A Canadian model for developing mental health services in rural communities through linkages with urban centers

The development of mental health care services in rural areas has been a constant challenge in most countries of significant geographical size. By use of a case study from Canada, the development of a relationship between rural and urban mental health services was described. Issues including referral patterns, service accessibility, professional recruitment and the development of service in rural regions were studied. It is advanced that mental health administrators, policy-makers, clinical service coordinators and educators will find that this approach to the development of mental health services in rural areas has some utility in Canada and in other countries.     

H1 and H2 receptor antagonists and hepatic oxygen supply-demand relationship in pigs

The hypothesis that histamine receptor (H1 and H2) blockade beneficially affects the hepatic oxygen supply-demand relationship was tested during experiments performed on 13 miniature pigs. Hepatic arterial and portal blood flows were measured with electromagnetic flowmeters. Cardiac output was determined by thermodilution. H1 and H2 receptor blockade was achieved with promethazine, 5 mg.kg-1 and cimetidine 30 mg.kg-1 IV, respectively. The study demonstrated no significant effect of H1 and H2 receptor blockade on hepatic oxygen uptake and no noticeable effects of cimetidine on hepatic circulation. However, promethazine decreased total hepatic blood flow, primarily by decreasing portal blood flow; this resulted in an increase in oxygen extraction as reflected in a decreased oxygen content in hepatic venous blood. The results reject the posed hypothesis: H1 receptor antagonist promethazine decreased, while H2 receptor antagonist cimetidine did not affect hepatic blood flow and oxygen supply; hepatic oxygen demand remained unaffected during H1 and H2 receptor blockade.     

The use of an antibiotic-impregnated spacer block for revision of the septic total knee arthroplasty

Through the use of an antibiotic-impregnated polymethylmethacrylate spacer block in two-stage exchange arthroplasty, the chronically infected total knee arthroplasty can, in most cases, be effectively salvaged. In a review of 28 such consecutive cases by a single surgeon, all revised implants were retained except one which required arthrodesis. In the remaining cases, mean Hospital for Special Surgery knee scores were 86, with mean total range of motion of 90 degrees . All wounds healed eventually, and seven patients were thereafter able to undergo other total joint arthroplasties. Advantages of this technique included maintenance of ligamentous balance as well as bone stock with weight bearing, local antibiotic delivery, and facilitation of reimplantation.     

Implantation of human fetal ventral mesencephalon to the right caudate nucleus in advanced Parkinson's disease

Disaggregated ventral mesencephalic tissue from single aborted human fetuses of 11 to 18 weeks' gestation was implanted stereotaxically into a consistent striatal site in 12 patients with advanced Parkinson's disease. All were receiving optimum levodopa therapy and were examined preoperatively and at 3,6,9, and 12 months postoperatively. Immunosuppression was not used. There were significant sustained improvements at 12 months in three patients; motor fluctuations were absent in two. There were modest group improvements up to 6 months, with increased quality of "on" and "off" phases, quantity of on times, and specific improvements in contralateral upper limb bradykinesia. Preoperative levodopa requirements were reduced to a mean of 64% at 6 months and 61% at 12 months. Deterioration below baseline ratings occurred in three of nine patients who had consistent follow-up to 12 months. Grafting of midgestational human fetal tissue can lead to improvement in Parkinson's disease. Individual disease severity may be critical, and further trials are needed to identify host factors influencing outcome.     

Surgery centers continue pattern of growth

The number of outpatient surgery centers grew at an 11% clip in 1990, fueled by the continued shift of patients and procedures to the outpatient setting, according to a recent survey by SMG Marketing Group, a Chicago-based healthcare consulting and market research firm. But while figures project continued growth, competition and government regulation could limit future expansion.     

Endogenous opiates-a progress report.

The "opiate receptor" has become a well-accepted entity, stimulating the search for an endogenous agonist. This has successfully revealed several different endogenous peptide opiates whose physiological role is under intense investigation, contributing to our understanding of pain and of opiate tolerance and dependence. A review of the current literature is presented.     

