Quinoline antifolate thymidylate synthase inhibitors: variation of the C2- and C4-substituents

Modifications to the bicyclic ring system of the potent thymidylate synthase (TS) inhibitor N-[4-[N-[(2-amino-3,4-dihydro-4-oxo-6- quinazolinyl)methyl]-N-prop-2-ynylamino]benzoyl]-L-glutamic acid (1, CB3717) have led to the synthesis of a series of quinoline antifolates bearing a variety of substituents at the C2 and C4 positions. In general the synthetic route involved the coupling of the appropriate diethyl N-[4-(prop-2-ynylamino)benzoyl]-L-glutamate with a disubstituted 6-(bromomethyl)quinoline followed by deprotection using mild alkali. The compounds were tested as inhibitors of partially purified L1210 TS. As a measure of cytotoxicity, the compounds were tested for their inhibition of the growth of L1210 cells in culture. Good enzyme inhibition and cytotoxicity were found for compounds containing chloro, amino, or methyl substituents at the C2 position with chloro or bromo substituents at C4. The effect on enzyme inhibition of varying the N10 substituent of 2h was similar to that observed in the quinazolinone-containing antifolates, indicating that the quinoline compounds may be interacting with the enzyme in a similar way to the quinazolinones. Also, the introduction of a 2'-fluoro substituent into the benzoyl ring of several of the quinoline antifolates led to an increase in both TS inhibition and the inhibition of L1210 cell growth. These data demonstrate that the N3-H of the pyrimidine ring of the quinazolinone antifolates is not required for binding to TS if appropriate substituents are placed at the C2 and C4 positions of the bicyclic ring system.

Detection of bone marrow abnormalities in patients with Hodgkin's disease by T1 mapping of MR images of lumbar vertebral bone marrow

Pixel by pixel T1 mapping of MR images has been used in conjunction with image analysis techniques to study the lumbar vertebral bone marrow of 20 patients with refractory or relapsed Hodgkin's disease prior to salvage chemotherapy, or high dose chemotherapy with autologous bone marrow rescue. Compared to 18 age matched controls, seven patients had significantly abnormal lumbar vertebral marrow T1 histograms with median, 5% and 95% centile T1 values that lay outside a three dimensional 95% probability region obtained for the normals. Six of these patients had increased areas of high T1 consistent with bone marrow involvement with lymphoma; although, only in two of them had Hodgkin's disease been detected by bilateral iliac crest bone marrow biopsy. Post-treatment studies were performed in four patients who had abnormal areas of high T1 in the lumbar vertebral bone marrow. All showed normalisation of the T1 histogram, with a reduction of T1 values to within the normal range as defined by the studies of age matched controls. T1 mapping of bone marrow offers potential for detecting bone marrow infiltrates in patients with lymphoma, and also for the assessment of treatment response.

Clinical, cognitive, and neurophysiological effects of alprazolam in children and adolescents with overanxious and avoidant disorders

In a double-blind, placebo-controlled study, the efficacy and safety of alprazolam was investigated in childhood and adolescent anxiety disorders. Thirty patients (mean, 12.6 years) diagnosed with overanxious or avoidant disorders participated in the study. Evaluations included clinical, laboratory, cognitive, and qualitative EEG measurements. On a clinical global rating, there was no statistical difference between alprazolam and placebo. Relative to baseline EEG, acute alprazolam administration increased beta power in the right occipital lead, and chronic administration increased beta power in both leads. Alprazolam was well tolerated, and adverse effects were few, mild, and transient.

The quantitative study of lumbar vertebral bone marrow using T1 mapping and image analysis techniques: methodology and preliminary results

A method of quantifying lumbar vertebral bone marrow using pixel by pixel T1 mapping of spin echo magnetic resonance images is described. The accuracy and precision of the relaxation time measurements is confirmed by studies with the EEC Concerted Research Project, test object no. 5. The T1 data from all the pixels sampled from lumbar vertebral marrow are displayed as a histogram. By "thresholding" relative to normal control data the spatial distribution of high or low T1 pixels can be demonstrated. The approach is superior to that of the conventional region of interest method for quantifying and analysing relaxation time data, and allows tissue heterogeneity to be studied. Studies in patients with aplastic anaemia and acute leukaemia have been performed.

