Mood and Anxiety Disorders and Suicidality in Patients With Newly Diagnosed Focal Epilepsy: An Analysis of a Complex Comorbidity

BACKGROUND AND OBJECTIVES

Mood, anxiety disorders, and suicidality are more frequent in people with epilepsy than in the general population. Yet, their prevalence and the types of mood and anxiety disorders associated with suicidality at the time of the epilepsy diagnosis are not established. We sought to answer these questions in patients with newly diagnosed focal epilepsy and to assess their association with suicidal ideation and attempts.

METHODS

The data were derived from the Human Epilepsy Project study. A total of 347 consecutive adults aged 18-60 years with newly diagnosed focal epilepsy were enrolled within 4 months of starting treatment. The types of mood and anxiety disorders were identified with the Mini International Neuropsychiatric Interview, whereas suicidal ideation (lifetime, current, active, and passive) and suicidal attempts (lifetime and current) were established with the Columbia Suicidality Severity Rating Scale (CSSRS). Statistical analyses included the t test, χ2 statistics, and logistic regression analyses.

RESULTS

A total of 151 (43.5%) patients had a psychiatric diagnosis; 134 (38.6%) met the criteria for a mood and/or anxiety disorder, and 75 (21.6%) reported suicidal ideation with or without attempts. Mood (23.6%) and anxiety (27.4%) disorders had comparable prevalence rates, whereas both disorders occurred together in 43 patients (12.4%). Major depressive disorders (MDDs) had a slightly higher prevalence than bipolar disorders (BPDs) (9.5% vs 6.9%, respectively). Explanatory variables of suicidality included MDD, BPD, panic disorders, and agoraphobia, with BPD and panic disorders being the strongest variables, particularly for active suicidal ideation and suicidal attempts.

DISCUSSION

In patients with newly diagnosed focal epilepsy, the prevalence of mood, anxiety disorders, and suicidality is higher than in the general population and comparable to those of patients with established epilepsy. Their recognition at the time of the initial epilepsy evaluation is of the essence.

Efficacy and Tolerability of Clobazam in Adults With Drug-Refractory Epilepsy

OBJECTIVES

To evaluate the effectiveness and tolerability of clobazam as an adjunctive treatment for adults with drug-resistant epilepsy.

METHODS

We performed a single-center, retrospective chart review of patients aged ≥18 years with drug-resistant epilepsy who started clobazam between 2010 and 2018. Included patients had outpatient visits both before and ≥1 month after clobazam initiation. Epilepsy classification, seizure frequency before and after clobazam, duration of clobazam treatment, and adverse effects were analyzed.

RESULTS

A total of 417 patients met the inclusion criteria. Mean age was 37.5 years, and 54% of patients were female. Patients were on a mean of 2.4 antiepileptic drugs at the time of initiation of clobazam. Epilepsy types were focal (56.8%), Lennox-Gastaut syndrome (LGS) (21.1%), generalized (15.1%), and unclassified (7.0%). At the first follow-up visit ≥1 month after clobazam initiation, 50.3% of patients had >50% reduction in seizure frequency, and 20.5% were seizure free. Of the initial cohort, 17.1% were followed >1 year and were seizure free at last follow-up. Response rates did not differ between different epilepsy classifications. Fifty-one percent of patients experienced ≥1 side effect, most commonly lethargy/fatigue (30.7%) or mood changes (10.8%). A total of 178 (42.6%) patients discontinued clobazam, most commonly due to adverse effects (55%).

CONCLUSIONS

Clobazam is effective and safe as a long-term adjunctive therapy for adults with drug-resistant epilepsy; efficacy in off-label use is similar to that in LGS.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that clobazam is an effective treatment for adults with drug-resistant epilepsy, independent of epilepsy classification.

IRIS: A Modular Platform for Continuous Monitoring and Caretaker Notification in the Intensive Care Unit

OBJECTIVE

New approaches are needed to interpret large amounts of physiologic data continuously recorded in the ICU. We developed and prospectively validated a versatile platform (IRIS) for real-time ICU physiologic monitoring, clinical decision making, and caretaker notification.

METHODS

IRIS was implemented in the neurointensive care unit to stream multimodal time series data, including EEG, intracranial pressure (ICP), and brain tissue oxygenation (PbtO2), from ICU monitors to an analysis server. IRIS was applied for 364 patients undergoing continuous EEG, 26 patients undergoing burst suppression monitoring, and four patients undergoing intracranial pressure and brain tissue oxygen monitoring. Custom algorithms were used to identify periods of elevated ICP, compute burst suppression ratios (BSRs), and detect faulty or disconnected EEG electrodes. Hospital staff were notified of clinically relevant events using our secure API to route alerts through a password-protected smartphone application.

