A111 A RECTUM-SPECIFIC SELECTIVE RESECTION ALGORITHM OPTIMIZES ONCOLOGIC OUTCOMES FOR LARGE NON-PEDUNCULATED RECTAL POLYPS

Background

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are complementary techniques for large (≥ 20mm) non-pedunculated rectal polyps (LNPRPs). A mechanism for appropriate technique selection has not been described.

Aims

To evaluate whether a selective resection algorithm using EMR and ESD, based on real-time optical evaluation, optimizes oncologic outcomes for LNPRPs

Methods

We evaluated the performance of a selective resection algorithm (SRA; 08/2017-04/2021) compared to a universal EMR algorithm (UEA; 07/2008-07/2017) for LNPRPs within a prospective observational study. In the SRA, LNPRPs with features of superficial submucosal invasive cancer (SMIC < 1000μm; S-SMIC; Kudo pit pattern Vi), or with an increased risk of SMIC (Paris 0-Is or 0-IIa+Is non-granular, 0-IIa+Is granular with a dominant nodule ≥ 10mm) underwent ESD. The remaining LNPRPs underwent EMR. Algorithm performance was evaluated by SMIC identified after EMR, curative oncologic resection (R0 resection, S-SMIC, absence of negative histologic features), technical success, adverse events, and recurrence at first surveillance colonoscopy.

Results

480 LNPRPs were evaluated (290 UEA, 190 SRA). Median lesion size was 40mm (IQR 30-60mm). In the SRA, 103 (54.2%) and 87 (45.8%) LNPRPs underwent EMR and ESD, respectively. SMIC was identified in 56 (11.7%) LNPRPs. Significant differences in SMIC after EMR (SRA 1 (1.0%) vs. UEA 35 (12.1%); p = 0.001), curative oncologic resection (SRA 7 (33.3%) vs. UEA 2 (5.7%); p = 0.010), and recurrence (SRA 2 (1.6%) vs. UEA 40 (17.2%); p < 0.001) were identified. No significant differences in technical success or adverse events were identified (all p > 0.137). Among potentially curable malignant LNPRPs which underwent ESD, 100% (7/7) were cured.

Conclusions

A SRA optimizes oncologic outcomes for LNPRPs and mitigates the risk of piecemeal resection of cancers.

Funding Agencies

The Cancer Institute of New South Wales provided funding for a research nurse and data manager to assist with the administration of the study. Neal Shahidi was supported by the University of British Columbia Clinician Investigator Program. There was no influence from either institution regarding study design or conduct, data collection, management, analysis, interpretation, preparation, review, or approval of the manuscript.

Efficacy of mupirocin, neomycin and octenidine for nasal Staphylococcus aureus decolonisation: a retrospective cohort study

BACKGROUND

Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive Staphylococcus aureus (MSSA) is the most frequent organism, and the majority are endogenous. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI.

METHODS

Our hospital prospectively collected data on our MSSA decolonisation programme since 2013, including; all MSSA carriers, treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used.

RESULTS

During the study period 15,958 primary hip and knee replacements were performed. 3200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1210 neomycin and 1221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P < 0.0001). There was no difference in PJI rates (P = 0.452).

CONCLUSIONS

Mupirocin and neomycin are more effective than octenidine at MSSA decolonisation. There was poor correlation between the MSSA status after treatment (on day of surgery) and PJI rates. Further research is needed to compare alternative MSSA decolonisation treatments.

Comparison of Kjeldahl Method for Determination of Crude Protein in Cereal Grains and Oilseeds with Generic Combustion Method: Collaborative Study

Seven laboratories participated in a collaborative study to extend the applicability of the AOAC generic combustion method for determination of crude protein in animal feed (990.03) to include determination in cereal grains and oilseeds. In the study, method 990.03 was compared with the AOAC mercury catalyst Kjeldahl method for determination of protein in grains (979.09) and crude protein in animal feed (954.01). The study also evaluated the effect on the results of fineness of grind. For determination of crude protein in grains and oilseeds by the combustion method, standard deviations for repeatability and reproducibility ranged from 0.10 to 0.37 and from 0.25 to 0.54, respectively, and relative standard deviations for repeatability and reproducibility ranged from 0.77 to 2.57% and from 1.24 to 3.15%, respectively. The combustion method was adopted first action by AOAC International for determination of crude protein in cereal grains and oilseeds containing 0.2- 20% nitrogen.

Weight loss and frequency of body-weight self-monitoring in an online commercial weight management program with and without a cellular-connected 'smart' scale: a randomized pilot study

Objective

Evaluate the effects of an online commercial weight management program, with and without provision of a 'smart' scale with instructions to weigh daily and weekly tailored feedback, on weight loss and the frequency of body-weight self-monitoring.

Methods

Participants (N = 92; body mass index 27-40 kg/m²) were randomized to 6 months of no-cost access to the Weight Watchers Online (WWO) platform alone, or enhanced with a cellular-connected 'smart' scale, instructions to weigh daily and weekly pre-scripted email feedback (Weight Watchers Online Enhanced [WWO-E]). The number of days that weight was self-monitored (via 'smart' scale in WWO-E and manually in WWO) was recorded automatically across the 6-month trial. Objective weight was measured at baseline, 3 and 6 months.

Results

While both groups achieved statistically significant weight loss, mean ± standard error weight loss did not differ between WWO-E and WWO at 3 months (5.1 ± 0.6 kg vs. 4.0 ± 0.7 kg, respectively; p = 0.257) or 6 months (5.3 ± 0.6 kg vs. 3.9 ± 0.7 kg, respectively; p = 0.116). However, a greater proportion of WWO-E lost ≥5% of initial body weight at 3 months (52.2% vs. 28.3%; p = 0.033), but not 6 months (43.5% vs. 30.4%; p = 0.280), compared with WWO. Mean ± standard deviation days with self-monitored weight was higher in WWO-E (80.5 ± 5.6; 44.7% of days) than WWO (12.0 ± 1.0; 6.7% of days; p < 0.001) across the 6-month study period.

Conclusions

This is the first study to show that provision of a 'smart' scale with weekly tailored feedback substantially increased the frequency of self-weighing and the proportion of participants achieving an initial clinically significant ≥5% weight loss (52% vs. 28%) in an online commercial weight management program. Both WWO and WWO-E produced significant weight loss over 6 months. While mean weight losses were slightly greater in the enhanced group, the difference was not statistically significant in this small sample. This study provides support for the clinical utility of online commercial weight management programs and the potential for supporting technology such as 'smart' scales to improve adherence to body-weight self-monitoring and clinical outcomes.

Effects of fluoroquinolone restriction (from 2007 to 2012) on resistance in Enterobacteriaceae: interrupted time-series analysis

BACKGROUND

Antibiotic stewardship is a key component in the effort to reduce healthcare-associated infections.