Pilot study of anxiety and depression in prepubertal children

Early detection of anxiety and depression is important because of the relationship between these disorders, suicide and other problems (i.e. social, phobias, learning problems). This study screened prepubertal students in a school setting for symptoms of anxiety and depression using self-report measures (Revised Children's Manifest Anxiety Scale and the Children's Depression Inventory). Controls and children who scored high on measures of anxiety or depression or both were interviewed with their parents and were tested using the Diagnostic Interview for Children and Adolescents (computer version) and the Peabody Individual Achievement Test. Initial results indicated that anxiety is more prevalent in prepubertal children than depression. The correlation between different diagnostic measurements used in this project was calculated. A correlation was found between low scores of self-esteem and high scores of anxiety and depression on self-reports. It is concluded that self-report measures are good screening tools.

Renal dysgenesis in a monozygotic twin: association with in utero exposure to indomethacin

We report oligohydramnios and renal dysgenesis in one of identical twins, which might have resulted from in utero exposure to early, prolonged high-dose indomethacin. The proposita was the second of twin girls born at 36 weeks of gestation. Pregnancy was complicated initially by polyhydramnios in both amniotic sacs and premature uterine contractions. After administration of indomethacin and terbutaline from 16 to 30 weeks' gestation, serial prenatal ultrasound examinations ultimately showed oligohydramnios in twin B and resolution of polyhydramnios in twin A. On day 5 twin B developed hematuria, hypertension, renal failure, hyponatremia, hyperkalemia, metabolic acidosis, sodium wasting and severe, transient inability to excrete potassium. Renal sonography showed enlarged, hyperechoic kidneys with almost no corticomedullary differentiation. Renal biopsy revealed immature glomeruli, dilated Bowman's spaces, dilated tubules, and interstitial fibrosis. The liver was histologically normal. Indomethacin may induce oligohydramnios and transient renal insufficiency in humans and renal dysgenesis in fetal monkeys; it might have induced the abnormalities in this patient.

Ammoniated mercury ointment as a cause of peripheral neuropathy

A 72-year-old Caucasian man with widespread psoriasis presented with a sensory-motor peripheral neuropathy following 40 years' use of an ammoniated mercury ointment. No clinical involvement of his central nervous system was noted and no other possible causative factors for his peripheral nerve disease were found. D-Penicillamine treatment induced mercuriuresis and blood levels of mercury fell to normal. His peripheral neuropathy improved slowly after normalisation of the serum mercury. It is believed that his condition was caused by percutaneous absorption of mercury. Ammoniated mercury ointments should have no role in the current management of skin disorders.

The application of total vertical projections for the unbiased estimation of the length of blood vessels and other structures by magnetic resonance imaging

A new stereological method has recently been developed to estimate the total length of a bounded curve in 3D from a sample of projections about a vertical axis. Unlike other methods based on serial section reconstructions, the new method is unbiased (i.e., it has zero systematic error). A basic requirement, not difficult to fulfill in many cases, is that the masking of one structure by another is not appreciable. The application of the new method to real curvilinear structures using a clinical magnetic resonance (MR) imager is illustrated. The first structure measured was a twisted water-filled glass tube of known length. The accuracy of the method was assessed: With six vertical projections, the tube length was measured to within 2% of the true value. The second example was a living bonsai tree, and the third was a clinical application of MR angiography. The possibility of applying the method to other scientific disciplines, for example, the monitoring of plant root growth, is discussed.

Low-dose desferrioxamine test for the diagnosis of aluminium-related bone disease in patients on regular haemodialysis

Bone biopsy in an invasive method of diagnosing aluminium related bone disease (ABD). Toxic side-effects have been reported with the currently used 'high-dose Desferrioxamine (DFO) tests.' A low-dose DFO test was evaluated for the diagnosis of ABD in 28 symptomatic patients (13 male) on regular haemodialysis treatment. DFO 0.5 g diluted in 100 ml of 0.9% sodium chloride was given intravenously during the first 2 h of dialysis. Aluminium estimation before (t1) and 48 h after DFO challenge (t2) were made by DC plasma emission spectrometry. Following the DFO test bone biopsy was performed and the specimen stained for aluminium using soluchrome zurine. The DFO test was considered positive if the t2 concentration was 150 micrograms/l or treble the amount of t1. Nineteen patients (8 male) fell into this group and all except two had ABD. Of the nine remaining patients (5 male) who had a negative DFO test none had ABD. We conclude that ABD can be diagnosed safely in the majority of patients using a low-dose DFO test, thereby avoiding toxic side-effects.

