Safety and tolerability of transcranial magnetic and direct current stimulation in children: Prospective single center evidence from 3.5 million stimulations

BACKGROUND

Non-invasive brain stimulation is being increasingly used to interrogate neurophysiology and modulate brain function. Despite the high scientific and therapeutic potential of non-invasive brain stimulation, experience in the developing brain has been limited.

OBJECTIVE

To determine the safety and tolerability of non-invasive neurostimulation in children across diverse modalities of stimulation and pediatric populations.

METHODS

A non-invasive brain stimulation program was established in 2008 at our pediatric, academic institution. Multi-disciplinary neurophysiological studies included single- and paired-pulse Transcranial Magnetic Stimulation (TMS) methods. Motor mapping employed robotic TMS. Interventional trials included repetitive TMS (rTMS) and transcranial direct current stimulation (tDCS). Standardized safety and tolerability measures were completed prospectively by all participants.

RESULTS

Over 10 years, 384 children underwent brain stimulation (median 13 years, range 0.8-18.0). Populations included typical development (n = 118), perinatal stroke/cerebral palsy (n = 101), mild traumatic brain injury (n = 121) neuropsychiatric disorders (n = 37), and other (n = 7). No serious adverse events occurred. Drop-outs were rare (<1%). No seizures were reported despite >100 participants having brain injuries and/or epilepsy. Tolerability between single and paired-pulse TMS (542340 stimulations) and rTMS (3.0 million stimulations) was comparable and favourable. TMS-related headache was more common in perinatal stroke (40%) than healthy participants (13%) but was mild and self-limiting. Tolerability improved over time with side-effect frequency decreasing by >50%. Robotic TMS motor mapping was well-tolerated though neck pain was more common than with manual TMS (33% vs 3%). Across 612 tDCS sessions including 92 children, tolerability was favourable with mild itching/tingling reported in 37%.

CONCLUSIONS

Standard non-invasive brain stimulation paradigms are safe and well-tolerated in children and should be considered minimal risk. Advancement of applications in the developing brain are warranted. A new and improved pediatric NIBS safety and tolerability form is included.

The JAK inhibitor tofacitinib suppresses synovial JAK1-STAT signalling in rheumatoid arthritis

Objective

Tofacitinib is an oral Janus kinase (JAK) inhibitor for the treatment of rheumatoid arthritis (RA). The pathways affected by tofacitinib and the effects on gene expression in situ are unknown. Therefore, tofacitinib effects on synovial pathobiology were investigated.

Methods

A randomised, double-blind, phase II serial synovial biopsy study (A3921073; NCT00976599) in patients with RA with an inadequate methotrexate response. Patients on background methotrexate received tofacitinib 10 mg twice daily or placebo for 28 days. Synovial biopsies were performed on Days -7 and 28 and analysed by immunoassay or quantitative PCR. Clinical response was determined by disease activity score and European League Against Rheumatism (EULAR) response on Day 28 in A3921073, and at Month 3 in a long-term extension study (A3921024; NCT00413699).

Results

Tofacitinib exposure led to EULAR moderate to good responses (11/14 patients), while placebo was ineffective (1/14 patients) on Day 28. Tofacitinib treatment significantly reduced synovial mRNA expression of matrix metalloproteinase (MMP)-1 and MMP-3 (p<0.05) and chemokines CCL2, CXCL10 and CXCL13 (p<0.05). No overall changes were observed in synovial inflammation score or the presence of T cells, B cells or macrophages. Changes in synovial phosphorylation of signal transducer and activator of transcription 1 (STAT1) and STAT3 strongly correlated with 4-month clinical responses (p<0.002). Tofacitinib significantly decreased plasma CXCL10 (p<0.005) at Day 28 compared with placebo.

Conclusions

Tofacitinib reduces metalloproteinase and interferon-regulated gene expression in rheumatoid synovium, and clinical improvement correlates with reductions in STAT1 and STAT3 phosphorylation. JAK1-mediated interferon and interleukin-6 signalling likely play a key role in the synovial response.

Trial registration number

NCT00976599.

