The nurse's role in clinical trials

Parkinson's disease (PD) is a chronic and progressive degenerative disorder of the central nervous system characterized by tremor, rigidity, slowness of movement (bradykinesia) and postural abnormalities. The cause is unknown, but the pathology shows that dopamine is profoundly reduced in the basal ganglia of patients with PD. When dopamine is replenished by the administration of levodopa, most of the symptoms of parkinsonism are reduced significantly. Levodopa is considered to be the most reliable and effective symptomatic drug treatment for keeping patients autonomous and functionally independent for as long as possible.

A phase I randomized study of subcutaneous adjuvant IL-2 in combination with an autologous tumor vaccine in patients with advanced renal cell carcinoma

We performed a prospective, randomized study to determine whether subcutaneous administration of interleukin-2 (IL-2) in combination with an autologous renal cell vaccine is feasible and can potentiate antitumor immunity. Seventeen patients with metastatic renal cell carcinoma underwent surgical resection with preparation of an autologous tumor cell vaccine. Patients were vaccinated intradermally twice at weakly intervals with 10(7) irradiated tumor cells plus bacillus Calmette-Guérin, and once with 10(7) tumor cells alone. Patients were randomized to one of three groups: no adjuvant IL-2, low-dose IL-2 (1.2 x 10(6) IU/m2), or high-dose IL-2 (1.2 x 10(7) IU/m2). IL-2 was administered subcutaneously on the day of vaccination and the subsequent 4 days. Immune response was monitored by delayed-type hypersensitivity (DTH) response to tumor cells as compared with normal autologous renal cells. Sixteen of 17 patients received vaccine therapy. Four patients developed cellular immunity specific for autologous tumor cells as measured by DTH responses; two had received no IL-2 and two had received high-dose IL-2. There were two partial responses (PR) noted, both in patients who received high-dose IL-2. One responding patient was DTH(+) and one was negative. A third patient who was DTH(+) after vaccination with no IL-2 had a dramatic PR after receiving IL-2 subcutaneously in a subsequent protocol. Prospective testing of response to recall antigens indicated that only 5 of 12 tested patients were positive, including both clinical responders. These data suggest that subcutaneously administered adjuvant IL-2 does not dramatically augment the immunologic response to autologous renal cell vaccines as determined by the development of tumor-specific DTH response.

Systolic anterior motion of the mitral chordae tendineae: prevalence and clinical and Doppler-echocardiographic features

The objective of this investigation was to determine the prevalence and clinical associations of systolic anterior motion (SAM) of the mitral chordae (chordal SAM) in patients without evidence of hypertrophic cardiomyopathy. Although SAM of the mitral valve is thought to be a specific marker of hypertrophic obstructive cardiomyopathy, little is known about the clinical significance of chordal SAM either as an isolated echocardiographic finding (ICSAM) or in patients with mitral valve prolapse (MVP). A retrospective search of the clinical echocardiographic database was made to identify studies demonstrating chordal SAM with no other echocardiographic features of hypertrophic cardiomyopathy. The prevalence of chordal SAM was also ascertained in a group of 97 normal control subjects. Clinical, demographic, and two-dimensional and Doppler echocardiographic characteristics were compared between patients with and without MVP. Chordal SAM was identified in 3.9 percent of clinical studies but was rarely seen in normal volunteers (1 percent). Of the 57 patients with chordal SAM, 21 had systemic or cardiovascular conditions other than MVP associated with SAM (including 7 with aortic insufficiency and 8 with secondary concentric left ventricular hypertrophy), 18 (32 percent) had MVP, and 19 (33 percent) had no associated cardiovascular or systemic condition. These 19 patients with ICSAM were similar to patients with MVP and SAM with respect to age (44 +/- 8 vs 41 +/- 17 years), blood pressure, left ventricular wall thickness, ejection fraction, left atrial size, degree of mitral insufficiency, and left ventricular outflow tract velocity. Indications for the echocardiographic studies were similar between the two groups (chest pain, syncope, arrhythmia, cardiac source of embolus, and suspected MVP), but more patients in the ICSAM group were men (16 of 19 vs 8 of 18; p < 0.05). In conclusion, patients with ICSAM and CSAM associated with MVP are virtually indistinguishable by clinical, demographic, or Doppler-echocardiographic features. The syndrome of ICSAM deserves further study as a potentially clinically significant echocardiographic variant of the floppy mitral valve/MVP syndrome.

