Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis

PURPOSE

This research aimed to develop a clearer picture of the experience of residual limb pain and phantom limb pain following a lower limb amputation and to gain a greater understanding of their relationships with physical and psychosocial variables.

METHOD

One hundred and four participants completed the Trinity Amputation and Prosthesis Experience Scales (TAPES), which includes a section on each of, psychosocial issues, activity restriction, satisfaction with a prosthesis and pain (incidence, duration, level and extent of interference).

RESULTS

The results showed that 48.1% of the sample experienced residual limb pain and 69.2% experienced phantom limb pain. While fewer people experienced residual limb pain, those who did, experienced it for longer periods, at a greater level of intensity and with a greater amount of interference in their daily lifestyle, than people who were experiencing phantom limb pain. The experience of residual limb pain was associated with other medical problems and low levels of Adjustment to Limitation. Phantom limb pain was associated with older age, being female, above knee amputation, causes other than congenital causes, not receiving support prior to the amputation, the experience of other medical problems, low scores on Adjustment to Limitation and high scores on Aesthetic Satisfaction with the prosthesis.

CONCLUSION

These findings provide a greater understanding of the issues to be taken into consideration in the rehabilitation of people with a lower limb amputation.

Resistance training improves single muscle fiber contractile function in older women

The purpose of this study was to 1) examine single cell contractile mechanics of skeletal muscle before and after 12 wk of progressive resistance training (PRT) in older women (n = 7; 74 +/- 2 yr) and 2) to compare these results to our previously completed single cell PRT work with older men (n = 7; 74 +/- 2 yr) (Trappe S, Williamson D, Godard M, Porter D, Rowden G, and Costill D. J Applied Physiol 89:143--152, 2000). Knee extensor PRT was performed 3 days/wk at 80% of one-repetition maximum. Muscle biopsies were obtained from the vastus lateralis before and after the PRT. Chemically skinned single muscle fibers (n = 313) were studied at 15 degrees C for peak tension (P(o)), unloaded shortening velocity (V(o)), and power. Due to the low number of hybrid fibers identified post-PRT, direct comparisons were limited to MHC I and IIa fibers. Muscle fiber diameter increased 24% (90 +/- 2 to 112 +/- 6 microm; P < 0.05) in MHC I fibers with no change in MHC IIa fibers. P(o) increased (P < 0.05) 33% in MHC I (0.76 +/- 0.04 to 1.01 +/- 0.09 mN) and 14% in MHC IIa (0.73 +/- 0.04 to 0.83 +/- 0.05 mN) fibers. Muscle fiber V(o) was unaltered in both fiber types with PRT. MHC I and IIa fiber power increased (P < 0.05) 50% [11 +/- 2 to 17 +/- 2 microN. fiber length (FL). s(-1)] and 25% (40 +/- 8 to 51 +/- 6 microN. FL. s(-1)), respectively. However, when peak power was normalized to cell size, no pre- to postimprovements were observed. These data indicate that PRT in elderly women increases muscle cell size, strength, and peak power in both slow and fast muscle fibers, which was similar to the older men. However, in contrast to the older men, no change in fiber V(o) or normalized power was observed in the older women. These data suggest that older men and women respond differently at the muscle cell level to the same resistance-training stimulus.

An evaluation of a standards based portfolio

In undergraduate and postgraduate nursing studies, the essay type assignment is commonly used to assess student learning. The literature suggests that of the alternatives for the assessment of learning, the use of portfolios may be an effective tool. A portfolio is generally conceptualized as a collection of the students best work or a collection of work that evidences incremental development. For a particular unit of learning, 'Nursing Business', second year undergraduate students in the Bachelor of Nursing programme were required to complete a portfolio. The assessment directed the students to meet specific criteria which in turn reflected the learning outcomes. Therefore the portfolio in this study is more appropriately described as a standards based portfolio (SBP). A SBP is a series of student work that seeks to address pre-determined learning outcomes. This study is an evaluation of student perceptions of a SPB and of interest to the study was the relationship between theory and practice, the availability of resources to complete the assignment and the contribution the portfolio made to the process of learning.

An evaluation of a standards based portfolio

In undergraduate and postgraduate nursing studies, the essay type assignment is commonly used to assess student learning. The literature suggests that of the alternatives for the assessment of learning, the use of portfolios may be an effective tool. A portfolio is generally conceptualized as a collection of the students best work or a collection of work that evidences incremental development. For a particular unit of learning, 'Nursing Business', second year undergraduate students in the Bachelor of Nursing programme were required to complete a portfolio. The assessment directed the students to meet specific criteria which in turn reflected the learning outcomes. Therefore the portfolio in this study is more appropriately described as a standards based portfolio (SBP). A SBP is a series of student work that seeks to address pre-determined learning outcomes. This study is an evaluation of student perceptions of a SPB and of interest to the study was the relationship between theory and practice, the availability of resources to complete the assignment and the contribution the portfolio made to the process of learning.

Autosomal dominant peripheral cystic retinal patches and non-cystic retinal tufts associated with peripapillary crescents, retinal breaks and uveitis

PURPOSE

To characterise an Irish kindred with apparent autosomal dominant peripheral retinal lesions and peripapillary crescents associated with retinal breaks and uveitis and assess whether these findings were associated with altered homocysteine metabolism.

