An SPR based sensor for allergens detection

A simple, sensitive and label-free optical sensor method was developed for allergens analysis using α-casein as the biomarker for cow's milk detection, to be used directly in final rinse samples of cleaning in place systems (CIP) of food manufacturers. A Surface Plasmon Resonance (SPR) sensor chip consisting of four sensing arrays enabling the measurement of samples and control binding events simultaneously on the sensor surface was employed in this work. SPR offers several advantages in terms of label free detection, real time measurements and superior sensitivity when compared to ELISA based techniques. The gold sensor chip was used to immobilise α-casein-polyclonal antibody using EDC/NHS coupling procedure. The performance of the assay and the sensor was first optimised and characterised in pure buffer conditions giving a detection limit of 58ngmL^-1 as a direct binding assay. The assay sensitivity can be further improved by using sandwich assay format and amplified with nanoparticles. However, at this stage this is not required as the detection limit achieved exceeded the required allergens detection levels of 2µgmL^-1 for α-S1-casein. The sensor demonstrated good selectivity towards the α-casein as the target analyte and adequate recoveries from CIP final rinse wash samples. The sensor would be useful tool for monitoring allergen levels after cleaning procedures, providing additional data that may better inform upon wider food allergen risk management decision(s) that are made by food manufacturer. In particular, this sensor could potentially help validate or optimise cleaning practices for a given food manufacturing process.

The efficacy of screening for common dental diseases by hygiene-therapists: a diagnostic test accuracy study

Regularly attending adult patients are increasingly asymptomatic and not in need of treatment when attending for their routine dental examinations. As oral health improves further, using the general dental practitioner to undertake the "checkup" on regular "low-risk" patients represents a substantial and potentially unnecessary cost for state-funded systems. Given recent regulatory changes in the United Kingdom, it is now theoretically possible to delegate a range of tasks to hygiene-therapists. This has the potential to release the general dental practitioner's time and increase the capacity to care. The aim of this study is to compare the diagnostic test accuracy of hygiene-therapists when screening for dental caries and periodontal disease in regularly attending asymptomatic adults who attend for their checkup. A visual screen by hygiene-therapists acted as the index test, and the general dental practitioner acted as the reference standard. Consenting asymptomatic adult patients, who were regularly attending patients at 10 practices across the Northwest of England, entered the study. Both sets of clinicians made an assessment of dental caries and periodontal disease. The primary outcomes measured were the sensitivity and specificity values for dental caries and periodontal disease. In total, 1899 patients were screened. The summary point for sensitivity of dental care professionals when screening for caries and periodontal disease was 0.81 (95% CI, 0.74 to 0.87) and 0.89 (0.86 to 0.92), respectively. The summary point for specificity of dental care professionals when screening for caries and periodontal disease was 0.87 (0.78 to 0.92) and 0.75 (0.66 to 0.82), respectively. The results suggest that hygiene-therapists could be used to screen for dental caries and periodontal disease. This has important ramifications for service design in public-funded health systems.

Electron Paramagnetic Resonance Study of the Mononuclear Al Species Formed in the Reaction of Al Atoms and Cyclopropylamine at 77 K in an Adamantane Matrix

Ground-state Al atoms have been reacted with cyclopropylamine (CpNH2) in an adamantane matrix at 77 K. The four paramagnetic species generated in the reaction have been studied by electron paramagnetic resonance (EPR) spectroscopy and their magnetic parameters extracted from the EPR spectra. The isotropic Al hyperfine interactions (hfis) for these radicals vary from 801 to 962 MHz and are consistent with values previously reported for structurally similar Al-centered radicals. The major species formed in the reaction has a highly anisotropic a tensor indicative of an Al-centered radical with a substantial amount of the unpaired spin density residing in the Al 3p orbital. In addition, there is EPR evidence that the insertion products, CpNH(AlH) and CpAlNH2, are formed in the reaction, suggesting that Al atoms can activate the N-H and C-N bonds of amines. It has been shown that a molecule of CpNH2 coordinates to CpNH(AlH), causing the Al, N and H hfi of the N-H insertion product to decrease. The values of the nuclear hfis calculated for the insertion products, using a density functional theory (DFT) method, are comparable to the experimental values.

Randomised crossover study of the Flutter device and the active cycle of breathing technique in non-cystic fibrosis bronchiectasis

BACKGROUND

Airway clearance techniques are an important part of the routine care of patients with bronchiectasis. The use of the Flutter, a hand held pipe-like device causing oscillating positive expiratory pressure within the airways, has been proposed as an alternative to more conventional airway clearance techniques.

METHODS

A randomised crossover study was performed in 17 stable patients with non-cystic fibrosis bronchiectasis at home, in which 4 weeks of daily active cycle of breathing technique (ACBT) were compared with 4 weeks of daily physiotherapy with the Flutter device.

