Provision of, and patient satisfaction with, primary care services in a relatively affluent area and a relatively deprived area of Glasgow.

This paper presents the results of a survey of the structure of general practice in two contrasting areas within Greater Glasgow health board: the south west area had a more deprived social profile at the 1981 census and higher than average all cause and selected major cause standardized mortality ratios than the health board as a whole while the north west area had a more affluent social profile at the 1981 census and lower than average all cause and selected major cause standardized mortality ratios. The general practice survey data gathered in 1989 were supplemented with data from a survey of residents of the localities in three age cohorts carried out in 1987-88, which provided information on use of services, as well as perceived accessibility of and satisfaction with them. Despite the more deprived social and mortality profile of the south west area, and greater use of services, few systematic differences in the structure of general practices were found in the two areas. These findings support other studies which suggest that the stereotype of poorly resourced, low quality primary care in inner city areas may apply in London, but not elsewhere. Respondents in both areas were equally satisfied with services and found them accessible.     

Structure of autonomic neuromuscular junctions in the sinus venosus of the toad.

The structure of cholinergic and adrenergic neuromuscular junctions in the sinus venosus of the toad, Bufo marinus, was determined by electron microscopy. From random sections of sinus venosus tissue it appeared that there were variable separations between cholinergic or adrenergic varicosities and the nearest sinus venosus muscle cell. However, when the structure of complete cholinergic and adrenergic varicosities was determined by examining serial electron micrographs, virtually all varicosities that lost their covering of Schwann cell were found to form an area of close apposition with an adjacent muscle cell. At the region of close apposition, the neuromuscular cleft was filled with a single layer of basal lamina to give a neuromuscular separation of about 70 nm. Synaptic vesicles within a varicosity were usually found to be concentrated towards the region of close apposition. These observations are discussed in relationship to the idea that when transmission occurs at these neuromuscular junctions the transmitters act on discrete pools of specialized subsynaptic receptors.     

Biochemical composition of amniotic fluid and extraembryonic coelomic fluid in the first trimester of pregnancy.

OBJECTIVE: To determine the biochemical composition of amniotic fluid and extraembryonic coelomic fluid between 8 and 12 weeks gestation. DESIGN: Prospective observational study. SUBJECTS: 40 women with a normal pregnancy between 7 and 12 weeks gestation having termination of pregnancy. INTERVENTIONS: Before termination the women had a transvaginal ultrasound guided amniocentesis. Pure samples of amniotic fluid and extraembryonic coelomic fluid were obtained from each woman and standard biochemical variables were measured in each fluid sample immediately after collection. RESULTS: Levels of sodium, potassium and bicarbonate were significantly higher in amniotic fluid whilst chloride, urea, bilirubin, protein, albumin, glucose, creatinine, calcium and phosphate were present in higher concentrations in extraembryonic coelomic fluid. All differences in concentration were significant (P less than 0.05; unpaired t-test). No relation was demonstrated between electrolyte concentrations in amniotic fluid or coelomic fluid and stage of gestation. CONCLUSIONS: Amniotic fluid and extraembryonic coelomic fluid have a widely differing biochemical composition. The biological significance of these differences remains unexplained.     

Hypoglycemic drugs.

There are an estimated 14 million individuals in the United States with diabetes mellitus. These individuals suffer a very high incidence of podiatric complications. This article focuses on the pharmacologic agents used in the management of hyperglycemia in the patient with diabetes mellitus, including insulin and sulfonylureas.     

The evoked K-complex: all-or-none phenomenon?

The functional significance and topographical variation of the different components of the evoked K-complex were examined. In the first experiment, the intensity of the stimulus (80 and 60 dB SPL) and its rise-and-fall time (2 and 20 milliseconds) were manipulated during nonrapid eye movement sleep. In the second experiment the tonal frequency (500, 1,000 and 2,000 Hz) of the stimulus was manipulated. In the first experiment, nine stimuli were presented every 10 seconds, whereas in the second, 20 consecutive stimuli were presented. The evoked K-complex consisted of two different negative components peaking at approximately 350 and 550 milliseconds, respectively, and followed by a positive component peaking at approximately 900 milliseconds. K-complexes were easier to elicit for high-intensity fast rise-and-fall time stimuli than for low-intensity slow rise-and-fall time stimuli. The probability of occurrence was not affected by the tonal frequency of the stimulus. When a K-complex was evoked, the amplitude and latency of N350, N550 and P900 remained invariant regardless of its intensity, rise-and-fall or its tonal frequency. The N550-P900 portion of the K-complex therefore appears to be an all-or-none phenomenon. On trials in which a K-complex could not be elicited, N350 was still visible although much attenuated. In these trials, its amplitude was further reduced when stimulus intensity was lowered. N350 might need to reach a certain critical threshold before the much larger N550-P900 complex is elicited.     

