Bracing in severe skeletally immature adolescent idiopathic scoliosis: does a holding strategy change the surgical plan?

PURPOSE

The purpose of the study was to assess the changes in flexibility during night-time bracing in skeletally immature adolescent idiopathic scoliosis (AIS) with curves in the surgical range.

MATERIALS AND METHODS

We included a consecutive cohort of 89 AIS patients with curves ≥ 45° and an estimated growth potential. All patients were eventually treated with fusion surgery, and all patients had side-bending radiographs prior to both bracing and surgery. Curves were classified as structural or non-structural curves according to Lenke at both timepoints.

RESULTS

The main curve progressed by a mean of 12 ± 10° and the secondary curve by 8 ± 8°. Flexibility of the main curve decreased from 50 ± 19% to 44 ± 19% (p = 0.001) and the underlying curve from 85 ± 21% to 77 ± 22% (p = 0.005). In 69 patients (79%), the Lenke category did not progress during bracing. In 14 patients (15%), the progression in Lenke type occurred in the thoracic region (i.e., Lenke type 1 to type 2), while six patients (7%) progressed in the lumbar region (i.e., type 1 to type 3). In the 69 patients that did not progress, we found that the last touched vertebra moved distally by one or two levels in 26 patients.

CONCLUSIONS

This is the first study to describe that curve flexibility decreases during bracing in severe AIS. However, this had only a modest impact on the surgical strategy. Bracing as a holding strategy can be applied, but the risk of losing flexibility in the lumbar spine should be outweighed against the risks of premature fusion surgery.

Economic costs of Fusarium Head Blight, scab and deoxynivalenol

Fusarium Head Blight (FHB) has led to major economic costs for wheat and barley producers. Grain products and feed grain contaminated with deoxynivalenol (DON) (commonly known as vomitoxin) are subject to Food and Drug Administration advisory limits and as a result end-users place restrictions on their use. This has led to steep price discounts, as well as higher risks for producers and grain merchandisers. Varietal research has led to development of varieties that are resistant or moderately resistant to FHB. Studies indicate combinations of genetic resistance, fungicides and some management practices (combine settings, tillage practices, etc.) can be used to decrease economic costs due to FHB. The purpose of this study was to estimate the economic costs of scab. To do so we developed several economic models, analysed extensive data and conducted surveys of wheat flour millers, barley maltsters, and grain handlers. A detailed assessment of costs indicates the most important costs accrued by the wheat and barley industries were the risk premium paid to induce adoption of DON reducing technologies and the value of yield forgone. These were followed by the direct costs of fungicide, added shipping costs, testing and segregation and discounts.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients

OBJECTIVE

Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

DESIGN

We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

RESULTS

Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

CONCLUSION

In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

The peroxisome proliferator-activated receptor α agonist, AZD4619, induces alanine aminotransferase-1 gene and protein expression in human, but not in rat hepatocytes: Correlation with serum ALT levels

Alanine aminotransferase (ALT) in serum is the standard biomarker for liver injury. We have previously described a clinical trial with a novel selective peroxisome proliferator-activated receptor α (PPARα) agonist (AZD4619), which unexpectedly caused increased serum levels of ALT in treated individuals without any other evidence of liver injury. We pinpointed a plausible mechanism through which AZD4619 could increase serum ALT levels; namely through the PPARα-specific activation of the human ALT1 gene at the transcriptional level. In the present study, we present data from the preceding rat toxicity study, demonstrating that AZD4619 had no effect on rat serum ALT activity levels, and further experiments were performed to elucidate the mechanisms responsible for this species-related difference. Our results revealed that AZD4619 increased ALT1 protein expression in a dose-dependent manner in human, but not in rat primary hepatocytes. Cloning of the human and rat ALT1 promoters into luciferase vectors confirmed that AZD4619 induced only the human, but not the rat ALT1 gene promoter in a dose-dependent manner. In PPARα-GAL4 reporter gene assays, AZD4619 was >100-fold more potent on the human vs. rat PPARα levels, explaining the differences in induction of the ALT1 gene between the species at the concentration range tested. These data demonstrate the usefulness of the human and rat ALT1 reporter gene assays for testing future drug candidates at the preclinical stage. In drug discovery projects, these assays elucidate whether elevations in ALT levels observed in vivo or in the clinic are due to metabolic effects rather than a toxic event in the liver.

Intraoperative transfusion threshold and tissue oxygenation: a randomised trial

BACKGROUND AND OBJECTIVES

Transfusion with allogeneic red blood cells (RBCs) may be needed to maintain oxygen delivery during major surgery, but the appropriate haemoglobin (Hb) concentration threshold has not been well established. We hypothesised that a higher level of Hb would be associated with improved subcutaneous oxygen tension during major spinal surgery.

MATERIALS AND METHODS

Fifty patients aged 18 years or older scheduled for spinal fusion with instrumentation were included and randomised to receive RBCs at either a Hb concentration of 7·3 g dL(-1) (restrictive group) or a Hb concentration of 8·9 g dL(-1) (liberal group) (Registration no.: H-C-2009-072). Oxygen tension was measured with a polarographic electrode placed subcutaneously over the left deltoid muscle. The primary endpoint was subcutaneous oxygen tension at the time most patients were still undergoing surgery.

RESULTS

Forty-eight patients were included in the intention-to-treat analysis; 25 patients in the restrictive group and 23 patients in the liberal group. The median change in subcutaneous oxygen tension 60 min after surgical incision was -0·79 and -0·75 kPa in the restrictive and the liberal groups, respectively (P = 0·78). No significant difference was found in the lowest subcutaneous oxygen tension; -2·07 vs. -1·95 kPa in the restrictive and the liberal groups, respectively (P = 0·85).

CONCLUSION

A Hb concentration transfusion threshold of 8·9 g dL(-1) was not associated with a higher subcutaneous oxygen tension during major spinal surgery than a threshold of 7·3 g dL(-1), but the trial was compromised by methodological difficulties.

[Pancreatic necrosis: pro-endoscopic therapy]

The transmural endoscopic debridement and other minimally invasive therapies of infected postpancreatic necroses have been developed over the last decade as alternatives to open surgery. In several clinical centers the endoscopic approach has become standard therapy. The mortality rate in published series is in the range 0-15% and additional surgery is needed in 0-40%.Out of 73 own patients treated endoscopically between 2006 and 2010, 4 were operated because of bleeding, 2 with an acute abdomen and 3 with sepsis. Of the patients 6 died because of multi-organ failure and in 3 cases despite surgery. Main complications such as bleeding (n=20) and acute abdomen (n=7) were mostly treated conservatively. There was no procedure-related mortality. The endoscopic therapy was successful in 59 patients (80%) of whom 7 required further transmural endoscopic interventions for cystic relapses.At present, finding the best combination of endoscopic-transmural, percutaneous, laparoscopic and sometimes finally open surgical therapy remains an interdisciplinary challenge. The only randomized study published in this context clearly indicates that such a step-up approach is the most favorable.

