Surgical outcomes after radioactive 125I seed versus hookwire localization of non-palpable breast cancer: a multicentre randomized clinical trial

BACKGROUND

Previous studies have suggested improved efficiency and patient outcomes with 125I seed compared with hookwire localization (HWL) in breast-conserving surgery, but high-level evidence of superior surgical outcomes is lacking. The aim of this multicentre pragmatic RCT was to compare re-excision and positive margin rates after localization using 125I seed or hookwire in women with non-palpable breast cancer.

METHODS

Between September 2013 and March 2018, women with non-palpable breast cancer eligible for breast-conserving surgery were assigned randomly to preoperative localization using 125I seeds or hookwires. Randomization was stratified by lesion type (pure ductal carcinoma in situ (DCIS) or other) and study site. Primary endpoints were rates of re-excision and margin positivity. Secondary endpoints were resection volumes and weights.

RESULTS

A total of 690 women were randomized at eight sites; 659 women remained after withdrawal (125I seed, 327; HWL, 332). Mean age was 60.3 years in the 125I seed group and 60.7 years in the HWL group, with no difference between the groups in preoperative lesion size (mean 13.2 mm). Lesions were pure DCIS in 25.9 per cent. The most common radiological lesion types were masses (46.9 per cent) and calcifications (28.2 per cent). The localization modality was ultrasonography in 65.5 per cent and mammography in 33.7 per cent. The re-excision rate after 125I seed localization was significantly lower than for HWL (13.9 versus 18.9 per cent respectively; P = 0.019). There were no significant differences in positive margin rates, or in specimen weights and volumes.

CONCLUSION

Re-excision rates after breast-conserving surgery were significantly lower after 125I seed localization compared with HWL. Registration number: ACTRN12613000655741 (http://www.ANZCTR.org.au/).

Pseudo-Outbreak ofLegionella pneumophilaSerogroup 8 Infection Associated With a Contaminated Ice Machine in a Bronchoscopy Suite

Objective.

To investigate the marked increase noted over an 8-month period in the number ofLegionella pneumophilaisolates recovered from bronchoalveolar lavage fluid specimens obtained during bronchoscopy in our healthcare system.

Setting.

Bronchoscopy suite that serves a 580-bed tertiary care center and a large, multisite, faculty practice plan with approximately 2 million outpatient visits per year.

Methods.

Cultures of environmental specimens from the bronchoscopy suite were performed, including samples from the air and water filters, bronchoscopes, and the ice machine, with the aim of identifyingLegionellaspecies. Specimens were filtered and acid-treated and then inoculated on buffered charcoal yeast extract agar. Serogrouping was performed on all isolates recovered from patient and environmental samples.

Results.

AUL. pneumophilaisolates recovered from patients were serogroup 8, a serogroup that is not usually recovered in our facility. An epidemiologic investigation of the bronchoscopy suite revealed the ice machine to be contaminated withL. pneumophilaserogroup 8. Patients were exposed to the organism as a result of a recently adopted practice in the bronchoscopy suite that involved directly immersing uncapped syringes of sterile saline in contaminated ice baths during the procedures. At least 1 patient was ill as a result of the pseudo-outbreak. Molecular typing of isolates recovered from patient and environmental samples revealed that the isolates were indistinguishable.

Conclusions.

Extensive cleaning of the ice machine and replacement of the machine's water filter ended the pseudo-outbreak. This episode emphasizes the importance of using aseptic technique when performing invasive procedures, such as bronchoscopies. It also demonstrates the importance of reviewing procedures in all patient areas to ensure compliance with facility policies for providing a safe patient environment.

Glagov remodeling of the atherosclerotic aorta demonstrated by cardiovascular magnetic resonance: the CORDA asymptomatic subject plaque assessment research (CASPAR) project

BACKGROUND

Aortic atherosclerosis and coronary artery disease (CAD) are closely linked. Early detection of aortic atherosclerosis with the adoption of appropriate preventive measures may therefore help to reduce mortality and morbidity related to CAD. Arterial remodeling, by which the wall adapts to physiological or pathological insults by a change in vessel size, is being increasingly recognized as an important aspect of atherosclerosis. In this prospective longitudinal study we used cardiovascular magnetic resonance (CMR) to detect aortic plaque and to study aortic wall remodeling in asymptomatic subjects.

METHODS

We recruited 175 healthy volunteers (49 years, 110 men) and documented their cardiovascular risk profile. Each subject underwent echocardiogram (ECG)-gated T1-weighted spin-echo imaging of the infrarenal abdominal aorta at baseline and after 2 years.

FINDINGS

Of the 175 subjects who volunteered at baseline, CMR was successful in 174 (99%), with one (0.6%) failure due to claustrophobia. At 2 years, follow-up scanning was performed in 169 subjects (97%). Infrarenal aortic plaque was identified at baseline in nine (5.2%) subjects. This was reconfirmed in all nine (100%) cases at 2-year follow-up. No new cases of infrarenal plaque were identified at follow-up. The signal characteristics of the plaque on the subtracted images of the Dixon method indicate that all plaques were fibrous. In the nine subjects with infrarenal plaque, the total plaque burden increased as assessed by the total wall volume (561 to 677 mm3, p = 0.0063). The total vessel volume also increased (1737 to 1835 mm3, p = 0.031) but there was no change in the total luminal volume (1175 to 1157 mm3, p = 0.29).