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND KININ METABOLISM: EVIDENCE THAT ACE INHIBITORS MAY INHIBIT A KININASE OTHER THAN ACE

1. Angiotensin converting enzyme (ACE) converts angiotensin I to angiotensin II, and also metabolizes bradykinin-(1–9) to bradykinin-(1–7) and bradykinin-(1–7) to bradykinin-(1–5). Increases in endogenous kinin levels may contribute to the therapeutic effects of ACE inhibitors. 2. ACE inhibitors increase vascular levels of both bradykinin-(1–9) and its ACE cleavage product bradykinin-(1–7), at doses below the threshold for ACE inhibition, leading to the proposal that ACE inhibitors may also inhibit a non-ACE kininase which cleaves both kinin peptides; this non-ACE kininase may be the major pathway of kinin metabolism in the vasculature and some other tissues. 3. In support of this proposal, ACE inhibitors potentiate bradykinin-(1–9) effects at doses which have little or no effect on ACE activity, as indicated by angiotensin I conversion to angiotensin II. ACE inhibitors also potentiate the actions of ACE-resistant kinin analogues, which may be susceptible to metabolism by a non-ACE kininase. 4. Identification and characterization of the putative non-ACE kininase which is inhibited by ACE inhibitors may reveal novel approaches to the tissue-specific modulation of kinin levels.     

Use of intracavity saline instillation and transvaginal ultrasonography to detect tamoxifen-associated endometrial polyps.

There is sometimes a discrepancy between the apparent thickness of postmenopausal endometria, as determined by transvaginal ultrasonography, and the examination of endometrial biopsies. We describe a case which showed that tamoxifen (20 mg/day over 12 months) decreased impedance to blood flow in the uterine arteries and increased the apparent thickness of the endometrium. Conversely, the analysis of biopsies suggested the presence of an atrophic endometrium. The introduction of sterile saline into the uterine cavity during a repeat ultrasound scan revealed the presence of a large, free-floating endometrial polyp, which was subsequently difficult to see by hysteroscopy.     

Pseudopapilloedema in the linear naevus syndrome.

This case report describes the ophthalmic findings in a child with the linear naevus syndrome. The patient was referred by the Department of Paediatric Neurology with 'unilateral papilloedema'. This was thought to be a form of pseudopapilloedema, a finding that has not been previously described in this syndrome.     

Diagnosis and management (by subxiphoid pericardiotomy) of large pericardial effusions causing cardiac tamponade.

To determine the clinical features, course and outcome of patients with cardiac tamponade, 57 consecutive patients with new, large pericardial effusions were prospectively studied. Twenty-five patients (44%) developed cardiac tamponade with venous hypertension and a pulsus paradoxus greater than 10 mm Hg. Electrocardiography, radiographic studies and echocardiography did not differentiate patients with and without tamponade. All 57 patients underwent thorough diagnostic evaluation followed by subxiphoid pericardial biopsy and drainage. A diagnosis was obtained in 53 patients (93%). Collagen vascular disease was significantly more frequent in the 25 patients with than in the 32 without cardiac tamponade (24 vs 3%; p less than 0.05). The frequency of malignant and uremic effusions was equal in both groups, whereas radiation-induced effusions seldom produced tamponade. At 1-year follow-up, 3 patients (12%) with tamponade had recurrent effusions, and 1 needed reoperation. This was not significantly different from the 32 patients without tamponade. Twelve-month mortality was also similar in both groups (36 vs 44%). This prospective series disclosed several unexpected findings: (1) Cardiac tamponade occurred in almost 50% of patients with new large pericardial effusions; (2) both malignancy and collagen vascular disease occurred with equal frequency as etiologies, whereas radiation-induced tamponade was unusual; (3) thorough clinical evaluation resulted in few idiopathic etiologies; and (4) subxiphoid pericardiotomy was effective for both diagnosis and therapy of tamponade.     

Innovative endpoint determination system for antifungal susceptibility testing of yeasts.

Fungal infections and antifungal resistance are increasingly recognized. Antifungal susceptibility testing remains unstandardized, and a particularly important problem is endpoint determination. In this paper we propose the yeast metabolic reduction of the tetrazolium salt 2,3-bis(2- methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)carbonyl]-2H-tetraz olium hydroxide (XTT) as a colorimetric endpoint which is quantitative and objective. Amphotericin B, fluorocytosine, and fluconazole dose-response curves were obtained, and a metabolic MIC could be determined by using precise criteria.