METHODS

Family members were followed prospectively and regularly examined. Molecular genetic analysis was performed on family members to detect cystathionine beta-synthase (CBS) 307G-S and 5,10-methylenetetrahydrofolate (MTHFR) 677C-T mutations.

RESULTS

Over 11 years, 25 family members in four generations were examined, none of whom had significant refractive errors. Fifteen affected individuals had peripheral cystic retinal patches and in some cases non-cystic retinal tufts, associated with peripapillary pigmentation. Mean age at first examination of affected and non-affected individuals was the same. During follow-up the fundal findings remained unchanged in the affected group and no clinical characteristics developed in the unaffected individuals. Two affected siblings had associated uveitis and rhegmatogenous retinal detachment, which were successfully treated, while a third affected individual had a pigmented retinal break not requiring treatment. Heterozygosity for the CBS 307G-S mutation did not segregate with affected individuals while the MTHFR 677C-T mutation was not detected.

CONCLUSIONS

This family has previously undescribed fundal findings inherited in an apparent autosomal dominant pattern associated with retinal breaks and uveitis. There is no associated inherited alteration of homocysteine metabolism.

Acute tryptophan depletion in schizophrenia

BACKGROUND

Brain 5-hydroxytryptamine (5-HT) function is implicated in the pathophysiology of schizophrenia and the action of new generation antipsychotic drugs. By the method of acute tryptophan depletion (ATD) 5-HT can be selectively manipulated. The aim of this study was to examine the effects of ATD on symptoms, mood and cognition in schizophrenic patients.

METHODS

Twenty-eight schizophrenic patients participated in a within subject, double-blind, placebo-controlled counterbalanced cross-over study. Patients with a concurrent DSM-IV axis I diagnosis were excluded. Symptoms, mood and cognitive function were evaluated following ATD or ingestion of a control drink.

RESULTS

The depleting drink significantly reduced plasma total and free tryptophan. Tryptophan/LNAA ratios did not alter with the administration of the control drink, but differed significantly with ATD; however there was no significant change in tyrosine/LNAA ratio. ATD led to impairment in executive function that was dependent upon the order of administration. Tests of sustained attention, speed of processing, and everyday memory were not affected. No effects were observed on subjective mood ratings, movement disorders or PANSS scores.

CONCLUSIONS

Acute tryptophan depletion selectively alters cognition in schizophrenia, but has no effect on symptoms, mood ratings or movement disorders.

Positive meaning in amputation and thoughts about the amputated limb

The majority of research conducted on the aftermath of amputation understandably concerns itself with its most distressing aspects. This research aimed to explore whether and how people think about their amputated limb, and whether and if they considered anything good had emerged from their amputation. One hundred and four (104) people completed the Trinity Amputation and Prosthesis Experience Scales (TAPES) and two open-ended questions. The majority of participants were young and had traumatic amputations. Fifty-six percent (56%) of people thought about their amputated limb. People with bilateral or a trans-femoral amputation were more likely to think about their amputated limb than people with a trans-tibial amputation. Forty-eight percent (48%) considered that something good had happened as a result of the amputation. Furthermore, finding positive meaning was significantly associated with more favourable physical capabilities and health ratings, lower levels of Athletic Activity Restriction and higher levels of Adjustment to Limitation. Future research and clinical implications are discussed.

The treatment of scaphoid nonunion. A review of a novel technique using precision bone grafting compared with Herbert screw fixation and bone graft

We have retrospectively reviewed the results of 40 consecutive patients with nonunion of the scaphoid treated by the senior author (PG) between 1993 and 1996. These comprised two groups of patients. Group 1 comprised 20 patients treated between 1993 and 1994, with a Herbert screw and autograft, and Group 2, which also comprised 20 patients treated with the precision bone grafting technique which we describe. The precision bone grafting technique employs simple instrumentation to harvest bone percutaneously from the iliac crest and then insert it at the scaphoid nonunion site. The evaluation consisted of a clinical and radiological assessment of union and wrist function. Our review demonstrates a higher rate of union with the precision bone grafting technique than by the Herbert screw fixation with bone grafting.

The Structured Interview for Renal Transplantation--SIRT

Despite the fact that the demand for psychiatric evaluations of organ transplant recipients is increasing, there is not a commonly agreed upon protocol that can guide clinicians. A standard psychiatric interview, although necessary, is not sufficient when interviewing transplant candidates. In addition, it is important to acquire information specific to the medical regimen associated with renal disease and renal transplantation. The purpose of this paper is to present the Structured Interview for Renal Transplantation (SIRT). The SIRT was developed as a tool to guide clinicians through the interview process by providing a comprehensive structure while still allowing for flexibility. There are many advantages of using the SIRT--it is a tool that facilitates a clinician's ability to conduct a thorough evaluation in a time-efficient manner. It is also an excellent instrument for training clinicians, and the structure of the interview is appropriate for use in research.

