The strategic and operational characteristics of a distributed phased archive for a multivendor incremental implementation of picture archiving and communications systems

The long-term (10 years) multimodality distributed phased archive for the Medical Information, Communication and Archive System (MICAS) is being implemented in three phases. The selection process took approximately 10 months. Based on the mandatory archive attributes and desirable features, Cemax-Icon (Fremont, CA) was selected as the vendor. The archive provides for an open-solution allowing incorporation of leading edge, "best of breed" hardware and software and provides maximum flexibility and automation of workflow both within and outside of radiology. The solution selected is media-independent, provides expandable storage capacity, and will provide redundancy and fault tolerance in phase II at minimum cost. Other attributes of the archive include scalable archive strategy, virtual image database with global query, and an object-oriented database. The archive is seamlessly integrated with the radiology information system (RIS) and provides automated fetching and routing, automated study reconciliation using modality worklist manager, clinical reports available at any Digital Imaging and Communications in Medicine (DICOM) workstation, and studies available for interpretation whether validated or not. Within 24 hours after a new study is acquired, four copies will reside within different components of the archive including a copy that can be stored off-site. Phase II of the archive will be installed during 1999 and will include a second Cemax-Icon archive and database using archive manager (AM) Version 4.0 in a second computer room.

A generic digital imaging and communications in medicine solution for a bidirectional interface between the modality and the radiology information system

The Relay is a generic Digital Imaging and Communications in Medicine (DICOM)-compliant software package. It is a bidirectional interface between the modality and the radiology information system (RIS) that uses DICOM modality worklist and modality-performed procedure step services. This device can eliminate discrepancies between patient demographic information contained in the RIS and that entered at the imaging modality. The Relay receives the worklist for a modality from the RIS. It verifies the accession number (ACC#) and medical record number (MRN) received from the RIS for a study against the ACC# and MRN entered at the modality after that study is pushed to the Relay by the modality. If the values for the ACC# and MRN contained in the image header coincide with the values stored on the RIS, the patient demographics and study protocol contained in the RIS is downloaded into the image header. The study is then automatically routed to the specified destination without technologist intervention. Images whose header does not coincide with data on the RIS are flagged for subsequent reconciliation by the technologist. When the study is completed, the Relay updates the status of the study in the RIS, if the RIS provides DICOM performed procedure step service. When required, the Relay is able to split a single study into two or more series and assign each an ACC#. Other Relay functionality includes sending studies to multiple DICOM devices, adding comments to the image header, and DICOM print service. Should the archive be unavailable to receive images for whatever reason, the Relay can store studies so image acquisition can continue without interruption or it can divert studies directly to a diagnostic workstation. This Relay provides redundancy and fault-tolerance capabilities for picture archiving and communications systems. It is vendor-independent and will function with any DICOM modality, RIS, or archive.

Integration, acceptance testing, and clinical operation of the Medical Information, Communication and Archive System, phase II

The Medical Information, Communication and Archive System (MICAS) is a multivendor incremental approach to picture archiving and communications system (PACS). It is a multimodality integrated image management system that is seamlessly integrated with the radiology information system (RIS). Phase II enhancements of MICAS include a permanent archive, automated workflow, study caches, Microsoft (Redmond, WA) Windows NT diagnostic workstations with all components adhering to Digital Information Communications in Medicine (DICOM) standards. MICAS is designed as an enterprise-wide PACS to provide images and reports throughout the Strong Health healthcare network. Phase II includes the addition of a Cemax-Icon (Fremont, CA) archive, PACS broker (Mitra, Waterloo, Canada), an interface (IDX PACSlink, Burlington, VT) to the RIS (IDXrad) plus the conversion of the UNIX-based redundant array of inexpensive disks (RAID) 5 temporary archives in phase I to NT-based RAID 0 DICOM modality-specific study caches (ImageLabs, Bedford, MA). The phase I acquisition engines and workflow management software was uninstalled and the Cemax archive manager (AM) assumed these functions. The existing ImageLabs UNIX-based viewing software was enhanced and converted to an NT-based DICOM viewer. Installation of phase II hardware and software and integration with existing components began in July 1998. Phase II of MICAS demonstrates that a multivendor open-system incremental approach to PACS is feasible, cost-effective, and has significant advantages over a single-vendor implementation.

Rapid evaluation of weekly scintillation camera resolution and linearity using the orthogonal tri-hole phantom

OBJECTIVE

Both state and federal regulations require weekly monitoring of the resolution and linearity of the scintillation camera. Several phantoms are available to perform this quality control function. These include the quadrant bar. Bureau of Radiological Health (BRH), and orthogonal-hole (OH) phantoms. Each of these phantoms has either functional or temporal limitations on its use. The orthogonal tri-hole phantom (OTHP) was designed to overcome these limitations.

METHODS

The OTHP consists of a precision-drilled lead plate sandwiched between two plastic plates. The OTHP has an active area of 15 in. x 20 in. which contains an orthogonal array of three-hole (2.5-mm, 3.0-mm, and 4.0-mm) clusters. Intrinsic and extrinsic images were acquired for the OTHP, OH phantom, BRH phantom and quadrant bar phantom.

RESULTS

The OTHP test pattern allows resolution, linearity, object shape, and contrast to be evaluated simultaneously, either intrinsically or extrinsically, in a single image over the entire useful field-of-view.

CONCLUSION

The OTHP provides a more quantitative evaluation of the quality control parameters than any other phantom currently available. The use of the OTHP results in cost savings since both camera and technologist time are reduced because only one image is required instead of the two or four needed for other phantoms.

Renography before heart transplantation in patients with cardiomyopathy

In patients with ischemic cardiomyopathy (CM), abnormal renograms may result not only from circulatory failure (which should reverse after transplantation) but also from intrinsic renal disease (which contraindicates heart transplantation). Here, the outcome of heart transplantation was related to preoperative renograms, and the differentiating and prognostic value of renography was analyzed.

METHODS

The study population consisted of 50 patients with ischemic CM expecting heart transplantation. Anatomical renal pathology was excluded in all patients. Dynamic renal scintigraphy was performed with 99mTc-mercaptoacetyltriglycine. Background-subtracted renograms were inspected visually and characterized numerically. Mean parenchymal transit time (mPTT), renal tracer content at 15 min (RTC15) and retention index (RI) were determined. The parametric renogram values were related to a normal reference group of 64 patients. The preoperative renograms were matched with the postoperative outcome.

RESULTS

Three characteristic types of symmetrical findings in the kidneys were found: no pathological findings, mildly delayed peak and excretion phase and severely delayed peak and excretion phase. Pathological renograms were observed in 36 of 50 (72%) patients. The mean parametric renogram values in ischemic CM were as follows: Group A (normal kidney function), mPTT = 142+/-26.6 sec, RTC15 = 22.3%+/-4.6% and RI = 24.7+/-11.9; Group B (mild dysfunction), mPTT = 210+/-44.0 sec, RTC15 = 42.6%+/-10.3% and RI = 101.4+/-50.5; Group C (severe dysfunction), mPTT = 320+/-94.2 sec, RTC15 = 79.6%+/-15.9% and RI = 347.7+/-194.7; and reference patients (normal kidney function), mPTT = 137+/-31.1 sec, RTC15 = 22.8%+/-3.8% and RI = 24.6+/-7.9. Postoperative serum creatinine levels were <1.5 mg/dl in all Group A patients, between 1.5 and 2.5 mg/dl in 78% of Group B patients and >2.5 mg/dl in 75% of Group C patients.