Effects of treatment on airway microvascular leakage

Microvascular leakage, an essential component of inflammation, probably plays a critical role in asthma in producing plasma exudation and thickening of the bronchial mucosa which may underlie airway hyperresponsiveness. Several therapeutic approaches are possible to reduce this leakage, by blocking either the effects or the release of inflammatory mediators which induce the leakage. Drugs with these actions might be too specific to be of therapeutic value if many mediators are involved, as seems increasingly likely. Reduction of blood flow using selective vasoconstrictors is a more attractive approach and alpha 1-adrenoceptor agonists may be of value. Drugs that act directly on endothelial cells are probably the most useful, since they would be effective irrespective of the mechanism of leakage. Corticosteroids probably have this property, but whether beta-agonists or theophylline are clinically effective against airway microvascular leakage is not yet certain. The development of new drugs which can inhibit microvascular leakage is an important therapeutic approach for the future.

Toward a national strategic plan for quality assurance and utilization review education

This article discusses the need for a national plan for quality assurance and utilization review (QA/UR) education. Six points are addressed: the rationale for planning; the developments in quality assurance urging plan creation; external pressures on the QA field; internal interests in educational program development; a beginning vision of an educational future; and strategies for realizing the future. Additional planning and policy tasks are defined.

Inflammation and cartilage metabolism in rheumatoid arthritis. Studies of the blood markers hyaluronic acid, orosomucoid, and keratan sulfate

Single analyses of peripheral blood of rheumatoid arthritis (RA) patients showed a significant reduction in the mean value for keratan sulfate (KS) compared with that in control subjects, but the mean value for orosomucoid (OM) was elevated compared with that in control subjects. Some RA patients displayed highly elevated levels of hyaluronic acid (HA), while others exhibited normal levels. There was a significant inverse correlation between OM and KS content in RA patients, as well as a direct correlation between HA and OM. In longitudinal studies of RA patients, parallel changes in OM and HA and inverse changes between KS and OM or HA were commonly observed. Clinical analyses revealed that there was an inverse correlation between KS and morning stiffness, and direct correlations between the number of tender joints and HA, and between HA or the erythrocyte sedimentation rate and the number of joints with effusions. The reason(s) for the inverse correlation between KS and OM as an index of systemic inflammation remains to be established. Circulating HA represents an index of joint inflammation, for which a marker has not been previously available.

Bouffée délirante in Jamaican adolescent siblings

The high incidence of brief schizophrenia-like psychosis in developing countries is well documented in the literature. This paper presents two cases of bouffée délirante found in Jamaican adolescent sibs who had recently immigrated to Canada and discusses the importance of accurate diagnosis, in view of prognosis and treatment, for this disorder.

Measurement of anxiety and depression in children and adolescents

In summary, symptom checklists and rating scales are a cost-effective means of deriving an extensive amount of clinical information in a relatively short period of time. Measures designed to assess affect in children have primarily been self-report inventories owing to the subjective nature of the constructs being assessed. However, subscales for the assessment of anxiety and depression by significant others (parent, teacher, clinician) can be found on more general measures of behavior such as the Conners' Parent and Teacher Rating Scales, the Achenbach Parent and Teacher Forms of the Child Behavior Checklist, and the Brief Psychiatric Rating Scale for Children. In choosing from the array of available measures, emphasis should be placed on an examination of the psychometric properties of the scales. Inventories with demonstrated reliability and validity will provide the clinician with a much more useful profile of a patient's symptoms than will instruments with undocumented or poor psychometric properties. A major concern for all structured interviews is the relative lack of detailed reliability or validity studies. In addition, there are important caveats for such research. A high internal reliability may only demonstrate that one narrow aspect of depression has been measured or a high test-retest reliability may indicate that the interview is measuring a stable trait rather than a current state. Research on the validity and efficiency of the interviews requires careful consideration and consensus regarding acceptable comparison standards. At this time, variants of the "best estimate diagnosis" methodology appear to have gained widest acceptance. In general, there remains much work to be done before the distinct capabilities of the structured interviews are established. It should be noted that in all cases these interviews are evolving instruments and continue to undergo revision and refinement. However, one difference has evolved and may be relevant to the choice of instrument in specific studies. The highly structured interviews, such as the DICA and the DISC, are amenable to epidemiologic screening. They cover a wide range of disorders and have a relatively low threshold for disorder or high sensitivity. In application, these instruments will tend to overdiagnose. It will be necessary to use good clinical judgment in ruling out those disorders that do not apply. In contrast the semistructured interviews, such as the K-SADS and the ISC, have a relatively high diagnostic threshold or relatively high specificity for a few disorders. These instruments are probably best used for the purpose for which they were designed; that is, the selection of depressed and or anxious subjects for research studies.(ABSTRACT TRUNCATED AT 400 WORDS)