CONCLUSIONS

Cardiovascular magnetic resonance detects subclinical aortic atherosclerosis, can follow plaque burden over time, and confirms the presence of Glagov remodeling with preservation of the lumen despite progression of plaque. Cardiovascular magnetic resonance is well suited for the longitudinal follow-up of the general population with atherosclerosis, may help in the understanding of the natural history of atherosclerosis, and in particular may help determine factors to retard disease progression at an early stage.

Familial clustering of ruptured intracranial aneurysms in autosomal dominant polycystic kidney disease

Ruptured intracranial aneurysm (RICA) is a life-threatening complication of autosomal dominant polycystic kidney disease (ADPKD). A family history of RICA may be a risk factor for RICA. Six hundred eight adult members of 199 ADPKD families were interviewed, and family pedigrees were constructed. Individuals were classified as having definite, probable, or possible RICAs from evidence and history obtained in interviews. Central nervous system (CNS) events not consistent with RICA were classified as other CNS events. Seventy-seven CNS events occurred in 906 subjects with ADPKD (8.5%) versus 13 events in 823 subjects without ADPKD (1.6%; P < 0.0001). No event in subjects without ADPKD was consistent with an RICA. Twenty-seven other (non-RICA) CNS events occurred in subjects with ADPKD (3%) versus 13 events in subjects without ADPKD (1.6%; P = 0.05). The frequency of RICA was increased in subjects with ADPKD: 21 definite RICAs in subjects with ADPKD (2%) versus none in subjects without ADPKD (P < 0.001); 28 definite and probable RICAs in subjects with ADPKD (3%) versus none in subjects without ADPKD (P < 0.001); and 50 definite, probable, and possible RICAs in subjects with ADPKD (5.5%) versus none in subjects without ADPKD (P < 0.001). The null hypothesis that RICAs are randomly distributed among subjects with ADPKD was tested for definite RICAs (n = 21), definite and probable RICAs (n = 28), and definite, probable, and possible RICAs (n = 50). In the three categories, the null hypothesis was rejected at P less than 0.05, P less than 0.05, and P less than 0.005, respectively. Vascular CNS events occurred more frequently in ADPKD than non-ADPKD family members, and clustering of RICAs occurred in families with ADPKD.

Sexual development in marsupials: genetic characterization of bandicoot siblings with scrotal and testicular maldevelopment

In marsupials testis determination requires the presence of a Y chromosome. The sex determining region on the Y gene (SRY) is necessary for testicular development in eutherians and it is assumed to play a similar role in marsupials. Relatively few studies have investigated the genetic basis of sexual development, and as yet there is no direct evidence that SRY is required for testis development in marsupials. Studies on intersexual marsupials have revealed a fundamental difference between marsupial and eutherian sex determination. The scrotum of marsupials is analogous, not homologous, to the eutherian scrotum and is under the control of X-linked genes not androgens. The current study describes two bandicoot (Isoodon macrourus) siblings. Both siblings had underdeveloped male reproductive tracts and testicular dysgenesis, one was ascrotal and the other had a diminutive scrotum. Their karyotypes were normal for this species which eliminates the Y chromosome from some somatic tissues. SRY was detected by Southern blotting. SRY, ubiquitin activating enzyme-1 on the Y (UBE1Y) and glucose 6-phosphate dehydrogenase (G6PD) gene expression were examined. UBE1Y was widely expressed in many tissues. SRY gene expression was much lower than normal in the abnormal siblings and may be responsible for their failure of testicular and epididymal development. The cause of their scrotal abnormalities is unknown. It is possible that the separate defects of scrotal and testis development in the two siblings, which had normal relatives, were due to a mutation in a gene common to both developmental pathways.

Acute stroke teams: results of a national survey. National Acute Stroke Team Group

BACKGROUND AND PURPOSE

The sensitivity of the brain to brief periods of profound ischemia or prolonged periods of modest ischemia mandates an aggressive approach to acute stroke care. Past studies have shown that many stroke patients do not receive acute care in an urgent and timely fashion. The formation of acute stroke teams (AST) is one approach that can be used to accelerate the delivery of acute stroke care.

METHODS

We conducted a survey of major stroke program directors and neurovascular experts throughout the United States. The survey focused on issues related to the presence of AST, their staffing, operational features, and utilization at the surveyed programs and hospitals.

RESULTS

Surveys were returned from 45 of 60 centers. Ninety-one percent of the respondents indicated that they currently had an AST, with 66% formed between 1995 and 1997. Staffing of ASTs consisted of attending physicians (95%), nurses or study coordinators (73%), fellows (49%), and residents (46%). In almost all cases (98%), the AST was led by a neurologist or neurosurgeon, and 98% of the ASTs operated on a 24-hours-per-day, 7-days-per-week basis. The most common call frequency was 2 to 3 times per week (41%), followed by >5 calls per week (29%). In 59% of the cases, the teams cost </=$5000 per year to operate. The vast majority (78%) of ASTs responded within 10 minutes of receiving a call.

CONCLUSIONS

The formation of ASTs is quite common at the surveyed programs. Although staffing patterns vary, most teams are led by neurologists or neurosurgeons. The utilization of ASTs varies by facility, but they appear to be useful, with only a modest incremental financial cost. The use of ASTs may assist in providing more rapid medical care to stroke patients and increase the use of some acute therapies. Extension of the AST concept to nonacademic hospitals appears feasible.

