Explant culture, immunofluorescence and electron-microscopic study of flexor retinaculum in carpal tunnel syndrome

Although flexor-retinaculum (FR) release provides dramatic relief from carpal tunnel syndrome (CTS), the role of this ligament in CTS is not well understood. We have adopted a unique approach to study the cellular pathogenesis of CTS by establishing a method for the culture of cells of FR from subjects with and without CTS. The cultured cells were characterized by light, immunofluorescence, electron microscopy, Western blot analysis, and growth studies. Two main differences between the CTS and control cells included a faster growth rate and an altered fine morphology that reveals the contractile nature of the CTS cells. It is possible that the presence of these contractile cells in FR is responsible for increasing the contractility of the FR, leading to a decrease in the volume of the carpal tunnel, thus exerting pressure on the median nerve and triggering CTS.

Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies

OBJECTIVE

To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams.

DESIGN

One year retrospective and a 2 1/2 year prospective study.

SETTING

Two hospitals in West London and 88 general practitioners in 72 general hospitals.

SUBJECTS

209 adults with HIV infection.

INTERVENTION

General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced.

MAIN OUTCOME MEASURES

Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners.

RESULTS

The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved.

CONCLUSIONS

This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.

Passive smoking and impaired endothelium-dependent arterial dilatation in healthy young adults

BACKGROUND

Passive smoking has been linked to an increased risk of dying from atherosclerotic heart disease. Since endothelial dysfunction is an early feature of atherogenesis and occurs in young adults who actively smoke cigarettes, we hypothesized that passive smoking might also be associated with endothelial damage in healthy young-adult nonsmokers.

METHODS

We studied 78 healthy subjects (39 men and 39 women) 15 to 30 years of age (mean +/- SD, 22 +/- 4): 26 control subjects who had never smoked or had regular exposure to environmental tobacco smoke, 26 who had never smoked but had been exposed to environmental tobacco smoke for at least one hour daily for three or more years, and 26 active smokers. Using ultrasonography, we measured the brachial-artery diameter under base-line conditions, during reactive hyperemia (with flow increase causing endothelium-dependent dilatation), and after sublingual administration of nitroglycerin (an endothelium-independent dilator).

RESULTS

Flow-mediated dilatation was observed in all control subjects (8.2 +/- 3.1 percent; range, 2.1 to 16.7) but was significantly impaired in the passive smokers (3.1 +/- 2.7 percent; range, 0 to 9; P < 0.001 for the comparison with the controls) and in the active smokers (4.4 +/- 3.1 percent; range, 0 to 10; P < 0.001 for the comparison with the controls; P = 0.48 for the comparison with the passive smokers). In the passive smokers, there was an inverse relation between the intensity of exposure to tobacco smoke and flow-mediated dilatation (r = -0.67, P < 0.001). In contrast, dilatation induced by nitroglycerin was similar in all groups.

CONCLUSIONS

Passive smoking is associated with dose-related impairment of endothelium-dependent dilatation in healthy young adults, suggesting early arterial damage.

Quantal components of spontaneous excitatory junction potentials at visualised varicosities

The electrical signs of spontaneous transmitter release were recorded with an extracellular electrode from single visualized sympathetic varicosities on the mouse vas deferens. Ultrastructural examination of these varicosities with the electron microscope showed that they formed close-contacts with smooth muscle cells. Amplitude-frequency histograms of the spontaneous excitatory junction potentials (SEJPs) were constructed in order to determine the statistical nature of spontaneous transmitter release from a varicosity. SEJP histograms often possessed several peaks. Statistical tests showed that these were separate modes in the histograms indicating that the SEJPs were composed of subunits. The SEJP histograms were described by a mixture of distributions in which the components were identified as quanta and there was a Poisson release of quanta. The second mode in the SEJP histograms was sometimes twice that of the first mode but generally greater, suggesting a potentiation of the effects of one quantum released nearly simultaneously with another quantum. The components in the SEJP histograms were well fitted by either a Gaussian or a gamma distribution indicating that the quantum of transmitter could be described as a Gaussian or gamma variate.

