Use of a screen log to audit patient recruitment into multiple randomized trials in the intensive care unit. Canadian Critical Care Trials Group

OBJECTIVE

To develop and evaluate a screen log for monitoring enrollment in multiple randomized clinical trials conducted in a single center.

SETTING

University-affiliated 20-bed tertiary care medical-surgical intensive care unit (ICU).

PATIENTS

Consecutive ICU patients admitted between April 1995 and March 1997.

METHODS

We developed a screen log for multicentered studies conducted in our ICU. Using a multiple-project, unicenter perspective, we evaluated the screen log as a tool for monitoring eligibility and enrollment of patients in four multicentered randomized trials focused on stress ulcer prophylaxis, blood transfusion thresholds, immunotherapy for sepsis and mechanical ventilation strategies.

RESULTS

The screen log was used as an instrument to monitor trial execution. We recorded all aspects of study enrollment and created a taxonomy of reasons for nonenrollment into each trial. We calculated enrollment efficiency rates and used these data to develop strategies to maximize accrual. The screen log became a communication tool that fostered research-oriented continuous quality improvement initiatives for the management of concurrently conducted randomized trials in our ICU.

CONCLUSIONS

Intensivists participating in several clinical trials may be interested in monitoring and maximizing enrollment when conducting multiple studies and understanding the influence of each trial on enrollment into the others. The unicenter, multiple-project screen log is one tool that may help to achieve these goals.

The effects of moxonidine, a novel imidazoline, on plasma norepinephrine in patients with congestive heart failure. Moxonidine Investigators

OBJECTIVE

To evaluate the dose response relationship of moxonidine on plasma concentration of norepinephrine during acute and chronic administration in patients with congestive heart failure (CHF).

BACKGROUND

Sympathetic activation is increased in heart failure. Moxonidine is an imidazoline ligand acting on the central nervous system (CNS) receptors to decrease sympathetic activation.

METHODS

Ninety-seven patients with heart failure and New York Heart Association class II-III symptoms and ejection fraction <40% were randomized to placebo or one of three target doses of moxonidine, 0.1, 0.2 or 0.3 mg administered twice daily. An initial dose of moxonidine 0.1 mg twice a day (b.i.d.) was followed by weekly increments of 0.1 mg b.i.d. until target dose. The second and third study days occurred after four weeks (at target dose) and after 12 weeks, respectively. At each study day, repeated blood samples were drawn.

RESULTS

There was a significant dose-related decrease of systolic blood pressure across all three study days. Heart rate decreased significantly on study day 3 in a dose-related manner. The acute 2 h decrease in plasma norepinephrine in response to all three doses of moxonidine was significantly different compared with placebo after four and 12 weeks. There was a significant linear relation between dose and plasma norepinephrine after four and 12 weeks in both 2 h peak and the time averaged effect (>8 h). The number of adverse events was similar in the moxonidine and placebo groups.

CONCLUSIONS

The increased sympathetic activation in CHF can be reduced by moxonidine through CNS inhibition.

Consistency in the ratings of behaviors of communicatively impaired autistic and non-autistic preschool children

Typically, children with disabilities are evaluated clinically by a number of professionals with different backgrounds whose task is to provide a diagnosis and an intervention plan. This study was carried out to describe interrater agreement for pairs of independent observers rating with different instruments the behaviors of 505 communicatively impaired autistic and nonautistic preschool children. Observers were parents, teachers, neurologists, and psychiatrists. Parents and teachers responded to behavioral questionnaires, neurologists filled out the mental status part of a standardized neurologic evaluation, and psychiatrists an observational questionnaire. All four types of observers rated sociability, language, play, attention, stereotyped, and other aberrant behaviors. Agreement between pairs of raters was significant but moderate. Owing to range restriction with smaller numbers of subjects, agreement decreased for ratings of subsamples divided according to diagnosis, cognitive level, or age. There were some differences among observers' ratings of the severity of particular categories of behaviors, with physicians generally viewing the children as more severely impaired and teachers as least impaired. Interrater agreement was not enhanced when parents and teachers rated similarly worded behavioral items. Modest interrater agreement in this study, like agreement among disparate raters of children's behaviors in other studies, suggests that observers are sensitive to different aspects of behavior and that their ratings are more likely to be complementary than unreliable.

Effect of metal reconstruction plates on cobalt-60 dose distribution: a predictive formula and clinical implications

PURPOSE

We sought to create a predictive formula for the dose perturbations caused by head and neck reconstruction plates in the delivery of postoperative radiotherapy with 60Co beams.

MATERIALS AND METHODS

The dose perturbation effects of Vitallium and Titanium reconstruction plates and flat metal plates of aluminum (13Al), stainless steel (26Fe), tin (50Sn) and lead (82Pb) irradiated with a 60Co beam were measured in polystyrene phantoms using a film dosimetry system. We then used these results to create formulas to predict the effect of a metal reconstruction plate dependent upon its effective atomic number.

RESULTS

Percentage dose increases secondary to back scattering were 10% at 1 mm in front of the Vitallium plate and 40% at the plate while the percentage dose decrease was 29% at the plate and 10% 1 mm behind the plate. For the Titanium plate, the percentage dose increase was 5% at 1 mm in front the plate and 25% at the plate while the percentage dose decrease was 20% at the plate and 5% 1 mm behind the plate. For flat plates the percentage dose increases and decreases, respectively, at the plate surfaces were: 13Al (8%, 6%), 26Fe (35%, 16%), 50Sn (60%, 24%), and 82Pb (85%, 13%). A second order polynomial predicting the back scatter and shadowing effects was created, Y = a + bZ + cZ2, where Z is the effective atomic number of the plate while a, b, and c are the following constants: for back scatter a = 0.854 +/- 0.082, b = 0.0212 +/- 0.0044, c = -0.00011 +/- 0.00004 and for shadowing a = 1.108 +/- 0.021, b = -0.0141 +/- 0.0011, c = 0.00014 +/- 0.00001.

CONCLUSIONS

It is possible to predict the effect of a metal reconstruction plate upon the delivered postoperative radiotherapy dose. The dose perturbations around the plate only exist for a few millimeters, but this is substantially greater than the thickness of a normal tissue or tumor cell. Perhaps a coating of a low effective atomic number, biologically inert, substance might allow for greater dose homogeneity and decrease the risks of plate failure or tumor recurrence.