RESULTS

Sustained increases in ICP and concordant decreases in PbtO2 were reliably detected using user-defined thresholds and alert throttling. BSR trends computed by the platform correlated highly with manual neurologist markings (r2 0.633-0.781; p < 0.0001). The platform identified EEG electrodes with poor signal quality with 95% positive predictive value, and reduced latency of technician response by 93%.

CONCLUSION

This study validates a flexible real-time platform for monitoring and interpreting ICU data and notifying caretakers of actionable results, with potential to reduce the manual burden of continuous monitoring services on care providers.

SIGNIFICANCE

This work represents an important step toward facilitating translational medical data analytics to improve patient care and reduce health care costs.

Cenobamate (YKP3089) as adjunctive treatment for uncontrolled focal seizures in a large, phase 3, multicenter, open-label safety study

Objective

During the development of cenobamate, an antiseizure medication (ASM) for focal seizures, three cases of drug reaction with eosinophilia and systemic symptoms (DRESS) occurred. To mitigate the rate of DRESS, a start‐low, go‐slow approach was studied in an ongoing, open‐label, multicenter study. Also examined were long‐term safety of cenobamate and a method for managing the pharmacokinetic interaction between cenobamate, a 2C19 inhibitor, and concomitant phenytoin or phenobarbital.

Methods

Patients 18‐70 years old with uncontrolled focal seizures taking stable doses of one to three ASMs were enrolled. Cenobamate 12.5 mg/d was initiated and increased at 2‐week intervals to 25, 50, 100, 150, and 200 mg/d. Additional biweekly 50 mg/d increases to 400 mg/d were allowed. During titration, patients taking phenytoin or phenobarbital could not have their cenobamate titration rate or other concomitant ASMs adjusted; phenytoin/phenobarbital doses could be decreased by 25%‐33%.

Results

At data cutoff (median treatment duration = 9 months), 1347 patients were enrolled, of whom 269 (20.0%) discontinued, most commonly due to adverse events (n = 137) and consent withdrawn for reason other than adverse event (n = 74); 1339 patients received ≥1 treatment dose (median modal dose = 200 mg). The most common treatment‐emergent adverse events (TEAEs) were somnolence (28.1%), dizziness (23.6%), and fatigue (16.6%). Serious TEAEs occurred in 108 patients (8.1%), most commonly seizure (n = 14), epilepsy (n = 5), and pneumonia, fall, and dizziness (n = 4 each). No cases of DRESS were identified. In the phenytoin/phenobarbital groups, 43.4% (36/114) and 29.7% (11/51) of patients, respectively, had their doses decreased. At the end of titration, mean plasma phenytoin/phenobarbital levels were generally comparable to baseline.

Significance

No cases of DRESS were identified in 1339 patients exposed to cenobamate using a start‐low (12.5 mg/d), go‐slow titration approach. Cenobamate was generally well tolerated in the long term, with no new safety issues found. Phenytoin/phenobarbital dose reductions (25%‐33%), when needed during cenobamate titration, maintained stable plasma levels.

Early Preclinical Experience with a Novel Endobronchial Radiofrequency Ablation System for Lung Cancer Treatment

This paper introduces a novel technology for treating early-stage non-small cell lung cancer using an endobronchial approach via a flexible radiofrequency ablation (RFA) catheter. Methods - The RFA system consisted of an ablation catheter, radiofrequency generator, irrigation pump for infusion of hypertonic saline (HS) and a laptop. The catheter carried an occlusion balloon, a 5 mm long RF electrode, with irrigation holes, and a 1 mm long electrode for bipolar impedance measurements. The outer diameter was 1.4 mm for compatibility with current bronchoscopes, navigation systems and radial EBUS. The RFA system was extensively bench tested on fresh heart, liver and lung animal tissues using power levels of 30 - 60 W, RF energy delivery durations of 3 - 15 min and HS concentrations of 5% and 23.4%. Two swine were then treated at 60 W for 15 min per bronchus. Several bronchi were involved. For both animals and for all treatment sites, 20% HS was used. Animals were survived for six weeks. Results - Bench studies showed that 60 W, 7 - 15 min ablations can produce large ablation volumes, in excess of 3 - 4 cm diameter. In the chronic animal study, no clinically adverse events occurred. There was no evidence of hemorrhage. Animals vital signs, breathing patterns and their behavior were normal throughout the six-week period. Their appetite was normal and they gained weight according to expectations. The RF ablation created discrete volumes of thermal coagulative necrosis which were subsequently encapsulated ("walled off") by zones of organized fibrosis. The dimensions of coagulative necrotic sequestra met expectations, as at six weeks they exceeded volumes corresponding to 2 cm nodules, the size of tumors normally addressed in the peripheral lung by localized therapy. Conclusion - This therapy showed promise. Appropriate energy settings combined with suitable treatment locations safely produced large ablation volumes of uniform thermal coagulative necrosis. Further studies and optimization of treatment parameters can develop it into a mainstream therapy for treating early-stage lung tumors in humans.