Comparison of rocket and crossed immuno‐electrophoresis assays for determination of the level of actin complexing of Gc globulin

OBJECTIVE

Gc globulin (vitamin D-binding protein) is a component of the extracellular actin scavenger system. The level of Gc globulin is reduced in patients with fulminant hepatic failure, septic shock and trauma. Furthermore, low levels of Gc globulin in patients with fulminant hepatic failure and multiple trauma have been found to correlate with the morbidity and mortality of patients. Owing to a large increase in the turnover of Gc globulin upon complex formation with actin, it may be important to determine both the total Gc globulin concentration and the degree of complexing with actin for estimating the clinical prognosis of a patient. For this reason, we have compared a crossed immuno-electrophoresis method (CIE), suitable for visualizing the degree of complexing with actin, with a rocket immuno-electrophoresis method (RIE), previously used for determination of the complex degree.

MATERIAL AND METHODS

Sera from healthy donors and from patients with acetaminophen-induced liver disease or trauma were investigated using CIE, RIE and enzyme-linked immunosorbent assay (ELISA).

RESULTS

Using the CIE, no Gc globulin-actin complexes were detected among healthy donors. Complexes were present in 21 of 39 patients with liver disease and 3 of 37 trauma patients. High complex ratios (> 20 %) were found in 6 of 7 patients with hepatic encephalopathy. Using the RIE, complexes were detected in most samples.

CONCLUSION

The results show that the CIE method may be used for determining the degree of actin complexing in conjunction with ELISA or RIE in determining the levels of total Gc globulin.

A retrospective analysis of contamination and periphyton PICT patterns for the antifoulant irgarol 1051, around a small marina on the Swedish west coast

Irgarol is a triazine photosystem II (PSII) inhibitor that has been used in Sweden as an antifouling ingredient since the 1990s. Early microcosm studies indicated that periphyton was sensitive to irgarol at concentrations regularly found in harbours and marinas. However, field studies of irgarol effects on the Swedish west coast in 1994, using the pollution-induced community tolerance (PICT) approach, failed to detect any effects of the toxicant in the field. A PICT study involves sampling of replicate communities in a gradient of contamination, and a comparison of their community tolerance levels, with an increase being an indication that sensitive species have been eliminated and replaced by more tolerant ones. Typically, short-term assays are used to quantify the community tolerance levels. Later PICT studies in the same area over a 10 year period demonstrate that irgarol tolerance levels have increased, although the contamination pattern has been stable. Our results support the hypothesis that that the PICT potential was low initially, due to a small differential sensitivity between the community members, and that a persistent selection pressure was required to favour and enrich irgarol-tolerant species or genotypes.

Tesaglitazar, a PPARα/γ Agonist, Induces Interstitial Mesenchymal Cell DNA Synthesis and Fibrosarcomas in Subcutaneous Tissues in Rats

The development of the dual peroxisome proliferator-activated receptor (PPAR) alpha/gamma agonist tesaglitazar as an oral antidiabetic was recently discontinued. Here we present tumor data from a 2-year carcinogenicity study in rats given 0.3, 1, 3, and 10 micromol/kg tesaglitazar is presented with focus on the findings of subcutaneous fibrosarcomas. To investigate the mechanism for induction of fibrosarcomas, replicative DNA synthesis (immunohistochemical detection of BrdU-labeled cells) and expression of PPARgamma (immunohistochemistry and reverse transcription-polymerase chain reaction) in subcutaneous adipose tissues was assessed in rats administered 1 or 10 micromol/kg for 2 weeks or 3 months. Poorly differentiated subcutaneous mesenchymal sarcomas with a predominant spindle cell appearance occurred at the highest dose level of 10 micromol/kg in both sexes, and these tumors were diagnosed as fibrosarcomas. The 10-micromol/kg dose was at or above the maximum tolerated dose and caused considerable cardiovascular mortality. Tesaglitazar stimulated DNA synthesis mainly in subcutaneous interstitial mesenchymal cells. The percentage of BrdU-labeled interstitial cells was increased at 1 and 10 micromol/kg after 2 weeks. The increase in DNA synthesis was still significant at the end of the 12-week treatment at 10 mumol/kg, the dose producing fibrosarcoma. However, at 1 micromol/kg, a dose below the no-observed-effect level for fibrosarcoma, the level of DNA synthesis was similar to control levels at 12 weeks. Immunohistochemical analyses showed no detectable PPARgamma protein in the majority of BrdU-labeled interstitial mesenchymal cells in white and brown fat. This indicates that stimulation of DNA synthesis is not mediated via direct activation of PPARgamma in these cells. The results suggest that the induction of rat fibrosarcoma by tesaglitazar, at exposures 100-fold above the human therapeutic exposure, may involve proliferation of undifferentiated mesenchymal cells in subcutaneous tissues.

The effects of 10 degrees reverse trendelenburg position on ICP and CPP in prone positioned patients subjected to craniotomy for occipital or cerebellar tumours

BACKGROUND

Control of ICP-hypertension is of utmost importance during craniotomy. The effects of reverse Trendelenburg position (RTP) upon ICP and CPP have recently been studied in supine positioned patients.

METHOD

In this study we investigated changes in intracranial pressure (ICP), mean arterial blood pressure (MABP), CPP and jugular bulb pressure (JBP) before and one minute after 10( degrees ) RTP in 26 prone positioned patients with either occipital (n=12) or cerebellar tumours (n=14). ICP was measured by a subdural approach after removal of the bone flap. Tension of the dura was estimated by the surgeons by digital palpation before and after change in position.

FINDINGS

In patients with occipital tumours ICP decreased from 21.0 to 15.6 mm Hg (p<0.05). MABP decreased from 87.9 to 83.3 mm Hg (p<0.05), JBP decreased from 14.3 to 7.7 mm Hg (P<0.05), while CPP was unchanged. In patients with cerebellar tumours ICP decreased from 18.3 to 14.2 mm Hg (p<0.05). MABP decreased from 93,8 to 90.5 mm Hg (p<0.05), JBP decreased from 12.1 to 5.0 mm Hg (P<0.05), while CPP was unchanged. There were no significant differences between the two groups with regard to changes in ICP, MABP, CPP and JBP. The change in ICP was accompanied by a significant decrease in dural tension (p<0.05).

