A new method to measure renal tubular degradation of small filtered proteins in man using radiolabelled aprotinin (Trasylol).

1. A method has been developed to measure the renal tubular degradation of small filtered proteins in man using radiolabelled aprotinin (Trasylol), a 6500 Da cationic polypeptide. 2. Aprotinin (0.5 or 5.0 mg) was labelled with either 99mTc (40 MBq) or 131I (1 MBq) and injected intravenously in 19 renal patients (10 with normal renal function and nine on haemodialysis). Activity in plasma and urine was measured over 48 h, and chromatography with Sephadex-G-25-M was used to separate labelled aprotinin from free 99mTcO4- or 131I-. Renal uptake was measured for 99mTc-labelled aprotinin only. 3. The volumes of distribution were similar in all patients: 18.2 +/- 0.4 litres in those with normal renal function and 20.2 +/- 0.1 litres in the others. Chromatography showed all plasma activity as undegraded aprotinin and urine activity only as the free labels (99mTcO4- or 131I-). 4. In patients with normal renal function, activity in the kidneys rose rapidly to 24.2 +/- 2.8% of dose after 90 min and to 42.2 +/- 3.4% of dose after 24 h. In the dialysis patients, activity over the kidneys was only 2.7 +/- 0.8% of dose at 24 h. Extra-renal uptake was insignificant in all patients with normal kidney function. 5. Both 99mTcO4- and 131I- appeared in the urine promptly after injection, and the rates of excretion of the two isotopes were similar, varying little over 24 h (1.8 +/- 0.04% of dose/h and 1.7 +/- 0.04% of dose/h for 99mTc and 131I, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)     

Longitudinal assessment of antipneumococcal susceptibility in the United States

The prevalence of antimicrobial resistance among 4,940 U.S. pneumococcal isolates collected during 1999 was as follows: penicillin, 16.2%; amoxicillin-clavulanate, 12.2%; cefuroxime, 28.1%; ceftriaxone, 3.6%; trimethoprim-sulfamethoxazole, 30.3%; azithromycin, 21.4%; levofloxacin, 0.6%; and moxifloxacin, 0.1%. Compared to the previous 1997-1998 study (Jones et al., Antimicrob. Agents Chemother. 44:2645-2652, 2000), increases were noted for resistance to penicillin (3.7%; P < 0.001), amoxicillin-clavulanate (3.9%; P < 0.001), cefuroxime (5.7%; P < 0.001), azithromycin (2.4%; P = 0.014), trimethoprim-sulfamethoxazole (15.4%; P < 0.001), and levofloxacin (0.3%; P = 0.017). Resistance to ceftriaxone (0.1%; P = 0.809) and moxifloxacin (0.03%; P = 0.570) decreased. Concurrently, multidrug resistance increased (P < 0.001) from 6.3% to 11.3%.     

Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs

STUDY OBJECTIVE: To evaluate the efficacy of a continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with unilateral multiple fractured ribs (MFR). DESIGN: Prospective nonrandomized case series. SETTING: Multidisciplinary tertiary hospital. PATIENTS: Fifteen patients with unilateral MFR. INTERVENTIONS: Insertion of a catheter into the thoracic paravertebral space. We administered an initial injection of 0.3 mL/kg (1.5 mg/kg) bupivacaine 0.5% with 1:200,000 epinephrine followed 30 min later by an infusion of bupivacaine 0.25% at 0.1 to 0.2 mL/kg/h for 4 days. Measurements and results: The following parameters were measured during the initial assessment before thoracic paravertebral block (TPVB), 30 min after the initial injection, and during follow-up on day 1 and day 4 after commencing the infusion of bupivacaine: visual analog pain score at rest and during coughing; respiratory rate; arterial oxygen saturation (SaO(2)); bedside spirometry (ie, FVC, FEV(1), FEV(1)/FVC ratio, and peak expiratory flow rate [PEFR]); arterial blood gas measurements; and O(2) index (ie, PaO(2)/fraction of inspired oxygen ratio). There were significant improvements in pain scores (at rest, p = 0.002; during coughing, p = 0.001), respiratory rate (p < 0.0001), FVC (p = 0.007), PEFR (p = 0.01), SaO(2) (p = 0.04), and O(2) index (p = 0.01) 30 min after the initial injection, which were sustained for the 4 days that the thoracic paravertebral infusion was in use (p < 0.05). PaCO(2) did not change significantly after the initial injection, but on day 4 it was significantly lower than the post-TPVB value (p = 0.04). One patient had an inadvertent epidural injection, and another developed transient ipsilateral Horner syndrome with sensory changes in the arm. No patient exhibited clinical signs of inadvertent intravascular injection or local anesthetic toxicity. CONCLUSION: Our results confirmed that continuous thoracic paravertebral infusion of bupivacaine is a simple and effective method of providing continuous pain relief in patients with unilateral MFR. It also produced a sustained improvement in respiratory parameters and oxygenation.     