Photosensitive epilepsy

Objective

The objective of this phase 2a study was to assess the activity of PF-06372865, a positive allosteric modulator (PAM) of α2/3/5 subunit-containing GABAA receptors with minimal activity at α1-containing receptors, which are believed to mediate many of the adverse events associated with benzodiazepines, in the epilepsy photosensitivity model as a proof-of-principle of efficacy.

Methods

Seven participants with a photoparoxysmal response to intermittent photic stimulation (IPS) at baseline were randomized in a double-blind, 4-period cross-over study examining single doses of 17.5 and 52.5 mg PF-06372865, 2 mg lorazepam (active control), and placebo. Standardized photosensitivity ranges (SPRs) to IPS were recorded at screening, predose, and 1, 2, 4, and 6 hours postdose. The primary endpoint was the average least squares mean change in the SPR in the participant's most sensitive eye condition, across all time points.

Results

Both doses of PF-06372865 produced a marked and statistically significant mean reduction in SPR compared to placebo, which was similar in degree to lorazepam. There was complete suppression of SPR in 6/7 participants following PF-06372865 or lorazepam administration. PF-06372865 was safe and well-tolerated.

Conclusion

PF-06372865 demonstrated highly robust efficacy. This demonstrates anticonvulsant activity of a novel α2/3/5-subtype selective GABAA PAM in humans. Further study of the antiepileptic properties of PF-06372865 is warranted.

Clinicaltrials.gov identifier

NCT02564029.

Classification of evidence

This study provides Class II evidence that for people with a stable photoparoxysmal response to intermittent photic stimulation, PF-06372865 reduces the SPR.

Propranolol-Associated Hypoglycemia in Patients on Maintenance Hemodialysis

Propranolol is widely employed in hemodialysis patients for the control of renin-dependent hypertension. Infrequent reports have linked hypoglycemia and propranolol, especially in complex situations such as malnutrition, anesthesia, and excessive insulin use. Three patients on maintenance hemodialysis taking propranolol developed severe hypoglycemia resulting in cardiac arrest. The life-threatening hypoglycemia occurred without apparent precipitating cause and unaccompanied by the classical signs and symptoms of hypoglycemia. These three cases suggest that propranolol in a setting of chronic renal failure and dialysis may bring about severe hypoglycemia, a complication previously unsuspected.

Interactions between hair cells shape spontaneous otoacoustic emissions in a model of the tokay gecko's cochlea

BACKGROUND

The hearing of tetrapods including humans is enhanced by an active process that amplifies the mechanical inputs associated with sound, sharpens frequency selectivity, and compresses the range of responsiveness. The most striking manifestation of the active process is spontaneous otoacoustic emission, the unprovoked emergence of sound from an ear. Hair cells, the sensory receptors of the inner ear, are known to provide the energy for such emissions; it is unclear, though, how ensembles of such cells collude to power observable emissions.

METHODOLOGY AND PRINCIPAL FINDINGS

We have measured and modeled spontaneous otoacoustic emissions from the ear of the tokay gecko, a convenient experimental subject that produces robust emissions. Using a van der Pol formulation to represent each cluster of hair cells within a tonotopic array, we have examined the factors that influence the cooperative interaction between oscillators.

CONCLUSIONS AND SIGNIFICANCE

A model that includes viscous interactions between adjacent hair cells fails to produce emissions similar to those observed experimentally. In contrast, elastic coupling yields realistic results, especially if the oscillators near the ends of the array are weakened so as to minimize boundary effects. Introducing stochastic irregularity in the strength of oscillators stabilizes peaks in the spectrum of modeled emissions, further increasing the similarity to the responses of actual ears. Finally, and again in agreement with experimental findings, the inclusion of a pure-tone external stimulus repels the spectral peaks of spontaneous emissions. Our results suggest that elastic coupling between oscillators of slightly differing strength explains several properties of the spontaneous otoacoustic emissions in the gecko.

1 and 2 mg 17β-estradiol combined with sequential dydrogesterone have similar effects on the serum lipid profile of postmenopausal women

OBJECTIVES

The aim of this study was to assess the effects of 1 and 2 mg 17beta-estradiol on serum lipid profile. Beneficial effects have been clearly established in previous studies with a 2 mg dose; further evidence was required to confirm the beneficial effects of a 1 mg dose.

METHODS

This double-blind, placebo-controlled study involved 579 postmenopausal women randomized to oral treatment with placebo, 1 mg/day 17beta-estradiol sequentially combined with 5 or 10 mg/day dydrogesterone for the last 14 days of each 28-day cycle, or 2 mg/day 17beta-estradiol sequentially combined with 10 or 20 mg/day dydrogesterone for the last 14 days of each 28-day cycle. Treatment was continued for 26 cycles.