CONCLUSION

Renography revealed abnormal kidney function when structural pathology was excluded. The renographic abnormalities in ischemic CM did not reflect simply the circulatory failure. The numerical grading of renograms allowed patient stratification, suggestive of possible renal insufficiency after cardiac transplantation and immunosuppressive therapy. With further experience, renography may become a useful tool for predicting postoperative outcome in ischemic CM.

Human immunodeficiency virus induction of corticotropin in lymphoid cells

Disruption of the linkage among the immune, nervous, and endocrine systems may contribute to the pathology and symptoms of acquired immunodeficiency syndrome (AIDS). We investigated the role of human immunodeficiency virus (HIV) in altering these linkages via induction of corticotropin (ACTH) by lymphocytes. Cultured T lymphocytes (H9 cell line) were infected with HIV-1, after which ACTH production was measured and characterized at various time intervals by immunofluorescence and Western blotting. We report a coordinate expression of ACTH and p24 HIV core protein in H9 cells. Also, the kinetics of HIV-induced ACTH production by H9 T lymphoma cells are demonstrated using three different strains of HIV as well as UV-inactivated HIV. ACTH production corresponded with the appearance of p24 antigen and was maximal 35 days after infection. UV-inactivated HIV and the viral envelope protein, gp120, were also able to induce ACTH production in these cells, indicating that viral replication was not required for the ACTH induction. The HIV-induced ACTH was synthesized de novo and had the size and biological activity of pituitary ACTH. Inhibition of ACTH in HIV-infected lymphocyte cultures by anti-ACTH antiserum enhanced viral p24 expression. The significance of lymphocyte ACTH in AIDS is not clear, but these results suggest that it may restrict HIV replication and possibly infection.

"Flip-flap" mastopexy

The "flip-flap" mastopexy modifies the McKissock vertical bipedicle design by creating a wide superiorly based flap of breast tissue deep to the vertical bipedicle. Transposition of this flap up and beneath the upper breast, with suture anchoring to the pectoralis fascia at the level of the second rib, restores upper breast fullness, decreases mastopexy-wrecking lower breast bulk, and provides a pleasant forward thrust of the nipple-areolar complex. The "flip-flap" is effective for improving the long-term aesthetic outcome for both reduction mammaplasty and mastopexies of moderate- to full-sized breasts.

Comparison of the effects of enucleation and orbital reconstruction using free-fat grafts, dermis grafts, and porous polyethylene implants in infant rabbits

Twenty-nine infant rabbits from four litters were randomly assigned to three groups. No surgery was performed on left eyes. All right eyes were enucleated. Group 1, the control group, had no right-socket reconstruction. Group 2 had reconstruction using free-fat and dermis grafts. Group 3 had reconstruction using porous polyethylene implants. On attaining adult size, rabbits were killed, decapitated, and prepared for measurements. Orbital volume measurements were performed twice and orbital entrance areas were determined once. No significant differences were noted between first and second measurements of orbital volumes. Right orbital volumes were significantly smaller than left orbits in all groups except for the second measurement of the polyethylene implant group. Right orbital entrance areas were significantly smaller than left areas in the control and the free-fat and dermis graft groups. Right orbital entrance areas of the polyethylene group were not significantly smaller than the corresponding left orbital entrance areas. The use of free-fat and dermis grafts for orbital reconstruction in anophthalmic infant rabbits did not significantly stimulate orbital bone growth. In one trial, the polyethylene implant group displayed right orbital volumes and orbital entrance areas that were not significantly smaller than controls.

Construction of a family of biphenyl combinatorial libraries: structure-activity studies utilizing libraries of mixtures

A set of biphenyl aminoacid building blocks has been synthesized. These were used to construct partially-peptidic combinatorial libraries as equimolar multi-component samples. Activity of members of this library as vitronectin receptor antagonists is described, together with SAR studies of the most active members. These studies illustrate several important features of combinatorial libraries.

Archive selection for the MICAS, a multi-vendor incremental approach to PACS

From the time a decision was made to purchase an archive until a purchase order was issued took approximately 10 months. During this period an RFI was developed, issued and the results analyzed. Technical discussions were held and site visits were made. To ensure that current information was available, a complete review of available multi-modality DICOM compliant archives were made at the 1997 RSNA. With this information in-hand and the future development path for MICAS specified, a detailed RFQ was developed, responses were received and evaluated. A purchase order was to be issued by the end of the first quarter 1998. The archive vendor will have been selected by the time this paper appears in print. The oral presentation of this work will review the responses of the archive vendors and present the basis for selection. It is planned to publish our findings. The archive is the heart and brains of PACS. It controls information acquisition, distribution and storage plus work flow. It is critical that DICOM compliance and interoperability between all components of the PACS be an absolute requirement, especially for the archive.

Human papillomavirus and risk of oral cancer

Although human papillomavirus (HPV), a sexually transmitted virus, is established as a necessary cause for more than 95% of cervical carcinomas, the association with oral squamous cell carcinoma is less well delineated. The purpose of this study was to determine the frequency and types of HPV in squamous cells of a group of patients with newly diagnosed oral or pharyngeal cancer (n = 93) compared with an age- and gender-frequency-matched control group of patients with no history of oral cancer (n = 205). HPV was evaluated from a mouth rinse collection of cells in the oral cavity and tested by 32P-labeled HPV generic probes and DNA sequencing for HPV types. HPV was identified in 15% of the oral cancer cases but in fewer than 5% of the controls (P < .05). The risk of cancer associated with HPV infection was independent of tobacco and alcohol use (adjusted odds ratio [OR] = 3.70; 95% confidence interval [CI]: 1.47-9.32; P < .05). HPV types included similar and other types not identified previously in the genital tract. There was no statistically significant increased risk of cancer among former tobacco users (former vs. never users: adjusted OR = 0.67, 95% CI: 0.31-1.44, P < .05), but the risk was significantly increased for current users (current vs. never: adjusted OR = 2.63; 95% CI: 1.22-5.71; P < .05). Likewise, former alcohol users were not at increased risk of disease (former vs. never: adjusted OR = 1.78; 95% CI: 0.87-3.67), whereas current alcohol users were (current vs. never: adjusted OR = 2.57; 95% CI: 1.22-5.42; P < .05). HPV-related genital lesions (14.3% vs. 10.6%), oral-genital sexual behavior (42.4% vs. 45.2%), and number (11 or more) of sexual partners (23% v. 17%) were not significantly different between cases and controls. These data suggest that in addition to tobacco and alcohol, HPV plays a role in the development of oral cancer.

