Triaging for Supportive Care Services: Do People Want and Accept Referral?

Background: Distress is the 6th vital sign in cancer yet it is only assessed in an ad hoc way in most cancer services. The Distress Thermometer (DT) and the associated Problem Checklist (PC) are the most widely available tools although few studies report on how they are used to effectively triage services. Aim: To explore the link between distress assessment, problem identification, referral to specific supportive care services by staff, and service uptake by cancer patients and survivors among a sample of people attending a major cancer hospital in Victoria Australia. Methods: A secondary analysis of quality assurance audit data were undertaken using data collected from patient medical records between January 2013 and June 2014. Data extracted were; age, sex, post code, language spoken, disease and treatment information, distress as measured by the DT and problems as identified by the PC. For the current study the focus was on the number of referrals offered and the number accepted or declined. The type of services referred to was also examined. Results: Data were collected for 877 patients although missing data resulted in a final sample size of 853. Only data associated with the first DT of each patient are presented. 729 patients (86%) participated in distress screening. The distress threshold of 4 was reported by 50% of participants, highlighting the prevalence of distress requiring support. This 50% reported an average of 9 problems on the PC, many of which came from the physical domain, with 91% reporting at least 1 physical problem. Other problems reported were emotional (74% of the sample); practical (24%), family (14%) and spiritual (2%). Referral data, which was available for 614 people, indicated that over 60% (372) were offered at least one referral. Referral offer was significantly predicted by DT score, and number of problems reported. Acceptance was significantly related to total number of problems, treatment type, and type of referral; referral for physical treatment was most likely to be accepted (87%) whereas referral for emotional support was least likely (53%). Conclusion: Routine distress screening and problem identification are critical to triaging to supportive care services. In a tertiary care setting, not all people will be screened or will want to be screened; not all people will be referred to services; and not all people will accept referral. Nonetheless, problems are extensive with most survivors reporting experiencing several problems. Despite a focus on the physical, these problems extend to other domains, including the emotional, and it is important that services are available to support these needs.

Current Challenges and Opportunities for Better Integration of Human Factors Research with Development of Clinical Information Systems

Objectives Clinical information system (CIS) developers and implementers have begun to look to other scientific disciplines for new methods, tools, and techniques to help them better understand clinicians and their organizational structures, clinical work environments, capabilities of clinical information and communications technology, and the way these structures and processes interact. The goal of this article is to help CIS researchers, developers, implementers, and evaluators better understand the methods, tools, techniques, and literature of the field of human factors.

Methods We developed a framework that explains how six key human factors topics relate to the design, implementation, and evaluation of CISs.

Results Using this framework we discuss the following six topics: 1) informatics and patient safety; 2) user interface design and evaluation; 3) workflow and task analysis; 4) clinical decision making and decision support; 5) distributed cognition; and 6) mental workload and situation awareness.

Conclusions Integrating the methods, tools, and lessons learned from each of these six areas of human factors research early in CIS design and incorporating them iteratively during development can improve user performance, user satisfaction, and integration into clinical workflow. Ultimately, this approach will improve clinical information systems and healthcare delivery.

Potential value of phosphate compounds in enhancing immobilization and reducing bioavailability of mixed heavy metal contaminants in shooting range soil

Shooting range soils contain mixed heavy metal contaminants including lead (Pb), cadmium (Cd), and zinc (Zn). Phosphate (P) compounds have been used to immobilize these metals, particularly Pb, thereby reducing their bioavailability. However, research on immobilization of Pb's co-contaminants showed the relative importance of soluble and insoluble P compounds, which is critical in evaluating the overall success of in situ stabilization practice in the sustainable remediation of mixed heavy metal contaminated soils. Soluble synthetic P fertilizer (diammonium phosphate; DAP) and reactive (Sechura; SPR) and unreactive (Christmas Island; CPR) natural phosphate rocks (PR) were tested for Cd, Pb and Zn immobilization and later their mobility and bioavailability in a shooting range soil. The addition of P compounds resulted in the immobilization of Cd, Pb and Zn by 1.56-76.2%, 3.21-83.56%, and 2.31-74.6%, respectively. The reactive SPR significantly reduced Cd, Pb and Zn leaching while soluble DAP increased their leachate concentrations. The SPR reduced the bioaccumulation of Cd, Pb and Zn in earthworms by 7.13-23.4% and 14.3-54.6% in comparison with earthworms in the DAP and control treatment, respectively. Bioaccessible Cd, Pb and Zn concentrations as determined using a simplified bioaccessibility extraction test showed higher long-term stability of P-immobilized Pb and Zn than Cd. The differential effect of P-induced immobilization between P compounds and metals is due to the variation in the solubility characteristics of P compounds and nature of metal phosphate compounds formed. Therefore, Pb and Zn immobilization by P compounds is an effective long-term remediation strategy for mixed heavy metal contaminated soils.

Adapting Situational Awareness Measures for Hydropower Display Evaluations

This study used Situation Awareness (SA) as a measure to evaluate two new functional displays supplementing existing monitor displays in a large hydropower system control room. Because it was impractical to use traditional SA measures this paper proposes a novel SA measurement framework, in which controllers' SA levels are derived from their in-the-loop utterance and viewing patterns, their context-specific reports of the situations, and their overall SA reflections. Results indicate that the SA measures not only support and complement one another, but also are consistent with performance results. This study offers a novel approach of using convergent lines of evidence to assess SA in the situations that involve a whole control room or command centre or in situations constrained by time and resources.

