Fundamental motor patterns of the mammalian fetus. Techniques that permit direct observation of fetuses in vivo recently have expanded our understanding of prenatal behavioral development in mammals. Although fetal motor activity seems to lack the dynamic, goal-directed character of postnatal behavior, the dimensions that define behavioral organization after birth are applicable to the movements expressed by fetuses. Fetal activity exhibits temporal, sequential, and spatial organization that emerges between the inception of movement and term. Fetal rodents, for example, exhibit coordinated motor patterns antecedent to postnatal righting, locomotion, suckling, maternal-infant communication and grooming behavior, while other action patterns appear to be functional adaptations to the intrauterine niche. Fetuses also are behaviorally responsive to sensory stimulation and changes in environmental conditions in utero. Expression of these behavioral properties emphasizes continuity between prenatal and postnatal life while implying an adaptive role for behavior before birth.


Mechanical trauma as a risk factor in classic amyotrophic lateral sclerosis: lack of epidemiologic evidence. We have examined the relationship between mechanical injuries and the subsequent development of classic amyotrophic lateral sclerosis (ALS) through a critical review of the literature. Only prospective evaluation of a large cohort of trauma victims can provide an unbiased answer to this controversy. However, such an evaluation would be prohibitively expensive, and the results would not be available in our lifetime. The results of retrospective case-control studies are conflicting in part because of biases in the selection of patients and controls, poor definition of the nature and extent of the trauma and its chronological relationship to the onset of ALS, and a non-uniform approach to the collection of antecedent information. More rigorously designed studies show no association of ALS to antecedent trauma. The existing data thus do not suggest that mechanical trauma is a risk factor for ALS. Future case-control studies should conform to a standardized methodology. The critical analysis presented here of the research on the purported connection between mechanical injury and ALS may serve as a model for the evaluation of the role of trauma in other chronic diseases. Application of these methodological principles may bring increased scientific rigor to assessing the frequently litigated question of what constitutes a true trauma sequela.


Neuronal thread protein over-expression in brains with Alzheimer's disease lesions. Neuronal thread protein (NTP) is a recently characterized molecule that is over-expressed in brains with Alzheimer's disease (AD) lesions. The present study encompasses a detailed analysis of NTP expression in AD compared with other neurodegenerative diseases and aged controls. Using a specific monoclonal antibody, NTP immunoreactivity was evaluated in 309 paraffin-embedded sections from 8 different regions of the frontal, parietal, and temporal lobes of 73 brains with AD, AD + Down's syndrome (DN), AD + Parkinson's disease (PD), PD dementia (PDD), aged controls, and disease controls with Huntington's disease, multi-infarct dementia, or schizophrenia. In 250 adjacent blocks of snap-frozen unfixed tissue the concentration of NTP (ng/mg of protein) was measured using a 3-site forward sandwich monoclonal antibody based immunoradiometric assay (M-IRMA). Immunohistochemical studies demonstrated that brains with AD, AD + PD, and AD + DN contained significantly higher densities of NTP immunoreactive neurons and more frequent immunostaining of neuropil and white matter fibers compared with PDD and aged controls (both P < 0.001) which had few or no AD lesions. In addition, the overall mean concentrations of NTP in AD, AD + PD, and AD + DN were significantly higher than in PDD and aged controls (P < 0.005). Greater degrees of NTP immunoreactivity and higher concentrations of the protein in cerebral tissue were significantly correlated with AD diagnosis and abundant neurofibrillary tangles (P < 0.005). The findings suggest that NTP over-expression may serve as a marker for the type of neuronal degeneration that occurs in AD.