Eating and mood disorders in young children

This article addresses issues emerging from research and clinical work done with young children who develop eating and mood disorders. A literature review and vignettes of anorexia nervosa in prepubertal children are presented, and research on the relationship between eating disorders and mood disorders is examined. Three cases of prepubertal children with growth problems and features of eating and mood disorders and a developmental model of eating disorders and their relationship to mood disorders are explored. In conclusion, a series of questions and suggestions for research and therapy are posed about young children with eating and mood disorders and the relationship between them.

Cardiac responses to head up tilt during early extrauterine life: relevance of active acquisition of erect posture

Mammals must adapt to gravity on passing from the intrauterine to the extrauterine environment. In order to evaluate the cardiovascular effects of gravity in the first phases of extrauterine life, the effects of passive orthostatism on the cardiac filling volume were investigated through longitudinal haemodynamic studies in 14 normal healthy males before (6 months) and after (18 months) acquiring the ability to stand. Left ventricular diameter (by echocardiographic measurement), arterial blood pressure (by sphygmomanometry) and heart rate were measured in the supine and upright position at both ages. At 6 months the left ventricular end diastolic volume was not modified by a change in posture [supine 6(SEM 3) ml, upright 6(3) ml], so heart rate was minimally altered [supine 128(9), upright 130(11) beats.min-1] and blood pressure remained stable [supine 74(6), upright 73(5) mm Hg]. After the acquisition of the erect posture (18 months) left ventricular end diastolic volume was reduced [supine 14(3), upright 8(2) ml], heart rate increased [supine 110(11), upright 127(12) beats.min-1] and blood pressure remained constant [supine 80(6), upright 79(7) mm Hg]. The assumption of the erect posture therefore represents a phase when, for the first time in the natural history of the cardiovascular system, translocation of intravascular volume from the cardiopulmonary area to the periphery stimulates nervous and humoral responses to control the dynamics of body fluids and arterial blood pressure in a gravitational environment.

Intravascular exchange and bolus transfusion in the severely isoimmunized fetus

Eight Rh-sensitized fetuses, between 21 weeks 2 days and 35 weeks of gestation, received 31 intravascular transfusions (13 exchange and 18 bolus) and one intraperitoneal transfusion under ultrasonographic guidance. The interval between transfusions was 13.4 +/- 4.7 days. Posttransfusion hematocrit dropped at a rate of 1.0% +/- 0.6% per day. Procedure time for the bolus transfusion was shorter than for the exchange transfusion (t test, p less than 0.001). Bleeding from the puncture site complicated 10 of the 31 intravascular transfusions, without apparent maternal or fetal consequences. Fetuses were delivered between 33 and 36 weeks of gestation, after lung maturity was achieved.

A percutaneous approach to cardiac haemodynamics in anaesthetised rats

Established methods for evaluating cardiac function in small animals involve surgical manoeuvres. We describe a method for evaluating left ventricular volume (LVV) and pressure (LVP) in anaesthetised adult rats. Under fluoroscopic control a 23 G needle was inserted into the left ventricular cavity of anaesthetised normotensive WKY rats. LVV was determined by biplane angiography and LVP was measured directly. Surface electrocardiograms were recorded throughout the procedure. In 8 animals the study was repeated three times, one week apart. Animals were then sacrificed and tissues harvested for histological examination. In 8 rats, the technique was found to be reproducible and there was no evidence of functional (ECG) or pathological myocardial damage following repeated measurements. In conclusion this technique provides a reproducible method of measuring LVV and LVP, allowing longitudinal haemodynamic studies in anaesthetised rats.