Evaluating services for women with serious and ongoing mental health problems: developing an appropriate research method

Despite an increase in the literature on women with less disabling or transitory mental health problems, there is little relating to women with serious and ongoing difficulties. In considering the means by which the needs of this population might be studied, tension arises over methodology. Research comparing the clinical, functional and service use characteristics of women and men might demonstrate their different mental health problems but would neither elucidate women's particular needs nor examine the social reasons for this difference. A feminist methodology would, however, offer a means of exploring the experiences of women, a framework for understanding sex differences, and generate findings that would be beneficial to women. The present study gives an insight into ways in which the exploration of sex differences can be combined with a study of women for women without compromising the relevance and impact of the findings.

Knowledge and attitudes of hospital personell toward older adults

The Facts on Aging Quiz was given to 693 hospital personnel to examine their knowledge of and attitudes toward older adults. Respondents 40 years of age and over had better knowledge scores than respondents 16-29 years old. Individuals with associate, baccalaureate or graduate degrees had higher knowledge scores than respondents with a high school education. Clinical employees and volunteers had higher knowledge scores than non-clinical employees. Approximately 25% of the hospital personnel exhibited a negative bias (i.e., attitude) toward older adults. Considering the health care utilization of older adults, it is important that all individuals working within a hospital environment exhibit knowledge of and appropriate attitudes toward them. Implications for gerontological education programs based on adult-learning techniques are noted.

Estimation of bladder volume using portable ultrasound in clam enterocystoplasty patients

PURPOSE

We evaluated portable ultrasound for the measurement of residual volume following clam enterocystoplasty.

MATERIALS AND METHODS

Bladder volumes were measured in 25 clam enterocystoplasty patients using a portable ultrasound machine and compared with urethral catheter volumes. A similar study was performed on a control group of 50 patients with normal bladder architecture.

RESULTS

There was a close correlation (r = 0.978) between ultrasound and catheter volumes in the control group with a regression line slope of 0.88. There was an equally close correlation (r = 0.960) in the clam enterocystoplasty group but the regression line slope was lower at 0.65, which suggests an underestimation of the true bladder volume. There was a significant difference (p < 0.0001) between the ultrasound-to-catheter volume ratio in the 2 groups.

CONCLUSIONS

Portable ultrasound is inaccurate for the measurement of residual bladder volume in clam enterocystoplasty patients.

Statistics of quantal secretion during long trains of sympathetic nerve impulses in mouse vas deferens

1. A statistical analysis has been made of the occurrence of excitatory junctional currents (EJCs) of similar amplitude recorded with an extracellular electrode during long trains of nerve impulses to the mouse vas deferens. 2. The number of EJCs of similar amplitude that occurred in consecutive impulses during trains of 500-1000 impulses at 0.5-2.0 Hz increased with the number of EJCs evoked during the train. 3. There was no evidence of significant dependence between consecutive EJCs of similar amplitude in sixteen out of eighteen trains in eighteen preparations. 4. The time course of clusters of EJCs of similar amplitude was examined by determining the standard deviation of different groups of EJCs within a cluster throughout their time course. Most EJCs within a cluster could be grouped with a coefficient of variation < 0.1 throughout their time course. 5. The observations on EJCs of similar amplitude leave open the possibility that secretion from single varicosities is, in general, multiquantal.

Carotid intima-media thickness is only weakly correlated with the extent and severity of coronary artery disease

BACKGROUND

Intima-media thickness (IMT) of the common carotid artery (CCA), measured with external vascular ultrasound, has been widely used in clinical trials as a surrogate marker for coronary atherosclerosis. Despite this, the degree of correlation between carotid IMT and the extent and severity of coronary artery disease (CAD) is not known.