Early development and embryology of the platypus

Information on the pre-hatching development of the platypus, Ornithorhynchus anatinus, is reliant on a small number of specimens, whose precise age is unknown. Material collected for J. P. Hill and now housed in the Hubrecht International Embryological Laboratory, Utrecht, contributes a major source of specimens. This paper presents new observations on developmental stages from the Hill collection, which allow for a more complete description of pre-hatching development. A feature of the pre-embryonic development of the platypus is the incomplete meroblastic cleavage. A column of fine yolk spheres extends from beneath the embryonic blastodisc towards the centre of a yolky vitellus, as seen in birds. The major expansion of extra-embryonic membranes occurs after the formation of the primitive streak. The primitive streak develops within an embryonal area as part of the superficial wall of the yolk-sac, a feature also shared with marsupials, birds and reptiles. The full-term, subspheroidal, intrauterine egg of the platypus has a major axis of about 17 mm and contains a flat, 19-20 somite, neurula-stage embryo which has prominent trigeminal ganglion primordia. The embryo at this stage is in a period of rapid modelling of the major early organ primordia of the nervous system, cardiovascular system, excretory system, and somite-derived components of the body wall. Soon after laying, five primary brain vesicles are present, the trigeminal ganglia CN5 as well as CN7, CN8, CN9, CN10, CN11 and CN12 are well developed. The alimentary system has an expanded stomach, pancreatic primordia and a gall bladder. Mesonephric tubules are associated with patent mesonephric ducts, which empty laterally into the cloaca. Extra-embryonic membranes at this stage show an extensive chorioamniotic connection that extends through the greater part of the caudal half of fused amniotic folds. The vascularized yolk-sac consists of a superficial yolk-sac omphalopleura and a deep yolk-sac splanchnopleure. The non-vascularized yolk-sac comprises one-quarter of the ahembryonal pole. Some distinctive monotreme features have developed by the mid-incubation period. The head is bent at an acute angle to the main body axis. The blunt upturned snout marks the site of the future oscaruncle and on the maxilla there is a median primordial papilla representing the egg tooth. The eye is open with a partly pigmented retinal ring. The forelimbs have partly separated digits, and the hindfeet are paddles. Just before hatching the upturned snout contains an oscaruncle and a sharp recurved median egg tooth. Forelimbs are pronated with separate digits possessing claw primordia. Portions of the highly vascularized extra-embryonic membranes are attached to the umbilical region and the flattened vesicular allantois has a distal region fused with the chorion. Prominent features of the hatchling are the presence of a bluntly conical oscaruncle and a translucent, horn-like egg tooth. These structures are though to enable the hatchling to extricate itself from the egg shell. At hatching, the forelimbs exhibit clawed digits and are capable of digitopalmar prehension. Hindlimbs are still paddles with digital rays. A prominent yolk-sac navel is present. The newly hatched platypus has an external form similar to that of a new-born marsupial. The early development of the platypus has many major differences to the developmental sequence for humans, which has been categorized by the use of Carnegie Stages. The rate of somitogenesis of the platypus is faster in relation to the central nervous system morphogenesis than seen in humans, and the size of the early platypus embryonal area is massive in relation to that of humans. The unique morphology and function of extra-embryonic membranes in the platypus defies comparative staging with human development. Structures adapted for altricial survival of the platypus hatchling require the acquisition of functional competence at an earlier stage of organogenesis than seen in eutherians, although they are reminiscent of those found in new-born marsupials.

Calcium intake by rats: influence of parathyroid hormone, calcitonin, and 1,25-dihydroxyvitamin D

We examined the contribution of the primary hormones of calcium homeostasis to the control of calcium intake in the rat. Male Sprague-Dawley rats with 50 mM CaCl2 solution as their only source of calcium received subcutaneous hormone infusions for 13 days. Parathyroid hormone (PTH; 40, 80, or 160 ng/h) produced sustained dose-related decreases in CaCl2 intake. High doses of calcitonin (CT; 32 or 64 ng/h) increased CaCl2 intake transiently, and low doses (4, 8, or 16 ng/h) had no effect. 1,25-Dihydroxyvitamin D [1,25(OH)2D] in doses > 1 ng/h initially increased CaCl2 intake, but the effects of moderate doses (2 or 4 ng/h) tended to dissipate, and the sustained effect of high doses (8 or 16 ng/h) was to reduce CaCl2 intake. Infusions of combinations of the hormones had effects consistent with their individual actions: there was no evidence for synergy. Based on changes in plasma hormone concentrations, it appeared that most of the infusions had effects within the physiological range. Consistent with hypotheses that calcium appetite is mediated by circulating calcium, PTH and CT infusions produced reciprocal changes in plasma calcium concentrations and CaCl2 intake. However, the finding that 1,25(OH)2D elevated both plasma calcium concentrations and CaCl2 intake raises the possibility that one or more of the hormones may mediate calcium appetite directly.

Relationship of trait, Type A behavior, and physical fitness variables to cardiovascular reactivity and coronary heart disease risk potential

PURPOSE

This research investigated the effects of individual characteristics on cardiovascular reactivity, and in turn on the potential for developing coronary heart disease.

DESIGN

Path analysis was performed using LISREL, a structural equation modeling program providing maximum likelihood estimators and goodness-of-fit measures.

SETTING

Data were collected during a health assessment program, from participants attending a Department of Defense senior service school.

SUBJECTS

Participants were 134 senior-ranking male military and civilian employee volunteers, representing approximately 84% of all students in training.