RESULTS

High density lipoprotein (HDL) cholesterol levels were significantly (p<0.05) increased after 26 cycles in all active treatment groups compared with placebo. In addition, low density lipoprotein (LDL) cholesterol and lipoprotein(a) levels were significantly reduced, and apolipoprotein A1 and triglyceride levels were significantly increased, in all active treatment groups after 13 and 26 cycles.

CONCLUSIONS

The results of this study clearly indicate that sequential combinations of either 1 or 2 mg 17beta-estradiol with dydrogesterone are associated with long-term, favorable changes in the serum lipid profile. There was no evidence that dydrogesterone compromised the 17beta-estradiol-induced improvements in lipid profile.

Irinotecan plus temozolomide in children with recurrent or refractory neuroblastoma: A phase II Children's Oncology Group study

10011

Background: Treatment of children with relapsed or refractory neuroblastoma (NB) remains a challenge. Responses to irinotecan (IRN) + temozolomide (TEM) were seen in NB xenograft-bearing mice, and objective responses were observed in patients with NB treated on a phase I study of this combination. Methods: A phase II study of IRN (10 mg/m2/dose IV daily × 5 days times; 2 weeks) + TEM (100 mg/m2/dose PO daily × 5 days) for children with relapsed or refractory NB was conducted. A one-stage design (endpoint: best overall response) required 5 or more responders out of the first 25 evaluable patients on each of two strata: 1) patients with disease measurable by CT or MRI; and 2) patients with disease detected only by bone marrow aspirate/biopsy and/or MIBG scan. Patients with stable disease or better after 3 cycles could receive an additional 3 cycles of study therapy. International Neuroblastoma Response Criteria were used for response assessment. Radiographic responses were centrally reviewed. Results: Fifty-five eligible and evaluable patients were enrolled, 28 on stratum 1 and 27 on stratum 2. Four responses were observed in the first 25 evaluable stratum 1 patients, and five responses were observed in the first 25 evaluable stratum 2 patients. Three patients had complete responses, but the overall objective response rate (CR+PR) was 16% (9/55). Eleven (stratum 1) and 13 (stratum 2) patients had stable disease. Less than 5% of patients experienced Grade 3 or 4 diarrhea. Although 18% of patients on stratum 1 and 35% of patients on stratum 2 experienced Grade 3 or 4 neutropenia during the first 3 cycles of therapy, <10% of all patients developed evidence of infection while neutropenic. Thrombocytopenia (Grade 3 or 4) was observed in only 7% of patients on stratum 1 and 12% on stratum 2. Conclusions: The combination of IRN+TEM was well tolerated in patients with recurrent or refractory NB. There were 9 objective responses, including 3 complete responses. The minimum desired response rate was attained within stratum 2, but not stratum 1. IRN+TEM may be an appropriate backbone for further study in the relapse setting in combination with novel, targeted agents.

No significant financial relationships to disclose.

Kidney dialysis-associated amyloidosis: a molecular role for copper in fiber formation

In the US alone, more than 250,000 people have impaired renal function that necessitates treatment by dialysis. A debilitating complication of long-term treatment is the deposition of beta2-microglobulin (beta2m) as amyloid fibers within the joint space. However, the intrinsic propensity of isolated beta2m protein to initiate in vitro fiber formation is negligible under conditions matched to the neutral pH and ionic conditions of serum. Here, we present evidence for a novel interaction between beta2m and Cu(2+) at a concentration within institutionally recommended limits for this metal ion in dialysate solution. Mass spectrometry, using electrospray ionization from native conditions, demonstrates that the binding of Cu(2+) is specific over Ca(2+) or Zn(2+). Despite maintaining a native-like conformation upon Cu(2+) binding, the folded protein is unusually destabilized against thermal and urea denaturation. We further demonstrate that destabilization by Cu(2+) uniquely promotes de novo fiber formation at 37 degrees C and neutral pH. Since the incidence of amyloidosis is dramatically reduced upon elimination of copper from dialysis membranes, our results provide a molecular understanding for dialysis-associated amyloid formation by beta2m.

Testosterone-mediated neuroprotection through the androgen receptor in human primary neurons