AIM

To describe the implementation and analyse the impact of fluoroquinolone restriction on resistance in Enterobacteriaceae, focusing on urinary isolates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, which were historically almost universally resistant to fluoroquinolones.

METHODS

ESBL-producing E. coli hospital and community isolates, obtained between April 2009 and March 2012 from consecutive non-duplicate urine samples, were included in an interrupted time-series analysis based on a Poisson distribution model. Periods before and after fluoroquinolone restriction were compared. The trend in fluoroquinolone resistance in all urinary isolates of Enterobacteriaceae (N ≈ 20,000 per year) and blood culture isolates of E. coli (N ≈ 350) between 2009 and 2013 were also analysed.

FINDINGS

A large decline in the percentage of ciprofloxacin-resistant ESBL-producing urinary E. coli isolates was observed in both hospital (risk ratio: 0.473; 95% confidence interval: 0.315-0.712) and community settings (0.098; 0.062-0.157). The decline was also marked in all urinary isolates of Enterobacteriaceae and E. coli isolates from blood cultures.

CONCLUSION

We conclude that reducing fluoroquinolone usage to a level of ≤2 defined daily doses per 100 occupied bed-days in hospital sufficiently removed selection pressure to allow resistant Enterobacteriaceae – specifically, the UK endemic strains of ESBL-producing E. coli – to revert back to fluoroquinolone susceptibility within a short span of four months. This was accompanied with a concomitant reduction in overall ESBL burden.

A group-specific sequencing approach to investigate the presence of atypical human leucocyte antigen alleles

Accurate human leucocyte antigen (HLA) typing results are essential in determining the degree of compatibility between donor and recipient in both solid organ (SO) and hematopoietic stem cell (HSC) transplantation. Current HLA typing methodologies can generate ambiguous results which may need resolving. This group-specific sequencing approach allowed investigation into the presence of the low expressor HLA-A*24:02:01:02L allele and the rare HLA-A*02:64 allele in a SO transplant recipient and a HSC transplant recipient, respectively. Locus-specific amplification of HLA-A was performed. Exons 2 and 3 were sequenced in both directions followed by group-specific sequencing to resolve ambiguities. Hemizygous sequence data of intron 2 generated from the HLA-A*24 allele indicated the presence of the HLA-A*24:02:01:01 allele. HLA-A*02:64 was identified by sequencing the allele in isolation over exons 2 and 3 and allowed confirmation of this allele sequence with the IMGT/HLA database (Accession number AY297166). This approach is cost efficient and can be modified to sequence alleles at other HLA loci. It has also been adapted to characterize the novel HLA-DQB1*06:48 allele (Accession number HE647646) as well as the non-HLA gene, UGT2B17, making it a useful tool to augment existing typing methodologies.

Evaluation of satraplatin in dogs with spontaneously occurring malignant tumors

BACKGROUND

Satraplatin is the 1st orally bioavailable platinum anticancer drug.

OBJECTIVE

Our objectives were to evaluate efficacy in vitro against a canine cancer cell line, to determine the maximally tolerated dose (MTD) of satraplatin in tumor-bearing dogs, to identify the dose-limiting and other toxicities in dogs, and to record pharmacokinetics (PK).

ANIMALS

Dogs with macro- or microscopic malignant neoplasia.

METHODS

D17 canine osteosarcoma cells first were evaluated in a clonogenic survival assay. Then, dogs with a diagnosis of malignant neoplasia were prospectively entered in standard 3 + 3 cohorts. Additional patients were entered at the MTD to assess efficacy. Total and free platinum (by ultrafiltrate) concentrations were determined with inductively coupled plasma mass spectroscopy.

RESULTS

Satraplatin inhibited clonogenic survival in vitro at clinically relevant and achievable concentrations. Twenty-three dogs were treated, 14 with PK evaluation. The MTD was 35 mg/m(2)/d for 5 days, repeated every 3-4 weeks. Bioavailability was 41%. PK variables (mean ± SD) at the MTD included T(max) 1.8 (± 0.7) hours, C(max) 72 (± 26) ng/mL, area under concentration (AUC)(0-24 h) 316 (± 63) h × ng/mL, and MRT 7 (± 1.3) hours. Higher AUC after the 5th versus the 1st dose suggested drug accumulation. Interestingly, platelets consistently reached nadir sooner than did neutrophils (day 14 versus 19). Myelosuppression was dose-limiting and gastrointestinal toxicity was mild.

CONCLUSIONS AND CLINICAL IMPORTANCE

Satraplatin was well tolerated in tumor-bearing dogs, thus warranting further investigation in a phase II trial.

Can pre-operative skin marking transfer methicillin-resistant Staphylococcus aureus between patients?

National guidelines state that in patients undergoing operations the site of the procedure should be marked. In clinical practice the same marker is used repeatedly. We are not aware of any investigation regarding the theoretical risk of transferring organisms such as methicillin-resistant Staphyloccocus aureus (MRSA) between patients by a skin marker.

In an experimental setting, Penflex and Viomedex skin markers were tested 30 times each after contaminating them with a standard inoculum of MRSA. The survival of the organism on the tip of the markers was assessed by culture on MRSA-indicator nutrient agar plates at 0, 5, 15 and 60 minutes, 24 and 48 hours and at 1, 2, and 3 weeks after contamination.

There was a significant difference between the markers, with the Penflex showing no survival of MRSA after 15 minutes whereas the Viomedex product continued to produce MRSA cultures for up to three weeks.

Outbreak of Pseudomonas aeruginosa folliculitis associated with a swimming pool inflatable

On 18 February 2002, the Communicable Disease Unit was notified by the local Public Health Service Laboratory of a child with a positive skin swab for Pseudomonas aeruginosa. This child had attended the local swimming pool and played on an inflatable, subsequently presenting to a Primary Care Nurse Practitioner with folliculitis. A total of 35 cases was identified during the outbreak. This paper describes a case-control study and microbiological sampling of the cases, the suspected inflatable and a survey of 10 swimming pool inflatables in the local area. The odds ratio for developing folliculitis following use of the inflatable was 12 (95% CI 1.05-136.80). The strain of P. aeruginosa found on the inflatable was identical to that obtained from skin swabs of cases. Nine of 10 (90%) of the inflatables sampled were colonized by P. aeruginosa. Attention should be given to the problem of routine decontamination of swimming pool inflatables. P. aeruginosa folliculitis needs to be considered in the differential diagnosis of skin rashes in children, especially in Primary Care.