Cardiogenic hypertension in maturing dogs

The purpose of this study was to evaluate whether the heart can induce high blood pressure by maintaining an inappropriately elevated cardiac output/body weight ratio during growth. Direct (femoral artery) mean arterial pressure (MAP), heart rate, cardiac output/body weight ratio (as defined by M-mode echocardiography), and total peripheral vascular resistance were measured and calculated every 2 months in nine conscious dogs during development from 2 to 10 months of age. In four dogs a J-shaped catheter for atrial pacing was chronically implanted at the age of 3 months, and their hearts were permanently paced at 130 beats/min until maturity. The aim of atrial pacing was to prevent the natural slowing of the heart rate and, consequently, to maintain a cardiac output/body weight ratio that was inappropriately high in relation to age during growth. Five dogs were studied as controls. No hemodynamic differences were observed until the age of 4 months. From the age of 5 to 10 months heart rate was kept at 130 beats/min by atrial pacing in the atrially paced group, and the mean cardiac output/body weight ratio did not decrease (196 +/- 24 vs 191 +/- 34 [SE] ml/min/kg). MAP rose from 62 +/- 4 to 116 +/- 8 mm Hg, and total peripheral resistance increased from 0.34 +/- 0.07 to to 0.61 +/- 0.09 mm Hg/ml/min/kg.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of angiotensin and angiotensin blockade on coronary circulation and coronary reserve

Angiotensin is a potent coronary vasoconstrictor, but little is known of the effects of long-term activation of the renin-angiotensin system on coronary reserve in humans. The effects of exercise on coronary hemodynamics were determined in eight patients with mild essential uncomplicated hypertension, before and after treatment with furosemide (50 mg, to ensure activation of the renin-angiotensin system). Coronary sinus blood flow was measured by thermodilution technique, intra-arterial blood pressure was measured from the ascending aorta, and plasma renin activity was determined by radioimmunoassay. Oxygen supply and demand were derived (using coronary sinus blood flow multiplied by the arteriovenous oxygen difference to equal oxygen supply and heart rate multiplied by the mean systolic blood pressure to equal oxygen demand) both at rest and during isometric exercise (handgrip to 50 percent of maximal effort for three minutes). The study was a single-blind crossover (furosemide versus placebo) design. Furosemide produced a significant reduction in coronary sinus blood flow, associated with an increase in coronary vascular resistance. Changes in mean arterial pressure and heart rate were insignificant. Slight reductions in plasma volume and mean right atrial pressure were observed. During isometric exercise, the increase in oxygen supply for a given increment in oxygen demand was attenuated by furosemide. The contribution of the renin-angiotensin system to this effect was determined by the short-term administration of 25 mg of the angiotensin converting enzyme inhibitor captopril. Forty-five minutes after oral captopril, coronary reserve was restored to pretreatment values. In conclusion, furosemide modulates coronary reserve, and it is likely that this is because furosemide mediates activation of renin-angiotensin system, thus reducing the vasodilatory capacity of the coronary arteries.

The relationship between anxiety and depression in children: rating scales and clinical variables

The present study examined the relationship between anxiety and depression in children in the context of proposed adult models. The results support the qualitative distinction between anxious and depressed patient groups on subsets of rating scale measures and clinical variables. In contrast to anxious children who were younger, (day patients) had been ill for longer than one year, presented with behavioral problems, and were low on observer ratings of depressive symptoms; depressed children were older, (inpatients) had been ill for less than one year, presented with emotional problems and were high on observer ratings of both anxious and depressive symptoms. The finding that the older depressed children were concurrently anxious while the younger anxious children were not concurrently depressed is discussed from the viewpoint of a hypothesized temporal sequence between anxiety and depression. The implication of this and other related findings are discussed in regard to their importance for differential diagnosis and prognosis.