Correlates of early onset and chronicity of homelessness in a large urban homeless population

This study examined temporal relationships between relative onsets of mental illness and homelessness in a cross-sectional study of 900 homeless people compared with a matched, never-homeless sample from the Epidemiologic Catchment Area study. All psychiatric disorders preceded homelessness in the majority. Only one disorder, alcohol use disorder (in men only), had significantly earlier onset in homeless subjects. Regarding number of symptoms or earlier age of onset of psychiatric disorders, earlier onset of homelessness was associated with several diagnoses: schizophrenia, major depression, generalized anxiety disorder, alcohol and drug use disorders, and antisocial personality. In multiple regression models, history of dysfunctional family background and maternal psychiatric illness were also associated with earlier onset of homelessness, whereas education was protective. Chronicity of homelessness was associated with number of symptoms of alcohol use disorder and earlier age of onset of drug use disorder, presence and number of symptoms of schizophrenia and antisocial personality, and earlier onset of major depression and conduct disorder. In multiple regression models, more education, but not family background problems, was associated with shorter lifetime duration of homelessness. These findings provide information relevant to the roles of mental illness and personal vulnerability factors in the onset and chronicity of homelessness.

The association of psychiatric diagnosis with weather conditions in a large urban homeless sample

Assessment of psychiatric disorders encounters unique complexities in homeless populations. Although the use of structured diagnostic instruments has significantly improved research methodology in this area, questions remain about the validity of using cross-sectional diagnostic methods derived from studies of more general populations. In particular, the validity of structured diagnostic instruments in the assessment of schizophrenia, depression, drug use disorder, and antisocial personality disorder (ASPD) in homeless populations has been questioned. The purpose of this study was to examine the association of psychiatric diagnoses with the weather. It was hypothesized that self-report of psychiatric illness may be affected by prevailing weather conditions. Nine hundred homeless subjects randomly sampled from St. Louis shelters, day centers, and unsheltered locations were interviewed over a 1-year period. Official average daily temperature and amount of precipitation on the day of each subject's interview were compared with lifetime and current psychiatric diagnoses ascertained by the Diagnostic Interview Schedule. Similar analyses were performed in general population data from the Epidemiologic Catchment Area study. The study found that among homeless men, inclement weather on the day of interview was associated with lifetime and current diagnoses of major depression, lifetime drug use disorder, lifetime diagnosis of ASPD, and current alcohol use disorder. These findings, however, were not present in homeless women and not reflected in the general population. The results, although limited, suggest that weather may confound cross-sectional, standardized methods of psychiatric diagnosis in homeless men. Weather-related factors among homeless men are associated with ascertainment of both lifetime and current diagnosis of major depression, as well as lifetime drug use disorder and ASPD and current alcohol use disorder. Possible interpretations of these findings are discussed, with implications for intervention strategies for psychiatric disorders in the larger context of homelessness and social problems.

Role of radionuclide phallogram in therapeutic decision-making for erectile dysfunction

OBJECTIVE

The purpose of this study is to evaluate the role of radionuclide phallograms in therapeutic decision-making for erectile dysfunction.

METHOD

Forty-eight impotent men being considered for pharmacologically-induced penile erection therapy (PIPE) had radionuclide phallograms (RP) as part of their evaluation. RP were performed using 99mTc-labeled autologous red blood cells and provided a measurement of penile blood volume (PBV) change following the intracorporeal injection of 0.25 to 0.3 mL of a papaverine/phentolamine mixture.

RESULTS

Thirty-eight patients showed a good response with a mean PBV increase 2.6 times baseline (range 1.2 to 8.9). Ten patients had significantly lower PBV changes (P = 0.001) than the first group, with a mean PBV increase of 1.6 times baseline (range 1.1 to 2.4). These ten patients were dissatisfied with pharmacologically induced penile erection (PIPE) therapy after an unsuccessful treatment trial.

CONCLUSION

We conclude that the RP can help to discriminate between patients who will benefit from PIPE therapy and those who will not.

Flavopiridol induces apoptosis of normal lymphoid cells, causes immunosuppression, and has potent antitumor activity In vivo against human leukemia and lymphoma xenografts

Flavopiridol is a novel semisynthetic flavone derivative of the alkaloid rohitukine. Flavopiridol is known to inhibit potently the activity of multiple cyclin-dependent kinases. We have assessed its effects on normal and malignant cells in preclinical animal models of localized and disseminated human hematopoietic neoplasms. Flavopiridol, when administered as daily bolus intravenous (IV) injections, produced selective apoptosis of cells in the thymus, spleen, and lymph nodes, resulting in atrophy of these organs. With the exception of the intestinal crypts, apoptosis or tissue damage was absent in all other organs investigated (kidneys, liver, lungs, bone/bone marrow, muscle, and heart). Flavopiridol had a marked apoptotic effect documented by DNA nick-end labeling, or DNA agarose gels in xenografts of human hematopoietic tumors HL-60, SUDHL-4, and Nalm/6. After treatment with 7.5 mg/kg flavopiridol bolus IV or intraperitoneal on each of 5 consecutive days, 11 out of 12 advanced stage subcutaneous (s.c.) human HL-60 xenografts underwent complete regressions, and animals remained disease-free several months after one course of flavopiridol treatment. SUDHL-4 s.c. lymphomas treated with flavopiridol at 7.5 mg/kg bolus IV for 5 days underwent either major (two out of eight mice) or complete (four out of eight mice) regression, with two animals remaining disease-free for more than 60 days. The overall growth delay was 73.2%. The acquired immunodeficiency syndrome-associated lymphoma AS283 showed no significant response when flavopiridol was used in advanced s.c. tumors, but when treatment was initiated in early stages, there was a complete regression of the early tumors, and a significant overall growth delay (>84%). When flavopiridol was used in severe combined immunodeficient mice bearing disseminated human acute lymphoblastic leukemia Nalm/6 cells, there was 15-day prolongation in survival (P = .0089). We conclude that flavopiridol greatly influences apoptosis in both normal and malignant hematopoietic tissues. This activity was manifested in our study as a potent antileukemia or antilymphoma effect in human tumor xenografts, which was dose and schedule dependent. These findings provide compelling evidence for the use of flavopiridol in human hematologic malignancies.

Potential for the effects of anabolic steroid abuse in the immune and neuroendocrine axis

Some of the effects that high-dose anabolic steroid abuse have and could have on the interactions between the immune and neuroendocrine systems are reviewed. Considering the past demonstrations on the actions of normal steroids on endocrine and immune responses, it is apparent that pharmacologically high doses of both normal and derivatized androgens (anabolic steroids) could have a significant effect. Indeed, some of the pathologies attributed to anabolic steroid abuse point to disturbances in the intimate connection between neuroendocrine and immune function and interaction. We attempt to review both the direct and indirect effects of this abuse, not only on this interaction but also on certain immune functions in particular.

Phenytoin-induced thrombocytopenia treated with intravenous immune globulin

PURPOSE

To describe the use of intravenous immune globulin (IVIG) in an 8-year-old girl with phenytoin-induced thrombocytopenia and leukopenia.

PATIENTS AND METHODS

An 8-year-old girl had fever, rash, thrombocytopenia, and leukopenia 18 days after initiation of phenytoin therapy. The phenytoin level was elevated. She was treated with 1 g/kg of IVIG.

RESULTS

The thrombocytopenia improved dramatically after IVIG therapy. There was a slower response to the leukopenia.

CONCLUSIONS

Phenytoin hypersensitivity can present with thrombocytopenia and leukopenia. Treatment with IVIG was associated with a rapid rise in the platelet count in the patient in this report. IVIG should be considered for patients with phenytoin-induced thrombocytopenia.