Estrogen is an active neuroprotectant and is presently investigated as a potential therapy against Alzheimer's disease for women. To determine if male hormones could also be neuroprotective, we investigated the effect of testosterone, methyltestosterone, and epitestosterone at physiological concentrations on primary cultures of human neurons induced to undergo apoptosis by serum deprivation. Serum deprivation significantly induces neuronal apoptosis in a protracted fashion. As expected, physiological concentrations of 17-beta-estradiol and transcriptionally inactive 17-alpha-estradiol protect neurons against apoptosis. Similar to 17-beta-estradiol, physiological concentrations of testosterone are also neuroprotective. Androgen receptors are present at 8 +/- 2 fmol/mg protein in the neuron cultures. The non-aromatizable androgen, mibolerone, is also neuroprotective and aromatase inhibitor, 4-androsten-4-OL-3,17-dione, does not prevent testosterone-mediated neuroprotection. In contrast, anti-androgen, flutamide, eliminates testosterone-mediated neuroprotection. Testosterone analog, methyltestosterone, showed androgen receptor-dependent neuroprotection that was delayed in time indicating that a metabolite may be the active agent. The endogenous anti-androgen, epitestosterone, also showed a slight neuroprotective effect but not through the androgen receptor. These results indicate that androgens induce neuroprotection directly through the androgen receptor. These data suggest that androgens may also be of therapeutic value against Alzheimer's disease in aging males.

Reusable biopsy forceps: a prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability

BACKGROUND

Recent studies have indicated that reusable biopsy forceps remain contaminated after reprocessing and can only be used a mean of 12 to 25 times without malfunction. Because this contradicts traditional endoscopic practice, our study investigated the ability to sterilize a type of commercially available biopsy forceps and prospectively evaluated their function in vivo until malfunction and/or breakage.

METHODS

Thirty reusable biopsy forceps were studied, 15 of which were contaminated for 5 trials each with 10(6) Bacillus stearothermophilus, and 15 of which were prospectively evaluated clinically over an 18-month period (9/98-3/00). Contaminated forceps were reprocessed by using a standard protocol and placed in a sterile bag containing soy broth. The latter was passed through a 0.2 micron filter and was subsequently cultured. In vivo data included biopsy site, size, adequacy, problems obtaining a biopsy specimen, and reasons for ultimate forceps failure.

RESULTS

After contamination, all biopsy forceps yielded a heavy growth of B stearothermophilus. No forceps, including 5 that were piecemeal dismantled with a wire cutter, had residual bacteria after reprocessing. In the in vivo study, 1507 biopsy sessions were undertaken in 1339 procedures. Forceps were categorized as new or like-new in 1259 of 1339 (94%) procedures, some loss of function but usable in 72 of 1339 (5.4%), and inadequate function or broken at use in 8 of 1339 (0.6%). Histologically, 1501 specimen sets were adequate (99.6%) and mean specimen size was 2.7 +/- 0.1 mm. Mechanical problems were noted in only 38 of 1507 (3%) sessions to include such things as sticky forceps, and the mean number of uses to malfunction or breakage was 91 +/- 15 (SEM) (range 19-132).

CONCLUSIONS

This reusable biopsy forceps can be sterilized and used a mean of 91 times with adequate tissue sampling. Mechanical problems were minor to time of breakage. Contingent on acquisition and reprocessing costs as well as the number of procedures performed, this reusable forceps has the potential for significant cost savings.

Starts of bacterial genes: estimating the reliability of computer predictions

Exact mapping of gene starts is an important problem in the computer-assisted functional analysis of newly sequenced prokaryotic genomes. We describe an algorithm for finding ribosomal binding sites without a learning sample. This algorithm is particularly useful for analysis of genomes with little or no experimentally mapped genes. There is a clear correlation between the ribosomal binding site (RBS) properties of a given genome and the potential gene start prediction accuracy. This correlation is of considerable predictive power and may be useful for estimating the expected success of future genome analysis efforts. We also demonstrate that the RBS properties depend on the phylogenetic position of a genome.

Combining diverse evidence for gene recognition in completely sequenced bacterial genomes

Analysis of a newly sequenced bacterial genome starts with identification of protein-coding genes. Functional assignment of proteins requires the exact knowledge of protein N-termini. We present a new program ORPHEUS that identifies candidate genes and accurately predicts gene starts. The analysis starts with a database similarity search and identification of reliable gene fragments. The latter are used to derive statistical characteristics of protein-coding regions and ribosome-binding sites and to predict the complete set of genes in the analyzed genome. In a test on Bacillus subtilis and Escherichia coli genomes, the program correctly identified 93.3% (resp. 96.3%) of experimentally annotated genes longer than 100 codons described in the PIR-International database, and for these genes 96.3% (83.9%) of starts were predicted exactly. Furthermore, 98.9% (99.1%) of genes longer than 100 codons annotated in GenBank were found, and 92.9% (75.7%) of predicted starts coincided with the feature table description. Finally, for the complete gene complements of B.subtilis and E.coli , including genes shorter than 100 codons, gene prediction accuracy was 88.9 and 87.1%, respectively, with 94.2 and 76.7% starts coinciding with the existing annotation.

Cardiovascular risk factors during sequentially combined 17 beta oestradiol and dydrogesterone (Femoston); results from a one-year study in postmenopausal women

OBJECTIVES

To assess the effects of Femoston (2 mg micronised 17 beta oestradiol daily, sequentially combined in one tablet with 10 mg dydrogesterone for 14 days per 28 day cycle) on the serum lipid profile of postmenopausal women.