Immunodetection and characterization of the degradation of cartilage proteoglycans in vitro and in vivo

The large aggregating cartilage proteoglycans can be detected immunologically using antibodies directed against the hyaluronic acid-binding region, core protein, keratan sulfate, chondroitin sulfate, and hyaluronic acid. With radioimmunoassays we have detected proteoglycans released from adult human articular cartilage in vitro and in vivo. In vitro cleavage appears to occur mainly adjacent to the hyaluronic acid binding region with the release of the rest of the molecule. Two distinct populations have been observed, the larger of which is chondroitin sulfate-rich and the smaller keratan sulfate-rich. Although they are a little smaller and probably aggregate less with hyaluronic acid, these populations correspond in size and composition to two similar populations detected in situ in healthy adult human articular cartilage. In vivo studies of synovial fluid have revealed that the proteoglycan fragments are smaller and the most commonly detected fragment is the hyaluronic acid binding region. This suggests that in vivo further degradation occurs, probably due to degradation mediated by the inflamed synovium and polymorphonuclear leucocytes present in the synovial fluid of inflamed joints.

The immunologic detection and characterization of cartilage proteoglycan degradation products in synovial fluids of patients with arthritis

Antibodies were used in radioimmunoassays with gel chromatography to detect the hyaluronic acid-binding region, core protein, and keratan sulfate of human cartilage proteoglycan in the synovial fluids of patients with rheumatoid arthritis, juvenile rheumatoid arthritis, and osteoarthritis. All fluids contained proteoglycan that was mainly included on Sepharose CL-4B; this result indicates cleavage of proteoglycan (which is normally excluded). The hyaluronic acid-binding region was the smallest and most commonly detected fragment. It was relatively free of keratan sulfate and core protein, and it could sometimes bind to hyaluronic acid. Other larger fragments containing core protein and/or keratan sulfate were detected in every fluid.

Treatment of major affective disorder with fluvoxamine

A placebo-controlled, double-blind study of 63 inpatients with major affective disorder was performed to compare the safety and efficacy of fluvoxamine and imipramine. Results indicate that fluvoxamine and imipramine are superior to placebo and demonstrate a trend toward superiority of fluvoxamine over imipramine. Fluvoxamine was generally well tolerated in most patients.

Converting-enzyme inhibition and coronary blood flow

The effects of converting-enzyme inhibition (25 mg oral captopril) on coronary hemodynamics in the presence and absence of activation of the renin-angiotension system were studied in 10 patients with mild essential hypertension with no evidence of ischemic heart disease. Coronary blood flow was determined by thermodilution before and after 1 week of diuretic therapy in six patients and before and after placebo in four patients. The diuretic (50 mg/day furosemide) reduced coronary blood flow and increased coronary vascular resistance; in these same patients, captopril reduced mean arterial pressure and the rate-pressure product but increased coronary flow significantly. There was no change in any of these variables after captopril in the placebo group. Similar results were obtained in normotensive rats treated with hydrochlorothiazide; the increase in coronary flow after captopril correlated significantly with the control plasma renin activity. These results in hypertensive humans and normotensive experimental animals indicate that diuretic therapy reduces coronary blood flow significantly, and angiotensin can play a significant role in modulating coronary vascular resistance under conditions associated with activation of the renin-angiotensin system.

Human renovascular effects of dopexamine hydrochloride: a novel agonist of peripheral dopamine and beta 2-adreno-receptors

The effects of dopexamine on the renal circulation have been examined to show whether any augmentation of renal blood flow (RBF) was secondary to the effect of the drug on cardiac output (CO) or whether it had any additional direct renal vasodilator activity. Eight male patients with mild to moderate hypertension, who were undergoing renal vein catheterization for renin estimation, were studied. Dose related increments in RBF (baseline (B) = 504 ml X min-1; after treatment (D) = 605 ml X min-1), CO (B = 5.9 l X min-1; D = 6.7 l X min-1), heart rate (B = 77 beats/min; D = 100 beats/min) and systolic blood pressure (B = 143 mmHg; D = 166 mmHg) were observed on administration of dopexamine 3 micrograms X kg-1 X min-1, with insignificant changes in diastolic blood pressure (B = 84.4 mmHg; D = 90 mmHg) and total peripheral resistance (B = 17.85; D = 17.25 Units). There was a slight but significant reduction in renal vascular resistance (B = 20.59, D = 18.75). The ratio of RBF to CO (%) confirmed that the increase in RBF due to dopexamine hydrochloride was greater that attributable to the increase in CO or perfusion pressure alone (RBF/CO B = 8.5%, D = 9%), consistent with selective renal vasodilatation. The fall in renin activity and lack of systemic vasodilatation suggest that this was a DA1-receptor mediated effect.