The effect of two cognitive aid designs on team functioning during intra-operative anaphylaxis emergencies: a multi-centre simulation study

This multi‐centre repeated measures study was undertaken to determine how contrasting designs of cognitive aids affect team performance during simulated intra‐operative anaphylaxis crises. A total of 24 teams consisting of a consultant anaesthetist, an anaesthetic trainee and anaesthetic assistant managed three simulated intra‐operative anaphylaxis emergencies. Each team was assigned at random to a counterbalanced order of: no cognitive aid; a linear cognitive aid; and a branched cognitive aid, and scored for team functioning. Scores were significantly higher with a linear compared with either a branched version of the cognitive aid or no cognitive aid for ‘Team Overall Behavioural Performance’, difference between study groups (F‐value) 5.8, p = 0.01. Aggregate scores were higher with the linear compared with the branched aid design (p = 0.03). Cognitive aids improve co‐ordination of the team's activities and support team members to verbalise their actions. A linear design of cognitive aid improves team functioning more than a branched design.

Post-menopausal presentation of yolk sac germ cell tumour

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Yolk sac germ cell tumours are rare in post-menopausal patients.

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Most involve mixed yolk sac tumours

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Consider diagnosis in patients with a pelvic–abdominal mass and raised AFP

Do we understand the pathophysiology of endometrial cancer?

Endometrial carcinoma is the fourth most common cancer in U.K. women. Previous literature describes local, haematological or lymphatic dissemination to common sites including vaginal vault, lungs, liver, bones and brain. The authors present two unusual cases of endometrial cancer metastases to the psoas major muscle and laparoscopic port sites. Case 1 involves a 71-year-old female who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and peritoneal washings (TAH, BSO, PW) for Grade 1 endometrial cancer, Stage lB. Three years later she represented with lower back and right hip pain, with MRI imaging revealing psoas muscle metastases. Case 2 describes a 60-year-old female who underwent laparoscopic-assisted vaginal hysterectomy (LAVH), BSO+ PW for Grade 1 endometrial cancer, Stage 1B. Three years postoperatively she presented with a lateral abdominal mass overlying the laparoscopic port site scar, which was Grade 1 endometrial cancer on biopsy. These rare metastatic locations question our traditional understanding of the pathophysiology of endometrial carcinoma.

Imiquimod therapy for extramammary Paget's disease of the vulva: a viable non-surgical alternative

Extramammary Paget's disease (EMPD) is a rare intraepidermal adenocarcinoma that can affect the vulval skin. Surgical excision is the gold-standard treatment, however, recurrence rates are high and extensive excisions can produce long-lasting cosmetic and functional defects. We describe one of the largest case series to-date (n = 6) on the use of topical 5% imiquimod cream as a novel treatment option and discuss our experiences. With the addition of our six cases to the literature, there are now 29 documented cases of vulval EMPD treated with 5% imiquimod cream. Of these, 50% of primary disease cases and 73% of recurrent primary disease cases have achieved clinical resolution with 5% imiquimod therapy alone. These findings suggest that imiquimod provides a viable alternative to surgical excision for vulval EMPD. However, we acknowledge that this is a simple retrospective analysis and that treatment scheduling and follow-up needs investigation in a trial setting.

Extracellular release of free fatty acids by rat T lymphocytes is stimulus-dependent and is affected by dietary lipid manipulation

[(3)H]-Arachidonic acid-labelled rat T lymphocytes released radioactivity extracellularly when stimulated by the calcium ionophore A23187 or by monoclonal antibodies to some cell surface structures (CD2, CD5, CD11a, CD18, CD54, T-cell receptor) but not to others (CD49d, CD62L); release was greater with the calcium ionophore. Almost all of the radioactivity released from anti-CD2-stimulated lymphocytes was recovered in the free fatty acid fraction, whereas only about 50 per cent of that released after A23187 stimulation was recovered in this fraction. A23187 stimulation resulted in release of arachidonic acid from a variety of phospholipids (phosphatidylinositol, phosphatidylcholine and perhaps phosphatidylethanolamine), while the monoclonal antibody stimulation released arachidonic acid from phosphatidylinositol and perhaps phosphatidylcholine. Unstimulated lymphocytes released a range of fatty acids extracellularly, with palmitic acid accounting for 35-40 per cent and arachidonic acid for 5 per cent of released fatty acid. Stimulation of lymphocytes with either anti-CD2 or A23187 increased total fatty acid release 1.5- to 1.8-fold. In both cases palmitic acid remained the most predominant fatty acid released but the contribution of arachidonic acid increased. The type of lipid fed to the rats significantly influenced the amount and type of fatty acid released. Fish oil feeding significantly reduced extracellular fatty acid release by stimulated lymphocytes.

Closed circuit anaesthesia in ventilated patients using the Komesaroff vaporizer within the circle

A study was undertaken to assess the performance of the Komesaroff vaporizer, placed within the circuit, in ventilated patients during maintenance of closed circuit anaesthesia with halothane or isoflurane. Following intravenous induction, anaesthesia was maintained by inhalation. This was achieved using a conventional vaporizer outside the circle for the first 10 minutes to manage the fast uptake phase. The fresh gas flow was then reduced to the basal oxygen requirement with the Komesaroff vaporizer within the circle maintaining inhalational anaesthesia. Complete isolation of the circuit was achieved by returning all anaesthetic gases to the circuit following analysis and using a bag-in-bottle ventilator. The Komesaroff vaporizer dial was positioned at between the first and second division and end-tidal volatile anaesthetic agent levels were measured. This study demonstrated that at dial positions 1 or 1.5 with either agent, the end-tidal volatile concentration plateaued at clinically acceptable levels. The Komesaroff vaporizer can therefore be used safely in ventilated patients to maintain closed circuit anaesthesia provided clinical observation and monitoring are meticulous.