METHODS AND RESULTS

Common carotid IMT was measured by ultrasound in 350 consecutive subjects of age 60 +/- 10 years (range, 30 to 85 years) on the day of coronary angiography. Carotid mean IMT was 0.83 +/- 0.20 mm (range, 0.43 to 1.80 mm), and maximum IMT was 1.04 +/- 0.27 mm (range, 0.49 to 2.19 mm). Coronary angiograms were analyzed by independent observers for disease severity (number of vessels with > or = 70% stenosis), extent score, and a modified Gensini score. Mean carotid IMT was weakly but significantly correlated with CAD severity (r = .26), extent (r = .23), and modified Gensini score (r = .29, P < .0001 for all correlations). Carotid IMT was not clinically useful, however, because it was not specific or sensitive enough to identify patients with or without significant CAD. Increasing age, male sex, and presence of diabetes were all associated with a significantly (P < .01) higher CAD score than the average for any level of carotid IMT, suggesting differential effects of these traditional risk factors on the coronary and common carotid arteries.

CONCLUSIONS

Although carotid IMT is significantly correlated with extent and severity of CAD, the relationship is weak. This relatively poor correlation (r2 < .10) should be considered in the interpretation of clinical trials that use carotid IMT as a surrogate end point for coronary atherosclerosis.

Oral L-arginine inhibits platelet aggregation but does not enhance endothelium-dependent dilation in healthy young men

OBJECTIVES

Our aim was to assess the effect of oral L-arginine on endothelial or platelet physiology in humans.

BACKGROUND

L-Arginine is the substrate for nitric oxide synthesis, and in cholesterol-fed rabbits, oral L-arginine improves endothelium-dependent dilation, inhibits platelet aggregation and reduces atheroma. In hypercholesterolemic humans, intravenous L-arginine immediately improves endothelium-dependent dilation; however, the vascular effects of oral L-arginine in healthy humans have not previously been investigated.

METHODS

In a prospective, double-blind, randomized crossover trial, 12 healthy young men 27 to 37 years old took L-arginine (7 g three times daily) or placebo for 3 days each, separated by a washout period of 7 to 14 days.

RESULTS

After L-arginine, plasma levels of arginine (mean +/- SEM 303 +/- 36 vs. 128 +/- 12 mumol/liter, p = 0.01) and urea (6.7 +/- 0.5 vs. 5.2 +/- 0.2 mmol/liter, p < 0.01) were higher than levels measured after placebo, and platelet aggregation in response to adenosine diphosphate was markedly impaired (37 +/- 12% vs. 81 +/- 3%, p = 0.02). The inhibition of platelet aggregation correlated with the plasma level of L-arginine (r = 0.74, p = 0.01), and it could be completely or partially reversed by ex vivo incubation with N-monomethyl-L-arginine, a specific nitric oxide synthase inhibitor. Platelet cyclic guanosine monophosphate levels were higher after oral L-arginine than at baseline (1.91 +/- 0.46 vs. 1.38 +/- 0.40 pmol/10(9) platelets, p = 0.04). No changes were seen in fasting lipid levels, heart rate, blood pressure, endothelium-dependent dilation of the brachial artery (measured in response to reactive hyperemia, using external vascular ultrasound) (6.1 +/- 0.7% vs. 6.5 +/- 0.7%, p = NS) or in plasma levels of nitrosylated proteins (a marker of in vivo nitric oxide production) (3.5 +/- 0.5 vs. 3.3 +/- 0.4 mumol/liter, p = NS) 1 to 1.5 h after the last dose of L-arginine.

CONCLUSIONS

In these healthy young adult men, oral L-arginine inhibited platelet aggregation by way of the nitric oxide pathway. However, it had no effect on systemic hemodynamic variables, plasma nitrosylated protein levels or endothelium-dependent dilation. Therefore, at certain doses, oral L-arginine may result in a relatively platelet-specific increase in nitric oxide production.

