Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users

The introduction of highly active antiretroviral therapy (HAART) has resulted in marked reductions in mortality and acquired immunodeficiency syndrome (AIDS) incidence across all risk groups; however, the proportionate decrease among injecting drug users (IDUs) has been less impressive. Much of the disparity in benefit to IDUs has been a consequence of decreased access to and receipt of potent antiretroviral combinations. Strategies to increase access to and utilization of HAART have included entry into drug treatment and abstinence. Unfortunately, as few as 15%–20% of active drug users in the United States, and in many other countries, are in drug treatment at any one time. We report a pilot project among out-of-drug treatment IDUs infected with human immunodeficiency virus (HIV); HIV therapy was successfully provided to active heroin injectors using the Community Health Care Van (CHCV) at sites of needle exchange. Subjects were willing to initiate, but were not receiving, recommended HIV therapy and were not interested in formal drug treatment. Antiretroviral therapy regimens were selected and linked to heroin injection timing. Weekly visits were scheduled by CHCV staff to assess adverse side effects and encourage adherence. Of the 13 participants, the mean baseline HIV-1 RNA level and CD4 lymphocyte count were 162,369 (log 5.21) copies per milliliter and 265 cells per milliliter, respectively. By 6 months, the proportion whose HIV-1 RNA was below the limits of detection (<400 copies/mL) was 85% (N=11); 77% (N=10) had nondetectable levels by 9 months. By 12 months, 54% (N=7) had a persistently nondetectable viral load, and the net increase in CD4 lymphocyte count was 150 cells per milliliter. As an additional and unintended benefit of this pilot project, 9 (69%) subjects chose to enter drug treatment after achieving a nondetectable viral load. Entry into drug treatment was associated with durability of viral suppression. This small pilot study suggests that health services based on needle exchange may enhance access to HAART among out-of-treatment HIV-infected IDUs. In addition, it demonstrates that this population can benefit from this therapy with the support of a nontraditional, community-based health intervention.     

High technology medicine and the physician-patient relationship

While technologic problems in critical care have become highly refined with precise solutions, ethical problems and solutions have remained fairly primitive. A useful distinction between technology and techniques is made with individual technologies being the parts that make up the therapeutic techniques as a whole. The phenomena of “technical convergence” is discussed wherein we may control each part of the system, but the system itself may be out of control. This is explained in terms of the logical fallacy of composition, noting that a whole may not necessarily have the same characteristics of its parts. Resolution of some of the ethical problems in critical care is suggested through a reexamination of the physician-patient relationship. It is noted that the relationship needs to be personal-technologic rather than sociotechnologic in nature, with the former focusing solely on the best interest of the individual patient and the latter focusing more on the broader concerns of society in the allocation of limited resources. The detrimental effects for the physician as well as the patient of the shift toward the sociotechnologic relationship is explored, especially the dehumanization of the physician. A call for a reaffirmation of the traditional professional model of medicine emphasizing the best interest of patients as opposed to the more popular business model emphasizing materialism and efficiency is given.     

Postoperative radiotherapy for locally advanced colon cancer

Background: The role of adjuvant postoperative radiotherapy for locally advanced colon cancer is not well documented. Methods: Seventy-eight patients who underwent a complete resection of B2-C colon cancer received postoperative radiotherapy. Twenty-eight patients received ⩽45 Gy; 50 patients received 50–55 Gy. Twenty-seven patients received adjuvant fluorouracil-based chemotherapy. All patients were followed for a minimum of 3 years; no patients were lost to follow-up. Results: The overall local control rate was 88%. The 5-year actuarial rate of local control was 96% after 50–55 Gy postoperative radiotherapy compared with 76% after <50 Gy (p=0.0095). Multivariate analysis of local control showed that only radiotherapy dose significantly influenced this end point. Cause-specific survival rates at 5 years were B2, 67%; B3, 90%; C1, 100%; C2, 61%; C3, 36%; and overall, 63%. Multivariate analysis of cause-specific survival showed that only stage significantly influenced this end point. Bowel obstruction caused by adhesions developed in three patients and required a laparotomy; radiation-induced sarcoma developed in one additional patient. Conclusions: Postoperative radiotherapy appears to reduce the risk of local recurrence in patients with locally advanced colon cancer. The optimal dose is probably 50–55 Gy at 1.8 Gy per fraction. Postoperative radiotherapy may improve cause-specific survival for patients with stages B3 and C2 cancers.     

