Disparities in the treatment of primary hyperparathyroidism: A scoping review and conceptual model

BACKGROUND

Primary hyperparathyroidism is underdiagnosed and surgical treatment is underutilized and inequitably distributed. We present a review of the current literature on disparities in the treatment of hyperparathyroidism, with a focus on gaps in knowledge and paths forward.

METHODS

We searched PubMed and Scopus for abstracts related to disparities in hyperparathyroidism.

RESULTS

16 articles (of 1541) met inclusion criteria. The most commonly examined disparity was race. Notably, Black, Hispanic, and Asian patients were less likely to undergo surgery after diagnosis, face delays in obtaining treatment, and less likely to see a high-volume surgeon. Similar disparities in care were noted among those without insurance, older patients, and patients with limited English proficiency.

CONCLUSION

There are clear inequities in the treatment of hyperparathyroidism. Current research is in an early "identification" phase of disparities research; a new conceptual model based on established socioecological frameworks is provided to help move the field forward to "understanding" and "intervening" in surgical disparities.

Cannabis Use in Adolescent and Young Adult Athletes: A Clinical Review

CONTEXT

Cannabis use among the general population has increased over time, in part due to decriminalization of use and greater social acceptance of cannabis use. These changes have contributed to increased availability of cannabis products, thus raising the likelihood that a subset of adolescent and young adult athletes will use cannabis. Therefore, it is imperative that clinicians and other providers working with young athletes have a thorough understanding of the impact cannabis can have on the athletic performance and overall health of a young athlete.

EVIDENCE ACQUISITION

PubMed (Medline), CINAHL, PsycINFO, and SportDiscus databases were used to perform a literature search of articles published between January 1, 2010 and December 31, 2022. Additional articles were reviewed based on references obtained from initial articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Survey studies suggest that up to 1 in 4 athletes have used cannabis at least once in the last year. Age, sex, race, sexual orientation, level of competition, and country of residence of an athlete all contribute to differing rates of cannabis use among athletes. The scientific literature does not support using cannabis for athletic performance, and multiple studies have demonstrated notable impairments in objective athletic performance measures. Cannabis use can also negatively impact an athlete's overall health via cardiovascular, gastrointestinal, and mental health symptoms and disorders.

CONCLUSION

Cannabis use among adolescent and young adult athletes is common, and rates of use are influenced by many different factors. Current evidence suggests that cannabis use can worsen sport performance, negatively impact an athlete's general health, and contribute to negative mental health outcomes.

Multi-locus sequence typing and phylogenetics of Cryptococcus neoformans AD hybrids

Hybrid AD strains of the human pathogenic Cryptococcus neoformans species complex have been reported from many parts of the world. However, their origin, diversity, and evolution are incompletely understood. In this study, we analyzed 102 AD hybrid strains representing 21 countries on five continents. For each strain, we obtained its mating type and its allelic sequences at each of the seven loci that have been used for genotyping haploid serotypes A and D strains of the species complex by the Cryptococcus research community. Our results showed that most AD hybrids exhibited loss of heterozygosity at one or more of the seven analyzed loci. Phylogenetic and population genetic analyses of the allelic sequences revealed multiple origins of the hybrids within each continent, dating back to one million years ago in Africa and up to the present in other continents. We found evidence for clonal reproduction and long-distance dispersal of these hybrids in nature. Comparisons with the global haploid serotypes A and D strains identified new alleles and new haploid multi-locus genotypes in AD hybrids, consistent with the presence of yet-to-be discovered genetic diversity in haploid populations of this species complex in nature. Together, our results indicate that AD hybrids can be effectively genotyped using the same multi-locus sequencing type approach as that established for serotypes A and D strains. Our comparisons of the AD hybrids among each other as well as with the global haploid serotypes A and D strains revealed novel genetic diversity as well as evidence for multiple origins and dynamic evolution of these hybrids in nature.

Anxiety Disorders in Athletes

Athletes and non-athletes experience many anxiety-related symptoms and disorders at comparable rates. Contributory factors may include pressure to perform, public scrutiny, sporting career dissatisfaction, injury, and harassment and abuse in sport. Anxiety may negatively impact sport performance. Specific types of anxiety may have unique presentations in athletes. It is important to rule out general medical and substance-related causes of anxiety symptoms. Psychotherapy and pharmacology treatment options should be considered, bearing in mind athletes' environmental circumstances and physiologies.

Goal Setting for Aging Adults and Care Partners: A Scoping Review

Background and Objectives

Evidence demonstrates that goal-setting and care partner support help aging adults improve their health. Less is known about how aging adults and care partners collaboratively participate in goal setting, revealing a potential gap in care delivery processes. The current review describes the scope of the literature on this topic.

Research Design and Methods

A search was conducted in several relevant databases and 1,231 articles were screened for the following inclusion criteria: (a) participants included aging adults (50+ years) and care partners, (b) goal setting was conducted, and (c) articles were in English.

Results

Common goals reported by aging adults were independence, improving or maintaining functioning, addressing symptoms, and remaining socially active. Care partners listed similar goals but also identified accessing services and supports as important. The level of care partner involvement varied across articles, with some care partners serving in a supportive role, some setting goals concurrently with the aging adult, and others setting goals on behalf of the aging adult.

