Models of care for musculoskeletal health: a cross-sectional qualitative study of Australian stakeholders' perspectives on relevance and standardised evaluation

BACKGROUND

The prevalence and impact of musculoskeletal conditions are predicted to rapidly escalate in the coming decades. Effective strategies are required to minimise 'evidence-practice', 'burden-policy' and 'burden-service' gaps and optimise health system responsiveness for sustainable, best-practice healthcare. One mechanism by which evidence can be translated into practice and policy is through Models of Care (MoCs), which provide a blueprint for health services planning and delivery. While evidence supports the effectiveness of musculoskeletal MoCs for improving health outcomes and system efficiencies, no standardised national approach to evaluation in terms of their 'readiness' for implementation and 'success' after implementation, is yet available. Further, the value assigned to MoCs by end users is uncertain. This qualitative study aimed to explore end users' views on the relevance of musculoskeletal MoCs to their work and value of a standardised evaluation approach.

METHODS

A cross-sectional qualitative study was undertaken. Subject matter experts (SMEs) with health, policy and administration and consumer backgrounds were drawn from three Australian states. A semi-structured interview schedule was developed and piloted to explore perceptions about musculoskeletal MoCs including: i) aspects important to their work (or life, for consumers) ii) usefulness of standardised evaluation frameworks to judge 'readiness' and 'success' and iii) challenges associated with standardised evaluation. Verbatim transcripts were analysed by two researchers using a grounded theory approach to derive key themes.

RESULTS

Twenty-seven SMEs (n = 19; 70.4 % female) including five (18.5 %) consumers participated in the study. MoCs were perceived as critical for influencing and initiating changes to best-practice healthcare planning and delivery and providing practical guidance on how to implement and evaluate services. A 'readiness' evaluation framework assessing whether critical components across the health system had been considered prior to implementation was strongly supported, while 'success' was perceived as an already familiar evaluation concept. Perceived challenges associated with standardised evaluation included identifying, defining and measuring key 'readiness' and 'success' indicators; impacts of systems and context changes; cost; meaningful stakeholder consultation and developing a widely applicable framework.

CONCLUSIONS

A standardised evaluation framework that includes a strong focus on 'readiness' is important to ensure successful and sustainable implementation of musculoskeletal MoCs.

Photoinduced heterodisulfide metathesis for reagent-free synthesis of polymer nanoparticles

Reagent-free synthetic methods are of great interest because of their simplicity and implications in green chemistry. We have taken advantage of photoinduced heterodisulfide metathesis to generate crosslinked polymer nanoparticles. The method of development and the mechanistic basis for the synthetic approach are outlined in this communication.

Evidence-based review for patients undergoing elective hip and knee replacement

BACKGROUND

The objective of this study was to evaluate the evidence for different interventions in the preoperative, perioperative and post-operative care for people undergoing elective total hip (THR) and knee (TKR) replacement surgery.

METHOD

A multidisciplinary working group comprising consumers, managers and clinicians from the areas of orthopaedics, rheumatology, aged care and rehabilitation evaluated randomized controlled trials (RCTs) and systematic reviews/meta-analyses concerning aspects of preoperative, perioperative and post-operative clinical care periods for THR/TKR through systematic searching of Medline, Embase, CENTRAL and the Cochrane Database of Systematic Reviews from May 2007 to April 2011. Multiple reviewers determined study eligibility and one or more members extracted primary study findings. The body of evidence were assessed and specific recommendations made according to NHMRC guidelines.

RESULTS

Twenty-five aspects were identified for review. Recommendations for 16 of 25 areas of care were made: impact of waiting, multidisciplinary preparation, preoperative exercise, smoking cessation, interventions for comorbid conditions, predictors of outcome, clinical pathways, implementation of a blood management programme, antibiotic prophylaxis, regional anaesthesia and analgesia, use of a tourniquet in knee replacement, venous thromboembolism prophylaxis, early post-operative cryotherapy, early mobilization and continuous passive motion. In the post-operative period, study heterogeneity across all aspects of care precluded specific recommendations.

CONCLUSIONS

There was a deficiency in the quality of the evidence supporting key aspects of the continuum of care for primary THR/TKR surgery. Consequently, recommendations were limited. Prioritization and funding for research into areas likely to impact clinical practice and patient outcomes after elective joint replacement surgery are the next important steps.