The pulmonary pharmacology of [4-methoxy-N1-(4-trans-nitrooxycyclohexyl)-N3-(3-pyridinylmethyl)-1,3-benzenedicarboxamide] (2NTX-99), an anti-atherotrombotic compound with therapeutic potential in pathological conditions that target lung vasculature

The pharmacological activity of 2NTX-99 ([4-methoxy-N1-(4-trans-nitrooxycyclohexyl)-N3-(3-pyridinylmethyl)-1,3-benzenedicarboxamide]) was investigated in vitro in the intact, rat pulmonary vasculature and in guinea pig airways. Rat lungs were perfused at constant flow and changes in vascular tone recorded. Challenge with the TXA₂ analogue 9,11-dideoxy-9α11α-methanoepoxy ProstaglandinF₂ (U46619, 0.5 μM) increased vessel tone (32.48±1.5 vs 13.13±0.56 mmHg; n=12). 2NTX-99 (0.1-100 μM; n=5), caused a concentration-dependent relaxation, prevented by 1H-[1,2,4]oxadiazolo[4,3,-a]quinoxalin-1-one (ODQ, 10 μM, n=4), an inhibitor of soluble guanylate cyclase. Acetylcholine (0.1-10 μM; n=3) and a reference NO-donor, isosorbide-5-mononitrate (5-100 μM; n=4), were ineffective. Intraluminal perfusion of washed human platelets (2 × 10⁸ cells/ml) increased intravascular pressure after challenge with arachidonic acid (AA, 2 μM; n=5), an increase abolished by acetylsalicylic acid and significantly reduced by 2NTX-99 (40 μM; n=5). TXB₂ in the lung perfusate was detected after platelet activation, 2NTX-99 inhibited TXA₂ synthesis (6.45±0.6 and 1.10±0.2 ng/ml, respectively). 2NTX-99 did not alter central or peripheral airway responsiveness to Histamine (0.001-300 μM; n=6), U46619 (0.001-3 μM, n=3) or LTD₄ (1 pM-1 μM; n=6). 2NTX-99 vasodilates the pulmonary vasculature via the release of nitric oxide (NO) and reduces intraluminal, AA-induced, TXA₂ formation. The combined activity of 2NTX-99 as an NO-donor and a TXA₂-synthesis inhibitor provides strong support for its potential therapeutic use in pathologies of the pulmonary vascular bed (e.g. pulmonary hypertension).

Predictors of growth and body composition in HIV-infected children beginning or changing antiretroviral therapy

OBJECTIVES

The aim of the study was to describe growth and body composition changes in HIV-positive children after they had initiated or changed antiretroviral therapy (ART) and to correlate these with viral, immune and treatment parameters.

METHODS

Ninety-seven prepubertal HIV-positive children were observed over 48 weeks upon beginning or changing ART. Anthropometry and bioelectrical impedance analysis results were compared with results from the National Health and Nutrition Examination Survey 1999-2002 (NHANES) to generate z-scores and with results for HIV-exposed, uninfected children from the Women and Infants Transmission Study (WITS). Multivariate analysis was used to evaluate associations between growth and body composition and disease parameters.

RESULTS

All baseline lean and fat mass measures were below those of controls from NHANES. Weight, height and fat free mass (FFM) index (FFM/height(2)) z-scores increased over time (P = 0.004, 0.037 and 0.027, respectively) and the waist:height ratio z-score decreased (P = 0.045), but body mass index and per cent body fat z-scores did not change. Measures did not increase more than in uninfected WITS controls. In multivariate analysis, baseline height, mid-thigh circumference and FFM z-scores related to CD4 percentage (P = 0.029, P = 0.008 and 0.020, respectively) and change in FFM and FFM index z-scores to CD4 percentage increase (P = 0.010 and 0.011, respectively). Compared with WITS controls, baseline differences in height and mid-thigh muscle circumference were also associated with CD4 percentage. Case-control differences in change in both subscapular skinfold (SSF) thickness and the SSF:triceps skinfold ratio were inversely associated with viral suppression. No measures related to ART class(es) at baseline or over time.

CONCLUSIONS

In these HIV-positive children, beginning or changing ART was associated with improved growth and lean body mass (LBM), as indicated by FFM index. Height and LBM related to CD4 percentage at baseline and over time. Altered fat distribution and greater central adiposity were associated with detectable virus but not ART class(es) received.