Discussion and Implications

This review revealed concordant and discordant prioritization of goals within dyads. These findings illustrate the importance and potential complexity of including care partners in the goal-setting process. We also found that collaborative goal-setting and care partner-directed goals are scarce, indicating the need for additional work in this area. Collaborative goal setting aligns with person and family-centered care approaches and can contribute to better care plans that meet the needs of aging adults and their care partners.

The Impact of Modifiable Preoral Factors on Swallowing and Nutritional Outcomes in Healthy Adults: A Scoping Review

PURPOSE

Swallowing has previously been characterized as consisting of four phases; however, it has become apparent that these four phases are not truly discrete and may be influenced by factors occurring prior to bolus entrance into the oral cavity (i.e., preoral factors). Still, the relationship between these factors and swallowing remains poorly understood. The aim of this review was to synthesize and characterize the literature pertaining to the influence of preoral factors on swallowing and nutritional outcomes in healthy individuals.

METHOD

We performed a scoping review, searching the databases of PubMed, CINAHL, Cochrane, and Scopus. Search terms included those related to swallowing, experience of preoral factors, and exclusionary terminology to reduce animal and pediatric literature. Our initial search revealed 5,560 unique articles, of which 153 met our inclusionary criteria and were accepted into the review.

RESULTS

Of the accepted articles, 78% were focused exclusively on nutritional outcomes, 17% were focused on both swallowing and nutritional outcomes, and 5% were focused on solely swallowing outcomes. Of the preoral factors examined, 99% were exteroceptive in nature (17% olfactory, 44% visual, 21% auditory, 7% tactile, 11% other), while 1% were proprioceptive in nature.

CONCLUSIONS

This review supports the influence of preoral factors on swallowing and nutritional outcomes. However, there is a large emphasis on the visual modality and on nutritional outcomes. Nearly none of the literature found in this review directly measured swallowing safety, efficiency, or physiology. Future work will benefit from a larger focus on proprioceptive preoral factors as they relate to swallowing outcomes.

Imagining Eco-Wellness: A Scoping Review of Interventions Aimed at Changing Individual Behaviors to Promote Personal Health and Environmental Sustainability

INTRODUCTION

Climate change poses enormous threats to humanity and much of life on earth. Many of the behavioral patterns that drive climate change also contribute to the epidemics of obesity, diabetes, and cardiovascular disease.

OBJECTIVES

The primary objective of this study was to compile and categorize the literature on interventions aimed at modifying individual behaviors to promote both personal health and environmental sustainability. Secondary objectives were to help define the emerging field of behavioral eco-wellness and to discuss future directions, including the need for assessment tools and analytic strategies.

METHODS

A scoping review was conducted to locate, categorize, and interpret current scientific studies of interventions aimed at changing individual behaviors to promote both personal health and environmental sustainability.

RESULTS

Other than a pilot study that this team previously conducted, nothing was found that strictly fit the inclusion criteria. However, we did find 16 relevant studies that fit neatly within 4 broad topical areas: active transportation, dietary intake, indoor air quality, and green space immersion.

DISCUSSION

While this systematic scoping review found little meeting original criteria, we did find that 4 separate fields of study are converging on a scientific area that we are calling behavioral eco-wellness, defined as the simultaneous pursuit of both personal health and environmental sustainability. The emerging field could provide a conceptual framework and methodological toolkit for those seeking to enhance sustainability while supporting health behaviors, including dietary intake. This, in turn, could help to inform and motivate the urgent action needed to confront both climate change and the epidemics of obesity, diabetes, and cardiovascular disease.

Diagnostic Accuracy of Fine-Needle Biopsy in the Detection of Thyroid Malignancy: A Systematic Review and Meta-analysis

Importance

Fine-needle biopsy (FNB) became a critical part of thyroid nodule evaluation in the 1970s. It is not clear how diagnostic accuracy of FNB has changed over time.

Objective

To conduct a systematic review and meta-analysis estimating the accuracy of thyroid FNB for diagnosis of malignancy in adults with a newly diagnosed thyroid nodule and to characterize changes in accuracy over time.

Data Sources

PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched from 1975 to 2020 using search terms related to FNB accuracy in the thyroid.

Study Selection

English-language reports of cohort studies or randomized trials of adult patients undergoing thyroid FNB with sample size of 20 or greater and using a reference standard of surgical histopathology or clinical follow-up were included. Articles that examined only patients with known thyroid disease or focused on accuracy of novel adjuncts, such as molecular tests, were excluded. Two investigators screened each article and resolved conflicts by consensus. A total of 36 of 1023 studies met selection criteria.

Data Extraction and Synthesis

The MOOSE guidelines were used for data abstraction and assessing data quality and validity. Two investigators abstracted data using a standard form. Studies were grouped into epochs by median data collection year (1975 to 1990, 1990 to 2000, 2000 to 2010, and 2010 to 2020). Data were pooled using a bivariate mixed-effects model.

