A functional polymorphism within the mu-opioid receptor gene and risk for abuse of alcohol and other substances

Genetic association studies investigating the role of the +118A allele of the human mu-opioid receptor gene in risk for alcohol dependency have produced inconsistent findings, possibly because of the failure to recognize sampling methodology difficulties inherent in association studies of polygenic disorders. We examined the frequency of the AA genotype and A allele in several groups of substance-dependent cases, unrestricted controls, and super controls screened for the use of alcohol and cigarettes. Our findings and analyses suggest that the OPRM1 +118 polymorphism is a general risk gene for substance dependence, but is not specific to a particular substance. The nature of the conferred risk is likely to be in use of multiple substances, but it is not yet determined if the risk could be expressed in severity of use of any particular substance. The contribution of the gene to risk for substance dependence is small, and is detected most easily in studies that use control samples that are screened for all forms of substance dependence.

Uterine artery resistance and anxiety in the second trimester of pregnancy

OBJECTIVE

To investigate the association between maternal anxiety and uterine artery resistance index (RI) at 20 weeks of gestation.

METHODS

Uterine artery blood flow was assessed using color Doppler ultrasound and maternal anxiety was measured using the Hospital Anxiety and Depression (HAD) scale in 96 healthy primigravid women attending consecutively for their routine 20-week anomaly scan.

RESULTS

The mean uterine artery RI was 0.54 (95% confidence interval, 0.52-0.56) and the median HAD anxiety score was 6 (range, 0-20). There was no association between RI and anxiety scores (r = 0.09, P = 0.36). Women scoring as definite cases of anxiety did not have a significantly elevated uterine artery RI or increased frequency of waveform notching compared to women with doubtful or no anxiety.

CONCLUSIONS

The data of this study do not suggest a significant association between maternal anxiety and uterine artery RI at 20 weeks of gestation in healthy primigravid women with normally developing pregnancies. A prospective cohort study would be useful to determine the nature of the relationship between maternal anxiety, alteration in uterine artery blood flow and abnormal pregnancy outcome.

Provider attitudes and use of alternative medicine in a midwestern medical practice in 2001

OBJECTIVE

To determine the current level of use, referral and desire for service of different complementary and alternative (CAM) therapies among Gundersen Lutheran Medical Center providers.

METHODS

A survey was conducted in January of 2001 of all medical and associate staff.

RESULTS

The response rate was 79%; 55% reported using 1 or more of 18 therapies for themselves. Over 25% of providers used nutritional supplements, herbal medicines, or hydrotherapy with a patient. Over half of providers had referred a patient for biofeedback or chiropractic care. Over half of providers would like to offer acupuncture, biofeedback, chiropractic care, hydrotherapy, nutritional supplements, or massage to patients in the future. Associate staff, female staff, primary care providers, and those who had personally used CAM therapies were more likely to have used, referred, or wish to offer more therapies in the future. There was little support for aromatherapy, magnetic field therapy, naturopathic medicine, or ethnic healing methods.

CONCLUSIONS

Use of and desire for complementary therapies at Gundersen Lutheran was higher than expected by the Integrative Medicine Oversight Committee. Health care organizations should consider having a process in place to manage the increasing demands for complementary and alternative therapies.

Mediation of proliferating cell nuclear antigen (PCNA)-dependent DNA replication through a conserved p21(Cip1)-like PCNA-binding motif present in the third subunit of human DNA polymerase delta

The subunit that mediates binding of proliferating cell nuclear antigen (PCNA) to human DNA polymerase delta has not been clearly defined. We show that the third subunit of human DNA polymerase delta, p66, interacts with PCNA through a canonical PCNA-binding sequence located in its C terminus. Conversely, p66 interacts with the domain-interconnecting loop of PCNA, a region previously shown to be important for DNA polymerase delta activity and for binding of the cell cycle inhibitor p21(Cip1). In accordance with this, a peptide containing the PCNA-binding domain of p21(Cip1) inhibited p66 binding to PCNA and the activity of native three-subunit DNA polymerase delta. Furthermore, pull-down assays showed that DNA polymerase delta requires p66 for interaction with PCNA. More importantly, only reconstituted three-subunit DNA polymerase delta displayed PCNA-dependent DNA replication that could be inhibited by the PCNA-binding domain of p21(Cip1). Direct participation of p66 in PCNA-dependent DNA replication in vivo is demonstrated by co-localization of p66 with PCNA and DNA polymerase delta within DNA replication foci. Finally, in vitro phosphorylation of p66 by cyclin-dependent kinases suggests that p66 activity may be subject to cell cycle-dependent regulation. These results suggest that p66 is the chief mediator of PCNA-dependent DNA synthesis by DNA polymerase delta.