A guide to defining and implementing protocols for the welfare assessment of laboratory animals: eleventh report of the BVAAWF/FRAME/RSPCA/UFAW Joint Working Group on Refinement

The refinement of husbandry and procedures to reduce animal suffering and improve welfare is an essential component of humane science. Successful refinement depends upon the ability to assess animal welfare effectively, and detect any signs of pain or distress as rapidly as possible, so that any suffering can be alleviated. This document provides practical guidance on setting up and operating effective protocols for the welfare assessment of animals used in research and testing. It sets out general principles for more objective observation of animals, recognizing and assessing indicators of pain or distress and tailoring these to individual projects. Systems for recording indicators, including score sheets, are reviewed and guidance is set out on determining practical monitoring regimes that are more likely to detect any signs of suffering. This guidance is intended for all staff required to assess or monitor animal welfare, including animal technologists and care staff, veterinarians and scientists. It will also be of use to members of ethics or animal care and use committees. A longer version of this document, with further background information and extra topics including training and information sharing, is available on the Laboratory Animals website.

Refinements in husbandry, care and common procedures for non-human primates: Ninth report of the BVAAWF/FRAME/RSPCA/UFAW Joint Working Group on Refinement

Preface Whenever animals are used in research, minimizing pain and distress and promoting good welfare should be as important an objective as achieving the experimental results. This is important for humanitarian reasons, for good science, for economic reasons and in order to satisfy the broad legal principles in international legislation. It is possible to refine both husbandry and procedures to minimize suffering and improve welfare in a number of ways, and this can be greatly facilitated by ensuring that up-to-date information is readily available. The need to provide such information led the British Veterinary Association Animal Welfare Foundation (BVAAWF), the Fund for the Replacement of Animals in Medical Experiments (FRAME), the Royal Society for the Prevention of Cruelty to Animals (RSPCA) and the Universities Federation for Animal Welfare (UFAW) to establish a Joint Working Group on Refinement (JWGR) in the UK. The chair is Professor David Morton and the secretariat is provided by the RSPCA. This report is the ninth in the JWGR series. The RSPCA is opposed to the use of animals in experiments that cause pain, suffering, distress or lasting harm and together with FRAME has particular concerns about the continued use of non-human primates. The replacement of primate experiments is a primary goal for the RSPCA and FRAME. However, both organizations share with others in the Working Group, the common aim of replacing primate experiments wherever possible, reducing suffering and improving welfare while primate use continues. The reports of the refinement workshops are intended to help achieve these aims. This report produced by the British Veterinary Association Animal Welfare Foundation (BVAAWF)/Fund for the Replacement of Animals in Medical Experiments (FRAME)/Royal Society for the Prevention of Cruelty to Animals (RSPCA)/Universities Federation for Animal Welfare (UFAW) Joint Working Group on Refinement (JWGR) sets out practical guidance on refining the husbandry and care of non-human primates (hereinafter primates) and on minimizing the adverse effects of some common procedures. It provides a valuable resource to help understand the physical, social and behavioural characteristics and needs of individual primates, and is intended to develop and complement the existing literature and legislative guidelines. Topics covered include refinements in housing, husbandry and common procedures such as restraint, identification and sampling, with comprehensive advice on issues such as primate communication, assessing and facilitating primate wellbeing, establishing and maintaining social groups, environmental and nutritional enrichment and animal passports. The most commonly used species are the key focus of this resource, but its information and recommendations are generally applicable to other species, provided that relevant individual species characteristics are taken into account.

A comparison between clearing and radiographic techniques in the study of the root-canal anatomy of maxillary first and second molars

AIM

To compare a clearing technique with conventional radiography in studying certain features of the root-canal system of maxillary right first and second molars. A secondary aim was to assess interexaminer agreement for these features using radiographs.

METHODOLOGY

Eighty-three recently extracted permanent maxillary right first molars and 40 recently extracted maxillary right second molars from an Irish population were included. Standard periapical radiographs were taken from a buccolingual and mesiodistal direction. The specimens were then decoronated, demineralized in 10% hydrochloric acid for 8 days and then cleared using methyl salicylate. The cleared teeth were examined using a dissecting microscope (x20), and data relating to number of roots, canal type following Vertucci's classification, presence of lateral canals, presence of transverse anastomoses and position/number of apical foramina were collected. The radiographs were examined by two independent trained endodontists using an X-ray viewer and a magnifying lens (x2) in a dark room for the same features studied using the clearing technique.