MEASURES

Five individual characteristics, four measures of cardiovascular reactivity, and one coronary heart disease risk potential variable were investigated. These included Physical Fitness, Type A behavior, Trait Anger and Trait Anxiety, Diastolic and Systolic Blood Pressure measures, and Coronary Heart Disease Risk.

RESULTS

Significant path coefficients (critical ratios > 2) indicated that the mean diastolic blood pressure under a video stress condition was predictive of increased potential of developing coronary heart disease (.51), while hard driving Type A behavior was a cardiovascular reactivity antecedent associated with an increase in coronary heart disease risk directly (.14) and indirectly (.39). Physical fitness, on the other hand, had a positive affect in that increased fitness was related to lower cardiovascular reactivity when participants were stressed (-.58).

CONCLUSIONS

Physical fitness is indirectly beneficial in reducing coronary heart disease risk potential by reducing an individual's diastolic blood pressure response, while scoring high as a Type A Hard Driving personality increases cardiovascular reactivity and coronary heart disease risk. This study is limited to middle-aged males who were generally healthy and displayed concern for their health.

Carotid endarterectomy for the asymptomatic patient

The history of the debate on how best to manage the patient with asymptomatic cerebrovascular disease is reviewed. Several recent studies have compared best medical with surgical management. The author concludes with a perspective on the present and future management options.

Evidence-based medicine, critical pathways, practice guidelines, and managed care. Reflections on the prevention and care of stroke

Because managed care plans are exerting enormous pressure to reduce the cost of medical care, neurologists need to enhance their skills at identifying appropriate, high-quality, and cost-effective care for patients with neurological disorders. A variety of health services research methods are available that foster evidence-based decisions and de-emphasize intuition in decision making. Despite imperfect data and a lack of familiarity with some of these methods, we have found them useful in developing guidelines and pathways for the prevention and management of stroke. Neurologists should become more familiar with the pragmatic benefits, limitations, and obstacles that hinder acceptance and implementation of these approaches. If we wish to continue to influence the medical decision process, we must focus on the provision of quality neurological care and not on the managed care plan.

Venous stasis orbitopathy: a clinical and echographic study

AIMS

A variety of acute and chronic orbitopathies may be distinguished by standardised echography. Venous stasis orbitopathy (VSO) often presents with orbital signs when secondary to cavernous sinus and middle cranial fossa disorders. In this study, the aim was to assess whether differentiation between vascular and nonvascular causes of VSO could be made on the basis of clinical and echographic features at the time of presentation.

METHODS

This study comprised 37 patients with echographic features of VSO (17 patients with arteriovenous fistulae, confirmed by computed tomography imaging or angiography, and 20 patients with non-vascular diseases). Excluded were patients with orbital mass lesions detected by echography and muscle enlargement due to other causes (for example, orbital myositis). Patients with a suspected mass involving the orbital apex and echographic features of VSO were included. After full neuro-ophthalmic and ocular examination, both orbits were examined to document maximal thickness and reflectivity of four recti muscles and compared with the normal contralateral orbit with standardised A-scan (Kretz-technik 7200MA or Ophthascan) and contact B-scan (Ultrascan or Ophthascan S).

RESULTS

Cumulative ocular recti muscle thickness was significantly greater in patients with arteriovenous fistulae compared with the non-fistula group (23.3 (SD 3.7) and 17.8 (2) mm, p = 0.001). Clinically, the presence of a bruit and a uniocular rise in intraocular pressure were significantly greater in the fistula group of patients.

CONCLUSIONS

Standardised echography is a safe and non-invasive method of diagnosing VSO in patients presenting with signs of proptosis, ophthalmoplegia, and inflammation of the conjunctiva. Furthermore, using these standard techniques the two major causes of VSO (arteriovenous fistulae and compressive mass lesions) could be differentiated.

Evidence of a direct role for growth hormone (GH) in mammary gland proliferation and lactation

A panel of monoclonal antibodies to the growth hormone (GH) receptor/binding protein was used to demonstrate the existence and detail the expression of GH receptors in ductal and alveolar epithelial cells from rat and rabbit mammary glands by immunohistochemistry. Intense immunoreactivity was present in membrane, cytoplasm and some nuclei of epithelial cells during proliferation and lactation. Receptor expression decreased during weaning and was absent or weak in regressive mammary glands. Immunoreactivity was weak in ductal epithelial cells from virgin adult animals. Pronounced expression of GH receptor/binding protein was observed with two monoclonal antibodies and lesser reactivity was seen with others, paralleling their affinities for the receptor. The cytoplasmic presence of this putatively plasma membrane located GH receptor is accounted for by the existence of a soluble form on the GH receptor, namely the growth hormone binding protein derived from the membrane receptor by cleavage. Primary localization of the receptor in proliferating and lactating epithelial cells suggests that the rat and rabbit mammary gland is a GH target tissue. This finding is in contradiction to both classical GH action and the somatomedin hypothesis and challenges the widely held view that GH has no direct influence on mammary growth and function.

First-year residents' caring, medical knowledge, and clinical judgment in relation to laboratory utilization

PURPOSE

To investigate first-year residents' levels of caring (concern for others' well-being), medical knowledge, and clinical judgment in relation to their levels of laboratory utilization.

METHOD

Self-report questionnaires about caring, knowledge, and judgment were given in 1986-87 to 36 first-year residents in a three-year internal medicine residency program of the McGaw Medical Center of Northwestern University. Inpatient laboratory utilization data obtained from structured chart audits over a one-year period were used to construct comparable diagnosis- and severity-specific physician practice profiles, from which the residents received overall utilization scores for laboratory test charges. Statistical methods included Cronbach's alpha reliability coefficient and multiple regression analysis.

