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7788483
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Case report: concordant traumatic brainstem contusion delayed diagnosis in a young man with Wilson's disease.
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Wilson's disease is a hereditary autosomal recessive disorder of copper metabolism. The corresponding gene locus has been localized on the long arm of chromosome 13. Three different clinical variants of the disease can be distinguished: hepato-cerebral, abdominal/hepatic, and central nervous type. The heterogeneity of symptoms can cause problems in differential diagnosis, especially when another concordant disorder can also explain the pathogenesis of symptoms. The case report of a young man who suffered from brainstem contusion demonstrates the possibilities of misinterpretation because presenting symptoms could be attributed either to traumatic brain injury followed by adjustment disorder or Wilson's disease. Clinical signs included leftsided hemiparesis, bilateral gaze direction nystagmus, marked dysarthria with consecutive pervasive mutism, choreo-athetoid movements, spasmodic torticollis and diplopia dependent on gaze direction. Slit lamp examination showed Kayser-Fleischer's corneal ring. EEG- and computer assisted tomography investigations revealed non-specific findings. The patient was treated with D-Penicillamine. Alternative treatment with oral zinc preparations is discussed.
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7788482
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Case report: successful treatment of a case of extreme isolation.
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Tom, aged 10, presented as a stiff, plump boy with a very awkward gait and a completely blank facial expression. He was terrified of other children and could allow no one closer than an arm's length away from him. It transpired that for most of his life he had been kept "safe" in his bare room by his parents whose firstborn child had died. After 8 years of treatment he is now studying at a university and although he lives at home he seems to have made some friends. His facial expressions and tone of voice are now appropriate.
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7788481
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An epidemiological and clinical approach to adolescent suicide. A comparison between suicidal and non-suicidal clinical groups in a health foundation center for French students.
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Suicidal behaviour among young people represents a major public health problem. This study seeks to compare the major sociological, clinical, schooling and family features of suicidal and non-suicidal subgroups of adolescents hospitalised in the Health Foundation Center for French Students of neufmoutiers en Brie (France). All these adolescents suffered from the severe mental disorders. The adolescents from the suicidal subgroup presented significantly fewer psychoses and more mood disorders than those of the non-suicidal subgroup. Half of the patients from the suicidal subgroup presented some features of personality disorders, mostly borderline personality disorders. Nevertheless, their global functioning was more frequently improved between admission and discharge than was the case for the non-suicidal group.
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7788480
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Family stress, family functioning and emotional/behavioural problems following child psychiatric treatment.
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This study assesses family stress, family functioning and emotional/behavioural problems in a sample of 80 formerly daytreated or residentially treated boys after a mean discharge period of four years. Family stress was assessed with a Questionnaire of Life Events (QLE) and family functioning with the Family Adaptability and Cohesion Evaluation Scales (FACES). Emotional/behavioural problems were measured with the Child Behavior Checklist (CBCL). The results showed that there were significant relationships between the QLE, FACES and CBCL scores. In particular, experiencing less negative life events and a more rigid type of family functioning appeared favourable with respect to several types of behavioural problems. When the interrelationships between the family factors and other factors such as age and socio-economic status were taken into account statistically, the number of negative life events appeared the most influential family factor.
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7788479
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Behavioral problems of adolescents with chronic physical illness: a comparison of parent-report and self-report measures.
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This study reports on the extent of behavior problems in Israeli adolescents suffering from chronic illness. A comparison was made between parent-reported and self-reported behavioral symptomatology using the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). 103 outpatients, aged 11-16 years, suffering from cystic fibrosis (CF), asthma, or hematological/oncological conditions were assessed. Healthy adolescents and adolescents referred for psychiatric assessment comprised the comparison groups. Parent- and self-reports were significantly positively correlated in each group (all chronically ill children r = .22; Healthy group r = .27; psychiatric group r = .50), but the correlations were particularly low (and non-significant) in younger adolescents with hematological/oncological conditions or HCF., pointing to the need for physicians to include parents' and adolescents' viewpoints in their assessments of these adolescents' psychosocial state. The mean number of parent-reported and self-reported behavior problems in the illness groups was no different from that of the Healthy group but significantly lower than that of the psychiatric group.
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7788478
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Competencies and problems reported by parents of Greek and American children, ages 6-11.
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This study compared parent-reported competencies and behavioral/emotional problems in demographically-matched samples of Greek and American children, ages 6-11. Parents of 356 children of each nationality completed the Child Behavior Checklist (CBCL). Competence scores were higher for American children, except on Academic Competence, where scores were higher for Greek children. Greek scores were significantly higher than American scores on the Withdrawn, Anxious/Depressed, Attention Problems, Delinquent Behavior, Aggressive Behavior, Internalizing, Externalizing, and Total Problem scales. On the Anxious/Depressed syndrome, nationality accounted for 14% of the variance. There were few main effects for sex and age and fewer interactions. The higher problem scores in the Greek sample were partly due to the tendency of Greek parents to use extreme item scores. When items were scored present v. absent, Greek scores were higher only on Withdrawn, Anxious/Depressed, Internalizing, and Total Problems, while American scores were higher on Somatic Complaints and Thought Problems. Nationality differences in rates of referral for mental health services and sample differences in exclusion criteria for prior mental health services may have contributed to differences in problem scores. Results are compared to findings from other cross-cultural studies.
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7788467
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Age as a factor in identifying young adult chronic patients who are difficult to treat.
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Age younger than 35 years has been used as a factor in identifying young adult chronic mentally ill patients, a group considered difficult to treat due to their rebelliousness, lack of insight about their mental illness, and increased likelihood of showing symptoms of borderline or antisocial personality disorder. In a sample of psychiatric outpatients, the authors found that a subgroup of patients under age 35 fit this profile, while other patients under age 35 and nearly all patients over age 35 did not. The authors conclude that age is a legitimate factor in identifying a subgroup of challenging patients and that such patients may outgrow many troublesome characteristics as they age.
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7788466
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Prevalence and symptoms at onset of bipolar illness among adolescent inpatients.
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The records of 236 adolescents (116 males and 120 females) admitted to an inpatient psychiatric unit over an eight-year period were retrospectively reviewed to determine the characteristics of patients with a discharge diagnosis of bipolar disorder. Forty-two patients had a diagnosis of an affective disorder, including 18 patients (nine males and nine females) with bipolar disorder. Mean age at onset of illness for patients with bipolar disorder was 15.7 years, and their onset of illness was likely to have been associated with psychotic symptoms. On admission, they were more likely to show symptoms of mania than of depression.
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7788465
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Depression and anxiety disorder among older male inmates at a federal correctional facility.
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The conditions of incarceration and the sociodemographic and health characteristics of 95 older male inmates of a federal correctional facility were studied to determine the relationship of such variables to rates of psychiatric disorder among older male inmates. A total of 51 inmates (53.7 percent) met one-month criteria for psychiatric disorder, a much higher rate than among a community sample of men in the same geographic area. Compared with inmates without such disorders, inmates with disorders were likely to be younger, to have a history of psychiatric disorder and substance abuse, to have poorer physical health, to have impaired social support, and to be serving a determinate sentence with no possibility of parole. Few were receiving treatment while incarcerated.
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7788464
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A survey of new long-stay hospital patients in an Irish health board area.
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The aims of this study were to determine the number and rate of accumulation of new long-stay hospital patients in one of Ireland's eight health board areas, to describe their demographic and clinical features, and to assess their needs in relation to possible community placement. Demographic and clinical information was obtained on all patients over age 17 who had been continuously hospitalized in area hospitals for more than one year and less than six years on the census day of March 1, 1992. The Community Placement Questionnaire was used to rate the patients' social functioning, problem behavior, physical disability, social contact, and needs for accommodation and day care. The survey identified 175 new long-stay patients, mainly middle aged to elderly. Schizophrenia was the most common psychiatric diagnosis. The bed occupancy rate for these patients was 14 per 100,000 population, and the annual accumulation rate was 2.3 per 100,000 population. New long-stay patients were chronically ill with significant psychiatric and social disabilities. Involuntary patients were overrepresented in the group. Two-thirds could be placed in the community if facilities were available and had sufficiently high staffing levels.
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7788463
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Projections of housing disruption among adults with mental illness who live with aging parents.
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The need to plan for the future housing needs of adults with serious mental illness who reside with aging parents is an issue of increasing importance to mental health policy makers as well as family members. This study provides estimates of the number of adults with severe and persistent mental illness in New York State who could be expected to experience housing disruption because of their parents' death. Demographic modeling methods were applied to data from a variety of sources, including surveys of mentally ill adults receiving public mental health services in New York State and demographic statistics on the general state population. An estimated 13,400 to 49,600 adults with severe and persistent mental illness who receive services from the public mental health system in New York State reside with one or both parents. Within this group, between 300 and 1,200 adults could have been expected to experience housing disruption due to parental death each year between 1990 and 1994. Demographic trends indicate that through 2009, these disruptions will increase at a faster rate than growth in the state's general adult population. Additional housing with mental health supports and other programs will be needed to accommodate the growing number of severely mentally ill adults whose housing may be disrupted because of the death of their parents.
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7788461
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New directions in research on involuntary outpatient commitment.
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Involuntary outpatient commitment has been used as a method of improving tenure in community programs for individuals with severe and persistent mental illness. This paper reviews literature on research about involuntary outpatient commitment and suggests questions and methods for future research. Literature describing research studies of involuntary outpatient commitment, located by searching MEDLINE and following up references cited in relevant articles, was reviewed with attention to patient characteristics and diagnostic, treatment, and outcomes measures. Involuntary outpatient commitment appears to provide limited but improved outcomes in rates of rehospitalization and lengths of hospital stay. Variability in community treatment makes interpretation of other types of outcome difficult. Few studies specifically identify results among patients with severe and persistent mental illness. No studies have examined the extent to which outpatient commitment affects compliance and treatment when essential community services such as case management are consistently and aggressively provided, nor have studies controlled for potentially confounding factors such as treatment and nontreatment effects, including informal coercion. A randomized trial of involuntary outpatient commitment should be useful in evaluating the effectiveness of this type of intervention.
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7788462
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18-month outcome of clozapine treatment for 100 patients in a state psychiatric hospital.
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The atypical antipsychotic medication clozapine is an effective treatment for refractory psychosis; however, the efficacy of clozapine when used in public mental health programs has yet to be fully characterized. This study assessed the outcome of clozapine treatment in a state hospital. The medical records of the first 100 patients to receive clozapine in a state hospital, from six months before clozapine treatment through 18 months of treatment, were reviewed. The patients had chronic psychotic disorders that had responded poorly to treatment with conventional antipsychotic medication. Eighteen months after beginning clozapine, 45 patients were much improved, and 18 were somewhat improved. All except one of the improved patients were continuing clozapine treatment. Forty patients were living in community settings, 59 remained hospitalized, and one had died of an illness unrelated to clozapine. Violent episodes in the hospital decreased during the first six months of clozapine treatment. Thirteen patients had one or two seizures while taking clozapine, 12 of whom successfully continued clozapine treatment. One patient developed agranulocytosis, and one developed leucopenia; each recovered fully after clozapine treatment was discontinued. Clozapine was an effective treatment for refractory psychotic disorders when given as a part of routine state hospital treatment.
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7788460
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Effects of social skills training and social milieu treatment on symptoms of schizophrenia.