N-acetylcysteine prevents development of the hyperdynamic circulation in the portal hypertensive rat

Partial portal vein ligation (PPVL) leads to the development of a hyperdynamic circulation. It is associated with elevated levels of tumor necrosis factor (TNF-alpha) and nitric oxide (NO) production, both of which can result in oxidant injury. In this study, we have investigated whether PPVL is associated with the development of oxidative stress, by measuring urinary F2-isoprostanes. In addition, we have examined whether N-acetylcysteine (NAC) can ameliorate oxidant injury and prevent the development of the hyperdynamic circulation. Urinary excretion of F2-isoprostanes increased sixfold following PPVL together with a significant increase in plasma nitrite and nitrate. Treatment with NAC inhibited the formation of F2-isoprostanes as well as the increase in plasma nitrite and nitrate. Hemodynamic studies in anesthetized rats showed that following PPVL, cardiac output and portal pressure increased, and systemic vascular resistance decreased, consistent with the development of a hyperdynamic circulation. These changes were prevented by chronic administration of NAC. We conclude that NAC prevents the development of the hyperdynamic circulation and that the formation of reactive oxygen species may be important in the pathogenesis of these hemodynamic changes.

Low levels of eicosapentaenoic and docosahexaenoic acids mimic the effects of fish oil upon rat lymphocytes

Fish oil is rich in the long chain n-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); typically these fatty acids constitute 20 to 25 g/100 g total fatty acids in fish oil. Feeding rodents diets rich in fish oil has been shown to decrease lymphocyte proliferation and natural killer cell activity. It is not known what level of EPA + DHA is required in the diet to exert these effects. This question was addressed in the current study. Weanling rats were fed on high fat (178 g/kg) diets which contained 4.4 g alpha-linolenic acid (control) or 4.4 g EPA + DHA (4.4 EPA + DHA) or 6.6 g EPA + DHA (6.6 EPA + DHA)/100 g total fatty acids. The n-6 to n-3 polyunsaturated fatty acid ratio was maintained at approximately 7. The fatty acid compositions of the serum and of spleen leukocytes were markedly influenced by that of the diet. Spleen lymphocyte proliferation in response to concanavalin A, spleen natural killer cell activity and PGE2 production by spleen leukocytes were reduced by feeding the EPA + DHA diets compared with feeding the control diet; the 4.4 and 6.6 EPA + DHA diets caused very similar reductions. The 4.4 EPA + DHA diet reduced popliteal lymph node weight following a localised graft versus host response; this response was not investigated in rats fed the 6.6 EPA + DHA diet. The reductions in lymphocyte functions and in the in vivo graft versus host response caused by the EPA + DHA diets were similar to those previously reported following the feeding of diets rich in fish oil. Thus, this study shows that diets containing relatively low levels of EPA + DHA (20 to 25% of the level found in fish oil) exert immunomodulatory effects. Furthermore, this study suggests that the maximal effect of EPA + DHA is exerted when these fatty acids constitute a level of less than or equal to 4.4 g/100 g total dietary fatty acids.

Dietary fish oil appears to prevent the activation of phospholipase C-gamma in lymphocytes

Rats were fed on a low fat diet or on high fat diets which included coconut oil, olive oil, safflower oil, evening primrose oil or fish oil as the principal fat source. The level of phosphatidylinositol-4, 5-bisphosphate in spleen lymphocytes was unaffected by diet. However, the fish oil diet significantly decreased the concentration of inositol-1,4,5-trisphosphate in stimulated lymphocytes; this concentration was also reduced following olive oil feeding. Diet did not significantly affect the level of phospholipase C-gamma1 in spleen lymphocytes but the tyrosine phosphorylation state of this enzyme in stimulated lymphocytes, as well as that of a range of other proteins, was decreased following feeding the fish oil and, to a lesser extent, the olive oil diets. It is concluded that fish oil feeding appears to result in inhibition of one or more tyrosine kinases.

Dietary fish oil diminishes lymphocyte adhesion to macrophage and endothelial cell monolayers

To further investigate the immunomodulatory effects of dietary lipids, rats were fed on a low-fat diet or on high-fat diets that contained hydrogenated coconut, olive, safflower, evening primrose or fish oil as the principal fat source. The fish oil diet decreased the level of expression of CD2, CD11a, CD18 and CD44 on the surface of freshly prepared lymphocytes and of CD2, CD11a, CD18, CD54 (intercellular adhesion molecule-1; ICAM-1) and CD62L (L-selectin) on the surface of concanavalin A (Con A)-stimulated lymphocytes. The olive oil diet also resulted in decreased expression of some adhesion molecules. The fish or olive oil diets, and to a lesser extent the safflower or evening primrose oil diets, decreased the adhesion of both freshly prepared and Con A-stimulated lymphocytes to macrophage monolayers. The fish oil diet, and to a lesser extent the olive or evening primrose oil diets, reduced the ability of Con A-stimulated lymphocytes to adhere to untreated endothelial cells. Furthermore, the fish oil diet resulted in a 50% reduction in Con A-stimulated lymphocyte adhesion to tumour necrosis factor-alpha (TNF-alpha)-stimulated endothelial cells. This study demonstrates that dietary lipids affect the expression of functionally important adhesion molecules on the surface of lymphocytes. Furthermore, this study suggests that such diet-induced effects on adhesion molecule expression might alter the ability of lymphocytes to bind to macrophages and to endothelial cells. Of the diets studied fish oil causes the most significant effects. The results of this study suggest that a reduction in cellular infiltration may partly explain the protective effect of a fish-oil-rich diet against the development of inflammatory and cardiovascular diseases.