Undoing the lag in the technique of conflict and defense analysis

When the individual skills of a psychotherapist or psychoanalyst coincide with what serves as a sublimation for the practitioner, the gratification in the clinical work is especially enhanced. If those moments of applied skill also are a part of the specific therapeutic action of that form of treatment, a fortunate combination exists. As Freud expanded the potential of psychoanalytic treatment when he reformulated the theory of anxiety, he also provided access to improved therapeutic actions in the course of analyzing intrapsychic conflict. This meant that some of the sublimations in practicing the earlier techniques no longer coincided with what could be the therapeutic actions characteristic of the more effective analysis of conflict. The lag in adding new technical measures to psychoanalytic methodology is more fully accounted for by a reluctance on the part of some analysts to sacrifice certain traditional sources of sublimated projection in interpretations and to seek other sublimations commensurate with Freud's more advanced view of analyzing defenses.

Extremely low birth weight and control infants at 2 years corrected age: a comparison of intellectual abilities, motor performance, growth and health

A 2-year cohort of 63 surviving extremely low birth weight (ELBW) infants was prospectively studied and 60 of these infants, together with 44 normal birth weight control infants, were assessed at 2 years of age for intellectual abilities, motor skills, growth and health. The total ELBW group differed significantly from controls on overall Griffiths developmental quotient (99.3 vs. 103.8 P = 0.02) and in the personal/social subscale (100.7 vs. 106.7 P = 0.01). A subset of 43 of the ELBW infants was identified as low risk at discharge. No statistically significant differences were present between the low risk ELBW subset and controls in intellectual abilities though both the total ELBW group and the low risk ELBW subset differed from controls in fine and gross motor abilities, and in weight at 2 years. The total ELBW group also experienced more frequent ill health and hospital readmission.

Total parenteral nutrition modifies the acute phase response to Crohn's disease

Measurements of the acute phase proteins, C-reactive protein (CRP) and orosomucoid are widely used to monitor the activity of Crohn's disease. The effect of TPN upon the levels of acute phase proteins is unknown. Serum levels of CRP and orosomucoid were measured simultaneously over a four year period in 13 patients receiving TPN for Crohn's disease, nine patients with noninflammatory causes of intestinal failure, and 16 patients with Crohn's disease treated without TPN. An acute phase response was found with a similar frequency in both groups of patients with Crohn's disease (73.6% and 83.9% for Crohn's with and without TPN respectively), but was less prevalent in patients receiving TPN for non-inflammatory causes of intestinal failure (56.1%, P < 0.01). In this latter group, the acute phase response consisted primarily of an isolated elevation of orosomucoid (78.4%), compared with patients with Crohn's disease alone (21.1%, P < 0.001) and with Crohn's disease and TPN (46.6%, P < 0.05). Liver function abnormalities were seen on 68.8% of occasions in patients with noninflammatory causes of intestinal failure who had elevated levels of orosomucoid, compared with 34.9% of occasions on which orosomucoid levels were normal (P < 0.001). TPN may lead to isolated elevation of serum levels of orosomucoid, reducing the value of this acute phase protein in monitoring the activity of Crohn's disease in patients receiving TPN.

Excessive infant crying: a controlled study of mothers helping mothers

OBJECTIVE

To determine the efficacy of behavioral management counseling in the treatment of persistent, excessive infant crying (> 3 hours per day).

DESIGN

Two treatments, one no treatment control group. Infants were group-matched according to baseline fuss/cry levels, sociodemographic, and infant variables. Treatments were carried out sequentially by the same counselors.

SETTING

Telephone counseling by volunteers (mothers) of CRY-SIS, a national support group for the parents of crying infants.

PATIENTS AND INTERVENTIONS

Sequential sample of 27 mother-infant pairs receiving treatment 1 (Tr1, empathy: talking through the problem), 21 receiving treatment 2 (Tr2, behavioral management: specific care taking suggestions) and 44 receiving no treatment (C, controls). Infants were between 1 to 5 months of age.

MEASUREMENTS AND RESULTS

Mother-infant pairs had a pretreatment baseline assessment and a posttreatment follow-up (3 months after baseline) using 1-week diaries. Total fuss/cry duration reduced significantly more in the behavioral management group (by 51%) than the empathy group (37%) or the control group (35%). This was mainly due to significantly reduced evening fussing/crying in Tr2 (67%) compared with Tr1 (45%) and C (42%). No differences in total number of fuss/cry bouts/day were found. However, the number of fuss/cry bouts reduced significantly more in the evening in Tr2 (by 55%) compared with Tr1 (27%) and C (32%). Behavioral management mothers evaluated the same counselors as more sympathetic, knowledgeable, and understanding. Tr2 was also perceived by mothers to have helped them more in reducing the crying problem, coping with the infant, and improving the relationship with their infant than Tr1. No effects of treatment on infant difficult temperament were found.

CONCLUSIONS

Behavioral management was more effective in reducing fussing/crying than spending time with the mother talking through the problem or just waiting for spontaneous remission. Treatment by suitably but briefly trained lay counselors is an inexpensive and successful treatment option.