Impact of demographic and medical factors on satisfaction with life after spinal cord injury: a normative study

OBJECTIVE

The aim of this study was (1) to examine demographic and medical predictors of the Satisfaction With Life Scale (SWLS) among individuals with spinal cord injury (SCI) and (2) to provide a normative table for the SWLS that includes appropriate adjustments for the most important predictors of life satisfaction.

STUDY DESIGN

We examined predictors of the SWLS including age, education, sex, race, injury duration, number of rehospitalizations, marital status, employment status, SCI etiology, and level of neurological impairment.

PARTICIPANTS

Individuals in the National Spinal Cord Injury Statistical Center database [from 18 SCI model systems (1995-1999)] undergoing follow-up assessment were included for study.

OUTCOME MEASURE

Satisfaction With Life Scale.

RESULTS

Univariate analyses indicated that marital and employment status, race, sex, education, and injury duration were significant factors associated with scores on the SWLS. In general, individuals who were female, white, married, and currently employed and had a higher education and longer injury duration reported significantly higher scores on the SWLS (P < .01). Effect-size estimates for these factors ranged from 0.16 to 0.41. Regression analyses showed that education, employment status, and injury duration were the strongest unique predictors of satisfaction with life but accounted for only 10% of the variance.

CONCLUSION

The SWLS is a global measure of life satisfaction and is relatively unrelated to demographic and medical characteristics. Normative tables are provided for epidemiologic comparison.

Treatment of canine hemangiopericytomas with photodynamic therapy

BACKGROUND AND OBJECTIVES

Canine hemangiopericytomas are a commonly occurring neoplasm with a clinical course of recurrence after surgical removal. This study sought to evaluate Photochlor (HPPH) photodynamic therapy (HPPH-PDT) as an adjuvant therapy to prevent recurrence of tumor after surgical removal.

STUDY DESIGN/MATERIALS AND METHODS

Sixteen dogs with naturally occurring hemangiopericytomas were treated with surgical removal of the tumor followed by PDT using Photochlor as the photosensitizer. Photochlor was injected intravenously at a dose of 0.3 mg/kg. Forty-eight hours later the treatment consisted of surgical removal of the tumor followed by HPPH-PDT.

RESULTS

Nine dogs (56%) had recurrence of tumor from 2 to 29 (median 9) months after treatment. These results are comparable or not as good as other forms of therapy.

CONCLUSIONS

Photochlor photodynamic therapy applied after surgery appears to have no advantage over other forms of therapy in regards to preventing recurrence. Delayed wound healing and infections are problematic and make HPPH-PDT an undesirable addition to surgery for the treatment of this tumor type.

The effects of HDV-insulin on carbohydrate metabolism in Type 1 diabetic patients

The aim of this study was to compare the metabolic effects of a single equimolar subcutaneous injection of hepatic directed vesicle-insulin (HDV-insulin) and regular insulin on glucose levels and intermediary metabolism during a 75-g oral glucose tolerance test (OGTT). Nine Type 1 diabetic patients underwent two experiments separated by 4 weeks. Each experimental protocol consisted of an identical evening meal followed by overnight euglycemic control achieved by a continuous low-dose insulin infusion. The next morning a subcutaneous injection (0.1 U/kg) of HDV-insulin or regular insulin was administered 30 min before a 75-g OGTT. The overnight basal insulin infusion was maintained unaltered throughout the 150-min OGTT. Plasma glucose, glucoregulatory hormones (insulin, glucagon, cortisol), and intermediary metabolites (lactate, alanine, glycerol, NEFA, beta-hydroxybutyrate) were measured to assess the metabolic effects of the two insulin preparations. Compared to regular insulin, an equivalent subcutaneous dose of HDV-insulin significantly lowered glucose levels during OGTT (mean reduction 2.2+/-0.4 mmol/l; P<.005). Plasma levels of insulin and glucagon were equivalent during both series of experiments. Blood lactate, glycerol and plasma NEFA levels were not different during OGTT indicating similar peripheral action of the insulins. beta-Hydroxybutyrate levels were significantly reduced (P<.05) following HDV-insulin supporting a preferential hepatic action of the preparation. We conclude that HDV-insulin can significantly lower plasma glucose excursions compared to an equivalent dose of regular insulin during an OGTT in Type 1 diabetic patients. The metabolic profile of equivalent peripheral insulin, glucagon and glycerol levels but reduced beta-hydroxybutyrate values support a hepatospecific effect of HDV-insulin.

Sexual dimorphism in counterregulatory responses to hypoglycemia after antecedent exercise

After antecedent hypoglycemia, counterregulatory responses to subsequent hypoglycemia exhibit greater blunting in men than in women. Because physical exercise and hypoglycemia share multiple counterregulatory mechanisms, we hypothesized that prior exercise may also result in gender-specific blunting of counterregulatory responses to subsequent hypoglycemia. Thirty healthy subjects (15 women and 15 men; age, 28 +/- 3 yr; body mass index, 23 +/- 1 kg/m2) were studied during 2-d experiments. Day 1 consisted of either identical 90-min morning and afternoon cycle exercise at 50% maximum oxygen expenditure or two 2-h episodes of hyperinsulinemic euglycemia. Day 2 consisted of a 2-h morning hyperinsulinemic-hypoglycemic clamp. Endogenous glucose production was measured using [3-(3)H]glucose. Muscle sympathetic nerve activity was measured using microneurography. Day 2 insulin (540 +/- 36 pmol/liter) and plasma glucose (2.9 +/- 0.06 pmol/liter) levels were similar in men and women during the last 30 min of hypoglycemia. Compared with antecedent euglycemia, d 1 exercise produced significant blunting of d 2 counterregulatory responses to hypoglycemia. Several key d 2 counterregulatory responses were blunted to a greater extent in men than in women: glucagon (men, -105 +/- 14; women, -25 +/- 7 ng/liter; P < 0.0001), epinephrine (men, -2625 +/- 257 pmol/liter; women, -212 +/- 573; P < 0.001), norepinephrine (men, -0.50 +/- 0.12 nmol/liter; women, -0 +/- 0.11; P < 0.001), and muscle sympathetic nerve activity (men, -13 +/- 4; women, -4 +/- 4 bursts/min; P < 0.01). Cardiovascular responses (heart rate and systolic and mean arterial blood pressures) were also more blunted by antecedent exercise in men than in women. After d 1 exercise, the amount of glucose infused during d 2 hypoglycemia in men was increased 6-fold compared with that after d 1 euglycemia. This amount was significantly increased (P < 0.01) compared with the 2-fold (P < 0.01) increment in glucose infusion that was required in women after d 1 exercise. Lipolysis was unaffected by d 1 exercise in women, but was significantly blunted during d 2 hypoglycemia in men. In summary, two bouts of prolonged, moderate exercise (90 min at 50% maximum oxygen expenditure) induced a marked sexual dimorphism in key neuroendocrine (glucagon, catecholamines, and muscle sympathetic nerve activity) and metabolic (glucose kinetic, lipolysis) responses to next day hypoglycemia.