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The study compared the effects of social skills training and social milieu treatment on symptoms of schizophrenia, particularly on negative symptoms. Thirty-three patients aged 18 to 55 years with a diagnosis of schizophrenia were randomly assigned to a nine-week program of social skills training or social milieu treatment. Patients were assessed at three-, six-, and nine-week intervals during treatment and at follow-up using the Positive and Negative Syndrome Scale (PANSS), which measured both positive and negative symptoms of schizophrenia and general psychopathology. Fifteen patients completed social skills training, and 13 completed social milieu treatment. Comparison of PANSS scores at different assessment times showed that both treatments were effective in reducing symptoms, but social skills training appeared to be more effective in reducing negative symptoms. No differences were found between treatment groups in relapse rates or in symptom measures at three-month follow-up. However, six-month follow-up data available only for the social skills training group showed that improvement in negative symptoms had begun to decline. Psychosocial approaches are a necessary component in the treatment of patients with schizophrenia, and social skills training appears to be particularly helpful. The gradual decline in improvement in negative symptoms at six-month follow-up suggests the need for more extended treatment.
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7788458
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Service utilization and costs of care for severely mentally ill clients in an intensive case management program.
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The study evaluated the effects of an intensive case management model on clients' use of inpatient and outpatient psychiatric care and on the costs of care. Ninety clients of a county mental health system who were frequent users of inpatient services were randomly assigned to either an intensive case management group, a traditional case management group, or a control group who received no particular services. Outcome variables measured over a two-year period were number of units used by clients and costs of inpatient care in county and private facilities and various types of outpatient care, including day treatment and use of an emergency psychiatric unit. Clients who received intensive case management had fewer inpatient days and reduced overall costs for mental health services. Assertive outreach and intensive case management can reduce hospitalizations of clients who are frequent users of inpatient care and can reduce overall mental health care costs. Mental health consumers employed as case management aides can play an important role in the delivery of mental health services, particularly with frequent users of inpatient care.
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7788459
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Evaluating the effectiveness of a residential rehabilitation program for homeless veterans.
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This study sought to evaluate the effects of a residential rehabilitation program for homeless mentally ill veterans on several measures of subjects' community adjustment. Subjects' housing status, financial and vocational status, psychological stability, utilization of coping resources, and extent of social contacts were measured at entry into the program and at follow-up six months after discharge. Data were available for 58 subjects at follow-up. Outcomes for subjects who successfully completed the program were compared with outcomes for those who did not. As a group, subjects assessed at follow-up showed significant improvement in housing, financial, and vocational status, in severity of several symptoms of psychological and emotional distress, in utilization of some types of coping resources, and in measures of social contacts and satisfaction. However, subjects who completed the program were more likely to have improved their housing, financial, and vocational situations. Comprehensive residential rehabilitation programs can help homeless veterans improve several aspects of their lives and maintain stability in those areas after discharge.
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7788457
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Disability compensation and work among veterans with psychiatric and nonpsychiatric impairments.
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This study examined the relationship of Department of Veterans Affairs disability compensation payments and employment among veterans with psychiatric disorders and veterans whose impairments were nonpsychiatric. Data from a 1987-1988 national survey of Vietnam-era veterans (N = 1,634) were used to evaluate the relationship between compensation payments and employment. The employment activity of veterans whose application for benefits was rejected was compared with that of veterans who were awarded benefits. Multivariate analytic techniques were used to control for health status and other factors that also influence an individual's decision to work. Veterans who received compensation of less than $500 a month were no less likely to work than were rejected applicants. Overall, the effect of compensation payment was significant but modest: each additional $100 a month was associated with a 2 percent decline in the number of veterans who worked, a decline of an hour a week in the number of hours worked, and a reduction of $1,000 a year in estimated employment income. No significant differences were observed in the relationship between disability payments and employment among veterans with psychiatric disorders and those with other functional impairments. The association of disability compensation with nonparticipation in the labor force is generally small, except at high levels of payment, and is no greater for veterans with psychiatric disorders than for those with nonpsychiatric impairments.
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7788456
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Relationships between psychiatric symptomatology, work skills, and future vocational performance.
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Experts do not agree on what, if any, relationships exist between diagnosis, symptomatology, work skills, and the future vocational performance of persons with severe mental illness. The objective of this study was to longitudinally examine such relationships, using a sample of clients who were attending psychosocial rehabilitation programs. Subjects were 275 clients of three psychosocial rehabilitation programs who had expressed a vocational goal. They were assessed at intake into the study and then quarterly until they left the rehabilitation program. The variables examined included symptoms, measured by the Brief Psychiatric Rating Scale; diagnosis; work skills, measured by the Griffiths Work Behavior Scale; and vocational status at end-point. Among subjects remaining in the study for one year, both symptomatology and work skills improved significantly. Moderately significant negative correlations were found between symptoms and work skills; subjects who became employed had lower symptom scores and higher work skills than persons who never became employed. Although a moderate relationship was found between symptomatology and work skills, symptoms should not be considered a proxy measure for vocational functioning among persons with severe mental illness. Participation in psychosocial rehabilitation programs appeared to have a salutary effect on symptoms and work skills.
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7788455
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A psychiatrist-rated battery of measures for assessing the clinical status of psychiatric inpatients.
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Despite the increasing demand for outcome assessment measures, no published reports have provided a standardized way to assess psychiatric inpatients that includes diagnosis and observer ratings of psychopathology. This paper reviews general principles for selecting outcome assessment measures, proposes a battery of instruments based on already available measures to assess clinical status in psychiatric inpatients, reviews methods of implementing the battery in an academic inpatient psychiatric setting, and presents preliminary data on its interrater reliability, construct validity, and range of response to acute hospitalization. Preliminary results suggest that the battery may be useful for resident and medical student education and for enhancing quality assurance and continuous quality improvement.
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7788449
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[Activity of adenosine in relation to tumor necrosis factor (TNF). Therapeutic outlook].
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At physiological and pharmacological doses, adenosine protects tissues against a varieties of injuries: ischemia-reperfusion, convulsions, inflammation.... We tested the hypothesis that the antiinflammatory properties of adenosine occur via a down-regulation of TNF. Agonists of adenosine receptors (ARA) and agents potentiating endogenous adenosine (APA) were evaluated for their effects on TNF production by endotoxin-stimulated human monocytes. Additionally, one of the most potent agonists, R-phenylisopropyladenosine (R-PIA), was tested on two experimental models of acute phase response, endotoxin shock and carrageenan-induced plantar oedema. Several ARA and APA inhibited monocyte TNF production in a concentration-dependent manner. R-PIA and other ARA were active at micromolar concentrations. The property is pharmacologically relevant since rats receiving a lethal dose of endotoxins were protected by R-PIA and endotoxin-induced serum TNF levels were abolished by a pretreatment with R-PIA. Inhibitory effects on serum TNF production were obtained with similar doses of dexamethasone sodium phosphate and one hundred-fold higher doses of pentoxifylline. R-PIA was also found active on carrageenan-induced oedema. The anti-oedematous properties of R-PIA were associated with a marked reduction of locally-produced TNF and were also observed after the administration of dexamethasone, pentoxifylline and a neutralizing anti-TNF antibody. Our results indicate that adenosine is a potent inhibitor of TNF production induced by different stimuli. This property could lead to therapeutic applications in inflammatory diseases and other in which TNF is known to play a pathogenic or aggravating role. Comparison between ARA and APA in terms of tolerance and efficacy merits further attention.
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7788448
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[Importance of measuring exposure to the principal indoor allergens in allergic asthma].
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Domestic allergens, such as mite and cat allergens, are a leading cause of allergic asthma. Allergen exposure is a risk factor for sensitization. Allergens also play a major role in the development of inflammation and non specific bronchial hyperreactivity as well as in the apparition and modulation of symptomatic asthma. The development of new means of detecting allergens (i.e. immunochemical assays including monoclonal antibodies, quantitative and semiquantitative guanine measurements for mite allergens) has made possible to identify allergens sources and reservoirs. The form in which domestic allergens become airborne is important. The group I and II allergens from mites, the major cockroach allergens are carried on large particles (mean size > 10 microns diameter); in contrast, the major cat allergens are airborne on small particles (40% < 5 microns). Guanine, a metabolic excretion product of mites, is used as a marker for mite feces and is correlated with the presence of major allergens from mites. A colorimetric method (Acarex-TestR) provides a simple and inexpensive method of assaying indoor mite allergen exposure for both doctor and patient alike. By using Acarex-TestR it is possible to evaluate the mite allergen exposure for a population in a particular country. The detection of allergens sources and reservoirs, the quantification of domestic allergens has enabled the evaluation of the effect of a reduction in allergen exposure to be better assessed. Recognition of the risks, environmental control and reduction in allergen loads, should be among the objectives of asthma management.
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7788447
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[Malignant lymphoma with medium-sized macronucleolated cells in the dog: involvement of an original cell from the marginal zone of the reactive lymph node].
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Among the non-Hodgkin's malignant lymphomas of the dog, which are largely dominated by the centroblastic heterogeneous type, there is an original form of malignant lymphoma which is homogeneous and diffuse, with macronucleolated medium-sized cells. These cells seem to be morphologically very similar to those which constitute the majority population in the marginal zone of the secondary follicle of the lymph node in the dog, and which appear in the course of certain conditions: systemic lupus erythematosus, leishmaniasis, satellite lymph nodes in benign or malignant tumors. The aim of this study was twofold: on the one hand to establish, in the canine species, the identity of the lymphomatous cells and the reactive cells that make up the marginal zone, i.e. the filiation between the hyperplastic marginal zones and the macronucleolated malignant lymphoma with medium-sized cells, and, on the other hand, to compare this type of malignant lymphoma with those which are reputed to originate in the marginal zone in humans, for example the malignant lymphoma of the lymphoid tissue associated with the mucous membranes, and the monocytoid malignant B-cell lymphomas. Ninety four malignant lymphomas were observed between 1989 and 1994 at the Veterinary School in Lyon; these consisted of 71 cases showing medium or high-grade malignancy, 17 cases with small cells, of low-grade malignancy, and 6 cases of mycosis fungoides. Among the 71 cases of medium and high-grade malignancy, 8 were immunoblastic, 5 centroblastic homogeneous, 50 centroblastic heterogeneous, and 8 homogeneous with macronucleolated medium-sized cells. The methods used in these 94 cases were of a morphological type: cytology, histology, transmission microscopy and immunohistochemistry. The cytohistological, ultrastructural and immuno-phenotypical characteristics (CD3-, CIg-, Ki-67- phenotype) of the lymphomatous cells and the cells of the marginal zone were found to be identical, in the dog; this strongly suggests B-lineage cells which do not secrete cytoplasmic immunoglobulins and are not involved in the cell cycle. Finally, these cells seem to us to be morphologically very similar to the minority population described by Van den Oord in the marginal zone of the secondary follicles in the lymph node in humans, in certain reactive situations.
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7788444
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[Controlled hypercapnia: a new strategy in the treatment of severe respiratory insufficiency].