RESULTS

No significant differences between the two techniques were found. Median weekly sputum weights were similar with a median treatment difference of 7.64 g (p=0.77) and there was no evidence of treatment order or order interaction effects (p=0.70). Health status (Chronic Respiratory Disease Questionnaire) and ventilatory function did not change significantly during either treatment period. There was no significant change in peak expiratory flow rate or in breathlessness (Borg score) after individual physiotherapy sessions with either technique. A questionnaire indicated subjectively that patients preferred the Flutter (11/17) to ACBT for routine use.

CONCLUSIONS

Daily use of the Flutter device in the home is as effective as ACBT in patients with non-cystic fibrosis bronchiectasis, and has a high level of patient acceptability.

Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR)

Oral transmucosal fentanyl citrate (OTFC); Actiq) is a drug delivery formulation used for management of breakthrough cancer pain. Previous studies with open-label comparisons indicated OTFC was more effective than patients' usual opioid for breakthrough pain. The objective of this study was to compare OTFC and morphine sulfate immediate release (MSIR) for management of breakthrough pain in patients receiving a fixed scheduled opioid regimen. This double-blind, double-dummy, randomized, multiple crossover study was conducted at 19 US university- and community-based hospitals and clinics and comprised 134 adult ambulatory cancer patients. Patients were receiving a fixed scheduled opioid regimen equivalent to 60-1000 mg/day oral morphine or 50-300 microg/h transdermal fentanyl, were using a 'successful' MSIR dose (15-60 mg) as defined by entry criteria, and were experiencing 1-4 episodes of breakthrough pain per day. In open-label fashion, OTFC was titrated such that a single unit (200-1600 microg) provided adequate pain relief with acceptable side effects. Successfully titrated patients entered the double-blind phase of the study and received ten prenumbered sets of randomized capsules and oral transmucosal units. Five sets were the successful OTFC dose paired with placebo capsules, and five sets were placebo OTFC paired with capsules containing the successful MSIR dose. Patients took one set of study medication for each episode of target breakthrough pain. Pain intensity (PI), pain relief (PR) and global performance of medication (GP) scores were recorded. Pain intensity differences (PID) were calculated and 15-min PID was the primary efficacy variable. Adverse events were recorded. Sixty-nine percent of patients (93/134) found a successful dose of OTFC. OTFC yielded outcomes (PI, PID, and PR) at all time points that were significantly better than MSIR. GP also favored OTFC and more patients opted to continue with OTFC than MSIR following the study. Somnolence, nausea, constipation, and dizziness were the most common drug-associated side effects. In conclusion, OTFC was more effective than MSIR in treating breakthrough cancer pain.

Diet controversies in lipid therapy

Increasing awareness of the relationship between diet and disease has prompted a notable increase in nutrition research. The focus of many of these studies continues to be on amount and type of fat in the diet. At the same time, a great deal of attention is being directed at other dietary components and their mode of action. The results are promising. More definitive answers must await future clinical trial data. However, the total dietary approach, including compliance measures, remains the foundation on which other nutrition recommendations should be based.

Dimensions of decreased psychological well-being in advanced dementia

Evaluation of psychological well-being among persons with an advanced dementia is primarily dependent on verbal and non-verbal cues and behaviors that are observed and interpreted by others. The purpose of the present study was to determine how many components of psychological well-being can be measured. Fifty-seven individuals who were institutionalized for advanced dementia and exhibited agitation or withdrawal were evaluated by direct observations and by interviews with nursing home staff. Engagement was measured by the Lawton Positive Affect scale, visual analog scale, and reported degree of patient's interest in the environment. Mood was measured by a global indicator of mood interpreted from facial expression and two mood items from the Multidimensional Observation Scale for Elderly Subjects. Agitation was measured by a visual analog scale and by the Short Form of the Cohen-Mansfield Agitation Inventory. Correlation analyses and multidimensional scaling provided evidence for three dimensions of psychological well-being: engagement-apathy, happy sad mood, and calm-agitation. Evaluation of these three dimensions is important for measuring quality of care in long-term care settings and for determining effectiveness of therapeutic interventions.

Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease

OBJECTIVE

To evaluate the efficacy of Simulated Presence, a personalized approach to enhance well-being among nursing home residents with Alzheimer's disease and related dementia's (ADRD).

DESIGN

Latin-Square, double blinded, 3-factor design with restrictive randomization of three treatments (the study intervention, a placebo audio tape of a person reading the newspaper, and usual care). The three factors were treatment, time, and facility type.

SETTING

Nine nursing homes in Eastern Massachusetts and Southern New Hampshire.

PARTICIPANTS

Fifty-four subjects with documented ADRD who were aged 50 years or older, medically stable, had resided in their current nursing home for at least 3 months, and who had no planned discharge. All subjects had a history of agitated or withdrawn behaviors.

INTERVENTION

The purpose of Simulated Presence is to provide a personalized intervention for persons with moderate to severe cognitive impairment. Through a unique testing process, some of the best loved memories of the ADRD person's lifetime are identified and then those memories are introduced to the patient in the format of a telephone conversation using a continuous play audio tape system. The intervention may be used for extended periods of time because each repetition is viewed as a fresh, live telephone call as a result of the short-term memory deficit of the person with ADRD.