Scintillation camera quality control, Part I: Establishing the quality control program

This is the first article in a four-part series on scintillation camera quality control. This series of articles will include both theory and practical knowledge on setting up a quality control program, acceptance testing and quality control for planar, SPECT and special imaging procedures. On completion of this article the reader should be able to: (a) discuss the purpose of a quality control program; (b) know how to establish the performance criteria for a scintillation camera; (c) know how to design a quality control program; (d) be able to set up the schedule for the quality control program; (e) understand the economics of quality control; and (f) justify the expenditure of the institution's resources on quality control.

Cost-identification analysis in oral cavity cancer management

The objectives of this study were to investigate potential relationships between pretreatment patient-mix characteristics, treatment modalities, and costs generated during the pretreatment work-up, treatment, and 1-year follow-up periods for patients with oral cavity cancer (OCC). Another objective was to identify potential areas for cost reduction and improved resource allocation in the management of OCC patients. Using a retrospective cohort of 73 patients with OCC, pretreatment patient-mix characteristics and treatment modalities were evaluated in relation to university-based charges incurred during the pretreatment evaluation, treatment, and 1-year follow-up periods. Simple regression and stepwise multiple regression analyses were used to develop predictive models for cost based on independent variables, including age, AJCC TNM clinical stage, smoking history, American Society of Anesthesiologists (ASA) class, comorbidity as defined by the Kaplan-Feinstein grade and treatment modality. The dependent measurements included all physician, office, and hospital charges incurred at the University of Iowa Hospitals and Clinics during the pretreatment evaluation, treatment, and follow-up periods, as well as the total pretreatment through 1-year follow-up management costs. Independent variables that were identified as being significantly associated with treatment costs included T classification, N classification, TNM stage, unimodality versus multimodality treatment, and the Kaplan-Feinstein comorbidity grade. Age, smoking status, and ASA class were not significantly associated with costs. The majority of the OCC management costs were incurred during the treatment period. The most substantial decreases in management costs for OCC will be realized through measures that allow identification and treatment of disease at an early stage, in which single-modality treatment may effectively be used. Resource allocation for OCC should support the investigation of measures through which the diagnosis and treatment of OCC at the earliest possible stage is facilitated. The presence of comorbid illness is a significant component in the determination of management costs for OCC and should be included in analyses of resource allocation for OCC. The singular diagnosis of OCC encompasses a wide range of patient illness severity, and diagnosis-related reimbursement schemes for OCC treatment should optimally differentiate between early and advanced stage disease.

Preclinical evaluation of 9-chloro-2-methylellipticinium acetate alone and in combination with conventional anticancer drugs for the treatment of human brain tumor xenografts

Some ellipticine derivative salts, including 9-chloro-2-methylellipticinium (CME), have been found to have a marked selectivity against all eight brain tumor cell lines of the U.S. National Cancer Institute's disease-oriented in vitro screen. We initiated in vivo antitumor studies to explore the feasibility for further development of this class of compounds. We found that CME was extremely toxic to nude mice when given i.p. at a dose of 25 mg/kg for 3 consecutive days. Animals treated by this route experienced an increase in hepatic transaminases and histopathological changes in the liver, compatible with mitochondrial damage. In contrast, when the portal circulation was bypassed and the same dose of CME was given i.v., animals tolerated daily bolus injections for 5 consecutive days. This 5-day i.v. bolus schedule had consistent antitumor activity, with 28.1% growth delay on s.c. implanted human U251 gliomas. When the potentially high peaks of CME in the portal circulation were avoided by using a 3-day continuous infusion with osmotic minipumps implanted i.p. to release 3.4 mg kg(-1) h(-1) or 6.6 mg kg(-1) h(-1) CME, there were only modest increases in liver enzymes and leukopenia, but no meaningful antitumor activity was observed. In contrast, continuous infusion in the s.c. space was well tolerated and was accompanied by a demonstrable growth delay in s.c. U251 human gliomas of 37.8%. When CME was used in conjunction with carmustine, etoposide or cisplatin, no synergistic activities were observed, but additive effects were demonstrated. Our pharmacokinetic and disposition studies with CME argue against the notion that large and invasive tumors in the brain lack blood-brain barrier features. When CME was used in animals bearing orthotopically implanted U251 gliomas in the brain of nude mice, the survival of the treated animals was not better than vehicle controls, and the addition of CME to carmustine therapy did not improve the survival of those animals treated with carmustine alone. We conclude that, in spite of its marked cytotoxicity in vitro on a variety of human brain tumor cell lines, including U251 glioma cells, CME has a modest antitumor effect on extracranially implanted U251 glioma tumors, and no beneficial effect in animals bearing the same U251 tumor in the brain, owing to a poor penetration into the brain parenchyma.

A comparison of clinical and structured interview diagnoses in a homeless mental health clinic

OBJECTIVE

This study compared psychiatric diagnoses ascertained by independent clinicians with structured research interviews of homeless psychiatric patients assessed in a mental health clinic and in the community. Problems of both overdiagnosis and underdiagnosis in structured research interviews compared to clinician assessment were predicted.

METHOD

Over a period of a year, 97 patients referred to a mental health clinic for homeless people were assessed with the Diagnostic Interview Schedule (DIS) administered by a clinical social worker who then completed a full clinical psychiatric social work assessment. These same patients received a thorough and systematic clinical psychiatric evaluation by a psychiatrist or psychologist, both experienced with this population. These clinicians gathered data from multiple sources, often with extended observation over time. The DIS and clinician diagnoses were made blind to one another and then compared; the clinician was often made aware of some of the symptoms that the social worker had elicited, but not whether the elicited material was from the DIS or from the clinical assessment. Diagnoses of 33 clinic patients previously assessed by trained nonclinician DIS interviews in an epidemiologic study of the homeless population in the community were also compared to clinician diagnoses, and no information from these patients' survey DIS interviews was made available to the clinicians.

RESULTS

Compared to clinician assessment, structured interviews underdiagnosed antisocial personality disorder (ASPD) and overdiagnosed major depression. Alcohol use disorder and schizophrenia showed only small discrepancies by assessment method. Drug use disorder revealed no bias according to method of ascertainment, but showed very discrepant kappa levels comparing DIS to clinician assessment in the two different comparison contexts.

CONCLUSIONS

If structured research methods assessing the homeless population actually overestimate depression, underestimate ASPD, and misclassify drug abuse, then policies stemming from structured interview research recommendations may call for levels and types of services not optimally suited to the reality of this population's needs. Because mental illness and substance abuse are thought to be critical factors in the generation and perpetuation of homelessness, the issue of accurate diagnosis is tantamount to understanding and providing workable solutions to the problem of homelessness. Further research is needed to untangle potential confounders of the homeless situation to psychiatric diagnosis.

One-year follow-up of survivors of a mass shooting

OBJECTIVE

This report describes a 1-year follow-up study of survivors of a mass shooting incident. Acute-phase data from this incident were previously reported in this journal.

METHOD

The Diagnostic Interview Schedule/Disaster Supplement was used to assess 136 survivors at 1-2 months and again a year later, with a 91% reinterview rate.