Evaluation of the short-term impact of counseling in general practice

This paper describes the findings of a randomised controlled trial of the short-term impact of counseling in the general practice setting. Compared with patients who received usual advice from their general practitioner for acute problems such as relationship difficulties, anxiety and depression, those who received counseling from qualified counselors working within the primary health care context showed greater improvement in psychological health as measured by the General Health Questionnaire. Significantly fewer of those counselled were prescribed anti-depressant drugs by the general practitioners in the study, or were referred to psychiatrists or clinical psychologists for care. In addition those patients who attended sessions with the practice counselor were more likely to report that they were satisfied with their treatment and more expressed feelings of well-being.

There's life in the review body yet

I enjoyed Graham Scott's feature on the future of the Review Body but I disagree with his conclusion that its days are numbered.

Thermogenic, hormonal, and metabolic effects of a TPN mixture. Influence of glucose and amino acids

The thermogenic, hormonal, and metabolic effects of intravenous nutrition were examined by administering a complete total parenteral nutrition (TPN) mixture to 11 subjects, and the relative contributions of the glucose and amino acid components of the mixture were evaluated by administering these nutrients separately (n = 7 and n = 6, respectively). The complete TPN mixture caused a 22.9% rise in resting energy expenditure (REE), which significantly exceeded that associated with glucose (10.4% P < 0.02). The rise in REE produced by the amino acids (11.5%) did not differ significantly from that associated with administration of the TPN or glucose. The rise in REE associated with the TPN was almost exactly equal to the sum of the rises associated with the separate components of the mixture (22.9% and 22.0%, respectively), indicating that glucose and amino acids contributed equally to the thermogenic effect of the TPN mixture. In contrast, although the amino acid component of the TPN mixture was associated with small but significant reductions in plasma free fatty acid and glycerol concentration and with small increases in plasma insulin concentration, the effects of the complete TPN mixture were significantly greater and attributable to the glucose component.

Symptomatic relief from treatment-induced psychosis in Parkinson's disease: an open-label pilot study with remoxipride

Current treatment strategies for levodopa-induced psychosis in Parkinson's disease have had limited success. Remoxipride, a selective D2 receptor antagonist, was administered in an open label pilot study to seven parkinsonian patients exhibiting thought disorder. Symptoms improved significantly in six patients after treatment durations of 1-6 months and cleared completely in two individuals. One patient (at age 90 the oldest in the group) could not tolerate the compound due to significant motor deterioration, and the drug had to be discontinued after 1 week. In all remaining patients, no motor complications appeared, and therapeutic effects of remoxipride continued for up to 3 months after treatment cessation and have lasted for 2 years now in one individual. Further study of this compound in the context of treatment-induced psychosis in Parkinson's disease appears to be warranted.

Modulation of mustard toxicity by tacrine

Compounds containing the chloroethyl group are potent inhibitors of DNA synthesis and cell growth. Tacrine, a choline carrier inhibitor, was found to protect both HeLa cells and rat thymocytes against the effects of nitrogen mustard. DNA synthesis was restored from 13 to 71% of the control value and cell viability restored from 27 to 57% of the control value by exposure of the cells to an equimolar concentration of tacrine immediately prior to nitrogen mustard. In contrast, tacrine was unable to significantly protect rat thymocytes against the toxic effects of sulphur mustard. These results have implications for the clinical use of nitrogen mustard.

Use of on-line gas analysis to monitor recombinant mammalian cell cultures

The development of a system capable of accurately measuring the oxygen uptake and carbon dioxide production rates during mammalian cell cultures is described. A detailed study of the specifications of the various components used in the system for the measurement of gas flow rates and composition, coupled with the validation of the system independent of the bioreactor was carried out. The aim of this study was to identify and eliminate where possible the errors controlling the accuracy of determination of gaseous metabolic rates. This study showed the importance of controlling the temperature of gaseous oxygen entering the system. With such temperature control, it was possible to obtain data with an accuracy of +/- 5% at the 95% confidence level. Another source of error, the use of bi-carbonate buffer, was studied. A mathematical model was used to compensate for the affect of such buffers on the determination of carbon dioxide production rates. The use of the system for the continuous determination of gaseous metabolism during the growth and production phase for recombinant CHO cell cultures is described.

Exercise conditioning in older coronary patients. Submaximal lactate response and endurance capacity

BACKGROUND

Older coronary patients are at high risk of cardiac disability. Exercise conditioning programs have been demonstrated to improve functional capacity, particularly in younger coronary patients. In this study, the effects of aerobic conditioning on submaximal and maximal indicators of exercise performance were examined in 45 older coronary patients.