Effects of dimethylthiourea on ischemic brain damage in hyperglycemic rats. Hyperglycemia is known to worsen the outcome of transient global or forebrain ischemia. The aggravating effect is believed to be mediated by the additional formation of lactate- and of H+. Recent evidence suggests that reactive oxygen species contribute to the damage after brain ischemia. Since acidosis accelerates free radical damage in vitro, we decided to explore if ischemic damage in hyperglycemic subjects is ameliorated by dimethylthiourea (DMTU), an established free radical scavenger. In one series of hyperglycemic rats, we studied whether preischemic administration of DMTU alters the clinical outcome, notably the incidence and frequency of seizures. In two different series, the effect of DMTU on tissue damage was assessed by light microscopy after 15 h of recovery. Longer periods could not be studied since seizures developed. In the first of these series the animals were anesthetized with isoflurane, and in the second with halothane. The latter anesthesia largely suppressed the "early" postischemic seizures, i.e. those occurring after 1-4 h. Dimethylthiourea treatment altered the clinical outcome after ischemia. Thus, the "late" postischemic seizures appeared milder and occurred significantly later than in untreated animals. The fatal outcome was also delayed since treated animals died after 35.5 +/- 8.2 h (mean +/- SD) of recirculation, as compared to 19.8 +/- 3.6 h of recirculation in control animals. However, all DMTU-treated (and control) animals died. In the first morphological series (isoflurane anesthesia) the histopathological analysis was complicated by the occurrence of prefixation seizures; such seizures were recognized in 4/16 animals. When these 4 animals were excluded from the analysis (2 treated and 2 control animals), DMTU pretreatment did not ameliorate the damage, except in the substantia nigra pars reticulata (P < 0.05). In the second series, comprising animals anesthetized with halothane, only one animal out of 16 had "early" seizures, and none showed "late" seizures before death. Among these animals DMTU treatment significantly ameliorated damage to caudoputamen and cingulate cortex (P < 0.01). We conclude that treatment with the free radical scavenger DMTU partly ameliorates ischemic brain damage associated with excessive acidosis, and marginally delays the development of post-ischemic seizures. However, the effects were moderate and could, at least in part, have been caused by nonspecific effects of DMTU. Furthermore, all DMTU-treated animals died. The results thus give little support to the notion that the aggravating effects of acidosis is due to enhancement of free radical production.


MRI, brain iron and experimental Parkinson's disease. Abnormal levels of brain iron have been reported in parkinsonism, which is characterized principally by degeneration of dopaminergic (DA) nigrostriatal neurons. There are conflicting reports, however, of both increased and decreased iron in parkinsonism. An animal model of parkinsonism was used to clarify the contribution of the loss of nigrostriatal DAergic neurons to abnormal iron accumulations. In rats with 6-hydroxydopamine induced unilateral DA depletion, brain iron deposition and its day-to-day stability was studied in vivo using T2-weighted magnetic resonance imaging (MRI) scans taken on 4 consecutive days beginning 1-2 months post-surgery and post-mortem by Perls'-DAB histochemical stain. Unilateral DA depletion (parkinsonism model) produced large day-to-day fluctuations in T2 relaxation time in the striatum. The T2 relaxation time in Sham control rats was relatively minor. The uptake and transport of iron by intrinsic cells of the striatum may vary, and this variability may have been exaggerated by the destruction of DAergic nigrostriatal neurons, which are known to modulate the activity of the intrinsic cells. Inconsistent reports of increased or decreased iron in parkinsonism may reflect, in part, single time-point measures of widely fluctuating iron.


Electrophysiologic study of HIV-1 + patients without signs of peripheral neuropathy. HIV-1 seropositive patients have a high frequency of nervous system diseases, and asymptomatic abnormalities are frequently detected. We studied 124 neurologically asymptomatic HIV-1 seropositive subjects and 23 normal control subjects by nerve conduction studies. No alterations were detectable in the asymptomatic stages of infection (CDC groups II and III), while subclinical peripheral nervous system (PNS) impairment was detected in symptomatic HIV-1 stages (CDC group IV). Specifically, in CDC group IV we observed a reduction in the motor conduction velocity of the deep peroneal nerve and the median nerve, and a similar reduction of the sensory conduction velocity of the sural nerve. There were no differences of the amplitude and area of the muscular response or of the sensory nerve action potential. As our patients did not present clinical or laboratory evidence for a toxic-dismetabolic etiology, our data indicate a progressive myelin damage more directly related to HIV-1 infection. This subclinical finding may have importance for the progression of the disease in the PNS.


Nonvacuolar myopathy in a large family with both late adult onset distal myopathy and severe proximal muscular dystrophy. Late adult onset distal myopathies usually show vacuolar degeneration as a characteristic feature in muscle pathology. In this study vacuolar degeneration was not present in 12 patients with late adult onset distal myopathy. All patients were members of a large kindred, with 26 patients showing this new form of distal leg myopathy. Additionally, a severely disabling proximal muscular dystrophy appeared in eight other members of the large consanguineous kindred. Muscle biopsies were obtained from clinically affected muscles, and from clinically unaffected muscles in patients with distal myopathy. For comparison specimens from various muscles of patients with severe proximal dystrophy were also studied. Histopathological changes correlating to muscular dystrophy were extensive in all muscles studied in patients with proximal dystrophy, and in tibial anterior muscles in patients with distal myopathy. Mild myopathic changes, mainly increased internal nuclei in muscle fibers, were detected in clinically unaffected muscles in the distal myopathy. The spectrum of findings is compatible with the hypothesis of previous clinical and genetic studies, indicating that the severe proximal dystrophy could be a homozygous manifestation of the dominantly inherited gene of the distal tibial muscle dystrophy.