Molecular and cellular causes of abnormal uterine bleeding of endometrial origin

Women today may reasonably anticipate in the order of some 400 menstrual cycles over their reproductive lifespan. The endometrium is thus subject to repeat cycles of shedding and repair and notably healing of the endometrium post menses is "scarless". The local molecular and cellular mechanisms involved in post menstrual resolution of the inflammatory events associated with menstruation and endometrial repair remain to be fully determined. Menstrual complaints are common. It is highly likely that unrestrained local inflammatory events and/ or deficient repair processes within the endometrium contribute to the women's experience of heavy menstrual bleeding (HMB). The management of women with HMB may need to utilize therapeutic approaches that optimize endometrial repair processes, post menses. These approaches may be necessary in addition to current therapies that hitherto have focused on limiting the local inflammation associated with menstruation. Research endeavors thus need to focus upon the molecular and cellular causes of problematic uterine bleeding. Herein the events associated with pre-menstrual progesterone withdrawal, limitation of blood loss, the expression of vasoactive mediators and factors that may modulate vascular morphology are described. Such lines of enquiry and knowledge will be essential if novel targets for treatment of menstrual bleeding complaints, such as HMB, are to be identified.     

Methods of surveillance for HIV infection at U.S. sentinel hospitals

The U.S. sentinel hospital surveillance system for human immunodeficiency virus (HIV) infection includes approximately 40 short-stay hospitals located in 31 metropolitan areas in the United States and Puerto Rico. Several hospitals began testing in late 1986, and additional sentinel hospitals have since been recruited. At each sentinel hospital, anonymous, unlinked testing for antibody to HIV is conducted monthly on 300 blood specimens, selected systematically and stratified by age of the patient. Specimens are excluded from patients whose reason for hospital visit on that occasion was for a medical condition associated with HIV infection or with risk factors for HIV infection, in order to limit the expected overrepresentation of HIV-infected persons among hospital patients compared with the general catchment population of the hospital. The incidence of acquired immunodeficiency syndrome (AIDS) in metropolitan areas with sentinel hospitals has been approximately twice the incidence of AIDS in the entire United States. However, while absolute levels of HIV seroprevalence should therefore be interpreted with caution, trends in the age-, sex-, and race-specific HIV seroprevalence at sentinel hospitals likely reflect trends in the communities served by the hospitals. Although concentrated in areas disproportionately affected by AIDS, sentinel hospitals will contribute seroprevalence data over time that reflect the impact of HIV infection across all age and behavioral risk groups. Sentinel hospitals will also constitute a key surveillance system to help integrate the age group-specific and risk group-specific findings from other activities in the CDC family of seroprevalence surveys.     

Knowledge translation case study: a rural community collaborates with researchers to investigate health issues

INTRODUCTION: Knowledge translation implies the exchange and synthesis of knowledge between researchers and research users, employing a high level of communication and participation, not only to share the knowledge found through research, but also to implement subsequent strategies. Prince Edward Island, a rural province in Canada, provided the setting to exchange knowledge between researchers and a rural community on the health issues affecting children. METHODS: A case study reports census data, demographic trends, and information about health issues immediate to the community. These focus groups were held to plan solutions to the community's health priorities. The process was participatory, characterized by community involvement. RESULTS: Those participating in the focus groups were interested in research findings and literature to solve local problems. Parenting and mental health were determined to be priority issues requiring broader community engagement. The process of translating knowledge into action after the focus groups met lacked widespread involvement of the community. DISCUSSION: Although encouraged to do so, the larger rural community did not participate in examining research findings or in planning interventions. The parents in this community may not have perceived themselves as having influence in the process or goals of the project.     