A phase II, open-label study of ispinesib (SB-715992) in patients with platinum/taxane refractory or resistant relapsed ovarian cancer

5562

Background: Kinesin spindle protein (KSP) is required for mitotic spindle bipolarity and cell cycle progression. Ispinesib (ISP), a selective KSP inhibitor, blocks assembly of the mitotic spindle leading to cell cycle arrest and cell death. Methods: This was a phase II study to determine the effectiveness of ISP in patients (pts) with platinum/taxane resistant or refractory ovarian cancer. Pts with progression during, or recurrence < 6 months after prior platinum/taxane therapy, ECOG status 0–2, and CA-125 > 40 U/ml were eligible. ISP was given as a 1 hr IV infusion of 18 mg/m2 Q 21 days. A 2-stage Green-Dahlberg design was employed. In Stage I, 20 evaluable pts were enrolled. If there were no CA-125 responses (Rustin criteria), the study was to be stopped. If > 1 CA-125 responses were seen, 15 more pts were to be enrolled in Stage 2. Overall response was defined by pts who achieved both CA-125 and RECIST criteria. Results: 22 pts with carboplatin/taxane resistant (9) or refractory disease (13) were enrolled: median age = 63 (43–80); 21 were Caucasian; median no. of cycles = 2 (1 - >16). All pts were evaluable for CA-125 assessment. The best CA-125 response was SD in 10 pts (45%); 12 pts had PD (55%). The best radiographic response was a confirmed PR lasting > 30 weeks in one pt who also met CA-125 progression criteria (5%); 5 pts (26%) had SD; and 13 pts (68%) had PD. The most common AEs, in decreasing order, were neutropenia, fatigue, anemia, leukopenia, thrombocytopenia, diarrhea, nausea, vomiting, and decreased appetite. The most frequent Gr 3/4 AE was neutropenia. Conclusions: This study was terminated after Stage I as the CA-125 response criterion to progress to Stage II was not met. One confirmed radiographic partial response was observed. ISP was well tolerated with an acceptable safety profile.

No significant financial relationships to disclose.

Unexpected relationship between plasma protein binding and the pharmacodynamics of 2-NAP, a CCK1-receptor antagonist

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT?: * Two chemically diverse CCK1 receptor antagonists have been shown clinically to inhibit CCK-evoked contraction of human gallbladder [2, 3]. These studies have not examined the relationship between plasma concentration and effect, the latter usually considered to be predictive from the free drug concentration [8]. * We wanted to examine our novel CCK1 receptor antagonist in this validated model and also to explore its PK-PD relationship.

WHAT THIS STUDY ADDS

* 2-NAP inhibited CCK-evoked human gallbladder contraction in vivo but at a plasma free concentration that was, in theory, too low to have achieved adequate CCK1 receptor occupancy. * The study serves as a caveat to the assumption that free plasma concentration can be used to predict pharmacological effect.

AIMS

To study the pharmacokinetics and pharmacodynamics of 2-NAP (2-naphthalenesulfonyl-L-aspartyl-(2-phenethyl)amide), a selective CCK1 receptor antagonist in healthy volunteers.

METHODS

2-NAP was given to 12 healthy male volunteers in an ascending dose, safety and PK phase 1a study by 1 h i.v. infusion (0.6-9.6 mg kg(-1) h(-1)). A further 12 healthy male volunteers received i.v. CCK-8S (6.25 pmol kg(-1) h(-1)) to produce gallbladder contraction, measured by ultrasound recordings of gallbladder volume, and the effect of concurrent i.v. 2-NAP administration was studied. Plasma protein binding in vitro and ex vivo was measured by ultrafiltration and by equilibrium dialysis.

RESULTS

2-NAP was generally well tolerated, displayed linear pharmacokinetics and a very high degree of plasma protein binding (99.9%). A 105 min i.v. CCK-8S infusion induced a reduction in gallbladder volume of 14.9 (+/-7.0) ml during placebo co-infusion and this was reduced to 2.4 (+/-5.9) ml when 2-NAP was co-infused with CCK-8S (P = 0.00024, paired t-test, mean change 12.5 ml; 95% CI For mean 7.4, 18.3 ml). This extent of inhibition was consistent with a 2-NAP total plasma concentration of 36 microm, but when protein binding corrections were made, the 'free concentration' of 2-NAP was only 0.04 microm, a value much less than the average equilibrium dissociation constant of 2-NAP for human CCK1 receptors ( approximately 0.7 microm).