Main Outcomes and Measures

The primary outcome was accuracy of FNB for diagnosis of malignancy. Accuracy was hypothesized to increase in later time periods, a hypothesis formulated prior to data collection.

Results

Of 16 597 included patients, 12 974 (79.2%) were female, and the mean (SD) age was 47.3 (12.9) years. The sensitivity of FNB was 85.6% (95% CI, 79.9-89.5), the specificity was 71.4% (95% CI, 61.1-79.8), the positive likelihood ratio was 3.0 (95% CI, 2.3-4.1), and the negative likelihood ratio was 0.2 (95% CI, 0.2-0.3). The area under the receiver operating characteristic curve was 86.1%. Epoch was not significantly associated with accuracy. None of the available covariates could explain observed heterogeneity.

Conclusions and Relevance

Accuracy of thyroid FNB has not significantly changed over time. Important developments in technique, preparation, and interpretation may have occurred too heterogeneously to capture a consistent uptrend over time. FNB remains a reliable test for thyroid cancer diagnosis.

Complication Rates of Total Thyroidectomy vs Hemithyroidectomy for Treatment of Papillary Thyroid Microcarcinoma: A Systematic Review and Meta-analysis

Importance

Papillary thyroid microcarcinomas (PTMCs) have been associated with increased thyroid cancer incidence in recent decades. Total thyroidectomy (TT) has historically been the primary treatment, but current guidelines recommend hemithyroidectomy (HT) for select low-risk cancers; however, the risk-benefit ratio of the 2 operations is incompletely characterized.

Objective

To compare surgical complication rates between TT and HT for PTMC treatment.

Data Sources

SCOPUS, Medline via the PubMed interface, and the Cochrane Central Register of Controlled Trials (CENTRAL); through January 1, 2021, with no starting date restriction. Terms related to papillary thyroid carcinoma and its treatment were used for article retrieval. This meta-analysis used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline and was written according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) proposal.

Study Selection

Original investigations of adults reporting primary surgical treatment outcomes in PTMC and at least 1 complication of interest were included. Articles evaluating only secondary operations or non-open surgical approaches were excluded. Study selection, data extraction, and risk of bias assessment were performed by 2 independent reviewers and conflicts resolved by a senior reviewer.

Data Extraction and Synthesis

Pooled effect estimates were calculated using a random-effects inverse-variance weighting model.

Main Outcomes and Measures

Cancer recurrence and site, mortality (all-cause and disease-specific), vocal fold paralysis, hypoparathyroidism, and hemorrhage/hematoma. Risk of bias was assessed using the McMaster Quality Assessment Scale of Harms scale.

Results

In this systematic review and meta-analysis, 17 studies were analyzed and included 1416 patients undergoing HT and 2411 patients undergoing TT (HT: pooled mean [SD] age, 47.0 [10.0] years; 1139 [84.6%] were female; and TT: pooled mean [SD] age, 48.8 [10.0] years; 1671 [77.4%] were female). Patients undergoing HT had significantly lower risk of temporary vocal fold paralysis compared with patients undergoing TT (3.3% vs 4.5%) (weighted risk ratio [RR], 0.4; 95% CI, 0.2-0.7), temporary hypoparathyroidism (2.2% vs 21.3%) (weighted RR, 0.1; 95% CI, 0.0-0.4), and permanent hypoparathyroidism (0% vs 1.8%) (weighted RR, 0.2; 95% CI, 0.0-0.8). Contralateral lobe malignant neoplasm recurrence was 2.3% in the HT group, while no such events occurred in the TT group. Hemithyroidectomy was associated with a higher overall recurrence rate (3.8% vs 1.0%) (weighted RR, 2.6; 95% CI, 1.3-5.4), but there was no difference in recurrence in the thyroid bed or neck.

Conclusions and Relevance

The results of this systematic review and meta-analysis help characterize current knowledge of the risk-benefit ratio of HT vs TT for treatment of PTMC and provide data that may have utility for patient counseling surrounding treatment decisions.

Norwich COVID-19 testing initiative pilot: evaluating the feasibility of asymptomatic testing on a university campus

Background

There is a high prevalence of COVID-19 in university-age students, who are returning to campuses. There is little evidence regarding the feasibility of universal, asymptomatic testing to help control outbreaks in this population. This study aimed to pilot mass COVID-19 testing on a university research park, to assess the feasibility and acceptability of scaling up testing to all staff and students.

Methods

This was a cross-sectional feasibility study on a university research park in the East of England. All staff and students (5625) were eligible to participate. All participants were offered four PCR swabs, which they self-administered over two weeks. Outcome measures included uptake, drop-out rate, positivity rates, participant acceptability measures, laboratory processing measures, data collection and management measures.

Results

798 (76%) of 1053 who registered provided at least one swab; 687 (86%) provided all four; 792 (99%) of 798 who submitted at least one swab had all negative results and 6 participants had one inconclusive result. There were no positive results. 458 (57%) of 798 participants responded to a post-testing survey, demonstrating a mean acceptability score of 4.51/5, with five being the most positive.

Conclusions

Repeated self-testing for COVID-19 using PCR is feasible and acceptable to a university population.