Phosphorylation of myosin light chain kinase by p21-activated kinase PAK2

Phosphorylation of myosin II regulatory light chains (RLC) by Ca(2+)/calmodulin-dependent myosin light chain kinase (MLCK) is a critical step in the initiation of smooth muscle and non-muscle cell contraction. Post-translational modifications to MLCK down-regulate enzyme activity, suppressing RLC phosphorylation, myosin II activation, and tension development. Here we report that PAK2, a member of the Rho family of GTPase-dependent kinases, regulates isometric tension development and myosin II RLC phosphorylation in saponin permeabilized endothelial monolayers. PAK2 blunts tension development by 75% while inhibiting diphosphorylation of myosin II RLC. Cdc42-activated placenta and recombinant, constitutively active PAK2 phosphorylate MLCK in vitro with a stoichiometry of 1.71 +/- 0. 21 mol of PO(4)/mol of MLCK. This phosphorylation inhibits MLCK phosphorylation of myosin II RLC. PAK2 catalyzes MLCK phosphorylation on serine residues 439 and 991. Binding calmodulin to MLCK blocks phosphorylation of Ser-991 by PAK2. These results demonstrate that PAK2 can directly phosphorylate MLCK, inhibiting its activity and limiting the development of isometric tension.

Metabolic response during sport rock climbing and the effects of active versus passive recovery

The objectives of this study were to 1) continuously assess oxygen uptake during and after difficult sport rock climbing and 2) to evaluate the effects of active versus passive recovery on post-climbing blood lactate and hand grip strength. Fifteen expert rock climbers attempted to climb (i.e., red point lead) a 20 m difficult route (5.12 b, YDS scale) set on an indoor climbing wall. Subjects were assigned to either active recovery (AR; n = 8), consisting of recumbent cycling at 25 Watts, or passive recovery (PR; n = 7). Expired air was analyzed during climbing and through a 10-minute recovery period by a lightweight battery-powered open circuit system. Oxygen uptake (VO2) and heart rate (HR) were measured continuously and averaged over 20-second intervals. These data were expressed as averages over the entire climb (VO2avg and HRavg) and as peak values. An estimated resting VO2 of 250 ml x min(-1) was subtracted from the interval VO2 values to provide net VO2 data which were subsequently converted to absolute VO2 values in liters for climbing (C - VO2net) and recovery (R - VO2net). Total net VO2 was calculated as the sum of C - VO2net plus R - VO2net. Blood samples were obtained via fingerprick at pre-climb and at 1-, 10-, 20-, and 30-minutes post-climb and analyzed for whole blood lactate. Handgrip strength was measured via dynamometry at pre-climb and at 1-, 10-, 20-, and 30-minutes post-climb. Mean climbing time was 2.57 +/- 0.41 min. During climbing, VO2avg and HRavg means were 1660 +/- 340 ml x min(-1) and 148 +/- 16 b x min(-1) respectively with mean peaks of 2147 +/- 413 ml x min(-1) and 162 +/- 17 b x min(-1). Relative VO2avg was 24.7 +/- 4.3 ml x kg(-1) x min(-1) with a mean peak value of 31.9 +/- 5.3 ml x kg(-1) x min(-1). Mean values for C - VO2net and R - VO2net were 4.009 +/- 0.929 L and 2.809 +/- 0.518 L respectively for the PR group with mean total net VO2 at 6.818 +/- 1.291 L. For the AR group mean values for C - VO2net and R - VO2net were 4.216 +/- 1.174 L and 7.691 +/- 3.154 L respectively with a mean total net VO2 of 11.906 +/- 4.172 L. There was no difference between the groups for C - VO2net, however R - VO2net and total net VO2 were significantly different (p < 0.05) between PR and AR. Blood lactate increased significantly with climbing in both AR and PR groups. Lactate remained elevated in the PR group until 30 minutes post-climb, but had returned to pre-climb level by 20 minutes in the AR group. Handgrip strength was significantly decreased at 1-minute post-climb for the AR group, but was not significantly changed for the PR group. Although climbers may be able to attain a plateau in VO2, the observed accumulation of lactate in the blood combined with the elevated recovery VO2 indicate a higher overall energy demand than indicated via the recorded VO2 during climbing. Low intensity active recovery appears to significantly reduce accumulated blood lactate within 20 minutes following difficult climbing, however further research is required to establish whether this strategy is advantageous for subsequent climbing performance.

Reduction in pain associated with open carpal tunnel decompression

Patients treated by open carpal tunnel decompression under local anaesthetic experience significant pain with the introduction of local anaesthetic before operation. A prospective double-blind randomized placebo controlled trial was carried out to assess whether this pain could be reduced with the pre-application of a topical lignocaine-prilocaine anaesthetic cream. Nineteen patients undergoing simultaneous bilateral operations were studied. Pain, measured with a visual analogue scale, was significantly reduced on the sides treated with anaesthetic cream. On a four point verbal scale the rating on the placebo side was "moderate" or "severe", compared to "mild" on the anaesthetic cream side. The reduction in pain was greater in women, possibly due to a relatively thinner dermis. There were no adverse effects.

Psychological adjustment and coping in adults with prosthetic limbs

The potential mediating effects of different coping strategies on the adjustment to living with a prosthetic limb were investigated in 44 adult amputees. Participants completed a questionnaire inquiring about coping, pain, emotional well-being, demographics, and disability-related variables. The coping strategy adopted and the extent of the adjustment to the prosthetic limb varied with age, site of limb loss, and cause of amputation. Furthermore, coping style mediated the adjustment to wearing a prosthetic limb. The results are discussed in terms of future applications and research.