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Permissive hypercapnia (PHY) represents an interesting approach in critically ill ventilated patients, because it allows to ensure adequate gas exchange while avoiding the adverse effects related to excessive airway pressures. Its objective is to improve oxygenation while reducing the risk of barotrauma and circulatory impairment. This concept is all the more important when considering that in majority of lung diseases for which MV is applied, lung involvement is highly inhomogeneous, meaning that the functionally normal or near normal areas are the most exposed to the deleterious effects of overdistension. Undesired physiological effects of non massive respiratory acidosis (PaCO2 < or = 80 mmHg, arterial pH > or = 7.15) are reversible and mostly minor. This good tolerance legitimizes two strategies: firstly to accept hypercapnia in conditions such as acute severe asthma for which enforced normalization of PaCO2 would imply potentially lethal complications, and secondly to deliberately induce respiratory acidosis while using very low airway pressures and alveolar ventilation to limit or prevent overdistension lung damage in injured as well as in normal areas. When the cerebral vasodilation induced by CO2 might aggravate a preexisting intracranial disorder, PHY is obviously contraindicated.
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7788446
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[Validity of cerebral angiography via venous route in the diagnosis of brain death].
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The success of transplantations relies on uninjured organs i.e., harvested before circulatory failure. At present, french law concerning cerebral death criteria (circulaire ministérielle n. 3 du 21.01.91) requires the association of clinical patterns and 2 repeated, unreactive and flat electroencephalographic (EEG) tracings. Blood and urinary samples also need to be free from any nervous system depressant drug, the patient has not to be hypothermic. These obligations are not always compatible with patients status or local organization. The consequence might be organ loss or delay in harvesting schedule. A review of the literature points out the trap in realization and analysis of EEG in this kind of intensive care patients. Angiogram, on the opposite, is influenced neither by nervous system depressant drug nor by hypothermia. As it is in some other western countries, it should be proposed as the reference.
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7788445
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[Venous angiography: importance in the diagnosis of brain death. 125 cases].
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According to many ethical and humanitarian arguments, the diagnosis of "brain death" is more and more an emergency. The forensic criteria include abolition of consciousness, abolition of brain stem reflexes, abolition of spontaneous breathing joined to electrocerebral silence. However using EEG criteria of electrical silence may be unreliable because of technical artefacts or depressed electrical activity due to drug intoxication and hypothermia. Venous angiography was used in 125 cases: our experience proves reliability and efficiency of angiographic criteria for diagnosis of brain death. For organ transplant, it is better to be as fast as possible: transplanted organ will be better and it reduces the cost of a long useless intensive care. When it is necessary, we suggest to allow the choice between EEG and angiography.
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7788443
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[Food-induced anaphylaxis. A new French multicenter study].
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The frequency of food-induced anaphylactic shocks (FIAS) has been investigated beside 46 emergency departments, 29 departments of Dermatology, and 19 departments of Intern Medicine or Pneumology. 794 A.S. have been reported. FIAS represent 10.2% of the etiologies. More than a third of them are relapsing anaphylaxis. Food allergy had been previously identified in 23.4% of cases. The allergen was present as a hidden allergen or inadvertently consumed in 30.8% of FIAS. 9.9% of the patients were asthmatic. An enhancing factor was heightened in 25.9% of cases: alcohol, exercise, simultaneous intake of aspirin, beta-blockers, conversion enzyme inhibitors. Other factors predisposing to food anaphylaxis were a cross-reactivity shared by pollens and fruit, latex and exotic fruit, house dust mites and snails, or mastocytosis. More than 15 allergens were detected: egg (11.6%), fish (10.4%), crustaceans (10.4%), milk (6.5%), fruit-latex group (6.5%), peanut and other legumes (soy, peas, lentils, guar gum...), celery, garlic, etc... The food allergen still remained unknown in 25% of cases. However, the rate of efficiency of the diagnosis reached 94% in the Allergy Units. In addition 10.2% of A.S. were considered idiopathic, raising the hypothesis of allergy to masked food allergens. Compared to a previous study from the 1982's, this survey shows a striking increased prevalence of FIAS. The frequency of recurrent anaphylaxis, occurring in one-third of cases, is also highlighted and makes plausible once more the role of masked food allergens. The authors insist upon the need of a thorough allergologic investigation in all the cases of A.S. An informative labelling about the presence or absence of food proteins which are mostly allergenic should be recommended. The need of a thorough allergologic investigation is supported not only by the incidence of FIAS but also by the incidence of idiopathic anaphylaxis: 10.2%.
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7788441
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[Reconstruction by free jejunal transplant after circular pharyngolaryngectomy (functional results and survival)].
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One hundred and ninety seven patients with cancer of the hypopharynx underwent after circular resection, reconstruction with a free jejunal graft. The quality of free jejunal grafts is controlled by many investigations: clinical examination, radiography, electromyography, fibroscopy with biopsy. These investigations show that technically jejunal grafts must be short and linear to give the best functional results. Average resumption of oral intake was 14 days. Oral feeding was possible in 92% of cases. The free jejunal grafts with microsurgery are one of the more reliable procedures for reconstruction of pharynx and cervical esophagus after resection for cancer. (2 post-operative deaths and 8 grafts necrosis on 197 cases). The cumulative survival rate of 5 years was 35% for free jejunal graft. Survival depends on selection of the patients for local and nodes invasion. The quality of survival has improved. This operation must be reserved for the hypopharyngeal cancers which need a circular resection and do not invade the esophagus. The surgery is performed for a curative aim. The distant follow up of the patients is imperative: consultation every four months and then every six months: clinical examination, endoscopic, E.N.T., bronchial, and esophageal investigation. Chemotherapy and radiotherapy have specific indications.
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7788440
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[Sexual mutilation in women].
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The sexual mutilations, a fairly topical subject, remain very frequent (between 80 and 100 millions). The excisions are in practice mainly in Africa (in at last 20 countries), but also in the Far-East and Indonesia. In some cases, such practices are very mutilative (Pharaonic infibulation). They may drag to the death, through haemorrhage or infection. The short and long term medical complications are fearful, tetanus, vesicovaginal fistulae, vaginal or vulvar sclerosis, forbidding any sexual involvement and hampering delivery. The grounds of these practices are basically customary and not religious. Women shall be subservient to men and any manhood mark, embodied by the clitoris, shall disappear. However these manoeuvres are decreasing, due to the women emancipation, and, particularly, in Africa, some leaders are aware of their graveness and are punishing heavily the excision, taking model of the French Penal Code. The immigrants, who, in France, have these mutilations undertaken, are incurring imprisonment sentences (precedents are frequent). They must comply with the French laws.
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7788439
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[Production and proinflammatory activity of tumor necrosis factor alpha in the glomerulus].
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The production and the effects of tumor necrosis factor alpha (TNF alpha) have been studied in isolated glomeruli and cultured glomerular cells from animal or human origin. Glomeruli from rats injected with E. coli lipopolysaccharide (LPS) and glomeruli exposed to LPS in vitro release TNF alpha into the medium. The glomerular cells responsible for TNF alpha synthesis are mesangial cells. Production of TNF alpha is controlled by other locally produced mediators. Prostaglandin E2 and interleukin-10 are inhibitory. Hydroxyl radicals stimulate the transformation of the transmembrane form of TNF alpha into its soluble form which is secreted into the medium. TNF alpha acts on its producing cells and on the neighbouring cells. It induces contraction of mesangial cells, increases the synthesis of a variety of local mediators including prostaglandins, platelet-activating factor and chemotactic agents, particularly interleukin-8. Synthesis of this cytokine implies activation of tyrosine kinase and of transcription factors, essentially NFkB. Taken together, these results suggest that TNF alpha plays a marked role in the development of glomerular injury and incite us to search for treatments inhibiting its synthesis and its effects.
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7788437
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[Origin of allergens in the cat].
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Danders and animal products have long been recognized as major allergens. One of the most common animals responsible for allergy is cat. Fel d I the major allergen has been detected in fur and a number of authors have claimed that saliva is the principal source of this major allergen and that pelt is contaminated as a result of licking during grooming. We could demonstrate that one of the major sources of Fel d I present on the skin are sebaceous glands and that the production of Fel d I is under hormonal control at least in male cats. Castration decreases significantly the level of Fel d I on the skin and the injection of testosterone reverses the phenomenon. These data lead to continue the work about the regulation of this protein and the knowledge of its biological function.
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7788436
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[Magnetic Resonance Imaging study of the role of the blood-brain barrier in the pathogenesis of experimental allergic encephalomyelitis: application to multiple sclerosis].
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Nuclear magnetic resonance imaging (MRI) proved to be, from the first, a very sensitive method, allowing the visualisation of multiple sclerosis lesions, yet which never permitted to establish a non equivocal relationship between the semeiology of such lesions and the clinical signs. The multifocal aspect of disseminated multiple sclerosis lesions is probably one of several factors accounting for this discrepancy. The study of an autoimmune disease, experimental allergic encephalomyelitis (EAE), regarded as a suitable model for multiple sclerosis in humans, has been performed using MRI in order to unravel the pathogenesis of the disease and apprehend the mechanisms responsible for the formation of multiple sclerosis lesions. The study focused on the part played by the blood-brain barrier (BBB) in the induction process of an autoimmune disease, since the central nervous system is normally screened from immunological supervision, by this barrier. Models both of acute EAE, induced by active or passive transfer of the antigen (myelin basic protein-MBP)--and chronic EAE, induced by passive transfer of MBP-specific T cells and myelin glycoproteins or MOG-specific monoclonal antibodies, have been reproduced, and their evolution followed up using high field MRI. Every time, the crucial role of the BBB was evidenced by the synchronism existing between the clinical signs, the appearance of lesions, preferentially in the most sensitive or permeable areas, and the BBB breakdown encouraged by the action of adjuvants. The physiopathological study of EAE using MRI is suggestive of the concept of systemic disease for multiple sclerosis, according to a two-step process, involving, in a first stage some primary viral or bacterial infection, causing T-cells to be sensitized to the host's own proteins by molecular mimicry, and in a second stage some bacterial infection or accidental circumstances which, resulting in a BBB breakdown, would provide immunocompetent cells with an opportunity to reach their target.
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7788430
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Virologic and immunologic characterization of symptomatic and asymptomatic primary HIV-1 infection.
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To define virologic and immunologic differences in patients with acute symptomatic and asymptomatic primary human immunodeficiency virus type 1 (HIV-1) infection, sequential plasma specimens were obtained longitudinally for 1-2 years postseroconversion from subjects with well-documented time of seroconversion. Thirteen of them had an acute symptomatic primary infection, eight subjects had asymptomatic primary infection and long-term follow-up, and 27 had asymptomatic seroconversion and short-term follow-up. Quantitative plasma HIV-1 RNA levels, CD4+ lymphocyte counts, and levels of antibodies to gp120, p66, p41, p31, p24, and p17 were measured. At the time of seroconversion, there was no significant difference in HIV-1 RNA levels and CD4+ counts between symptomatic (n = 13) and asymptomatic (n = 27) subjects. Subsequently, however, establishment of low levels of plasma HIV-1 RNA was seen significantly more frequently in asymptomatic (n = 8) than in symptomatic (n = 13) primary infection; this correlated with higher levels of some (anti-gp120 and anti-p31) anti-HIV-1 antibodies and a slower decline in CD4+ lymphocyte counts. These results indicate that immunologic control of viremia early after infection may be a critical determinant to subsequent clinical course of HIV-1 infection. They also suggest that persons with acute symptomatic primary infection may generally progress to having acquired immune deficiency syndrome (AIDS) more rapidly than people with low-grade symptoms or asymptomatic primary infection.
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7788429
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Incubation period of vertically acquired AIDS in Europe before widespread use of prophylactic therapies.
