an adverse prognostic marker in acute coronary syndromes (ACS), but the epidemiology of abnormal haemoglobin levels in such patients is uncertain.

AIMS

To investigate the prevalence, nature and predictors of abnormal haemoglobin levels in ACS patients at admission.

DESIGN

Observational study.

METHODS

All emergency admissions from January to April 2005 were assessed within 24-48 h of hospital admission. ACS patients (unstable angina, non-ST-elevation or ST-elevation myocardial infarction) were enrolled (n = 320, 190 men). Clinical information was recorded.

RESULTS

Overall, 71% had unstable angina; 18% non-ST-elevation myocardial infarction (MI), and 11% ST-elevation MI. Mean +/- SD haemoglobin was 14.3 +/- 1.7 g/dl in men and 13.2 +/- 1.5 g/dl in women. Abnormal haemoglobin was more common in men (65, 34%) than in women (34, 22%) (p = 0.013). Anaemia (haemoglobin <13 g/dl in men, or <12.0 g/dl in women) was recorded in 35 (18%) men and 24 (18%) women. All had admission haemoglobin >8 g/dl, and anaemia was usually normocytic. Multivariate predictors of anaemia (OR, 95%CI) were age (1.07, 1.04-1.1) and serum albumin (0.90, 0.81-1.00). Elevated haemoglobin (>16 g/dl) was recorded in 30 (16%) men and 4 (3%) women (p < 0.01), and was more common in ST-elevation MI patients (26%) than in unstable angina or non-ST elevation MI patients (9%) (p = 0.005). In patients who underwent invasive management with a post-procedure haemoglobin the following day (n = 85), 15 (18%) new cases of anaemia were detected. Admission duration correlated with haemoglobin (p < 0.01), creatinine (p < 0.01), troponin I (p < 0.01) and C-reactive protein (p < 0.01). Anaemia was more common in those who died in hospital (3, 60%) than in those who survived (56, 18%) (adjusted p = 0.0135).

DISCUSSION

Abnormal haemoglobin levels were common in our ACS admissions. Anaemia was generally mild. Increasing age and interventional management were associated with anaemia, which in turn was associated with adverse in-hospital outcomes. Interventions to prevent and detect anaemia in this setting merit prospective testing.