Acute intoxication with guaifenesin, diphenhydramine, and chlorpheniramine

Mixed drug reactions are frequently encountered in emergency department overdose cases and also in fatal intoxications. Assessment of the relative contribution of each drug in producing adverse effects is often compounded by lack of case history and the paucity of cases reported in the literature. This report describes a fatal intoxication with three common over-the-counter medications: guaifenesin, diphenhydramine, and chlorpheniramine. A 48-year-old woman was found dead in the attic bedroom of her residence. Specimens obtained at autopsy for toxicologic analysis included heart blood, urine, bile, gastric contents, vitreous humor, and cerebrospinal fluid. The over-the-counter drugs were identified and quantitated by acid/neutral or basic liquid-liquid extraction followed by gas chromatographic analysis with nitrogen phosphorus detection. Concentrations of guaifenesin, diphenhydramine, and chlorpheniramine detected in the heart blood were 27.4, 8.8, and 0.2 mg/L, respectively. The cause of death was determined to be acute intoxication by the combined effects of guaifenesin, diphenhydramine, and chlorpheniramine, and the manner of death was determined to be suicide. To our knowledge, the blood guaifenesin concentration in this case is the highest reported concentration to date associated with an acute intoxication.

The General Medical Health Rating: a bedside global rating of medical comorbidity in patients with dementia

OBJECTIVE

Dementia is a serious public health problem. General medical comorbidity is common in dementia patients and critical to their care. However, little is known about medical comorbidity in these patients, and there are no straightforward bedside global rating scales for the seriousness of comorbid medical illness. This paper describes the development and measurement properties of the General Medical Health Rating (GHMR), a rapid global rating scale of medical comorbidity in dementia patients.

DESIGN

Interrater reliability, concurrent validity, and predictive validity of the GMHR are reported.

SETTING

An outpatient dementia clinic, assisted living, and nursing home.

PARTICIPANTS

A total of 819 consecutive dementia clinic outpatients and 180 consecutive admissions to Copper Ridge, a long-term care residence for people with dementia, were included in the study.

RESULTS

GMHR was found to be highly reliable (weighted kappa = .91). Across all stages and types of dementia, GMHR ratings were correlated with number of comorbid medical conditions, number of medications being taken for comorbid conditions, and with activity of daily living impairment, even after adjustment for severity of dementia. GMHR ratings were also a strong predictor of falls and of mortality in long-term care residents after adjustment for age and severity of dementia.

CONCLUSION

GMHR is a reliable, valid, global bedside measure of severity of general medical comorbidity for patients with dementia that can be used for clinical and research purposes.

Wandering behaviour in community-residing persons with dementia

OBJECTIVES

To examine wandering behaviour in elderly demented persons in the community setting with respect to dementia characteristics and other factors that might influence wandering behaviour; to generate a statistical model to assess the relative importance of these various factors in predicting wandering behaviour.

DESIGN

Cross-sectional, case-control investigation.

SETTING

University-affiliated outpatient neuropsychiatric assessment center.

PARTICIPANTS

Six hundred and thirty-eight consecutive community-residing new patients with dementia referred for evaluation.

MEASUREMENTS

Comprehensive neuropsychiatric evaluation, including rating with Mini-Mental State Examination; General Medical Health Rating; Comell Scale of Depression in Dementia and caregiver interview.

RESULTS

Wandering behaviour occurred in 17.4% of participants. It was significantly more prevalent in patients with Alzheimer Dementia (AD), patients with dementia of longer duration, and patients with more severe dementia. Wandering behaviour was associated with moderate to severe depression, delusions, hallucinations, and sleep disorder. Other significant associations of wandering behaviour included use of neuroleptic medication and male gender. After statistical adjustment for other variables, duration of dementia, severity of dementia and presence of sleep disorder retained significant statistical association with wandering behaviour.

CONCLUSIONS

Wandering behaviour among community-residing elderly dementia patients is associated with a number of factors, some of which may be subject to modification. It is possible that management of coexistent psychopathology, particularly of sleep disorder, and of the underlying disease process of AD would help to ameliorate this problematic behavioural disorder. Further investigation is warranted into the relationship between neuroleptic medication and wandering behaviour and into possible alternative measures to control agitation in elderly dementia patients.

Physical aggression in dementia patients and its relationship to depression

OBJECTIVE

The goal of this study was to determine the frequency of physically aggressive behavior in community-residing patients with dementia and its relationship to depression.

METHOD

A consecutive series of 541 patients with DSM-IV-defined dementia underwent comprehensive neuropsychiatric evaluation and were rated on the Cornell Scale for Depression in Dementia, the Mini-Mental State, the Psychogeriatric Dependency Rating Scale, and the General Medical Health Rating.

RESULTS

Physically aggressive behavior was exhibited by 79 patients in the 2 weeks before evaluation. Aggressive behavior was closely associated with moderate to severe depression, male gender, and greater impairment in activities of daily living, even after adjustment for delusions, hallucinations, sleep disturbance, and severity of cognitive impairment. After adjustment for depression, gender, and impairment in activities of daily living, there was no association between physically aggressive behavior and the presence of either delusions or hallucinations.

CONCLUSIONS

A substantial minority of patients with dementia exhibit physically aggressive behavior, and this aggression is strongly linked with the presence of depressive symptoms. It is possible that the identification and treatment of depression in dementia may be a means of preventing and managing physically aggressive behavior.

Tumors and DNA adducts in mice exposed to benzo[a]pyrene and coal tars: implications for risk assessment

Current methods to estimate the quantitative cancer risk of complex mixtures of polycyclic aromatic hydrocarbons (PAH) such as coal tar assume that overall potency can be derived from knowledge of the concentration of a few carcinogenic components such as benzo[a]pyrene (B[a]P). Genotoxic damage, such as DNA adducts, is thought to be an essential aspect of PAH-induced tumorigenesis and could be a biomarker for exposure useful for estimating risk. However, the role of B[a]P and the relationship of adduct formation in tumorigenesis have not been tested rigorously in models appropriate for human health risk assessment. Therefore, we directly compared tumor induction and adduct formation by B[a]P and coal tars in several experimental protocols, including one broadly accepted and used by regulators. We found that B[a]P content did not account for tumor incidences after exposure to coal tars. DNA adducts were found in both tumors and tumor-free tissue and tumor outcomes were not predicted by either quantitation of total DNA adducts or by the DNA adduct formed by B[a]P. These data suggest that risk assessments based on B[a]P content may not predict accurately risk to human health posed by environmental PAH.

Relationship of cognitive and functional impairment to depressive features in Alzheimer's disease and other dementias

Patients with clinical diagnoses of Alzheimer's disease, vascular dementia, or undifferentiated dementia were rated on standardized measures of depression, cognitive impairment, and functional impairment. Logistic regression was used to evaluate the relationship between functional or cognitive impairment, as well as their interaction, and depressive features in each group. This analysis revealed notable differences by type of dementia. The results imply that the mechanisms underlying depression in Alzheimer's disease may be different from those in vascular and other types of dementia. These results also provide indicators to the clinician for further evaluation of depression in different dementia subtypes.

Anastrozole versus megestrol acetate in the treatment of postmenopausal women with advanced breast carcinoma: results of a survival update based on a combined analysis of data from two mature phase III trials. Arimidex Study Group

BACKGROUND

This report presents the results of a survival update based on the combined data from two studies that compared the efficacy and tolerability of anastrozole (1 or 10 mg once daily), a selective, nonsteroidal aromatase inhibitor administered orally, and megestrol acetate (40 mg 4 times daily) in the treatment of postmenopausal women with advanced breast carcinoma whose disease had progressed after treatment with tamoxifen.