RESULTS

The multiple regression analysis showed that medical knowledge was an independent predictor of increased laboratory utilization (standardized beta = .54, p < .04, partial R2 = .07); clinical judgment was an independent predictor of decreased utilization (standardized beta = -.53, p < .05, partial R2 = .06); and caring was unrelated to utilization (standardized beta = .15, ns, partial R2 = .01).

CONCLUSION

The finding that clinical judgment was related to less laboratory utilization suggests that future research should investigate the decision-making concomitants of judgment to better understand its translation into resource utilization. It is possible that the relationship between medical knowledge and laboratory utilization is developmentally specific, and thus the knowledge of more experienced physicians, who would likely be more precise decision makers than first-year residents, may be related to decreased rather than increased utilization.

Monotreme development with particular reference to the extraembryonic membranes

This paper considers many of the salient features of monotreme development, particularly morphogenesis of the extraembryonic membranes. The uterine endometrium of both monotremes and marsupials exhibits a progesterone driven luteal phase where accelerated utilization of endometrial nutrients is evidenced by a rapid post-primitive streak expansion in the dimensions of the extraembryonic membranes. Monotremes share with marsupials, birds, and reptiles an unspecialized vertebrate mode of genesis of the embryonic disc on the peripheral surface of the yolk-sac. The fused vascularized respiratory chorioallantois is estimated to have a functional life of not more than the terminal 4 to 5 days of the monotreme incubation period. This time interval is of a slightly greater order of magnitude than that found in marsupials with a fused chorioallantois, so far described, but in the context of the proportional elapse of post-primitive streak organogenesis would fall within the marsupial grade. The dominant extraembryonic membrane for nutritive and respiratory function in both monotremes and marsupials is the yolk-sac. This contribution shows that monotremes and marsupials share a much larger suite of developmental anatomical features than previously reported. The evolutionary biologist is confronted with the challenge of how to assign an appropriate weighting to these features as marsupials are considered by many researchers to be allied phylogenetically more closely with eutherian mammals than with monotremes.

Different effects of three aldosterone treatments on plasma aldosterone and salt intake

Adrenalectomized male rats received a nominal dose of 47.6 micrograms/day aldosterone for 14 days by daily injections, osmotic minipumps, or controlled-release pellets. Plasma aldosterone concentrations were barely detectable (< 20 pg/ml) 24 h after rats received aldosterone by injection, remained constant at 200 pg/ml in rats with osmotic minipumps, and dropped from > 500 to 75 pg/ml during the first week after implantation of controlled-release pellets. For the most part, the effects of the different treatments on NaCl intake were related to their effects on plasma aldosterone levels according to a U-shaped function. However, NaCl intake was dissociated from plasma aldosterone levels when treatment first began or was discontinued. NaCl intake may be a function of the amount of aldosterone delivered but not necessarily plasma aldosterone concentration.

Independence of salt intake induced by calcium deprivation from the renin-angiotensin-aldosterone system

We investigated whether the elevated NaCl intake shown by calcium-deprived rats is mediated by the renin-angiotensin-aldosterone system. First, we looked for manifestations of altered renin-angiotensin-aldosterone system activity during the progression of calcium deficiency. There were no differences between control and calcium-deprived rats in plasma aldosterone concentrations, plasma renin activity, plasma sodium concentrations, sodium balance, or blood pressure. Second, we used selective pharmacological antagonists to examine whether disruption of the renin-aldosterone-angiotensin system influenced salt intake. Blockade of aldosterone receptors with spironolactone (25 mg.kg-1 x day-1 sc for 7 days) had no effect on NaCl intake of control or calcium-deprived rats. Angiotensin AT1 receptor blockade with losartan potassium (0.5-10 mg/kg orally) had no effect on NaCl intake of control or calcium-deprived rats but doses > 0.5 mg/kg decreased NaCl intake of adrenalectomized rats. Taken together, these findings indicate that the renin-angiotensin-aldosterone system does not mediate the increased NaCl intake produced by calcium deficiency. The appetite for salt produced by calcium deficiency involves a different physiological substrate from most other models of NaCl intake.

Independence of salt intake from the hormones regulating calcium homeostasis

Rats deprived of dietary calcium increase voluntary intake of NaCl solutions. We investigated whether the major hormones controlling calcium homeostasis are responsible for this increase in salt intake. Removing endogenous sources of calcitonin and parathyroid hormone by thyroidectomy and/or parathyroidectomy had no effect on NaCl intake. The surgically compromised rats and their intact controls drank similar amounts of NaCl in response to manipulations of diet calcium content. Despite normal NaCl intakes, rats with parathyroidectomy had low plasma calcium concentrations and a strong appetite for 50 mM CaCl2 solution. Chronic infusion of parathyroid hormone into rats with thyroparathyroidectomy decreased NaCl intake. Intact rats fed an American Institute of Nutrition (AIN)-76A-based vitamin D-deficient diet increased NaCl intake slightly and showed a strong appetite for CaCl2, but other rats maintained normocalcemic by the addition of calcium, phosphorus, and lactose to the vitamin D-deficient diet had normal NaCl and CaCl2 intakes. Chronic infusions of 1,25-dihydroxyvitamin D3 into intact rats had no effect on NaCl intake. Taken together, these results indicate that the increase in NaCl intake produced by calcium deprivation is not mediated by changes in circulating levels of calcium, calcitonin, parathyroid hormone, or 1,25-dihydroxyvitamin D3. Furthermore, the major calcium-regulating hormones are not involved in the control of "spontaneous" NaCl intake in the rat.

