Treatment of cigarette dependency. What American pulmonary physicians do

Physician advice and counseling can significantly help patients stop smoking. Consequently, we surveyed 588 of 2,207 actively practicing American pulmonary clinicians attending the 1983 Annual Meeting of the American Thoracic Society to determine what they did to help their patients stop smoking. Ninety-nine and one tenth percent of those pulmonary internists who had never smoked recorded the smoking habits of their patients and 100% advised smokers to stop. In contrast, pulmonary internists who themselves smoked cigarettes were significantly less inclined to do these two things; 84.6% and 92.3%, respectively (p less than 0.01). There was also a trend for more never smoking internists to provide additional services to patients wishing to stop smoking. Of the pulmonary internists, 86.8% wanted to learn new techniques to help their patients stop smoking. Essentially, 75% of the small sample of pediatric pulmonary specialists surveyed felt that determining whether their patients smoked or not and providing services to help them stop smoking was "not applicable" to their practice.     

Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire

OBJECTIVE: Bipolar spectrum disorders, which include bipolar I, bipolar II, and bipolar disorder not otherwise specified, frequently go unrecognized, undiagnosed, and untreated. This report describes the validation of a new brief self-report screening instrument for bipolar spectrum disorders called the Mood Disorder Questionnaire. METHOD: A total of 198 patients attending five outpatient clinics that primarily treat patients with mood disorders completed the Mood Disorder Questionnaire. A research professional, blind to the Mood Disorder Questionnaire results, conducted a telephone research diagnostic interview by means of the bipolar module of the Structured Clinical Interview for DSM-IV. RESULTS: A Mood Disorder Questionnaire screening score of 7 or more items yielded good sensitivity (0.73) and very good specificity (0.90). CONCLUSIONS: The Mood Disorder Questionnaire is a useful screening instrument for bipolar spectrum disorder in a psychiatric outpatient population.     

Real-time in vivo loading in the lumbar spine: part 1. Interbody implant: load cell design and preliminary results

STUDY DESIGN: Instrumented interbody implants were placed into the disc space of a motion segment in two baboons. During the animal's activities, implants directly measured in vivo loads in the lumbar spine by telemetry transmitter. OBJECTIVES: Develop and test an interbody implant-load cell and use the implant to measure directly loads imposed on the lumbar spine of the baboon, a semiupright animal. SUMMARY OF BACKGROUND DATA: In vivo forces in the lumbar spine have been estimated using body weight calculations, moment arm models, dynamic chain models, electromyogram measurements, and intervertebral disc pressure measurements. METHODS: An analytical model was used to determine the force-strain relation in a customized interbody implant. After validation by finite element modeling, strain gauges were mounted onto the implant and connected to a telemetry transmitter. Implants were placed surgically into the L4-L5 disc space of skeletally mature baboons and the transmitter in the flank. After surgery, load data were collected from the animals during activities. Radiographs were taken monthly to assess fusion. RESULTS: The implant-load cell is sufficiently sensitive to monitor dynamic changes in strain and load. During extreme activity, highest measurable strain values were indicative of loads in excess of 2.8 times body weight. CONCLUSIONS: The study technique and technology are efficacious for measuring real-time in vivo loads in the spine. Measuring load on an intradiscal implant over the course of healing provides key information about the mechanics of this process. Loads may be used to indicate performance demands on the intervertebral disc and interbody implants for subsequent implant design.     

Porcine stem cell engraftment and seeding of murine thymus with class II+ cells in mice expressing porcine cytokines: toward tolerance induction across discordant xenogeneic barriers