Inhibition of vasopressinergic neurons by central injection of a specific aminopeptidase A inhibitor

The brain angiotensin (Ang) system plays an important role in the central control of vasopressin release. Using EC33, a selective aminopeptidase A inhibitor which blocks the metabolism of Ang II in Ang III, we previously reported that vasopressin release was under the control of Ang III and not Ang II. To determine accurately the action of EC33, the effects of intracerebroventricular injection of Ang peptides or EC33 on extracellular unit activity of vasopressinergic neurons in the supraoptic nucleus of urethane-anaesthetized rats were examined. Angiotensin II (15-30 ng) or Ang III (15 ng) increased the firing rate of all neurons tested. Conversely, EC33 (10 microg) reduced or completely abolished (30-60 microg) the basal firing rate for 4-6 min in all eight neurons tested. EC33 (30 microg) also inhibited the activity induced by 30 ng Ang II. It was concluded that the observed activity of Ang II required its conversion to Ang III and that endogenous Ang III may exert a tonic control on the basal firing level of vasopressinergic neurons.

Eicosapentaenoic and docosahexaenoic acids alter rat spleen leukocyte fatty acid composition and prostaglandin E2 production but have different effects on lymphocyte functions and cell-mediated immunity

Weanling rats were fed on high-fat (178 g/kg) diets which contained 4.4 g alpha-linolenic (ALA), gamma-linolenic, arachidonic (ARA), eicosapentaenoic (EPA), or docosahexaenoic acid (DHA)/100 g total fatty acids. The proportions of all other fatty acids, apart from linoleic acid, and the proportion of total polyunsaturated fatty acids (PUFA) (approximately 35 g/100 g total fatty acids) were constant, and the n-6 to n-3 PUFA ratio was maintained as close to 7 as possible. The fatty acid compositions of the serum and of spleen leukocytes were markedly influenced by that of the diet. Prostaglandin E2 production was enhanced from leukocytes from rats fed the ARA-rich diet and was decreased from leukocytes from the EPA- or DHA-fed rats. Replacing dietary ALA with EPA resulted in diminished ex vivo lymphocyte proliferation and natural killer (NK) cell activity and a reduced cell-mediated immune response in vivo. In contrast, replacing ALA with DHA reduced ex vivo lymphocyte proliferation but did not affect ex vivo NK cell activity or the cell-mediated immune response in vivo. Replacement of a proportion of linoleic acid with either gamma-linolenic acid or ARA did not affect lymphocyte proliferation, NK cell activity, or the cell-mediated immune response. Thus, this study shows that different n-3 PUFA exert different immunomodulatory actions, that EPA exerts more widespread and/or stronger immunomodulatory effects than DHA, that a low level of EPA is sufficient to influence the immune response, and that the immunomodulatory effects of fish oil may be mainly due to EPA.

Electromyographic biofeedback for gait training after stroke

OBJECTIVE

To examine the effects of electromyographic (EMG) biofeedback training on the recovery of gait in the acute phase post stroke.

DESIGN

Patients were randomly assigned to EMG biofeedback or control groups. They received treatment three times a week for six weeks. All patients were assessed prior to treatment, after 18 treatment sessions, and at three months follow-up.

SETTING

The study was carried out at Scunthorpe General Hospital in North Lincolnshire. The subjects were acute stroke patients who had been admitted on to the medical and elderly wards.

INTERVENTIONS

The EMG biofeedback group were treated using EMG as an adjunct to physiotherapy. The patients were encouraged to facilitate or inhibit abnormal muscle tone via auditory or visual signals transmitted from electrodes placed over the appropriate muscles. The control group were treated using the same techniques, electrodes were used with this group of patients, but the EMG machine was turned off and faced away from the patient and the therapist to control the placebo effect.

OUTCOME MEASURES

A large battery of outcome measures was used for physical and psychological assessment. The physical measures consisted of active movement, muscle tone, sensation, proprioception, mobility and activities of daily living (ADL). The psychological measures included orientation, memory, spatial performance, language and IQ.

RESULTS

Twenty-one patients were included in the study. Scores were combined into four groups: mild EMG, severe EMG, mild control and severe control. Results showed that there was an improvement in physical scores for active movement, mobility and ADL over time, but there was no significant difference between the EMG and control groups. Scores on the psychological tests were within normal limits, and there was no difference in performance between the EMG and control groups.

CONCLUSIONS

This study showed no significant differences in the rate of improvement after stroke between the two groups. Although EMG biofeedback was used as an adjunct to physiotherapy and represented clinical practice, the results provide little evidence to support the clinical significance of using EMG biofeedback to improve gait in the acute phase after stroke.

Dietary fish oil diminishes the antigen presentation activity of rat dendritic cells

Rats were fed for 6 weeks on a low fat (LF) diet or on high fat diets containing safflower oil [SO; rich in n-6 polyunsaturated fatty acids (PUFAs)] or fish oil (FO; rich in n-3 PUFAs). Lymph-borne dendritic cells (L-DC) were isolated after cannulation of the thoracic duct and were used as antigen [keyhole limpet hemocyanin (KLH)]-presenting cells in an ex vivo assay that used KLH-sensitized spleen lymphocytes as the responder cells. FO feeding significantly diminished the antigen presentation activity of L-DC compared with L-DC from rats fed each of the other diets. The antigen presentation activity of L-DC from rats fed the SO diet was greater than that of L-DC from rats fed the LF diet. Feeding the FO diet significantly reduced both the proportion of CD2-positive L-DC and the level of CD2 expression on L-DC compared with feeding each of the other diets; the proportions of L-DC staining positive for CD40, CD18, CD54, CD11a, and MHC II were unaffected by diet. However, FO feeding reduced the level of expression of CD18, CD11a, MHC II, and CD54 on L-DC compared with feeding the other two diets; the level of expression of CD40 was unaffected by diet. This is the first study to report effects of dietary fatty acids on dendritic cells. The suppressive effect of FO feeding may account for some of the beneficial effects of n-3 polyunsaturated fatty acids observed in clinical settings, such as prolonged survival of grafts and diminished chronic inflammatory responses. However, such an effect may also be detrimental because host defense toward bacterial and other antigens could be compromised.