Effect of morning exercise on counterregulatory responses to subsequent, afternoon exercise

The aim of this study was to determine whether a bout of morning exercise (EXE(1)) can alter neuroendocrine and metabolic responses to subsequent afternoon exercise (EXE(2)) and whether these changes follow a gender-specific pattern. Sixteen healthy volunteers (8 men and 8 women, age 27 +/- 1 yr, body mass index 23 +/- 1 kg/m(2), maximal O(2) uptake 31 +/- 2 ml x kg(-1) x min(-1)) were studied after an overnight fast. EXE(1) and EXE(2) each consisted of 90 min of cycling on a stationary bike at 48 +/- 2% of maximal O(2) uptake separated by 3 h. To avoid the confounding effects of hypoglycemia and glycogen depletion, carbohydrate (1.5 g/kg body wt po) was given after EXE(1), and plasma glucose was maintained at euglycemia during both episodes of exercise by a modification of the glucose-clamp technique. Basal insulin levels (7 +/- 1 microU/ml) and exercise-induced insulin decreases (-3 microU/ml) were similar during EXE(1) and EXE(2). Plasma glucose was 5.2 +/- 0.1 and 5.2 +/- 0.1 mmol/l during EXE(1) and EXE(2), respectively. The glucose infusion rate needed to maintain euglycemia during the last 30 min of exercise was increased during EXE(2) compared with EXE(1) (32 +/- 4 vs. 7 +/- 2 micromol x kg(-1) x min(-1)). Although this increased need for exogenous glucose was similar in men and women, gender differences in counterregulatory responses were significant. Compared with EXE(1), epinephrine, norepinephrine, growth hormone, pancreatic polypeptide, and cortisol responses were blunted during EXE(2) in men, but neuroendocrine responses were preserved or increased in women. In summary, morning exercise significantly impaired the body's ability to maintain euglycemia during later exercise of similar intensity and duration. We conclude that antecedent exercise can significantly modify, in a gender-specific fashion, metabolic and neuroendocrine responses to subsequent exercise.

Effects of antecedent prolonged exercise on subsequent counterregulatory responses to hypoglycemia

In the present study the hypothesis tested was that prior exercise may blunt counterregulatory responses to subsequent hypoglycemia. Healthy subjects [15 females (f)/15 males (m), age 27 +/- 1 yr, body mass index 22 +/- 1 kg/m(2), hemoglobin A(Ic) 5.6 +/- 0.5%] were studied during 2-day experiments. Day 1 involved either 90-min morning and afternoon cycle exercise at 50% maximal O2 uptake (VO2(max)) (priorEXE, n = 16, 8 m/8 f) or equivalent rest periods (priorREST, n = 14, 7 m/7 f). Day 2 consisted of a 2-h hypoglycemic clamp in all subjects. Endogenous glucose production (EGP) was measured using [3-3H]glucose. Muscle sympathetic nerve activity (MSNA) was measured using microneurography. Day 2 insulin (87 +/- 6 microU/ml) and plasma glucose levels (54 +/- 2 mg/dl) were equivalent after priorEXE and priorREST. Significant blunting (P < 0.01) of day 2 norepinephrine (-30 +/- 4%), epinephrine (-37 +/- 6%), glucagon (-60 +/- 4%), growth hormone (-61 +/- 5%), pancreatic polypeptide (-47 +/- 4%), and MSNA (-90 +/- 8%) responses to hypoglycemia occurred after priorEXE vs. priorREST. EGP during day 2 hypoglycemia was also suppressed significantly (P < 0.01) after priorEXE compared with priorREST. In summary, two bouts of exercise (90 min at 50% VO2(max)) significantly reduced glucagon, catecholamines, growth hormone, pancreatic polypeptide, and EGP responses to subsequent hypoglycemia. We conclude that, in normal humans, antecedent prolonged moderate exercise blunts neuroendocrine and metabolic counterregulatory responses to subsequent hypoglycemia.

Effects of morning hypoglycemia on neuroendocrine and metabolic responses to subsequent afternoon hypoglycemia in normal man

There is general agreement that prior hypoglycemia blunts subsequent hypoglycemic counterregulatory responses. However, there is considerable debate concerning the timing and number of prior hypoglycemic episodes required to cause this blunting effect. The aim of this study was to determine whether one episode of hypoglycemia could modify neuroendocrine, metabolic, and symptom responses to hypoglycemia induced 2 h later. A total of 24 (12 male and 12 female) young, healthy, overnight-fasted subjects participated in a series of glucose clamp studies. A total of 16 individuals underwent 2 randomized studies of either identical 2-h morning and afternoon hyperinsulinemic (490 +/- 60 pmol/L) hypoglycemia (2.9 +/- 0.1 mmol/L) separated by 2 h or, at least 2 months later, 2-h morning and afternoon hyperinsulinemic (492 +/- 45 pmol/L) euglycemia (5.1 +/- 0.1 mmol/L). A total of 8 other subjects participated in a single experiment that consisted of 2-h morning hyperinsulinemic (516 +/- 60 pmol/L) euglycemia (5.1 +/- 0.1 mmol/L) and 2-h afternoon hyperinsulinemic (528 +/- 66 pmol/L) hypoglycemia (2.9 +/- 0.1 mmol/L) also separated by 2 h. Morning hypoglycemia significantly (P < 0.01) reduced (33-55%) the responses of epinephrine, norepinephrine, glucagon, GH, cortisol, and pancreatic polypeptide during afternoon hypoglycemia. Hypoglycemic symptoms (primarily neuroglycopenic) were also significantly (P < 0.01) reduced during afternoon hypoglycemia. Plasma glucose, insulin, nonesterified fatty acids, glycerol, lactate, beta-hydroxybutyrate (P < 0.01), GH, and cortisol (P < 0.05) levels were significantly increased at the start of afternoon hypoglycemia following morning hypoglycemia. Morning hypoglycemia created an insulin-resistant state during afternoon hypoglycemia. Despite blunted neuroendocrine responses, glucose infusion rates required to maintain hypoglycemia and increases in glucose oxidation were significantly attenuated during afternoon compared with morning hypoglycemia. This was in marked contrast to euglycemic control experiments where glucose infusion rates and nonoxidative glucose disposal were significantly increased during afternoon relative to morning studies. We conclude that in normal man one episode of prolonged, moderate, morning hypoglycemia can produce substantial blunting of neuroendocrine and symptomatic responses to subsequent near-term hypoglycemia, and the induction of posthypoglycemic insulin resistance can compensate for blunted neuroendocrine responses by limiting glucose flux and specifically glucose oxidation during subsequent near-term hypoglycemia.