RESULTS

The Kappa values for the agreement between the radiographic examiners A and B and the clearing technique and between the two examiners for the number of roots were 0.60, 0.64 and 0.53; for the root-canal type, 0.37, 0.41 and 0.42; for the number of roots with lateral canals, 0.21, 0.18 and 0.14; and for the transverse anastomoses, 0.29 for radiographic Examiner A. Radiographic Examiner B did not feel capable of accurately recognizing transverse anastomoses from the radiographs. For the position/number of apical foramina, the Kappa values were 0.33 and 0.24, respectively. In general, the Kappa values were low to modest for all comparisons.

CONCLUSIONS

It is concluded that the agreement between the two radiographic examiners and the agreement between either radiographic examiner and the clearing technique were poor to moderate, indicating the limited value of radiographs alone when studying certain aspects of the root-canal system.

Molecular phylogenetics of western North American frogs of the Rana boylii species group

Phylogenetic relationships among frogs of the genus Rana from western North America are investigated using 2013 aligned bases of mitochondrial DNA sequence from the genes encoding ND1 (subunit one of NADH dehydrogenase), tRNA(Ile), tRNA(Gln), tRNA(Met), ND2, tRNA(Trp), tRNA(Ala), tRNA(Asn), tRNA(Cys), tRNA(Tyr), and COI (subunit I of cytochrome c oxidase), plus the origin for light-strand replication (O(L)) between the tRNA(Asn) and tRNA(Cys) genes. The aligned sequences contain 401 phylogenetically informative characters. A well-resolved phylogenetic hypothesis in which the Rana boylii species group (R. aurora, R. boylii, R. cascadae, R. muscosa, and R. pretiosa) is monophyletic is obtained. Molecular sequence divergence suggests that the R. boylii species group is approximately 8 million years old. The traditional hypothesis showing monophyly of the yellow-legged frogs (R. boylii and R. muscosa) is statistically rejected in favor of a hypothesis in which R. aurora, R. cascadae, and R. muscosa form a clade. Reanalyses of published nuclear ribosomal DNA restriction-site data and allozymic data support a monophyletic R. boylii group, but do not effectively resolve relationships among species within this group. Eight populations of R. muscosa form two major clades separated by a biogeographic break in the Sierra Nevada of California. This biogeographic break is broadly concordant with breaks found in four other amphibian and reptilian taxa. The two major clades within R. muscosa are estimated to have diverged approximately 2.2 million years before present. Each of these major clades contains two subgroups showing approximately 1.5 million years divergence, implicating climatic effects of Pleistocene glaciation in vicariance. The four distinct subgroups of R. muscosa separated by at least 1.4 million years of evolutionary divergence are suggested as potential units for conservation.

Successful treatment of feline pancreatitis using an endoscopically placed gastrojejunostomy tube

A cat with pancreatitis, diagnosed using abdominal ultrasonography, fine-needle aspirate cytopathology, and increased concentration of serum trypsin-like immunoreactive substance, was treated successfully using jejunal alimentation provided through a percutaneous gastrojejunostomy tube. This method of jejunal feeding is less technically difficult, less stressful for the patient, and has fewer complications than surgically placed jejunostomy tubes. Nutritional support with jejunal feeding is superior to total parenteral nutrition, as it maintains gut integrity, decreases septic complications, and may reduce exogenous insulin requirements. The methods of tube insertion and maintenance, and the physiological advantages over other feeding methods are described.

The complement component C1s is the protease that accounts for cleavage of insulin-like growth factor-binding protein-5 in fibroblast medium

Cultured fibroblasts secrete an 88-kDa serine protease that cleaves insulin-like growth factor binding protein-5 (IGFBP-5). Because IGFBP-5 has been shown to regulate IGF-I actions, understanding the chemical identity and regulation of this protease is important for understanding how IGF-I stimulates anabolic functions. The protease was purified from human fibroblast-conditioned medium by hydrophobic interaction, lectin affinity, and heparin Sepharose affinity chromatography followed by SDS-polyacrylamide gel electrophoresis. An 88-kDa band was excised and digested with lysyl-endopeptidase. Sequencing of the high pressure liquid chromatography-purified peptides yielded the complement components C1r and C1s. To confirm that C1r/C1s accounted for the proteolytic activity in the medium, immunoaffinity chromatography was performed. Most of the protease activity adhered to the column, and the eluant was fully active in cleaving IGFBP-5. SDS-polyacrylamide gel electrophoresis with silver staining showed two bands, and IGFBP-5 zymography showed a single 88-kDa band. Amino acid sequencing confirmed that the 88-kDa band contained only C1r and C1s. C1r in the fibroblast medium underwent autoactivation, and the activated form cleaved C1s. C1s purified from the conditioned medium cleaved C(4), a naturally occurring substrate. The purified protease cleaved IGFBP-5 but had no activity against IGFBP-1 through -4. C1 inhibitor, a protein known to inhibit activated C1s, was shown to inhibit the cleavage of IGFBP-5 by the protease in the conditioned medium. In summary, human fibroblasts secrete C1r and C1s that actively cleave IGFBP-5. The findings define a mechanism for cleaving IGFBP-5 in the culture medium, thus allowing release of IGF-I to cell surface receptors.