Phorbol ester-induced down modulation of tailless CD4 receptors requires prior binding of gp120 and suggests a role for accessory molecules

The entry of human immunodeficiency virus type 1 into cells proceeds via a fusion mechanism that is initiated by binding of the viral glycoprotein gp120-gp41 to its cellular receptor CD4. Species- and tissue-specific restrictions to viral entry suggested the participation of additional membrane components in the postbinding fusion events. In a previous study (H. Golding, J. Manischewitz, L. Vujcic, R. Blumenthal, and D. Dimitrov, J. Virol. 68:1962-1968, 1994), it was found that phorbol myristate acetate (PMA) inhibits human immunodeficiency virus type 1 envelope-mediated cell fusion by inducing down modulation of an accessory component(s) in the CD4-expressing cells. The fusion inhibition was seen in a variety of cells, including T-cell transfectants expressing engineered CD4 receptors (CD4.401 and CD4.CD8) which are not susceptible to down modulation by PMA treatment. In the current study, it was found that preincubation of A2.01.CD4.401 cells with soluble monomeric gp120 for 1 h at 37 degrees C primed them for PMA-induced down modulation (up to 70%) of the tailless CD4 receptors. The gp120-priming effect was temperature dependent, and the down modulation may have occurred via clathrin-coated pits. Importantly, nonhuman cell lines expressing tailless CD4 molecules did not down modulate their CD4 receptors under the same conditions. The gp120-dependent PMA-induced down modulation of tailless CD4 receptors could be efficiently blocked by the human monoclonal antibodies 48D and 17B, which bind with increased avidity to gp120 that was previously bound to CD4 (M. Thali, J. P. Moore, C. Furman, M. Charles, D. D. Ho, J. Robinson, and J. Sodroski, J. Virol. 67:3978-3988, 1993). These findings suggest that gp120 binding to cellular CD4 receptors induces conformational changes leading to association of the gp120-CD4 complexes with accessory transmembrane molecules that are susceptible to PMA-induced down modulation and can target the virions to clathrin-coated pits.

Noninvasive pulse wave analysis for the early detection of vascular disease

A noninvasive technique has been developed and validated for calculating capacitive and oscillatory systemic arterial compliance with the use of pulse wave analysis and a modified Windkessel model. Application of the technique to subjects with hypertension, postmenopausal women with symptomatic coronary artery disease, and appropriate control subjects has confirmed a reduction of oscillatory compliance in the disease states and an increase in capacitive and oscillatory compliances in response to vasodilator drugs. This method should be useful in screening subjects for early evidence of vascular disease and in monitoring the response to therapy.

Temporal and spatial patterns of opsin gene expression in zebrafish (Danio rerio)

In zebrafish, the first class of cone photoreceptor to become morphologically distinct is the ultraviolet-sensitive short single cone, at 4 days postfertilization, whereas the last class, the red- and green-sensitive double cone, becomes distinct at 10 days postfertilization. We have examined the time course of visual pigment gene expression in zebrafish using whole-mount in situ hybridization. Within the retina, opsins may be detected as early as 40 h postfertilization with the ultraviolet and rod visual pigments being expressed before the blue- (48 h) and red- (60 h) sensitive pigments. In the pineal, red-sensitive opsin is expressed at 48 h postfertilization. Visual pigment expression provides a useful tool for investigations of early cell fate in zebrafish.

Non-invasive measurement of human endothelium dependent arterial responses: accuracy and reproducibility

OBJECTIVE

To assess a non-invasive test for endothelial dysfunction, an important early event in the atherogenic process.

METHODS

Using high resolution ultrasound, the accuracy of detecting small changes in vessel diameter was assessed using phantom "arteries", and the same equipment was then used to measure flow mediated dilatation in the brachial artery of 40 healthy adults aged 22-51 years, studied on four occasions; intervals between scans were 1-2 days, 1-2 weeks, and 2-4 months.