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European surveillance data on vertically acquired (VA) AIDS cases were used to investigate the incubation period of AIDS in the absence of widespread prophylactic treatment and to assess the uncertainty associated with parametric estimates based on retrospective data. Nonparametric and parametric analyses, taking into account the effects of data truncation, were based on a total of 792 children diagnosed with AIDS between July, 1982, and June, 1990, inclusive. Among HIV-infected children who develop AIDS within 8 years, the nonparametric estimate of the median age at diagnosis was 34 months. If 20% of children are assumed to develop AIDS by the age of 1 year (a plausible estimate on the basis of published cohort data), the estimated median among all maternally HIV-infected children is 4.4 years, with 26% of children expected to remain AIDS free by 8 years of age. Results from the parametric (double Weibull) model support the hypothesis of a bimodal distribution, with a subgroup of children progressing rapidly to AIDS at a median age of approximately 5 months. However, neither the relative size of this group nor the median age at which AIDS develops in the remaining children can yet be estimated with any reasonable precision.
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7788428
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Recent infection with human immunodeficiency virus and possible rapid loss of CD4 T lymphocytes.
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To assess a hypothesized trend that persons recently infected with the human immunodeficiency virus (HIV) may have more rapid declines in absolute CD4 T-lymphocyte (CD4+ cell) counts than those who were HIV-infected in earlier years, sequential CD4+ cell counts in three groups who had definable dates of HIV seroconversion between 1978 and 1992 were reviewed. The CD4+ cell counts examined were from some of the longest extant studies in the United States: 100 homosexual and bisexual men engaged in ongoing observational cohort studies in San Francisco, Denver, and Chicago since 1978 (Group 1); 89 persons in South Carolina infected after 1986 (Group 2); and 155 injecting drug users participating in an observational cohort study in Baltimore since 1988 (Group 3). For all groups, individually and in the aggregate, mean CD4+ cell counts declined rapidly in the first year after HIV infection and then stabilized. However, there was no clear trend for lower (or higher) CD4+ cell counts by fixed time after HIV seroconversion among those seroconverting in recent compared with earlier calendar years. These data do not support a hypothesized trend for more rapid loss of CD4 T lymphocytes--and, by implication, more pathogenic strains of HIV-1--among persons acquiring HIV infection in recent years.
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7788426
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Clinical experience with atovaquone on a treatment investigational new drug protocol for Pneumocystis carinii pneumonia.
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The clinical experience of human immunodeficiency virus (HIV) + patients treated with oral atovaquone for acute Pneumocytstis carinii pneumonia (PCP) under a Treatment Investigational New Drug (IND) protocol (mild or moderate PCP) and an Open-Label Study protocol (severe PCP) was evaluated. A total of 940 patients intolerant of or unresponsive to trimethoprimsulfamethoxazole were enrolled from private practices, clinics, and institutional HIV treatment centers in the United States. Demographics data and the history and severity of PCP were collected at enrollment. The number of therapy days, adverse experiences, clinical response to therapy, and mortality were collected at day 21. Reporting of serious, unexpected adverse experiences attributable to therapy was required. Of the 760 (96%) patients with mild to moderate disease for whom follow-up observation was complete, 591 (78%) responded clinically to treatment, 177 patients (23%) discontinued treatment prematurely, and 50 patients (7%) died. Of the 140 patients (95%) with severe PCP with follow-up data, 79 (56%) responded to treatment, 45 (32%) discontinued treatment early, and 53 patients (38%) died. Adverse events that resulted in temporary or permanent discontinuation of therapy included diarrhea, vomiting, elevated liver enzyme levels, nausea, and fever. No serious unexpected adverse events attributable to the drug were reported. The treatment IND mechanism enabled a large number of patients with acute PCP to be treated with this experimental therapy while the drug was under regulatory view.
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7788425
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A phase I evaluation of concomitant rifabutin and didanosine in symptomatic HIV-infected patients.
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It has been suggested that didanosine (ddI) may undergo hepatic metabolism. Rifabutin is an inducer of drug metabolism. Fifteen human immunodeficiency virus-infected patients whose conditions were stabilized on twice-daily doses of ddI participated in a Phase I, open-label, pharmacokinetic and safety drug interaction study between rifabutin and ddI. Twelve patients completed the study. All patients received their regular ddI dose (167-375 mg) on day 1. On days 2-13 they received once-daily rifabutin (600 mg, three patients; 300 mg, nine patients) with their regular twice-daily ddI regimen. On days 14-16 they received rifabutin alone. Serial blood and urine samples were collected for 12 h on day 1 and for 24 h on days 13 and 16, and safety evaluations were made throughout the study. Average day 1/day 13 ddI pharmacokinetic ratios and 95% confidence interval values for Cmax, AUC0-infinity, Cls/F, and t 1/2, lambda z were 1.17 (0.96-1.38), 1.13 (0.99-1.27), 0.91 (0.81-1.01), and 0.97 (0.79-1.15), respectively (p > 0.05 for all comparisons; paired t test). A 20% difference in AUC0-infinity could be detected with 90% power. Also, there were no significant changes in laboratory values or electrocardiograms, or in rifabutin pharmacokinetic parameters when the two agents were coadministered. Based on the safety and pharmacokinetic assessments, rifabutin did not appear to interact with ddI.
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7788424
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Clinical evaluation of Amplicor HIV-1 test for detection of human immunodeficiency virus type 1 proviral DNA in peripheral blood mononuclear cells.
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We report here the clinical evaluation of Amplicor polymerase chain reaction (PCR) assay for the detection of the human immunodeficiency virus type 1 (HIV-1) in peripheral blood mononuclear cells (PBMCs). Results obtained with Amplicor HIV-1 test were compared to serological status and a standard PCR assay using SK38/SK39 and oligomer hybridization with SK19. A panel of 208 well-characterized specimens was analyzed, including PBMC lysates from 47 antibody-negative high-risk individuals, eight antibody-negative low-risk subjects, two subjects with acute retroviral disease, 35 asymptomatic seropositive subjects (59 samples) with CD4 counts > 400/mm3, 31 patients (46 samples) with AIDS-related complex (ARC), 30 patients (40 specimens) with AIDS, and six seropositive patients with unknown clinical status. Amplicor demonstrated a specificity of 100% and a sensitivity of 98.7%. Of the two false-negative samples with Amplicor, one was negative for beta-globin amplification, whereas a dilution of the other sample turned positive for HIV-1. Inhibitors of Taq polymerase were thus believed to be responsible for the negative results. This study demonstrates that commercialized nonisotopic PCR assays reach adequate levels of sensitivity and specificity for diagnosis of HIV-1 infection and could be considered in clinical situations in which serology is not helpful.
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7788422
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A prospective study of mother-to-infant HIV transmission in tribal women from India.
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The transmission of human immunodeficiency virus type 1 from infected mothers to their babies was assessed by serologic, virologic, and clinical means. Of the 160 antibody-positive women enrolled at the beginning of the study, 13 had overt clinical symptoms (CDC stage III/IV). Termination of pregnancy was done, on request, in seven of these cases. The rest delivered prematurely. A total of 143 parturient women and their infants were followed prospectively until the babies were 18 months of age. Fifteen infants (9%) died of AIDS before 14 months of age. The remaining 128 children (91%) were alive at the end of the study period. Seventy-four seropositive children (46%) became seronegative and were considered noninfected. None of the seronegative children reverted to seropositive status despite the fact that they were breast-fed. The majority of the seropositive children (63%) became symptomatic and clinically ill during infancy. The overall mother-to-infant vertical transmission rate was 48%.
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7788423
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The prognostic value of plasma viremia in HIV-infected patients under AZT treatment: a two-year follow-up study.
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To determine the prognostic value of plasma viremia in long-term zidovudine (AZT)-treated HIV-infected patients, HIV-1 plasma viremia (PV) was quantified in 28 HIV-infected patients before and during AZT long-term treatment; the follow-up also included p24 antigenemia and CD4 cell counts. The variations of these markers during the follow-up period, the correlation with the clinical outcome (progressors versus nonprogressors), and the discrepancies between PV and surrogate markers were then analyzed. A significant and stable decrease in PV titer was observed in only nonprogressors (Friedman test, p < 0.005). At the end of follow-up, 11 (73%) of the 15 non-progressors were PV responders (patients who remained or became PV- long-term), whereas all the 13 progressors were PV nonresponders (patients who remained or became PV+). These results indicated a strong correlation between PV and clinical outcome (Fischer's exact test, p < 0.0001). The persistence, increase, or reappearance of viral replication appeared to be an important predictor of poor clinical outcome in HIV-infected patients under AZT treatment. This finding could provide a rational basis to help the clinician's decision in the clinical treatment of HIV-infected patients.
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7788421
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Multiple superinfections fail to activate defective human immunodeficiency virus-1 (HIV-1) infection of rabbits.
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Superinfection of human immunodeficiency virus (HIV)-1-infected rabbits with Treponema pallidum, Mycobacterium avium, herpes simplex, Candida albicans, Mycoplama incognitus, and malignant catarrhal fever virus, as well as irradiation or cortisone treatment, fails to activate production of infectious virus. For up to 6 months after infection of rabbits with HIV-infected cells or free virus, there are neither clinical symptoms nor positive laboratory tests for detection of HIV. However, after superinfection with other agents, HIV sequences may be transiently found in peripheral blood mononuclear cells by polymerase chain reaction (PCR), and multiple antibodies to HIV antigens may be detected by Western blotting. Both the PCR positivity and Western blot reactivity become negative with time after superinfection. Other than delayed healing of the skin lesions produced by T. pallidum and vaccinia in HIV-infected rabbits, there is no evidence of any immune abnormality. After death, gag sequences are detectable in the splenocytes of essentially every HIV-infected rabbit, and the splenocytes of eight of 25 infected rabbits responded by proliferation to HIV peptides. In addition, gag sequences are detectable in rabbits that are injected with lymphoid cells from HIV-infected rabbits. However, after multiple testing of both peripheral blood of living rabbits and organs of rabbits that died or were killed (spleen, brain, lymph nodes, liver, and gastrointestinal tract), no viable virus has ever been convincingly detected by in vitro cultivation with indicator cells. In contrast to some other published reports, these data indicate that HIV-1 infection of rabbits does not provide a model for AIDS pathogenesis therapy or prevention, but it may be useful as a model to study the relative resistance of a small fraction of the human population to development of AIDS after HIV infection.
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7788406
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Midwifery in Indonesia: a professional snapshot.
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In 1988, Indonesia had the highest maternal mortality rate in South East Asia, but the Government's commitment to reducing this has already demonstrated a measure of success. Initiatives include: use of voluntary healthcare workers (kaders) in the local community family planning initiatives raising awareness of the status of women in society by the appointment of a Minister for Women's Affairs. The commitment of both the government and midwives to promoting safe motherhood in Indonesia should make a significant contribution to achieving the WHO aim of halving the maternal mortality rate by the year 2000.
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7788408
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TQM in action ... the experience of a nursing documentation project team.
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This is the second article in a two-part series that describes the implementation of TQM at the Jewish Home of Rochester, New York, a 362 bed long term care facility. The first article gave an overview of the implementation process in the organization. This article describes the work of one of the initial project teams.
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7788395
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Midwifery-managed units.
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Midwives involved in the establishment of a midwifery-managed unit were given the opportunity to express their concerns anonymously. The principal areas of concern they identified were: Risks to mother and baby. Transfers from the unit to the district general hospital. Refusals by clients. Indemnity, litigation and protection by management. Prescribing, training and updating.