Haemodynamic effects of three doses of dihydroergotamine during spinal anaesthesia

We performed a randomized study comparing the haemodynamic effectsof three doses of the vasopressor dihydroergotamine (DHE) (5,10 and 15 µg kg^–1) in 30 ASA 1 and 2 patients,aged 53–87 yr, undergoing spinal anaesthesia. Non-invasivesystolic arterial pressure (SAP), heart rate and central venouspressure (CVP) were recorded continuously for 25 min. Intravenousfluids were withheld during this period. All three doses ofDHE reversed the lowering effects of spinal anaesthesia on SAPand CVP (P<0.0001), and these effects were smooth in onsetand sustained. Whereas the lowest (5 µg kg^–1)dose restored SAP and CVP to near prespinal values, the higher(10 and 15 µg kg^–1) doses resulted inabove-baseline increases in SAP of 7% and in CVP of 2.7 cm H₂O(P<0.05). The haemodynamic profile of DHE makes it a usefulagent for managing hypotension during spinal anaesthesia. Adose of 5–10 µg kg^–1 is recommended. Br J Anaesth 2001; 87: 499–501     

A prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain

Objectives

To assess the short- and long-term effectiveness of spinal manipulation therapy, and to identify the effect of manipulation on lumbar muscle endurance in patients with chronic low back pain (LBP).

Design

A randomised controlled trial comparing manipulation and exercise treatment with ultrasound and exercise treatment.

Setting

An outpatient physiotherapy department.

Participants

One hundred and twenty patients with chronic LBP were allocated at random into the manipulation/exercise group or the ultrasound/exercise group.

Interventions

Both groups were given a programme of exercises. In addition, one group received spinal manipulation therapy and the other group received therapeutic ultrasound.

Main outcome measures

Pain intensity, functional disability, lumbar movements and muscle endurance were measured shortly before treatment, at the end of the treatment programme and 6 months after randomisation using surface electromyography.

Results

Following treatment, the manipulation/exercise group showed a statistically significant improvement (P = 0.001) in pain intensity [mean 16.4 mm, 95% confidence interval (CI) 6.1-26.8], functional disability (mean 8%, 95% CI 2-13) and spinal mobility (flexion: mean 9.4 mm, 95% CI 5.5-13.4; extension: mean 3.4 mm, 95% CI 1.0-5.8). There was no significant difference (P = 0.068) between the two groups in the median frequency of surface electromyography (multifidus: mean 6.8 Hz, 95% CI 1.24-14.91; iliocostalis: mean 2.4 Hz, 95% CI 2.5-7.1), although a significant difference (P = 0.013) was found in the median frequency slope of surface electromyography in favour of spinal manipulation for multifidus alone (mean 0.3, 95% CI 0.1-0.5). A significant difference was also found between the two groups in favour of the manipulation/exercise group at 6-month follow-up.

Conclusions

Although improvements were recorded in both groups, patients receiving manipulation/exercise showed a greater improvement compared with those receiving ultrasound/exercise at both the end of the treatment period and at 6-month follow-up.     

Intrusive automatic or nonpropositional inner speech following bilateral cerebral injury: A case report

Abstract

We report the case of a patient, ML, who experienced persistent inner speech vocalizations following bilateral brain injury. The vocalizations consisted of fragments of hymns or prayers learned in childhood; also, repetitions of recent thoughts or heard speech. These were not of a schizophrenic type: they were in her own voice, did not ‘speak to her’ or give orders, and were clearly acknowledged to be internal in origin. We offer a tentative explanation in terms of the excitation of a right hemisphere store of early-acquired, overlearned material combined with the dysfunctioning of a left hemisphere working memory system.