INTERPRETATION

In prone positioned patients 10 degrees RTP significantly reduces ICP, JPB and MABP within one minute, while CPP is unchanged.

Pediatric hospitalists: quality care for the underserved?

Despite the rapid growth in pediatric hospitalist services, there is little empiric information about the impact of pediatric hospitalists. This study compared process and outcome variables related to the inpatient care of 182 pediatric patients, half of whom were cared for by hospitalists and half by their primary care providers (PCP). Results indicated that, while hospitalists cared for patients of substantially lower socioeconomic status, they delivered care more economically for patients with asthma, with no significant differences in rates of return to the emergency room or rehospitalizations. Children in both services demonstrated equivalent levels of returning to their PCP for follow-up visits and were in equally good health 1 month after discharge. Additionally, no negative impact was evident on patient satisfaction at discharge; in fact, the hospitalists' patients were more satisfied with aspects of their care. Hospitalists may, therefore, provide a vital service by ensuring quality inpatient care for low-income children.

Increased turnover of Gc-globulin in patients with hepatic encephalopathy

BACKGROUND

A low serum level (< 100 mg/L) of the actin-scavenger Gc-globulin is a prognostic marker of non-survival in fulminant hepatic failure (FHF). It is unknown whether decreased production or increased consumption (or both) is responsible for the low Gc-globulin levels.

METHODS

Ten patients with FHF and four patients with acute or chronic liver disease (AOCLD) with hepatic encephalopathy (HE) grades II-IV were included. Eight patients with cirrhosis (chronic liver disease, CLD) without HE served as controls. Total, free, and actin-bound Gc-globulin were measured in samples from an artery, a central vein, and a hepatic vein. In 12 patients (9 FHF, 3 AOCLD), concentrations were measured before and after high volume plasmapheresis (HVP).

RESULTS

Total Gc-globulin was reduced to 21%, 40%, and 43% of the normal level in the FHF, AOCLD, and CLD groups, respectively, whereas bound Gc-globulin was within normal range in all patients. The Gc:actin complex ratio was increased 3.8, 2.5, and 1.9-fold compared with normal levels. Total, free, and bound serum Gc-globulin levels did not differ among arterial, systemic venous, or hepatic venous blood. Total Gc-globulin rose to >100 mg/L in all patients after HVP, whereas bound Gc-globulin remained unchanged. The Gc-globulin production rate in FHF and AOCLD patients was increased to 4.1 +/- 1.3 mg/min compared to literature values of 0.6 mg/min in healthy individuals. The estimated half-life of total Gc-globulin was shorter in the patients compared to healthy individuals (127 +/- 56 min and 870 min, respectively).

CONCLUSIONS

Gc-globulin levels were reduced in patients with FHF and AOCLD because a 7-fold increase of Gc-globulin production rate could not compensate for the accelerated clearance. Bound Gc-globulin was maintained within normal levels in all circumstances studied, indicating a possible regulatory role of this parameter in the clearance of actin.

Temporal profile of total, bound, and free Gc-globulin after acetaminophen overdose

Low admission values of the actin scavenger Gc-globulin are associated with an adverse outcome in acetaminophen (paracetamol) overdose. This prospective longitudinal study including 84 patients with acetaminophen overdose characterizes the temporal profile of Gc-globulin during the entire length of hospitalization. Serum Gc-globulin (total, actin bound, and free) levels and actin-complex ratio were measured on admission and every 12 hours until discharge. In 32 patients without hepatotoxicity (non-HEPTOX group; peak transaminase levels < 1,000 U/L), total and free Gc-globulin levels and complex ratio remained within normal range during hospitalization. Among 52 patients with hepatotoxicity (HEPTOX group; peak transaminase levels > 1,000 U/L), 15 patients had hepatic encephalopathy (HE), and 37 patients did not. In these 2 groups, total and free Gc-globulin levels decreased to 97 and 50 mg/L and 148 and 86 mg/L, respectively (normal mean, 340 and 299 mg/L), the nadir occurring at 72 hours postoverdose. Complex ratio peaked at 60 hours at levels more than 3-fold greater than normal. Conversely, bound Gc-globulin remained within normal levels for all patients throughout the observation period. At day 2, a total Gc-globulin cutoff value of less than 120 mg/L correctly predicted HE in 75%, and a value greater than 120 mg/L correctly predicted the absence of HE in 91% of patients. In conclusion, Gc-globulin is severely stressed in patients with hepatotoxicity. Extreme values occurred at 60 to 72 hours postoverdose, a period in which Gc-globulin protection against actin toxicity may be inadequate. A total Gc-globulin level less than 120 mg/L on day 2 is a good predictor of later HE. Bound Gc-globulin is maintained at constant levels independent of total Gc-globulin levels, suggesting a balanced upregulation of the removal of bound Gc-globulin even under conditions with increased actin release.

Nonorganic pain drawings are associated with low psychological scores on the preoperative SF-36 questionnaire in patients with chronic low back pain

The Short Form 36 questionnaire (SF-36) measures general health and well-being. Within the last 5 years it has been used increasingly to characterise patients in the medical literature. Relatively few studies have used the SF-36 on patients with chronic low back pain undergoing preoperative evaluation, but results suggest that it may be predictive of surgical outcome. Pain drawings are a routine part of evaluation prior to spinal surgery in several centres, since their classification of organic or nonorganic has been shown in some studies to correlate well with psychological characteristics predicting poor outcome. The purpose of the present study was to assess possible correlations between nonorganic pain drawings and the psychological scales in the SF-36. We included 128 patients in the study, all of them referred from other hospitals. Previous spinal surgery had been undergone by 25%, and 59% required daily medication because of low back pain. All patients completed pain drawings using predefined symbols These pain drawings were scored dichotomously as organic or nonorganic based on a brief description of a typical nonorganic characteristics. Patients also completed the Danish version of the SF-36 questionnaire. Statistical analysis was performed using logistic regression analysis. The pain drawing classification was used as the dependent variable and scores on the eight scales of the SF-36 as independent variables. P values of <0.05 were considered significant. The mean scores of the patient population on all eight scales were significantly lower than Danish norms. The only scales that correlated with the presence of nonorganic pain drawings were emotional role (RE) and mental health (MH), both measuring psychological health. The odds ratio (OR) of receiving a nonorganic pain drawing was 22 (95% confidence interval, or CI, 7-65) if the scores on RE and MH were more than 2 standard deviations (SD) below the Danish norm. This is the first study providing evidence that pain drawing ratings are influenced by the psychological scales of the SF-36. The clinical relevance of this observation regarding prediction of outcome after spinal surgery should be assessed in future studies.