METHODS

188 healthy postmenopausal women with intact uteri (aged 40 to 65 years) were enrolled in an open, multicentre, one-year study. Serum lipids and lipoproteins were measured at baseline and after 3, 6 and 12 months.

RESULTS

A total of 155 women completed the one-year study. Mean serum levels of total cholesterol and low-density lipoprotein (LDL)-cholesterol were significantly reduced (P < 0.01) at all assessments compared with baseline; the reductions observed at the final assessment were 5 and 20%, respectively. A significant increase of 20% (P < 0.01) was seen in high-density lipoprotein (HDL)-cholesterol levels by month 12. Mean levels of triglycerides were also increased (p < 0.01). Blood pressure and heart rate remained unchanged throughout the study.

CONCLUSIONS

The results show that the overall effects of Femoston on the serum lipid profile are comparable to those found with oestrogen therapy alone and should reduce the risk of cardiovascular disease in postmenopausal women.

Cyclosporin use in the precolectomy chronic ulcerative colitis patient: a community experience and its relationship to prospective and controlled clinical trials. Pacific Northwest Gastroenterology Society

OBJECTIVE

To define what effect seminal and controlled clinical trials have on practice patterns within a gastroenterological community. To define whether these practice patterns reproduce reported treatment methods and whether results comparable with those reported in such trials are noted within a community practice setting.

METHODS

Mailed surveies, with telephone follow-up, were sent to all members of the Pacific Northwest Gastroenterology Society. Respondents were queried regarding cyclosporin use in the precolectomy chronic ulcerative colitis (CUC) patient. Data collected included patient demographics, disease duration and extent, pre-treatment use of steroids, method, dosage, and duration of cyclosporin therapy, side effects, and short-term and subsequent clinical results.

RESULTS

Twenty-one percent of 81 respondents had used cyclosporin for precolectomy CUC, approximately one-half using constant infusion and one-half using parenteral bolus therapy. Side effects attributed to the cyclosporin were noted in eight of 30 patients (27%), and acute colectomy was avoided in 17 patients (57%). Subsequent colectomy was required in an additional nine patients (73% total) within a 6-month follow-up period, a significantly higher colectomy rate than that reported in prospective trials.

CONCLUSIONS

Potential reasons precluding cyclosporin use within the gastroenterological community may include lack of knowledge about cyclosporin therapy for CUC, lack of opportunity, skepticism, fear of medication side effects, survey sampling error, or treatment philosophy. Potential reasons for failure to duplicate the results reported in controlled trials are more complex but may include inadequate treatment duration the learning curve associated with the use of a new medication, or acceptance of colectomy as the treatment of choice in patients with acutely or chronically debilitating disease.

Sequencing potential of nested strand hybridization

The capability of the sequencing by nested strand hybridization (SNSH) method to sequence unseparated pools of DNA fragments was assessed in computer simulation experiments. The results demonstrate the high resolving power of the method and its tolerance to false-positive errors. We determine the optimal proportion between the fragment length and the pool size at a given length of oligonucleotide probes, compare SNSH to the standard SBH, and suggest the best experimental setting for the special case of sequencing of long isolated fragments.

Comparison of cord blood and peripheral blood mononuclear cells as targets for viral isolation and drug sensitivity studies involving human immunodeficiency virus type 1

We have shown that umbilical cord blood mononuclear cells (CBMC) are at least as sensitive as peripheral blood mononuclear cells (PBMC) for isolation of human immunodeficiency virus type 1 from the PBMC of infected individuals. Viral replication was more efficiently monitored by a p24 antigen capture assay than by a viral reverse transcriptase test, regardless of whether CBMC or PBMC were employed. We also found that CBMC and PBMC yielded similar results with regard to the susceptibility profiles of both wild-type and drug-resistant variants of human immunodeficiency virus type 1 for 3'-azido-3'-deoxythymidine, 2',3'-dideoxycytidine, and the (-) enantiomer of 2',3'-dideoxy-3'-thiacytidine. Finally, viruses isolated on CBMC could be routinely grown on PBMC and vice versa.