Actinomycetales infections in slender-horned gazelles: six cases (1987-1989)

Disseminated Actinomycetales infections were diagnosed in 6 slender-horned gazelles at a zoologic park over a 17-month period. Nocardia and Mycobacterium spp were isolated. Possible predisposing causes leading to infection were investigated. Environmental contamination where the gazelles were housed was not high, and other breeds of gazelles at the park did not become infected, indicating that environmental exposure was not the sole factor involved. Information gathered from questionnaires sent to other zoologic parks and personnel communications indicated that this was not an isolated incident. Investigation into the genetic lineage of the gazelles revealed substantial inbreeding in prior generations. These findings suggested inbreeding may have been an important predisposing factor leading to infection. Careful scrutiny to ensure maximal heterozygosity of future breedings is warranted.

Ultrastructure and distribution of epidermal sensory receptors in the beak of the echidna, Tachyglossus aculeatus

Within the rostral one centimetre of the Echidna beak, three specialised receptors were found: a mucous sensory gland, a rod-like structure, and an innervated epidermal pit. The mucous sensory gland consists of a dermal mucous gland and a modified epidermal portion. Bulbous nerve terminals, similar to those reported for the Platypus, were found within the modified epidermal portion of the mucous gland. The rod-like structure contains four types of nerve terminals: Merkel cells, Paciniform corpuscles, and a central and a peripheral vesicle chain receptor. Apart from minor differences, the rod-like structure is similar to that previously reported for the Platypus. Preliminary results are presented for a third structure: an innervated epidermal pit. Topographical and ultrastructural analyses are used in the context of functional interpretation.

Gentamicin and vancomycin removal by continuous venovenous hemofiltration

The dispositions and dose requirements for vancomycin and gentamicin were investigated in a 58-year-old man who was receiving long-term continuous venovenous hemofiltration. Estimates of clearance were obtained using a Bayesian parameter estimation program and stayed remarkably consistent throughout the therapy. Single daily doses of both vancomycin and gentamicin generally maintained the profiles for both drugs around the target ranges of peak 5-10 mg/L (gentamicin) and 25-40 mg/L (vancomycin) and trough less than 2 mg/L (gentamicin) and less than 10 mg/L (vancomycin).

Comparison of enflurane and halothane in hypotensive eye surgery

Thirty patients undergoing elective eye surgery had anaesthesia induced with sodium thiopentone, suxamethonium and d-tubocurarine chloride. Patients were ventilated with nitrous oxide, oxygen and either halothane or enflurane. The volatile agents were used to decrease the systolic blood pressure to 80 mmHg. The volatile agent concentration in the blood was measured at 30 min intervals. Both agents were effective in producing hypotension, but enflurane was the more potent hypotensive agent in terms of MAC equivalents. There was no significant differences between the agents with respect to speed of recovery.

Impairment of theophylline clearance by a hypocaloric low-protein diet in chronic obstructive pulmonary disease

The effect of a hypocaloric, low protein diet on theophylline kinetics was studied in a 70-year-old man with chronic obstructive pulmonary disease who lost 6.2 kg of weight. Total systemic clearance, unbound clearance, and intrinsic hepatic clearance fell dramatically. Theophylline elimination half-life rose from 8.4 to 17.1 h. Therefore, a diet deficient in both calories and protein can significantly impair theophylline clearance and prolong theophylline elimination half-life.

Longer hospitalization at Veterans Administration hospitals than private hospitals. Verification and additional insights

Utilizing 1,297 male patients under the primary care of an identical group of house officers and under treatment between 1985 and 1987 for ten common medical diagnoses, length of hospitalization was compared between a private sector (n = 481) and Veterans Administration (VA) (n = 816) facility, both affiliated with the same medical school. All patients were rated by the Horn Severity of Illness Index. After researchers controlled for diagnosis, severity of illness, age, race, and physician, results in this study indicate that an additional 3.2 days of hospitalization were associated with the VA facility. This finding is consistent with earlier reports of inappropriate hospitalization at the VA hospital and suggests that VA facility planners need to evaluate whether longer lengths of stay (LOS) are merited.

Cerebral blood flow determination within the first 8 hours of cerebral infarction using stable xenon-enhanced computed tomography

Cerebral blood flow mapping with stable xenon-enhanced computed tomography (Xe/CT) was performed in conjunction with conventional computed tomography (CT) within the first 8 hours after the onset of symptoms in seven patients with cerebral infarction. Six patients had hemispheric infarctions, and one had a progressive brainstem infarction. Three patients with very low (less than 10 ml/100 g/min) blood flow in an anatomic area appropriate for the neurologic deficit had no clinical improvement by the time of discharge from the hospital; follow-up CT scans of these three patients confirmed infarction in the area of very low blood flow. Three patients with moderate blood flow reductions (15-45 ml/100 g/min) in the appropriate anatomic area had significant clinical improvement from their initial deficits and had normal follow-up CT scans. One patient studied 8 hours after stroke had increased blood flow (hyperemia) in the appropriate anatomic area and made no clinical recovery.