International trials and national practice: A questionnaire survey of current physician practice in the treatment of acute myocardial infarction

To establish current national clinical practice in the care of patients with acute myocardial infarction (AMI), a questionnaire survey of 50 consultant physicians currently working in the Republic of Ireland was carried out. There were 45 (90%) respondants. 32/45 (71%) give thrombolysis in CCU only; 13/45 (29%) give thrombolysis in casualty also. Streptokinase (Stk) is the first choice thrombolytic agent for the majority. 14/45 (31%) use tPA for anterior AMI in patients under 60 years. Angiotensin converting enzyme (ACE) inhibitors are given by 34/45 (76%) to patients with evidence of left ventricular dysfunction. ACE inhibitors are neither used routinely nor are they prescribed in the first three days after the AMI by the majority of the physicians surveyed. Serum magnesium is checked routinely by 5/45 (11%) and intravenous magnesium is given routinely by 5/45 (11%). The percentage of AMI patients considered for angiography varied from 10–50%. Despite reports from randomised, controlled trials showing reduced mortality in patients given tPA (versus Stk), routine early ACE inhibition and intravenous magnesium post-AMI, most clinicians in Ireland use streptokinase, selective late ACE inhibition and no magnesium. The reasons for the dichotomy between the favourable results of randomised clinical trials and routine practice are speculative.     

Effects of Myocardial Water Exchange on T1 Enhancement during Bolus Administration of MR Contrast Agents

Interpretation of first-pass myocardial perfusion studies employing bolus administration of T₁ magnetic resonance (MR) contrast agents requires an understanding of the relationship between contrast concentration and image pixel intensity. The potential effects of myocardial water exchange rates among the intravascular, interstitial, and cellular compartments on this relationship are controversial. We directly studied these issues in isolated, nonbeating canine interventricular septa. Myocardial T₁ was measured three times/s during bolus transit of intravascular (albumin-Gd-DTPA and poly-lysine-Gd-DTPA) and extracellular (gadoteridol) contrast agents. For polylsine-Gd-DTPA, the peak changes in myocardial 1/T₁ (ΔR1) scaled nonlinearly with perfusate contrast concentration whereas a linear relationship would be expected for fast water exchange among the vascular, interstitial, and cellular compartments. For all agents, the peak ΔR1 were much smaller than the values expected on the basis of fast myocardial water exchange. The data demonstrate that in isolated myocardial tissue, myocardial T₁ enhancement during bolus administration of contrast can be strongly affected by myocardial water exchange for both intravascular and extracellular MR contrast agents.     

Practical guidelines for action regarding application of CPR/DNR

Technological advances in the field of medicine have resulted in the prolongation of lives that under ordinary conditions would have terminated. Such advances, though calling attention to the wonders of modern technology, are not without significant complications. The injudicious application of extraordinary procedures for extending life highlights problems that affect medical, social, and psychological as well as moral and ethical realms. The complexity of the problems has long since perplexed health/human service practitioners charged with effecting and/or assisting in the implementation of the critical life-death decisions on which this paper focuses.

A systematic strategy is outlined to guide human service providers in making decisions regarding the application or withholding of life-sustaining procedures. Emphasis is placed upon the integrity of self-determination as it relates to competency. Procedures for the incompetent patient are recommended.     