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Background

External change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.

Methods

We searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.

Results

Academic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.

Conclusions

Our results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

Long-term effects of antidepressants on cognition in patients with Alzheimer's disease

PURPOSE

Approximately 25-40% of patients with Alzheimer's disease (AD) may develop depression. Antidepressants are typically used to treat depression in this population. However, their effect on cognition has been rarely studied and the results are conflicting. In addition, the long-term effects of antidepressants on cognition have not been studied. Therefore, the objective of the study was to evaluate the effects on cognition in patients with AD treated with antidepressants for at least 9 months.

METHODS

Data on antidepressant use over a minimum period of 9 months were retrospectively collected for patients with AD receiving cholinesterase inhibitors. Data on cognition were analyzed to compare those taking antidepressant therapy and those not receiving antidepressants.

RESULTS

Ninety-nine of 210 patients met our inclusion criteria. Fifty-eight patients were prescribed an antidepressant (e.g. selective serotonin reuptake inhibitors (SSRIs), newer generation antidepressants). Sertraline (mean dose: 82 mg/day) and citalopram (mean dose: 35 mg/day) were the most commonly prescribed antidepressants. The baseline mean Mini Mental State Examination (MMSE) score was 16.32 with an average annual rate of cognitive decline of 2.55 for patients receiving antidepressants compared with 16.59 (P = NS) and 2.27 (P = NS) for those not taking antidepressants.

CONCLUSIONS

Our small sample data indicate no differences in baseline MMSE scores and cognitive decline between the two groups, suggesting antidepressants did not contribute significantly to cognitive decline over a utilization period of at least 9 months.

Bone tumor radiograph review by pathologists prior to pathologic diagnosis: a receiver operator curve analysis of diagnostic utility

Radiologic-pathologic correlation has long been considered a prerequisite for the accurate diagnosis of bone lesions. We investigated using receiver-operating characteristic analysis the accuracy of histopathologic diagnoses with and without pathologist review of radiographs. While accuracy of diagnosis did improve when the radiographs were reviewed by the pathologist, this increase did not reach statistical significance (P=0.1311). Potential reasons for this finding including case selection and reviewer expertise are discussed. Based on our study, the review of radiographs did not result in a statistically significant difference in accuracy of the pathologic diagnosis of bone tumors. However, our data suggest that there may be a difference particularly in selected cases and among certain observers.

Predicting surgical outcome for pain relief and return to work

BACKGROUND

We evaluated a new psychological test (Paindex) for identifying and quantifying psychological factors associated with poor surgical outcome, and predicting the degree of pain relief and return to work.

METHOD

This test was administered to 120 randomly selected patients before carpal tunnel and laminectomy surgeries.

RESULTS

This test correctly predicted the probability of pain relief and return to work in 46 of the 50 laminectomy patients (92%), and 63 of the 70 carpal tunnel patients (90%). The overall test sensitivity was 86% and the specificity 94%.

CONCLUSION

These findings indicate that this can be a useful adjunctive test for identifying psychological problems that could have a bearing on the decision to operate and then problems that could occur after surgery, particularly in cases where the extent and degree of pain and disability are judged to be considerably in excess of the objective medical findings.

Predicting surgical outcome for pain relief and return to work

BACKGROUND

We evaluated a new psychological test (Paindex) for identifying and quantifying psychological factors associated with poor surgical outcome, and predicting the degree of pain relief and return to work.

METHOD

This test was administered to 120 randomly selected patients before carpal tunnel and laminectomy surgeries.

RESULTS

This test correctly predicted the probability of pain relief and return to work in 46 of the 50 laminectomy patients (92%), and 63 of the 70 carpal tunnel patients (90%). The overall test sensitivity was 86% and the specificity 94%.

CONCLUSION

These findings indicate that this can be a useful adjunctive test for identifying psychological problems that could have a bearing on the decision to operate and then problems that could occur after surgery, particularly in cases where the extent and degree of pain and disability are judged to be considerably in excess of the objective medical findings.

Dermatofibrosarcoma protuberans treated with Mohs surgery. A case with CD34 immunostaining variability

BACKGROUND

Immunohistochemical stains for CD34 antigen can help in differentiating dermatofibrosarcoma protuberans (DFSP) from other fibrohistiocytic tumors and in demarcating its surgical margins during Mohs surgery. However, variable expression of CD34 antigen in nodular areas can sometimes result in negative staining of tissue sections creating diagnostic and therapeutic dilemmas.

OBJECTIVE

To show the variable expression of CD34 antigen in a DFSP tumor.

METHODS

Case presentation of DFSP with immunohistochemical staining using the ABC peroxidase macromolecular complex.

RESULTS

Microscopic examination of paraffin-embedded sections showed CD34-negative DFSP tumor cells with positive staining of endothelial cells. On frozen sections at the time of surgery the tumor cells stained strongly positive for CD34.

CONCLUSION

This case demonstrates the variable expression of CD34 antigen by DFSP tumors and emphasizes the need to interpret with caution the results of these immunostains during Mohs surgery.