Correlation between clinical and molecular features in two MELAS families. We describe the clinical, morphological, biochemical presentation in two MELAS families, and correlate it with the distribution and proportion of mitochondrial DNA carrying the A to G transition at nt 3243. Family A was characterized by late onset MELAS in two members, CPEO in one, and mild CNS involvement in another. 20-61% of mtDNA of affected and unaffected individuals was mutated in muscle, 2-18% in blood. There was no obvious correlation between clinical picture and proportion of mutated mtDNA. In family B full MELAS syndrome appeared only in the third generation, but the mutation was also detected in muscle of asymptomatic individuals of the first and second generation. The proportion of mutated mtDNA in blood, and to a lesser extent in muscle, correlated with the severity of the clinical presentation. The MELAS mutation is consistently detected in all asymptomatic maternal relatives of MELAS patients. We conclude that different clinical presentations of mitochondrial encephalomyopathy may coexist in the same family, and correlation between clinical severity and molecular abnormality is not always recognizable. Presence of the MELAS mutation in muscle and blood is a necessary but not sufficient condition for the expression of the typical MELAS phenotype.


Should all patients with atrial fibrillation be screened with echocardiography? To address a patient care problem suggested by a quality assurance study: Should physicians of patients with atrial fibrillation who have not had echocardiography performed be encouraged to obtain echocardiograms in order to discover heretofore undetected mitral stenosis, which could be treated with anticoagulation, in order to avert strokes? Decision analysis using a Markov-chain technique and quality-adjusted life expectancy. Outpatient clinics. Patients aged 40-80 years with chronic atrial fibrillation. The following strategies were studied: 1) obtain echocardiograms for all patients and anticoagulate those with mitral stenosis; 2) anticoagulate patients with classic auscultatory sounds of mitral stenosis and obtain echocardiograms for patients with other murmurs; if an echocardiogram reveals mitral stenosis, anticoagulate; 3) anticoagulate all patients with murmurs; 4) anticoagulate all patients; 5) observe all patients (natural history). The base analysis, using data available in the literature and on site, indicated that though performing echocardiography on all patients with atrial fibrillation gave the best quality-adjusted life expectancy, the differences among the five strategies studied were small. In addition, sensitivity analysis revealed that the decision was sensitive to many of the variables used in the analysis, especially the efficacy and the risks of anticoagulation. A recommendation that cardiac ultrasonography be done for all patients with atrial fibrillation in order to detect clinically unrecognized mitral stenosis cannot be made.


Detection of pyuria and bacteriuria in symptomatic ambulatory women. To compare the abilities of two methods for rapid detection of pyuria and three methods of urinalysis to predict significant bacteriuria in symptomatic ambulatory women. Prospective simultaneous comparison of the results of dipstick urinalysis, standard microscopic urinalysis, and hemocytometric cell counting and Gram staining with the results of a standard urine culture. Two outpatient ambulatory care facilities serving predominantly minority and uninsured individuals. Nonpregnant women presenting with symptoms of urinary tract infection without symptoms of vaginal infection. 105 women with symptoms were evaluated. The sensitivities of the dipstick urinalysis and the microscopic urinalysis in predicting pyuria as defined by hemocytometry were 0.76 and 0.77, respectively, and their specificities were 0.94 and 0.97, respectively. The sensitivities and specificities of the three methods of urinalysis in predicting greater than or equal to 10(4) colony-forming units (CFU)/mm3 in a urine culture were 0.88 and 0.70 for the leukocyte esterase-nitrite dipstick urinalysis, 0.98 and 0.68 for the standard microscopic urinalysis, and 1.00 and 0.49 for the Gram staining and hemocytometric cell counting. The standard urinalysis was the most accurate single method to predict significant bacteriuria in symptomatic ambulatory women. Sequencing the dipstick urinalysis with the standard urinalysis may be a cost-effective approach to evaluating these patients in clinical practice.