Small-angle x-ray scattering study of kinetics of spinodal decomposition in N-isopropylacrylamide gels

We present synchrotron-based time-resolved small-angle x-ray scattering (SAXS) measurements of spinodal decomposition in a covalently cross-linked N-isopropylacrylamide gel. The range of wave numbers examined is well beyond the position of the maximum in the structure factor S(q,t). The equilibrium structure factor is described by the sum of a Lorentzian and a Gaussian. Following a temperature jump into the two phase region, the scattered intensity increases with time and eventually saturates. For early times the linear Cahn-Hilliard-Cook (CHC) theory can be used to describe the time evolution of the scattered intensity. From this analysis we found that the growth rate R(q) is linearly dependent on q(2), in agreement with mean-field theoretical predictions. However the Onsager transport coefficient Lambda(q) approximately q(-4), which is stronger than the q dependence predicted by the mean-field theory. We found that the growth rate R(q)>0, even though the wave numbers q probed by SAXS are greater than sqrt[2]q(m) where q(m) is the position of the peak of S(q,t), also in agreement with the mean-field predictions for a deep quench. We have also examined the range of validity of the linear CHC theory, and found that its breakdown occurs earlier at higher wave numbers. At later times, a pinning of the structure was observed. The relaxation to a final, microphase-separated morphology is faster and occurs earlier at the highest wave numbers, which probe length scales comparable to the average distance between crosslinks.

Metabolic and cardiovascular responses during work on a high ropes course

BACKGROUND

High ropes course facilities are employed in adventure programs to promote self-esteem, stress management, and problem-solving skill development. Although the combination of fear, anxiety, and potentially high levels of physical exertion during such activity could yield situations of cardiac risk for certain individuals, no previous research has described the physiological nature of high ropes course work. The purpose of this study was to observe the metabolic and cardiovascular responses to a typical high ropes course experience.

METHODS

Seventeen subjects gave informed consent to complete a 5-element sequence on an indoor high ropes course. The elements included step-swings (SS), swinging tires (ST), a 4-inch balance beam (B1), a vertical cargo net (CN), and a second beam (B2). These elements were positioned in series at a height of 20 feet above the floor. Expired air was analyzed continuously using a portable open circuit metabolic analyzer and heart rate (HR) was recorded at 5-second intervals via telemetry. Pre- and postcourse blood samples were obtained via finger-prick and analyzed for lactate (BL). Systolic (SBP) and diastolic (DBP) blood pressures were taken at an orientation session prior to each subject's test date and at pre-, mid-, and post course points during each test session.

RESULTS

The mean ropes course work time was 11.2 +/- 2.9 min. Mean averaged/peak oxygen uptake (VO2), ventilation (VE), HR, and energy expenditure (EE) were 13.9 +/- 2.3/21.6 +/- 3.7 ml.kg-1.min-1, 36.4 +/- 8.1/49.6 +/- 10.3 l.min-1, 142 +/- 16/167 +/- 15 b.min-1, and 5.1 +/- 0.9/7.7 +/- 1.0 kcal.min-1 respectively. In descending order, mean EE was 6.2 +/- 1.1, 6.2 +/- 0.8, 5.4 +/- 1.0, 4.5 +/- 0.5, and 4.2 +/- 0.5 kcal +/- min-1 for the B2, ST, CN, B1, and SS elements respectively. Blood lactate increased (p < 0.05) from a pre course value of 1.9 +/- 0.6 mmol.l-1 to 5.0 +/- 1.1 mmol.l-1 post course. SBP values at pre- (136.7 +/- 16.0), mid-(169.8 +/- 19.7), and postcourse (154.1 +/- 19.2) were higher (p < 0.05) than the orientation SBP of 126.2 +/- 14.7 mmHg. Mid- and post course SBP means were significantly higher than the precourse mean. A significant difference was found for DBP between the midcourse (86.3 +/- 8.9) vs the orientation mean (79.1 +/- 6.8) only.

CONCLUSIONS

Based upon the results of this study, average high ropes course work can be classified as aerobically moderate to heavy, at just over 4 METs with peak periods over 7 METs. Transient elevation in DBP may occur during elements with a high level of upper body work. High ropes course work does not present an unusually high physiological stress for healthy, physically fit individuals.

Validity of the MMPI-2 and Beck Depression Inventory for making decisions of organ allocation in renal transplantation

Psychosocial factors are presented which affect clinical decision-making regarding the allocation of renal organs. Patients were rated as being either High Risk or Low Risk transplant candidates. High Risk candidates were scored as being significantly different from the Low Risk candidates on many psychosocial variables. Interestingly, significant differences were not found between these two groups on either the MMPI-2 or the Beck Depression Inventory. The validity of using information from these inventories to allocate organs is discussed.

Double gloving and a glove perforation indication system during the dental treatment of HIV-positive patients: are they necessary?

AIM

The aim of this study was to compare the incidence of glove perforation when double gloved or single gloved during the routine treatment of HIV-positive patients. In addition, a glove perforation indication system based on a double gloving technique was assessed.

DESIGN

Prospective, randomised and open study of glove perforation.

METHODS

138 consecutive HIV-positive patients underwent routine dental treatment by senior dental staff and dental hygienists in a teaching hospital. Staff wore either single gloves (Regent Biogel D or standard surgical gloves) or double gloves (Regent 'Reveal' perforation indication system or standard surgical gloves). A subjective assessment of glove comfort, sensitivity and ease of donning was made using a visual analogue scale.

RESULTS

The incidence of glove perforation/procedure was low, 2.9%. There were no skin penetrating injuries, visible exposure to body fluids or unnoticed perforations. Double gloving was subjectively less comfortable and sensitive than single gloving (P < 0.0001). The glove perforation indication system did not increase the detection of intra-operative perforations.