Clinical assessment of a chemosensitivity assay as a treatment planning tool for dogs with cancer

This study evaluated the clinical utility of a commercially available chemosensitivity assay. In the first part of the study, tumor tissues from dogs with various malignancies were tested, and the dogs were treated with a mitoxantrone/cyclophosphamide combination protocol. Tumor response was evaluated and compared to the predicted response. Assay results were not a significant predictor of clinical response to chemotherapy or of survival time. In the second part of the study, assay results were used to direct therapy in dogs with refractory lymphoma. There was no significant correlation (p equals 0.323) between predicted response and case outcome.

Effects of differing durations of antecedent hypoglycemia on counterregulatory responses to subsequent hypoglycemia in normal humans

The aim of this study was to determine whether the duration of antecedent hypoglycemia regulates the magnitude of subsequent counterregulatory failure. A total of 31 lean healthy overnight-fasted individuals (16 men/15 women) were studied. There were 15 subjects (8 men/7 women) who underwent two separate 2-day randomized experiments separated by at least 2 months. On day 1, 2-h hyperinsulinemic (9 pmol x kg(-1) x min(-1)) euglycemic (5.2 +/- 0.1 mmol/l) or hypoglycemic (2.9 +/- 0.1 mmol/l) glucose clamps (prolonged hypoglycemia) were carried out in the morning and afternoon. Of the other subjects, 16 participated in a 2-day study in which day 1 consisted of morning and afternoon short-duration hypoglycemia experiments (hypoglycemic nadir of 2.9 +/- 0.1 mmol for 5 min), and 10 of these individuals underwent an additional 2-day study in which day 1 consisted of morning and afternoon intermediate-duration hypoglycemia (hypoglycemic nadir of 2.9 +/- 0.1 mmol for 30 min). The next morning (day 2) all subjects underwent an additional 2-h hyperinsulinemic-hypoglycemic clamp (2.9 +/- 0.1 mmol/l). The rate of fall of glucose (0.07 mmol/min) was carefully controlled during all hypoglycemic studies so that the glucose nadir was reached at 30 min. Despite equivalent day 2 plasma glucose and insulin levels, there were significant differences in counterregulatory physiological responses. Steady-state epinephrine, glucagon, growth hormone, cortisol, and pancreatic polypeptide levels were similarly significantly blunted (P < 0.01) by the differing duration day 1 hypoglycemia compared with day 1 euglycemia. Muscle sympathetic nerve activity and endogenous glucose production were also similarly blunted (P < 0.01) by day 1 hypoglycemia (relative to day 1 euglycemia). Day 2 hypoglycemic symptoms were significantly reduced (P < 0.01) after day 1 prolonged intermediate- but not short-duration hypoglycemia. In summary, two episodes of short-duration moderate hypoglycemia can produce significant blunting of key neuroendocrine and metabolic counterregulatory responses. Hypoglycemic symptom scores are reduced by prolonged but not short-duration prior hypoglycemia. We conclude that in healthy overnight fasted humans, 1) neuroendocrine, autonomic nervous system, and metabolic counterregulatory responses are sensitive to the blunting effects of even short-duration prior hypoglycemia, and 2) the duration of antecedent hypoglycemia results in a hierarchy of blunted physiological responses with hypoglycemic symptom awareness less vulnerable than neuroendocrine responses.

Dosimetric effects of patient displacement and collimator and gantry angle misalignment on intensity modulated radiation therapy

PURPOSE AND OBJECTIVE

The primary goal of this study was to examine systematically the dosimetric effect of small patient movements and linear accelerator angular setting misalignments in the delivery of intensity modulated radiation therapy. We will also provide a method for estimating dosimetric errors for an arbitrary combination of these uncertainties.

MATERIALS AND METHODS

Sites in two patients (lumbar-vertebra and nasopharynx) were studied. Optimized intensity modulated radiation therapy treatment plans were computed for each patient using a commercially available inverse planning system (CORVUS, NOMOS Corporation, Sewickley, PA). The plans used nine coplanar beams. For each patient the dose distributions and relevant dosimetric quantities were calculated, including the maximum, minimum, and average doses in targets and sensitive structures. The corresponding dose volumetric information was recalculated by purposely varying the collimator angle or gantry angle of an incident beam while keeping other beams unchanged. Similar calculations were carried out by varying the couch indices in either horizontal or vertical directions. The intensity maps of all the beams were kept the same as those in the optimized plan. The change of a dosimetric quantity, Q, for a combination of collimator and gantry angle misalignments and patient displacements was estimated using Delta=Sigma(DeltaQ/Deltax(i))Deltax(i). Here DeltaQ is the variation of Q due to Deltax(i), which is the change of the i-th variable (collimator angle, gantry angle, or couch indices), and DeltaQ/Deltax(i) is a quantity equivalent to the partial derivative of the dosimetric quantity Q with respect to x(i).

RESULTS

While the change in dosimetric quantities was case dependent, it was found that the results were much more sensitive to small changes in the couch indices than to changes in the accelerator angular setting. For instance, in the first example in the paper, a 3-mm movement of the couch in the anterior-posterior direction can cause a 38% decrease in the minimum target dose or a 41% increase in the maximum cord dose, whereas a 5 degrees change in the &theta;(1)=20 degrees beam only gave rise to a 1.5% decrease in the target minimum or 5.1% in the cord maximum. The effect of systematic positioning uncertainties of the machine settings was more serious than random uncertainties, which tended to smear out the errors in dose distributions.

CONCLUSIONS

The dose distribution of an intensity modulated radiation therapy (IMRT) plan changes with patient displacement and angular misalignment in a complex way. A method was proposed to estimate dosimetric errors for an arbitrary combination of uncertainties in these quantities. While it is important to eliminate the angular misalignment, it was found that the couch indices (or patient positioning) played a much more important role. Accurate patient set-up and patient immobilization is crucial in order to take advantage fully of the technological advances of IMRT. In practice, a sensitivity check should be useful to foresee potential IMRT treatment complications and a warning should be given if the sensitivity exceeds an empirical value. Quality assurance action levels for a given plan can be established out of the sensitivity calculation.

Treatment of canine oral squamous cell carcinomas with photodynamic therapy

Eleven dogs with naturally occurring oral squamous cell carcinomas were treated with photodynamic therapy (PDT) using Photochlor (HPPH) as the photosensitizer. The largest length of the tumours measured in a two-dimensional plane ranged from 0.9 to 6.8 cm. Seven of the tumours invaded underlying bone as determined by radiograph appearance. Photochlor was injected intravenously at a dose of 0.3 mg kg(-1). Forty-eight hours later the tumours were treated. Tumours with a surface to base depth of greater than 1 cm were surgically reduced to less than 1 cm. Irradiation with 665 nm light with an energy density of 100 J cm(-2) was administered. Eight dogs were considered cured with no tumour recurrence for at least 17 months after treatment. Local treatment of oral squamous cell carcinomas with PDT appears to give results similar to those obtained with surgical removal of large portions of the mandible or maxilla. The cosmetic results with PDT are superior to those of radical surgical removal. The new sensitizer, Photochlor, appears effective for oral squamous carcinomas with results similar to those reported for other sensitizers.