RESULTS

Differences between pairs of phantom "arteries" with diameters 0.1-0.2 mm apart were correctly estimated in 162 of 264 cases (61%); no measurement by any of four independent observers was > 0.1 mm in error, and the mean error was 0.04 mm. For in vivo scans, the overall coefficient of variation for flow mediated dilatation was 1.8% (1.6% for women, 1.9% for men, P = 0.18). In 34/40 subjects (85%), all values for flow mediated dilatation were within 2.5% of the overall mean for each subject. A nested analysis of variance showed the expected between patient variability, and also significant day to day variation, but little between weeks or months. Using these data to generate power function analyses, we calculated that for individuals, an improvement in flow mediated dilatation of 4-8% is significantly greater than natural variability. In clinical trials, a mean improvement in flow mediated dilatation of at least 2% would usually be required to detect a treatment benefit, with much larger subject numbers needed for a parallel group compared to a crossover trial design.

CONCLUSIONS

Vascular responses to endothelium dependent and independent stimuli in systemic arteries can be studied non-invasively in man. Subjects should be studied on at least two occasions before and after any intervention, to optimise the chance of showing a significant effect from any potentially beneficial therapy.

Involvement of the V1/V2 variable loop structure in the exposure of human immunodeficiency virus type 1 gp120 epitopes induced by receptor binding

The binding of human immunodeficiency virus type 1 (HIV-1) to the cellular receptor CD4 has been suggested to induce conformational changes in the viral envelope glycoproteins that promote virus entry. Conserved, discontinuous epitopes on the HIV-1 gp120 glycoprotein recognized by the 17b, 48d, and A32 antibodies are preferentially exposed upon the binding of soluble CD4 (sCD4). The binding of the 17b and 48d antibodies to the gp120 glycoprotein can also be enhanced by the binding of the A32 antibody. Here we constructed HIV-1 gp120 mutants in which the variable segments of the V1/V2 and V3 structures were deleted, individually or in combination, while the 17b, 48d, and A32 epitopes were retained. The effects of the variable loop deletions on the function of the HIV-1 envelope glycoproteins and on the exposure of epitopes induced by sCD4 or A32 binding to the monomeric gp120 glycoprotein were examined. The variable-loop-deleted envelope glycoproteins were able to mediate virus entry, albeit at lower efficiencies than those of the wild-type glycoproteins. Thus, the V1/V2 and V3 variable sequences contribute to the efficiency of HIV-1 entry but are not absolutely required for the process. Neither the V1/V2 nor V3 loops were necessary for the increase in exposure of the 17b/48d epitopes induced by binding of the A32 monoclonal antibody. By contrast, induction of the 17b, 48d, and A32 epitopes by sCD4 binding apparently involves a movement of the V1/V2 loops, which in the absence of CD4 partially mask these epitopes on the native gp120 monomer. The results obtained with a mutant glycoprotein containing a deletion of the V1 loop alone indicated that the contribution of the V2 loop to these phenomena was more significant than that of the V1 sequences. These results suggest that the V1/V2 loops, which have been previously implicated in CD4-modulated, postattachment steps in HIV-1 entry, contribute to CD4-induced gp120 conformational changes detected by the 17b, 48d, and A32 antibodies.

Thyrotropin-releasing hormone: does two hundred micrograms provide effective stimulation to the preterm fetal pituitary gland compared with four hundred micrograms?

OBJECTIVE

Our purpose was to compare the response of the fetal pituitary-thyroid axis to 200 and 400 micrograms of thyrotropin-releasing hormone administered to the mother immediately before delivery with a control group.

STUDY DESIGN

A randomized controlled trial was conducted of 26 women at gestational ages between 24 weeks and 33 weeks 6 days who had received one or more doses of betamethasone who were expected to be delivered within 1 to 4 hours. Women received either 200 or 400 micrograms of thyrotropin-releasing hormone or were in the control group.

RESULTS

Thyroid-stimulating hormone determinations on cord blood had a higher mean level in both treatment groups compared with the control group. No differences were seen in cord blood results between the two treatment groups for thyroid-stimulating hormone, thyroxine, triiodothyronine, free thyroxine, free triiodothyronine, and prolactin levels. The only other differences found were in a higher level in total thyroxine and a lower level of free thyroxine in the 400 micrograms thyrotropin-releasing hormone group compared with the 200 micrograms group in the 48-hour blood determinations.