Rural palliative care needs: a survey of primary care professionals in Powys, Wales

The county of Powys in rural Wales has a population of about 125,000 people and no district general hospitals. In 1999, 12 Macmillan general practitioner clinical facilitators were appointed as part of a pilot project aiming to provide a coordinated framework for the commissioning of specialist cancer and palliative care services, extended clinical care to cancer and non-cancer patients, and an educational intervention to raise the standards of generalist palliative care. A survey of facilitators, general practitioners, district nurses and community hospital nurses was undertaken early in the project. Palliative care formed a small but significant part of respondents' workload. Specialist palliative care services were seen as helpful but distant from the patients. Pain and symptom control were seen to be problematic in patients with diagnoses other than cancer. Services that provided 24-hour nursing care at home were thought to be in need of development by most respondents.

The adult attachment interview: rating and classification problems posed by non-normative samples

Non-normative samples can pose major procedural and coding challenges to interviewers and raters of the Adult Attachment Interview (AAI). With reference to interview transcripts drawn from a population of personality disordered offenders detained in a high-security hospital, specific difficulties are identified and discussed. These difficulties have their roots in three separate but overlapping areas: extreme attachment-related experience; interviewees' psychological or psychiatric state; and factors relating to the context in which the interview is conducted. They raise questions about whether and when the use of the interview should be restricted, the rating rules elaborated and/or the rating system expanded. Suggestions are made as to how some of the difficulties might be addressed.

Disorganised attachment behaviour among infants born subsequent to stillbirth

There is limited evidence that siblings of stillborn infants are more vulnerable to psychological problems. This case-controlled study examines the relationship between previous stillbirth and the next child's pattern of attachment and explores factors in the mother which may be associated with and which may explain the pattern of infant attachment. We examined 53 infants next-born after a stillbirth, and 53 control infants of primigravid mothers. Maternal demographic, psychiatric, and attachment data were collected in pregnancy, and self-report measures of depression collected in the first year. Infant attachment patterns to the mothers were assessed when the infants were 12 months old using the Ainsworth Strange Situation Procedure. Infants next-born after stillbirth showed significant increase in disorganisation of attachment to the mother compared with control infants (p < .04). The difference was not accounted for by differences in psychiatric symptoms or demography. It was strongly predicted by maternal unresolved status with respect to loss as measured in the Adult Attachment Interview, and less strongly by maternal experience of elective termination of pregnancy and by the mother having seen her stillborn infant. The study adds weight to previously reported clinical observations, that infants born after stillbirth may be at risk of an increase in psychological and behavioural problems in later childhood. The strong association between disorganisation of infant attachment and maternal state of mind with respect to loss suggests that the mother's state of mind may be causal, and raises interesting questions about the mechanism of intergenerational transmission. Given the existing evidence of later developmental problems, longer-term follow-up of these children would be valuable.

Localization of the large subunit of replication factor C near the 5' end of DNA primers

Replication factor C (RFC) is a heteropentameric sliding clamp loader protein essential for processive synthesis of DNA by eukaryotic DNA polymerases delta and epsilon. To study the interaction of RFC with 3' and 5' ends of the DNA primer, we have developed chemical photocrosslinking assay using a synthetic DNA gap and DNA primer-template structures. We have found that the radioactively labeled primers containing a photoreactive group at their 5' end could crosslink with the largest RFC subunit (RFC140) on primer-templates and DNA gap structures, but that 3' end photoreactive primers could only crosslink with RFC140 within the DNA gap structure. Addition of replication protein A (RPA) to the reaction mixture resulted in the crosslinking of RPA subunits and inhibited crosslinking of RFC140 using 3' but not 5' photoreactive primers present at the gap. The results suggest specific contacts between RFC140 and the 5' end of the DNA primer. Together with previous data, these experiments allow us to propose a model for the DNA polymerase switch during eukaryotic DNA replication.