Trauma stimulates the synthesis of Gc-globulin

OBJECTIVE

Actin is the dominating intracellular protein and is released to the circulation after tissue injury. Gc-globulin is one of the plasma proteins responsible for removal of actin from the circulation. Recent studies have shown that the level of Gc-globulin is reduced shortly after trauma. Serial changes in Gc-globulin after severe injury have not been studied so far and could provide additional information about the role of Gc-globulin in the pathophysiological response to trauma.

DESIGN

Prospective, observational.

SETTING

Surgical intensive care unit in a university hospital.

PATIENTS

Thirty-eight patients were included in the study: 12 women and 26 men with a median age of 38 years (range 19-86) and a median Injury Severity Score (ISS) of 18 (range 6-45). Seven patients died, on day 5, 8, 8, 10, 10, 13 and 21, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The serum concentration of Gc-globulin (Gctotal) and the percentage of Gc-globulin bound to actin (Gc%complexed) were measured daily for 1 week using rocket immunoelectrophoresis. Concentrations of free Gc-globulin (Gcfree) and Gc-globulin bound to actin (Gcbound) were calculated from these analytical results. The concentration of Gctotal and Gccomplexed correlated significantly (r = -0.99, p < 0.001) throughout the time period. After day 3 levels of Gc%complexed normalised, whereas levels of Gctotal continued to increase above control values. The concentrations of Gctotal and Gcfree were significantly lower in non-survivors compared to survivors; p = 0.005 and p = 0.03, respectively. This was combined with an inverse correlation of Gcbound between these two groups (r = -0.73; p = 0.04).

CONCLUSIONS

Severe injury results in a prolonged load on the extracellular actin scavenger system; more pronounced in patients who do not survive. Gc-globulin displays characteristics of an acute phase reactant, with supra-normal serum levels 1 week after severe injury. Serial measurements of Gc-globulin after trauma could prove to be a method of early identification of patients with increased risk of mortality.

Gc-globulin is an acute phase reactant and an indicator of muscle injury after spinal surgery

OBJECTIVES AND DESIGN

Actin is the dominating protein in mammalian cells, including muscle cells, and is released into the circulation after tissue injury. Gc-globulin, one of the proteins in the Extracellular Actin Scavenger System (EASS) is responsible for the clearance of actin from the circulation. Clinical studies show that plasma levels of Gc-globulin are reduced in situations with tissue death, and that the degree of reduction correlates with development of organ dysfunction and survival. The purpose of the present study was to describe the serial changes in Gc-globulin after a standardized surgical procedure resulting in major muscle injury, comparing changes in Gc-globulin with changes in other acute phase proteins.

MATERIAL AND METHODS

Twelve patients who underwent posterolateral lumbar fusion from L4 or L5 to sacrum were included in the study. Peripheral venous blood samples were obtained before surgery and on day 1, 3, 5, 12, 21, and 28 after surgery. Serum samples were analyzed for total Gc-globulin (Gc(total)), percentage of Gc-globulin complexed with actin (GC(complexed)), albumin, orosomucoid, haptoglobin, transferrin and creatin phosphokinase (CK).

RESULTS

Gc(total) decreased to 87% of pre-operative values on day one. Thereafter the levels increased to a maximum of 135% of pre-operative values on day five, approaching baseline values towards the end of the observation period. Compared to this, changes in GC(complexed) displayed a mirror-like time-course, with levels of Gc(total) and GC(complexed) being significantly inversely correlated on day one (P < 0.05). Levels of albumin remained below pre-operative values the first three weeks post-operatively, reaching baseline at the end of the observation period (P < 0.05).

CONCLUSION

The initial changes in Gc-globulin can be explained by increased release of actin from injured muscle tissue. Subsequently Gc-globulin displays characteristics of a so-called positive acute phase reactant, supporting previous in vitro studies, and clinical studies after minor surgery. In spite of genetic linkage and structural homology Gc-globulin and albumin are regulated differently after surgical trauma.

Toxicities and outcomes associated with nefazodone poisoning: an analysis of 1,338 exposures

Toxicities and medical outcomes associated with nefazodone poisoning were characterized using national poisoning data from the American Association of Poison Control Centers and through prospective collection of additional data elements. Nefazodone exposures involving concomitant agents were excluded. There were 1,338 human exposures included in the final data analysis. Seventy-five percent of exposures were acute and 20% involved children < 13 years. Twenty-five percent of patients remained asymptomatic. There were no deaths. No dose response relationship was evident in the 45 cases where estimated doses were available. The most common manifestations were drowsiness (17.3% of all patients), nausea (9.7%), and dizziness (9.5%). The most common serious clinical effect was hypotension (1.6%). The median onset time for symptoms was 1.75 hours. Manifestations resolved within 8 to 24 hours. Most patients were treated with only gastrointestinal decontamination. No patients required intubation, mechanical ventilation, or vasopressors. Nefazodone appears to be of low toxicity during poisonings.

Plasma gelsolin is reduced in trauma patients

Tissue injury results in the release of the intracellular protein actin which is cleared from the circulation by the plasma proteins gelsolin and Gc-globulin, constituting the Extracellular Actin Scavenger System (EASS). Experimental studies have shown that excessive amounts of actin in the circulation can lead to a condition resembling multiple organ dysfunction syndrome (MODS), and we have previously demonstrated that the level of Gc-globulin is decreased after severe trauma. The purpose of the present study was to determine whether the plasma levels of gelsolin were altered in the early phase after trauma. Twenty-three consecutive trauma patients were studied. Plasma samples were assayed for gelsolin by immunonephelometry with polyclonal rabbit antihuman gelsolin prepared in our own laboratory. The median time from injury until the time the first blood sample was taken was 52 min (range 20-110) and the median Injury Severity Score (ISS) was 20 (range 4-50). The gelsolin level on admission was reduced significantly in the trauma patients compared with normal controls. The median level was 51 mg/L (7-967) vs. 207 mg/L (151-621), P < 0.0001. There was no correlation between admission levels of gelsolin and ISS or survival. This study illustrates that the plasma concentration of gelsolin is significantly diminished immediately after traumatic injury. Further studies are necessary to establish a role for gelsolin or EASS in the development of MODS in trauma patients. The level of serum or plasma gelsolin can be determined rapidly and accurately using a nephelometric assay.

Admission level of Gc-globulin predicts outcome after multiple trauma

BACKGROUND

Actin is the dominating protein in mammalian cells. Release of excessive amounts of actin into the circulation may result in a condition resembling multiple organ failure. The purpose of this study was to determine if admission levels of Gc-globulin can predict survival after multiple trauma. Also, we wanted to compare the predictive ability of Gc-globulin with that of the TRISS-Like scoring system.