The Chromosomal Basis of Sex-Differentiation in Marsupials

Data on ten intersexual marsupials, eight of which were of known karyotype, are presented and reviewed. Three of the intersexes were known or suspected XO/XX or XO/XX/XXX, two were XXY, one was XXY/XY/XX and two were XY in sex chromosome constitution. In all three intersexes which had an XO cell line, but in which no Y chromosome was found in any cell, a small empty scrotum was found to one side of the midline or in the midline. Those which had a non-midline scrotum had mammary tissue on the opposite side and a partial or complete pouch. The intersex with the midline scrotum had no pouch or mammary glands. Unilateral or bilateral putative spermatic cords, not containing a ductus deferens, descended to the scrotum, but in all other respects the internal reproductive systems were like those of normal XX female marsupials. Intersexes with no Y chromosome were of female body size when adult. The XXY and XXY/XY/XX intersexes all had complete pouches and mammary glands and none had a scrotum. All had well developed male internal reproductive systems and undescended testis-like gonads, and were of intermediate body size. Both XY intersexes also had complete pouches and mammary glands, no scrotum, and male-type internal reproductive systems with undescended testes which were normal except for absence of post- primary spermatocyte stages of spermatogenesis. One XY intersex was fully adult and it did not differ from normal XY males of the same species in body measurements, body weight and secondary sex coloration. One of the intersexes of unknown karyotype, but of suspected XX chromosome constitution, was morphologically like the XO/XX/XXX mosaic with a centrally placed scrotum. The other, of suspected XY chromosome constitution, was essentially comparable to the XY intersexes. The data are interpreted, at the whole chromosome level, as follows. In the presence of a single active X chromosome scrotal and spermatic cord development were initiated, whereas they were inhibited in the presence of two X chromosomes. Complete scrotal development completely inhibited, and unilateral scrotal development partly inhibited, pouch and mammary gland development. The Y chromosome was responsible for primary gonadal sex and, apparently through production of MIS, eliminated the Miillerian (i.e. female) sex ducts. Development of a male type of reproductive system was dependent on presence of a Y chromosome and, apparently, androgen production from testes or testis-like gonads. At the gene level the data may be interpreted in terms of a hypothetical S or 'switch' locus, carried on the X chromosome, which induced scrotal development in single dose and a pouch and mammary glands in double dose. If this hypothesis is correct, it would explain the occurrence of incomplete X-chromosome inactivation in marsupials; complete X-inactivation is impossible in marsupials because it would leave each female with a scrotum, not a pouch.

Effects of nadolol on arrhythmias during laparoscopy performed under general anaesthesia

Cardiac arrhythmias are a well recognized complication of anaesthesia for laparoscopy. The effect of nadolol, given by mouth 12 h before operation, was compared with placebo on arrhythmias in 86 females undergoing laparoscopy. All types of arrhythmia were documented; there was a 97% incidence in the placebo group, but in the nadolol group there was a smaller incidence of supraventricular tachycardia, ventricular ectopics and atrioventricular dissociation (P less than 0.01). There was no significant difference in the incidence of sinus bradycardia. Nadolol may be recommended as a safe agent to be given by mouth before laparoscopy to reduce the frequency of cardiac arrhythmias during anaesthesia.

Diet-induced changes in trough theophylline concentrations in an elderly asthmatic patient

A 66-year old obese man with asthma was given a hypocaloric (1100 Kcal) and low protein (35 g) diet for nine days. While receiving theophylline (Theodur), 200 mg bid, his morning trough theophylline concentrations rose from 3.40 micrograms/ml to 12.7 micrograms/ml by day 9 of this diet. Following discontinuation, his theophylline concentration fell to 5.95 micrograms/ml by day 6 on home diet. The patient lost 3.67 kg during the nine-day study. Thus, a brief exposure to a hypocaloric, low protein diet in this elderly patient with asthma caused a dramatic rise in trough theophylline concentrations.

A path analysis of medical school and residency performance. Implications for housestaff selection

The selection and subsequent performance of 212 internal medicine residents was examined by factor analysis and path analysis. A three-factor solution accounted for most of the variance among the nine selection variables. These three factors, labeled Board Scores, Faculty Evaluations, and Academic Distinction, were then combined with in-training residency performance evaluations and composite scores on the ABIM certifying examination to produce a comprehensive path model of house staff selection and performance. The Academic Distinction factor emerged as the strongest predictor of residency performance,; the Faculty Evaluations factor was also a significant component of the model. Standardized test scores correlated poorly with clinical performance. The data suggest that increased attention to the content of letters of reference could substantially improve their predictive validity. Other means of reporting subjective evaluations may also be needed to increase the stature of non-cognitive attributes in house staff selection decisions.

Concluding remarks to the First National Flying Fox Symposium

NA

The Eaton-Lambert (myasthenic) syndrome in association with systemic lupus erythematosus

We describe a case of the Eaton-Lambert (myasthenic) syndrome (ELS) in a 56-year-old woman with systemic lupus erythematosus. Treatment with successive courses of plasmapheresis produced clinical and electrophysiologic improvement in her ELS, without affecting her systemic lupus erythematosus. This case supports both the association of ELS with autoimmune disorders, and the use of plasmapheresis in the treatment of ELS.