MEASUREMENTS

Direct observations of outcomes included using a newly developed scale, the Scale for the Observation of Agitation in Persons with Dementia, an agitation visual analog scale, the Positive Affect Rating Scale (mood and "interest"), a withdrawal visual analog scale, and facial diagrams of mood. Reported measures included daily staff observation logs of responses to interventions offered, and weekly staff surveys using the short-form Cohen-Mansfield Agitation Inventory and the Multidimensional Observation Scale for Elderly Subjects (mood and "interest"). Severity of dementia was assessed by the Mini-Mental State Exam, the Test for Severe Impairment, the Bedford Alzheimer's Nursing Scale, and the ADL Self-Performance Scale.

RESULTS

Chi-square analysis of direct observations, using facial diagrams, revealed that Simulated Presence was equivalent to usual care (P = .141) and superior to placebo for producing a happy facial expression (P = .001). A positive effect was also documented in nursing staff observation logs using Analysis of Variance techniques (ANOVA) for subjects during Simulated Presence phases compared with the placebo phases (P < .001) and usual care phases (P < .001). According to ANOVA analyses of "interest" from weekly surveys, Simulated Presence was superior to both usual care (P = .001) and placebo (P = .008). We were unable to find evidence of significant differences (P < .05) among interventions for other direct observations and weekly reports of overall agitation or mood aspects of withdrawal. Subjects accepted the intervention most of the time, except for five subjects who refused it more than 50% of the time.

CONCLUSION

This study provided evidence that Simulated Presence can be effective in enhancing well-being and decreasing problem behaviors in the nursing home setting as a substitute for or complement to usual care.

Cyclosporine plasma unbound fraction in heart and lung transplantation recipients

To investigate the variability in the unbound fraction (fu) of cyclosporine in recipients of heart, heart-lung, and lung transplantation, cyclosporine fu was determined ex vivo in plasma by equilibrium dialysis. In a retrospective study, 260 samples of plasma (one to seven per patient) were obtained from 89 heart (86%), lung (9%), and heart-lung (5%) transplant patients. The unbound fraction (x100) of cyclosporine ranged from 0.52% to 3.94%, with an overall mean of 1.53%+/-0.375% (SD). The mean percentage unbound for individual patients ranged from 0.71% to 1.98%, giving a 2.8-fold interpatient variation. In heart transplant recipients (66 patients), the values of fu were significantly lower (p < 0.01) during more severe rejection episodes, which required antirejection treatment (endomycardial biopsy result of grade 3a and higher) than in the absence of rejection (grade 0) or during grade la rejections. The value of fu did not vary with organ transplanted (p = 0.35) or etiology of organ failure (p = 0.32). Cyclosporine fu was negatively correlated with the age of the patient (r = -0.18, p < 0.05). Correlations were not observed between fu and blood biochemical and cytologic indices. However, fu was significantly lower (p < 0.01) in hypercholesterolemic transplant recipients (1.37+/-0.52%) than in normocholesterolemic patients (1.60+/-0.63%). Administration of simvastatin resulted in a significant increase in the mean fu from 1.40+/-0.09%) to 1.82+/-0.13% (paired t test, n = 13; p < 0.01). In patients who received ketoconazole, fu was not different from controls. These findings suggest that the level of cyclosporine fu may be an important determinant of immunosuppressive activity of cyclosporine. Moreover, the variation in fu could be strongly related to the concentration of serum lipoproteins; interpretation of the results of cyclosporine monitoring thus requires consideration of the lipidemic status of the patient.

Inactivating mutations in an SH2 domain-encoding gene in X-linked lymphoproliferative syndrome

X-linked lymphoproliferative syndrome (XLP) is an inherited immunodeficiency characterized by increased susceptibility to Epstein-Barr virus (EBV). In affected males, primary EBV infection leads to the uncontrolled proliferation of virus-containing B cells and reactive cytotoxic T cells, often culminating in the development of high-grade lymphoma. The XLP gene has been mapped to chromosome band Xq25 through linkage analysis and the discovery of patients harboring large constitutional genomic deletions. We describe here the presence of small deletions and intragenic mutations that specifically disrupt a gene named DSHP in 6 of 10 unrelated patients with XLP. This gene encodes a predicted protein of 128 amino acids composing a single SH2 domain with extensive homology to the SH2 domain of SHIP, an inositol polyphosphate 5-phosphatase that functions as a negative regulator of lymphocyte activation. DSHP is expressed in transformed T cell lines and is induced following in vitro activation of peripheral blood T lymphocytes. Expression of DSHP is restricted in vivo to lymphoid tissues, and RNA in situ hybridization demonstrates DSHP expression in activated T and B cell regions of reactive lymph nodes and in both T and B cell neoplasms. These observations confirm the identity of DSHP as the gene responsible for XLP, and suggest a role in the regulation of lymphocyte activation and proliferation. Induction of DSHP may sustain the immune response by interfering with SHIP-mediated inhibition of lymphocyte activation, while its inactivation in XLP patients results in a selective immunodeficiency to EBV.