Anaesthesia for day-case surgery

With the current expansion of day surgery, many patients scheduled for elective surgery in British hospitals will receive their treatment on a day basis. Day-case anaesthesia exerts a profound effect on the success and feasibility of day-case surgery. Inpatient anaesthetic techniques are not always the most suitable in this area where even minor morbidity is important. This article examines the differences between inpatient and day-case anaesthesia, and makes a case for the increased recognition of the special requirements of the day-case patient.

Alcoholic hepatitis

Anorexia, weight loss, fatigue, symptoms of alcohol withdrawal and hepatomegaly are common early presenting signs and symptoms of alcohol abuse. The clinical diagnosis of alcoholic hepatitis can be made in alcoholics with associated fever, leukocytosis, jaundice and tender hepatomegaly. Associated laboratory abnormalities may include leukocytosis or leukopenia, anemia, a prolonged prothrombin time and elevated liver enzymes, including aspartate amino-transferase (AST), alanine aminotransferase (ALT), alkaline phosphatase and bilirubin. An AST-to-ALT ratio greater than 2 is common in patients with alcoholic hepatitis. Liver biopsy may be required to establish the diagnosis and to identify other pathology, such as cirrhosis. Histologic diagnosis of alcoholic hepatitis requires the presence of liver cell damage, an inflammatory infiltrate and fibrosis. Biopsy-proven cirrhosis with alcoholic hepatitis or a significantly elevated total bilirubin level and prolonged prothrombin time are associated with a worse prognosis. Abstinence from alcohol, nutritional supplementation and corticosteroids are the mainstays of treatment for severe alcoholic hepatitis.

Blood loss following tonsillectomy in children. A blind comparison of diclofenac and papaveretum

One hundred and ninety-eight children, aged 3 to 12 years, who were scheduled for tonsillectomy were randomly allocated to receive either diclofenac 1.0 mg.kg-1 or papaveretum 0.2 mg.kg-1 by intramuscular injection after induction of anaesthesia. There were no significant differences between the treatment groups in operating theatre blood loss, the frequency of bleeding on the ward, or the need for operative haemostasis. However, the incidence of above average bleeding in the recovery room was significantly higher in the diclofenac group (p < 0.05). Similarly, marked restlessness in the recovery room was more frequent in the diclofenac group (p < 0.01). In both treatment groups there was an association between bleeding and restlessness during recovery so the increased bleeding in the diclofenac group may not be a direct effect.

Suppression of murine retroviral disease by 2',3'-didehydro-2',3'-dideoxythymidine (D4T)

The thymidine analog, 2',3'-didehydro-2',3'-dideoxythymidine (D4T), and 3'-azido-3'-deoxythymidine (AZT) were evaluated for activity against Friend virus complex (FV) in Mus dunni cells using a focal immunoenzyme assay. The 50% effective doses were, respectively, 1.2 and 0.1 microM for the two compounds; the 50% cytotoxic doses using trypan blue dye exclusion were 25.4 and > 100 microM. Four FV inhibition experiments with D4T were run in F1 hybrid mice containing the Rfv-3r/s genotype. This mouse strain allows the study of treatment effects on development of specific neutralizing antibodies and on splenomegaly, splenic and plasma virus titers, and splenic viral RNA. In the first experiment, D4T was given by oral gavage (p.o.) three times daily (t.i.d.) for 14 days beginning 4 h post-virus inoculation. All dosages used (187.5, 375, 750 mg/kg/day) significantly inhibited all viral parameters. Other experiments used D4T p.o. twice daily, with dosages of 46.9, 93.8, 187.5 and 375 mg/kg/day or four times daily with a dose of 375 mg/kg/day. No significant disease inhibition was seen using the twice daily treatment schedule, but efficacy was apparent using the four times daily treatment. The final experiment repeated the initial study, extending the t.i.d. treatments to 25 days and using dosages of 46.9, 93.8, 187.5 and 375 mg/kg/day. All but the lowest dose reduced each virus parameter. None of the D4T treatment regimens caused death in toxicity controls, although moderate host weight loss or less weight gain was seen, and variable hematocrit decreases occurred, particularly in mice receiving the highest drug dosage. Inhibition of natural killer (NK) cell activity also was seen in these same animals, but in infected mice, FV-induced decrease in NK cell activity was prevented by D4T treatment. Virus-specific neutralizing antibodies developed in all infected, treated animals. These data indicate D4T has potential as a possible candidate for anti-human immunodeficiency virus evaluations in the clinic.

Outcomes of the first Family Practice Chief Resident Leadership Conference

In June 1989 the first Family Practice Chief Resident Leadership Conference was presented to 27 Texas second-year residents who had been selected to serve as chief residents during their third year. The objectives of the conference were to assist these emerging leaders to develop better stress management and leadership skills and to strengthen their ties with the Texas Academy of Family Physicians. The conference featured two major workshops on stress management and leadership skills, and included plenary speeches and large and small group discussions. This article reports the outcomes of the conference as measured by the evaluation instrument completed by participants. Analysis of the results indicated that the conference had a positive effect on the residents.