Effects of dietary protein on theophylline pharmacokinetics and caffeine and aminopyrine breath tests

The effects of low- and high-protein diets on theophylline kinetics and the time course of changes in 13C-labeled caffeine and aminopyrine CO2 breath tests were examined in six young men. With a low-protein diet, mean theophylline clearance fell 21% (P less than 0.04) and the t1/2 rose from 8.0 to 10.6 hours (P less than 0.02). With a high-protein diet, mean theophylline clearance rose 26% (P less than 0.004) and the t1/2 shortened to 7.4 hours (P less than 0.03). Theophylline volume of distribution and protein binding did not change. Renal clearance of theophylline was lowered during the low-protein diet. Theophylline clearance correlated with caffeine breath test values during the low- (r = 0.73) and high- (r = 0.70) protein diets. Theophylline clearance correlated less well with the aminopyrine breath test values during the low- (r = 0.47) and high- (r = 0.55) protein diets. Thus dietary protein significantly influenced theophylline clearance, but the caffeine and aminopyrine breath tests showed a differential response to this important environmental factor.

Effects of certain i.v. anaesthetics on liver blood flow and hepatic oxygen consumption in the greyhound

The effects of increasing concentrations of thiopentone, Althesin and etomidate on liver blood flow and hepatic oxygen consumption were investigated in the anaesthetized greyhound. All three agents studied produced dose-related decreases in general cardiovascular indices such as mean arterial pressure, cardiac output and systemic vascular resistance; all three anaesthetics produced decreases in liver blood flow. During the low rates of infusion with Althesin and etomidate, significant decreases in hepatic arterial blood flow were recorded at a time when the systemic circulation was not significantly affected. Indeed, during the low rates of infusion with each of the three agents, hepatic arterial resistance and mesenteric vascular resistance increased by up to 40% above baseline values. During the high rates of infusion, hepatic arterial and mesenteric vascular resistances either returned to or decreased below control values and the decreases in liver blood flow were a consequence of generalized cardiovascular depression. Despite relatively unchanged hepatic oxygen consumption, all the anaesthetics produced significant decreases in the hepatic oxygen supply.

The embryological development and cytodifferentiation of the anterior pituitary in the marsupial, Isoodon macrourus

Light and electron microscopy were used to study the development of the anterior pituitary gland from fetal stages to the end of pouch life in the marsupial I. macrourus. The early morphological development of the anterior pituitary in I. macrourus follows a similar pattern of events to that described for eutherians. Rathke's and Seessel's pouches were present in 10 1/2 day old embryos. At birth these pouches had formed a multi-chambered vesicle which was still connected to the stomodeum by a thin cord of tissue. A small number of granules (200-400 nm dia.) were found in cells at birth. These cells could not be classified on ultrastructural features but alcian blue-periodic acid Schiffs-orange G staining suggested one cell type was possibly a presumptive thyrotroph. There were no capillaries in the pars distalis at birth. The cords connecting Rathke's and Seessel's pouches to the stomodeum were located at the site of the periosteal bud of the developing basisphenoid which commenced to ossify at 7 days. At this stage presumptive thyrotrophs, gonadotrophs, and somatotrophs could be distinguished using alcian blue-periodic acid Schiffs-orange G staining. However, five cell types could be categorised at the same age using ultrastructural characteristics alone. Precise names for these cells are unavailable but two closely resemble presumptive mammotrophs and thyrotrophs described for another marsupial M. eugenii. By 13 days after birth the anterior pituitary of I. macrourus had become vascular and acidophils were concentrated in a posterior zone. There was little gross morphological change from 13 to 66 days after birth by which the time weaning has occurred. Cilia were seen in cells of the anterior pituitary and mitosis of granulated cells was observed from birth onwards. There is a considerable range of variation in pituitary cytogenesis amongst marsupials, and its functional significance awaits further investigation.

Potential effects of nutritional state on pulmonary function in cystic fibrosis

There are a number of observations which suggest that malnutrition and decreasing pulmonary function are parallel phenomena in chronic lung disease. Causality for either has not been established. A potential link between the two may be the diminishing function of respiratory muscles which accompanies weight loss. Data from adult patients with chronic obstructive lung disease are presented which suggest that respiratory muscle fibers progressively atrophy, not hypertrophy, in the face of increasing airway obstruction. This lack of compensation is probably nonspecific since nonrespiratory muscles demonstrate the same trend. This observation may explain some of the impaired respiratory muscle function which has been documented in patients with chronic lung disease. There are no morphologic data available for older patients with cystic fibrosis, but the processes which impair muscle function may prove to be similar in both groups of patients. The effect of malnutrition on respiratory muscle fiber size remains to be determined.

Clinical conference in pulmonary disease. Factors influencing upper airway closure

The factors which produce closure of the upper airway (UAW) in patients with the sleep apnea syndrome are still poorly understood. A distinction should be made between the factors which induce closure and those which reopen the UAW. Neurologic factors include arousal phenomena, the magnitude and timing of various motor outputs, and postsynaptic inhibition. Mechanical factors include the anatomy of the UAW, especially that above the tongue, the position of the neck and jaw, and mucosal adherence once occlusion has occurred. Muscle factors include the type of myosin isozyme, the forces generated by the large number of UAW muscles and the diaphragm, and the possibility of high-frequency fatigue occurring during occlusion. Hypoxia and acidosis probably play a critical role in making the UAW less stable. Currently, the best method to prevent UAW closure is by nasal CPAP. Patients with life-threatening arrhythmias due to sleep apnea should have a tracheostomy. The role of drugs is controversial. Respiratory or muscle stimulants should probably be avoided; oxygen, medroxyprogesterone, and protriptyline may be useful adjuncts.