METHODS

Fifty-seven patients with a median ISS 18 (16-75) were included. All patients had a blood sample taken median 42 min after the injury (19-110 min). Serum Gc-globulin was measured by rocket immunoelectrophoresis.

RESULTS

On admission, all patients had significantly reduced levels of Gc-globulin compared with normal controls. Gc-globulin was significantly higher in the group of survivors (n = 41), compared with non-survivors (n = 16). Median 237 mg/l vs. 188 mg/l (P < 0.01). The predictive ability of Gc-globulin regarding death was similar to that of TRISS-Like with positive predictive values of 69%, a negative predictive value of 84%, a sensitivity of 56% and a specificity of 90%.

CONCLUSIONS

The predictive value of Gc-globulin regarding survival was similar to that of an established scoring system. Gc-globulin, alone or in combination with other parameters, may serve as a routine tool for early identification of patients at risk after severe injury, increasing the possibility of early intervention.

Self-reported need of information, counselling and education: needs and interests of re-applicants

An interview study was performed to establish and evaluate the need for education and counselling of hearing aid users (HA users) in order to review present procedures of information and potential referral to the educational sector. The study comprises 102 consecutively selected hearing-impaired adults (>18 years), the only inclusion criterion being experienced HA user. The interview took place immediately after the patient's latest HA fitting appointment and consisted of 24 structured and closed questions. The findings indicate that a significant proportion of HA users, especially the elderly, do not experience a need for or show an interest in further education and counselling concerning their hearing handicap. It is concluded that the present organization of services meets the demands of a majority of re-applicants.

Serum Gc-globulin in the early course of multiple trauma

OBJECTIVES

In patients with multiple trauma, actin released from damaged cells may cause severe circulatory disturbance due to thrombi formation. The aim of this study was to evaluate serum concentrations of the actin scavenger, Gc-globulin, in relation to the severity of injury and outcome.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Trauma center at a university hospital.

PATIENTS

Twelve patients with multiple trauma, consecutively included, according to defined criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serum Gc-globulin concentrations were measured at the time of admission and daily thereafter for 1 wk or until death. In all patients, the Gc-globulin concentration was significantly low (p < .0001), and the proportion of Gc-globulin bound to actin was already increased compared with normal values (p < .0001) by the time of hospital arrival. There was an inverse correlation between the mean concentration of serum Gc-globulin in the first week after trauma and the Injury Severity Score (r = -0.72, p < .05). Surviving patients had a significantly (p < .05) higher concentration of serum Gc-globulin in the first week after trauma compared with nonsurvivors.

CONCLUSIONS

Serum concentrations of Gc-globulin were significantly low in trauma patients. The reduction took place within 60 mins after injury. Because the normal half-life of Gc-globulin is almost 48 hrs, our observations suggest a marked consumption of Gc-globulin immediately after the trauma. This finding could be the first clinical evidence that Gc-globulin plays a role in the systemic inflammatory response syndrome after trauma. This result is supported by the finding that lack of Gc-globulin was related to nonsurvival and the severity of the trauma.

Comparison of the levels of quality of inpatient care delivered by pediatrics residents and by private, community pediatricians at one hospital

PURPOSE

To compare the quality and cost of inpatient care provided by pediatrics residents with the quality and cost of that provided by private, practicing pediatricians.

METHOD

Valley Children's Hospital--a 175-bed, private, nonprofit, university-affiliated pediatric hospital located in Fresno, California--has both a resident service and a community physician service. From May 1994 to March 1995 a total of 154 pediatric patients (64 from the resident service, 90 from the community service) were selected for the study using incidental sampling. In order to be included in the study, patients had discharge diagnoses of uncomplicated gastroenteritis or asthma. The parent or guardian of each patient completed a satisfaction questionnaire at discharge and agreed to a home visit one month later, when the same questionnaire and another were completed. Patients' charts were studied for treatment procedures, and follow-up data for a year were compiled. Statistical analyses were conducted with analysis of variance for continuous measures and chi-squares for dichotomous variables.

RESULTS

The findings indicated no difference between the two services in terms of the parents' and guardians' satisfaction with patient care, hospital charges, and degrees of adherence to follow-up care after discharge. The community physicians were more likely than were the residents to employ non-standard laboratory and management procedures with both the asthma and gastroenteritis patients. The asthma patients cared for by community physicians had significantly more frequent asthma attacks after discharge, with a higher frequency of patients being subsequently treated in the emergency room and readmitted to the hospital, than did the asthma patients cared for by the residents.

CONCLUSION

Common perceptions that physicians-in-training (1) overuse medical services and (2) fail, due to their inexperience, to provide high-quality services were not supported in this study.

A validational study of the Structured Interview of Symptoms Associated with Sexual Abuse (SASA) using three samples of sexually abused, allegedly abused, and nonabused boys

OBJECTIVE

With the rapid rise of sexual abuse allegations, there is a growing need to develop instruments to help clinicians determine the likelihood that sexual abuse has occurred.

METHOD

This study evaluated the discriminant validity of a structured parent interview regarding emotional, behavioral, and physical symptoms by comparing results among three subsamples of age matched boys: 22 sexually abused boys whose perpetrator confessed, 47 boys evaluated in a sexual abuse clinic but without a history of perpetrator confession and 52 nonabused boys selected after rigorous screening.

RESULTS

In comparison with the nonabused (NA) boys, the sexually abused boys were significantly more likely to demonstrate sudden emotional and behavioral changes, frequent stomach aches, more knowledge about sex and sexual activities than expected for age, unusual aggressiveness toward playmate or toy's private parts, crying easily, difficulty getting to sleep, and a change to poor school performance. The internal reliability of the SASA was determined to be .83 and scoring of an abbreviated 12-item scale demonstrated a sensitivity of 90.9% and a specificity of 88.5%.

CONCLUSIONS

The findings suggest that Structured Interview of Symptoms Associated with Sexual Abuse (SASA) is an effective tool which may help in the comprehensive assessment of boys who may have been sexually abused.