Root canal anatomy of maxillary first and second permanent molars

AIM

The aim of this investigation was to study the root canal anatomy of maxillary first and second molar teeth from an Irish population sample using a clearing technique.

METHODOLOGY

Eighty-three extracted permanent maxillary right first molars and 40 permanent right maxillary second molars were included in this investigation. The specimens were demineralized and then cleared using methyl salicylate. The following observations were made: number of roots, prevalence of fusion, types of root canals using Vertucci's classification, presence and position of lateral canals, presence and position of transverse anastomoses, number and position of apical foramina and the frequency of occurrence of apical deltas.

RESULTS

Eleven per cent of maxillary first molars and 43% of maxillary second molars had fused roots. A total of 78% of mesiobuccal roots in maxillary first and 58% in maxillary second molars had two canals. Sixty-two per cent of maxillary first and 50% of maxillary second molars had two apical foramina. There was a significant inverse relationship between age and the occurrence of two canals and between age and the occurrence of transverse anastomoses in both tooth morphotypes (P < or = 0.05).

CONCLUSIONS

It is concluded that a significant proportion of the first and second molar specimens studied had two canals in the mesiobuccal root (78% and 58%, respectively) and that the occurrence of two canals and transverse anastomoses decreased significantly with increasing age.

Prospects for reducing and refining the use of dogs in the regulatory toxicity testing of pharmaceuticals

A workshop was held to critically discuss the need for a nonrodent species and the role of the dog in regulatory toxicity testing of pharmaceuticals; to discuss opportunities to reduce and refine the use of dogs in preclinical toxicology; and to identify a number of specific recommendations which could be feasibly achieved to move the process forward. To facilitate a preliminary evaluation of the contribution of dog studies to the risk assessment process, anonymised, unpublished data were provided from fully evaluated, repeat-dose toxicity studies in the rat and dog. Results of the International Life Sciences Institute (ILSI) Human Toxicity Project were also presented and discussed. Analysis of the data demonstrated that the dog can provide additional toxicity information, which, in some cases, was shown to be predictive for humans. Discussions indicated that there is potential for achieving a reduction in dog use and several possible approaches were identified. To further the progress of this initiative, there is a need to collate the results of pharmacology, toxicology, and clinical studies to address some of the proposed approaches. One of the outcomes of the workshop will be the establishment of a steering group to co-ordinate data collation for further analysis.

Gonococcal lipooligosaccharide is a ligand for the asialoglycoprotein receptor on human sperm

In the present study, we show that Neisseria gonorrhoeae lipooligosaccharide (LOS) can bind to the asialoglycoprotein receptor (ASGP-R) on human sperm. This work demonstrates the presence of ASGP-R on human sperm. Binding of purified ASGP-R ligand decreased in the presence of gonococci. Binding of purified iodinated gonococcal LOS identified a protein of molecular weight corresponding to that of human ASGP-R. The presence of excess unlabelled LOS blocked binding of iodinated gonococcal LOS. Binding of wild-type gonococcal LOS to sperm was higher than that of mutant LOS lacking the galactose ligand for ASGP-R. These data suggest that the ASGP-R on human sperm cells recognizes and binds wild-type gonococcal LOS. This interaction may contribute to the transmission of gonorrhea from infected males to their sexual partners.