Laboratory diagnosis of iron-deficiency anemia: an overview. To determine the diagnostic values of laboratory tests used in the diagnosis of iron-deficiency anemia, the authors conducted a systematic overview of the relevant literature. Computerized searches of the MEDLINE database yielded 1,179 potentially relevant citations. Fifty-five studies included the results of laboratory tests and histologic examination of the bone marrow for at least 50% of an identifiable patient group. In these 55 studies, quality was assessed and descriptive information concerning the study populations, the tests conducted, and the results was extracted, all in duplicate. Serum ferritin radioimmunoassay was by far the most powerful test, with an area under the receiver operating characteristic curve of 0.95. Test properties differed for populations of patients with inflammatory, liver, or neoplastic disease and patients without these conditions. Likelihood ratio lines, which allow precise interpretation of results across the entire range of ferritin concentration values, were constructed for the individual populations. Serum ferritin radioimmunoassay is an extremely powerful test for the diagnosis of iron-deficiency anemia and, appropriately interpreted, can be applied to the complete range of patients.


Use of health services before the diagnosis of melanoma: implications for early detection and screening. To determine whether persons with melanoma were integrated into the health care system prior to diagnosis. Population-based survey by mailed questionnaire. 216 persons with malignant melanoma diagnosed in Massachusetts in 1986. Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported physician skin examinations. Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However, most of these persons neither received skin examinations nor examined their own skin during that time. While additional study is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate melanoma screening into routine care.


Technetium bone scanning in the diagnosis of osteomyelitis: a meta-analysis of test performance. Diagnostic Technology Assessment Consortium. To determine the diagnostic performance of technetium bone scanning in the setting of possible osteomyelitis in the foot of a patient who has diabetes or other vasculopathy. Meta-analysis. Data identification and study selection: To be eligible for inclusion, a report must have used intravenous technetium-99m methylene diphosphonate or a similar agent in humans over the age of 16 years, must have addressed possible osteomyelitis of the lower extremity with ulcer or soft-tissue inflammation in the setting of diabetes, neuropathy, or vasculopathy, and must have allowed the generation of a two-by-two table. A structured search of the MEDLARS database found 296 possibly eligible reports; ten met all the inclusion criteria. The reported sensitivity and specificity of each report were converted to their logistic transforms and a straight line was fitted by weighted least-squares regression. The line was then back-transformed to yield a summary receiver operating characteristic curve. The false-positive rate of the bone scan is at best in the range of 10 to 20%. This occurs at sensitivities between 70 and 80%. The studies with increased sensitivity also reported sizable increases in the false-positive rate ranging from 20 to over 90%. Even small increases in sensitivity have necessitated large sacrifices in specificity. Seven of the ten studies reported specificities under 70%. Published data defining the effectiveness of technetium bone scanning for the diagnosis of osteomyelitis in the impaired foot indicate relatively poor performance. In many clinical situations, the specificity of the bone scan will not be high enough to confirm the diagnosis of osteomyelitis.


The influence of patient smoking status on therapeutic decisions. To assess the effect of patient smoking status on internists' inclinations to recommend certain types of therapy for conditions that are and conditions that are not related to smoking. Five hundred ninety-eight internists identified systematically from the Directory of Medical Specialists (first entry on each page of text) were asked to complete a questionnaire about how their treatment decisions for five therapies differed as a function of patient smoking status. The responses of the 320 internists who completed and returned the questionnaire showed that smoking status had little effect on physicians' inclinations to recommend herniorrhaphy, hemodialysis, or bronchodilator therapy. However, physicians were considerably less inclined to recommend coronary artery bypass grafting or peripheral arterial surgery to patients who smoked. Reduced efficacy and greater risk of therapy were the most frequent reasons given for the observed decrease. Reduced entitlement by smokers to complex therapies for smoking-related diseases and the withholding of therapy as a bargaining tool to induce smokers to quit were also cited as reasons. Some internists believe they are less likely to recommend complex therapies for smoking-related diseases to patients who continue to smoke. Some of this decrease may be attributable to the notion that smokers are less entitled to complex therapies or that withholding therapies is a permissible way to influence patients to adopt more healthful lifestyles. Whether these physician attitudes reflect actual practice is yet to be shown.


The relationship of presenting physical complaints to depressive symptoms in primary care patients. To assess the relationship of specific patient chief physical complaints to underlying depressive symptoms in primary care practice. A cross-sectional study that was part of a larger prevalence study of depression in primary care. A general medical primary care practice in a teaching medical center in rural New England. 1,042 consecutive outpatients screened for depression with the Hopkins Symptom Checklist 49-item depression scale and for whom physicians filled out a form recording both specific chief complaints and two aspects of complaint presentation style, clarity and amplification. None. Complaints that discriminated between depressed and non-depressed patients (at the p = 0.05 level) were sleep disturbance (PPV 61%), fatigue (PPV 60%), multiple (3+) complaints (PPV 56%), nonspecific musculoskeletal complaints (PPV 43%), back pain (PPV 39%), shortness of breath (PPV 39%), amplified complaints (PPV 39%), and vaguely stated complaints (PPV 37%). Depressed patients are common in primary care practice and important to recognize. Certain specific complaints and complaint presentation styles are associated with underlying depressive symptoms.