Effects of varying the type of saturated fatty acid in the rat diet upon serum lipid levels and spleen lymphocyte functions

To obtain further information about the effects of specific dietary saturated fatty acids, weanling male rats were fed for 6 weeks on low fat (7.7% by weight) or high fat (17.8% by weight) diets which differed according to the principal fatty acids present. The diets were rich in caprylic and capric acids (medium chain triacylglycerols; MCT), lauric acid, palmitic acid at the sn-1(3) position, palmitic acid at the sn-2 position or stearic acid. The total proportions of saturated (42-46%), monounsaturated (36%), n-6 polyunsaturated (15%) and n-3 polyunsaturated (2.2%) fatty acids were the same in all diets. Serum cholesterol concentrations were not different among rats fed the different diets, except that the concentration in the serum of rats fed the high fat diet with palmitic acid in the sn-2 position was high. This was reflected in higher HDL and LDL cholesterol concentrations in the serum of animals fed this diet. Triacylglycerol (TAG) concentrations tended to be higher in the serum of rats fed the low fat diets compared with those fed the high fat diets. They were lowest in the serum of MCT-fed rats irrespective of the level of fat in the diet and were highest in the serum of rats fed the low fat diet rich in stearic acid. These differences were due to lower chylomicron and VLDL TAG concentrations in the serum of MCT-fed rats and higher chylomicron and VLDL TAG concentrations in the serum of low fat, stearic acid-fed animals. The fatty acid compositions of the serum and of spleen lymphocytes were influenced by that of the diet fed. The ex vivo proliferation of lymphocytes from the spleens of rats fed the high fat diet rich in palmitic acid at the sn-2 position was greater than that of lymphocytes from animals fed the other diets. Natural killer (NK) cell activity tended to be lower for spleen lymphocytes from rats fed high fat diets than for those fed low fat diets irrespective of the principal saturated fatty acid present. NK cell activity was highest for spleen lymphocytes from animals fed the diets rich in palmitic acid and was lowest for those from animals fed the high fat diet rich in stearic acid. Spleen lymphocytes from the latter animals had the lowest proportion of CD16+ cells, a marker for NK cells. Thus, this study shows that the type of saturated fatty acid present in the diet not only has subtle effects upon blood lipid and lipoprotein levels but can significantly affect lymphocyte functions. Spleen lymphocyte NK cell activity is decreased as the fat content of the diet increases. NK cell number and activity are reduced by a high fat diet rich in stearic acid. Spleen lymphocyte proliferation is enhanced by palmitic acid-rich diets, particularly if palmitic acid is in the sn-2 position of dietary TAG.

The ratio of n-6 to n-3 polyunsaturated fatty acids in the rat diet alters serum lipid levels and lymphocyte functions

Previous studies have reported that feeding rats diets rich in fish oils, which contain high proportions of the n-3 polyunsaturated fatty acids (PUFA) eicosapentaenoic and docosahexaenoic acids, results in lowering of blood lipid levels and suppression of lymphocyte functions tested ex vivo and in vivo. The effects of other n-3 PUFA, such as alpha-linolenic acid, which is found in high proportions in linseed oil, are not as well documented. Therefore, in the present study, weanling male rats were fed for six weeks on one of five high-fat (20% by weight) diets made by mixing together sunflower and linseed oils; the resulting blends had n-6/n-3 PUFA ratios of 112.5:1 (pure sunflower oil), 14.8:1, 6.5:1, 0.81:1, and 0.33:1 (pure linseed oil); the levels of all other components in the diet were identical. The final body weight and total dissectable fat were lowest in rats fed the pure linseed oil diet. Serum cholesterol, triacylglycerol and nonesterified fatty acid concentrations decreased as the n-6/n-3 PUFA ratio of the diet decreased. The fatty acid composition of the serum and of spleen lymphocytes was influenced by the diet fed-there was a progressive decrease in the proportions of linoleic and arachidonic acids and a progressive increase in the proportion of alpha-linolenic acid as the n-6/n-3 PUFA ratio of the diet decreased. Eicosapentaenoic and docosahexaenoic acids were detected in the serum but not in spleen lymphocytes. Inclusion of alpha-linolenic acid in the diet resulted in significant suppression of spleen lymphocyte proliferation in response to the T-cell mitogen concanavalin A and in spleen lymphocyte natural killer cell activity, both measured ex vivo. The localized graft vs. host response, a measure of cell-mediated immunity in vivo, progressively decreased as the n-6/n-3 PUFA ratio of the diet decreased. Thus, this study shows that dietary alpha-linolenic acid results in lowered blood lipid levels and suppressed lymphocyte functions ex vivo and in vivo. With respect to these effects, alpha-linolenic acid is as potent as dietary fish oil.

THE SIGNIFICANCE OF AN ABSENT ANKLE REFLEX

We assessed the prevalence of abnormal ankle reflexes in 1074 adult patients attending orthopaedic clinics and related it to age. Those with possible pathological causes of reflex loss were excluded.