A five-year multicenter study of the susceptibility of the Bacteroides fragilis group isolates to cephalosporins, cephamins, penicillins, clindamycin, and metronidazole in the United States

Over 2800 clinical strains of the Bacteroides fragilis group were collected during a 5-year period from ten geographically separate sites and tested for their susceptibility to various antimicrobial agents using a broth microdilution method. Among the cephalosporins, ceftizoxime was the most active (13% resistance) and importantly exhibited relatively equal activity against both B. fragilis species and non-B. fragilis species. Cefotaxime exhibited similar activity with an overall resistance rate of 18%. Both ceftriaxone and cefoperazone were appreciably less active cephalosporins especially against non-B. fragilis species. With regard to cephamycins, cefoxitin (MIC90, 32 micrograms/ml) was more active than cefotetan (MIC90, > or = 256 micrograms/ml) and cefmetazole (MIC90, 64 micrograms/ml). Non-B. fragilis species were highly resistant to cefotetan and cefmetazole. Imipenem was highly active against all strains with the exception of four strains of B. fragilis. Ampicillin-sulbactam, amoxicillin-clavulanate, piperacillin-tazobactam, and cefoperazone-sulbactam were all highly active with resistance rates < 2%. No resistance was detected to metronidazole, whereas 14% of isolates were resistant to clindamycin. When compared with other studies, these findings underscore the wide variability in susceptibility patterns reported nationwide and the need to continue monitoring these patterns to aid in choosing the most active compounds for therapy.

A preliminary study of cardiopulmonary resuscitation by circumferential compression of the chest with use of a pneumatic vest

BACKGROUND

More than 300,000 people die each year of cardiac arrest. Studies have shown that raising vascular pressures during cardiopulmonary resuscitation (CPR) can improve survival and that vascular pressures can be raised by increasing intrathoracic pressure.

METHODS

To produce periodic increases in intrathoracic pressure, we developed a pneumatically cycled circumferential thoracic vest system and compared the results of the use of this system in CPR (vest CPR) with those of manual CPR. In phase 1 of the study, aortic and right-atrial pressures were measured during both vest CPR (60 inflations per minute) and manual CPR in 15 patients in whom a mean (+/- SD) of 42 +/- 16 minutes of initial manual CPR had been unsuccessful. Vest CPR was also carried out on 14 other patients in whom pressure measurements were not made. In phase 2 of the study, short-term survival was assessed in 34 additional patients randomly assigned to undergo vest CPR (17 patients) or continued manual CPR (17 patients) after initial manual CPR (duration, 11 +/- 4 minutes) had been unsuccessful.

RESULTS

In phase 1 of the study, vest CPR increased the peak aortic pressure from 78 +/- 26 mm Hg to 138 +/- 28 mm Hg (P < 0.001) and the coronary perfusion pressure from 15 +/- 8 mm Hg to 23 +/- 11 mm Hg (P < 0.003). Despite prolonged unsuccessful manual CPR, spontaneous circulation returned with vest CPR in 4 of the 29 patients. In phase 2 of the study, spontaneous circulation returned in 8 of the 17 patients who underwent vest CPR as compared with only 3 of the 17 patients who received continued manual CPR (P = 0.14). More patients in the vest-CPR group than in the manual-CPR group were alive 6 hours after attempted resuscitation (6 of 17 vs. 1 of 17) and 24 hours after attempted resuscitation (3 of 17 vs. 1 of 17), but none survived to leave the hospital.

CONCLUSIONS

In this preliminary study, vest CPR, despite its late application, successfully increased aortic pressure and coronary perfusion pressure, and there was an insignificant trend toward a greater likelihood of the return of spontaneous circulation with vest CPR than with continued manual CPR. The effect of vest CPR on survival, however, is currently unknown and will require further study.

A preliminary comparative study of the retentive properties of four post and core systems in etched preparations

Post and core systems anchored and supported by endodontic files, Para Posts, Boston Posts and Flexi Posts were subjected to tensile testing in an Instron testing machine. All forces were applied to the cores until the post-core system was removed. The test results revealed no statistically significant difference among post and core systems built up with Para Posts, Boston Posts or Flexi Posts. The endodontic files proved to be significantly less retentive than the other post systems evaluated. Under the conditions of this study, the use of endodontic files as retentive posts is not supported.

Listeria monocytogenes causing endovascular infection

Listeria monocytogenes is an uncommon cause of mycotic aneurysms, endocarditis, and other endovascular infections. When they occur, these infections usually involve patients with relatively normal host defenses, but with abnormal vascular intima or cardiac valves. We have reported a Listeria monocytogenes infection at the site of a posttraumatic aortic aneurysm.

The influence of birth setting on the father's behavior toward his partner and infant

As part of a controlled, clinical trial conducted to compare medical and psychological outcomes of a birth room and a conventional hospital setting, we examined the behavior of fathers toward their partners and infants. One hundred fourteen couples were systematically assigned to either locale by strict alternation. They learned about this allocation on arrival at the hospital in labor. Observations of fathers' behavior were made at midlabor and during home visits at three months and one year. During labor, fathers assigned to the conventional setting were more involved in helping and encouraging their partners. Parenting behavior was not influenced by the birth setting. Unexpectedly, fathers were more involved with their infants when the mothers had expressed less satisfaction with childbirth. Compensation behavior may explain these results, which can be seen as appropriately adaptive in the face of perceived environmental deficiencies affecting the laboring woman and the infant.