METHODS

Two randomized, parallel-group, multicenter trials were conducted, involving a total of 764 patients. The two trials were identical in design; both were double blind for anastrozole and open label for megestrol acetate. Overview analyses were conducted with the intent of strengthening the interpretation of results from each trial. The median follow-up duration for this survival update was 31 months.

RESULTS

At the clinical dose of 1 mg daily, anastrozole demonstrated a statistically significant survival advantage over megestrol acetate, with a hazard ratio of 0.78 (P < 0.025)(0.60 < 97.5% confidence interval [CI] <1.0). The 1 mg anastrozole group also had a longer median time to death (26.7 months) compared with 22.5 months for the megestrol acetate group. The 10 mg anastrozole group also had a survival benefit over the megestrol acetate group, with a hazard ratio of 0.83 (P=0.09, not significant)(0.64 < 97.5% CI < 1.1). Higher 2-year survival rates were observed for both anastrozole treatment groups than for the megestrol acetate group (56.1%, 54.6%, and 46.3% for the groups given 1 mg anastrozole, 10 mg anastrozole, and megestrol acetate, respectively).

CONCLUSIONS

This combined analysis of two trials of postmenopausal patients with advanced breast carcinoma has clearly demonstrated that, after disease progression with tamoxifen, treatment with anastrozole 1 mg once daily results in a statistically and clinically significant advantage over a standard treatment, megestrol acetate. This important benefit, in addition to the good tolerability profile of anastrozole, supports the use of this drug as a valuable new treatment option for this patient population.

Investigation of hepatic cytochrome P-450 enzyme induction and DNA adduct formation in male CD/1 mice following oral administration of toxaphene

Exposure of experimental animals to toxaphene induces hepatic cytochrome P-450 (CYP). Although chronic administration of toxaphene to mice was found to cause an increased incidence of liver tumors, a mechanism for its carcinogenicity has yet to be elucidated. We investigated two potential mechanisms of toxaphene-induced carcinogenicity: peroxisomal proliferation and DNA binding. Peroxisomal proliferation was evaluated by measuring the level of immunodetectable CYP 4A1, an isozyme of CYP that is specifically induced by peroxisomal proliferators, in hepatic microsomes from CD1 mice that were treated by oral gavage for seven consecutive days with corn oil vehicle or 10, 25, 50 or 100 mg kg(-1) toxaphene. In comparison to control mice, toxaphene-treated mice had increased liver weight, increased liver/body weight ratios and increased levels of total hepatic CYP and cytochrome b5. No increase in the level of immunodetectable levels of CYP 4A1 was found in hepatic microsomes from toxaphene-treated mice when compared to controls. In contrast, increases in immunodetectable CYP 4A1 were detected in hepatic microsomes from mice treated with the peroxisomal proliferator clofibrate. These findings suggest that toxaphene-induced induction of CYP may not involve CYP 4A1 and that peroxisomal proliferation may not be involved in toxicity. Significant increases in immunodetectable levels of CYP 2B were, however, detected in toxaphene-treated mice, and are consistent with earlier reports demonstrating that toxaphene, like many other pesticides, induces the phenobarbital-inducible subfamily of CYP. Analysis of DNA adduct levels in the livers of toxaphene-treated mice by DNA 32P-post-labeling showed no evidence of DNA adduct formation.

Major and minor depression in Alzheimer's disease: prevalence and impact

One hundred nine outpatients with Alzheimer's disease (AD) were neuropsychiatrically evaluated and rated on standardized measures of depression, activities of daily living (ADL), nonmood behavioral disturbance, and burdensome events such as serious wandering, falls, and accidents. Distribution of depression scores revealed three patient groups: very few depressive symptoms (51%), minor depression (27%), and major depression (22%). Major depression was associated with substantially greater impairment in ADL, worse nonmood behavioral disturbance (such as aggression), and more frequent serious wandering, even after adjusting for severity of dementia or comorbid health problems. Minor depression was also associated with nonmood behavioral disturbance and wandering. The authors conclude that both major and minor depression are common in AD and produce considerable mood and nonmood morbidity affecting both patients and caregivers. Efforts are warranted to identify and treat depression in AD.

Dysregulated expression of neutrophil apoptosis in the systemic inflammatory response syndrome

OBJECTIVE

To study the effect of the systemic inflammatory response syndrome (SIRS) or major elective surgery on the apoptosis of circulating polymorphonuclear neutrophils because an activated inflammatory response is terminated, in part, through the programmed cell death, or apoptosis, of its effector cells.

DESIGN

A prospective inception cohort study.

SETTING

A mixed surgical and medical intensive care unit of an adult tertiary care hospital.

PATIENTS

Sixteen patients with SIRS, 7 uninfected patients who had undergone elective aortic aneurysmectomy, and 8 healthy laboratory control subjects.

INTERVENTIONS

Serial blood samples were drawn for evaluation of neutrophil apoptosis, activational state, and surface receptor expression by flow cytometry.

MAIN OUTCOME MEASURES

Spontaneous apoptosis was significantly delayed in neutrophils from patients with SIRS (8.6%+/-6.8%) and patients who had undergone elective aortic aneurysmectomy (11.0%+/-5.0%) when compared with controls (34.9%+/-6.8%). These neutrophils were activated as evidenced by enhanced respiratory burst activity and augmented surface expression of CD11b. Apoptosis in response to engagement of cell surface Fas (also known as CD95 or APO-1) with an agonistic antibody was blunted. Plasma from patients with SIRS or patients who had undergone elective aortic aneurysmectomy suppressed the apoptotic responses of control neutrophils (plasma from patients with SIRS, 18.8%+/-10.3%; plasma from patients who had undergone elective aortic aneurysmectomy, 20.0%+/-6.1%; P<.01). Western blot analysis showed normal expression of the key proapoptotic proteases, interleukin 1beta converting enzyme and CPP32 (also known as YAMA, apopain, and caspase 3), indicating that delayed apoptosis was not a consequence of decreased levels of proapoptotic enzymes.

CONCLUSIONS

Circulating neutrophils from patients with SIRS or from patients who have undergone major elective surgery show delayed expression of constitutive programmed cell death, and antiapoptotic factors are present in the general circulation. While prolonged neutrophil survival may represent an appropriate adaptive response to injury, the presence of activated and apoptosis-resistant cells in an antiapoptotic environment may contribute to the systemic inflammatory injury characteristic of SIRS and predispose to the development of the multiple organ dysfunction syndrome.