CONCLUSION

Both 200 and 400 micrograms of thyrotropin-releasing hormone provided fetal pituitary stimulation, as reflected in fetal thyroid-stimulating hormone levels in cord blood, and both gave significantly higher levels compared with a control group.

Probabilistic secretion of quanta at somatic motor-nerve terminals: the fusion-pore model, quantal detection and autoinhibition

The probability of detecting first, second, and later quanta secreted at release sites of a motor-nerve terminal during the early release period following a nerve impulse has been addressed. The possibility that early quantal release autoinhibits later quantal release during this period has also been ascertained. In this investigation, a model for the secretion of a quantum at a release site is developed in which, following the influx and diffusion of calcium ions to a release site protein associated with synaptic vesicles, kappa steps of association of the ions with the protein then occur at rate alpha. The release site protein then undergoes a conformational change which may not go on to completion if calcium ions dissociate from the protein at rate gamma. If this process does reach completion then a fusion-pore between the vesicle and the presynaptic membrane is created; this happens at rate delta. Key assumptions of this fusion-pore model are that the quantal secretions from each site are independent of each other, and that there is a large number of vesicles, each with a small probability of secretion, so that the number of secretions is Poisson in nature. These assumptions allow analytical expressions to be obtained for predicting the times at which first, second and later quanta are secreted during the early release period following an impulse. To test the model, experiments were performed in which the times of first, second and later quantal releases were determined at discrete regions along the length of visualized motor-terminal branches in toad (Bufo marinus) muscles. Estimates of model rate constants and of kappa from the times for first quantal secretions failed to give satisfactory predictions of the observed times of later secretions. Therefore, either the model fails, or the procedure used for detecting later quantal events as a consequence of their being masked by earlier quantal events is inadequate. To solve this detection problem, a two-dimensional analysis of the spread of charge following the secretion of a quantum at a random site on the motor-terminal branch has been done. This allows determination of the probability that later quanta will be detected following secretion of earlier quanta. The detection model was then incorporated into the fusion-pore model to predict the times at which second and later quanta occur during the early release period, based on the estimates of the model parameters derived from the analysis of first quantal releases. Good estimates were now obtained for the observed times of second and later quantal releases, indicating that appropriate procedures must be adopted for adequate detection of quantal secretions. Furthermore, the experiments provide support for the fusion-pore model. It has been suggested that the binomial nature of quantal release from the entire motor-nerve terminal may be explained if early quantal release inhibits later quantal release during the early quantal release phase (M. R. Bennett & J. Robinson 1990, Proc. R. Soc. Lond. B 239, 329-358). Although the fusion-pore detection error model gave good predictions of the observed times of first, second and later quantal releases, these may be improved if a model for autoinhibition is included. In this model the first quantum was taken as giving rise to an inhibition of secretion that propagates to surrounding release sites with a constant velocity, v. A combined model incorporating the fusion-pore detection error model and that for autoinhibition was then used to predict second and later quantal latencies, by using the first quantal latencies to determine the estimates for the parameters in the combined model. When this analysis was done on the times for quantal secretion at sites on thirteen different motor-nerve terminals, the value of v was estimated as zero in each case, so that no autoinhibitory effect was observed.

Project 2000: a review of published research

The findings of research into the implementation of the Project 2000 reforms of nurse education in England and Wales are reviewed in this paper. The work of nine research teams who have published their findings between 1990 and 1994 is reviewed. Following a brief summary of the major Project 2000 recommendations, the findings of the various research teams are presented. Both successes and difficulties in implementing Project 2000 are highlighted. The findings are discussed in the light of the original Project 2000 proposals, and it is concluded that, notwithstanding 'teething' difficulties, the Project 2000 reforms are proving workable in practice.