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7788392
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Alternative therapies offer more say in care.
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Alternative medicine is holistic in its approach to the individual. Orthodox medicine, in contrast, is biomedical, viewing the body mechanistically. Alternative therapies are not without risk, and many are an unknown quantity. Mothers often feel that their own wants and values are disregarded because of professional or administrative pressure. Midwives should not prescribe alternative medicines or practise any therapies unless properly trained and then only if it is not in breach of hospital or health authority policy. Increasingly, midwives are involved in formulating new policies, so enabling the promotion of beneficial change.
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7788391
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The duration of the second stage of labour.
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Fetal outcomes following extended second-stage labour include respiratory acidosis, lower umbilical vein and artery pH, lactacidaemia and early neonatal seizures. Maternal outcomes following extended second-stage labour include postpartum haemorrhage, puerperal fever, backache, musculoskeletal problems, stress incontinence and denervation of the pelvic floor. It is suggested that intervention should be based on the use of judgement and skill rather than strict adherence to timetables.
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7788390
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Slimming and fertility.
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Severe reducing diets cause low levels of progesterone, slowing down follicular growth, inhibiting the surge of luteinising hormone (LH) and preventing ovulation. If less severe, slimming may depresses hormone levels by producing too small a corpus luteum and may result in a miscarriage. A reducing diet over a longer period may also affect fertility. Women planning pregnancy should be advised on the regularity as well as the adequacy of meals during the preconception period. A woman's nutritional status may be adequate for fertility but inadequate to produce a baby in the optimum birthweight range. There is a recovery period from amenorrhoea when it is wise not to conceive.
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7788389
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The Southampton Wave.
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The course planning team at Southampton University College of Midwifery wanted to offer a diploma course which reflected the realities of midwifery education in the clinical setting. For this a curriculum model--The Wave--was developed. The Wave is not a static model, but reflects the changes a midwifery curriculum must absorb in context and circumstances. Allocation of students to clinical areas is linked with course content, allowing direct application of theory to practice and practice to theory.
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7788388
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Safe motherhood in the United Kingdom.
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The Safe Motherhood Initiative (SMI) is a global effort to reduce maternal mortality and morbidity. The target is to reduce maternal deaths by at least half by the year 2000. The SMI aims to enhance the quality and safety of women's lives through the adoption of a combination of health and non-health strategies. The SMI places special emphasis on the need for better and more widely available maternal health services, the extension of family planning education and services, and effective measures aimed at improving the status of women. Activity within the SMI may take many forms: Increasing awareness of the dimensions of the problem and the need for action. Strengthening maternal health services. Training of health workers and others. Facilitating educational and economic opportunities for women. Research, particularly operational research. Partners within the SMI are governments, agencies, non-governmental organisations and other groups and individuals who stimulate and participate in efforts likely to reduce the number of women suffering and dying as a result of pregnancy and childbearing.
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7788382
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Caesareans on the rise--a cause for concern?
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The number of caesarean sections performed in the UK has increased nearly threefold since 1973. Improvements in the safety of the procedure and in neonatal intensive care may account for this increase. Caesareans are being performed increasingly for breech presentations. Fear of litigation has been cited as a reason for the increase. Midwives should be working with the pregnant woman long before the question of a caesarean arises.
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7788380
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Maternity care for the visually impaired.
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Midwives should not express doubts about a blind woman's ability to cope but try to boost the woman's confidence and encourage her to build on her skills. The mother needs to understand that as her abdomen enlarges and her centre of gravity shifts, she may find it more difficult to assess her own body space and her relationship to other objects. Blind women appreciate continuity of care from a small number of known professionals and may prefer a home birth or domino scheme. For those who go to hospital, help with negotiating busy waiting areas, pulling up chairs and getting into bed is likely to be welcomed. The support of another blind mother is invaluable as experiences can be shared.
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7788381
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Individualised care--from blueprint to practice.
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The first task was to develop a midwifery model, which initially meant establishing a philosophy of midwifery care. The next task was to consider documentation to support the system. The third part of the working group's remit was to educate their peers about the system. After implementation of the system, evaluation will be necessary.
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7788378
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How effective is antenatal education?
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Ideal opportunities exist to offer women information during routine antenatal and postnatal care. Within the present antenatal system the midwife may not be using her teaching skills, or those skills may be out of date with modern developments. Education about childbirth could begin in schools. The midwife could also fulfil another valuable role, as mediator, providing parents with links with each other. Midwives should remember that parents have a lot to offer them as a resource.
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7788379
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Handle with care.
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25% of all midwives have taken sick leave because of back injury. The onus is on the employer to see that employees are not made to undertake risky manual handling work. The place of confinement should be checked beforehand for suitability and safety. Temporary staff are covered by the risk assessment process, but independent midwives are not.
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7788377
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Breastfeeding--midwives' personal experiences.
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99% of midwife mothers surveyed had a positive attitude to breastfeeding. 82% of these midwives considered that they had been successful in their attempt to breastfeed their own babies. 66% felt that the theory of breastfeeding they learned was applicable in practice. Of those for whom theory was applicable in practice, 76% felt that their theoretical knowledge also contributed to a positive personal experience of breastfeeding. The factors which contributed to successful breastfeeding were a relaxed approach, a positive attitude, determination and good support from partners and other midwives. The factors which contributed to unsuccessful breast-feeding were breast problems, fatigue, and poor milk supply. Midwife mothers would have appreciated more support with breastfeeding-many felt that they were left to cope on their own because they were health professionals.
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7788370
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Midwifery in Mexico.
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In Mexico, traditional midwives maintain the customs and rituals that have surrounded pregnancy and childbirth since pre-Hispanic times. 'Empirical' midwives are allowed to practise on the basis of experience and a minimal two-week training programme. Graduate nurse-midwives usually go into general nursing and few practise midwifery, despite taking a year's specialist training in their four-year course. A project with graduate nurse-midwives demonstrated safe practice--the nurse-midwives delivered 1,500 babies with no maternal deaths and only two infant deaths in the five-year period.
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7788369
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Good nutrition for the vegetarian mother.
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A pregnant or nursing vegetarian mother needs to be aware of the need to vary her diet because the nutrients that she would otherwise get from meat or fish are more widely scattered in foods of plant origin. Diets which exclude dairy products require more careful planning. Particular attention needs to be made to the mother's intake of iron, calcium, vitamin B12 and vitamin D. Vegetarian mothers do not show a higher incidence of complications of pregnancy, but there are some links between vegetarians and lower birthweight and earlier labour. On weaning the infant's diet should not be too bulky and should provide adequate vitamin D and B12.
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7788367
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Vaginal birth after lower segment caesarean section.
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One delivery in eight in the UK is by caesarean section. Women who have had a previous caesarean section may approach a midwife in subsequent pregnancies because they want more control over their labour. Vaginal birth after caesarean section (VBAC) is a safe option for women with a lower segment scar. Factors associated with a favourable outcome include spontaneous labour and freedom of movement during labour. Factors hindering successful outcome include reduced mobility, use of oxytocin, and time limits set on progress of labour.
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7788366
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Continuing education--a choice between affluence and deprivation.
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The study sought to identify reasons why initial enthusiasm for in-service training was not reflected in actual attendance. An interview and questionnaire survey of 61 midwives in a London health authority assessed their perceptions of, motivation for and participation in continuing professional education (CPE). The midwives surveyed appreciated the need for CPE, kept up with professional reading and took part in a wide range of educational activities. Managers and staff midwives were the poorest attenders at study days and training sessions, which may have adverse consequences for their development. It is suggested that CPE improves clinical standards and raises morale (a cycle of affluence) and that it may also prevent stress and 'burnout'.
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7788365
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Getting to know your client.
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Continuity is important in many aspects of life, but particularly during pregnancy and childbirth when a woman is experiencing physical and emotional upheaval. Midwives need to explore the allocation of resources to ensure continuity of care. A caseload system in which a midwife takes on about 36 women a year offers the client continuity and the midwife a satisfying working style which fits in with her own needs. A caseload may include high-risk pregnancies, which may provide the midwife with learning experience. Teaming up with others is the best way to run a caseload, and would leave enough midwives to provide expert staff on labour and postnatal wards.
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7788364
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Choice and control for the disabled mother.
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One-to-one maternity care is most appropriate to the disabled woman's needs. The midwife should find out about the sources of help available to the disabled mother--lay sources of support and information should be tapped as well as professional expertise. Vaginal delivery should not be ruled out and is possible in the majority of cases. While tiredness is a problem for any new mother, midwives should guard against 'taking over' too much responsibility from the disabled mother in the mistaken belief that they are 'helping'.
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7788362
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The maternity care of Muslim women.
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There are approximately 1.7 million Muslims in the UK. Followers of Islam observe certain religious and cultural practices during pregnancy and childbirth which midwives need to know and understand. Husband or children should not be used as interpreters as it is culturally unacceptable for many Muslim women to talk about intimate matters in front of their families. Midwives should not make assumptions when offering pain relief - in Islam pain is accepted as a natural part of childbirth. There may be some misconceptions about breastfeeding (for example, that colostrum is 'unclean'), and Muslim mothers - like all new mothers - need education and support.
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7788359
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Intention and reality in infant feeding.
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Eighty women in a Nottingham practice completed antenatal and postnatal questionnaires about breastfeeding: 94% agreed that breastmilk was better than infant formula, but only 76% intended to breastfeed. The study confirms previous reports that primiparous women have a higher breastfeeding failure rate (45% had stopped by eight weeks). Women who gave later first feeds, or who were offered supplementary feeds in the postnatal ward, were more likely to be bottlefeeding at eight weeks. Hospital stays of less than 24 hours were strongly associated with successful feeding. Mothers receive little breastfeeding support from family or friends in the immediate postnatal period.
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7788357
|
Brave new world?
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Arguments in favour of embryo research Prevention of congenital defects. Reduction in number of miscarriages. Better understanding of infertility. Arguments against embryo research Morally unacceptable to take potential human life. The 14-day limit on research is arbitrary. Fears about the creation of 'superspecies' and 'designer babies'. Fear of embryo 'trade' in which embryos are bought and sold.
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7788358
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Natural family planning.
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Natural family planning (NFP) methods can be effective if taught well and practised by well-motivated couples. Midwives should be able to give couples an understanding of the basic principles of the methods. The observable signs of the fertile cycle are changes in basal body temperature, in the consistency of cervical mucus and in the texture and position of the cervix. Practised properly the ovulation method can have a failure rate of as little as 2.2 pregnancies per 100 woman-years. The ovulation method is a suitable method for mothers who have breastfed to detect the onset of ovulation.
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7788355
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Demystifying the research process in education.
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A well-developed base of empirical research is essential for accountable midwifery practice. Midwives need to develop 'research confidence'. The research process is explained sequentially from identification of the research problem, through literature review, research design, methodology, data collection and analysis. Research will enable the midwifery profession to develop further by uncovering the knowledge embedded in practice and in the education and management of midwives.
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7788353
|
A simulated insect diet as a water source for quail: effects on body mass and reproduction.
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Compared with control birds receiving ad libitum free-water, the total water intake of male and female northern bobwhite declined when only mealworms were available as a source of water. Male northern bobwhite sustained tissue mass and reproductive function with mealworms as their only source of water. Female northern bobwhite could not sustain body, ovary, and oviduct mass, and rate of egg production with mealworms as their only source of water. We suggest that, without free-water, breeding females require a diet with a water:dry matter ratio of greater than 1:1.29 (> 44% water).