RheothRx (poloxamer 188) injection for the acute painful episode of sickle cell disease: a pilot study

RheothRx (Glaxo Wellcome Inc, Research Triangle Park, NC; poloxamer 188) Injection is a nonionic surfactant with hemorrheologic properties that suggest it may be useful in treating acute painful episodes (vasoocclusive crises) of sickle cell disease (SCD). We conducted a randomized, double-blind, placebo-controlled pilot study to evaluate the safety and efficacy of poloxamer, formulated as RheothRx Injection, in 50 patients with SCD. Patients with moderate to severe painful episodes requiring parenteral analgesics were randomized to receive a 48-hour infusion of either RheothRx or placebo. Pain was assessed every 4 hours. Efficacy endpoints included: (1) painful episode duration, (2) days of hospitalization, (3) quantity of analgesics used, and (4) pain intensity scores. Three subgroups of patients were considered for efficacy analyses based on the actual duration of the study drug infusion and the completeness of pain score data collection. Compared with placebo and depending on the subgroup, RheothRx-treated patients showed a 16% to 45% decrease in duration of painful episodes, a 1- to 2-day reduction in hospital stay, a threefold to fivefold reduction in analgesic requirements, and a 1-point reduction (using a 5-point scale) in average pain intensity scores at 72 hours. RheothRx was well tolerated; no clinically significant differences were observed between treatments with respect to adverse experiences or other safety measures. In addition, there were no differences between treatment groups in the incidence of recurrent painful episodes. In this study, RheothRx significantly reduced total analgesic use and pain intensity and showed trends to shorter duration of painful episodes and total days of hospitalization. In patients with moderate to severe vasoocclusive pain, RheothRx was safe and may offer a therapeutic benefit.

Issues of death and dying: the perspective of critical care nurses

A major shift in the care of terminally ill people, due to advances in technology, and the development of legislation regarding patient self-determination and autonomy, has occurred over recent years. Critical care nurses (CCNs) are involved daily in issues of death and dying and are very aware of the needs, fears and psychosocial issues of patients and their families. Professional associations see a legitimate role for nurses in assisting the dying to achieve a dignified death. For legislation, policies and guidelines surrounding end-of-life issues to be effective, and to assist nursing staff with these sensitive, often difficult concerns, it is important that data on the opinions and perspectives of CCNs be objectively obtained. In a study by the Department of Social and Preventive Medicine at the University of Queensland, questionnaires were sent to 1100 randomly sampled community members and almost 1200 health professionals (nurses, general practitioners and specialists), including 299 CCNs. The response rate of CCNs to a 30-page postal questionnaire was 79 per cent (n = 231), indicating those nurses' high levels of interest in and/or concern regarding this area. CCNs supported the use of advance directives, the appointment of proxies and the need for doctors and nurses to give sufficient medication to relieve pain, even if this hastened the death of the patient. In addition, CCNs, more than any other professional group, supported the right of the terminally ill patient to physician-assisted suicide or euthanasia, their responses being very similar to those of community members. CCNs clearly face issues which, from legal, medical and ethical viewpoints, cause them concern. In sharing their personal experiences, CCNs stressed the need for more communication between doctors and patients, as well as between doctors and nurses. In addition, CCNs saw a clear role for themselves as advocates for patients/families in the decision-making process.

Natural history of blood pressure in sickle cell disease: risks for stroke and death associated with relative hypertension in sickle cell anemia

PURPOSE

Blood pressure in individuals who have sickle cell disease has been reported to be lower than published normal values. We determine whether and to what degree this is true, using data obtained as part of a large natural history study.

PATIENTS AND METHODS

Blood pressure was measured annually for 3,317 subjects with sickle cell disease who were 2 years old or older. Values obtained were compared with those reported by the National Health and Nutrition Examination Survey I and II (NHANES I and II). They were further analyzed with respect to age, sex, height, weight, hematologic diagnosis, blood urea nitrogen and creatinine, stroke, and death.

RESULTS

Blood pressure was significantly lower in subjects with sickle cell anemia than published norms for age, race, and sex, a difference that increased with age. It correlated with body mass index, hemoglobin, measures of renal function and age, but the strength of the correlation varied among age and sex subgroups. The risk for occlusive stroke increased with systolic but not diastolic pressure. Mortality was related to elevated blood pressure in males (P < 0.05) and to a lesser extent in females (P = 0.10). In subjects with hemoglobin SC disease, blood pressure also deviated from normal but to a lesser degree.

CONCLUSION

Blood pressure is generally lower than normal in individuals with sickle cell anemia. Those with high values relative to this population had an increased risk of stroke and death. Blood pressure should be monitored but values obtained must be assessed relative to the lower values expected for patients with this disease. Those with blood pressure values above 140/90 mm Hg should be evaluated and considered for treatment.

Intravenous clofilium for conversion of atrial fibrillation

Clofilium was administered to 14 patients with mainly chronic atrial fibrillation in a pilot study. QTc prolongation was observed, and 2 patients had conversion to sinus rhythm after drug infusion.

Depression, delusions, and hallucinations in Alzheimer's disease: no relationship to apolipoprotein E genotype

The apolipoprotein E (APOE) locus on chromosome 19 has been shown to modify risk, and age at onset, of Alzheimer's disease (AD). The authors hypothesized that the phenotypic expression of different psychiatric symptoms in patients with AD would be associated with variability in APOE locus. Neuropsychiatric and genetic testing of 120 probable AD patients revealed 28% had major depression, 17% had minor depression, 30% had delusions, and 14% had hallucinations; 69% were carriers of at least one APOE E4 allele (14% homozygous E4/E4, 49% heterozygous E3/E4, 6% heterozygous E2/E4, 29% homozygous E3/E3, 2% heterozygous E2/E3). Prevalence of the various psychiatric disturbances did not differ significantly in AD patients with different APOE genotypes. Apolipoprotein E does not appear to modify the risk of developing AD-associated psychiatric symptomatology.

Carcinogenicity of benzo[a]pyrene and manufactured gas plant residues in infant mice

The present study determined tumorigenicity, tumor classification and DNA damage induced in infant mice by benzo[a]pyrene (B[a]P) or Manufactured Gas Plant (MGP) residues after a single exposure. Male and female B6C3F1 mice were exposed to B[a]P or MGP residue from a single environmental site (MGP-4) and males were also exposed to MGP residue composite from seven different sites (MGP-M7). At 26, 39 and 52 weeks after exposure tumorigenesis was assessed in lung, forestomach and liver. Formation and persistence of DNA adducts were quantified by 32P-postlabeling. Exposure of males to B[a]P induced liver tumors in a dose and time dependent manner. MGP induced more advanced tumors than B[a]P. Only a single liver tumor was found in MGP-4 treated females. No forestomach and few pulmonary adenomas were induced in males or females. MGP-4, MGP-M7 or B[a]P induced DNA adducts in males and females. Adducts in liver, lung and forestomach peaked on different days and decreased at different rates. At 24 h post-exposure, no significant differences in initial DNA adduct levels occurred in males and females exposed to MGP-4 or B[a]P. Lack of DNA damage (adducted DNA) did not account for non-responsiveness of lung and forestomach in B6C3F1 genders as well as in liver in females. MGP tumorigenicity could not be accounted for solely by B[a]P content nor did it reflect additivity of B[a]P and other carcinogenic polycyclic aromatic hydrocarbons (PAHs) in MGP. Synergy among MGP-PAHs, presence of unidentified carcinogens and/or promoters in MGP may account for MGP potency. The B6C3F1 infant male model is a convenient and rapid assay for assessing MGP liver tumorigenicity and potency.