Occlusion of left common iliac vein by a distended urinary bladder in a male with paraplegia due to spinal cord injury

STUDY DESIGN

A report of a male subject who sustained paraplegia at T-5 level due to spinal cord injury (SCI) 18 years ago, and in whom, occlusion of the left common iliac vein by a distended bladder was detected during a routine follow-up.

OBJECTIVES

To illustrate a rare complication of chronic distension of the urinary bladder viz occlusion of the left common iliac vein, which persisted even after providing adequate bladder drainage by intermittent catheterisation.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

As part of a routine follow-up, we performed intravenous urography by injecting 50 ml of Ultravist 300 in a vein over the dorsum of the left foot. Opacification of collateral veins in the pelvis was seen in the 5- and 10-min films, which suggested iliac venous occlusion. In order to confirm the diagnosis, contrast was injected intravenously in the left foot and venography was performed.

RESULTS

Venography revealed a distended left common iliac vein with contrast flowing into the right internal iliac vein through collateral veins in the pelvis; the right common iliac vein and inferior vena cava were patent. Duplex Doppler sonography showed compression of left common iliac vein by the posterior wall of a distended bladder with absence of blood flow through the compressed segment. Computerised tomography (CT) confirmed the diagnosis of extrinsic compression of the left common iliac vein against the promontory of sacrum by a distended bladder. CT excluded other causes for iliac vein occlusion.

CONCLUSION

In a male subject with SCI, chronic bladder distension produced occlusion of the left common iliac vein. Health professionals caring for individuals with SCI should be aware that long-standing bladder distension could cause pressure effects upon adjacent structures in the pelvis.

Incidence, correlates and predictors of post-traumatic stress disorder in the pregnancy after stillbirth

BACKGROUND

Many women may suffer psychological symptoms after stillbirth and in the subsequent pregnancy. Stillbirth has not been demonstrated previously to be a stressor for post-traumatic stress disorder (PTSD).

AIMS

To assess incidence, correlates and predictors of PTSD during and after the pregnancy following stillbirth.

METHOD

A cohort study of pregnant women whose previous pregnancy ended in stillbirth.

RESULTS

PTSD symptoms were prevalent in the pregnancy following stillbirth. Case-level PTSD was associated with depression, state-anxiety and conception occurring closer to loss. Symptoms generally resolved naturally by 1 year post-partum (birth of healthy baby).

CONCLUSIONS

Women are vulnerable to PTSD in the pregnancy subsequent to stillbirth, particularly when conception occurs soon after the loss.

Right heart assist ensures hemodynamic stability during beating heart coronary surgery on marginal arteries. An animal experimental porcine study

OBJECTIVES

In many heart centers myocardial revascularization using beating heart coronary surgery has partly replaced conventional coronary artery bypass grafting (cCABG) using cardiopulmonary bypass. However, access to the marginal arteries is problematic and hampered by space limitations, which might compromise the quality of the anastomoses and it entails a significant risk of hemodynamic instability subsequent to the manipulations of the heart. Hemodynamic impairment may be caused by dislocation of the low-pressure right atrium and ventricle. Therefore, it was hypothesized that the use of Right Heart Assist (RHA) may be able to ensure hemodynamic stability when tilting and manipulating the heart.

DESIGN

In an animal experimental model RHA was implemented in order to study the hemodynamic impact of dislocating the heart in a standardized fashion.

RESULTS

Dislocation of the unassisted heart to expose the first and second marginal branches caused a decline in arterial blood pressure, cardiac output and venous saturation of 38-48%. Supported by RHA this decrease was minimized to 0-17%.

CONCLUSION

RHA for beating heart procedures indicates several advantages: ample time and safety while making the anastomoses at the marginal branches, less space limitations and enhanced control of hemodynamic stability compared with no RHA. This operation technique is challenging current practice and indications, and may potentially replace cCABG for the majority of patients.