METHODS AND RESULTS

Forty-five patients (mean age, 69 +/- 6 years; range, 62 to 82 years) entered 3-month and 12-month (n = 11) endurance training programs. Training effects were assessed during an exhaustive submaximal exercise protocol with measurement of endurance time, serum lactate, perceived exertion, and expired ventilatory measures. Exhaustive endurance time increased by more than 40% (30 +/- 10 to 41 +/- 10 minutes), with associated decreases in serum lactate, perceived exertion, minute ventilation, heart rate, and systolic blood pressure during steady-state exercise. Respiratory exchange ratio during steady-state exercise, an indicator of substrate utilization, decreased, indicating a shift toward greater use of free fatty acids as a metabolic fuel. In a subset of 10 patients, percent body fat was decreased (32 +/- 8% to 29 +/- 10%) over a period of 3 months.

CONCLUSIONS

Older coronary patients respond to aerobic conditioning with remarkable improvements in submaximal endurance capacity, out of proportion to the more modest increases in VO2max. Activities that were exhaustive before training became sustainable for extended periods of time at a lower perceived exertion. Measurements of serum lactate, respiratory exchange ratio, and ventilation during steady-state exercise document that at an identical absolute work load after conditioning, exercise is performed using aerobic substrate to a greater degree, and ventilatory response to a given work load is lessened.

Individualizing aminophylline doses in premature infants using bioelectrical impedance: a non-invasive approach

The role of bioelectrical impedance (BI) in estimating the pharmacokinetics and, therefore, individualized doses, of aminophylline in preterm infants (gestational age 26-35 weeks) was assessed in a two-phase study. Multiple regression analysis in the first group of neonates (phase I, n = 19) identified resistance, reactance, weight and length as optimal predictors of distribution volume (adjusted R2 = 0.84, coefficient of variation (CV) = 10.17%), and length2/impedance and postconceptual age as predictors of clearance (adjusted R2 = 0.74, CV = 26.73%). Application of these models to an independent group (phase II, n = 20) generated doses which satisfactorily achieved target theophylline loading and steady-state (SS) 'peaks' of 10 micrograms/mL and SS 'troughs' of 7.7 +/- 0.6 micrograms/mL. A better understanding of specific criteria and limitations of the impedance technique in neonates is necessary in order to refine BI measurements.

Value of postprocedural chest radiographs in the adult intensive care unit

OBJECTIVE

To evaluate the necessity for postprocedural chest radiographs after catheterization of central veins, insertion of pulmonary artery catheters, and placement of endotracheal tubes.

DESIGN

Prospective, controlled study.

SETTING

Two academic tertiary adult ICUs.

PATIENTS

Consecutive patients (n = 316) requiring central vein cannulation or endotracheal intubation in the ICUs.

INTERVENTION

After each invasive procedure, the physician was instructed to complete a detailed evaluation sheet. Criteria based on the details of the procedure and immediate postprocedural clinical evaluation of the patient were used to determine the likelihood of a radiologically detectable complication. Actual radiologic findings were subsequently compared against clinical predictions.

MAIN OUTCOME MEASUREMENTS

Ability of housestaff to correctly predict the absence of radiologically detectable postprocedural complications (predictive negatives).

RESULTS

Ability to predict the absence of complications after cordis catheter insertions via the subclavian vein or internal jugular vein was very high (151/152; p < .001). Unsuspected complications were more frequent with central vein multilumen catheter insertions (3/24; p < .001). Ability to predict uncomplicated pulmonary artery catheterization was also high (110/111; p < .001). Physicians were unable to predict the majority of complications associated with endotracheal intubations (28/32; p > .50).

CONCLUSIONS

The use of a protocol that includes an evaluation of the characteristics of the procedure and postprocedural physical examination can greatly reduce the need for routine chest radiographs after subclavian and internal jugular vein cordis catheterizations and pulmonary artery catheter placement. Chest radiographs should be performed after endotracheal intubation and multilumen catheter insertion.

Thermogenic and hormonal responses to amino acid infusion in septic humans

Metabolic effects of a commercially available amino acid infusate were investigated in five preoperative patients with abdominal sepsis and five healthy subjects. Oxygen consumption (VO2) was measured continuously during the 3-h study, and blood samples were taken regularly for hormone and metabolite analyses. During 1 h of preinfusion measurements, VO2 was 15% higher (P less than 0.05) in the septic patients. Preinfusion plasma cortisol, glucagon, and catecholamines were also significantly elevated in the septic group. The amino acid solution (9 g nitrogen; 950 kJ; 227 kcal) was infused into each subject through their central venous catheter during the 2nd and 3rd h of the study. VO2 increased similarly in both groups by approximately 21% during the infusion (P less than 0.05), whereas respiratory quotient increased significantly in only the controls (P less than 0.05). Plasma insulin and glucagon concentrations rose significantly in both groups during the infusion, despite little change in glucose levels. Plasma norepinephrine increased in both groups, although the response was significant in only the control subjects. In summary, the amino acid infusate stimulated metabolic rate similarly in the septic and nonseptic subjects.