RESULTS

In the acute postdisaster period, 28% of subjects met criteria for posttraumatic stress disorder (PTSD), and 18% of subjects qualified for another active psychiatric diagnosis. At follow-up, 24% of subjects reported a history of postdisaster PTSD (17% were currently symptomatic), and 12% another current psychiatric disorder. Half (54%) of all 46 individuals identified as having had PTSD at either interview were recovered at follow-up, and no index predictors of recovery were identified. There were no cases of delayed-onset PTSD (beyond 6 months). Considerable discrepancy in identified PTSD cases was apparent between index and follow-up. Inconsistency in reporting, rather than report of true delayed-onset, was responsible for all PTSD cases newly identified at 1 year. The majority of subjects with PTSD at index who were recovered at follow-up reported no history of postdisaster PTSD at follow-up, suggesting considerable influence of fading memory.

CONCLUSIONS

This study's findings suggest that disaster research that conducts single interviews at index or a year later may overlook a significant portion of PTSD. The considerable diagnostic comorbidity found in this study was the one robust predictor of PTSD at any time after the disaster. Disaster survivors with a psychiatric history, especially depression, may be most vulnerable to developing PTSD and therefore may deserve special attention from disaster mental health workers.

Perceived benefit and mental health after three types of disaster

The study of growth and perceived benefit after traumatic events has been hailed as one of the most promising directions for stress research. This research, however, has been limited by several methodological limitations. These limitations are addressed in this prospective study, which examines perceived benefit and mental health adjustment after 3 different types of disaster. Survivors of a tornado in Madison, Florida, had the highest rates of perceived benefit, followed by survivors of a mass killing in Killeen, Texas, and survivors of a plane crash in Indianapolis, Indiana. Perceived benefit 4-6 weeks postdisaster predicted posttraumatic stress disorder 3 years later. Perceived benefit moderated the effect of severity of disaster exposure on mental health diagnosis change over time. Without perceived benefit, as exposure severity increased, the amount of recovery decreased. If benefit was perceived, as exposure severity increased, the amount of recovery increased. Implications for clinical interventions and future research are discussed.

Connective tissue activation. XXXVII. Effects of cytokine combinations, implications for an integrated cytokine network

OBJECTIVE

Since many cytokines have been identified in chronically inflamed human synovium, it is possible that particular cytokines or combinations of cytokines play dominant roles in driving or inhibiting metabolic processes important to inflammation. To assess these possibilities, we compared selected effects of individual cytokines and their binary, ternary, and higher combinations in human synovial cell cultures.

METHODS

Cytokines studied known to occur in human synovial tissue included: interleukin 1beta (IL-1beta), IL-6, tumor necrosis factor-alpha, granulocyte macrophage colony stimulating factor, interferon-gamma, acidic fibroblast growth factor (aFGF), basic FGF (bFGF), platelet derived growth factor, transforming growth factor-beta1, connecting tissue activating peptide-III, and epidermal growth factor. The growth related effects of these agents singly and in combinations were assessed by measuring newly synthesized [3H]DNA and [14C]GAG (glycosaminoglycan) in human synovial cell cultures. Cytokine induced synthesis of prostaglandin E2 (PGE2) was measured by ELISA.

RESULTS

Most cytokine combinations resulted in additive/synergistic anabolic effects, except when IL-1beta was present; IL-1beta was markedly antagonistic to the mitogenic effects of other cytokines tested. Combinations of platelet derived cytokines were the most potent stimulators of DNA synthesis, while combinations of synovial derived cytokines were more active in stimulating GAG synthesis. Synovial cells exposed simultaneously to both platelet and synovial derived cytokines produced large quantities of [14C]GAG and showed a modest increase in [3H]DNA synthesis. IL-1beta, alone or in combinations, was dominant with respect to stimulation of PGE2 synthesis. Acetylsalicylic acid substantially interfered with all the effects of cytokine combinations measured.

CONCLUSION

Quantitative alterations in synovial cell synthesis of GAG and DNA varied greatly depending on the ambient mixture of cytokines. Virtually all combinations of cytokines tested gave rise to large increases in synovial cell synthesis of GAG. Four platelet derived cytokines, a "physiologic combination," appeared to be dominant agents in stimulating DNA synthesis. This effect was profoundly reduced by the antagonistic effect of IL-1beta, mediated in part by PGE2. The patterns of cytokine combination induced metabolic effects suggest that the "cytokine network" has a significant measure of redundancy with respect to control of synovial cell metabolism.

Perceived benefit and mental health after three types of disaster

The study of growth and perceived benefit after traumatic events has been hailed as one of the most promising directions for stress research. This research, however, has been limited by several methodological limitations. These limitations are addressed in this prospective study, which examines perceived benefit and mental health adjustment after 3 different types of disaster. Survivors of a tornado in Madison, Florida, had the highest rates of perceived benefit, followed by survivors of a mass killing in Killeen, Texas, and survivors of a plane crash in Indianapolis, Indiana. Perceived benefit 4-6 weeks postdisaster predicted posttraumatic stress disorder 3 years later. Perceived benefit moderated the effect of severity of disaster exposure on mental health diagnosis change over time. Without perceived benefit, as exposure severity increased, the amount of recovery decreased. If benefit was perceived, as exposure severity increased, the amount of recovery increased. Implications for clinical interventions and future research are discussed.

Comparison of the Alcohol Dependence Scale and diagnostic interview schedule in homeless women

The Alcohol Dependence Scale (ADS) is a 25 item self-report instrument designed to evaluate the degree of severity of alcohol dependence. Although previous studies have reported on the validity of the ADS, no studies using the ADS have been done on the homeless population, a special and rapidly growing population. To assess the utility of the ADS in a population of homeless, substance-abusing women, the ADS questionnaire was compared with the DSM-III-R alcohol use disorder diagnosis as measured by the Diagnostic Interview Schedule (DIS). Both the ADS and the DIS were administered to 149 homeless, substance-abusing women by trained, lay interviewers. There was good agreement between the ADS and the past-year DIS diagnosis of alcohol use disorder. The level of agreement between the ADS and DIS, as well as sensitivity and specificity, for various ADS cutoff scores are reported to facilitate selection of cutoff scores by clinicians and future researchers.

The frequency of human papillomavirus detection in postmenopausal women on hormone replacement therapy

Postmenopausal women enrolled in the Iowa portion of the postmenopausal estrogen/progestin interventions randomized clinical trial (n = 105) during 1989-1991 were studied for (i) the prevalence of human papillomavirus (HPV) in this older age population (ages 45-64), and (ii) the association between hormone replacement therapies (HRTs) and changes in detection of HPV over a 2-year time period. HPV is causative in most cervical and some other genital cancers and in the presence of steroid hormones has been shown to increase neoplastic transformation by HPV in vitro. Using PCR to detect HPV DNA, the overall frequency of the virus regardless of time period was 50.3% (n = 53) with a baseline (BL) frequency of 38.1% and the second year follow-up (FU) of 22.9%. The oncogenic types HPV-16 (75.5%) and HPV-31 (20.8%) were the most commonly reported. All those with persistently detected infection (10.5%), defined as HPV+ at both BL and FU, were identified with HPV-16 or -18. Between these two time periods there were no significant differences in HPV frequency between the placebo and combined HRT groups (BL-/FU+, 21% vs 18%; BL+/FU-, 71% vs 80%). While the study is based on a small sample, the findings suggest that short-term use of HRTs is not associated with an increased risk of HPV detection, but assessment of effects from long-term use is needed. The data also indicate that the frequency of HPV found in older women is higher than previously suspected but that short-term changes in HPV detected in this age group are unrelated to the development of precancerous cervical lesions.