Promotion criteria for family practice residents: perceptions of program directors

This study utilized a modified Delphi technique to identify criteria considered important in the promotion of family practice residents. A designated expert panel consisting of the directors of the family practice residency programs in the State of Texas was used as the data source for the study. The Delphi results revealed a marked degree of consensus among the state program directors for 16 of 20 criteria evaluated. The criteria identified did not define comprehensive competency areas or goals. Further studies utilizing this information to develop comprehensive goals or to evaluate a program's current policies are proposed.

Cerebral amyloid angiopathy presenting as transient ischemic attacks. Case report

Cerebral amyloid angiography can cause ischemic stroke and transient ischemic attacks (TIA's), as illustrated by this case report and literature review. It is possible that the use of anticoagulant or platelet-antiaggregant drugs in elderly patients with TIA's but no angiographic abnormalities may increase the risk of hemorrhage from unsuspected amyloid angiopathy.

IgE immune complexes induce immediate and prolonged release of leukotriene C4 (LTC4) from rat alveolar macrophages

Alveolar macrophages obtained by lung lavage from rats were incubated with monoclonal mouse anti-DNP IgE and specific antigen (DNP-HSA) and were found to release a slow reacting substance (SRS), which was characterized by high performance liquid chromatography as leukotriene C4 (LTC)4. Alveolar macrophages incubated with 1 microM A23187 (calcium ionophore) released similar amounts of SRS (6.0 +/- 2.2 and 5.7 +/- 3.7 X 10(-10) mol of LTC4 per 5 X 10(6) alveolar macrophages, respectively). The optimal conditions and mechanism of LTC release by IgE and antigen were examined. LTC4 release was maximal when freshly retrieved alveolar macrophages were incubated for 20 min with 10 micrograms/ml IgE and then for 20 min with 100 ng/ml antigen or for 20 min with IgE and antigen that had been preincubated together for 30 min at room temperature. In addition, LTC4 release was maximal when cells were challenged with IgE and antigen in a protein-free balanced salt solution and when the cells were tumbled to prevent adherence. Dose response experiments revealed that macrophages released LTC4 when stimulated with as little as 10 ng IgE and 100 ng DNP-HSA. Alveolar macrophages did not release LTC when challenged with IgE or DNP-HSA alone. Activation of LTC4 release by IgE and antigen was rapid in onset (2.5 to 5 min), and washing to remove fluid phase IgE and antigen revealed that once activated, alveolar macrophages were capable of prolonged and continuous release of LTC4. Peritoneal lavage cells stimulated with IgE and antigen did not release SRS but could release SRS when incubated with A23187 (5.7 +/- 1.3 X 10(-10) mol LTC4/5 X 10(6) macrophages). A large variability existed between individual rats in the ability of their alveolar macrophages to be activated by IgE and antigen to release LTC4. DNP-HSA labeled with 125I was used to show formation of immune complexes of IgE and antigen when IgE and antigen were incubated together before macrophage challenge. IgE immune complexes containing as little as 2 ng of antigen elicited the release of LTC4 from alveolar macrophages. These data indicate that rat alveolar macrophages release primarily LTC4 when challenged with IgE immune complexes, and that the alveolar macrophage may differ in this respect from peritoneal macrophages that do not release detectable quantities of LTC4 when challenged under identical conditions.

IgE immune complexes induce immediate and prolonged release of leukotriene C4 (LTC4) from rat alveolar macrophages

Alveolar macrophages obtained by lung lavage from rats were incubated with monoclonal mouse anti-DNP IgE and specific antigen (DNP-HSA) and were found to release a slow reacting substance (SRS), which was characterized by high performance liquid chromatography as leukotriene C4 (LTC)4. Alveolar macrophages incubated with 1 microM A23187 (calcium ionophore) released similar amounts of SRS (6.0 +/- 2.2 and 5.7 +/- 3.7 X 10(-10) mol of LTC4 per 5 X 10(6) alveolar macrophages, respectively). The optimal conditions and mechanism of LTC release by IgE and antigen were examined. LTC4 release was maximal when freshly retrieved alveolar macrophages were incubated for 20 min with 10 micrograms/ml IgE and then for 20 min with 100 ng/ml antigen or for 20 min with IgE and antigen that had been preincubated together for 30 min at room temperature. In addition, LTC4 release was maximal when cells were challenged with IgE and antigen in a protein-free balanced salt solution and when the cells were tumbled to prevent adherence. Dose response experiments revealed that macrophages released LTC4 when stimulated with as little as 10 ng IgE and 100 ng DNP-HSA. Alveolar macrophages did not release LTC when challenged with IgE or DNP-HSA alone. Activation of LTC4 release by IgE and antigen was rapid in onset (2.5 to 5 min), and washing to remove fluid phase IgE and antigen revealed that once activated, alveolar macrophages were capable of prolonged and continuous release of LTC4. Peritoneal lavage cells stimulated with IgE and antigen did not release SRS but could release SRS when incubated with A23187 (5.7 +/- 1.3 X 10(-10) mol LTC4/5 X 10(6) macrophages). A large variability existed between individual rats in the ability of their alveolar macrophages to be activated by IgE and antigen to release LTC4. DNP-HSA labeled with 125I was used to show formation of immune complexes of IgE and antigen when IgE and antigen were incubated together before macrophage challenge. IgE immune complexes containing as little as 2 ng of antigen elicited the release of LTC4 from alveolar macrophages. These data indicate that rat alveolar macrophages release primarily LTC4 when challenged with IgE immune complexes, and that the alveolar macrophage may differ in this respect from peritoneal macrophages that do not release detectable quantities of LTC4 when challenged under identical conditions.