Acute inhalation toxicity of eugenol in rats

The acute toxicity of inhaled eugenol was assessed by exposure of three groups of five male and five female rats to a submicron aerosol of eugenol for 4 h followed by a 14-day observation period. A fourth group, also of five male and five female rats and exposed to air only under similar conditions, served as a control group for comparison. The three concentrations of eugenol to which the different groups were exposed were 2.58, 1.37 and 0.77 mg/l. The mass median aerodynamic diameters and geometric standard deviations of the aerosols were, respectively, 0.82 m (g 2.26), 0.88 m (g 2.05) and 0.9 m (g 1.87). Clinical signs observed during exposure consisted principally of moderately increased salivation and restlessness (indicative of irritation) and abnormal breathing patterns. The signs were graded, being less marked in animals exposed to the lower concentrations of eugenol. All three groups, exposed to high, medium and low levels of eugenol, lost weight overnight following exposure. Associated with the weight loss were marked reductions in food and water intake. The responses appeared to be largely independent of the concentration of eugenol inhaled, although there was some evidence of a graded effect on water intake. There was rapid recovery, with food and water consumption data comparable with control values throughout most of the remainder of the 14-day observation period. Also, by the end of the observation period, group mean body weights were comparable. Upon sacrifice and macroscopic examination of the animals, abnormalities were detected in the lungs only of a few animals: 3/10 control, 2/10 eugenol 2.58 mg/l, and 2/10 eugenol 0.77 mg/l. These consisted of dark red/red (raised) areas up to 4×4 mm. Such abnormalities are not uncommon in the lungs of laboratory maintained rats and their presence with equal incidence in control animals suggests that they are unlikely to be related to inhalation of eugenol. Lung weight to body weight ratio values for all groups were similar, providing no evidence of any persistent effect of eugenol on the lungs of the rats. Similarly, histopathological examination of the lung failed to reveal any treatment-related changes. A few incidental lesions present were considered spontaneous in origin and therefore of no toxicological importance.     

The ultrastructure of the avian Golgi tendon organ

The ultrastructure of the avian Golgi tendon organ (GTO) is described and compared with those of mammals using transverse sections through the myo-tendinous junctions of wing muscles of adult mallard ducks. The capsule, which is continuous with the perineural epithelial sheath of the Ib afferent nerve fiber, consists of four to seven flattened cellular lamellae. Two to four muscle fibers attach to large collagen bundles which enter the GTO through a tight collar at the proximal end of the fusiform capsule. These collagen bundles divide into many smaller bundles, which run longitudinally through the lumen in compartments formed by septal cells. The septal cells contain many prominent lipid accumulations. The Ib axon divides several times, and the unmyelinated branch axons weave between the small collagen bundles. Schwann cell processes or basement membrane usually intervene between the axons and collagen bundles. The small collagen bundles regroup into larger bundles, which pass through tight capsular collars and merge with the main muscle tendon. The size of the duck GTOs was measured and found to be smaller than the GTOs of man, cat or rat.     

Lung surfactant gelation induced by epithelial cells exposed to air pollution or oxidative stress

Lung surfactant lowers surface tension and adjusts interfacial rheology to facilitate breathing. A novel instrument, the interfacial stress rheometer (ISR), uses an oscillating magnetic needle to measure the shear viscosity and elasticity of a surfactant monolayer at the air-water interface. The ISR reveals that calf lung surfactant, Infasurf, exhibits remarkable fluidity, even when exposed to air pollution residual oil fly ash (ROFA), hydrogen peroxide (H2O2), or conditioned media from resting A549 alveolar epithelial cells (AEC). However, when Infasurf is exposed to a subphase of the soluble fraction of ROFA- or H2O2-treated AEC conditioned media, there is a prominent increase in surfactant elasticity and viscosity, representing two-dimensional gelation. Surfactant gelation is decreased when ROFA-AEC are pretreated with inhibitors of cellular reactive oxygen species (ROS), or with a mitochondrial anion channel inhibitor, as well as when A549-rho0 cells that lack mitochondrial DNA and functional electron transport are investigated. These results implicate both mitochondrial and nonmitochondrial ROS generation in ROFA-AEC-induced surfactant gelation. A549 cells treated with H2O2 demonstrate a dose-dependent increase in lung surfactant gelation. The ISR is a unique and sensitive instrument to characterize surfactant gelation induced by oxidatively stressed AEC.     

Calcineurin B1 is essential for positive but not negative selection during thymocyte development

During development, discrete cell fates often result from variation in the intensity of a particular signal. The mechanisms underlying these seemingly analog-to-digital switches are not understood. In developing T lymphocytes, low-intensity signals through the antigen receptor result in positive selection while more intense signals give rise to negative selection. By deleting the genetic locus encoding the regulatory B1 subunit of calcineurin specifically in thymocytes, we found an absolute requirement for calcineurin in positive selection. In contrast, calcineurin activity was dispensable in several models of negative selection. Unexpectedly, we found that removal of calcineurin activity from thymocytes results in inefficient ERK activation at the double-positive stage of thymocyte development, when selection occurs. These studies clarify the mechanism by which graded signals are converted to discrete outcomes in T cell development and further indicate that the developmental roles of calcineurin likely contribute to immunosuppression by calcineurin inhibitors.