Nonoperative treatment of major blunt renal lacerations with urinary extravasation

PURPOSE

We determined whether nonoperative treatment of major renal lacerations with urinary extravasation adversely affects patient outcome.

MATERIALS AND METHODS

We reviewed all nonoperatively treated patients who presented between 1983 and 1994 with blunt renal trauma with major lacerations on initial staging computerized tomography. Patients with major lacerations associated with (31) and without (15) extravasation were compared for complications, blood transfusions and length of hospital stay.

RESULTS

Urinary extravasation spontaneously resolved in 27 of 31 patients (87.1%), while 4 (12.9%) required a ureteral stent for persistent extravasation. No complications occurred in patients without extravasation. Mean hospitalization was 8.3 and 7.7 days for patients with isolated renal injuries with and without extravasation, respectively. Blood transfusions were required in 4 patients with and none without extravasation.

CONCLUSIONS

Nonoperative treatment of major renal lacerations with urinary extravasation is safe and effective. Although delayed intervention may be required, complications can often be treated with endourological or percutaneous methods.

A diagnostic comparison of homeless and nonhomeless patients in an urban mental health clinic

This study compared demographic and diagnostic characteristics of a sample of homeless outpatient mental health clinic attenders with a domiciled comparison group from the same clinic. Data on demographic variables and DSM-III-R psychiatric diagnoses were collected over a two-year period on a consecutive sample of 166 homeless and 117 nonhomeless clinic attenders. Data on demographics and psychiatric diagnoses of the homeless clinic attenders were further compared with data collected systematically from 900 homeless individuals in the same city. In the clinic, homeless subjects were more often members of ethnic minorities, and homeless women were significantly younger and better educated than their nonhomeless counterparts. Rates of schizophrenia, bipolar disorder, and somatization disorder were not significantly different between homeless and nonhomeless groups. Major depression was about four times as prevalent in nonhomeless men as in homeless men. Homeless men were significantly more likely than nonhomeless men to qualify for a diagnosis of alcohol use disorder, and homeless women were more likely than other women to qualify for a diagnosis of drug use disorder. Both homeless men and women were significantly more likely than their domiciled counterparts to meet criteria for antisocial personality disorder. Personality disorder other than antisocial was more prevalent in nonhomeless men than in homeless men. Combined rates of personality disorder were significantly higher among homeless than nonhomeless women, but not men. Homeless clinic attenders were demographically and diagnostically very similar to a general homeless population in the same city. The only diagnosis that was more prevalent in the homeless clinic than in the homeless community was antisocial personality disorder. We concluded that because of difference in diagnostic prevalence, homeless and nonhomeless individuals in mental health clinics need to be considered independently. Clinicians treating homeless outpatients may benefit from having special facility in diagnosis and management of antisocial personality disorder and substance abuse, along with expertise in other psychiatric disorders in this population.

Association between female infertility and agricultural work history

Lifetime industrial and occupational histories of women with a medically-confirmed diagnosis of infertility (n = 281) were compared to a group of postpartum women (n = 216) for risks of infertility. Controlling for age of first pregnancy or self-report of infertility, date of outcome, cigarette use, and employment in other types of industries, women were at increased risk of infertility if they had worked in industries associated with agriculture (OR = 7.0, 95% CI 2.3-20.8; cases = 11.7%, controls = 1.9%). Among the occupations in which women worked prior to outcome, only those in agriculture were at significantly elevated risk (adj. OR = 11.3, CI 2.6-48.8; cases = 10.0%, controls = 0.9%). Among those who resided on a farm, the risk of infertility was significantly increased (adj. OR = 1.8, CI 1.2-2.7; cases = 37.4%, controls = 25.8%) although yearly duration of farm residence was not (adj. OR = 0.99, CI 0.95-1.03). Farm residence did not alter the OR seen in agricultural industries or occupations. The risk of being diagnosed with an ovulatory or tubal factor increased 4-16-fold among those who had worked in agricultural industries or occupations. These data suggest that, as has been established in men, agriculturally-related exposures may be a significant risk for infertility in women.

Psychiatric disorders among the homeless: a comparison of older and younger groups

The purpose of this study is to identify differences between older and younger homeless subgroups. Nine hundred homeless persons were interviewed using the National Institute of Mental Health Diagnostic Interview Schedule, and DSM-III-R diagnoses were made. Results showed that 79 (13%) of the 600 men and 10 (3%) of the 300 women were in the older (age > or = 50 years) group. Compared with their younger counterparts, older subjects were more likely to be male and white, to report lower incomes and poorer health, and to meet criteria for lifetime alcohol-use disorder. Fewer older than younger subjects met criteria for lifetime drug use disorder and post-traumatic stress disorder. These findings suggest that older and younger individuals have different vulnerabilities to homelessness.

Occupational exposures and risk of female infertility

This study examined the association between occupational chemical and radiation exposures and risk of medically diagnosed infertility in 281 women compared with 216 fertile women. After adjustment for age and exposures that occurred before case/referent ascertainment, there was an increased risk of infertility among those women exposed to volatile organic solvents (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.11 to 2.71), chemical dusts (OR, 2.66; CI, 1.17 to 6.05), pesticides (OR, 3.02; CI, 1.10 to 8.29), and video display terminals (OR, 2.21, CI, 1.22, to 4.01). Among the medically diagnosed causes of infertility, the adjusted risk associated with having an ovulatory factor increased among those women exposed to solvents (OR, 1.75; CI, 1.03 to 2.98), dusts (OR, 3.00; CI, 1.19 to 7.52), or pesticides (OR, 3.82; 1.28 to 11.42). Solvents and dusts also were associated with a higher risk of tubal-factor infertility (solvents; OR, 1.95; CI, 1.08 to 3.52; dusts: OR, 2.87; CI, 1.05 to 7.88) and endometriosis (solvents: OR, 2.13; CI, 0.96 to 4.72; dusts: OR, 3.63; CI, 0.99 to 13.28). Video display terminal exposure was more likely to be found among those women diagnosed with endometriosis (OR, 3.69; CI, 1.50 to 9.13) and cervical-factor infertility (OR, 2.65; CI, 0.99 to 7.12). Results suggest that among women with a medically confirmed diagnosis, fertility may be adversely affected by a variety of occupational chemical exposures.

The genetic program of genital human papillomaviruses in infection and cancer

Human papillomavirus (HPV) infection has been recognized as the major cause of cervical cancer. This article summarizes the functions of HPV gene products that cause abnormal cell growth--E6 and E7--and reviews how cellular and viral factors influence their synthesis. E6 and E7 inactivate two cellular tumor-suppressor gene products, p53 and RB. In cervical cancer, E6-E7 gene control is deranged by mutations in viral control sequences and in integrated HPV fragments by the disruption of the viral repressor E2. Elimination of this sequence makes E6-E7 mRNAs unstable, and deranges cellular regulation at the integration site. It is apparent that an intricate interplay of cellular and viral factors determines whether the outcome is active papillomavirus infection, viral latency, or ultimately, genital cancer.