BACKGROUND: Mixed hematopoietic chimerism is a reliable means of tolerance induction, but its utility has not been demonstrated in discordant xenogeneic combinations because of the difficulty in achieving lasting hematopoietic engraftment. Miniature swine are likely to be suitable organ donors for humans. To evaluate the ability of mixed chimerism to induce swine-specific tolerance in widely disparate xenogeneic recipients, this study aimed to achieve long-lasting chimerism in a pig to mouse combination. METHODS: Immunodeficient transgenic mice were developed by crossing transgenic founders carrying porcine interleukin-3, granulocyte macrophage-colony stimulating factor, and stem cell factor genes with severe combined immunodeficient mice or non-obese diabetic/severe combined immunodeficient mice. Swine bone marrow transplantation was performed in these mice, and porcine chimerism was followed for 20 weeks. RESULTS: Whereas swine cells became undetectable in all non-Tg littermates by 7 weeks, high levels of porcine hematopoietic chimerism, including the presence of porcine class II+ cells in the host thymus were maintained in Tg mice for >20 weeks. Colony-forming assays revealed the presence of large numbers of swine hematopoietic progenitor cells in the marrow of these mice at 20 weeks after bone marrow transplantation. CONCLUSIONS: These transgenic mice demonstrate for the first time that spontaneous migration of marrow donor antigen-presenting cells to an intact recipient thymus can occur and that porcine stem cells can persist in this highly disparate species combination. These data therefore support the feasibility of the eventual goal of tolerance induction by mixed chimerism in discordant xenogeneic combinations.     

Intragraft events preceding chronic renal allograft rejection in a modified tolerance protocol

BACKGROUND: Inbred miniature swine treated for 12 days with high-dose cyclosporine A develop tolerance to histocompatibility complex (MHC) class I-mismatched renal allografts. When this protocol was modified by adding thymectomy before transplant, all animals developed acute rejection. Thereafter, by day 100, one half developed chronic rejection (progression group) and the other half recovered (recovery group). This provides an excellent experimental model to identify the mechanisms of chronic rejection as well as the early changes that may predict chronic rejection. METHODS: We assessed the cellular infiltration, immune activation, humoral immunity, and cell- and antibody-mediated graft injury in the progression and the recovery groups. In addition, we also examined circulating donor reactive cytotoxic T lymphocyte (CTL) and antidonor antibody in both groups. RESULTS: From days 8 to 18 after transplantation, the two groups were indistinguishable. Both showed acute rejection with endarteritis (type II); had IgG and IgM deposition in glomeruli and small vessels; had an infiltrate with similar numbers of T cells, proliferating (PCNA+) and activated (interleukin-2 receptor+) cells; and had a similar degree of parenchymal cell apoptosis [in situ DNA nick-end labeling (TUNEL)+]. However, by days 30 to 60, the two groups could be distinguished by several intragraft features. The recovery group became tolerant and had diminished T-cell infiltration, activation and proliferation, and no detectable antibody deposition. The number of TUNEL+-injured parenchymal cells decreased. In contrast, the progression group showed persistent cell infiltration with activation and proliferation. Significantly prominent TUNEL+ apoptotic parenchymal cells in tubules, glomeruli, peritubular capillaries and arteries were seen from day 30 to day 100. Circulating donor reactive CTL and antidonor class I IgG were detected in the progression group at higher levels than in the recovery group from days 30 to 60. CONCLUSION: In tolerance-induction protocols, unstable tolerance induction is associated with the persistent immunologic activation that mediates immunologic destruction of graft parenchymal cells and chronic rejection. Certain of the described immunopathologic findings (activation, proliferation, apoptosis, and antibody deposition) may be useful in distinguishing the type of rejection, that is, whether the allograft will progress to chronic rejection or recovery.     

Treating nondementia illnesses in patients with dementia

Physicians increasingly are called on to provide primary care for the growing population of people with Alzheimer-type dementia. However, little attention has been paid to the care of nondementia illnesses in this group of patients. To illustrate how presence of dementia can alter the risk-benefit ratio of treatment of a common medical problem, we present a case study in which a patient with dementia developed disastrous adverse effects to a drug commonly used to treat osteoporosis. This case and 2 composite vignettes illuminate how presence of dementia should influence the decision-making process for treatment of nondementia illnesses. We address issues such as decreased decision-making capacity, problems with reporting adverse effects, decreased cognition leading to problems with treatment adherence, and the role of screening and basic questions about acceptable burdens of treatments in patients with limited prognosis. We suggest ways to improve communication with patients with dementia in an effort to minimize complications and improve care, as well as policy changes to include patients with dementia in clinical trials. JAMA. 2000;283:3230-3235