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7788352
|
Effect of sera from lean and obese pigs on the differentiation of porcine adipose stromal-vascular cells in culture.
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Primary cultures of stromal-vascular (S-V) cells from adipose tissue of new-born pigs were used to evaluate the characteristics of four sera obtained from male and female genetically lean or obese pigs weighing 50-60 kg. (2) Lean pig sera (LPS) stimulated greater levels of sn-glycerol-3-phosphate dehydrogenase (GPDH) activity in cultured cells than obese sera (OPS). Male LPS tended to promote higher GPDH specific activity than female LPS or male and female OPS. When GPDH was expressed on a per DNA basis, male LPS significantly (P < 0.05) increased GPDH per unit DNA compared with female LPS or male and female OPS.
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7788351
|
Outward chloride/potassium co-transport in insect neurosecretory cells (DUM neurones).
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The mechanism underlying outward chloride transport in the cell body and in the neuritic field of cockroach Dorsal Unpaired Median (DUM) neurones was assessed using the intracellular microelectrode technique. The chloride equilibrium potential was indirectly estimated from the reversal potentials of responses to gamma-aminobutyric acid (GABA) pressure ejections and of inhibitory postsynaptic potential (IPSP) evoked by electrical stimulation of the anterior connectives. Changes in intracellular chloride concentration [Cl-]i following various treatments were estimated from the amplitude changes of soma GABA responses and IPSP. Decreasing external Cl- concentration reduced the amplitude of GABA-mediated inhibitory events without affecting the membrane potential. Cl-/K+ co-transport was assessed by increasing external K+ concentration. The rate of outward Cl- movement was reduced furosemide but not by SITS or DIDS. All these results suggest that Cl- is not passively distributed in DUM neurones and that an active outwardly directed Cl-/K+ co-transport is implicated in the regulation of [Cl-]i.
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7788350
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In situ degradation and absorption of [15N]urea in chicken ceca.
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[15N]Urea was introduced (in situ) into a ligated cecal pouch of chickens to determine if it is degraded therein and absorbed into the blood as ammonia during the following 60 min. A mean of 49% of the introduced urea-15N was recovered from the blood of the mesenteric vein draining the cecal pouch and 26% was recovered from the cecal lumen fluid. Of the urea-15N introduced into the pouch, 4%, 2%, 15% and 5% were detected as urea, ammonia and non-protein fractions, except urea and ammonia, and proteins in the lumen fluid, respectively. Non-protein-15N, except urea and ammonia, protein-15N, urea-15N and ammonia-15N values recovered in the cecal venous blood were 10%, 19%, 18% and 2% of the introduced 15N, respectively. Urea concentration in the cecal venous blood increased from 0.71 mg to 3.13 mg per 100 ml for the first 15 min after introduction of urea-15N (P < 0.01) then decreased until 60 min. No significant change was found in blood ammonia concentration, however, despite a small increase during the period 15-45 min after urea-15N introduction. Ammonia-15N increased in the caecal venous blood for the first 30 min then decreased to a plateau level of 43% of the peak level. The rates of increase of urea-15N and non-protein-15N concentrations attained maxima in the blood as early as 15 min, then decreased linearly (P < 0.05). It is concluded that, although urea is actively degraded to ammonia in the ceca, it is mostly absorbed from the ceca, not in the form of ammonia, but as protein, urea and amino acids.
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7788349
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Calcium-dependent regulation of membrane ion permeability in a cell line derived from the equine sweat gland epithelium.
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We measured the rates of 125I- and 86Rb+ efflux from preloaded, cultured equine sweat gland cells. The calcium ionophore ionomycin increased the efflux of both isotopes. Anion efflux was unaffected by Ba2+, but this cation inhibited 86Rb(+)-efflux, suggesting that [Ca2+]i-activated potassium channels were present. Activation of these channels was not, however, important for the efflux of anions. We measured 125I- efflux from valinomycin-depolarised cells in which anion cotransport was inhibited. Changes in 125I- efflux reflect changes in anion permeability under these conditions, and ionomycin caused a clear permeability increase that was abolished by the anion channel blocker diphenylamine-2-carboxylate. ATP and UTP increased the efflux of both isotopes, suggesting that type P2U purine receptors allow these nucleotides to regulate membrane permeability.
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7788348
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Acclimation of a non-indigenous sub-Arctic population: seasonal variation in thyroid function in interior Alaska.
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Total, as well as free, T4 and T3 levels were obtained over four seasons for young male infantry soldiers assigned to interior Alaska. Significant seasonal variations were found in both T3 and T4. Total T4 and T3 levels were highest in winter, while free T4 and T3 levels were highest in early spring. Correlations with melatonin levels from a concurrent study showed an association between late day (17.00) mean spot melatonin levels during the preceding summer and T3 levels in winter and spring. Differences in seasonal T4 and T3 levels between indigenous and newly arrived people in the sub-Arctic may be related not only to cold acclimation but also to light.
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7788347
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Visual word activation in pure alexia.
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A patient with pure alexia (DM) is shown to perform rapid and accurate lexical decisions for common words without the ability to recover their complete identity. We provide evidence using a speeded decision task that DM is not forced to rely on a laborious analysis of individual letter forms when judging the lexical status of orthographic patterns varying in length, though he clearly must use this approach to fully identify a word for explicit report. By contrast, the ability to rapidly classify a word apparently does not extend to judgements of its superordinate category. DM makes semantic decisions for visual words by adopting the same inefficient procedure he uses for verbal report of their identity. The results provide further constraints on the functional deficit responsible for pure alexia. We argue that DM is able to monitor the overall activation of word units without achieving full identification and that such a process may be a characteristic of the normal reading mechanism.
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7788346
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Syntactic processing in agrammatic aphasia by speakers of a Slavic language.
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It is widely believed that agrammatic aphasics have lost the ability to assign complete syntactic representations. This view stems from indications that agrammatics often fail to comprehend complex syntactic structures, as for example, some types of relative clauses. The present study presents an alternative account. Comprehension by Serbo-Croatian-speaking agrammatic aphasics was tested on four types of relative clause structures and on conjoined clauses. The relative clauses varied in type of embedding (embedded vs. nonembedded) and in the location of the gap (subject position vs. object position). There were two control groups: Wernicke-type aphasics and normal subjects. The findings from a sentence-picture matching task indicated that agrammatic aphasics were able to process complex syntactic structures, as evidenced by their well-above chance performances. The success rate varied across different types of relative clauses, with object-gap relatives yielding more errors than subject-gap relatives in all groups. Each group showed the same pattern of errors: agrammatic subjects were distinguished from Wernicke subjects and normal subjects only in quantity of errors. These findings are incompatible with the view that the agrammatics are missing portions of the syntax. Instead, their comprehension deficits reflect varying degrees of processing impairment in the context of spared syntactic knowledge.
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7788345
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Decline in homophone spelling associated with loss of semantic influence on spelling in Alzheimer's disease.
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The homophone spellings of 20 subjects with Alzheimer's disease (AD) and mild dementia were compared to those of matched normal controls. Both groups were tested once (Time 1) and then again 9 months to 1 year later (Time 2). At Time 1, AD subjects misspelled more homophones than the control group and the discrepancy between the two groups' performances significantly increased by Time 2. Two types of errors were tabulated: homophone confusions (i.e. an inappropriate yet correctly spelled homophone given the context, such as spelling doe, given the context "bake the bread dough") and other spelling errors (e.g. doue, dogh). The relationship between homophone confusions and confrontation naming increased from Time 1 to Time 2. In contrast, the relationship between the number of spelling errors (that were not homophone confusions) and confrontation naming performance was not significant at Time 2. One subgroup of 3 subjects showed an increase in homophone confusions and confrontational naming errors and not more spelling errors. Another subgroup of 4 subjects showed neither an increase in homophone confusions nor in confrontational naming errors, but did show an increase in spelling errors. Based on these results, we suggest that homophone confusions are primarily due to impairment of semantic access to a functional orthographic output lexicon. Other spelling errors may reflect post-linguistic spelling deficits without a significant change in the use of semantic input for spelling homophones.
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7788344
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Hypothesis on the nature of comprehension deficit in a patient with transcortical mixed aphasia with preserved naming.
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Patients with poor comprehension and preserved naming have been occasionally described. Such patients, who are affected by transcortical aphasia, have been taken as evidence of the possibility of naming an object while bypassing the semantic system. We describe a patient affected with mixed transcortical aphasia who presented a clear dissociation between ability in naming and difficulties in performing word-picture matching tasks. The pattern is explained by the existence of covert compulsory automatic naming that interferes with less automatic procedures involved in word-picture matching. In fact, when we tried to oppose automatic naming by using, in word-picture matching tasks, pictures difficult to name, the comprehension improved. This finding excludes a semantic deficit at the basis of poor comprehension of our patient. We suggest that the dissociation between naming and comprehension could be an expression of a computational limitation within the processes involved in word-picture matching, due to the competition for limited processing resources by automatically activated hyperactive naming.
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7788341
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Calcium pyrophosphate dihydrate crystal deposition disease in the elderly.
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Calcium pyrophosphate dihydrate deposition disease can mimic a large number of joint diseases. We report on three patients with predominantly systemic symptoms. Diagnostic pitfalls and treatment delays in these patients are discussed. Once the diagnosis is considered, confirmation is readily obtained by examination of the joint fluid and treatment promptly relieves symptoms.
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7788340
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Aspergillus arthritis of the shoulder in a renal transplant recipient. Failure of itraconazole therapy.
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We report a case of Aspergillus arthritis of the shoulder in a renal transplant recipient. Cultures of three joint fluid specimens grew Aspergillus fumigatus. Itraconazole as sole treatment resulted in initial clinical and roentgenographic improvements but failed to prevent deterioration in joint function. A relapse with fatal neurologic involvement occurred. Immune deficiency-inducing risk factors for aspergillosis include neutropenia and corticosteroid therapy. Previously published cases of Aspergillus arthritis of limb joints are reviewed. The advantages and limitations of itraconazole as single drug therapy are outlined.
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7788339
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Intrasacral meningocele. Report of a case.
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A case of intrasacral meningocele with low back pain and sciatica as the presenting manifestations in a 47-year-old male is reported. Magnetic resonance imaging established the diagnosis. Surgical treatment was successful.
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7788338
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Bone tissue in rheumatoid arthritis (2). Pathophysiologic data, pathologic findings, and therapeutic implications.
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The occurrence of bone decalcification during rheumatoid arthritis is well documented, despite discrepancies among published data. The most recent studies support a decrease in bone mass, especially at the proximal femur, although estimations of the extent of bone loss ascribable to rheumatoid arthritis vary. The fracture risk is increased by approximately 100% in rheumatoid arthritis patients. Bone mass is negatively correlated with functional impairment, joint motion restriction and disease activity as assessed by laboratory tests for inflammation. Increased physical activity can reduce bone loss. Markers for bone formation (osteocalcin, procollagen type I carboxy-terminal propeptide) are normal or decreased, whereas markers for bone resorption (hydroxyproline, pyridinoline, and deoxypyridinoline) are elevated. This decoupling of bone formation and resorption may be responsible for bone loss. Although estrogen therapy can keep in check menopause-related bone loss, earlier findings suggesting that estrogens may have beneficial effects on the joint disease itself have been disproven. The value of preventive bisphosphonate therapy is currently under debate.