Effect of exercise induced hypoxaemia on myocardial repolarisation in severe chronic obstructive pulmonary disease

BACKGROUND

Exercise training is being promoted increasingly for patients with chronic obstructive pulmonary disease (COPD). Many of these patients experience exercise related arterial desaturation but the clinical importance of these hypoxaemic episodes is not known. QTc dispersion is a marker of myocardial repolarisation abnormalities and there has been much interest in its role as a non-invasive predictor of cardiac arrhythmias and sudden death. However, little is known about the dynamic effects that exercise and hypoxaemia have on QTc dispersion in patients with COPD.

METHODS

20 patients with severe COPD (FEV1 < 40% predicted) undertook two 15 minute treadmill tests at a speed calculated to produce a constant workload of 50% maximum oxygen consumption (VO2max) during which they were blindly given either air or 35% oxygen in random order. Physiological measurements taken throughout exercise included 12 lead electrocardiograms from which QTc dispersion values were calculated according to standard criteria. Nine of the patients who desaturated with exercise were studied further. A similar degree of hypoxaemia was induced at rest by giving them a titrated mixture of air and oxygen and the changes in QTc dispersion were recorded.

RESULTS

11 of the 20 patients developed significant hypoxaemia (desaturation by > or = 5% to < 90%) with exercise breathing air. There were no significant changes in QTc dispersion with either exercise or hypoxaemia. There were no significant changes in QTc dispersion when comparing those who did and did not desaturate, and those with and without a high baseline QTc dispersion values (60 ms). Induced hypoxaemia without exercise also failed to worsen QTc dispersion.

CONCLUSIONS

No evidence was found to suggest that exercise, even when associated with hypoxaemia, causes myocardial repolarisation abnormalities in patients with COPD.

Cosmid contig and transcriptional map of three regions of human chromosome 21q22: identification of 37 novel transcripts by direct selection

Human chromosome 21 is associated with many disorders, including Down syndrome (DS). In an effort to identify genes involved in brain development or function and therefore implicated in the mental retardation associated with DS, we chose YACs from three regions of chromosome 21: a region within the so-called "Down syndrome critical region," a region proximal to it, and one distal to it. We made cosmid libraries from these YACs and generated high-resolution physical maps by constructing cosmid contigs. These are the first cosmid contigs on chromosome 21 outside the critical region. The cosmids were used for direct selection of cDNAs to isolate chromosome 21 expressed sequences. We have isolated 45 nonredundant partial cDNAs and mapped these back to the cosmid contigs. We isolated 3 nonoverlapping portions of DSCR1 and a part of GIRK2 and identified 3 nonoverlapping partial cDNAs with similarity to the rat Dyrk gene, which turned out to be the human homologue (MNB) of the Drosophila minibrain gene. Twelve sequences had matches with either STS or EST entries in the databases, including a chromosome 21 EST, a chromosome 21 STS, and 6 unmapped expressed sequence entries. Only 1 sequence resulted in a match with a protein entry. The remaining 25 sequences revealed no similarity to any database entry. All of these partial cDNAs are expressed as determined by Northern blotting or by RT-PCR.

New gene for autosomal recessive non-syndromic hearing loss maps to either chromosome 3q or 19p

Autosomal recessive non-syndromic hearing loss (ARNSHL) is the most common form of prelingual inherited hearing impairment. A small consanguineous family with this disorder was ascertained through the Institute of Basic Medical Sciences in Madras, India. Conditions such as rubella, prematurity, drug use during pregnancy, perinatal trauma, and meningitis were eliminated by history. Audiometry was performed to confirm severe-to-profound hearing impairment in affected persons. After excluding linkage to known DFNB genes, two genomic DNA pools, one from the affected persons and the other from their non-affected siblings and the parents, were used to screen 165 polymorphic markers evenly spaced across the autosomal human genome. Two regions showing homozygosity-by-descent in the affected siblings were identified on chromosomes 3q21.3-q25.2 and 19p13.3-p13.1, identifying one (or possibly both) as the site of a novel ARNSHL gene.

Modulation coding for pixel-matched holographic data storage

We describe a digital holographic storage system for the study of noise sources and the evaluation of modulation and error-correction codes. A precision zoom lens and Fourier transform optics provide pixel-to-pixel matching between any input spatial light modulator and output CCD array over magnifications from 0.8 to 3. Holograms are angle multiplexed in LiNbO(3):Fe by use of the 90 degrees geometry, and reconstructions are detected with a 60-frame/s CCD camera. Modulation codes developed on this platform permit image transmission down to signal levels of ~2000 photons per ON camera pixel, at raw bit-error rates (BER's) of better than 10(-5). Using an 8-12-pixel modulation code, we have stored and retrieved 1200 holograms (each with 45,600 user bits) without error, for a raw BER of <2x10(-8).

Outpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease

BACKGROUND

This is a study of an outpatient programme for rehabilitation of patients with severe ventilatory impairment due to chronic obstructive pulmonary disease (COPD). Its main purpose was to assess the feasibility of such a programme and so no control group was included.