Community hospital experience with recombinant tissue plasminogen activator in acute myocardial infarction. Clinical features, outcomes, and hospital charges of 51 consecutive patients who had had acute myocardial infarction (MI) and who had received intravenous tissue plasminogen activator (TPA) at a community teaching hospital were reviewed retrospectively. The overall mortality rate was 22%, including four patients (8%) who had died of hemorrhagic complications, three of whom (6%) had had intracerebral hemorrhages. Despite similar mean ages and lengths of hospital stay, TPA patients had had significantly higher total hospital charges and ancillary charges than had had concurrent MI patients who had not received TPA (p less than 0.0001). In a community hospital setting, older patients may be at higher risk for intracranial hemorrhage when treated with TPA, especially in the presence of other risk factors.


The inter-rater reliability and internal consistency of a clinical evaluation exercise. To assess the internal consistency and inter-rater reliability of a clinical evaluation exercise (CEX) format that was designed to be easily utilized, but sufficiently detailed, to achieve uniform recording of the observed examination. A comparison of 128 CEXs conducted for 32 internal medicine interns by full-time faculty. This paper reports alpha coefficients as measures of internal consistency and several measures of inter-rater reliability. A university internal medicine program. Observations were conducted at the end of the internship year. Participants were 32 interns and observers were 12 full-time faculty in the department of medicine. The entire intern group was chosen in order to optimize the spectrum of abilities represented. Patients used for the study were recruited by the chief resident from the inpatient medical service based on their ability and willingness to participate. Each intern was observed twice and there were two examiners during each CEX. The examiners were given a standardized preparation and used a format developed over five years of previous pilot studies. The format appeared to have excellent internal consistency; alpha coefficients ranged from 0.79 to 0.99. However, multiple methods of determining inter-rater reliability yielded similar results; intraclass correlations ranged from 0.23 to 0.50 and generalizability coefficients from a low of 0.00 for the overall rating of the CEX to a high of 0.61 for the physical examination section. Transforming scores to eliminate rater effects and dichotomizing results into pass-fail did not appear to enhance the reliability results. Although the CEX is a valuable didactic tool, its psychometric properties preclude reliable assessment of clinical skills as a one-time observation.


Three years later: grief, view of life, and personal crisis after death of a family member. In an initial study, 19 persons were interviewed during the first year after the sudden death of a family member. Seventeen were interviewed again three years after their bereavement. Participants were divided into four groups, representing patterns of crisis behavior: boundless, spontaneous, emerging, and suppressed grief. Characteristics of the four groups were still discernible after three years. Those with spontaneous and emerging grief grew to cope in similar ways. In the initial study, a close correlation had been found between personality, view of life, and response to crisis, respectively, an observation that still held true after three years. No specific doctrine or belief system could be linked to the coping process, but a connection did exist between view of life, as expressed through basic attitudes, and the grieving process.


Lacrima mortis: the last tear.

Lacrima mortis: the last tear. A tear, usually at the moment of death, has been observed in 14% of dying patients. No associated factors have been established and the cause of the "last tear" is not known.


Moving toward continuous quality improvement. Consumers are looking for better quality health care for their dollar. Nursing is challenged with providing excellent care in an age of shrinking resources. After years of chart audits and quality assurance, a new and broader focus is emerging. Continuous quality improvement is the latest theme in the ever-changing area of quality. It seeks to improve care through improving the processes used in delivering the care. A smooth transition from quality assurance to continuous quality improvement is possible through a complete understanding of both concepts, a willingness to work with others in the organization, and the ability to focus on process rather than on people.


Trends in hospital utilization in AIDS care 1987-1991: implications for palliative care. St. Paul's Hospital, Vancouver has the largest Canadian experience of the care of persons with HIV/AIDS. This article reviews St. Paul's experience during the period 1987-1991, with particular emphasis on issues in palliative AIDS care. These issues include the implications of prolonged palliative care at home, precipitous readmissions to hospital for terminal care, and long-stay terminal admissions. Aspects of treatment and social factors which have an impact on palliative AIDS care are also identified. The implications for program development in both community and institutional settings are discussed.