CONCLUSIONS

The pharmacological effect of a drug is usually considered to be determined by its free concentration. However, the complete inhibition of CCK-8S-evoked gallbladder contraction by a free plasma concentration of 0.04 microm 2-NAP was much greater than would have been predicted from simple drug-receptor occupancy theory and cautions against the general use of free concentration of drug for predicting pharmacological effect.

Health information privacy and syndromic surveillance systems

The development of syndromic surveillance systems to detect potential terrorist-related outbreaks has the potential to be a useful public health surveillance activity. However, the perception of how the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule applies to the disclosure of certain public health information might affect the ability of state and local health departments to implement syndromic surveillance systems within their jurisdictions. To assess this effect, a multiple-question survey asked respondents to share their experiences regarding patient confidentiality and HIPAA Privacy Rule requirements when implementing syndromic surveillance systems. This assessment summarizes the results of a national survey of state terrorism-preparedness coordinators and state epidemiologists and reflects the authors' and others' experiences with implementation.

Acquisition of CD80 (B7-1) by T cells

Activation of T cells usually requires two signals. Signal 1 is mediated via a peptide-MHC on the APC; signal 2 is mediated via a costimulatory molecule on the APC surface. We demonstrate here that naive CD4(+) T cells actually acquire the costimulatory molecule CD80 (B7-1) from syngeneic APCs after activation. This phenomenon was demonstrated showing acquisition of CD80 by T cells from CD80/CD86 (B7-2) knockout mice, and by treating T cells with cyclohexamide to further rule out endogenous expression of CD80 by T cells. Moreover, no CD80 mRNA could be detected in T cells that had acquired CD80. The amount of acquisition of CD80 by T cells was shown to be directly related to both the strength of signal 1 and the amount of CD80 on the APC. Specificity of this acquisition was also shown by the lack of acquisition by T cells from CD28 knockout mice (implicating CD28 in this process), the lack of acquisition of CD40 (another molecule on the APC surface) by T cells, and confocal microscopy studies. We demonstrate for the first time that 1) naive T cells, following acquisition of CD80 from APCs, were themselves shown to be capable of acting as APCs; and 2) memory T cells that have acquired CD80 from APCs undergo apoptosis in the presence of increased levels of signal 1. Thus we demonstrate both immunostimulatory and immunoregulatory functions as a result of CD80 acquisition by different T cell populations.

The metabolism of native and randomized butterfat chylomicrons in the rat is similar

Reportedly, randomly rearranging the position of fatty acids (FA) in butterfat triacylglycerol (TAG) by interesterification, thereby lowering the proportion of saturated FA in the sn-2 position, reduces its hypercholesterolemic and hypertriglyceridemic properties when fed to humans. The aim of this work was to determine if these reductions in plasma cholesterol and TAG could be explained by an improved rate of clearance from the plasma of chylomicrons composed of randomized butterfat, using a rat model. Acute chylomicron clearance studies demonstrated no differences in fractional clearance rates of cholesteryl esters and TAG from the plasma of rats infused with chylomicrons produced from gastric feeding of either native (NBF) or randomized (RBF) butterfat. Although there was a 14% decrease in the level of saturated FA occupying the sn-2 position of TAG in RBF compared with NBF, this difference became negligible (approximately 5%), following digestion of the fat and subsequent repackaging of TAG into chylomicrons. These observations suggest that the previously observed reduction in hypercholesterolemic properties of randomized butterfat in rat is unlikely to be explained by improved clearance of chylomicron TAG.

Clinicopathologic variables predictive of residual dysplasia after cervical conization

OBJECTIVE

To evaluate the clinicopathologic variables that are important for predicting residual dysplasia after cervical conization or the loop electroexcisional procedure.

STUDY DESIGN

A retrospective review of 80 cases was performed on patients with squamous dysplasia in the conization specimen, endocervical curettage (ECC) performed immediately after resection, margin status reported by the pathologist and adequate postprocedure follow-up.