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7788337
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Bone tissue in rheumatoid arthritis (1). Bone mineral density and fracture risk.
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Rheumatoid arthritis is associated with locoregional decalcification, which can be clearly demonstrated at the distal radius using single-photon absorptiometry. Bone loss at this site is probably due to the predominant involvement of the hands and wrists during rheumatoid arthritis. Estimates of the frequency of generalized bone loss have varied with the measurement technique used and the study design. Studies using dual-photon absorptiometry with a radioactive source have yielded conflicting data. The most recent studies of bone mineral density used dual energy X-ray absorptiometry, which is currently the best method in terms of reproducibility and precision; results suggested bone loss in the proximal femur, whereas lumbar spine measurements were usually normal or very slightly decreased. Findings from the few longitudinal studies are discordant; this may be ascribable to differences in bone mass measurement techniques, study population characteristics, and follow-up duration. Whereas bone loss was not demonstrated in the earliest longitudinal studies, recent investigations suggested that bone mineral density was decreased in rheumatoid arthritis patients as compared with controls. Corticosteroid therapy, even in daily dosages of less than 10 mg/d prednisone-equivalent, was associated with an approximately 10% decrease in bone mass after six months, in both cross-sectional and longitudinal studies. Rheumatoid arthritis patients had a two-fold increase in fracture risk, independently from their bone mass. Factors associated with higher fracture risks were corticosteroid therapy, physical inactivity, and female gender.
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7788336
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Contribution of parathyroid hormone-related peptide to the evaluation of hypercalcemia.
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Hypercalcemia of malignancy is due either to local osteolysis at the site of bone metastases or to production by the malignancy of parathyroid hormone-related peptide, which shares some of the effects of parathyroid hormone. We used a radioimmunoassay (antiserum specific to the amino-terminus) to measure serum parathyroid hormone-related peptide levels in controls (n = 61), chronic renal failure patients (n = 10), patients with primary hyperparathyroidism (n = 19), cancer patients with (n = 35) or without (n = 57) hypercalcemia and/or bone metastases (n = 53 and n = 39, respectively), and patients with hematologic malignancies (n = 15). We set the upper limit of normal of the parathyroid hormone-related peptide assay at 2.7 pmol/L. The peptide was undetectable in two-thirds of healthy controls. Renal failure did not interfere with the assay. Eighteen of the 19 patients with primary hyperparathyroidism had normal levels. In contrast, 82% of patients with humoral hypercalcemia of malignancy (i.e., without detectable bone metastases) had increased levels; in this subgroup there was a significant inverse correlation between serum levels of the peptide and phosphorus. Elevation of parathyroid hormone-related peptide levels was less common among hypercalcemic patients with metastatic bone disease (38%). Four of the seven hypercalcemic patients with hematologic malignancies had elevated parathyroid hormone-related peptide levels. In our overall study population, serum calcium levels were weakly but significantly correlated with parathyroid hormone-related peptide levels. In conclusion, elevated parathyroid hormone-related peptide in a patient with hypercalcemia suggests a malignant disease.(ABSTRACT TRUNCATED AT 250 WORDS)
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7788335
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Adult-onset idiopathic phosphate diabetes. II. Time-course of clinical, laboratory test, and bone mineral density abnormalities under combined phosphate and calcitriol therapy.
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to investigate the time-course of clinical, laboratory test, and bone mineral density abnormalities in patients with mild phosphate diabetes treated for at least one year with calcitriol, 0.5 to 1.5 micrograms, and oral phosphate, 788 to 2300 mg per day, in three divided doses. we studied eight patients with mild phosphate diabetes defined as a rate for tubular reabsorption of phosphate of less than 18% with a maximal rate for tubular reabsorption of phosphate (Tm) of less than 0.77 in the absence of any detectable cause of secondary tubular disease. Treatment efficacy was evaluated on the basis of pain severity, pain-related functional disability, serum phosphate and calcium levels, maximal rate for tubular reabsorption of phosphate, and dual-photon absorptiometry-measured bone mineral density. three patients experienced complete relief of pain and fatigue and were able to resume their normal activities. Partial relief was seen in two other patients. The three remaining patients had no response to treatment. Renal colic occurred in one patient. None of the patients developed hypercalcemia.
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7788334
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Adult-onset idiopathic phosphate diabetes. I. Chronic pseudoinflammatory back pain and osteopenia.
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to investigate clinical, laboratory test, and bone mineral density abnormalities in 19 adults with phosphate diabetes of unknown etiology diagnosed in a rheumatology department on the basis of a maximal rate for tubular reabsorption of phosphate (TmPO4/GFR) of 0.77 or less. there were 14 males and five females with a mean age of 36.7 years (range 20 to 68 years) at symptom onset and 43.9 years (24-70) at diagnosis. Seventeen patients (90%) had back pain and 13 (68%) had nerve root pain. The pain was nocturnal only or both nocturnal and diurnal in 14 cases (74%). Other manifestations were fatigue (n = 7, 37%), myalgia (n = 6, 32%), fracture (n = 6, 32%), renal colic (n = 4, 21%), and pseudodepression (n = 10, 53%). Laboratory test abnormalities were as follows: serum phosphate, 0.72 mmol/L (0.58-0.89); rate for tubular reabsorption of phosphate, 74% (54-84%); maximal rate for tubular reabsorption of phosphate, 0.58 (0.4-0.76); urinary calcium/urinary creatinine > 0.48 in nine patients (47%); and fractional potassium excretion > 20% in seven patients (37%). Normal values were found for serum levels of Ca++, Na++, Mg++, creatinine, cortisol, T3, T4, TSH, 25(OH)D3, and 1,25(OH)2 D3. Tests for glycosuria and amino aciduria were negative. Bone mineral density measurements showed z-scores of -2.13 (+0.9 to -4.25) at L2-L4, and -1.34 (+1.5 to -3.2) at the femoral neck. Bone histology showed osteoporosis with a mild increase in osteoid deposition. idiopathic adult-onset phosphate diabetes manifests as chronic back pain and nerve root pain, sometimes with fatigue and depression. Bone mineral density values are decreased and histology shows osteopenia. Differential diagnoses include spondyloarthropathy, disk disease, fibromyalgia, and depression. Determination of the maximal rate for tubular reabsorption of phosphate is the only means of establishing the diagnosis.
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7788333
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Sensitivity to change of various roentgenological severity scoring systems for osteoarthritis of the hip.
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joint space assessment on roentgenograms is considered reliable for evaluating the anatomic severity of hip osteoarthritis. Methods for measuring this parameter include the scoring system developed by Kellgren and Lawrence, joint space width measurement, and joint space surface area measurement after digitalization of roentgenograms. to compare the sensitivity to change of the three above-listed methods. the study included patients with hip osteoarthritis meeting ACR criteria for whom two roentgenograms showing evidence of hip osteoarthritis taken 10 to 15 months apart were available. Roentgenograms were read by a single investigator who was unaware of the chronological order of films. Sensitivity to change of the three measurement techniques was determined by calculating standardized response mean (mean change/standard deviation of change). the study evaluated 34 hips (68 roentgenograms) in 22 patients (12 females and ten males, mean age 63 +/- 10 years) with osteoarthritis of one (n = 10) or both (n = 12) hips. Standardized response mean were 0.37, 0.33, and 0.16 for joint space width, joint space surface area, and the Kellgren-Lawrence score, respectively. this study suggests that joint space width or surface area may be more sensitive than the Kellgren-Lawrence score for monitoring the course of hip osteoarthritis.
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7788332
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HLA-DPB1*0201 is associated with particular clinical features of rheumatoid arthritis.
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to determine the effect of HLA-DPB1 status on rheumatoid arthritis (RA) susceptibility and disease expression. HLA-DPB1 alleles were identified in 158 RA patients and 106 controls using PCR-sequence specific oligonucleotide probing. HLA-DPB1 allele frequencies were compared between patient and control groups and the strength of associations assessed using odds ratios and with 95% confidence intervals (CI). Associations observed in the total RA group were confirmed using a relative predispositional effect (RPE) analysis. an association between DPB1*0201 and RA was observed (OR 1.8, 95% CI 1.0-3.4). By contrast, negative associations were found with DPB1*0301 (OR 0.5, 95% CI 0.3-1.0) and DPB1*1101 (OR 0.06, 95% CI 0.001-0.5). These associations were confirmed using RPE analysis. On further analysis the increase in DPB1*0201 and decrease in DPB1*0301 frequencies in RA was found to be independent of DR4 status. The association of DPB1*0201 with RA appears to be most pronounced in male patients (OR 3.3, 95% CI 1.3-8.3), seronegative patients (OR 2.6, 95% CI 0.9-7.3) those with non-erosive disease (OR 2.6, 95% CI 0.9-7.3) or in patients with high titre antinuclear antibodies (OR 2.4, 95% CI 0.8-7.1). HLA-DPB1 alleles may be associated with the pattern of disease expression in certain RA patients and in some cases confer protection against disease.
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7788324
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Longitudinal insufficiency fractures of the femoral shaft.
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Most insufficiency fractures of the femur are transverse fractures of the femoral neck. We report two 77-year-old female patients with longitudinal fractures of the femoral shaft; one had a vertical fracture line in the proximal part of the shaft and the other a spiroid line in the middle third of the shaft. Both patients experienced apparently spontaneous onset of incapacitating mechanical pain in the hip or thigh; duration of the pain at evaluation was ten days in one case and six months in the other. Potential risk factors were osteoarthritis of the hip and the presence of metalwork in the knee. Increased radionuclide activity at the fracture site was seen on the bone scans. In one patient, roentgenographic and computed tomography findings were normal and the diagnosis was established by magnetic resonance imaging. In the other, the fracture line was seen clearly on computed tomography sections. Longitudinal fractures often escape diagnosis initially because roentgenographic changes are delayed. Hyperactivity on the bone scan is suggestive but sometimes so extensive as to mislead the diagnosis. The callus and, less frequently, the fracture line are sometimes seen on computed tomography sections. The role of magnetic resonance imaging remains to be determined.
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7788323
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Monostotic Paget's disease involving the calcaneus. Diagnostic and therapeutic problems. Two case-reports.
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The authors report the cases of two patients who had chronic incapacitating heel pain unresponsive to standard therapy. They were both found to have Paget's disease of the calcaneus. The diagnosis was difficult because the typical roentgenological changes required time to develop and because no other sites were involved. Local corticosteroid injections, elimination of weight-bearing, and standard analgesic therapy were ineffective. Bisphosphonate therapy (pamidronate) given as intravenous infusions ensured prompt lasting pain relief, making ambulation possible.
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7788322
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Rehabilitation of low back pain patients. A review.
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Numerous methods have been developed for the rehabilitation of low back pain patients, including spinal flexion and extension exercises, lumbar spine locking in an intermediate position, enhancement of spinal and pelvic proprioceptive sensibility, swimming pool therapy, back schools, and functional restoration. Each seeks to achieve a goal assumed to be central to the prevention of a first or recurrent episode of low back pain. Goals include short-term pain relief, an improved ability to achieve self-sedation, abdominal and lumbar muscle strengthening, increased hip and lumbar spine mobility, improved lumbar and pelvic proprioceptive sensibility, intervertebral joint stabilization, lumbar posture modification and improved general fitness. Less than 30 studies meeting widely accepted validity and applicability criteria for therapeutic trials have addressed the clinical efficacy of rehabilitation in low back pain patients. Most studies of the back school approach have found no benefit. Spinal flexion and extension exercise programs have yielded short-lived improvements, with no differences across methods. There is evidence that functional restoration programs based on graded activity may provide long-term benefits including better social and occupational outcomes. We have evaluated the physical therapy methods most commonly taught to and used by physical therapists in France.