Persons with cancer speak out: reflections on an important trend in Canadian health care. In this paper I have described some of the recent developments in the growth of a patient/survivor movement in Canada. Arguments for the value of increased patient participation include providing a needed balance to the traditional medical perspective, addressing patient needs free from other vested interests, providing insights available only to cancer survivors, and facilitating empowerment. A number of current and potential difficulties related to increasing cancer survivor involvement have been raised, ranging from deliberate opposition from health administrators to disapproval from professionals of survivors' emotional expression to patient unwillingness. The greatest challenge is to move beyond token patient representation to substantive participation.


Risk management strategies.

Risk management strategies. Risk management is defined in the Intravenous Nursing Standards of Practice as a "process that centers on identification, analysis, treatment and evaluation of renal and potential hazards." Just what type of risk do these hazards pose and what types of "real and potential hazards" are there? The first question is the easiest to answer.


Nursing care planning for terminally ill cancer patients receiving home care. Nursing home care for terminally ill cancer patients was organized according to nursing care plans that were based on diagnoses as recommended by the North American Nursing Diagnosis Association (NANDA). This study was carried out among a sample of 40 patients receiving home health care for a period of 1 to 19 weeks. More than 697 nursing diagnoses were identified in the study. The most frequently recorded nursing diagnoses were anxiety, constipation, and diminished food intake. Fifteen of the 40 patients in the study were able to complete a weekly self-report of their symptoms. The patients' own descriptions of their symptoms were then compared with their symptoms as identified by nursing staff. There was a congruence in 63% of reported instances. Although nurses' assessments were not always in agreement with the symptoms reported by the patients, agreement was more frequently found with somatic symptoms than with psychological ones. One conclusion is that nursing plans should incorporate multidimensional methods for assessing patients' real needs.


Implantable ports: everything you always wanted to know. During the last decade, tremendous usage of intravascular drugs and fluids has increased the need for reliable venous access. Implantable ports have become a reliable access device that can be used to administer fluids, medications, and blood products, and to obtain blood samples. A variety of implantable ports is used clinically that varies in reservoir size, profile, portal body material, and the chemical composition of the catheter. While the implanted port needs little or no care by the patient, the nurse must be able to use this device safely, recognizing and intervening appropriately if they occur. In this article, types of implantable ports available on the market, nursing management of significant complications, and nursing responsibilities for care are reviewed.


Benchmarking: a tool for excellence in palliative care. Quietly and without fanfare, total quality management (TQM) is being implemented in a branch of health care where quality of care has particular impact on the patient's comfort and well-being. Some palliative care providers, dedicated to improving the quality of life for the dying, have fulfilled all the criteria to be contenders for prestigious quality honors like the Baldrige Award in the United States and the Canada Award for Excellence. Their secret is simple: the patient defines quality, and the palliative care team acts on that definition. Benchmarking, a TQM tool, allows institutions and organizations to benefit from sharing their best processes, and keeps the TQM continuous improvement cycle on track.


Antibiotic lock technique.

Antibiotic lock technique. Central venous catheters deliver life-prolonging medications to Group IVC AIDS patients. Unfortunately, the access device frequently provides a foci for debilitating infections. A Group IVC AIDS patient experienced repeated methicillin-resistant Staphylococcus epidermidis colonization and infection of his central venous access device. An antibiotic lock technique was created using a flush solution of vancomycin 1 mg/ml with 100 unit heparin/ml. The patient locked his catheter with 2.0 ml every evening for a period of 5 days. Repeat catheter and peripheral culturing occurred 72 hours after the 5-day period. After using the antibiotic lock technique, the patient maintained his catheter without further infection for an additional 2 months. This new approach may represent improved therapy and prevent the hazards of catheter exchange and systemic antibiotic therapy.


Primary care providers' perceptions of care. The Regional Palliative Care Unit in Ottawa conducted a retrospective study to determine how satisfied patients and families were with the service the Unit offers. Forty-five primary care providers, bereaved from 6 to 12 months, completed the 64-item semistructured telephone interview in a mean time of 20 minutes. The 59 closed-ended questions rated satisfaction levels concerning various aspects of the palliative care service on a 5-point Likert scale. Five open-ended questions elicited family priorities and suggestions for improvement. The major finding was that care was perceived to be highly satisfactory. Unexpected outcomes of the study were the identification by family members of the criteria for a "good death" and families' perceptions that the Unit offers the best quality of life and death even for those patients who resist admission to the hospice setting.