Phase I trial of concurrent tirapazamine, cisplatin, and radiotherapy in patients with advanced head and neck cancer

PURPOSE

To determine the maximum-tolerated dose of tirapazamine when combined with cisplatin and radiation in patients with T3/4 and/or N2/3 squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

The starting schedule was conventionally fractionated radiotherapy (70 Gy in 7 weeks) with concomitant cisplatin 75 mg/m2 and tirapazamine 290 mg/m2 (before cisplatin) in weeks 1, 4, and 7 and tirapazamine alone 160 mg/m2 three times a week in weeks 2, 3, 5, and 6. Positron emission tomography scans for tumor hypoxia (18F misonidazole) were performed before and during radiotherapy.

RESULTS

We treated 16 patients with predominantly oropharyngeal primary tumors, including 10 patients with T4 or N3 disease. Febrile neutropenia occurred toward the end of radiotherapy in three out of six patients treated on the initial dose level. Two of these patients also developed grade 4 acute radiation reactions. Another 10 patients were treated with the same doses, but the week 5 and week 6 tirapazamine doses were omitted. This resulted in less neutropenia and only one dose-limiting toxicity (DLT) (febrile neutropenia), and eight out of 10 patients completed treatment without any dose omissions. In these 10 patients, the acute radiation toxicities were not obviously enhanced compared with chemoradiotherapy regimens using concurrent platinum and fluorouracil. 18F misonidazole scans detected hypoxia in 14 of 15 patients at baseline, with only one patient having detectable hypoxia at the end of treatment. With a median follow-up of 2.7 years, the 3-year failure-free survival rate was 69% (SE, 12%), the 3-year local progression-free rate was 88% (SE, 8%), and the 3-year overall survival rate was 69% (SE, 12%).

CONCLUSION

DLT was due unexpectedly to febrile neutropenia, which could be overcome by omitting tirapazamine in weeks 5 and 6. The combination of tirapazamine, cisplatin, and radiotherapy resulted in remarkably good and durable clinical responses in patients with very advanced head and neck cancers. It warrants further investigation.

Ultrasonography of the femoral vessels in the groin: implications for vascular access

The femoral artery and vein are commonly used for access to the circulation. Accidental puncture of one vessel whilst attempting to cannulate the other is a common complication. Identification of relevant surface anatomical landmarks and ultrasonography of both groins was performed on 50 consecutive adult patients admitted to the intensive care unit. In most patients there was overlap of the artery over the vein far closer to the inguinal ligament than conventional anatomical texts would indicate. The frequency and degree of overlap increased as the vessels descended distally towards the knee. Surface anatomical landmarks were not useful in predicting the underlying anatomy. The side-by-side relationship of artery and vein is commonest close to the inguinal ligament. Therefore, to avoid damage to the neighbouring vessel, percutaneous access should be undertaken just below the inguinal ligament.

Silent hydronephrosis/pyonephrosis due to upper urinary tract calculi in spinal cord injury patients

STUDY DESIGN

A study of four patients with spinal cord injury (SCI) in whom a diagnosis of hydronephrosis or pyonephrosis was delayed since these patients did not manifest the traditional signs and symptoms.

OBJECTIVES

To learn from these cases as to what steps should be taken to prevent any delay in the diagnosis and treatment of hydronephrosis/pyonephrosis in SCI patients.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

A retrospective review of cases of hydronephrosis or pyonephrosis due to renal/ ureteric calculus in SCI patients between 1994 and 1999, in whom there was a delay in diagnosis.

RESULTS

A T-5 paraplegic patient had two episodes of urinary tract infection (UTI) which were successfully treated with antibiotics. When he developed UTI again, an intravenous urography (IVU) was performed. The IVU revealed a non-visualised kidney and a renal pelvic calculus. In a T-6 paraplegic patient, the classical symptom of flank pain was absent, and the symptoms of sweating and increased spasms were attributed to a syrinx. A routine IVU showed non-visualisation of the left kidney with a stone impacted in the pelviureteric junction. In two tetraplegic patients, an obstructed kidney became infected, and there was a delay in the diagnosis of pyonephrosis. The clinician's attention was focused on a co-existent, serious, infective pathology elsewhere. The primary focus of sepsis was chest infection in one patient and a deep pressure sore in the other. The former patient succumbed to chest infection and autopsy revealed pyonephrosis with an abscess between the left kidney and left hemidiaphragm and xanthogranulomatous inflammation of perinephric fatty tissue. In the latter patient, an abdominal X-ray did not reveal any calculus but computerised axial tomography showed the presence of renal and ureteric calculi.