IgA myeloma of donor origin arising 7 years after allogeneic renal transplant

We report the case of a 38-year-old man who developed IgA myeloma of donor origin 7 years after allogeneic renal transplant. The diagnosis of multiple myeloma was unequivocal and based on positive results from serum electrophoresis, skeletal survey and bone marrow investigations. The donor origin of the myeloma cells was confirmed by DNA fingerprinting. We believe this is the first reported case of disseminated multiple myeloma of donor origin developing after allogeneic renal transplant and, as such, gives some insight into the natural history and biology of the disease.

Tryptophan hydroxylase polymorphisms in suicide victims

Both environmental and genetic factors appear to contribute to the risk for suicide. The serotonergic system has been implicated in depression, impulsivity and suicidality. Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in the synthesis of serotonin. Suicide has been associated with polymorphisms in intron 7 of the TPH gene. These alleles were studied in samples from 47 deceased Caucasian males as part of the Utah Youth Suicide Study. A 918 base pair fragment spanning the region of interest was amplified. The A218C polymorphism was visualized by restriction fragment length polymorphism (RFLP) and the A779C was sequenced. Neither A218C nor A779C appeared to be associated with suicide in this population. These results did not change when the sample was stratified by age (10-21 years, 22-31 years) or when violent suicides were selected. The complexity of the phenotype of suicide may reflect multiple biological and social etiologic factors, and poses a worthy challenge for genetic studies.

Effects of gender on neuroendocrine and metabolic counterregulatory responses to exercise in normal man

Significant, sexual dimorphisms exist in counterregulatory responses to commonly occurring stresses, such as hypoglycemia, fasting, and cognitive testing. The question of whether counterregulatory responses differ during exercise in healthy men and women remains controversial. The aim of this study was to determine whether a sexual dimorphism exists in neuroendocrine, metabolic, or cardiovascular responses to prolonged moderate exercise. Sixteen healthy (eight men and eight women) subjects matched for age (28+/-2 yr), body mass index (22+/-1 kg/m2), nutrient intake, and spectrum of physical fitness were studied in a randomized fashion during 90 min of exercise on a cycle ergometer at 80% of their anaerobic threshold (approximately 50% VO2 max). Respiratory quotient and oxygen consumption relative to body weight were identical in men and women. Glycemia was equated (5.3+/-0.2 mmol/L) during exercise via an exogenous glucose infusion. Gender had significant effects on counterregulatory responses during exercise. Arterialized epinephrine (1.05+/-0.2 vs. 0.45+/-0.04 nmol/L), norepinephrine (9.2+/-1.1 vs. 5.8+/-1.1 nmol/L), and pancreatic polypeptide (52+/-6 vs. 37+/-6 pmol/L) were significantly (P<0.01) increased in men compared to women, respectively. Plasma glucagon, cortisol, and GH levels responded similarly in men and women. Insulin values were higher at baseline in men and fell by a greater amount to reach similar levels during exercise compared to those in women. Endogenous glucose production, measured with [3-3H]glucose was similar in men and women. Carbohydrate oxidation was significantly increased in men relative to women (21.2+/-2 vs. 15.6+/-2 mg/kg fat free mass x min; P<0.05). Despite reduced sympathetic nervous system (SNS) drive, lipolytic responses were increased in women. Arterialized blood glycerol (215+/-30 vs. 140+/-20 micromol/L), beta-hydroxybutyrate (54+/-9 vs. 25+/-10 micromol/L), and plasma nonesterified fatty acids (720+/-56 vs. 469+/-103 micromol/L) were significantly (P<0.01) increased in women. In keeping with increased SNS activity, systolic blood pressure and mean arterial pressure were significantly increased (P<0.01) in men. In summary, this study demonstrates that a significant sexual dimorphism exists in neuroendocrine, metabolic, and cardiovascular counterregulatory responses to prolonged moderate exercise in man. We conclude that during exercise, men have increased autonomic nervous system (epinephrine, norepinephrine, pancreatic polypeptide), cardiovascular (systolic, mean arterial pressure) and certain metabolic (carbohydrate oxidation) counterregulatory responses, but that women have increased lipolytic (glycerol, nonesterified fatty acids) and ketogenic (beta-hydroxybutyrate) responses. Women may compensate for diminished SNS activity during exercise by increased lipolytic responses.

Effects of antecedent hypoglycemia on subsequent counterregulatory responses to exercise

Antecedent hypoglycemia can blunt counterregulatory responses to subsequent hypoglycemia. It is uncertain, however, if prior hypoglycemia can blunt counterregulatory responses to other physiologic stresses. The aim of this study, therefore, was to determine whether antecedent hypoglycemia attenuates subsequent neuroendocrine and metabolic responses to exercise. Sixteen lean, healthy adults (eight men and eight women, ages 28+/-2 years, BMI 22+/-1 kg/m2, VO2max 43+/-3 ml x kg(-1) x min(-1)) were studied during 2-day protocols on two randomized occasions separated by 2 months. On day 1, subjects underwent morning and afternoon 2-h hyperinsulinemic (528+/-30 pmol/l) glucose clamp studies of 5.3+/-0.1 mmol/l (euglycemic control) or 2.9+/-0.1 mmol/l (hypoglycemic study). On day 2, subjects underwent 90 min of exercise on a static cycle ergometer at 80% of their anaerobic threshold (approximately 50% VO2max). Glycemia was equated during day 2 exercise studies via an exogenous glucose infusion. Day 1 hypoglycemia had significant effects on neuroendocrine and metabolic responses during day 2 exercise. The usual exercise-induced reduction in insulin, together with elevations of plasma epinephrine, norepinephrine, glucagon, growth hormone, pancreatic polypeptide, and cortisol levels, was significantly blunted after day 1 hypoglycemia (P<0.01). Commensurate with reduced neuroendocrine responses, key metabolic counterregulatory mechanisms of endogenous glucose production (EGP), lipolytic responses, and ketogenesis were also significantly attenuated (P<0.01) after day 1 hypoglycemia. Significantly greater rates of glucose infusion were required to maintain euglycemia during exercise after day 1 hypoglycemia compared with day 1 euglycemia (8.8+/-2.2 vs. 0.6+/-0.6 micromol x kg(-1) x min(-1); P<0.01). During the first 30 min of exercise, day 1 hypoglycemia had little effect on EGP, but during the latter 60 min of exercise, day 1 hypoglycemia was associated with a progressively smaller increase in EGP compared with day 1 euglycemia. Thus, by 90 min, the entire exercise-induced increment in EGP (8.8+/-1.1 micromol x kg(-1) x min(-1)) was abolished by day 1 hypoglycemia. We conclude that 1) antecedent hypoglycemia results in significant blunting of essential neuroendocrine (glucagon, insulin, catecholamines) and metabolic (endogenous glucose production, lipolysis, ketogenesis) responses to exercise; 2) antecedent hypoglycemia may play a role in the pathogenesis of exercise-related hypoglycemia in type 1 diabetic patients; and 3) antecedent hypoglycemia can blunt counterregulatory responses to other physiologic stresses in addition to hypoglycemia.