RESULTS

Twelve patients had residual dysplasia. No case progressed to invasive carcinoma. A multivariate analysis was performed with presence or absence of residual dysplasia as the dependent variable and patient age, type of procedure (cold knife conization or loop excision), grade of dysplasia, margin status and ECC status as independent variables. Margin status was the strongest predictor of residual disease, followed by ECC status. Patient age had a minimal association with persistence. Of the 12 patients with residual dysplasia, 11 had a positive margin, and 8 had a positive ECC. Only 38% of patients with a positive margin had residual disease, but 67% with a positive margin and ECC had residual dysplasia.

CONCLUSION

Margin status and ECC are useful in predicting residual dysplasia after conization.

The enemy within: diarrheal rates among British and Australian troops in Iraq

British and Australian medical teams working in Northern Iraq in 1991 providing primary care to refugees and the war wounded were subjected to a descriptive retrospective survey, 5 weeks after arriving in Iraq. The aim was to document different rates of diarrhea in British and Australian troops. The British, who were not taking daily doxycycline and did not enforce a plate- and hand-washing routine, experienced higher rates of diarrhea (69% of British troops compared with 36% of Australian troops), which was more severe and of a longer duration (p < 0.001) and resulted in twice as many days being lost (p < 0.001) in spite of the British team being half the size of the Australian contingent, and the region having enteropathogens with a high rate of antibiotic resistance. Vigorous hand- and plate-washing routines along with doxycycline prophylaxis appear to significantly reduce incapacitation from diarrhea in this military setting and have an important implication for operational effectiveness.

Ontogeny of copepod predation in juvenile squid (Loligo opalescens)

Copepods are the major prey of juvenile squid, and small species of squid such as Loligo opalescens face a great challenge in catching these erratically moving crustaceans. We studied the ontogeny of copepod predation in laboratory-reared animals and found that mastery of copepod capture develops progressively, starting shortly after hatch with strong attacks of a simple type. Modifications of the initial basic attack lead to more specialized strategies that effectively extend the range of capture to both longer and shorter distances. This progression culminates, by approximately 40 days post-hatching, in adult-like prey capture behavior involving tentacle extension and retraction. Squid raised exclusively on easily captured Artemia nauplii and introduced to a copepod diet 40 days after hatching displayed only basic attack behavior, characteristic of very young squid. All of these attacks were unsuccessful, and very few of these animals survived the transition. Copepod capture thus appears to be a skill that must be acquired in an experience-dependent manner early in post-hatching life.

Managing diversity in the health care industry: a conceptual model and an empirical investigation

Between 1985 and 2000, 8 out of every 10 new entrants to the work force will be minorities, immigrants, or women. If the U.S. health care industry has to retain a competitive edge, it will have to effectively attract and manage the diverse talent that will characterize its new work force. This article analyzes the authors' cultural awareness survey results and suggests a strategic model for managing diversity in the health care industry.

Differential utilization of eicosapentaenoic acid and docosahexaenoic acid in human plasma

It has recently been shown that the omega 3 fatty acid status in humans can be predicted by the concentration of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids in plasma phospholipids [Bjerve, K.S., Brubakk, A.M., Fougner, K.J., Johnsen, H., Midjthell, K., and Vik, T. (1993) Am. J. Clin. Nutr., in press]. In countries with low intake of omega 3 fatty acids, the level of EPA in plasma phospholipids is often only about one-fifth the concentration of DHA. The purpose of this study was to investigate whether this difference in the concentration of these two fatty acids was due to a selective loss of EPA relative to DHA or to a lower dietary intake of EPA. Seven female volunteers ingested four grams of MaxEPA daily for 2 wk and in the following 4 wk they ate a diet almost completely devoid of the long-chain omega 3 fatty acids. The concentrations of the omega 3 fatty acids in the plasma cholesteryl esters, triglycerides and phospholipids and the high density lipoprotein phospholipids were examined at weekly intervals throughout the study. There was a more rapid rise in the concentration of EPA than in DHA levels in the supplementation period in all lipid fractions, but there was a disproportionate rise in DHA relative to EPA in the plasma lipids compared with the ratio in the supplement. In the depletion phase there was a rapid disappearance of EPA from all fractions, such that pre-trial levels were reached by one week post-supplementation.(ABSTRACT TRUNCATED AT 250 WORDS)

Case report: myiasis--the botfly boil

Cutaneous furunculoid myiasis arises from the infestation of skin or mucous membranes with dipterous larvae. Myiasis from the botfly Dermatobia hominis is a common parasitic disease of the tropics of Central and South America, and may present in the United States. With increasing travel by U.S. citizens, there is potential for increased occurrence; it is important to be able to accurately diagnose myiasis and differentiate it from entities with similar presentations, such as leishmaniasis. The authors describe four cases of myiasis from D. hominis infestation and review clinical features, differential diagnosis, and treatment.