Clinical outcome after spinal fusion with a rigid versus a semi-rigid pedicle screw system

Several biomechanical studies have evaluated the quality of fusion obtained with a rigid versus a semi-rigid pedicle screw implant. Some studies indicate that increased rigidity of the implant system results in an increased strength of the fusion mass. Other reports have underlined the risk of stress shielding due to rigid implant systems. Based on these findings some authors have recommended the use of a semi-rigid system. There are, however, few studies focusing on any possible difference in clinical outcome between the two different types of implant systems. Questionnaires were sent to 89 patients who had undergone primary spinal fusion with either a rigid or a semi-rigid pedicle-screw-based implant system. In every case the diagnosis was spondylolisthesis or degenerative lumbar disease. The questionnaires were analysed using forward stepwise logistic regression analysis. Eighty (90%) of the questionnaires were returned. There was a mean follow-up of 4 years (range 2-8 years). It was not possible to demonstrate any difference in clinical outcome between patients undergoing lumbar fusion with a rigid implant system and those given a semi-rigid system. The overall patient satisfaction rate was 69%, with no difference between the two types of implant. No difference in clinical outcome between the two types of implant was found. Considering the fact that the primary goal of spinal fusion procedure is to obtain a solid fusion mass, biomechanical tests favour the used of a rigid pedicle screw system. This fact combined with the fact that early mobilisation is possible with rigid implants justifies the use of rigid implant systems, although no difference in clinical outcome could be demonstrated in this study.

Predictors of 10-year macrovascular and overall mortality in patients with NIDDM: the Munich General Practitioner Project

The 10-year follow-up of the Munich General Practitioner Project was designed as a long-term prospective study to evaluate factors predicting macrovascular and overall mortality in a random cohort of non-insulin-dependent diabetic (NIDDM) patients. Of the original 290 patients (103 males, 187 females, median age 65 years) 92.5% could be assessed, 103 subjects had died, 58 from macrovascular causes. In an univariate analysis of baseline data, deceased patients, and especially those who died from macrovascular causes had significantly higher fasting blood glucose, HbA1c, von Willebrand-factor protein, urine albumin excretion, and serum beta 2-microglobulin, were significantly older, exhibited significantly more ischaemic heart disease (abnormal ECG Minnesota codes), carotid artery and peripheral vascular disease (both determined by ultrasound-Doppler), and had significantly inferior knowledge about diabetes and its treatment. No significant differences were seen for gender, blood pressure, smoking, total cholesterol, triglycerides, HDL-cholesterol, or the use of antidiabetic, antihypertensive or coronary drugs. In a multiple logistic regression analysis, the risk factors for macrovascular death were age, HbA1c and von Willebrand-factor protein. When baseline macrovascular disease was taken into account, carotid artery disease was also a determinant. The main variables from the metabolic syndrome (blood pressure, dyslipidaemia, body mass index) did not enter a multiple logistic regression analysis. The data suggest that age and haemoglobin A1c are major determinants, and that in addition von Willebrand-factor associated endothelial damage is a risk factor for macrovascular mortality in NIDDM patients.

Inhibition of a Src homology 2 domain containing protein tyrosine phosphatase by vanadate in the primary culture of hepatocytes

Inhibition of protein tyrosine phosphatase (PTP) activities by vanadate was examined in cultured rat hepatocytes. The incubation of hepatocytes with sodium orthovanadate inhibited PTP activities, measured with labeled polyglutamate tyrosine (4:1) and insulin receptor peptide (1142-1153), in a dose- and time-dependent manner. The PTP activities in cytosolic and particulate fractions were inhibited with the IC50 values of 30-50 and 2-20 microM, respectively. Vanadate-mediated inhibition of protein phosphatase, type 1 (a serine phosphatase) was less pronounced, requiring 50- to 150-fold higher concentrations. Molybdate and tungstate, the other potent inhibitors of PTPs, exerted approximately 70% less inhibition of enzyme activities compared to vanadate in intact liver cells. The cytosolic and particulate PTPs inhibited by vanadate were further resolved by fast protein liquid chromatography on Mono Q and Superose-12 columns. Vanadate exerted stable and differential inhibition of several PTPs. One of them was identified as SHPTP2 (Syp, SHP-2) in cytosolic as well as particulate fractions. Immunoprecipitation of this PTP with Syp-antibody coupled to protein A-agarose confirmed the vanadate-induced decrease in SHPTP2 activity. Vanadate did not alter the expression of SHPTP2 and its distribution between cytosolic and particulate fractions as indicated by the immunoblots. The decrease in the activities of PTPs in vanadate-treated hepatocytes in general was found to be reversed by the reducing agent dithioerythreitol. This study shows that vanadate inhibits many PTPs in intact liver cells, one of them being SHPTP2/SHP-2. The inhibition is stable after chromatography on ion-exchange and gel filtration chromatography. The enzyme inhibition seems to involve the oxidation of the thiol group of PTPs.

CO(2) and indomethacin vasoreactivity in patients with head injury

The purpose of this study was to compare the effect of hyperventilation and indomethacin on cerebral circulation, metabolism and pressures in patients with acute severe head injury in order to see if indomethacin may act supplementary to hyperventilation. Fourteen severely head injured patients entered the study. Intracranial pressure (ICP), mean arterial blood pressure (MABP) and cerebral perfusion pressure (CPP) were monitored continuously. Within the first four days after the trauma the CO(2) and indomethacin vasoreactivities were studied by measurements of cerebral blood flow (CBF) (Cerebrograph 10a, intravenous (133)Xe technique) and arterio-venous difference of oxygen (AVdO(2)). Ischaemia was evaluated from changes in CBF, saturation of oxygen in the jugular bulb (SvjO(2)), lactate and lactate/oxygen index (LOI). Data are presented as medians and ranges, results are significant unless otherwise indicated. Before intervention ICP was well controlled ,(14.8 (9-24) mmHg) and basic CBF level was 39.1 (21.6-75.0) ml/100 g/min). The arterio-venous oxygen differences were generally decreased (AVdO(2) = 4.3 (1.8-8.1) ml/100 ml) indicating moderate luxury perfusion. Levels of CMRO(2) were decreased (1.54 (0.7-3.2) ml/100 g/min) as well. During hyperventilation (delta PaCO(2)=0.88 (0.62-1.55) kPa) CBF decreased with 11.8 (-33.4-29.7) %/kPa and ICP decreased with 3.8 (0-10) mmHg. AVdO(2) increased 34.0 (4.0-139.2) %/kPa, MABP was unchanged, CMRO(2) and CPP increased (delta CPP = 3.9 (-10-20) mmHg). AVD (lactate) and LOI were unchanged. No correlations between CBF responses to hypocapnia and outcomes were observed. An i.v. bolus dose of indomethacin (30 mg) decreased CBF 14.7 (-16.7-57.4)% and ICP decreased 4.3 (-1-17) mmHg. AVdO(2) increased 27.8 (-40.0-66.7)%, MABP (delta MABP = 4.9 (-2-21) mmHg) and CPP (delta CPP = 8.7 (3-29) mmHg) increased while CMRO2 was unchanged. No changes in AVd (lactate) and LOI indicating cerebral ischaemia were found. Compared to hyperventilation (changes per 1 kPa, at PaCO(2) level = 4.05 kPa) the changes in MABP, CPP and CBF were significantly greater after indomethacin, while the changes in AVdO(2), ICP, SvjO(2) and LOI were of the same order of magnitude. No correlation between relative reactivities to indomethacin and CO(2), evaluated from changes in CBF and AVdO(2), or between the decrease in ICP after the two procedures were found. Thus, some patients reacted to indomethacin but not to hyperventilation, and vice versa. These results suggest that indomethacin and hyperventilation might act independently, or in a complementary fashion in the treatment of patients with severe head injury.