The absence of one or both reflexes was significantly related to increasing age; all patients under 30 years had both reflexes. Few had absent reflexes between 30 and 40 years, but over 40 years, the proportion with both reflexes absent increased rapidly from 5% (40 to 50 years) to 80% (90 to 100 years). Unilateral absence did not show the same pattern of increase being 3% to 5% at 40 to 60 years and 7% to 10% at over 60 years.

Our results suggest that a significant number of ‘normal’ adults have unilateral absence of an ankle reflex, but this finding is rare enough to be a definite clinical sign, irrespective of age.

The significance of an absent ankle reflex

We assessed the prevalence of abnormal ankle reflexes in 1074 adult patients attending orthopaedic clinics and related it to age. Those with possible pathological causes of reflex loss were excluded. The absence of one or both reflexes was significantly related to increasing age; all patients under 30 years had both reflexes. Few had absent reflexes between 30 and 40 years, but over 40 years, the proportion with both reflexes absent increased rapidly from 5% (40 to 50 years) to 80% (90 to 100 years). Unilateral absence did not show the same pattern of increase being 3% to 5% at 40 to 60 years and 7% to 10% at over 60 years. Our results suggest that a significant number of 'normal' adults have unilateral absence of an ankle reflex, but this finding is rare enough to be a definite clinical sign, irrespective of age.

Effect of dietary restriction on protein synthesis and wound healing after surgery in the rat

1. The healing of an abdominal muscle wound after surgery is associated with a considerable increase in the rate of protein synthesis. We have investigated whether this increase in protein synthesis is affected by chronic undernutrition, and whether this causes a delay in wound healing. 2. A group of rats was fed 58% of the voluntary food intake of a matched control group. After 7 days half the rats in each group underwent abdominal surgery. Forty-eight hours later all the rats were killed and muscle protein synthesis rate was measured by the flooding dose technique. 3. In a second experiment using the same dietary regimen rats were placed in metabolic cages after surgery and killed 7 days later. In addition to measurements of muscle protein synthesis, wound breaking strength was measured with a tensiometer and collagen content was also measured at the wound site. 4. Dietary restriction caused a loss of body weight, a decrease in nitrogen balance and a deficit in muscle protein mass. It also caused a decrease in protein synthesis rate in gastrocnemius muscle and in parts of the abdominal muscle distant from the site of the wound. However, it had no effect on the rate of muscle protein synthesis at the site of the wound either 2 or 7 days after surgery. The tensile strength and the collagen content of the wound were also unaffected by food restriction. 5. It is concluded that the wound healing process is uniquely protected from the effects of moderate undernutrition such as might be experienced by a chronically ill patient.

Effects of dietary lipid manipulation upon graft vs host and host vs graft responses in the rat

The popliteal lymph node (PLN) assay was used to establish whether dietary lipids with differing fatty acid compositions could affect cell-mediated immunity in the rat. Weanling rats were fed for 4 weeks on a lowfat (2.5% by weight; LF) diet or on diets containing 20% (by weight) hydrogenated coconut oil (HCO), olive oil (OO), safflower oil (SO), evening primrose oil (EPO), or menhaden (fish) oil (MO). Feeding the MO diet suppressed the graft vs host response compared with feeding the LF, HCO, SO, or EPO diets, while feeding the OO diet suppressed this response compared with feeding the LF or EPO diets. Feeding the MO diet suppressed the host vs graft response compared with feeding each of the other diets. Following the graft vs host reaction, PLN lymphocytes from animals fed the MO diet had significantly lower levels of expression of LFA-1 and CD2 compared with PLN lymphocytes from animals fed the LF diet; furthermore, they had lower levels of expression of T-cell receptor (TcR), CD4, CD8, LFA-1, and CD2 compared with lymphocytes from animals fed some, and in the case of CD2 each, of the other high-fat diets. Feeding the MO diet resulted in a lower proportion of cells expressing the interleukin-2 receptor, indicating an inhibition of lymphocyte activation, and a lower proportion of CD16+/CD3- cells, indicating a decrease in the proportion of NK cells within the PLN. Following the host vs graft reaction, PLN lymphocytes from animals fed the MO diet had significantly lower levels of expression of TcR and CD8 compared with lymphocytes from animals fed each of the other diets; furthermore, they had lower levels of expression of CD4, CD2, and LFA-1 compared with lymphocytes from animals fed the LF, HCO, OO, or SO diets. These observations indicate that the smaller PLN size of animals fed the MO diet results from an inhibition of activation and subsequent proliferation of cells within the node and perhaps also a suppression of movement of cells from the bloodstream to the PLN, due to decreased level of expression of adhesion molecules. These lowered levels of expression might be due to an inhibitory effect of the n-3 polyunsaturated fatty acids found in MO upon components of the signal transduction pathways involved in lymphocyte activation or upon expression of the genes for the surface molecules or both.