Psychological factors associated with disability in arthritis

A sample of chronically disabled arthritic patients was studied in 1981, and again in 1983, using a questionnaire which included attitudinal and mood items. The majority of patients had high pain and disability, and this did not significantly change between 1981 and 1983. The questionnaire was able to significantly discriminate between subjective disability and pain groups. This discrimination was more accurate than that made by orthopaedic surgeons using physical ratings alone, and possible 'good coping' and 'bad coping' profiles emerged.

Right ventricular infarction with shock but without significant left ventricular infarction: a new clinical syndrome

Right ventricular infarction has been described as concurrent with infarction involving the inferior (posterior) aspect of the left ventricular free wall and adjacent interventricular septum. Patients with right ventricular infarction typically show the ECG changes of inferior infarction in leads II, III, and aVF. This report describes two patients with right ventricular infarction but without changes in the QRS complex of the ECG, indicating an inferior infarct of the left ventricle. An autopsy-proven infarct of the right ventricular free wall with neither QRS nor other clinical evidence of left ventricular involvement was responsible for cardiogenic shock and death in one patient. This observation led to a review of a computerized data bank containing records of patients who had undergone cardiac catheterization to determine if there were other patients with clinical criteria suggesting right ventricular infarction without QRS changes of left ventricular infarction. One of the 167 patients with a history of a myocardial infarction also met the following clinical criteria: (1) transiently elevated total creatine kinase and creatine kinase myocardial band; (2) diffuse ST segment elevation without QRS changes indicative of left ventricular infarction on the ECG; (3) normal left ventricular function; (4) hemodynamic evidence of right ventricular dysfunction; and (5) cardiogenic shock.

Health beliefs and rehabilitation after lumbar disc surgery

Thirty per cent of patients fail to rehabilitate after back surgery. Pre-operative physical assessment cannot reliably identify these patients. A questionnaire assesses the health beliefs and extent of rehabilitation in 200 patients who have undergone a laminectomy. Objective medical data and ten subjective scales are analyzed, which correlate very highly with quality of rehabilitation. The questionnaire identifies 'at risk' individuals far better than objective physical findings, and it makes specific pathological attitudes clear. These attitudes can be used to direct existing post-operative care resources in an efficient way.

Prevalence and clinical correlates of pulmonary arterial hypertension in progressive systemic sclerosis

Forty-nine patients with progressive systemic sclerosis who had undergone extensive studies including pulmonary artery catheterization as part of an ongoing prospective study of the natural course of progressive systemic sclerosis were evaluated. The overall prevalence of pulmonary arterial hypertension in this population of patients with progressive systemic sclerosis was 33 percent, and among 10 subjects with the CREST syndrome the prevalence of pulmonary hypertension was 50 percent. The relation between pulmonary arterial hypertension documented at catheterization and abnormal results of noninvasive studies suggesting pulmonary hypertension, including physical examination, chest x-ray, electrocardiography, echocardiography, single-breath diffusing capacity, and vital capacity, was studied. Diffusing capacity was significantly lower in those patients with definite pulmonary hypertension (mean pulmonary artery pressure of 22 mg Hg or more) compared with those with a normal mean pulmonary artery pressure, and a diffusing capacity below 43 percent of predicted showed the greatest sensitivity (67 percent) of any single diagnostic test in detecting definite pulmonary hypertension. Chest x-ray suggesting pulmonary hypertension was the least sensitive of the tests evaluated, but showed the greatest specificity (100 percent) in identifying patients with pulmonary hypertension. A classification matrix based on discriminant function analysis utilizing the combination of diffusing capacity below 43 percent of predicted and chest x-ray and electrocardiographic findings correctly identified 75 percent of patients with definite pulmonary hypertension and 97 percent of patients with a normal pulmonary artery pressure, but failed to identify correctly patients with mild pulmonary hypertension (mean pulmonary artery pressure of 20 mm Hg). These findings indicate that specific noninvasive studies are helpful in assessing the likelihood of normal or definitely elevated pulmonary artery pressures in patients with progressive systemic sclerosis, but patients with mild pulmonary hypertension are not likely to be identified by these noninvasive studies.