Decrease in protein tyrosine phosphatase activities in vanadate-treated obese Zucker (fa/fa) rat liver

The inhibitory action of vanadate towards protein tyrosine phosphatase (PTPase) has been considered as a probable mechanism by which it exerts insulin-like effects. In this study, we have examined the in vivo effects of vanadate on PTPases in the liver of obese Zucker rats, a genetic animal model for obesity and type II diabetes. These animals were characterized by hyperinsulinemia and mild hyperglycemia. The number of insulin receptors were significantly (p < 0.01) decreased in liver. After chronic administration of vanadate in obese rats, 80% decrease in the plasma levels of insulin was observed. The insulin receptor numbers were significantly (p < 0.01) higher in vanadate-treated obese rats as compared to the untreated ones. The hepatic PTPase activities in cytosolic and particulate fractions, with phosphorylated poly glu:tyr (4:1) and the insulin receptor peptide (residues 1142-1153) as substrates, increased in obese rats. In vanadate-treated obese rat livers, the PTPase activities in both subcellular fractions with these substrates decreased significantly (p < 0.001). The decreases in PTPase activities from these groups of rats were further supported by chromatography on a Mono Q column. These data support the view that inhibition of PTPases plays a role in the insulin-mimetic action of vanadate.

Functional and social long-term results after free tissue transfer to the lower extremity

We report the long-term social and functional results in 53 patients receiving free tissue transfer after trauma to the lower extremity. The results are compared with those of a matched group of patients receiving primary amputation. The microsurgically treated patients had significantly more complaints over pain during walk (p = 0.02) and edema (p < 0.00005). Regarding social results, no significant differences between the two groups were found. Time until surgery, infection, or bone defect before free flap surgery did not alter the overall results significantly. It is concluded that the long-term functional and social results after free tissue transfer are almost the same as those achieved after simple amputation. Because the median time until free flap surgery in this series was 158 days, early limb-saving procedures could possibly improve the long-term results.

[Pregnancy and delivery in a woman with neuromuscular disease. Spinal muscular atrophy and severely reduced pulmonary function]

Pregnancy and delivery are described in a 22-year-old woman suffering from spinal muscular atrophy. In spite of severe respiratory insufficiency with a vital capacity of 0.6 litre, pregnancy and planned caesarean section in general anaesthesia went without complications. Some explanations for this are presented. Teams involving respiratory centres specialized in the treatment of patients with neuromuscular diseases, obstetricians and neurologists are recommended. These teams may carry out individual counselling, frequent controls, respiratory support and planning of delivery.

Laser Doppler flowmetry for estimation of bone blood flow: studies of reproducibility and correlation with microsphere technique

The blood flow in the femoral condyles of six pigs was measured by the microsphere technique and by laser Doppler flowmetry (LDF) before and after clamping of the external iliac artery. A significant decrease in the bone blood flow was found with both microsphere and LDF measurements, and a high correlation was found between the two methods. After release of the arterial clamp, the LDF values rapidly returned to approximately the same values as before clamping. In a second part of the study, the LDF output signal was studied in the intertrochanteric area of eight patients. The reproducibility of two LDF measurements at the same location was within 15%. The temporal variability of the LDF signal during 10 min of recording showed only slight variations. It is concluded that LDF is relative in nature and that the mean LDF output signal is suitable for monitoring dynamic responses of the bone blood flow to various stimuli. Several consecutive measurements have to be performed if the blood flow at different locations of a specific bone are to be compared with each other.

The relationship between inert gas wash-out and radioactive tracer microspheres in measurement of bone blood flow: effect of decreased arterial supply and venous congestion on bone blood flow in an animal model

Several methods have been employed in the study of bone perfusion. We used a method of determining inert gas wash-out by mass spectrometry in the study of blood flow rates in pigs. The method was validated by comparison of the result obtained with inert gas wash-out to that with measurement by microspheres. Furthermore, the effect of decreased inlet flow and venous congestion on the bone perfusion data was tested. The undisturbed bone blood flow was not significantly different when measured with wash-out of inert gas (7 +/- 0.7 ml/min/100 g) or with microspheres (9 +/- 2.9 ml/min/100 g), and the methods were correlated. Perfusion was reduced significantly, to 20% of the original value, after arterial occlusion. The changes in wash-out curves and accumulation of radioactive tracer provided substantial evidence for impaired intraosseous circulation following venous obstruction also. In conclusion, the study showed that this method of determining inert gas wash-out is feasible for studies of local perfusion rates in bone. The flow rates obtained by wash-out correlated well with the results of microsphere studies. In this animal model, both methods detected a fivefold reduction in flow rate after clamping of the arterial inflow. Obstruction of the venous outflow also impaired blood flow and lowered the cellular supply.

[Oxygen conserving nasal catheters. Oxymizer pendant]

The Oxymizer pendant consists of a 40 ml pendulating reservoir bag which is connected to the prongs by two tubes. Both reservoir and tubes serve as oxygen reservoirs. We wanted to examine if it was possible to save oxygen by changing from the usual nasal cannula to Oxymizer pendant. 11 patients with hypoxaemia due to chronic obstructive pulmonary disease were examined. We were able to reduce the oxygen requirement by approximately 65% without significant changes in SaO2. All 11 patients evaluated the Oxymizer pendant to be more comfortable than the usual nasal cannula.

Partial pressures of oxygen and carbon dioxide in bone and their correlation with bone-blood flow: effect of decreased arterial supply and venous congestion on intraosseous oxygen and carbon dioxide in an animal model

Pathological changes in bone have been related to a preceding impediment of the arterial or venous bone circulation and hypoxia. In this study, we analyzed the feasibility of mass spectrometry in measuring intraosseous oxygen and carbon dioxide. The partial pressures were also measured in intraosseous blood samples, and blood flow in bone was measured with the radioactive microspheres technique. The average partial pressure of oxygen in the lateral femoral condyle was 34 +/- 1.6 mm Hg when measured in intraosseous blood samples and 36.3 +/- 2.3 mm Hg when measured with the on-line mass spectrometer, with significant correlation between the methods. The absolute value of the partial pressure of carbon dioxide measured in situ with mass spectrometry was correlated with the value in the withdrawn blood. There was no significant difference in partial pressures of oxygen and carbon dioxide between the two sides or between repetitive measurements. Arterial occlusion resulted in severe hypoxia, whereas more moderate changes followed venous occlusion.