The kinetic and structural characterization of the reaction of nafamostat with bovine pancreatic trypsin

Nafamostat mesilate (FUT-175), a synthetic serine protease inhibitor, is active against a number of the serine proteases involved in coagulation. This has been proposed as the basis of its anticoagulant activity. We investigated the reaction of Nafamostat with bovine pancreatic trypsin as a model system. It was shown to act as a time-dependent competitive inhibitor, and the inhibition constants for the binding of Nafamostat to trypsin (i.e., K_i) and the overall inhibition constants (i.e., K_i^*) were calculated to be 11.5 μM and 0.4±0.14 nM, respectively. The second-order rate constant for the reaction was 4.5±0.19×10⁵ M⁻¹s⁻¹, and the product released following the acylation step, 6-amidino-2-naphthol, showed mixed-type inhibition. The competitive (K_ic) and uncompetitive (K_iu) inhibition constants were 14.7 μM and 19.5 μM, respectively. Formation of the acyl-enzyme intermediate was dissected into at least two steps, with rates of 0.9 s⁻¹ and 195 s⁻¹. The deacylation step was relatively much slower (3.2±0.19×10⁻⁵ s⁻¹), enabling the mass spectroscopic analysis of the acyl-enzyme intermediate, which confirmed the covalent attachment of 4-guanidinobenzoic acid to trypsin. The product of the deacylation step, 4-guanidinobenzoic acid, showed no inhibition up to a concentration of 200 μM. These data strongly suggest that while Nafamostat is a potent inhibitor of trypsin, it is actually an extremely poor substrate, and that apparent inhibition is due to the competitive formation of a very stable acyl-enzyme intermediate, analogous to some other active site titrants.     

Angiographically defined collateral circulation and risk of stroke in patients with severe carotid artery stenosis. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group

BACKGROUND AND PURPOSE: Blood supply through collateral pathways improves regional cerebral blood flow and may protect against ischemic events. The effect of collaterals on the risk of stroke and transient ischemic attack (TIA), in the presence of angiographic severe internal carotid artery (ICA) stenosis, was assessed. METHODS: Angiographic collateral filling through anterior communicating and posterior communicating arteries and retrograde filling through ophthalmic arteries were determined in all patients at entry into the North American Symptomatic Carotid Endarterectomy Trial. Kaplan-Meier event-free survival analyses were performed on 339 medically treated and 342 surgically treated patients. RESULTS: The presence of collaterals supplying the symptomatic ICA increased with severity of stenosis. Two-year risk of hemispheric stroke in medically treated patients with severe ICA stenosis was reduced in the presence of collaterals: 27.8% to 11.3% (P=0.005). Similar reductions were observed for hemispheric TIA (36.1% versus 19.1%; P=0.008) and disabling or fatal strokes (13.3% versus 6.3%; P=0.11). For surgically treated patients, the perioperative risk of hemispheric stroke was 1.1% in the presence of collaterals versus 4. 9% when absent. The 2-year stroke risks for surgical patients with and without collaterals were 5.9% versus 8.4%, respectively. Neither comparison in the surgical group was statistically significant. The observed reductions were independent of the degree of ICA stenosis and other vascular risk factors. CONCLUSIONS: Collaterals are associated with a lower risk of hemispheric stroke and TIA, both long term and perioperatively. Angiographic identification of collaterals assists in identifying patients with severe ICA stenosis at lower risk of stroke and TIA.     

Staff exposure to anaesthetic gases in theatre and non theatre areas

Environmental monitoring of anaesthetic gases was carried out in theatre areas in eight hospitals as well as in Delivery suites, radiology, radiotherapy and Dental suites. High staff exposures occurred in nontheatre areas although exposures in theatres were generally satisfactory. Environmental control measures are required where staff exposures exceed legal standards.     

Limb amputation on renal replacement therapy

Ten (10) diabetic and 7 non-diabetic patients on renal replacement therapy have undergone limb amputation in the authors' unit in the 1988 to 1996 period. The article examines the course of illness and survival patterns in this distinct and increasing sub-set in the amputee population. Rehabilitation and survival were significantly better in the diabetic group and it is recommended that it would be helpful for both prognosis and analysis if the sub-set of amputees on treatment for chronic renal failure is further divided into diabetic and non-diabetic sub-sets.