Servo-controlled indenter for determining the transverse stiffness of ventricular muscle

Regional ventricular wall stress is a critical determinant of cardiac function. There are, however, no validated methods for accurately estimating this stress. We have shown in the isolated ventricular septum that, during steady-state indentations, the transverse stiffness (the ratio of indentation stress [pressure acting on indenter face] to indentation strain [amount of indentation/nonindented thickness]) can be used as an estimate of the in-plane wall stress. Because of the long acquisition time for those transverse stiffness determinations, it was not possible to follow changes in wall stress over a single contraction. We recently developed a dynamic indentation system that can determine transverse stiffness in as little as 10 ms, allowing estimation of wall stress over a single contraction cycle. The apparatus consists of an indentation probe coupled to a linear motor. This indentation system was tested on two beating canine ventricular septa that were mounted in a biaxial system the could apply strains in the plane of the septa and measure the resulting in-plane stresses. The probe indented the septa with peak displacements of 0.1-0.5 mm at frequencies of 20 and 50 Hz. The transverse stiffness was calculated as the slope of the relation between the indentation stress and indentation strain during each high-frequency indentation. Consistent with earlier studies, the transverse stiffness was related to the inplane stress. In contrast to earlier studies, however, these dynamic transverse stiffness determinations could be made during a single contraction. Thus, dynamic transverse stiffness determinations allow estimation of wall stress in the isolated septa by minimal surface contact, and may lead to methods for estimating wall stress in the intact heart.

Multicenter in vitro comparison of piperacillin and nine other antibacterials against 1,629 clinical isolates

The antibacterial spectrum of activity of piperacillin was compared with that of other antibiotics against isolates of Escherichia coli, Enterobacter cloacae, Haemophilus influenzae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Pseudomonas cepacia, Pseudomonas maltophilia, Serratia marcescens, Enterococcus sp, Bacteroides fragilis, Bacteroides bivius, and Clostridium difficile obtained from laboratories at hospitals in St. Louis, in Memphis, and in Newark, New Jersey. Of the 1,629 isolates tested, 91% were susceptible to piperacillin, 90% to mezlocillin, 87% to ticarcillin/clavulanate and imipenem, 83% to ceftazidime, 81% to cefoperazone, 80% to ciprofloxacin, 77% to ceftriaxone, 71% to aztreonam, and 51% to cefoxitin.

Magnetic resonance imaging of the brain in bacterial endocarditis

Computed tomographic scanning of the brain is useful but not always conclusive in delineating central nervous system involvement in patients with bacterial endocarditis. Two patients are described in whom computed tomographic findings were normal, but magnetic resonance imaging revealed evidence of multiple brain abnormalities. Magnetic resonance imaging appears to be more sensitive than computed tomography for detecting central nervous system involvement in patients with bacterial endocarditis and should be employed when computed tomographic findings are normal in a patient with endocarditis and neurologic deterioration.

Retention of three post and core systems with and without etching

The retentive strength of post and cores fabricated entirely of composite material was compared to the retentive strength of Para Posts with composite cores in etched and unetched post preparations. Under tensile forces exerted upon the cores, only one post was removed. In all other samples the posts remained firmly embedded within the roots. The core material fractured at the occlusal surface of the roots. The Para Post with Composite core cemented into etched preparations was significantly more resistant to fracture than all other samples.

The biologic significance of cytologic atypia in progestogen-treated endometrial hyperplasia

Eighty-five menopausal women (mean age 56 years) with endometrial hyperplasia without (65 patients, group 1) and with cytologic atypia (20 patients, group 2) were followed up prospectively from 2 to 12 years (mean 7 years) to shed insight into their respective response to oral medroxyprogesterone acetate therapy. In group 1 9 of 65 patients (14%) had persistence, 4 (6%) had recurrence, and none developed carcinoma. In group 2 10 of 20 patients (50%) had persistence and 5 had recurrence with cytologically atypical disease. Five of 20 patients (25%) developed adenocarcinoma at 2 to 7 years (mean 5.5 years) after starting medroxyprogesterone acetate therapy. The data suggest that most women with hyperplasia respond to progestogenic therapy and are not at increased risk of developing cancer. The patients with an unfavorable response to medroxyprogesterone acetate and a significant elevation in cancer risk can be identified on the basis of cytologic atypia.

Achalasia in Zimbabwean blacks

The incidence and clinical features of achalasia in Zimbabwe have not previously been documented. During a 10-year period (1974-1983) 25 cases were seen in Bulawayo and Harare. The estimated incidence is 0,03/100 000 members of the population per year, which is much less than the incidence in Europe and America. Achalasia occurred at any age and there was a preponderance of cases in males. Dysphagia was invariable and its duration varied from 2 weeks to 15 years. Parotid enlargement was found in 2 patients and respiratory infections occurred relatively frequently. The importance of excluding oesophageal carcinoma is emphasized.