Large-scale purification of myeloperoxidase from HL60 promyelocytic cells: characterization and comparison to human neutrophil myeloperoxidase

A large-scale purification procedure was developed for the isolation of myeloperoxidase from HL60 promyelocytic cells in culture. Initial studies showed the bulk of peroxidase-positive myeloperoxidase activity to be located in the cetyltrimethylammonium bromide solubilized particulate fraction of cell homogenates. The myeloperoxidase was then chromatographically purified using concanavalin A followed by gel filtration. SDS-PAGE analysis of the final preparation showed the presence of only two proteins with molecular masses of approximately 55 and 15 kDa, corresponding to the large and small subunits of myeloperoxidase. These data, along with Reinheit Zahl (RZ) values (A(430)/A(280)) of greater than or equal to 0.72, indicate that the myeloperoxidase prepared by this method is apparently homogeneous. Preparations routinely yielded 12-20 mg of pure myeloperoxidase per 10 ml of cell pellet. The HL60 myeloperoxidase was shown to be indistinguishable from purified human neutrophil myeloperoxidase by size exclusion chromatography, analytical ultracentrifugation, SDS-PAGE, Western blot, and NH(2)-terminal sequence analysis. The activities of the two myeloperoxidase samples, as measured using either the tetramethylbenzidine or the taurine chloramine assay, were indistinguishable. Finally, both enzymes responded identically to dapsone and aminobenzoic acid hydrazide, known inhibitors of myeloperoxidase. A protocol is presented here for the rapid, large-scale purification of myeloperoxidase from cultured HL60 cells, as well as evidence for the interchangeability of this myeloperoxidase and that purified from human neutrophils.

Prognostic factors in resectable pancreatic cancer: p53 and bcl-2

The p53 tumor suppressor gene and the Bcl-2 proto-oncogene regulate cell cycle progression and apoptosis. We evaluated the expression of these molecular markers with standard pathologic prognostic variables in patients who received multimodality therapy for resectable adenocarcinoma of the pancreas to study the effect of p53 and Bcl-2 on survival duration. Immunohistochemical staining of archival material was performed to determine levels of expression of p53 and Bcl-2 proteins in 70 patients with adenocarcinoma of pancreatic origin. All patients underwent a potentially curative pancreaticoduodenectomy and standardized pathologic analysis of resected specimens. Potential pathologic and molecular prognostic variables were assessed for their effect on survival duration. Nuclear staining for p53 was observed in 33 (47%) of 70 specimens. Immunostaining for Bcl-2 was observed in 23 specimens (33%). A trend toward improved survival duration was seen in patients whose tumors stained positive for either p53 or Bcl-2. Negative staining for both markers predicted short survival (P = 0.01). By univariate and multivariate analyses, no single pathologic factor was associated with survival duration. Immunohistochemical staging using both p53 and Bcl-2 significantly predicted survival duration by univariate and multivariate analysis; patients whose tumors stained positively for p53 and/or overexpressed Bcl-2 had a significantly longer survival than those whose tumors stained negative for both proteins.

Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative, and pathologic analysis

Intraoperative assessment is inaccurate in defining the relationship of a pancreatic head neoplasm to adjacent vascular structures. We evaluated the ability of preoperative contrast-enhanced CT to predict the need for vascular resection during pancreaticoduodenectomy and examined the resected vessels for histologic evidence of tumor invasion. During a 7-year period, 63 patients underwent pancreaticoduodenectomy with en bloc resection of adjacent vascular structures for a presumed pancreatic head malignancy. Clinical, radiologic, operative, and pathologic data were reviewed and analyzed. Fifty-six patients underwent resection of the superior mesenteric-portal vein confluence, three patients required inferior vena cava resection, and the hepatic artery was resected and reconstructed in eight patients. The operative mortality rate was 1.6%, and the overall complication rate was 22%. CT predicted the need for resection of the superior mesenteric or portal veins in 84% of patients. Pathologic analysis revealed tumor invasion of the vein wall in 71% of resected specimens. Tumor invasion of vascular structures adjacent to the pancreas can be predicted with preoperative CT and should alert the surgeon that vascular resection may be required. Histologic evidence of tumor cell infiltration of vessel walls was present in the majority of the resected specimens.

Accuracy of tympanic temperature readings in children under 6 years of age

PURPOSE

Infrared tympanic thermometry (ITT) is increasingly used as a convenient, noninvasive assessment method for febrile children. However, the accuracy of ITT for children has been questioned, particularly in relation to specificity and sensitivity. This study was designed to (a) determine the correlation and extent of agreement between rectal temperature (RT) readings obtained by electronic thermometer and ear-based temperature readings obtained by ITT, and (b) determine the accuracy of detecting fever in children under 6 years of age.

METHODS

This correlational study used a sample of 241 paired ear and rectal temperatures obtained in the emergency department (ED) of a 920-bed regional hospital. All children under the age of 6 years who routinely received a rectal temperature measurement were eligible to participate. According to the ED protocol, rectal temperatures were obtained on all patients less than 3 years or patients 3-6 years that presented with a complaint of fever. For the study, tympanic measurements were also taken.