The SCID-D diagnostic interview and treatment planning in dissociative disorders

With the development of reliable diagnostic tools for the dissociative disorders, earlier implementation of appropriate therapy is now possible. The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D) (Steinberg, 1994b), an extensively field-tested semistructured interview, can assist clinicians with treatment planning as well as diagnosis. This article discusses the diagnostic interview process, the importance of feedback interviews, specific questions regarding consultation and referral, and the use of hypnosis. The final section correlates the five dissociative symptoms assessed by the SCID-D with different phases of treatment planning.

The psychological effects of a four-week emergency medicine rotation on residents in training

OBJECTIVE

To prospectively evaluate psychological stress reactions among residents in an emergency medicine (EM) rotation during a 4-week period.

METHODS

Pre- and postrotation psychological distress levels were assessed over a 4-week EM rotation. Subjects were evaluated by several psychometric measures. These included the assessment of anxiety, depressive, and other psychological symptoms by the Brief Symptom Inventory (BSI), and the occurrence of traumatic anxiety via the Dissociative Experience Scale (DES). Also assessed were the Impact of Events Scale and the Holmes Social Readjustment Ratings Scale (Holmes), a baseline life-change measure. Demographic data were obtained. The study occurred in a university-affiliated teaching hospital ED. The 45 EM residents and 27 non-EM residents were analyzed as a group, followed by subgroup analysis comparing EM vs non-EM residents.

RESULTS

An increase in psychological distress over the 4-week rotation was found in the non-EM group, but not in the EM group. For the non-EM residents, all 10 BSI scales worsened and 3 of 4 DES scales worsened (p = 0.002), indicative of increased psychological distress. In contrast, analysis of the 45 EM residents showed improvement in 8 of 10 BSI scales and 3 of 4 DES scales (p = 0.057).

CONCLUSION

A significant increase in psychologic distress was found among the non-EM residents during an EM rotation. The EM residents showed a trend for a decrease in psychological distress over the same 4-week period.

Thyroid function and thyroid tumors in toxaphene-treated rats

Historically, a direct and irreversible genotoxic reaction of a xenobiotic with DNA has been considered to be a universal and obligatory initiating event in the etiology of neoplasia, and it was assumed therefore that (1) there was no threshold other than zero exposure for cancer initiation, and (2) like radiation, exposure was additive over a lifetime. Human exposure to xenobiotics causing neoplasia in laboratory rodents has been regulated in many countries on that basis. In the last decade evidence has accumulated indicating that some neoplasia in laboratory rodents may not be caused by a direct and irreversible interaction of xenobiotics with DNA. In addition, it has been found that some neoplasia caused in laboratory rodents by xenobiotics may not be relevant for biochemical/physiological reasons. This has raised the question whether human exposure to these xenobiotics should be regulated by the no-threshold philosophy used for direct-acting genotoxic xenobiotics or whether they can be regulated by the threshold philosophy used for classical xenobiotic-induced toxic effects. In a bioassay carried out by the National Cancer Institute and published in 1979, toxaphene was found to cause an increase in the occurrence of two spontaneously occurring tumors in laboratory rodents that since have been found to have both genotoxic and nongenotoxic etiologies in laboratory rodents. Experiments described in this paper are part of a program to help elucidate whether the increased incidence of these two neoplasms in laboratory rodents could have had a nongenotoxic origin, and thus whether toxaphene could be regulated by a threshold approach. Forty male rats were orally intubated with 100 mg/kg/day technical grade toxaphene in corn oil for 3 days. The dose was reduced to 75 mg/ kg/day on Day 4 due to toxicity. This lower dose was administered daily for 25 days. Another group of 40 male rats was orally gavaged daily with equivalent volumes of corn oil. After 0, 7, 14, and 28 doses, 10 test and 10 vehicle control animals were sacrificed for gross and histopathological examination of thyroid, parathyroid, and pituitary glands. Weights of these endocrine organs, body weights, and brain weights were determined. Prior to sacrifice, a blood sample was obtained from each animal for preparation of serum for analyses of thyroid stimulating hormone (TSH), thyroxine (T4), thyroid hormone (T3), and reverse T3 (rT3). Thyroid glands were evaluated microscopically for follicular cell hypertrophy, hyperplasia, and colloid storage. There were significant time-related increases in serum TSH in the test animals after 7, 14, and 28 doses of toxaphene. The serum levels of T3, T4, rT3, and corrected T3 (CrT3) in the test group were not significantly different from controls at each interval. Thyroid gland weights and thyroid to brain weight ratios were not significantly (p > 0.05) increased in the test group at each sacrifice interval. Pituitary weight, brain weight, and the ratios of these organ weights to body weights were similar in the test and control groups at each sacrifice interval. Thyroid follicular cell hypertrophy and intrafollicular hyperplasia increased and thyroid follicular cell colloid stores decreased with duration of treatment with toxaphene. The hormonal and histopathologic changes seen in the test group were consistent with increased excretion of T3 and/or T4 resulting from cytochrome P450 enzyme induction in the liver. This mechanism for thyroid neoplasia is not known to occur in humans.

A new approach to the safety assessment of pharmaceutical excipients. The Safety Committee of the International Pharmaceutical Excipients Council

This article presents a set of proposed guidelines for the safety assessment of new pharmaceutical excipients. These guidelines were developed by the Safety Committee of the International Pharmaceutical Excipients Council and represent a new, scientifically based approach to establishing conditions for the safe use of proposed pharmaceutical excipients utilizing various routes of human exposure. They are based upon the best currently available toxicological science and have taken the deliberations of the International Conference on Harmonization into consideration. These guidelines were developed because there are no regulatory agency guidelines currently available which specifically address the toxicological testing of a material intended for use as an excipient in pharmaceutical preparations. Only materials which have been previously permitted for use in a pharmaceutical preparation or which have been permitted for use in foods may be considered safe under current practices. If implemented, these guidelines should expedite the review of a proposed new excipient by regulatory agencies.