Are the mentally ill homeless a distinct homeless subgroup?

The question has been raised whether it is useful or meaningful to dichotomize the homeless population by mental illness - i.e., to consider the mentally ill homeless as distinct from other homeless people. The current article presents evidence from a single data set to address this question empirically. Data from a randomly sampled population of 900 homeless men and women systemically interviewed using the Diagnostic Interview Schedule were examined to determine associations of mental illness with the problems of homelessness, controlling for the presence of substance abuse in the analyses. Although a few clinically meaningful associations with mental illness were found that might suggest directions for appropriate interventions, mental illness did not differentiate individuals in many important demographic and biographic respects. Individual diagnoses did not perform much better in differentiating the homeless by mental illness. Schizophrenia and bipolar mania showed a few significant associations not identified by the "major mental illness" construct. Major depression, constituting the majority of nonsubstance Axis I disorder in the homeless, provided no association beyond that obtained with the "major mental illness" category. The data provide little support for conceptualizing homeless subgroups or homelessness in general on the basis of mental illness alone. To do so also risks neglecting the emotional distress of the majority without major mental illness and the other problems that homeless persons share regardless of psychiatric illness. While serious mental illness is overrepresented among the homeless, it represents just one of many important vulnerability factors for homelessness. Substance abuse is far more prevalent than other Axis I disorders. Media images equating homelessness with major mental illness unnecessarily stigmatize homeless people and encourage oversimplified and narrowly conceived psychiatric interventions. While continuing attention is needed on improving identification and management of serious mental illness among the homeless, this must be accomplished within the broader context of social and economic aspects of homelessness.

Adrenocorticotropin--a central trigger in immune responsiveness: tonal inhibition of immune activation

Adrenocorticotropin is known for its key role in mediating neuroendocrine responses, especially in response to stress. Recently, it has been recognized to have direct immunomodulatory actions, most of which are suppressive. This is a widely conserved action which occurs in invertebrates and vertebrates. This conservation illustrates the fundamental nature of adrenocorticotropin's immunomodulatory action. Such a mechanism of action helps explain why the immunocytes themselves can serve as a source of adrenocorticotropin. Regulation of adrenocorticotropin production and action is complex and the result is an integration of multiple mechanisms. Serum adrenocorticotropin levels fluctuate in response to stimulatory and inhibitory factors. Further, peptidases can specifically process adrenocorticotropin into smaller active fragments, inactive peptides or into peptides with different activities. These proteolytic enzymes have a differential tissue and cellular distribution. Immune stimulating factors such as interleukin-1 can overcome adrenocorticotropin inhibition and secondarily, block adrenocorticotropin production through the release of corticosteroids. With an endogenous presence and complex regulation it has been difficult to characterize adrenocorticotropin's role in the immune system. Here, we propose that adrenocorticotropin is a tonis regulator of immune response, i.e. it tonally inhibits immunocytes which undergo disinhibition as the result of exposure to stimulatory signals, e.g. cytokines, neuropeptides, etc. Thus, adrenocorticotropin appears to set the threshold for immunoactivation by controlling the degree of immunoexcitability.

Human immunodeficiency virus envelope glycoprotein 120 alters sleep and induces cytokine mRNA expression in rats [published errata appear in Am J Physiol 1996 Aug;271(2 Pt 2):section R following table of contents and 1996 Dec;271(6 Pt 3):section R following table of contents]

Sleep is altered during the course of viral infection, including that in which the human immunodeficiency virus (HIV) is the etiologic agent. Alterations in the sleep of HIV-infected individuals occur early in the course of infection, prior to the onset of AIDS. The mechanisms for such alterations in sleep are not known. The HIV envelope glycoprotein 120 (gp120) induces the synthesis and secretion of cytokines that enhance [e.g., interleukin (IL)-1 and tumor necrosis factor] and suppress (e.g., IL-10 and IL-1 receptor antagonist) sleep. We used a well-defined rat model to test the hypothesis that the HIV gp120 alters sleep. Recombinant HIV-1IIIB gp120 was injected intracerebroventricularly (20- 500 ng) into rats prior to dark onset. Sleep-wake behavior was not altered after the 20-ng dose, whereas both non-rapid eye movement sleep (NREMS) and rapid eye movement sleep (REMS) were initially enhanced and subsequently suppressed after the 100-ng dose. NREMS was enhanced for 8 h after the 500-ng dose; REMS was not affected by this dose. Brain temperature was not altered by any of the gp120 doses used in this study. In addition, mRNA expression for IL-1 beta and IL-10 was induced in the hypothalamus by gp120; this brain region is crucial for the regulation of sleep. These new data support the hypothesis that altered cytokine concentrations within the central nervous system play a pivotal role in the complex alterations in sleep observed during HIV infection.

Surgical anticipatory stress manifests itself in immunocyte desensitization: evidence for autoimmunoregulatory involvement

The immunocyte behavior (conformational changes and locomotion in response to signal molecule challenge) in patients about to undergo elective cardiac surgery was studied to elucidate the effect of psychological anticipatory stress on the immune system. Granulocytes and monocytes from 10 patients and 35 non-surgical controls were examined. Computer-assisted microscopic image analysis, capable of measuring cellular conformational and velocity changes, was used to measure the responsiveness of these immunocytes to peptidergic and cytokine stimulation. Immunocyte desensitization would appear to account for the reduction in their abilities to respond to chemotaxic challenge associated with the pre-cardiac surgery state. Their abilities to respond to D-Ala2-Met-enkephalinamide (DAMA) were observed only at much higher concentrations than previously reported (10-11 M vs. 10-9 M prior to surgery). This finding, together with the observed decrease in adrenocorticotropin levels compared to non-surgical controls, suggests that neutral endopeptidase activity was elevated just prior to surgery. Indeed, neutral endopeptidase activity is statistically elevated in the pre-cardiac surgery state. Furthermore, glucocorticoid levels remained constant, within normal resting limits, in both groups. Thus, surgical anticipatory stress may manifest itself, in part, as a desensitization of various immunocytes. Thus, a psychological anticipatory stress response may be a precipitant of the desensitization. Although this desensitization seemed not to involve the entire hypothalamic-pituitary-adrenal axis, the data suggest that psychological anticipatory stress may initially involve and influence autoimmunoregulation.

Eighteen-month follow-up data on a treatment program for homeless substance abusing mothers

In response to the dearth of data on substance abuse treatment among homeless mothers, this study breaks new ground in presenting 18-month follow-up data on 149 homeless mothers with young children enlisted in a substance abuse treatment program. The effects of residential compared to nonresidential services were evaluated over the follow-up period. Although dropout rates were high, predictors of dropout were identified, and the residential had a lower dropout rate compared to the nonresidential comparison group. Members of both residential and nonresidential groups evidenced improvement in alcohol and drug problems and in housing stability, regardless of the amount of time they spent in the program. This project demonstrated that homeless mothers can be more successfully engaged in substance abuse programs with provisions of residential placement in addition to participation in a therapeutic community. Future interventions can take advantage of this knowledge in designing more effective programs.