CONCLUSIONS

There is unlikely to be any significant benefit from the use of a double gloving technique or perforation indication system during the routine dental treatment of HIV-positive patients.

Elevated blood lead levels in children are associated with lower erythropoietin concentrations

Eighty-six children (mean age, 34 months) were studied to determine whether elevated blood lead levels in children are associated with lower erythropoietin concentrations. The median erythropoietin concentration was 5.9 mIU/mL (range, 2.3 to 11.5 mIU/mL), and the median blood lead level was 0.87 micromol/L (18 microg/dL; range, 2 to 84 microg/dL). Blood lead concentration was inversely and independently related to erythropoietin concentration.

Chronic active destructive herpes simplex encephalitis with recovery of viral DNA 12 years after disease onset

Acute herpes simplex encephalitis (HSE) carries significant morbidity and mortality even after early treatment with antiviral agents (7). As well as causing acute neurological disease, Herpes viruses are associated with relapsing--remitting (Varicella--Zoster, Epstein-Barr) and chronic (Rasmussen encephalitis) disease processes (1). A two-year-old girl developed acute HSE which was followed by a 10-year neurologic illness characterised by asymmetric spastic tetraparesis, pseudobulbar palsy, the opercular syndrome of Foix-Chavany-Marie (4) and seizures. The neurological signs remained static until the child died suddenly 12 years after disease onset. Neuropathologic examination demonstrated active chronic encephalitis. Herpes simplex virus (HSV) DNA was recovered from formalin-fixed paraffin-embedded brain tissue. This case provides additional evidence for the development of chronic neurological disease attributable to persistence of herpes simplex virus type 1.

Proving the competence of nurses

Registration in itself is no guarantee that a nurse is competent to practise. A system of competence-based pracitising certificates linked with registration would raise the professionalism of nursing and assure the public it was receiving competent, safe nursing care.

De la Caffinière thumb carpometacarpal replacements. 93 cases at 6 to 16 years follow-up

The results of 93 de la Caffinière thumb joint replacements in 71 patients were reviewed between 6 and 16 years. The survival rate was 89% at 16 years. Eleven thumb joints had failed requiring revision. The commonest reason for failure was aseptic loosening of the trapezial component. The failure rate was higher in men of working age than any other group, which possibly reflects the increased demands on the prosthesis of these patients. We support the use of this implant for degenerative osteoarthritis, but caution against its use in men under 65 years.

Weight changes and serum sodium concentrations after an ultradistance multisport triathlon

OBJECTIVE

This study describes the incidence of hyponatremia and the weight changes during an ultradistance multisport triathlon.

DESIGN

Descriptive research.

SETTING

A 1-day triathlon in which each athlete kayaks 67 km, cycles 148 km, and runs 23.8 km.

PARTICIPANTS

Forty-eight athletes competing in the race were studied.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

All subjects were weighed before the race and on completion of the race. A blood sample for serum sodium was taken at the finish of the race.

RESULTS

The mean weight change over the course of the race was a loss of 2.5 kg (SD +/- 1.7, n = 48), or a mean percentage loss of body weight of 3.1% (SD +/- 2.07). This was highly statistically significant (p < 0.0001) using the Student paired t test. No athletes gained weight, and six athletes maintained their same weight. Only one athlete was hyponatremic (Na = 134 mEq/L). This athlete maintained his weight over the course of the race and he did not seek medical attention. The mean serum sodium concentration at the end of the race was 139.3 mEq/L (SD = 2.28, n = 47). There was a significant correlation (r = 0.30, p = 0.04) between sodium levels and weight change during the race: the greater the weight loss, the higher the serum sodium concentration. There was no significant correlation between the degree of weight loss and athletes' finishing times (r = 0.11, p = 0.45).

CONCLUSIONS

Symptomatic hyponatremia did not occur in the 1996 Coast to Coast multisport triathlon, although one athlete had borderline hyponatremia. Athletes lose significant amounts of weight over the course of this multisport event, but nevertheless manage to complete the race.

Lymphocyte, monocyte, and natural killer cell reference ranges in postpartal women

Normative values for immune-cell subsets in postpartal women, who are recovering from the relative immunosuppression of pregnancy, have not been established. Considerable differences in normative values for subsets of immune cells have been demonstrated based on sociodemographic factors, such as age and race. In order to make accurate clinical decisions about postpartal women, comparisons with normal reference ranges are necessary. Therefore, flow cytometric data for 51 healthy women at 4 months postpartum are presented and changes over the first 4 postpartal months are documented. The levels of some lymphocyte cell subsets, such as CD4+/CD45RA+ and Ia on lymphocytes, remained stable over time. The levels of other lymphocyte cell subsets, such as CD4+/CD29+, increased over the first 4 postpartal months, while those of other cell subsets, such as CD8 and CD11b, increased between delivery and 2 months postpartum and then dropped again by the fourth postpartal month. The levels of two natural killer cell subsets (CD3-/CD16+ and CD3-/CD57+) rose from delivery until 1 month postpartum and then plateaued. Comparisons were made with reference ranges of nonpostpartal groups provided in the literature and in a study of healthy women being conducted in the same laboratory, and postpartal women were found to have lower values of CD8, CD3-/CD16+, CD4+/CD45RA+, CD20, and CD11b than those reported in the literature.