Immunotoxicity of a reconstituted polynuclear aromatic hydrocarbon mixture in B6C3F1 mice

Previous studies on the immunotoxicity of a complex mixture of polynuclear aromatic hydrocarbon (PAH) by-products from a manufactured gas plant indicated possible synergistic interactions which were investigated by determining the immunosuppressive effects of a reconstituted PAH mixture in female B6C3F1 mice challenged with TNP-haptenated sheep red blood cells (SRBCs) (T-cell-dependent) or trinitrophenyl-lipopolysaccharide (TNP-LPS) (T-cell-independent) antigens. The reconstituted PAH mixture contained the following 17 congeners: 2-rings (indan, naphthalene, 1- and 2-methylnaphthalene), 3-rings (acenaphthylene, acenaphthene, dibenzofuran, fluorene, phenanthrene and anthracene), and > or = 4-rings (pyrene, fluoranthene, benz[a]anthracene, chrysene, benzo[b]fluoranthene, benzo[k]fluoranthene and benzo[a]pyrene), and resembled mixtures identified as by-products from manufactured gas plants. The reconstituted mixture and the 2-, 3- and > or = 4-ring PAH fractions all caused a dose-dependent decrease in the splenic plaque-forming cell (PFC) response to SRBCs or TNP-LPS, and their ED50 values for the four treatment groups were 86, 354, 145, and 23 or 163, 439, 637 and 31 mg/kg, respectively. The corresponding ED50 values for decreased serum anti-TNP IgM levels for these same mixtures were (TNP-haptenated SRBCs, T-cell-dependent) 144, 231, 42 and 27 units, respectively, and (TNP-LPS, T-cell-independent) 161, 406, 312 and 69 units, respectively. The suppression of anti-TNP IgM titers was similar to the suppression of the PFC response and shows that antigen-specific immunoglobulin titer can be used as a biomarker of PAH exposure. A direct comparison of the immunotoxic responses of the reconstituted PAH mixture and the corresponding dose of the > or = 4-ring PAHs indicated that the latter fraction was primarily responsible for the activity of the reconstituted mixture.

Isolation and characterization of variant benzo[a]pyrene-resistant T47D human breast-cancer cells

T47D human breast cancer cells were grown in 1 microM benzo[a]pyrene (BaP) for 3.5 months, and 2 BaP-resistant (BaPr) variant cell lines (CS and C10) were isolated. Decreased aryl hydrocarbon (Ah)-responsiveness in the CS and C1O BaPr cells was characterized by lower (80 to 900/o) induction of CYP1A1-dependent activity by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), lower levels of the nuclear Ah receptor complex and significantly decreased Ah receptor mRNA levels. Nuclear estrogen receptor (ER) binding and ER mRNA levels were similar in wild-type and mutant cell lines, whereas epidermal growth factor receptor mRNA levels were significantly decreased in the variant BaPr T47D cells. 17beta-Estradiol induced proliferation of both wild-type and BaPr T47D cells, and TCDD inhibited this response but did not down-regulate nuclear ER levels. The unique characteristics of the BaPr T47D variant cells will be used to further elucidate the mechanism of interaction between the ER and Ah receptor signalling pathways.

Demographic modelling of the HIV/AIDS epidemic on the Soweto population--results and health policy implications

In this paper we present the results of a local HIV/AIDS demographic modelling exercise for Soweto, Johannesburg. The Doyle model was used to project the growth of the HIV/AIDS epidemic in Soweto until the year 2010. High, medium and low AIDS scenarios are projected; these depend on reduction in the average number of sexual partners, increased condom use and effective treatment of sexually transmitted diseases. In 1993 the HIV prevalence was estimated to be 3% for all three of the low, medium and high AIDS scenarios, but differences emerge rapidly after this. By 2010 the projected HIV seroprevalences in the high, medium and low AIDS scenarios are 24%, 15% and 8% respectively, corresponding with 343,000, 222,000 and 118,000 HIV-infected people. By the year 2010, AIDS will have caused 135,000-270,000 deaths and during that year will account for 28-52% of all deaths. The total population will continue to increase in size, even in the high AIDS scenario, with the population growth rate ranging from 1.8% (low AIDS scenario) to 1% (high AIDS scenario) by the year 2010. This modelling exercise has demonstrated the enormous potential impact of timeous and effective implementation of currently available prevention strategies. The need to institute prevention programmes in the short term is therefore stressed. Recommendations are also made about the care of people with HIV/AIDS. Other areas are encouraged to attempt similar exercises in order to stimulate local and regional planning of HIV/AIDS prevention and care.

AIDS--knowledge, attitudes and practices among STD clinic attenders in the Cape Peninsula

This study aimed to determine knowledge about, attitudes to and practices associated with AIDS among sexually transmitted disease (STD) clinic attenders in the Cape Peninsula. A questionnaire containing open and closed questions in the appropriate language (English, Afrikaans or Xhosa) was administered by trained clinic staff to 306 patients in 9 of the 29 STD clinics in the region. The median age of attenders was 25 years. The median period of residence in the peninsula was 7 years. There was inadequate awareness of the asymptomatic carrier state, the incurability of AIDS and ways to prevent AIDS. Sexual practice was a high risk: 70.4% of male attenders reported 2 or more partners since the beginning of the year (average 9 months); 39.5% of men reported more than one episode of STD in the previous 2 years. Prostitution was perceived to be common in attenders' communities. There was a low perception of risk to self, and intention to change behaviour was low. More information about AIDS was requested by 98% of patients. These findings are discussed with reference to the health belief model, Fischbein and Ajzen's theory of reasoned action and Catania et al.'s AIDS risk reduction model. This study supports the urgent need for AIDS education and counselling programmes for patients with STDs in the region. Recommendations include the need to address the beliefs and attitudes that affect behaviour, as well as to convey knowledge.

Learning to listen: formative research in the development of AIDS education for secondary school students

AIDS, as a social phenomenon, is highly politicized and is an emotive issue. In South Africa there is considerable disagreement between different sectors and stakeholders involved in school education about what constitutes an appropriate approach to AIDS education. For AIDS education programmes in schools to make cultural sense and to be effective, adequate formative research of the social context and cultural meaning of the salient behaviours needs to be done, and this understanding needs to inform programme development. The school community needs to be involved in the programme design and evaluation. This paper describes some of the formative research undertaken during the development of an AIDS education programme for secondary school students in South Africa. The study was undertaken during 1991 and 1992 in a Cape Town secondary school. A description of three components of the formative research is given. For each, the qualitative research methods used, the difficulties encountered, some of the results, and their value are discussed. Qualitative research methods were able to provide a more holistic understanding of student sexuality and its cultural context. These methods also provided the means with which to develop a partnership with the teachers in the process of developing the AIDS education programme. Furthermore, when this partnership broke down, they provided the means to explore the crisis that emerged around conflicting assumptions and cultural values the researchers and the "researched' held with respect to AIDS education. The generalizability of the study's results and the transferability of the AIDS education programme that was developed are discussed with respect to the exigencies of epidemiology to impact on the public health of large populations, and those of qualitative research methods to generate in-depth understanding in limited contexts.

A population-based survey of obstetric practices among rural women in the Bizana district, Transkei

OBJECTIVE

To determine for the Bizana district, Transkei, the proportion of deliveries that occur at home, home delivery practices, the proportion of women with high-risk pregnancies delivered at home, attendance for antenatal care at the health services and at traditional healers, and the reasons why mothers choose to deliver at home or in the health services.

DESIGN

Questionnaire survey.

SETTING

Rural community, South Africa.

PARTICIPANTS

Two hundred women from randomly selected clusters, obtained from a multistage random sampling process.