Effects of ascorbic acid deficiency on the in vitro biosynthesis of cyclooxygenase metabolites in guinea pig lungs

Endogenous levels of ascorbic acid may play a role in regulating the biosynthesis of cyclooxygenase metabolites in lungs of male guinea pigs. The in vitro biosyntheses of prostaglandins, prostacyclin and thromboxane were examined using isolated microsomal membranes from control and ascorbic acid deficient guinea pigs, under conditions in which the substrate concentration ( [3H]-arachidonic acid) was varied from 10-100 microM. Maintenance of guinea pigs for two weeks on an ascorbic acid deficient diet did not alter lung/body weight ratios, nor protein content of the lungs. Lung microsomes from ascorbic acid deficient guinea pigs demonstrated a greater biosynthesis of total cyclooxygenase metabolites at low substrate concentrations. A significant increase in the PGF2 alpha synthesis was observed in the scorbutic microsomes at 20 microM arachidonic acid. At higher substrate concentrations the production of PGF2 alpha was significantly reduced in ascorbic acid deficient animals. By contrast, biosynthesis of thromboxane or prostacyclin in treated animals was not significantly different from control microsomes. At a substrate concentration of 100 microM, there was equivalent synthesis of total cyclooxygenase metabolites in control and vitamin C deficient animals. The changes in prostaglandin biosynthesis were not due to an interaction of ascorbic acid with glutathione levels in the lung. These results support the hypothesis that ascorbic acid may modulate cyclooxygenase activity in the lung in a substrate dependent nature.

Arachidonic acid metabolism and modulation of in vitro anaphylaxis by 5,8,11,14-eicosatetraynoic acid and 9a,12a-octadecadiynoic acid

1. 5,8,11,14-Eicosatetraynoic acid (ETYA) inhibited the antigen-induced contractions of tracheal spirals obtained from actively sensitized guinea-pigs. Consistent data were obtained only when the spirals were treated with indomethacin. 2. ETYA did not affect histamine-induced contractions of indomethacin-treated tracheal spirals. 3. 9a, 12a-Octadecadiynoic acid (Ro-3-1314) a potential inhibitor of linoleic acid metabolism, stimulated the antigen-induced contraction of guinea-pig tracheal spirals and the immunological release of slow reacting substances of anaphylaxis (SRS-A) from actively sensitized guinea-pig lung fragments. 4. Both ETYA and Ro-3-1314 inhibited the immunological release of malondialdehyde from guinea-pig lung fragments. 5. The data indicate that the effects of ETYA were due to inhibition of lipoxygenase and the effects of Ro-3-1314 were due to inhibition of cyclo-oxygenase. 6. The results suggest that products of lipoxygenase contribute to the antigen-induced contraction of guinea-pig lung, particularly when cyclo-oxygenase is inhibited. Under these conditions there may be redirection of the metabolism of arachidonic acid to favour production of constrictor products of lipoxygenase such as SRS-A.

Stimulation of the antigen-induced contraction of guinea-pig trachea and immunological release of histamine and SRS-A from sensitized guinea-pig lung by (2-isopropyl-3-indolyl)-3 pyridyl ketone (L8027) and indomethacin

1 (2-Isopropyl-3-indolyl)-3 pyridyl ketone (L8027) and indomethacin reduced basal tension and enhanced the antigen- and histamine-induced contractions of tracheal spirals obtained from actively sensitized guinea-pigs. The stimulating effect of L8027 required the presence of the drug, while that of indomethacin persisted after its removal from the organ bath. 2 L8027 and indomethacin stimulated the immunological release of histamine and slow reacting substance of anaphylaxis (SRS-A) and inhibited the de novo synthesis and release of malondialdehyde from actively sensitized guinea-pig lung fragments. 3 L8027 was 2,800 times more potent than indomethacin in both in vitro models of anaphylaxis. 4 A selective antagonist of SRS-A (FPL 55712) inhibited contractions produced by antigen, but had no effect on contractions produced by histamine. 5 Prostaglandins E and F2 alpha were continuously released into the organ bath fluid by the resting trachea. Contractions induced by antigen or histamine increased the rate of prostaglandin efflux. 6 L8027 had no effect on the efflux of prostaglandins E and F2 alpha at rest and during contraction. Indomethacin inhibited prostaglandin efflux at rest and during contraction while present in the organ bath. Prostaglandin efflux was restored to 80% of control after removal of indomethacin. 7 The results suggest that prostaglandins E and F2 alpha have no role in the stimulation by L8027 and indomethacin of the contractile responses of guinea-pig trachea. The possible mechanism for the effects of these drugs is discussed.