Endothelial injury in transgenic (mRen-2)27 hypertensive rats

Transgenic [(mRen-2)27] rats develop severe hypertension as the result of transfection with the mouse Ren-2 gene. This study tested the hypothesis that hypertensive [(mRen-2)27] rats have increased endothelial dysfunction by examining the extent of vascular endothelial cell injury and turnover within the thoracic aorta of age-matched female transgene positive [Tg(+)] and transgene negative [Tg(-)] littermates. Transgenic hypertensive rats had arterial pressures significantly higher than Tg(-) animals, but no differences in heart rate or body weight. The extent of endothelial cell injury was estimated in Haütchen preparations of thoracic aorta endothelium by counting cells immunostained for the presence of cytoplasmic immunoglobulin G (IgG) at sites with or without intercostal artery branches. Both Tg(+) and Tg(-) littermates had a greater percentage of injured endothelial cells at branch sites than at nonbranch aorta (P < .01). However, the number of vascular endothelial cells staining positively for IgG was significantly higher in hypertensive rats both at sites away from (P < .05) and in the immediate vicinity of (P < .1) the orifices of intercostal arteries. En face preparations of the thoracic aorta were also examined for cells incorporating 5-bromo-2 '-deoxyuridine (BrdU) to estimate the percentage of endothelial cells undergoing replication. There was no difference in endothelial cell replication at either branch or nonbranch sites between hypertensive and normotensive rats. However, the percentage of endothelial cells undergoing replication at branch sites in both Tg(+) and Tg(-) rats was significantly greater than at nonbranch sites (P < .01). These data provide the first demonstration for the effects of high blood pressure on the vascular endothelium of a monogenetic model of hypertension produced by increased activity of the renin-angiotensin system. The divergent effects of this form of hypertension on vascular endothelial injury and endothelial turnover suggest that the decrease in the reparative capacity of the vascular endothelium induced by the combination of hypertension and associated angiotensinemia may contribute to the endothelial dysfunction accompanying vascular remodeling.

Biomarkers of essential fatty acid consumption and risk of prostatic carcinoma

Animal studies have suggested that omega-6 fatty acids found in vegetable oils may promote prostate cancer. Our goal was to use erythrocyte membrane and adipose tissue fatty acid composition as biomarkers to investigate whether essential fatty acids modulated prostate cancer risk. An outpatient clinic-based study of 89 cases and 38 controls was conducted in North Carolina between July 1989 and December 1991. Cases were recruited from a university-based urology outpatient clinic. Eligible cases were more than 45 years of age and had histological confirmation of a prostate cancer diagnosis within 1 year of entry into the study. Controls were histologically confirmed free of prostate cancer. Erythrocyte membranes from venous blood and adipose tissue fatty acids from s.c. fat samples were analyzed in batches using capillary gas chromatography. Unconditional logistic regression analysis was used to calculate odds ratios for the association of each fatty acid with prostate cancer while controlling for potential confounders. Linoleic acid consumption was positively associated with prostate cancer risk. The odds ratios comparing the first and fourth quartiles of linoleic acid consumption were 3.54 (95% confidence interval, 1.0-12.53) with P trend < 0.04 for erythrocyte membranes, and 2.47 (95% confidence interval, 0.66-9.26) with P trend < 0.08 for adipose tissue. These data suggest that linoleic acid consumption may increase prostate cancer risk, which is consistent with results from animal experiments. Linoleic acid is found in vegetable oils used in cooking and in cereals, snack foods, and baked goods. Our data failed to demonstrate consistently a protective effect of marine omega-3 fatty acids on prostate cancer.

Marked reduction of anemia during pregnancy over a 10-year period in Montserrat

Anemia during pregnancy is associated with adverse outcomes including maternal and perinatal mortality. However, health education and other public health strategies seeking to reduce its prevalence have usually met with only limited success. The study reported here surveyed anemia of pregnancy on the island of Montserrat in 1980, 1985, and 1990. This involved examination of clinic and hospital records for over 90% of all women giving birth on Montserrat in 1980 and 1985, as well as 80% of those giving birth in 1990. This examination showed a dramatic reduction in the prevalence of anemia at the time of the first prenatal visit (a drop from 82% of the study women in 1980 to 23% in 1985 and 19% in 1990) and also a marked drop at three days postpartum (from 91% in 1980 to 41% in 1985 and 39% in 1990). Logistic regression analyses indicated that after controlling for three possible confounding factors (maternal age, parity, and weeks of gestation at first prenatal visit) the difference between the risk of developing anemia during pregnancy in 1980 as compared to 1985 or 1990 was still highly significant. The reasons for the observed drop in anemia's prevalence during the survey period are not entirely clear, partly because of the retrospective nature of the study. However, better nutrition resulting from improvement in the standard of living on Montserrat during the survey period could have been important, as could changes in health education and food supplementation activities.