Clinical utility of the TEMAS with nonminority children. The Tell Me a Story (TEMAS) Test is a thematic apperception technique composed of 23 chromatic pictures, depicting either minority or nonminority characters interacting in primarily urban and familial settings, and is scored for perceptual and cognitive style, affective state, and personality functioning. Previous research has supported the reliability and validity of the ethnic minority version of the TEMAS test for Hispanic and Black children and adolescents. In this study, we investigated the validity of the nonminority version by discriminating public school (n = 49) and outpatient (n = 36) samples of White examinees from inner city, low to lower middle socioeconomic status, largely female-headed households. Results indicate that TEMAS profiles significantly discriminated between the normal functioning and clinical groups (p < .001), with 86% classification accuracy. The results, which provide some support for the general clinical utility of the TEMAS technique, are discussed in terms of the need to develop and validate unbiased projective techniques for both ethnic minority and nonminority children.


Meta-interpretive reliability of computer-based test interpretations: the Karson Clinical Report. Meta-interpretive reliability is a new method to evaluate the accuracy with which personality trait scores are communicated via interpretive statements in a computer-based test interpretation (CBTI). The prototypic experimental design is based on a two-way repeated measures analysis of variance (ANOVA); the two effects are personality traits and randomly chosen CBTI protocols. In this application, 101 psychologists read four examples of the Karson Clinical Report (KCR, Karson & O'Dell, 1975) and estimated the original trait scores from the Sixteen Personality Factor Questionnaire (16PF; Cattell, Eber, & Tatsuoka, 1970) on which the KCR is based. Estimated trait score variance was significantly related to the Trait x Protocol interaction and the main effects for personality trait and differences among protocols (omega 2 = .55). The total effect size corresponded to a multiple correlation of .74, suggesting that the KCR had acceptable meta-interpretive reliability. The protocol effect denoted a context effect created by the juxtaposition of several interpretive statements. Additional analyses showed that individual differences among raters contributed to less than 1% of the estimated standard ten (sten) score variance. Meta-interpretive reliability is proposed as an index of the upper limit of validity for CBTIs.


Separation-individuation, family functioning, and psychological adjustment in college students: a construct validity study of the Separation-Individuation Test of Adolescence. We evaluated the construct validity of the Separation-Individuation Test of Adolescence (SITA; Levine, Green, & Millon, 1986). Based on a review of the theoretical literature on separation-individuation issues during late adolescence, predictions were made as to how SITA scores would correlate with aspects of family functioning and psychological adjustment. The SITA and a battery of self-report family and adjustment measures were administered to 454 college students (272 females and 182 males; 74% White, 16% African American, and 10% Asian American or Hispanic). Correlational analyses offered partial support for the construct validity of the SITA. Cluster analyses revealed four distinct groups of subjects (anxious deniers, healthy separators, peaceful detachers, and succorance seekers), each with its own coherent set of scores on the SITA and instruments measuring family relations and positive and negative psychological adjustment. Criticisms concerning the labels and composition of the SITA scales are also discussed.


The derivation of gender-role scales GM and GF for MMPI-2 and their relationship to Scale 5 (Mf). Separate scales for masculine and feminine gender roles (GM and GF, respectively) were developed for the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) based on the item endorsements of men and women in the restandardization sample. Each scale reflects the pattern of answers of a majority of the members of the respective sexes. There are no items in common between the two scales, and they correlate -.10 with each other for both men and women. Distributional, temporal stability, and internal consistency characteristics were analyzed, as well as their item overlap and correlations with the basic profile scales. These separate unipolar scales were contrasted with Scale 5 (the Masculinity-Femininity scale, Mf), the traditional measure of these constructs in the Minnesota Multiphasic Personality Inventory (MMPI). The conjoint use of GM and GF to form gender-role groups is recommended to supplement and clarify the ambiguity of midlevel scores on Scale 5.


Personality inventory responses of males with medically intractable seizures. The psychosocial adjustment of 50 male patients to intractable seizures was assessed by comparing their responses to a combined version of the Minnesota Multiphasic Personality Inventory (MMPI) and the California Psychological Inventory (CPI) to the responses of 50 medical, psychiatric, or nonclinical controls who denied seizures. The two groups were significantly different (p < .01) on one MMPI and 10 CPI scales. Significant (p < .01) between-group differences were also reflected in 29 of the 704 personality inventory items. Those items were rationally clustered according to content into six conceptually identifiable subscales; 30 additional items with similar content that were significant at the .05 level were added to those subscales. Comparison of subscale scores of an additional 30 seizure and 30 nonseizure subjects using analysis of variance revealed F values that reached statistical significance (p < .05) in four cases and approached significance (p = .07) in another. Applying coefficients derived from discriminant analysis of the first samples correctly classified 99% of the original patients and 85% of the validation subjects. Results reveal a logical, understandable, and largely adaptive response to intractable seizures and offer little support for the concept of a dysfunctional or pathological interictal personality style.