CONCLUSIONS

The symptoms of hydronephrosis may be bizarre and non-specific in SCI patients. The symptoms include feeling unwell, abdominal discomfort, increased spasms, and autonomic dysreflexia. Physicians should be aware of the serious import of these symptoms in SCI patients.

Use of digitally reconstructed radiographs in radiotherapy treatment planning and verification

The authors present 3 years of experience in using digitally reconstructed radiographs (DRR) for radiotherapy planning and verification. Comparison is made with simulation film (SF), to illustrate the advantages of DRR over SF. Emphasis is placed on using the appropriate equipment and applying the correct technique. A brief discourse on the principle of CT imaging is presented to illustrate the operation of CT software and optimization of image display for axial slices and DRR. Emphasis is placed on the application of clinical knowledge to enhance the usefulness, as well as the technical quality, of the DRR. Illustrative examples are given.

Impact of synthetic pyrethroid-sheep dip on the indigenous microflora of animal slurries

The chemical constituents of sheep dip in the UK are currently changing from organophosphate-based to synthetic pyrethroid-based insecticides. As a result, changes are also being made to the methods of disposal of these chemicals in the environment, such that pyrethroid sheep dips must now be diluted in animal slurry or water. To date, there is a lack of quantitative information on the impact of the insecticide on the indigenous microflora of animal slurries. This paper investigated the impact of Bayticol (synthetic pyrethroid sheep dip) over a range of concentrations on selected populations of bacteria within animal slurry. It was found that, with increasing pesticide concentration, there was up to a four orders of magnitude increase in the numbers of faecal coliforms and pathogens, such as putative Salmonella spp. These findings have implications for the disposal of sheep dip-amended animal slurries to land from several aspects: (i) the longevity of putative pathogens in the field may require re-evaluation of the time required before the return of grazing livestock to a slurry-amended field; (ii) the potential for the transfer of pathogenic bacteria and faecal coliforms into human and animal foodchains, and (iii) the increased potential for faecal coliforms being washed into streams, rivers and coastal bathing waters.

Similarities of substance use between medical and nursing specialties

This paper reviews and compares alcohol and other drug involvement findings in two professions, medicine and nursing, by specialty. Health care providers are naturally subgrouped by specialty, as this is a major work environment factor. The evidence indicates an association exists between practicing in certain medical or nursing specialties and substance use. In addition, similarities in specialty membership and substance use across medicine and nursing suggests there may be common risk factors related to substance use that could be addressed using interdisciplinary approaches.

[The evidence for primary axonal loss in multiple sclerosis]

INTRODUCTION

At what stage in the pathogenesis of multiple sclerosis (MS) does the damage to axons occur, and why should there be any axon loss at all in what is thought to be principally an axon sparing demyelinating disease? A recently described new technique for investigating axon damage depends for its ability on the immunoreactivity of amiloid precursor protein (APP), which has been shown to be more sensitive than silver stains for detecting damaged axons.

DEVELOPMENT

We used APP immunoreactivity as a method to investigate whether axon damage occurs in acute MS lesions. The results of our APP staining showed that the expression of APP in MS lesions is associated with acute MS lesions and the active border of less acute lesions. There was little, if any, APP expression in the chronic lesions. If we accept that the APP staining represents irreversible damage to some axons, the next question is what factors are responsible for mediating damage to axons in MS? Matrix metalloproteinases (MMP) are expressed by macrophages in acute MS lesions and in the active borders of active chronic lesions. The injection of highly-purified MMP into the brain results in demyelination, blood-brain barrier breakdown, and axonal loss. Moreover, the inhibition of the MMP activity reduces the severity of MS-like lesions in experimental models. Thus the properties and distribution of these enzymes make them rational targets for therapeutic intervention.

CONCLUSION

Whatever mechanism proves to be responsible for axonal damage in MS, it is clear that this disease should, perhaps, be more appropriately recognized as a primary demyelinating entity with associated primary axonal loss.