Comparison of the effects of a range of dietary lipids upon serum and tissue lipid composition in the rat

Since the type of fat consumed in the diet may play a role in the development of several disorders, it is important to ascertain the effects of different dietary fats upon parameters such as serum lipid levels and adipose deposition. The aim of this study was to determine the effects of feeding rats a range of fats with differing fatty acid compositions. Weanling male rats were fed for 10 weeks on a low fat (LF) diet or on one of five high fat diets, which contained 20% by weight of either hydrogenated coconut oil (HCO), olive oil (OO), safflower oil (SO), evening primrose oil (EPO) or menhaden (fish) oil (MO). Food intake, animal growth, tissue weights at sacrifice, serum and liver lipid concentrations and serum, heart, brain and adipose tissue fatty acid compositions were studied. The food intake of the LF-fed animals was greater than that of animals fed on the high fat diets; there were no differences in food intake between animals fed the high fat diets. The total energy intake was lower for animals fed on the HCO diet than for those fed on the LF, OO, EPO or MO diets; there were no other differences in energy intake between the groups. Animals fed the different diets had almost identical rates of weight gain up to 5 weeks; after this period of rapid growth, the increase in weight was slower in all groups but especially in the LF-fed animals. The LF-fed rats had a lower total weight gain and smaller final weights than rats fed on the high fat diets. Animals fed on the MO diet had a greater weight gain than those fed on the OO or EPO diets and their final weights were greater. The MO diet resulted in greatly increased liver weight compared with each of the other diets. The HCO, OO and EPO diets also increased liver weight compared with the LF diet. The total lipid content of the livers from rats fed the high fat diets was greater than that of those from rats fed the LF diet; the livers from animals fed the MO diet contained more lipid than those from animals fed each of the other diets. MO feeding increased the free cholesterol, cholesterol ester and triacylglycerol contents of the liver.(ABSTRACT TRUNCATED AT 400 WORDS)

Interaction between baricity (glucose concentration) and other factors influencing intrathecal drug spread

The effects of intrathecal injection of 0.5% bupivacaine in solutions containing various concentrations of glucose have been studied in four groups of 20 patients. When solutions containing 0.8% glucose were injected at the L3-4 interspace the median maximum extent of block was higher, and the range of blocks wider, with the 8% solutions. All patients receiving 0.8% glucose had blocks between the T5 and T10 dermatomes, confirming previous work on the benefits of this concentration of glucose. In the two other groups 0.5% bupivacaine containing 0 or 0.8% glucose was injected at the L2-3 interspace. In both groups of patients a wider range of blocks, with a median maximum extent that was higher, was produced. These results demonstrate how glucose concentration may be used to influence the spread of intrathecal solutions and how other factors can obscure the effect of glucose concentration.

A comparison of the costs of ceftazidime therapy and gentamicin combinations in three UK hospitals

This study compares the utilization costs of ceftazidime therapy with those of gentamicin in combination with other antibacterial drugs. The results show that the relatively high purchase cost of ceftazidime compared to combinations is more than counterbalanced by the additional materials used for drug administration and serum antibiotic assays, even when other drugs were combined with ceftazidime. The average drug and equipment costs were 230.13 pounds for ceftazidime regimens and 253.94 pounds for gentamicin regimens. It is also shown that ceftazidime therapy is associated with a reduction in personnel time compared to gentamicin regimens. The average times per patient for administration and assay were 1 h 43 min for ceftazidime and 4 h 57 min for gentamicin regimens. We conclude that ceftazidime regimens are cheaper than gentamicin regimens when all drug and equipment costs are quantified. Moreover, the use of ceftazidime will release staff time for other purposes.

Modulation of secretion by dopamine involves decreases in calcium and nicotinic currents in bovine chromaffin cells

1. Catecholamine secretion from cultured bovine adrenal chromaffin cells was decreased in a dose-dependent manner by the D2 dopamine agonists apomorphine and LY 17 1555. 2. 45Ca2+ uptake was similarly inhibited and whole-cell Ca2+ currents were reduced by apomorphine. 3. These inhibitory effects of D2 agonists depended on the secretagogue used, being much more pronounced for nicotine-evoked responses compared to high K+ stimulation, indicating another possible site of action of apomorphine up-stream of Ca2+ entry. 4. Inhibition by apomorphine of nicotine-evoked responses could not be explained by competitive antagonism against nicotine or DMPP (1,1-dimethyl-4-phenyl-piperazinium iodide). 5. Apomorphine caused reductions of inward whole-cell nicotinic current evoked by ACh and nicotine. 6. Inhibition of nicotine-evoked secretion and 22Na+ influx by apomorphine were not affected by tetrodotoxin, and voltage-dependent, whole-cell Na+ currents were unaltered by apomorphine. 7. No evidence was obtained for increases in K+ conductance by apomorphine. 8. Action potentials recorded in whole-cell current clamp were blocked by apomorphine when they were triggered by nicotinic depolarization but not when they were elicited by direct electrical stimulation. 9. Inclusion of GDP-beta-S in the pipette internal solution did not affect apomorphine-dependent inhibition of nicotinic-evoked responses, while the decrease in whole-cell Ca2+ current induced by apomorphine was completely inhibited in the presence of GDP-beta-S. 10. Increases in cyclic AMP caused by cholera toxin and forskolin did not change the apomorphine-dependent inhibitory effects on nicotine-evoked secretion, indicating that changes in cyclic AMP levels caused by dopamine receptor stimulation are probably not involved.

The influence of striatum on the substantia nigra: a study using the spreading depression technique

Effects of changes in striatal neurone activity on substantia nigra (SN) unit activity were studied in rats. Striatal changes were produced by the spreading depression (STSD) induced by perfusing the head of striatum with 0.06 M KCl via a push-pull cannula. In the medial part (caudate) striatal neurones are silent, with the arrival of STSD they exhibit a brief excitation coinciding with the onset of a slow wave of depolarisation in the extracellular steady potential. In the lateral part (putamen) striatal neurones are active, they undergo an arrest of their spontaneous activity for about 1 minute following the brief excitation. Antidromic activation of SN reticulata (SNr) neurones was attempted from the superior colliculus (SC). The majority of the 54 SNr neurones (96%) exhibited changes in firing rate during STSD. Ten neurones underwent brief single or repetitive changes of the same duration as the brief striatal excitation. Eight presented an initial brief change of activity followed by a longer duration inverse change in firing rate. Eighteen exhibited multiple brief changes followed by or superimposed on a long lasting decrease of firing rate and 50% of them were nigrotectal neurones. Sixteen neurones presented long duration biphasic changes in firing rate. Two SNr neurones and the 12 substantia nigra compacta (SNc) neurones studied were unaffected. Some neurones received both inhibitory and facilitatory striatal controls. In total thirty-nine neurones were inhibited and 47 facilitated, the origin of these effects from caudate and putamen are discussed. The excitatory action may be due to either a direct excitatory pathway or to a relayed effect of the inhibitory GABAergic pathway.