Development of CPR security using impact analysis

The HIPAA regulations will require that institutions ensure the prevention of unauthorized access to electronically stored or transmitted patient records. This paper discusses a process for analyzing the impact of security mechanisms on users of computerized patient records through "behind the scenes" electronic access audits. In this way, those impacts can be assessed and refined to an acceptable standard prior to implementation. Through an iterative process of design and evaluation, we develop security algorithms that will protect electronic health information from improper access, alteration or loss, while minimally affecting the flow of work of the user population as a whole.

Predicting community reintegration after spinal cord injury from demographic and injury characteristics

OBJECTIVE

To determine the influence of demographic and injury characteristics on the community reintegration of people with spinal cord injury (SCI).

DESIGN

Prospective cross-sectional and longitudinal examination of individuals with SCI.

SETTING

Follow-up of individuals at 1, 2, 5, 10, 15, and 20 years after SCI who received their initial rehabilitation in a Regional Model Spinal Cord Injury System.

PARTICIPANTS

A total of 3,835 individuals who met the inclusion criteria for the National SCI Database were studied cross-sectionally, and a subset of 347 individuals who were also enrolled in a longitudinal study of aging with SCI.

MAIN OUTCOME MEASURES

Subscales of the Craig Handicap Assessment and Reporting Technique (CHART).

RESULTS

Neurologic classification, age, years postinjury, gender, ethnicity, and education explain 29% of the variance in physical independence, 29% of the variance in mobility, 28% of the variance in occupation. 9% of the variance in social integration, and 18% of the variance in economic self-sufficiency.

CONCLUSIONS

Although these factors are inadequate to explain most of the variation in community reintegration (handicap) after SCI, they might appropriately be used to adjust for case-mix differences when comparing rehabilitation facilities and techniques.

Access to the environment and life satisfaction after spinal cord injury

OBJECTIVE

To determine the potential relation between satisfaction with life after spinal cord injury and access to the environment as measured by selected items from the Craig Handicap Assessment and Reporting Technique (CHART).

DESIGN

Prospective, correlational/predictive study using cross-sectional and longitudinal data from 18 Model Spinal Cord Injury Systems of Care.

SUBJECTS

Adult persons with traumatic-onset spinal cord injury (n = 650) evaluated at 1 or 2 years postinjury.

OUTCOME MEASURE

Satisfaction With Life Scale (SWLS).

PREDICTOR VARIABLES

Demographic characteristics, impairment and disability classifications. medical complications, rehabilitation insurance status, occupational status as measured by the CHART Occupation Scale, self-perceived health (from SF-36), and access to the environment as measured by items from the CHART Mobility Scale.

RESULTS

Access to the environment was positively and linearly associated with satisfaction with life, demonstrated both positive and negative change over time, and was positively associated with subject's neurologic status. Access to the environment added to the explanatory model to predict life satisfaction even after all other independent measures were accounted for.

CONCLUSION

Access to the environment (an "outside the person" factor) is important in predicting satisfaction with life for persons with spinal cord injury. The measure of access to the environment developed here is promising and worthy of further exploration and expansion.

Serum distemper virus and parvovirus antibody titers among dogs brought to a veterinary hospital for revaccination

OBJECTIVE

To determine serum canine distemper virus (CDV) and canine parvovirus (CPV) antibody titers in healthy dogs brought to a veterinary hospital for revaccination.

DESIGN

Case series.

ANIMALS

122 dogs.

PROCEDURE

Serum antibody titers were measured by means of hemagglutination inhibition (CPV titers) or serum neutralization (CDV titers) at the time dogs were brought to the hospital for revaccination. All dogs had been vaccinated between 271 and 1,665 days previously. Dogs were grouped by age, breed (purebred vs mixed breed), sex, and weight to determine whether these factors were associated with antibody titers. Serum CPV titers > or = 1:80 and serum CDV titers > or = 1:96 were considered protective.

RESULTS

Breed, sex, and weight were not significantly associated with serum CPV and CDV titers. Age was significantly associated with CPV titer, with younger dogs having higher titers, but was not associated with CDV titer. Thirty-three of 122 (27%; 95% confidence interval, 19.0 to 34.9%) dogs had a less-than-protective CPV titer. Twenty-five of 117 (21%; 95% confidence interval, 13.6 to 28.4%) dogs had a less-than-protective CDV titer.

CLINICAL IMPLICATIONS

Results suggest that, on the basis of serum antibody titers, the current practice of annual revaccination of dogs against CPV and CDV infection should be maintained. Measurement of antibody titers to determine whether revaccination is truly needed would seem justifiable in those dogs that have previously had an adverse reaction to vaccination.

Advances in total hip arthroplasty

Total hip arthroplasty is an operative procedure in which the diseased and destroyed hip joint is resected and replaced with a new bearing surface. Since its introduction into the surgical management of the arthritic hip in the early 1960s, total hip arthroplasty has helped alleviate the suffering of millions of patients throughout the world. Patients with coxarthrosis can now look to total hip arthroplasty as a reliable means of pain relief and improved function. While the operation has been successful over the years, problems have manifested themselves as the length of follow-up has increased. As total hip arthroplasty approaches its fourth decade of use, we outline these problems and the proposed solutions.

Body dissatisfaction as a mediator of the relationship between dietary restraint and bulimic eating patterns

The present study was designed to test whether dietary restraint mediates the relationship between body dissatisfaction and bulimic eating patterns in a sample of 172 university females. Contrary to what was expected the results showed that body dissatisfaction mediated the relationship between dietary restraint and bulimic patterns of eating. Thus the results highlight the primary importance of body dissatisfaction as a predictor of bulimic behavior. Body dissatisfaction encompasses a broad array of dimensions such as self-perceptions, cognitions, affect and behavior and it carries enormous explanatory power but its different components remain largely unexplored.