RESULTS

Correlation between rectal and tympanic temperature readings was statistically significant (r = 0.84, p < .001). The mean difference between rectal and tympanic temperatures was -0.60 degrees C. Threshold-adjusted accuracy in screening for fever was determined by sensitivity (80%), specificity (85%), positive predictive value (87%), and negative predictive value (85%).

CONCLUSIONS

Sensitivity, specificity, positive predictive value, and negative predictive value are unacceptably low and the number of children with fever who would be missed by screening with a tympanic thermometer is unacceptable. Findings of this study do not support the use of tympanic thermometers to detect fever in children under 6 years of age.

Ethics training for laboratory animal users

In the UK, all applicants for licences under the Animals (Scientific Procedures) Act 1986 must receive training in ethical aspects of laboratory animal use. There is, however, considerable uncertainty about the aims, suitable content and most appropriate means of delivery of such training. In this review a series of aims for licensee training in ethics are proposed, the key content is described and possible approaches to delivering such training are critically evaluated. Ethics training, it is argued, should: (i) be rooted in practice, focusing on the practical application of the Act to licensees' own work and encouraging them to take all possible steps to reduce or resolve any moral conflicts which the work entails; (ii) promote discussion, encouraging licensees to challenge their own views and critically appraise their work; and (iii) provide the necessary theoretical background to inform and stimulate such discussion. A variety of means of generating discussion and a range of practical considerations are explored.

Challenge of chimpanzees immunized with a recombinant canarypox-HIV-1 virus

To evaluate the potential protective efficacy of a live recombinant human immunodeficiency virus type 1 (HIV-1) canarypox vaccine candidate, two chimpanzees were immunized five times with ALVAC-HIV-1 vCP250, a recombinant canarypox virus that expresses the HIV-1[IIIB(LAI)] gp120/TM, gag, and protease gene products. One month after the last booster inoculation, the animals were challenged by intravenous injection of cell-associated virus in the form of peripheral blood mononuclear cells from an HIV-1[IIIB(LAI)]-infected chimpanzee. One chimpanzee with a neutralizing antibody titer to HIV-1[IIIB(LAI)] of 128 at the time of challenge was protected, whereas both the second animal, with a neutralizing antibody titer of 32, and a naive control animal became infected. At 5 months after challenge, the protected chimpanzee and a third animal, previously immunized with various HIV-1[MN] antigens, were given a booster inoculation. The two animals were challenged intravenously 5 weeks later with twenty 50% tissue culture infectious doses of cell-free HIV-1[DH12], a heterologous subtype B isolate. Neither chimpanzee had neutralizing antibodies to HIV-1[DH12], and neither one was protected from infection with this isolate. The immune responses elicited by vaccination against HIV-1[IIIB(LAI)] or HIV-1[MN] did not, therefore, protect the animals from challenge with the heterologous cell-free HIV-1[DH12].

Buffered lidocaine decreases the pain of digital anesthesia in the foot

The pain associated with injections for inducing digital anesthesia can be decreased by adding sodium bicarbonate to plain lidocaine. A randomized, double-blind study has demonstrated that 24 out of 30 participants indicated on a visual analogue scale that buffered lidocaine is less painful than plain lidocaine. The pain decreased by 50% or more for almost half of the participants. Practitioners can easily buffer lidocaine in the office by adding a small volume of sodium bicarbonate to plain lidocaine.

Prevalence of antibodies against simian immunodeficiency virus (SIV) and simian T-lymphotropic virus (STLV) in a colony of non-human primates in Kenya, East Africa

Sera (165 samples in 1988 and 66, follow-up samples in 1989) were collected from olive baboons, African green monkeys, Syke's monkeys and grey mangabeys kept in a semi-free, breeding colony at the Institute of Primate Research (IPR) in Nairobi, Kenya. The levels of antibodies to simian T-lymphotropic virus (STLV) or simian immunodeficiency virus (SIV), and the reactivity patterns of positive sera to various lentivirus subgroup antigens, were then determined. The results of tests using enzyme-immunoassay kits were confirmed by western blots. The prevalence of antibodies which reacted with the Kenyan SIVagm(KEN) isolate was 28% in the African green monkeys tested and 34% in the Syke's monkeys. STLV seroprevalence was 25% in the African greens and 20% in the Syke's. No antibodies to either SIV or STLV were detected in the olive baboons or grey mangabeys. More SIV-positive samples were detected in western blots when SIVagm(KEN) was used as antigen than when SIVagm(CAR014), a geographically distinct isolate from the Central African Republic, was used. However, SIVagm(KEN)-positive sera were more reactive against SIVagm(CAR014) than SIVsmm and SIVmac subgroup antigens, indicating that the two isolates from the African green monkey, CAR014 and KEN, remain antigenetically close even though they were recovered in two geographically distinct regions. To date, no clinical disease has been linked with SIV and STLV infection in the African green or Syke's monkeys in the colony. However, the relatively high prevalence of anti-SIV and anti-STLV antibodies in these monkeys offers an opportunity for prospective studies on the transmission and natural history of both viruses in a single colony.