Opioid and opiate immunoregulatory processes

The discovery of the ability of the nervous system to communicate through "public" circuits with other systems of the body is attributed to Ernst and Berta Scharrer, who described the neurosecretory process in 1928. Indeed, the immune system has been identified as another important neuroendocrine target tissue. Opioid peptides are involved in this communication (i.e., neuroimmune) and with that of autoimmunoregulation (communication between immunocytes). The significance of opioid neuropeptide involvement with the immune system is ascertained from the presence of novel delta, mu, and kappa receptors on inflammatory cells that result in modulation of cellular activity after activation, as well as the presence of specific enzymatic degradation and regulation processes. In contrast to the relatively uniform antinociceptive action of opiate and opioid signal molecules in neural tissues, the presence of naturally occurring morphine in plasma and a novel mu3, opiate-specific receptor on inflammatory cells adds to the growing knowledge that opioid and opiate signal molecules may have antagonistic actions in select tissues. In examining various disorders (e.g., human immunodeficiency virus, substance abuse, parasitism, and the diffuse inflammatory response associated with surgery) evidence has also been found for the involvement of opiate/opioid signaling in prominent mechanisms. In addition, the presence of similar mechanisms in man and organisms 500 million years divergent in evolution bespeaks the importance of this family of signal molecules. The present review provides an overview of recent advances in the field of opiate and opioid immunoregulatory processes and speculates as to their significance in diverse biological systems.

The presence and effects of mammalian signal molecules in immunocytes of the insect Leucophaea maderae

Opioid peptides activate immunocytes and opiate alkaloids inhibit this activation in the mussel, Mytilus edulis. Here we present evidence that cells of another invertebrate, Leucophaea maderae, can be influenced in a similar way by the Met-enkephalin analogue D-Ala2-Met5-enkephalin (DAMA) and morphine. Effects of different signal molecules on Leucophaea hemocytes were evaluated by computer-assisted image analysis of their conformational state. A small percentage of the untreated cells were found to display spontaneous conformational changes after 25 min of incubation without pharmacological agents which was noted as a decrease in both circularity factor and shape factor values. Activation caused the cells to become elliptical, a feature that appears to be characteristic of Leucophaea immunocytes. Administration of DAMA induced a similar activation of most of the cells. After 30 min these DAMA-activated cells started to display distinct locomotory activity not seen in the controls. alpha-Melanocyte-stimulating hormone (MSH, 10(-7)) added to the incubation medium after DAMA-activation caused the cells to return to their original "rounded" conformation. In addition, the presence of immunoreactive interleukin (IL-1), adrenocorticotropin (ACTH) and tumor necrosis factor (TNF) in the hemolymph was demonstrated. These data suggest an interaction between both vertebrate-type immunological signal molecules and neuropeptides in the regulation of immunological cells in Leucophaea.

Ultraviolet light and 8-methoxypsoralen inhibit expression of endothelial adhesion molecules

OBJECTIVE

Having previously found that treating small areas of synovitis within the knees of patients with rheumatoid arthritis (RA) with 8-methoxypsoralen (8-MOP) and laser-derived ultraviolet A (PUVA) resulted in decreases in adhesion molecule expression, we sought to determine the effect of PUVA on expression of vascular cellular adhesion molecule 1 (VCAM-1), intercellular adhesion molecule 1 (ICAM-1), and E-selection by human umbilical vein endothelial cells (HUVEC).

METHODS

Expression of VCAM-1, ICAM-1, and E-selectin on the surface of HUVEC was measured using specific antibodies and flow cytometry or a fluorescence plate reader, following treatment of cells with 8-MOP and UVA, before and after tumor necrosis factor (TNF) stimulation.

RESULTS

PUVA led to significant dose dependent decreases in the expression of VCAM-1 and E-selectin that had been induced with TNF before PUVA treatment. Pretreatment with PUVA was also able to prevent subsequent TNF induction of VCAM-1 expression. TNF-induced ICAM-1 expression was not decreased by PUVA, however, and pretreatment only partially decreased ICAM-1 expression.

CONCLUSION

The in vivo effects of PUVA may be explained, in part, by down regulation of adhesion molecule expression. The relative resistance of ICAM-1 to PUVA suggests some specificity to the effect on adhesion molecule expression.

Modulation of immune responses by anabolic androgenic steroids

Anabolic androgenic steroids (AS) have recently been placed on the Food and Drug Administration's (FDA's) list of controlled substances, because of the adverse effects seen in athletes taking accelerated dosages in attempts to enhance performance. Reported deleterious effects on abusers include sterility, gynecomastia in males, acne, balding, psychological changes, and increased risks of heart disease and liver neoplasia. Considering the roles of the immune and neuroendocrine systems and their interactions in many of these pathologies, it is important to determine the effects of these derivitized androgens on this connection. Little is known in this respect. We therefore determined the effects of anabolic steroids on certain immune responses and their effects on the extrapituitary production of corticotropin by lymphocytes. We present evidence that (1) both 17-beta and 17-alpha esterified AS, nandrolone decanoate and oxymethenelone, respectively, significantly inhibited production of antibody to sheep red blood cells in a murine abuse model; (2) the control androgens testosterone and dehydroepian-drosterone (DHEA) or sesame seed oil vehicle had no significant effects on antibody production; (3) nandrolone decanoate and oxymethenelone directly induced the production of the inflammatory cytokines IL-1 beta and TNF-alpha from human peripheral blood lymphocytes but had no effect on IL-2 or IL-10 production; (4) control androgens had no direct cytokine inducing effect; (5) nandrolone decanoate significantly inhibited IFN production in human WISH and murine L-929 cells; and (6) nandrolone decanoate significantly inhibited the production of corticotropin in human peripheral blood lymphocytes following viral infection. These data indicate that high doses of anabolic steroids can have significant effects on immune responses and extrapituitary production of corticotropin. Furthermore, the mouse model should provide an effective means by which to study other deleterious effects of anabolic steroid abuse in humans.

Interleukin-10 (cytokine synthesis inhibitory factor) acts in the central nervous system of rats to reduce sleep

Interleukin-10 (IL-10), originally designated a cytokine synthesis inhibitory factor, inhibits the synthesis of the pro-inflammatory cytokines IL-1 and tumor necrosis factor by stimulated human and mouse monocytes/macrophages; these cytokines are involved in the regulation of sleep. To determine if IL-10 reduces spontaneous sleep, we injected murine recombinant IL-10 intracerebroventricularly into rats prior to light onset. Non-rapid eye movements sleep was reduced. The behavioral responses to IL-10 were abolished by heat-inactivation of this cytokine. We believe these to be the first observations of central nervous system actions for this cytokine. These results further support the hypothesis that cytokines are involved in the regulation of sleep, and suggest an additional mechanism whereby sleep may be altered in response to an activated immune system.

Cyclotorsion in the seated and supine patient

We used Maddox double-rod measurements to determine if positionally induced ocular cyclotorsion occurs when a patient moves from the seated to supine position. Maddox double-rod measurements were determined twice while patients (N = 30) viewed a fixation light at a distance of 7 feet in both the seated and supine positions. The difference between axis measurements made in seated and supine positions was not statistically significant. There was also no significant difference between the two measurements made in the seated and in the supine positions. These data show that the eyes do not undergo positionally induced ocular cyclotorsion when a patient moves from a seated to a supine position.