MAIN OUTCOME MEASURES

Place of delivery, home delivery practices and antenatal care for the most recent delivery (within the previous 5 years).

RESULTS

Two-thirds had delivered at home and one-third within the health services. Of those who delivered at home, 62 (47%) were alone at the time of delivery while the remainder were assisted by a close relative or neighbour; 38% had one or more risk factors for obstetric complications. Ninety-seven per cent attended at least once for antenatal care. Home delivery practices and reasons for place of delivery are described.

CONCLUSIONS

Antenatal care should include education about the home management of a normal childbirth. Waiting areas for mothers should be established at hospital level for high-risk pregnant mothers.

Characterization of an additional articular cartilage vesicle fraction that generates calcium pyrophosphate dihydrate crystals in vitro

OBJECTIVE

We previously identified a unique fraction of porcine articular cartilage vesicles, sedimentable at 8 x 10(6) g/min, which generate calcium pyrophosphate dihydrate crystals (CPPD) in vitro. We sought to identify and characterize other fractions of articular cartilage digest, sedimentable at lower g forces, which may also contain mineralizing vesicles.

METHODS

Electron microscopy and alkaline phosphatase and nucleoside triphosphate pyrophosphohydrolase (NTPPPH) assays were used to analyze each fraction. Radiometric mineralization assays, Fourier transform infrared (FTIR) spectroscopy, and compensated polarized light microscopy were used to analyze crystals formed by these fractions.

RESULTS

Vesicles of varying sizes identical to epiphyseal cartilage matrix vesicles were seen in all sedimentable fractions examined, but were the exclusive component of fractions sedimentable at 3 x 10(6) g/min, termed the heavy vesicle fraction (HVF), and at 8 x 10(6) g/min, now termed the light vesicle fraction (LVF). All vesicle containing fractions supported ATP dependent calcium pyrophosphate precipitation. The HVF and LVF precipitated 30 x more calcium than vesicle poor supernatant (p < 0.01) and 1.5-4 x more than cell-free unfractionated digest (p < 0.01). HVF differed from LVF in that it contained 3-4 x higher NTPPPH specific activity (p < 0.05). HVF resembled LVF in that both precipitated crystals consistent with CPPD by FTIR spectroscopy and compensated polarized light microscopy.

CONCLUSION

These data expand our previous estimate of the total number of vesicles available for biologic mineralization and demonstrate heterogeneity of vesicle fractions. They support a key role for vesicles in CPPD crystal formation.

Immunosuppressive activity of polychlorinated biphenyl mixtures and congeners: nonadditive (antagonistic) interactions

The dose-response inhibition of the splenic plaque-forming cell (PFC) response and serum IgM units to the antigen, trinitrophenyl-lipopolysaccharide, was determined for several polychlorinated biphenyl (PCB) mixtures and congeners in female B3C3F1 mice. The ED50 values for Aroclor 1260-, 1254-, 1248-, and 1242-induced immunotoxicity varied by less than twofold from 355 to 699 mg/kg. The range of ED50 values for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), 3,3',4,4'-tetrachlorobiphenyl, 3,3',4,4',5-pentaCB, 3,3',4,4',5,5'-hexaCB, 2,3,3',4,4'-pentaCB, 2,3',4,4',5-pentaCB, 2,3,3',4,4',5-hexaCB, 2,3,3',4,4',5,5'-heptaCB, 2,2',3,3',4,4',5-heptaCB, and 2,2',3,4,4',5,5'-heptaCB were 4.6 to 4.9, 134 to 245, 4.7 to 7.0, 6.9 to 11.1, 88,000 to 121,000, 122,000 to 132,000, 99,000 to 157,000, 89,000 to 129,000, 117,000 to 240,000, and 132,000 to 238,000 micrograms/kg, respectively. The immunotoxicity-derived toxic equivalency factors (TEFs) for these congeners could be calculated from the ED50 (TCDD)/ED50 (congener) ratios and the TEF values were within the range of those previously determined for other aryl hydrocarbon receptor-mediated responses. Based on the known concentrations of these congeners in the PCB mixtures, TCDD or toxic equivalents (TEQs) in the mixture were calculated [i.e., TEQ = sigma (PCBcongener x TEF)] using the immunotoxicity-derived TEFs (plaque-forming cells/10(6) viable cells). TEQ values for Aroclors 1260, 1254, 1248, and 1242 were 16.0, 54.4, 260.4, and 197 ppm, respectively. Based on the ED50 value for the immunosuppressive activity of TCDD (4.8 micrograms/kg), the calculated ED50 values for immune suppression by Aroclors 1260, 1254, 1248, and 1242 were 300, 88, 18, and 24 mg/kg, respectively. The ED50 (observed)/ED50 (calculated) ratios were 1.2, 5.9, 21, and 22.0 for Aroclors 1260, 1254, 1248 and 1242, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of Cyp1a-1 and Cyp1a-2 gene expression by a reconstituted mixture of polynuclear aromatic hydrocarbons in B6C3F1 mice

The potential non-additive interactions of polynuclear aromatic hydrocarbon (PAH) mixtures as inducers of Cyp1a-1 and Cyp1a-2 gene expression were investigated in B6C3F1 mice using a reconstituted PAH mixture. The chemical composition (% by weight) of the reconstituted PAH mixture was: 2-ring PAHs--indan (0.22), naphthalene (23.8), 2-methylnaphthalene (23.2) and 1-methylnaphthalene (13.3); 3-ring PAHs--acenaphthylene (7.7), acenaphthene (0.6), dibenzofuran (0.7), fluorene (4.3), phenanthrene (10.5) and anthracene (3.4); > or = 4-ring PAHs--fluoranthene (2.4), pyrene (4.3), benz[a]anthracene (1.4), chrysene (1.5), benzo[b]fluoranthene (0.8), benzo[k]fluoranthene (0.9) and benzo[a]pyrene (0.9). The composition of the 2-, 3- and > or = 4-ring PAH fractions were based on the relative concentration of individual PAHs as noted above. The > or = 4-ring PAH fractions were based on the relative concentration of individual PAHs as noted above. The > or = 4-ring PAH fraction and reconstituted mixture induced hepatic microsomal ethoxyresorufin O-deethylase (EROD) activity and Cyp1a-1 mRNA levels, whereas the 2- and 3-ring PAHs were only weakly active. Direct comparison of the potencies of the reconstituted mixture and > or = 4-ring PAHs showed that the Cyp1a-1 induction activity of the reconstituted mixture was due to the > or = 4-ring PAHs. The reconstituted PAH mixture and > or = 4-ring PAHs also induced Cyp1a-2 hepatic mRNA levels and microsomal methoxyresorufin O-deethylase (MROD) activity; however, their dose-response curves indicated that the reconstituted PAH mixture was more potent as a Cyp1a-2 inducer than the > or = 4 ring PAHs. The differences in potency were due to 3-ring PAHs which were found to be strong inducers of hepatic Cyp1a-2 mRNA levels and microsomal MROD activity at the lowest dose administered (37 mg/kg). The 3-ring mixture caused a maximal 29-fold increase in hepatic MROD activity at a dose of 292 mg/kg, but only 28% of maximal induction of EROD activity. Northern analysis of liver mRNA from mice treated with 3-ring PAHs showed that there was minimal induction of Cyp1a-1 mRNA levels. The 3-ring PAHs did not competitively bind to the mouse hepatic cytosolic aryl hydrocarbon (Ah) receptor suggesting that 3-ring PAHs are a new class of Cyp1a-2 inducers which do not act through the Ah receptor.