Survival and viability of nonculturableEscherichia coli andVibrio cholerae in the estuarine and marine environment

Plating methods for estimating survival of indicator organisms, such asEscherichia coli, and water-borne pathogens includingVibrio cholerae, have severe limitations when used to estimate viable populations of these organisms in the aquatic environment. By combining the methods of immunofluorescent microscopy, acridine orange direct counting, and direct viable counting, with culture methods such as indirect enumeration by most probable number (MPN) estimation and direct plating, it was shown that bothE. coli andV. cholerae undergo a "nonrecoverable" stage of existence, but remain viable. Following 2-week incubations in saltwater (5-25%o NaCl) microcosms, total counts, measured by direct microscopic examination of fluorescent antibody and acridine orange stained cells, remained unchanged, whereas MPN estimates and plate counts exhibited rapid decline. Results of direct viable counting, a procedure permitting estimate of substrate-responsive viable cells by microscopic examination, revealed that a significant proportion of the nonculturable cells were, indeed, viable. Thus, survival of pathogens in the aquatic environment must be re-assessed. The "die-off" or "decay" concept may not be completely valid. Furthermore, the usefulness of the coliform and fecal coliform indices for evaluating water quality for public health purposes may be seriously compromised, in the light of the finding reported here.

Presence of serotonin in the palate just prior to shelf elevation

Since serotonin and its antagonists affect shelf rotation in mouse embryo culture, experiments were carried out to determine whether a serotonergic system is present in the palate. Employing [3H]5-HT, day-14.5 embryos incorporated the monoamine into palates. Active uptake of [3H]5-HT was shown since excised palates incorporated 9-fold more radioactivity at 37 degrees C than at 4 degrees C. Synthesis of palatal serotonin was measured. Embryos were cultured in the presence of the serotonin precursor, [3H]5-HTP, and radioactive 5-HT was monitored in the palate by thin-layer chromatography. Furthermore, excised palates were incubated with [3H]5-HTP and radioactive 5-HT was measured. Incorporation was linear for about 6 h. In addition, another radioactive compound was detected which had the same Rf as the methylated derivative, 5-methoxytryptamine. Synthesis of this compound was appreciable, about 30% of that of serotonin. Levels of serotonin in the palate were measured by high pressure liquid chromatography. Palates at day 14.5 of gestation contained 0.40 ng serotonin/mg protein, which was greater than that of tongue (0.33), body (0.14) but less than that of brain (3.09). Serotonin in palate and other embryonic tissues increased with time of development. Dopamine levels in the palate and other tissues were also determined. The distribution of serotonin in the palate was analyzed by culturing day-14.5 embryos in the presence of [3H]5-HTP, and after aldehyde fixation, paraffin embedment and sectioning, autoradiography was performed. Grains were observed throughout the palate in cells of regions 2 and 3, internal mesenchyme, tooth germ, and epithelium. Surprisingly, the pterygopalatine nerve, maxillary nerve and pterygopalatine ganglion contained an appreciable concentration of grains. Thus, the presence of serotonin in the palate is consistent with the neurotransmitter playing a role in shelf elevation.

The relationship arrhythmias and conduction disturbances to other manifestations of cardiopulmonary disease in progressive systemic sclerosis (PSS)

Disorders of rhythm and conduction are characteristic of the cardiac involvement in progressive systemic sclerosis (PSS), but their over-all frequency in PSS is not well established. Therefore, 46 ambulatory patients with PSS underwent several tests of cardiopulmonary function, including a 24-hour continuous electrocardiogram (Holter monitor). Conduction disturbances (sinus node dysfunction, first-degree heart block, pre-excitation), supraventricular arrhythmias (supraventricular tachycardia, atrial fibrillation, premature contractions of atrial or junctional origin) and ventricular arrhythmias (ventricular tachycardia, multifocal premature contractions) were observed on Holter monitoring in 26 subjects. Although these arrhythmias and conduction disorders were predictably observed in patients who complained of palpitations or syncope, or who had an electrocardiogram which showed first-degree heart block, ventricular bigeminy, left anterior superior hemiblock, prolonged p wave, right or left axis deviation, right or left ventricular hypertrophy, pathologic Q waves or low voltage, they were often found in patients who lacked other clinical evidences of heart disease. Arrhythmias and conduction disturbances were not significantly more frequent among patients with cardiomegaly or interstitial change on chest roentgenogram nor were they related to the presence or severity of abnormal lung function. This study suggests that Holter monitoring may be a valuable adjunct in evaluating heart disease in PSS.