Changes in substantia nigra pars reticulata activity following lesions of the substantia nigra pars compacta

Single unit activity of substantia nigra reticulata (SNr) neurons was recorded in normal rats and bilaterally in rats subjected to a unilateral 6-hydroxydopamine lesion of the substantia nigra compacta 2-4 weeks previously. Lesions were assessed by rotational behaviour to apomorphine. In normal rats the majority of neurons (63%) showed a regular firing pattern. Following lesion the percentage of these cells was similar in the SNr contralateral to the lesion but decreased on the lesioned side to 26%, whereas bursting activity developed (37% vs 5% in normal rats). The mean firing rate of reticulata neurons was slightly increased after lesion, but not statistically significant.

Cortifugal influences on dorsal column nuclei: an electrophysiological study in the rat using the cortical spreading depression technique

The sign and duration of corticofugal effects on the extracellularly recorded spontaneous activity of cuneate and gracile neurons were examined by means of the cortical spreading depression technique (CSD). Among the 40 units studied 22 showed changes in their spontaneous firing rate during the passage of a CSD. Changes were of either short (5-20 s) or long (greater than 20-140 s) duration. Increases and decreases in activity, as well as sequences of both types of alteration were observed. Short duration changes were more frequent and much more pronounced than those of long duration. From their time course and intensity the short duration effects seem to be related to the brief high frequency cortical neuron discharge that precedes the cortical silence due to CSD, whereas the long lasting effects seem related to the cortical block. It is concluded that the most important corticofugal effects on gracile and cuneate neurons are phasic in nature and the sensorimotor cortical regions were found to be responsible for these influences.

Effect of microstimulation of movement-evoking cortical foci on the activity of neurons on the dorsal column nuclei

Cortical foci in which stimulation produced movement in either the forelimb or hindlimb were isolated in rats. In each experiment, two foci were selected: one for movement in the forelimb, and the other in the hindlimb. Stimulation was subsequently reduced in order to avoid eliciting a movement, and the effects of this stimulation on activity of gracile and cuneate neurons were examined. Both excitation and inhibition were observed and were found to be arranged in a somatotopic manner. Excitation was almost exclusively obtained when the receptive field (RF) of a given neuron corresponded to the body surfaces overlying the joints involved in the cortically evoked movement. A high percentage of neurons with RFs on body surfaces corresponding to, or adjacent to, the region of cortically induced movement were inhibited, while the activity of neurons with RFs distant to the site of movement was seldom modified. These results suggest that cortical influences exerted on the dorsal column nuclei (DCN) in rats are organized in a somatotopic manner.

[Leão's spreading depression in the study of the relationship of central structures]

The use of Leão's spreading depression for studying the action of connections between central structures is examined. Extracellular recordings of cortical and striatal spreading depressions with single microelectrodes are presented using both a DC channel and spike recordings systems. Striatal spreading depression was produced by peristaltic perfusion of a KC1 solution via a push-pull cannula system. The characteristics of cortical and striatal spreading depressions were studied and their effects on antidromically provoked cellular spikes. Using double microelectrode recordings modifications of spontaneous activity provoked by cortical spreading depression were examined in n. ventralis posterior (VP) and centralis lateralis (CL) of the thalamus. In both nuclei a silence corresponding to the block of spontaneous activity of a localised cortical area was observed. The controls originated from different cortical regions for each nucleus. The discharge preceeding the onset of the spreading depression slow wave is reflected by a similar discharge in VP but not in CL. The differences in the frequency following of CL and VP was examined in order to explain this discrepancy. The results just summarized can be explained if we accept that a tonic facilitatory control exists between localised cortical areas and the two thalamic nuclei studied. Similar experiments were performed to study the controls exerted by cortical areas on dorsal column nuclei. Only phasic transitory effects were observed which were either an increase or a decrease in activity. These facilitatory or depressive effects were attributed to the initial excitation signalling the propagation of a cortical spreading depression. No tonic effects were observed. Striatal spreading depression was not accompanied by a cortical effect but on the contrary the activity of cells in substantia nigra was significantly altered. In pars reticulata two populations could be distinguished. The first presented a phasic increase followed by a long period of decreased activity, they are proposed to be under the control of striatum via an excitatory pathway. The second was initially depressed then presented a long period of increased activity. This probably reflects the block of an inhibitory striato-nigral pathway. Both striato nigral effects were tonic in nature. The possibility of separating the effects due to cortical excitation or cortical block are discussed as well as the problems of interpretation of long distance changes in cellular activity.

Pivmecillinam for bacteriuria in pregnancy

Pivmecillinam was given to 44 women with bacteriuria in pregnancy. Treatment was successful in 33 (87%) out of the 38 patients assessed. Thirty women subsequently received at random either a low-dose of pivmecillinam for up to three months or acted as a control group. Further bacteriuric episodes during pregnancy were recorded only in three patients in the control group. Thirty-nine out of the 41 women followed to term delivered healthy babies. One infant was stillborn and another child had a cleft palate. Neither was considered to be related to treatment with pivmecillinam.