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7788320
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Cervical epidural infection. Four case-reports.
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The authors report four cases of cervical epidural infection, in two females (aged 58 and 82 years) and two males (aged 41 and 51 years). Risk factors were noninsulindependent diabetes mellitus in one patient and multiple myeloma treated by chemotherapy in another. Duration of cervical pain at evaluation was five to 15 days. Three patients had a fever and a neurologic deficit: one had brachial diplegia; the myeloma patient developed brachial diplegia after a lumbar puncture and the diabetic patient developed quadriplegia with respiratory disorders also after a lumbar puncture. Cerebrospinal fluid studies showed elevated protein levels with approximately 20 cells per mm3 and no pathogens in smears or cultures. Roentgenograms were normal at admission. The diagnosis was established by myelography (n = 2) and/or computed tomography (n = 2) and/or magnetic resonance imaging (n = 2). The infected area was anterior in three cases and posterolateral in one. Two to seven vertebral levels were affected. A Staphylococcus aureus was recovered from the blood cultures in all four cases and from a local specimen in one of the two patients who had a laminectomy. Of the two patients who did not have surgery, one had a normal neurologic evaluation and the other was an elderly patient with myeloma. In both, antimicrobial and corticosteroid therapy ensured complete resolution of the infection, and the myeloma patient recovered normal neurologic function. Residual neurologic loss was seen in one of the two surgically-treated patients. Two patients developed discitis.
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7788319
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Polyarthritis in HTLV-1-infected patients. A review of 17 cases.
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A retrospective study was conducted in Martinique to identify patients with polyarthritis and positive serologic tests for the human T-cell lymphotropic virus Type I (HTLV-1). Patients with metabolic or bacterial causes of polyarthritis were excluded. We found 17 cases of HTLV-1-positive polyarthritis (6.7% of the total of polyarthritis patients followed in our department); there were 14 females and three males, and all the patients were West-Indian blacks. Mean age at diagnosis was 50 years. Five patients also had tropical spastic paraparesis. The polyarthritis was the inaugural manifestation of T-cell leukemia in one patient. Four patients had received blood transfusions. Fever, myalgia, and/or skin lesions were present at onset of the polyarthritis in seven cases. All 17 patients had peripheral, bilateral, symmetric polyarthritis; the most commonly involved sites were the hands (17/17) and knees (14/17). Three patients had rheumatoid factor and five had antinuclear antibody. Ten patients met at least four American Rheumatism Association criteria for rheumatoid arthritis; they accounted for 6.7% (10/150) of all polyarthritis patients managed in the same hospital department during the same period. We compared these ten patients with 20 HTLV-1-negative rheumatoid arthritis patients matched on gender, ethnic origin, and disease duration. There were no significant differences between the two groups for any of the parameters studied.
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7788318
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Are classification criteria for spondylarthropathy useful as diagnostic criteria?
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The authors used data from a study conducted under the auspices of the Société Française de Rhumatologie to evaluate the sensitivity and specificity of the individual items of two sets of criteria for spondylarthropathy. The study included 124 patients with spondylarthropathy and 1,964 controls. They found that the spondylarthropathy criteria with the highest sensitivities and specificities were useful not only for classifying patients but also for assisting in the diagnosis of spondylarthropathy.
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7788317
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A 7-year-old girl with a growth disturbance in the extremities.
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The following case describes the roentgenographic and clinical findings of a condition of interest to the orthopedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on this page. The final clinical and roentgenographic differential diagnosis can be found on the pages that follow.
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7788316
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A technique for cementing of the patellar component in total knee arthroplasty.
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A technique is described for cementing of the patellar component in total knee arthroplasty that involves pressurization of cement into the patellar-component lug holes, which are drilled in the bone prior to cementing the component. A radiographic comparison of cement penetration with this method versus that obtained by using conventional techniques is illustrated.
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7788315
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Spontaneous rupture of the tibialis anterior tendon.
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Spontaneous rupture of the tibialis anterior tendon is an uncommon occurrence that most often affects men in their fifth to seventh decades. These ruptures occur through abnormal tendons, but may cause little disability. Early repair does seem to improve the likelihood of a good result, however. The following is a case report, and the English literature is reviewed.
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7788314
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Clinical significance of leg-length inequality after total hip arthroplasty.
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Sixty-eight patients were interviewed and examined after total hip arthroplasty (THA) to determine the clinical consequences (patient satisfaction, shoe lift use, gait abnormalities, etc) of leg-length inequality. No patient met clinical or radiographic criteria for revision THA. Minimum follow-up was 2 years, and average follow-up was 6.6 years (range, 2 to 20.5 years). A questionnaire, with specific questions about leg-length inequality, was completed by each patient. Leg-length inequality was determined by orthoroentgenography and compared with clinical measurements of leg length. The average inequality in this series of patients was 9.7 mm. A significant number (32%) of patients were aware of this inequality; the average leg-length inequality in this group was 14.9 mm. More than half of these patients were disturbed by the inequality. The magnitude of leg-length inequality closely correlated with awareness of the inequality, abnormal gait, use of ambulatory assistive devices, the need for a shoe lift, prior leg-length inequality, and revision THA. Clinical measures of leg-length inequality correlated poorly with values determined orthoroentgenographically. The high rate of dissatisfaction among patients with a leg-length inequality and the untoward results associated with this inequality indicate that surgeons performing THA should familiarize themselves with a reliable method for equalizing leg lengths intraoperatively.
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7788313
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Femoral varus derotational osteotomy in cerebral palsy.
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The records concerning 64 hips in 36 cerebral palsy patients treated with varus derotational osteotomy (VDO) alone (2 hips), VDO with muscle releases (adductors, iliopsoas, hamstrings; 46 hips), and VDO, soft-tissue release, and innominate bone osteotomy (16 hips) were reviewed. There were 23 quadriplegic and 13 diplegic patients. Average age at surgery was 7 years. Average follow-up period was 3.8 years. All hips that had VDO, soft-tissue release, and innominate osteotomy were stable at follow-up. Nine hips of the 44 treated with VDO and muscle release alone dislocated, and required second osteotomies.
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7788312
|
In search of the perfect ACL brace.
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Following my own acute anterior cruciate ligament (ACL) tear and reconstruction, I embarked on a subjective evaluation of ACL functional braces voluntarily supplied by vendors. Both custom and off-the-shelf braces were evaluated during daily activities and running. Scored subjectively on an ascending scale of 1 to 3 were Comfort (including freedom from slippage, abrasions, and pressure phenomena), Convenience (ease of application), Control (perceived resistance to anterior tibial translation), and Cosmesis (appearance, profile). On this rating scale, 1 represents below average, 2 is average, and 3 is above average. The Comfort score was doubled, as this feature determined whether the brace would be worn. The individual scores were then totaled for an overall rating. To avoid bias, I did all trials prior to reviewing the literature. Scores for custom braces were: Townsend, 14; Omni Scientific Elite, 11; Innovation Sports C.Ti.2, 10; 3M Lenox Hill Spectralite, 9; Orthotech Performer, 9; DonJoy Defiance, 9; and Sutter Talon, 9. Scores for OTS braces were: DonJoy Goldpoint, 13; Orthotech Controller, 11; Bledsoe Force III Light, 11; 3M Lenox Hill OTS, 10; Innovation Sports MVP, 8; Bledsoe Force II, 8; Bledsoe Force II Light, 8; Omni Scientific Spectrum, 7; Townsend OTS, 7; and DonJoy Playmaker, 6. This study does not validate the requirement for a functional orthosis following ACL reconstruction, but if one is desired, I prefer the custom Townsend and the OTS DonJoy Goldpoint. Two other higher scoring OTS braces also proved satisfactory (OTS Orthotech Controller and OTS Bledsoe Force III Light). To accommodate the majority of patients, orthopedic surgeons may need to provide a variety of OTS braces.(ABSTRACT TRUNCATED AT 250 WORDS)
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7788311
|
Carcinogenicity and metallic implants.
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The literature related to the carcinogenetic potential of metallic implants was reviewed. There were 20 cases described in which tumors were identified in proximity to metallic implants. These cases occurred over a 34-year period. Investigators have identified a 70% increased incidence of lymphomas and hematopoietic tumors over that in the general population in patients who had received total hip arthroplasties. Carcinogenicity theories include the potential direct toxicity of materials, the effects of surface properties, the electromotive potential created by dissimilar metals in contact, the immunologic response to implants, and finally, the sustained presence of low-grade infection. Corrosion is a well-documented phenomenon and occurs with any type of metal. The rate of formation of corrosion products and their toxicity varies with the implant composition. Toxic effects of metals, such as malignant potential and other adverse effects, have been demonstrated in animal models. The published information on this controversial and very poignant issue of metallic carcinogenesis is useful for all orthopedic surgeons.
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7788310
|
Wrist arthroscopy.
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Miniaturization of arthroscopic equipment has allowed wrist arthroscopy to emerge as a powerful surgical tool in orthopedic surgery. The magnified view of the arthroscope has provided a new understanding of carpal anatomy and disease. Arthroscopy improves surgeons' ability to diagnose wrist disorders and enables them to perform operative procedures with less morbidity than would occur in open procedures.
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7788306
|
Structure-activity studies leading to potent chloride channel blockers: 5e-tert-Butyl-2-[4-(substituted-ethynyl)phenyl]-1,3-dithianes.
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5e-tert-Butyl-2e-[4-(substituted-ethynyl)phenyl]-1,3-dithianes+ ++ with selected functional groups (R) on the ethynyl moiety are potent blockers of the GABA-gated chloride channel measured as inhibitor concentration (IC50) for 4-n-[3H]propyl-1-(4-ethynylphenyl)-2,6,7- trioxabicyclo[2.2.2]octane binding to bovine brain membranes. The terminal R substituents were introduced by coupling 5e-tert-butyl-2e-(4-iodophenyl)-1,3-dithiane with HC identical to CR or 5e-tert-butyl-2e(4-ethynylphenyl)-1,3-dithiane with XR. The potency of the parent compound (R = H) with an IC50 of 21 nM is equaled or exceeded by up to 7-fold (i.e. IC50 = 3-21 nM) by several carboxylic acids [R = (CH2)nCO2H (n = 0-3), (CH2)nOCH2CO2H (n = 1-3), and CH2SCH2CO2H] and their esters and two phosphonic acids (CH2CH2PO3H2 and CH2OCH2PO3H2) but not their esters. These carboxylic and phosphonic acids (and their salts) include the most potent water-soluble chloride channel blockers known. Conversion to the monosulfones increases the activity of the R = H and CH2OH analogs by 1.2- to 3-fold but decreases that of the R = CH2CH2CO2R' (R' = H or CH3) derivatives by 3- to 13-fold. Quantitative structure-activity analyses for 44 2-[4-(substituted-ethynyl)phenyl]-dithianes suggests that the principal feature of the R substituent for high activity is its polarizable volume modeled as molecular refractivity, i.e. this substituent is not a well-defined pharmacophore and undergoes a structurally non-specific interaction with the receptor. These observations lay the background for preparing candidate affinity probes.
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