Correlation between biomarkers of omega-3 fatty acid consumption and questionnaire data in African American and Caucasian United States males with and without prostatic carcinoma

Results from animal studies suggest that omega-3 fatty acids from marine sources are protective against cancer. To determine whether adipose tissue and erythrocyte membrane fatty acid composition could serve as biomarkers of essential fatty acid consumption in subjects with prostate cancer, we compared fish consumption, which was estimated using a food frequency survey, to the omega-3 fatty acid content of adipose tissue and erythrocyte membranes. The study was conducted using 127 men who had undergone a prostate biopsy. All subjects were recruited from a university hospital urology clinic. African Americans comprised 23% of the subjects, and 70% were diagnosed with prostate cancer. We found a correlation of 0.44 with 95% confidence intervals (CIs) = 0.29-0.57 between reported fish consumption and the omega-3 fatty acid eicosapentaenoic acid composition in erythrocyte membranes and 0.38 with 95% CI = 0.21-0.53 when the dietary survey was compared to eicosapentaenoic acid in adipose tissue. The survey/biomarker correlations in cases were not significantly different from the correlations in controls. The study had 90% power to detect a 0.35 difference between correlations. These results suggest that the presence of prostate cancer does not affect the adipose tissue or erythrocyte membrane biomarkers of fatty acid consumption, and that erythrocyte membranes are as useful as biomarkers as is adipose tissue. Our findings corroborate previous studies that found that tissue biomarkers can reflect past fatty acid consumption and support the use of biomarkers in case-control studies using cancer patients.

Hypertonic saline improves brain resuscitation in a pediatric model of head injury and hemorrhagic shock

INTRODUCTION

Brain injury accompanied by hypovolemic shock is a frequent cause of death in multiply injured children. Hypertonic saline (HTS) has been shown to return hemodynamics to normal in adult models, without increasing intracranial pressure (ICP) as seen with crystalloids. To assess fluid resuscitation, the authors evaluated HTS versus lactated Ringer's solution (LR) with respect to hemodynamics and cerebrovascular hemoglobin oxygen saturation (Sco2) in anesthetized, head-injured, 1-month-old piglets.

METHODS

Group 1 (n = 6) was studied for 3.5 hours after a cryogenic brain injury and no shock. Groups 2 and 3 had cryogenic brain injury followed by hemorrhagic shock, in which mean arterial pressure (MAP) was reduced to 40 to 50 mm Hg and maintained for 30 minutes. Group 2 (n = 5) was then resuscitated with 1 mL of 7.5% HTS per 1 mL of blood loss. Group 3 (n = 6) was resuscitated with 3 mL of LR per 1 mL of blood loss. Sco2 was determined by near-infrared spectroscopy in the injured region of the brain. All data were analyzed using analysis of variance with repeated measures.

RESULTS

MAP, ICP, temperature, serum sodium, and cardiac output (CO) were similar in all groups during baseline and between groups 2 and 3 during shock. After resuscitation, MAP, CO, and core temperature were similar in all three groups, and serum sodium was increased in the HTS group (by 29%). Sco2 increased transiently after cryogenic injury in all groups, then gradually decreased to below baseline. After shock, Sco2 decreased precipitously in group 2 and 3. After resuscitation, Sco2 was different in the two resuscitation groups, increasing in the HTS group, above baseline values, but remaining below baseline values in the LR group (P < .002). ICP was lowered by HTS resuscitation and increased by LR resuscitation (P < .002)

CONCLUSION

In our model of head injury and shock, resuscitation with either HTS or LR restored MAP and CO to control levels. However, during shock, the injured brain was severely deoxygenated, and administration of HTS restored cerebral oxygenation whereas LR did not, reflecting improved cerebral resuscitation by HTS without elevating ICP. The data suggest that HTS is a better resuscitation fluid than LR in head-injured children with hemorrhagic shock.

A genetic defect in 5,10 methylenetetrahydrofolate reductase in neural tube defects

It is now well-established that folic acid, taken peri-conceptionally, can reduce the risk of neural tube defects (NTDs). Recent work has demonstrated that an abnormality of homocysteine metabolism is a critical factor. The gene for 5,10 methylenetetrahydrofolate reductase, an enzyme important in homocysteine metabolism, was studied in relation to NTDs. To determine the frequency of the allele for the thermolabile form of the reductase, DNA samples were collected from people with NTDs, parents of people with NTDs, and normal controls. Of 82 people with NTDs, 15 (18.3%) were homozygous for the abnormal, thermolabile allele. This was significantly higher (p = 0.01) than the rate of 6.1% in the control population (odds ratio 3.47, 95% CI 1.28-9.41). This is the first specific genetic abnormality to be identified in NTDs. It explains the association between some NTDs and elevated homocysteine, given that the reductase is important in homocysteine metabolism. It also explains how folic acid supplementation prevents some NTDs, by overcoming a partial block in the conversion of 5,10 methylenetetrahydrofolate to 5 methyltetrahydrofolate. Genetic screening could identify women who will require folic acid supplements to reduce their risk of having a child with an NTD.

Quality of life among 5,025 patients with left ventricular dysfunction randomized between placebo and enalapril: the Studies of Left Ventricular Dysfunction. The SOLVD Investigators

OBJECTIVES

This study was performed to assess the quality of life of patients with left ventricular dysfunction for up to 2 years after randomization to enalapril or placebo.

BACKGROUND

Previous reports have documented that survival of patients with congestive heart failure can be extended by the angiotensin-converting enzyme inhibitor enalapril. However, it is unknown whether enalapril has a long-term favorable impact on the quality of life in patients with heart failure.