Early protection of puppies against canine parvovirus: a comparison of two vaccines

Client-owned puppies randomly were assigned to receive one of two commercially available polyvalent vaccines. The response to the parvovirus portion of each vaccine was evaluated by determining antibody titers by hemagglutination inhibition. Significant differences were found between titers produced by the vaccines. Puppies vaccinated with one of the products had a more desirable result as demonstrated by a protective antibody titer after the first vaccination (p of 0.005), a protective antibody titer at a younger age (p of 0.02), a protective antibody titer by 12 weeks of age (p of 0.001), and a protective antibody titer by 16 weeks of age (p of 0.05). Puppies vaccinated with this product also had significantly higher titers at each sampling after vaccination.

Geometric evaluation of mandibular distraction

In planning mandibular distraction, the deficiency of the vertical ramus and body is measured. The position of the pin placement is evaluated by the following formula: [formula: see text] This is more accurately presented by the new formula. [formula: see text] In one patient the original formula evaluated the pin placement angle to be 9.94, compared with 9.92, in the more accurate but more complex new formula. When the gonial angle is obtuse, the difference is small. When the gonial angle is more acute, as in a normal gonial angle for a 2-year-old child--134 degrees--the difference is still only 0.1 degree. The original formula is simpler to use and is accurate enough for clinical use in mandibular distraction. The distraction distance is not the sum of the vertical ramal deficiency plus the body deficiency but is given by the following formula: [formula: see text] It would be accurate enough to plan the total distraction distance to be less than the sum of the two distances. The more acute the gonial angle is, the less the distraction distance will need to be.

Predicting depression and psychological distress in persons with spinal cord injury based on indicators of handicap

This study examined whether experiences of handicap influence levels of depression and distress among persons with spinal cord injury (SCI) during the years after initial discharge from rehabilitation. SCI outpatients (163), who had received inpatient treatment at one of two rehabilitation centers in Michigan and who were between 2 to 7 years since injury, participated in the study. Measures of depression, of psychological distress and of handicap were collected during 2 consecutive years utilizing the Zung Self-Rating Scale, the Brief Symptom Inventory and the Craig Handicap Assessment and Reporting Technique (CHART) in conjunction with the Perceived Handicap Questionnaire (PHQ), respectively. According to the study's findings, depressed/distressed SCI subjects reported spending more hours in bed (P < 0.01), fewer days out of the house (P < 0.03) and receiving more paid personal care assistance (P < 0.02) than did other subjects. They also expended more for general medical expenses (P < 0.001) and reported less access to readily available transportation (P < 0.003). CHART total scores, reflecting a simple objective measure of handicap as described by Whiteneck et al. (Whiteneck GG, Charlifue SW, Gerhart KA, Overholser JD, Richardson GN: Guide for Use of the CHART: Craig Handicap Assessment and Reporting Technique. Craig Hospital, CO, 1988) were significantly associated with both distress and depression as measured during the second year of data collection. Other significant predictors of depression and distress included subjects' self-perceived handicap (measured by the PHQ), gender, marital status and age.(ABSTRACT TRUNCATED AT 250 WORDS)

Coping with the late effects: differences between depressed and nondepressed polio survivors

This study examined differences between depressed and nondepressed individuals with a history of paralytic poliomyelitis in terms of demographics, health status and coping strategies. The prevalence of distress and depression in this group of 116 polio survivors was determined. Subjects completed the Brief Symptom Inventory, the Coping with Disability Inventory and a questionnaire concerning their polio histories and self-perceptions of health. Medical assessments were performed by physicians. Only 15.8% of the sample had scores indicating depression and elevated distress. Depressed/distressed polio survivors were more likely to: be living alone, be experiencing further health status deterioration, seek professional help, view their health as poor, report greater pain, be less satisfied with their occupational status and their lives in general and exhibit poorer coping outcome behaviors in relation to their disability. Three factors in coping with the late effects of polio were identified through a factor analysis of the Coping with Disability Inventory: positive self-acceptance, information seeking/sharing about the disability and social activism. Differences between depressed/distressed and other polio survivors were found across these three factors, with depressed/distressed subjects having significantly lower coping scores. These and other results are discussed.

Location of the second steroid-binding site on the glucocorticoid receptor

The ability of nonradioactive progesterone to accelerate the dissociation of tritiated dexamethasone from the agonist-binding site of the glucocorticoid receptor was used as a probe for the existence of a second antagonist steroid site. The goal was to evaluate if this second site was on the glucocorticoid receptor and, if so, on what region of that protein. The magnitude of acceleration of dissociation was assessed during purification of the receptor as well as with the untransformed (multimeric), transformed (monomeric), and mero-receptor. In each preparation progesterone caused a statistically significant increase in the rate of agonist dissociation. The documentation of acceleration of dissociation during purification suggests that progesterone one is interacting with a site on the glucocorticoid receptor and not with another protein. Evidence for the second binding site was found using each form of the receptor, untransformed, transformed, and mero-receptor, suggesting that the second binding site resides on the steroid-binding domain of the receptor which is on the carboxy-terminus, topographically close to the agonist-binding site.

Myocardial infarction complicating cardiovascular stress testing with normal coronary arteriography

A patient with normal coronary arteriography who experienced a non-Q myocardial infarction is described. The temporal relationship of ischemic symptoms, ECG changes, and rise in creatine phosphokinase (CPK) support a relationship to an exercise treadmill test.

Glucocorticoid receptor regulation: the effects of adrenalectomy, exogenous glucocorticoid, and stress on hepatic receptor number in male and female mice

Although glucocorticoids are known to regulate their own receptor number, the physiologic significance of this process is not known. In order to assess this process in intact animals the effects of adrenalectomy, stress, and exogenous glucocorticoid on the number of hepatic glucocorticoid receptors in Swiss-Webster mice were evaluated. In males 24 hr after adrenalectomy there was a clear 2- to 2.5-fold increase (upregulation) in glucocorticoid receptor number. Conversely, 24 hr after the ip administration of exogenous corticosterone there was a clear downregulation of receptor number. In each case (upregulation and downregulation) female mice were much less responsive than males. Three stressors were used to evaluate the effect of the endogenous secretion of glucocorticoids on downregulation. Male mice were exposed to ether, vibration, and confinement either once or daily for periods up to 3 days. Animals were sacrificed 24 hr after the last stress and hepatic receptor number was compared to an unstressed control. Cytosolic receptor number was not influenced by any of these stimuli. It is concluded that although glucocorticoids clearly regulate glucocorticoid receptor number, as demonstrated by adrenalectomy and the administration of steroids to adrenalectomized animals, the physiologic significance of this process is uncertain as receptor number does not appear to be changed by stimuli of adrenal glucocorticoids in the intact animal.