METHODS

The study included 44 patients (28 men) of mean age 66 years with COPD. They all had severe ventilatory impairment as defined by a forced expiratory volume in 1 second (FEV1) less than 40% of predicted. Initial assessment included a shuttle walking test, the Chronic Respiratory Disease Questionnaire (CRDQ), the Hospital Anxiety and Depression scale (HAD) and the Sickness Impact Profile (SIP). The patients then entered a 6-week outpatient programme during which they attended twice weekly for a 2 1/2 hour session. Assessment was repeated on completion of the study (the 3 1/2 month assessment) and at 6 months.

RESULTS

The shuttle walking distance improved significantly and was maintained at the improved level for 6 months. The improvement in all four dimensions of the CRDQ was statistically significant and reached clinical significance for fatigue and for mastery. On entry, a notable level of depression was found in 32% of patients, and of anxiety in 40%. There was significant reduction in both of these which was maintained at 6 months. There was no improvement in the SIP at 3 months, but significant improvement was found at 6 months.

CONCLUSIONS

This study shows that a successful outpatient programme can be conducted in patients with severe ventilatory impairment, and that apparent benefit in physical ability and in health-related quality of life can be achieved. The improvements were maintained at 6 months.

A human homologue of Drosophila minibrain (MNB) is expressed in the neuronal regions affected in Down syndrome and maps to the critical region

The minibrain (mnb) gene of Drosophila melanogaster encodes a serine-threonine protein kinase with an essential role in postembryonic neurogenesis. A corresponding human gene with similar function to mnb could provide important insights into both normal brain development and the abnormal brain development and mental retardation observed in many congenital disorders. Trisomy 21 or Down syndrome (DS) is the most frequent human birth defect. It is associated with mental retardation and a broad spectrum of physical abnormalities. A region on human chromosome 21 has been designated the Down syndrome critical region (DSCR) and when present in three copies, this is responsible for many of the characteristic features of DS, including mental retardation. We have isolated a human homologue of mnb from the DSCR. MNB encodes a 6.1 kb transcript which is expressed in foetal brain, lung, kidney and liver. Using a human probe, two major transcripts (6.1 and 3.1 kb) were identified in mouse and expression was detected in situ in several regions of the mouse brain, including the olfactory bulb, the cerebellum, the cerebral cortex, the pyramidal cell layer of the hippocampus and several hypothalamic nuclei. This expression pattern corresponds to the regions of the brain that are abnormal in individuals with DS and suggests that overexpression of MNB could have detrimental consequences in DS patients.

Primary care orthopedics and sports medicine in West Virginia

Previous studies at several family practice residency programs in the U.S. have shown that many family practice graduates feel inadequately prepared to offer fracture care or casting. In order to determine if this was a problem in West Virginia, a survey was sent to all family physicians in the state which asked about their type of practice and residency training, if they provided fracture care or casting services, if they offered sports medicine coverage for teams in their communities, attitudes about their own competency in caring for fractures, as well as other personal and demographic data. Our survey confirmed that only 118 family physicians provide fracture care (42%), and that only 91 provide casting services (32%). The surveys also revealed that rural physicians feel obligated to offer this service, despite the fact that they do not perceive themselves to be very competent in this aspect of patient care, and only 43 rural physicians offer sports medicine coverage (44%). As a result of these findings, we propose that a more adequate orthopedic experience be a part of family practice training, and that there should also be increased emphasis on insuring family practice residents have a basic competency in sports medicine.

Study Groups: Are They Effective in Preparing Students for NCLEX-RN?

The effectiveness of faculty-directed study groups as an intervention to prepare nurse candidates for NCLEX-RN was evaluated. The NCLEX-RN performance of a baccalaureate class who had participated in study groups was compared to the performance of a prior class who had not participated in study groups. Academic subgroups within the classes were compared to determine if study groups were equally effective across levels of academic achievement. The possible reasons for the significant difference in the NCLEX-RN passing rate between "at-risk" students who participated in study groups and at-risk students who did not participate in study groups are discussed. Discussion also considers possible factors influencing the generally better performance of study group participants at all academic levels. Suggestions for future intervention research direct attention to time intensity of interventions and research control through random assignments to treatment groups.

Towards optimal analgesia after caesarean section: comparison of epidural and intravenous patient-controlled opioid analgesia

The provision of optimal analgesia after caesarean section remains a challenge as satisfactory pain relief must be combined with patient satisfaction, including the ability to care for the newborn. In a prospective study of 132 patients, we have compared epidural analgesia with intravenous patient-controlled analgesia (IVPCA) after either epidural or general anaesthesia. Different bolus doses of opioid (pethidine 10 mg and 20 mg) in the IVPCA group were also compared. Although epidural morphine provided the greatest efficacy (average pain score out of 10 was 1.8 v. 2.9-3.4 for the other groups), IVPCA, especially with a bolus dose of 20 mg, and especially after epidural anaesthesia, provided the greatest patient satisfaction with the least side-effects.