Effect of variation in endogenous levels of ascorbic acid on the in vitro immunological release of histamine and slow reacting substance of anaphylaxis from actively sensitized guinea-pig lung fragments

1. The in vitro immunological release of histamine and slow reacting substance of anaphylaxis (SRS-A) from actively sensitized guinea-pig lung fragments was greatly reduced when the animals were maintained on an ascorbic acid-deficient diet. Excessive dietary levels of ascorbic acid did not increase mediator release above normal levels. 2. Restoration of ascorbic acid in the diet of scorbutic guinea-pigs restored in vitro immunological histamine to normal levels. 3. Variation in dietary levels of ascorbic acid had no effect on lung histamine content. 4. The lung ascorbic acid content was proportional to the dietary intake. Approximately 60% of the total lung ascorbic acid was removed by the process of chopping and washing of the tissue. This relationship was independent of dietary intake. 5. The results indicate that the immunological release of mediators of inflammation from guinea-pig lung is dependent on adequate endogenous levels of ascorbic acid.

Effect of inhibitors of prostaglandin synthesis and prostaglandins E2 and F2alpha on the immunologic release of mediators of inflammation from actively sensitized guinea-pig lung

Histamine and slow reacting substance of anaphylaxis (SRS-A) were released from actively sensitized guinea-pig chopped lung fragments (100 mg) in a concentration dependent manner by 0.2 to 100 microgram/ml of antigen. Individual variation between lungs in the proportion of the total histamine released by antigen (20 microgram/ml) showed a normal frequency distribution (n = 95). The effect of inhibitors of prostaglandin (PG) synthesis on the release of histamine and SRS-A was examined. Indomethacin (0.03--13 micrometer), racemic 6-chloro-alpha-methylcarbazole-2-acetic acid (0.03--3 micrometer) and sodium salicylate (0.8--8 micrometer) stimulated histamine release by high concentrations of antigen (more than 10 microgram/ml) but had no effect at low concentrations of antigen. These agents stimulated the release of SRS-A at all antigen concentrations tested. In contrast, 5,8,11,14-eicosatetraynoic acid (0.04--42 micrometer) had no effect on the release of histamine but inhibited the release of SRS-A. Histamine release was stimulated by exogenous PGF2alpha (0.01--1 micrometer) in lungs which had control releases in the 25th percentile of the frequency distribution, but was unaffected by exogenous PGE2 (0.01--10 micrometer). In the presence of blockade of PG synthesis by indomethacin (13 micrometer), the stimulatory effect of PGF2alpha was enhanced while PGE2 antagonized the stimulatory effect of indomethacin. These results suggest that 1) histamine and SRS-A release from guinea-pig lung is regulated in part by the de novo synthesis of prostaglandins and 2) that SRS-A synthesis and release is influenced by a metabolite of arachidonic acid produced by a metabolic pathway other than cyclooxygenase.

Alteration of in vivo zoxazolamine metabolism by carbon monoxide in normal and polycyclic hydrocarbon-treated immature male rats

The effect of carbon monoxide exposure on the in vivo metabolism of zoxazolamine in normal (corn oil-treated) and 3,4-benzpyrene- and 3-methylcholanthrene-treated, immature, male rats was examined. Pre-exposure of the animals for 90 min followed by determination of the duration of drug action while the animals were maintained in the experimental atmosphere resulted in a qualitative difference in response between normal and polycyclic hydrocarbon-treated animals over the concentration range of 150-450 ppm CO. Corn oil-treated animals demonstrated a decreased duration of drug action when exposed to CO, indicating an increase in the bioavailability of drug for metabolism which may be a result of an increase in liver perfusion rates. In contrast, polycyclic hydrocarbon-treated animals demonstrated an increased duration of drug action on exposure to CO. The qualitative difference in response to CO exposure in the two groups of animals may be due to differences in the sensitivity of cytochrome P-450 and cytochrome P-448 with respect to complexing with CO or to lowered intracellular PO2; or to differences in the dependency on blood flow of the rate of in vivo metabolism of zoxazolamine.

Reduction in basal adenylate cyclase activity during the immunologic release of histamine from guinea pig lung

Cyclic AMP has been implicated in the regulation of the immunologic release of histamine from lung and other tissues and cell types. The mechanism whereby intracellular levels of cAMP are altered during mediator release was investigated. Measurements of histamine, adenylate cyclase, and cAMP phosphodiesterase activities were made in actively and passively sensitized guinea pig lung after challenge with antigen. A transient decrease in basal adenylate cyclase activity occurred which returned to control levels after histamine release. There was no change in cAMP phosphodiesterase activity determined at substrate concentrations of 1 mM and 0.01 mM. The adenylate cyclase response did not occur under the following conditions: 1) incubation of nonsensitized lung with antigen, 2) incubation of sensitized lung with antigen in the absence of extracellular calcium, and 3) incubation of nonsensitized lung with compound 48/80. These observations indicate 1) the adenylate cyclase response and the immunologic release of histamine are intimately related, and 2) the reduction in intracellular levels of cAMP which have been reported to occur during immunologic histamine release are mediated via adenylate cyclase.