Appraisal of the clinical value of serotoninergic drugs

Principal objectives in obesity management comprise the prevention of weight gain, the promotion of weight loss, and the treatment of obesity-related complications, including diabetes, hypertension, and depression. Serotonin agonists reduce food intake. The resultant weight loss is variable and there appears to be no way of predicting good responders, nor is there evidence that additional weight loss attributable to drug therapy is sustained once treatment is discontinued, although nonpharmacological strategies for preventing weight regain are worthy of exploration. Serotonin agonists are of clinical value if there is a short-term need for weight reduction or if long-term pharmacotherapy can be justified. This implies that sometimes the dangers of the obese state outweigh the potential hazards of drug treatment. Clearly, if the same agent also improves diabetic control, blood pressure, or depression then a longer term usage is more readily justified. The extent to which this may be achieved by the currently available 5-HT agonists is discussed.

Clinical trial of the Norton Scale in acute care settings

This study investigated the effect of using Norton Scale assessment data in the nursing care of patients at risk of developing pressure ulcers. The results indicated that incorporating the Norton Scale in care planning resulted in benefits to patients through earlier and more effective nursing interventions.

Synthesis and bioevaluation of a rapidly biodegradable tissue adhesive: 1,2-isopropylidene glyceryl 2-cyanoacrylate

A rapidly biodegradable tissue adhesive, 1,2-isopropylidene glyceryl 2-cyanoacrylate, was synthesized and characterized by NMR. Bond strength was determined. Three types of corresponding polymers were prepared and evaluated for in vitro and in vivo toxicity. The polymers were generally found to be in the moderately toxic and toxic groups similar to the lower alkyl 2-cyanoacrylates.

Synthesis and bioevaluation of alkyl 2-cyanoacryloyl glycolates as potential soft tissue adhesives

A series of alkyl 2-cyanoacryloyl glycolate tissue adhesives were synthesized and characterized by NMR. Physical properties and bond strengths are presented. Within the series, bond strength decreased with increasing molecular weight. Corresponding polymers were evaluated by in vitro and in vivo techniques for biocompatibility. In general, in vitro biocompatibility increased with molecular weight. Based on in vitro and in vivo results, the isobutyl and isoamyl derivatives gave polymers that were most biocompatible, however, the entire series was found to be less reactive than poly(methyl 2-cyanoacrylate) and only the isopropyl derivative polymers more reactive than poly(isobutyl 2-cyanoacrylate). Approximately one-third of the isobutyl polymer biodegraded in vivo after 6 weeks.

Impaired 6-phosphofructokinase activity in mononuclear leukocytes from patients with type II diabetes mellitus

Seven cytoplasmic enzyme activities were measured in extracts of mononuclear leukocytes (lymphocytes plus monocytes) obtained from 19 type II diabetic humans and 10 healthy control subjects. 6-Phosphofructokinase activity was significantly decreased in cell extracts from diabetics, while other enzyme activities were similar in diabetics and controls. Since the effects of starvation on enzyme activities are sometimes similar to the effects of diabetes, the studies were repeated in 5 control subjects after a 2-day fast. This short period of starvation did not mimic the effect of diabetes on 6-phosphofructokinase activity. The decreased enzyme activity was not correlated with percent specific insulin binding to monocytes in the same cell preparations nor to clinical variables such as obesity or the broad range of fasting plasma glucose values encountered among the diabetics. We conclude that 6-phosphofructokinase activity in mononuclear leukocytes, as in other tissues, may be a marker for a postreceptor lesion associated with the insulin resistance found in type II diabetes mellitus.