Towards optimal analgesia after caesarean section: comparison of epidural and intravenous patient-controlled opioid analgesia

The provision of optimal analgesia after caesarean section remains a challenge as satisfactory pain relief must be combined with patient satisfaction, including the ability to care for the newborn. In a prospective study of 132 patients, we have compared epidural analgesia with intravenous patient-controlled analgesia (IVPCA) after either epidural or general anaesthesia. Different bolus doses of opioid (pethidine 10 mg and 20 mg) in the IVPCA group were also compared. Although epidural morphine provided the greatest efficacy (average pain score out of 10 was 1.8 v. 2.9-3.4 for the other groups), IVPCA, especially with a bolus dose of 20 mg, and especially after epidural anaesthesia, provided the greatest patient satisfaction with the least side-effects.

Prophylactic paracetamol for analgesia after vaginal termination of pregnancy

Many patients present to day surgery clinics for vaginal termination of pregnancy, a procedure which is frequently complicated by postoperative abdominal pain. We have assessed the efficacy of prophylactic paracetamol 1000 mg given orally shortly before surgery in 834 such patients in a randomised, placebo-controlled, double-blind study. Postoperative pain was reported in 35% of patients, with no significant difference between treated and control patients. This negative finding was unexpected and is so far unexplained, given the usual efficacy of oral paracetamol in relieving this type of pain after it has occurred.

Nutrition in advanced cancer: anorexia as an outcome variable and target of therapy

The endpoints used as outcome variables in clinical cancer treatment trials, including nutrition intervention studies, should contain items that are meaningful to the patient. Variables to consider are appetite, food intake, physical performance, psychological and social functioning, response to cancer therapies, survival time, nutrition status, associated morbidity, and costs. Ideally, the design and conduct of nutrition trials should be carried out by a multidisciplinary team comprising medical oncologists, physician specialists in nutrition, dietitians, and social scientists. Anorexia has not been a focus of nutrition support trials in the past partly because of the lack of effective strategies to reverse it. Anorexia is one important cause of cancer starvation, and it also causes patient discomfort. This paper describes outcome variables that include patient derived subjective factors such as anorexia, and outlines new strategies to reverse anorexia. Pharmacologic strategies tested to reverse anorexia include corticosteroids, anabolic steroids, cyproheptadine, hydrazine sulfate, cannabinoids, and megestrol acetate. Of these, only the latter has been consistently well tolerated and effective, with significant improvements in appetite and food intake demonstrated in large-scale, randomized, controlled trials involving more than 600 cancer patients. Dose-response studies have demonstrated increasing efficacy with increasing doses of megestrol acetate from 160 to 800 mg/day. Doses in excess of 800 mg/day are not currently recommended. The mechanisms of action of megestrol acetate involve both behavioral and metabolic effects, and its impact on energy expenditure, appetite, body composition, endocrine function, and lipid metabolism is the subject of ongoing research.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of epidural and intravenous opioid analgesia after elective caesarean section

Patient acceptance is a particularly relevant method of assessing currently employed epidural and intravenous techniques of opioid analgesia after elective caesarean section. We have prospectively studied 71 such patients, randomised postoperatively to receive epidural morphine, intravenous morphine or intravenous pethidine. When compared with either intravenous opioid, epidural morphine provided twofold better average or excellent analgesia with 30% less drowsiness but with about 50% more pruritus. In spite of this troublesome complication, more patients (83% vs 74%) preferred epidural to intravenous opioid analgesia.

The Effectiveness of an Intervention to Promote Successful Performance on NCLEX-RN for Baccalaureate Students at Risk for Failure

This study evaluated the effectiveness of an intervention designed to enhance the performance of high-risk baccalaureate students on the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Thirty senior nursing students met risk criteria drawn from the NCLEX-RN prediction literature: a nursing grade point average (GPA) of 2.40 or below, a ranking on the Mosby Assesstest at or below the 20th percentile, and/or a diagnosed learning disability. Fourteen students in this nonrandomized, posttest-only study received the intervention. Sixteen students served as a control group. The groups were equivalent on 12 academic variables prior to treatment. Concepts of test-wiseness and test-coaching served as the basis for the intervention. The NCLEX-RN passing rate for the group participating in the intervention was 92.9% compared to 50% for the control group. The findings of this study provide preliminary evidence that a long-term intervention can assist high-risk students in passing the NCLEX-RN.

The International Classification of Diseases: the structure and content of the Tenth Revision

The Tenth Revision of the International Classification of Diseases is due to be published this year, and introduced from 1993. The aim of the classification is to facilitate comparisons between countries at the same point in time and within, and between, countries over time. The provision of comparable statistics is essential for facilitating policy decisions relating to health promotion and disease prevention, and for the collection of epidemiological data for research purposes. This article describes the major changes and important features in this revision, and compares them to the Ninth Revision of the International Classification of Diseases.