Clinical manifestations of carcinoid disease

Carcinoid tumors are relatively uncommon tumors and their presentation is varied. For these reasons, a high index of suspicion is necessary in order to consider the diagnosis. It is important to separate the "syndrome" from the primary tumor. It is obviously more effective to diagnose the tumor itself before the syndrome manifests itself, usually as a result of metastatic disease. Since the tumors are characteristically slow-growing, the physician may be misled into thinking the patient has functional problems rather than a tumor. Some data and guidelines are given for focusing on the signs and symptoms of carcinoid disease.

Octreotide therapy in carcinoid disease

Octreotide therapy is expensive, but at present it and other somatostatin analogues appear to offer the best opportunity of controlling the symptoms of flushing and diarrhoea. It may also have other properties affecting general well-being. The question of whether it changes tumour growth remains unanswered and there is no convincing evidence that it alters survival. In all published studies the numbers of patients are small and there have been no control groups. However, since no other drug has yet proved effective against flushing, the somatostatin analogues, including octreotide, remain the treatment of choice for the symptomatic control of the carcinoid syndrome. Octreotide is of great therapeutic value pre-operatively and intra-operatively and it is essential that all operating theatres have this drug available for immediate use. Surgical debulking, if feasible, provides the best outcome potential in carcinoid disease. Present evidence suggests that the place of octreotide and other somatostatin analogues is in controlling the symptoms of the disease rather than its progress and in ensuring cardiovascular and respiratory stability during surgical procedures.

Passive immunization of rhesus macaques against SIV infection and disease

To evaluate the role of humoral immunity against simian immunodeficiency virus (SIV), we tested whether passive immunization with plasma from SIVmac251 vaccine-protected or healthy infected animals would protect rhesus monkeys against intravenous infection with ten 50% animal infectious doses of the cell-free homologous virus. The challenge dose of this SIVmac251 virus stock had previously caused persistent infection in all (21 of 21) nonimmunized controls. A plasma pool was obtained from a donor that had been immunized with an inactivated whole SIVmac251 vaccine produced in human T cells. This plasma pool contained low levels of SIVmac binding and neutralizing antibody but had a high titer of antibodies recognizing human cell proteins. Given 4 or 18 hr before intravenous challenge, this plasma completely protected three of eight recipients from infection and delayed virus detection in one recipient. The five unprotected animals had only a transient or undetectable p27 antigenemia and low virus load in their PBMCs, and all survived at least 7 months after infection. By contrast, no protection was observed in 6 monkeys given inactivated, pooled plasma or purified immunoglobulin (Ig) from healthy SIVmac251-infected animals. This plasma pool and the Ig preparation contained high levels of SIV-binding and neutralizing antibody but no reactivity to human cellular components. Five of the six recipients had persistent antigenemia after challenge and four died acutely from simian AIDS in 4-7 months. These studies suggest that passive transfer of antibody to human cellular antigens can confer protection against SIVmac whereas passive transfer of neutralizing antibodies without human cellular antibodies does not protect against the homologous virus and may enhance infection.

Inhibitory motor seizures: correlation with centroparietal structural and functional abnormalities

Six adults and 2 children with focal inhibitory motor seizures (ictal paralysis) were evaluated during a 4-year period. Paresthesias at seizure onset occurred during some seizures in all patients, and focal clonic activity followed paralysis in 4. EEG-CCTV recordings of the seizures in 2 patients showed that ictal paralysis coincided with an ictal discharge starting in one centroparietal area. MRI showed centroparietal structural lesions in six patients. One patient with a normal MRI scan had right centroparietal hypometabolism on PET. Inhibitory motor seizures must be differentiated from transient ischemic attacks and migraine. In our patients a centroparietal epileptogenic focus was suggested by neuroimaging studies, and in 2 instances by ictal EEG.