Halogenated aromatic hydrocarbon-induced suppression of the plaque-forming cell response in B6C3F1 splenocytes cultured with allogenic mouse serum: Ah receptor structure activity relationships

The immunosuppressive effects of halogenated aromatic hydrocarbons (HAHs) were investigated in B6C3F1 female mice and in mouse splenocytes cultured with allogenic mouse serum using the Mishell-Dutton model for in vitro immunization to trinitrophenyl-lipopolysaccharide (TNP-LPS). Exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), 2,3,4,7,8-pentachlorodibenzofuran (PeCDF), 1,2,3,7,8-PeCDF, 1,3,6,8-tetrachlorodibenzofuran (TCDF), 3,3',4,4',5-pentachlorobiphenyl (pentaCB), or 3,3',4,4',5,5'-hexaCB resulted in a dose-dependent suppression of the splenic plaque-forming cell (PFC) response both in vivo and in vitro. The effective dose required to decrease 50% (ED50) of the response to 2,3,7,8-TCDD, 2,3,4,7,8-PeCDF, 1,2,3,7,8-PeCDF, 1,3,6,8-TCDF, 3,3',4,4',5-pentaCB, or 3,3',4,4',5,5'-hexaCB in vivo was 14.1, 5.5, 1695, 34,800, 21, and 19 nmol/kg, respectively, and in vitro was 7.0, 10.6, 149, 2325, 9.1 and 9.1 nM, respectively. There was an excellent rank order and linear correlation between the in vivo versus in vitro activities for these HAHs (r < 0.99) and the relative immunosuppressive potencies of these compounds paralleled their binding affinities for the aryl hydrocarbon (Ah) receptor. These results show that splenocytes cultured with allogenic mouse serum is an Ah-responsive in vitro assay which can be used for quantitating the immunosuppressive effects of HAHs.

Oral iloprost as a treatment for Raynaud's syndrome: a double blind multicentre placebo controlled study

OBJECTIVE

To compare the efficacy, tolerance and safety of 50-150 micrograms orally administered iloprost given twice a day versus placebo in patients with Raynaud's syndrome.

METHODS

The study was multicentre (n = 3), double blind and placebo controlled. Sixty three patients who had eight or more vasospastic attacks per week were enrolled. After a one week run-in period, all patients received either iloprost or placebo treatment to a maximum tolerated dose of 150 micrograms twice a day for 10 days. Diary cards assessed the duration and severity of the vasospastic attacks. Side effects were monitored by direct questioning. A global assessment of treatment efficacy was made by the patient at the end of treatment and two weeks later.

RESULTS

Patient opinion tended to favour iloprost at the end of the 10 day treatment phase (p = 0.09) and this was significant at day 24 (the follow up visit) (p = 0.011). Although the duration and severity of attacks tended to decrease in the iloprost treated group, these results tended not to reach statistical significance (for severity p = 0.06 at end of treatment, p = 0.09 on day 24).

CONCLUSION

Iloprost administered intravenously has been shown to be of benefit in the treatment of the Raynaud's syndrome associated with systemic sclerosis, but this route of administration is inconvenient. This study evaluated the use of iloprost administered orally to patients with Raynaud's syndrome. Patient documented improvement was significantly improved by iloprost. Diary card analysis showed a trend in favour of iloprost, but these results did not reach statistical significance.

An enzyme-linked immunosorbent assay (ELISA) specific for antibodies to TNP-LPS detects alterations in serum immunoglobulins and isotype switching in C57BL/6 and DBA/2 mice exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin and related compounds

An enzyme-linked immunosorbent assay (ELISA) was developed to detect IgM and IgG antibodies specific for trinitrophenyl-lipopolysaccharide (TNP-LPS). Treatment of C57BL/6 and DBA/2 mice with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and other aryl hydrocarbon (Ah) receptor agonists followed by immunization with TNP-LPS resulted in a dose-dependent decrease in serum IgM which paralleled the decrease in the splenic PFC response. The ED50 values for the IgM and splenic PFCs in C57BL/6 mice for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), 3,3',4,4',5-pentachlorobiphenyl (pentaCB) and 3,3',4,4',5,5'-hexaCB were 2.8 and 1.6, 11 and 14, and 25 and 20 micrograms/kg, respectively; in the less Ah-responsive DBA/2 mice, the ED50 values were 8.5 and 10, 61 and 69, and 73 and 71 micrograms/kg, respectively. In addition, treatment of C57BL/6 mice with TCDD resulted in alterations of serum IgG relative to IgM and a delay of isotype switching was observed after immunization and boosting with TNP-LPS. This ELISA may prove to be a useful tool in monitoring immune function during long-term exposure of mice to TCDD and related compounds and exploring the mechanism of Ah receptor-mediated immunosuppression.

Distinguishing between multiple personality disorder (dissociative identity disorder) and schizophrenia using the Structured Clinical Interview for DSM-IV Dissociative Disorders

The authors describe the systematic assessment of dissociative symptoms using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) in 50 psychiatric outpatients with a referring DSM-III-R diagnosis of either schizophrenia or schizoaffective disorder (N = 31) and subjects with multiple personality disorder (MPD [DSM-IV name change: dissociative identity disorder]; N = 19). Results indicate that patients with MPD experience significantly higher scores for five specific dissociative symptoms than patients with schizophrenia or schizoaffective disorder. The range, severity, and nature of the five dissociative symptom areas evaluated by the SCID-D distinguish MPD from the occasional occurrence of dissociative symptoms which may be seen in schizophrenia. Systematic assessment of dissociative symptoms using the SCID-D can assist in accurate differential diagnosis of MPD and schizophrenia.

Participation of the school community in AIDS education: an evaluation of a high school programme in South Africa

An AIDS education programme was developed and evaluated in a high school in a socio-economically disadvantaged, urban, African area in South Africa. The programme, which addressed the whole school community, aimed to raise awareness about AIDS using a variety of educational methods and operating through a number of channels. Students and teachers were actively involved in its design and implementation. Students' knowledge of and attitudes towards AIDS prevention were investigated before and after the AIDS programme, and compared to a neighbouring school, in which no AIDS education was conducted. The programme greatly improved student knowledge of HIV transmission and prevention. It increased levels of acceptance of people with AIDS and had a small impact on behavioural intentions. The process of involving the school community in the design of the AIDS education programme is discussed.