Weight reduction for breast cancer prevention by restriction of dietary fat and calories: rationale, mechanisms and interventions

A large body of epidemiologic evidence and data drawn from animal feeding studies have led to the feasibility testing of clinical breast cancer prevention trials based on the restriction of dietary fat intake. The animal data strongly suggest that restricting calories as well as fat inhibits breast cancer promotion. Body fat correlates with dietary fat intake in human populations. Obese postmenopausal women have increased levels of circulating bioavailable estrogen capable of promoting breast cancer growth. We propose that restriction of dietary fat intake will decrease total calorie intake and result in a loss of body fat in postmenopausal women. This loss of fat will decrease estrogen production from adrenal androgens and increase bioavailable estrogen, leading to decreased promotion of estrogen-dependent breast tumors. Intervention programs targeted at weight reduction via restriction of calories, reduction of dietary fat and increased physical activity are logical, practical and measurable strategies for reducing the risk of breast cancer in women at moderate to increased risk. Failure to account for variations in adherence to a restricted-fat diet in past feasibility studies has cast doubt on the hypothesis that restricting dietary fat intake can be utilized to reduce the risk of breast cancer. Current studies examining nutritional, hormonal and physiologic data in conjunction with evidence of adherence to dietary and lifestyle change will likely clarify the hormonal and physiologic effects of this potential nutritional strategy for breast cancer prevention.

Phosphorylation of tyrosine enhances its electron transfer capability: a model of redox modulation as oncogene expression?

The influence of tyrosine and o-phosphotyrosine on the transfer of electrons to nitrobluetetrazolium (NBT) was studied. Tyrosine phosphate was found to strongly promote the transfer of electrons from ferrous iron to NBT, while tyrosine was inhibitory. The enhancement of NBT reduction by tyrosine phosphate was blocked by superoxide dismutase (SOD). The results suggest a role for phosphorylated tyrosine residues to promote intracellular redox reactions. We suggest that the role of tyrosine protein kinases in cell proliferation and transformation may be to regulate electron transport in as yet undefined cellular systems. Consistent with a unique role for phosphotyrosine, the other commonly occurring phosphoamino acids, o-phosphoserine and o-phosphothreonine were not effective electron transfer agents.

Neglect: what part of abuse?

Neglect and its consequences are important to study. At this time, there is little consensus on what it is specifically, but it is being reported with greater frequency and state agencies are concerned with the alarming number of incidents being called to the attention of their protective service staff. The purpose of this paper has been to describe some of the definitional and assessment problems related to elder neglect for the purpose of outlining a decision making aid that can guide individuals in their assessment of suspected neglect cases. While researchers continue to refine their understanding of the phenomenon of neglect, it is crucial that systematic guidelines be available which can assist in the evaluation of suspected neglect events. The clinical area may not be able to wait for the perfect definition of neglect. In the meantime, the health and safety of elders demands a process for consideration of the phenomenon.

Rising frequency of ulcer perforation in elderly people in the United Kingdom

Peptic ulcer admission rates were known to be declining in England and Wales in younger men and women at least until 1977, but rates in elderly men were stable and rates in older women were increasing. Analysis of the most recently available data shows that these trends have continued in England and Wales and similar trends are seen in the elderly populations in Scotland. Reasons for the increasing susceptibility of elderly people, particularly older women, to peptic ulceration are not clear. However, altered smoking habits seem unlikely to explain the change, whereas increased use of non-steroidal anti-inflammatory drugs may account for part of it.

Macrocephaly and minor congenital anomalies in children with learning problems

To determine whether existing data which indicate a significant prevalence of abnormal head circumference and minor congenital anomalies in referred learning disabled populations could be replicated in a nonreferred population, 75 children enrolled in learning disabilities resource programs in an elementary school district were compared with a matched group of 73 children. Macrocephaly (occipitofrontal head circumference of 2 or more SD above the mean) was noted significantly more often in resource than in control children (12 versus 3) (p less than 0.05). Macrocephalic resource children had significantly lower achievement scores than either normocephalic resource or control children (p less than 0.05). There were no significant differences between resource and control children for mean number of anomalies per child, frequency of individual anomalies per group, or evidence of recurring anomaly patterns in the resource children. The macrocephalic resource children revealed the same prevalence of anomalies as normocephalic resource and control children, with no evidence of recurring anomaly patterns. Resource children with four or more anomalies did not differ from those with three or fewer anomalies on any psychometric parameters. Clinical, familial, radiological, and psychometric investigation of several macrocephalic resource children indicated similar patterns of learning deficits and documented evidence of familial macrocephaly but did not show any recognizable CNS abnormalities. This study confirms a significant prevalence of macrocephaly in children with learning problems. It indicates the need for further research into the prevalance and patterns of learning deficits in children with familial macrocephaly. The results add to recent concerns about the psychoeducational criteria of specific learning disabilities.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute intravenous and sustained oral treatment with the beta1 agonist prenalterol in patients with chronic severe cardiac failure