Passive immunization of macaques against SIV infection

Passive immunization with plasma from an inactivated-whole SIVmac vaccine protected monkey conferred complete or partial protection to rhesus macaques challenged intravenously 4 or 18 hours later with 10 AID50 of homologous cell-free virus. In contrast, passive immunization with inactivated plasma or purified immunoglobulin (Ig) from SIVmac infected asymptomatic monkeys failed to protect any recipients similarly challenged and may have enhanced infection and accelerated disease. Administered 24 hours post challenge, anti-SIV Ig may also have enhanced the infection.

Adhesion of lymphocytic cells to human trophoblast cells in vitro

The adherence of lymphocytic MOLT-4/clone 8 cells and normal human peripheral blood mononuclear cells (PBMCs) to primary cultures of term human syncytiotrophoblast has been characterized. Adherence was measured using a fluorescence-based assay in which leukocytic cells were labelled with calcein-AM. Adherence of MOLT cells to syncytiotrophoblast increased in a time-dependent fashion up to about 4 h after which adhesion decreased. Adhesion was detectable at 4 degrees C but was greatly reduced compared to that seen at 37 degrees C. Binding increased linearly as the ratio of MOLT cells to trophoblast was increased. Scanning and transmission electron microscopy of MOLT cell-trophoblast cocultures revealed lymphocytes adherent to the free microvillous surface of the syncytiotrophoblast masses. MOLT cells also adhered to cytotrophoblast but the extent of binding was lower than to syncytiotrophoblast. Normal human peripheral blood mononuclear cells adhered to syncytiotrophoblast. Preincubation of trophoblast cells with trypsin in the presence of calcium had no effect on subsequent adhesion of MOLT cells. However, preincubation of trophoblast cells with trypsin in the absence of divalent cations reduced subsequent adhesion. Adhesion of MOLT cells to syncytiotrophoblast was dependent on magnesium and calcium. These results show for the first time that lymphocytic cells adhere to isolated human syncytiotrophoblast and raise the possibility that this may be an important phenomenon in vivo.

Human immunodeficiency virus type 1 (HIV-1) fusion with model membranes: kinetic analysis and the role of lipid composition, pH and divalent cations

The kinetics and extent of HIV-1 fusion with model membranes was studied. HIV-1 was labeled with octadecyl rhodamine B chloride, and fusion was monitored continuously as the dilution of the probe into target membranes. The results were analyzed by a mass action model which yielded good simulations and predictions for the kinetics and final extents of fluorescence increase. The model determined the percent of virions capable of fusing and rate constants of fusion, aggregation and dissociation. Ultrastructural analysis of the virus and reaction products by electron microscopy also provided evidence of HIV-1 fusion with membranes lacking CD4. HIV-1 fusion activity depends on the target membrane lipid composition according to the sequence: cardiolipin (CL) > > phosphatidylinositol > CL/dioleoylphosphatidylcholine (DOPC) (3:7), phosphatidic acid > phosphatidylserine (PS), PS/cholesterol (2:1) > PS/PC (1:1), PS/phosphatidylethanolamine (1:1) > DOPC, erythrocyte ghosts. Reduction of pH from 7.5 generally enhances the rate and extent of HIV-1 fusion. Physiologically relevant concentrations of calcium stimulate HIV-1 fusion with several liposome compositions and with erythrocyte ghost membranes. The fusion products of HIV-1 with liposomes consist of a single virus and several liposomes. The mass action analysis revealed that, compared to intact virions, the fusion products show a striking reduction in the fusion rate constant. Like influenza and Sendai viruses, HIV-1 fusion with membranes containing its own envelope glycoprotein(s) is strongly inhibited. Unlike these viruses, HIV-1 fusion is promoted by physiological levels of calcium. HIV-1 fusion with liposomes is qualitatively similar to simian immunodeficiency virus fusion.

Outsourcing: the new age of hospital supply management

As the healthcare industry faces increasing pressure to identify and cut costs, outsourcing of Central Service functions may become dominant. The authors represent Baxter Healthcare's vision for CS in the next decade, which includes supplying comprehensive case kits containing all the consumable supplies needed for a patient's entire length of stay. The goal is to replace large, on-hand inventories and expensive CS functions with a procedure-based processing, packing and delivery service. The vision is already underway from several vendors. There should be cost savings in picking and replenishment functions currently handled in the OR, repair and CS costs. Hospital personnel may not be replaced, but their functions will change. The arrangement requires long-term thinking, mutual acceptance of risk and the development of trust.