Older's classification of Colles' fractures. Good intraobserver and interobserver reproducibility in 185 cases

To evaluate the reliability of the Older classification, 4 observers classified 185 distal radius fractures twice with 1 month's interval. Both the intraobserver agreement and the interobserver agreement were high, with kappa values of 0.75 (0.69-0.79) and 0.69 (0.60-0.77), respectively. The agreement was especially high for type 1 and type 4 fractures. Older's method of classifying distal radius fractures can thus be recommended for clinical use.

Health problems in Norwegians travelling to distant countries

373 travellers to countries outside Europe and North America were recruited before departure summer 1988 at the Vaccination Office, Trondheim, Norway, and participated in a follow-up study on health problems related to travel. 313 of the travellers (84%) responded by answering a postal questionnaire one month after return; it dealt with prophylactic measures, life-style, and health problems associated with travelling. An 18% failure in malaria prophylaxis and some risk-taking behaviour related to alcohol and sex were recorded. Diarrhoea (usually mild) was reported by 59%; other symptoms were also frequent. Medical advice was sought by 18% while abroad; 7% consulted a doctor. Ill health made travelling less enjoyable than expected for 8%. After return, 25% had health problems; 9% saw a doctor, three travellers were hospitalized, and 6% were absent from work. Total morbidity was high, but seldom serious. Targeted advice, which can well be given by primary health care personnel, could help to reduce morbidity and risk behaviour and improve travellers' handling of ill health.

Characterization of rat brain NCAM mRNA using DNA oligonucleotide probes

A number of different isoforms of the neural cell adhesion molecule (NCAM) have been identified. The difference between these is due to alternative splicing of a single NCAM gene. In rat brain NCAM mRNAs with sizes of 7.4, 6.7, 5.2, 4.3 and 2.9 kb have been reported. We have synthesized six DNA oligonucleotides, that hybridize to different exons in the NCAM gene. Furthermore we have constructed three oligonucleotides, that exclusively hybridize to mRNAs lacking certain exons, by letting them consist of sequences adjacent to both sides of the splice sites. By means of these probes we have characterized the five NCAM mRNAs in rat brain.

The possible use of a spallation neutron source for neutron capture therapy with epithermal neutrons

Spallation is induced in a heavy material by 72-MeV protons. The resulting neutrons can be characterized by an evaporation spectrum with a peak energy of less than 2 MeV. The neutrons are moderated in two steps: first in iron and then in carbon. Results from neutron fluence measurements in a perspex phantom placed close to the moderator are presented. Monte Carlo calculations of neutron fluence in a water phantom are also presented under some chosen configurations of spallation source and moderator. The calculations and measurements are in good agreement and show that, for proton currents of less than 0.5 mA, useful thermal-neutron fluences are attainable in the depth of the brain. However, the dose contribution from the unavoidable gamma background component has not been included in the present investigation.

Blood oxygen parameters in patients with chronic obstructive pulmonary disease. An evaluation of measured and calculated 2,3-diphosphoglycerate concentrations

48 simultaneous arterial and venous blood samples from 15 patients with chronic obstructive pulmonary disease (COPD) were evaluated for calculated p50 and measured and calculated 2,3-diphosphoglycerate (DPG) concentration. 23 samples (48%) demonstrated a leftward shift in the calculated in vivo p50, whereas both measured and calculated DPG showed 5% below and 28% above reference range. Measured DPG was significantly higher than calculated DPG in the leftshifted group, whereas there was no significant difference in the non-leftshifted group. Mean arterial pH was alkalotic in the leftshifted group and significantly higher than mean pH in the non-leftshifted group. It is concluded that DPG concentration cannot be calculated by the algorithm in patients with COPD and a leftward shift in the oxygen dissociation curve.

The production by 72 MeV protons of keV neutrons for 10B neutron capture therapy

Fast neutrons, produced in a spallation process by 72 MeV protons hitting heavy nuclei, can be moderated down to keV energies, suitable for 10B capture therapy. Measurements of neutron flux from copper and lead targets, after moderation by water and hydrocarbons, have been performed, together with measurements of the fast neutron and gamma-backgrounds. The comparisons with Monte Carlo calculations show good agreement. As neutron fluences up to 10(12) to 10(13)n/cm2 can be produced within a few hours in about 0.5 m target distance the technique seems to be suitable for clinical experiments.

Pars plana vitrectomy and silicone oil injection in proliferative diabetic retinopathy

A retrospective study is reported on 106 eyes with proliferative diabetic retinopathy, treated by vitrectomy and silicone oil injection. Indications were traction detachment in 91 eyes and nonclearing rebleeding in 15 eyes; 31 eyes had previously had vitrectomy. Anatomical success was obtained at the end surgery in 91 eyes, and after a minimum follow-up of 6 months in 68 eyes (64%). Functional results were as follows: satisfactory visual acuity (0.5-0.05) in 23 eyes (22%), ambulatory vision (0.03-CF) in 14 eyes (13%), HM-LP in 54 eyes (51%), and NLP in 15 eyes (14%). The functional results are limited by recurrent detachments due to characteristic reproliferations under the silicone bubble or by ischemic diabetic angiopathy in the attached retina. A positive effect of silicone oil is demonstrated in the reduction of preexisting or postoperatively new iris neovascularization and in preventing postoperative rebleeding.

Inoculation with BK virus may break immunological tolerance to histone and DNA antigens

BK virus particles contain histones of host cell origin that combine with viral DNA to form minichromosomes. Data from earlier immunoblotting experiments demonstrated that rabbits inoculated i.v. with purified infectious BK virus produced antibodies not only to the viral structural protein VP1 but also to migrating polypeptides of a molecular mass ranging from 14-16 kDa. These proteins were believed to represent certain histone classes. To examine this hypothesis, sera from five rabbits inoculated with BK virus were analyzed by ELISA for antibodies against polynucleosomes, the individual histone classes, and double-stranded DNA, as well as against antigens carried by the structural viral proteins. Antibodies against polynucleosomes and also against histones H1 and H3 were found in sera from two of five inoculated rabbits. The same sera contained antibodies reacting with double-stranded DNA, whereas no antibodies against H2A, H2B, and H4 were detected. BK virus inoculation may thus lead to a break of tolerance, resulting in autoantibody production against highly conserved antigens that, in this context, may be regarded as "self-antigens", irrespective of the species in which they originate.