Prenalterol, a beta1 agonist, was given in a single blind acute intravenous study to seven patients with cardiac failure (New York Heart Association class II and III). It was then given in a double blind crossover study of sustained oral prenalterol to six of them. As a result of dose titration studies the oral dose of prenalterol given was 100 mg twice a day in all patients. Erect bicycle sprint tests were performed to exercise tolerance before and after treatment had been started. Cardiac function was assessed at rest and during graded supine bicycle exercise by determining haemodynamic indices using a Swan-Ganz catheter and radionuclide left ventricular ejection fractions. In the intravenous study cardiac function was assessed at rest and during exercise after a control infusion of dextrose and after an infusion of 5 mg prenalterol. In the oral crossover study a placebo or prenalterol were given for two periods of two weeks; at the end of each period exercise tolerance was measured and cardiac function assessed at rest and during exercise. Throughout the study period there was no change in symptoms, medication, or exercise tolerance. Intravenous prenalterol significantly improved cardiac function; left ventricular ejection fraction and cardiac index increased and left ventricular filling pressure fell both at rest and during exercise. Sustained oral treatment with prenalterol, however, did not improve resting left ventricular filling pressure or left ventricular ejection fraction at rest or during exercise but did increase heart rate at rest, and mean blood pressure and peripheral vascular resistance at rest and during exercise; in fact, during exercise left ventricular filling pressure was significantly increased while cardiac index and stroke volume index were decreased by prenalterol. Sustained oral treatment with prenalterol did not have the beneficial effects on cardiac function produced by intravenous treatment and in fact had deleterious effect on the measured indices of cardiac function during exercise.

Long-term nutritional assessment of patients with esophageal atresia and/or tracheoesophageal fistula

Fifty-three patients operated for esophageal atresia and/or tracheoesophageal fistula at the Childrens Hospital of Los Angeles returned for long-term nutritional assessment. The ages ranged from 11 months to 31 years of age with a mean age of 9 years 11 months. Nineteen percent of the patients were below the third percentile in height for their age, thus exhibiting evidence of chronic malnutrition. No significant differences could be demonstrated between patients with a birth weight above or below 2500 g or above or below 5 years of age. Patients over 13 years of age demonstrated considerably less evidence of chronic malnutrition (p less than .06), thus exhibiting a "catch-up" growth phenomenon. Associated anomalies and illnesses were frequently seen in patients with the most significant abnormal nutritional-assessment parameters. Nutritional assessment should be part of long-term management and follow-up of all patients with esophageal atresia or other congenital surgical anomalies.

Effect of total parenteral nutrition on marrow recovery during induction therapy for acute nonlymphocytic leukemia in childhood

Ten well-nourished children with acute nonlymphocytic leukemia (ANLL) were randomly assigned to groups that received (a) total parenteral nutrition (TPN) throughout the period of induction therapy or (b) standard nutritional support. Body mass and skin hypersensitivity reactions were better maintained in experimental patients. Patients on TPN had higher total white blood counts, absolute granulocyte counts, and platelet counts than did control patients during the course. No difference was apparent in the frequency of febrile episodes, or other aspects of the patients' courses. This preliminary report suggests that intensive nutritional support may accelerate the recovery of normal marrow function during induction therapy for ANLL.

Cellular phenotypes of normal and leukemic hemopoietic cells determined by analysis with selected antibody combinations

Individual leukemic cells and the corresponding rare normal cell types in nonleukemic bone marrow were analyzed with various combinations of antisera (labeled with different fluorochromes: TRITC and FITC). Double staining for membrane Ia-like molecules (TRITC) and nuclear terminal transferase (FITC) was a very useful combination that distinguished common non-T, non-B ALL (Ia+,TdT+) and thymic ALL (Ia-,TdT+) from the rare cases of B ALL (Ia+,TdT-) and from AML (frequently Ia+, TdT-; in some cases Ia-, TdT-). Additional antisera (such as anti-ALL, anti-HuTLA, anti-immunoglobulin reagents, etc.) confirmed the diagnosis and further characterized the leukemic blasts. Ia+,TdT+ cells could be observed in low numbers in normal and nonleukemic regenerating marrow and were probably normal precursor cells; this reagent combinations was, therefore, not useful for monitoring residual non-T, non-B ALL blasts in treated patients. Other marker combinations detecting pre-B ALL blasts (double staining for cytoplasmic IgM and nuclear TdT) and Thy-ALL blasts (HuTLA+,TdT+) were, however, virtually leukemia specific in the bone marrow and could be used to effectively monitor residual leukemic cells throughout the disease. These combined single-cell assays are not only economical and informative but are also important for assessing the heterogeneity of leukemia and for standardizing new mouse or rat monoclonal antibodies for diagnosis.

Sexual adjustment after lower extremity amputation

Sexual adjustment following lower extremity amputation was evaluated by interviewing 60 adults with recent amputations, 39 men and 21 women, after they had become independent in ambulation with a prosthesis. Among the men, 77% reported a substantial decrease in the frequency of sexual intercourse following amputation, while only 38% of the women reported a decrease. The decreased frequency was greater for nonmarried men than for married men, greater for men with above-knee amputations than for men with below-knee amputations, and greater for male amputee patients in whom phantom phenomena persisted compared to those in whom phantom phenomena no longer existed. The decreased frequency of intercourse for male amputee patients was unrelated to the patient's age, education, and etiology of amputation. There was no significant change in other aspects of sexual activity, including oral-genital relations, masturbation, homosexuality, and extramarital relations.