METHODS

A brief quality of life questionnaire assessing the quality of life was administered at baseline and at 6 weeks, 1 year and 2 years of follow-up to patients randomized to placebo or enalapril in the Studies of Left Ventricular Dysfunction (SOLVD). Participants had an ejection fraction < or = 0.35, no other serious illnesses and either symptomatic heart failure (treatment trial, n = 2,465) or asymptomatic left ventricular dysfunction (prevention trial, n = 2,560).

RESULTS

Among the 14 scales of quality of life, better scores at one or more follow-up intervals were noted in 6 scales in the treatment trial and in 1 scale in the prevention trial among patients assigned to enalapril. Consistent superiority with enalapril at two consecutive follow-up intervals was noted in the treatment trial for social functioning and dyspnea but for no scale in the prevention trial. However, an average of 40% of quality of life responses were missing at 2 years of follow-up because of death or failure to complete the questionnaire. In the treatment trial, survivors with more severe heart failure were less likely to complete the questionnaire.

CONCLUSIONS

Modest benefits in quality of life for > or = 1 year occurred when patients with left ventricular dysfunction and symptomatic heart failure were treated with enalapril. No apparent beneficial or adverse effect on quality of life was observed with enalapril in asymptomatic patients with left ventricular dysfunction.

Effects of long-term enalapril therapy on left ventricular diastolic properties in patients with depressed ejection fraction. SOLVD Investigators

BACKGROUND

The aim of the present study was to analyze the changes in left ventricular diastolic function that occur in patients with chronic severe left ventricular systolic dysfunction in the absence or presence of prolonged therapy with an angiotensin converting enzyme inhibitor.

METHODS AND RESULTS

Left ventricular function data (cineangiography plus Millar, frame-by-frame analysis) and right ventricular volumes (radionuclide angiography) were obtained at baseline and after an average follow-up of 12.4 months in 42 patients with a left ventricular ejection fraction of 35% or less. After baseline measurements, the patients were randomized to placebo (n = 16) or enalapril (10 mg BID, n = 26). In the placebo group, the changes in left ventricular function were characterized by increases in end-diastolic (159 +/- 43 to 170 +/- 44 mL/m2) and end-systolic (119 +/- 38 to 128 +/- 49 mL/m2) volumes accompanied by a downward and rightward shift of the diastolic pressure-volume relation. In contrast, decreases in end-diastolic (166 +/- 43 to 156 +/- 47 mL/m2) and end-systolic (125 +/- 43 to 111 +/- 42 mL/m2) volumes accompanied by a slight upward and leftward shift of the diastolic pressure-volume relation were noted in the enalapril group. These changes in left ventricular volumes were significantly different between groups (both P < .005) but were not attended by changes in left ventricular end-diastolic pressure, in time constant of isovolumic pressure decrease, or in right ventricular volumes. However, the chamber stiffness constant beta decreased from 0.044 +/- 0.027 to 0.032 +/- 0.019 mL-1/m2 in the placebo group, whereas it increased insignificantly in the enalapril group (0.040 +/- 0.028 to 0.041 +/- 0.028 mL-1/m2). These changes in chamber stiffness constant beta between baseline and follow-up were significantly different between placebo and enalapril groups (P < .05). Another index of chamber compliance, delta V/delta P, also confirmed the presence of opposite changes in left ventricular chamber compliance in the placebo group and in the enalapril group. The mean diastolic wall stress increased with placebo but not with enalapril (+51 versus -13 kdyn/cm2; P < .04) whereas left ventricular mass and the indexes of left ventricular sphericity tended to improve in the enalapril group. The changes in plasma levels of norepinephrine, atrial natriuretic peptide, and arginine vasopressin were, however, comparable in both groups.

CONCLUSIONS

The data indicate that in patients with severe systolic left ventricular dysfunction, the progressive left ventricular dilatation was accompanied by a decrease in left ventricular chamber stiffness; enalapril therapy was able to prevent or partially reverse these changes and tended to reduce left ventricular mass and ventricular sphericity. Those changes were suggestive of partial reversal of left ventricular remodeling by enalapril administration.

Cutaneous perianal recurrence of cancer after anterior resection using the EEA stapling device

We present a case of cutaneous recurrence from an adenocarcinoma of the rectum, which was diagnosed 7 months after anterior resection of the primary tumour had been performed using the EEA stapling device to fashion the anastomosis. We propose that the recurrence was caused by the seeding of exfoliated tumour cells into an area of perianal skin which was abraded during the introduction of the stapling gun.

Cryptosporidiosis in the Isle of Thanet; an outbreak associated with local drinking water

An outbreak of cryptosporidiosis occurred in the Isle of Thanet during December 1990 and January 1991. A total of 47 cases ranging in age from 2 months to 85 years were identified in residents from the Margate, Broadstairs and Ramsgate areas, with dates of onset of illness from 3 December to 14 January. A case-control study demonstrated a strong statistical association between illness and the consumption of unboiled tap water from a particular source, with evidence of a dose-response relationship. Although no cryptosporidial oocysts were identified in samples of untreated or treated water taken during the investigation, the results were consistent with the view that the source of infection was treated river water which was used to supplement borehole water.

Uncommon complications of laparoscopic sterilisation

We present three unusual complications of laparoscopic sterilisation with clinical presentation, pathology and management. We discuss the possible aetiological factors, pathogenesis and clinical importance in relation to each case.

Intraoperative computers: an idea whose time has come!

Enterprise Systems' James Alland and Patricia Gallagher discuss the reasons few operating rooms are automated and explain the benefits of intraoperative automation.