Refinement of a surgical technique using angulated needle holders and surgical instruments

Surgical techniques can be refined and dexterity improved by using angulated needle holders and instruments. This allows the surgeon to place his or her hand in the position of function while suturing either retrograde or antegrade, thus permitting flexion, extension, abduction, adduction, pronation and supination with circumduction to occur without restriction. Under normal circumstances abduction, pronation and extension are limited by anatomic factors, such as the greater mulitangular abutting the longer styloid process of the radius and the stronger ulnar collateral ligament restricting abduction. The chief indication for using angulated needle holders is in retrograde suturing, such as placing posterior row sutures in anastomosing blood vessels, intestine and the ureter. These instruments are not substitutes for straight needle holders but are chiefly an adjunct that permit the surgeon to perform movements with his hand at the wrist joint that are not allowed with the use of straight needle holders which require greater torque in performing operative procedures. They allow better exposure by improving visibility to the area being sutured since the surgeon is not looking down the barrel of the needle holder and has a clear unobstructed view. The instruments permit clamping and suturing of tissues and vessels in small deep wounds that do not readily admit nonangulated hemostats and needle holders, such as those in urologic and gynecologic operations. Instrument tying is easily accomplished because of the short shaft of the instrument, especially in plastic or surface surgical procedures. Furthermore, with angulation, one is able to grasp the needle holder between the thumb and volar aspect of the second and third digits, thus allowing easy retrograde movements that one experiences in grasping a thumb forceps. From the standpoint of medical egonometrics, hand fatigue is reduced since the needle holder does not have to be locked by closing the rings and engaging the serations each time the needle is handed to the surgeon for placement of sutures.

Anomalous glucose and insulin responses in patients with insulinoma. Caveats for diagnosis

Two patients with insulinomas had unusual glucose and insulin-secretory dynamics in response to prolonged fasting. In patient 1, low insulin values persisted throughout three separate supervised fasts without a steady rise in the insulin-glucose ratio. In patient 2, a rising insulin-glucose ratio during a fast returned to normal after a documented catecholamine surge following a transient hypoglycemic episode. While patient 1 had clearly elevated proinsulin values of 52% to 57%, patient 2 had a near-normal value of 23%. The diagnosis of an insulinoma can usually be made by obtaining simultaneous glucose and insulin values during a prolonged supervised fast. Rarely, however, anomalous results may be obtained during supervised fasts of patients with insulinoma, and a broader range of diagnostic tests will be required to establish the correct diagnosis.

Sternal safety blade for median or transverse sternotomy

Sternal safety blades are useful for splitting the sternum in approaching the anterior, superior, or middle mediastinum for the removal of lesions of the thymus, exploration of parathyroid adenomas, removal of large substernal thyroids, open heart procedures, and traumatic chest injuries. One of the chief indications for using the safety blade is in patients undergoing second open heart procedures, since the anterior mediastinum is markedly reduced in size, thus making the heart and great vessels vulnerable to injury.

Keeping appointments with clinical psychologists

Over a six-month period records were kept of appointment keeping by out-patients attending clinical psychologists. Background information was recorded. Approximately 20 per cent of appointments were cancelled or broken, and in a further 6 per cent patients arrived late. Compliance was significantly but not strongly related to sex, social class, marital and family factors, transport, diagnosis and amount of previous attendance. Patients who missed the first appointment were very likely to miss the second. The results were consistent with previous findings and suggestions are made for further investigation.

New, improved nasogastric duodenal mercury tip sump tube for use in the management of intestinal obstruction

A new, improved nasogastric duodenal mercury tip sump tube can be introduced simply and efficiently and is especially useful in the management of patients with partial and complete mechanical obstruction, thus sparing the patient surgical intervention and expensive hospitalization.

Gastro-intestinal helminths in white-tailed deer (Odocoileus virginianus) of Illinois

Two deer populations, one in northern Illinois the other in southern Illinois, were examined by necropsy (n = 44 and 40 respectively) for helminth parasites of the gastro-intestinal tract and abdominal cavity. Both herds were parasitized by Apteragia odocoilei, Haemonchus contortus, Gongylonema pulchrum, Setaria yehi, Trichuris ovis, and Moniezia benedeni. Nematodirus sp. was found only in deer of northern Illinois. Ostertagia mossi, Capillaria sp., Cooperia sp., and Oesophagostomum sp. were found only in deer of southern Illinois.