Personality characteristics of substance abusers: an MCMI cluster typology of recreational drug users treated in a therapeutic community and its relationship to length of stay and outcome. The purpose of this investigation was to define homogeneous personality subtypes among substance abusers treated in a long-term, inpatient, drug-free therapeutic community and to determine how the resulting typology was related to length of stay and treatment outcome. A hierarchical agglomerative cluster analysis was performed on the Millon Clinical Multiaxial Inventory (MCMI) scale scores of 235 admissions to a therapeutic community. Five cluster types emerged, which were similar to typologies found in studies with alcoholic inpatients. A concordant solution evolved when a different clustering algorithm was used with the same sample and when clustering was done with a different group of substance abusers. As hypothesized, clusters of patients with average MCMI elevations that indicated avoidant, schizoid, and antisocial qualities tended to stay in treatment fewer days and relapsed earlier during the 1-year follow-up. The implications for substance abuse treatment are discussed.


Development of the Multi-Trait Personality Inventory (MTPI): comparison among four Chinese populations. Anemic approach was adopted to develop a culture-specific instrument for the assessment of Chinese personality. The Multi-Trial Personality Inventory (MTPI) was administered to 1,673 men and 944 women in four major Chinese populations. It was found that Chinese in mainland China, Taiwan, Hong Kong, and the United States possess some common traits deeply rooted in the Chinese culture characterized by Confucian thoughts (e.g., self-discipline and moderation) and some additional traits nurtured by their respective environments. Consequently, findings of this study lent support to the hypothesis that, in spite of superficial discontinuities, there are basic continuities in the personality traits of mainland and overseas Chinese. The cross-cultural differences in personality were examined from a political-social perspective and also explained with a cultural-ecological model. In the development of the MTPI, a new methodology that relies on forming factor-consistent clusters was employed to deal successfully with the problem of complex factor space.


Utility of the SCL-90-R with depressed and conduct-disordered adolescent inpatients. We assessed the diagnostic utility of the Symptom Checklist-90-Revised (SCL-90-R) in a sample of adolescent inpatients. In Part 1 (n = 79), convergent and discriminant validity were demonstrated for SCL-90-R scales measuring depression and paranoid ideation. Canonical correlation showed that SCL-90-R scales tapped two dimensions of adolescent psychopathology, a primary dimension of dysphoria and a secondary dimension of anger and mistrust. In Part 2 (n = 50), adolescents diagnosed as having major depression showed significant elevations on scales measuring depression, anxiety, and obsessive-compulsive features. Although several scales had high diagnostic specificity for major depression and conduct disorder, sensitivity was low.


Effects of laboratory-induced controllable and uncontrollable stress on Rorschach variables m and Y. The research literature regarding stress and the Rorschach has frequently produced contradictory results. A possible explanation for the lack of consensus may be that past research has failed to consider the nature of the stressor. A potentially important dimension is whether the stressor is perceived as controllable or uncontrollable, particularly because these two types of stressors invoke distinctive sets of biobehavioral reactions. We examined the effects of experimentally induced uncontrollable and controllable stress on m and Y Rorschach responses. Uncontrollable laboratory stress was associated with an increase in both m and Y variants, whereas controllable laboratory stress was associated with an increase only in m. Potential implications and directions for future research are discussed.


Rorschach object relations of adolescents who committed homicide. We investigated the object relations of adolescents who committed homicide. A clinical sample of 55 adolescents who committed homicide did not differ from a comparison group of nonviolent delinquents on Rorschach measures of object differentiation, mutuality of autonomy, and aggressive content. However, the subgroup of adolescents who committed homicides in the context of another crime (e.g., robbery or burglary) did manifest significantly lower object relations (poorer object differentiation and more victim responses) than the subgroup of adolescents whose homicides were committed in the context of an interpersonal conflict or dispute with the victim. These findings support the need for differentiated classification of violent individuals as urged by Megargee (1970) over 20 years ago.


Assessment of shame and guilt and their relationships to psychopathology. Two studies are reported. First, we tested the previously validated Personal Feelings Questionnaire-2 (PFQ2; Harder & Zalma, 1990) shame and guilt measure and the Adapted Shame and Guilt Scale (ASGS; Hoblitzelle, 1982) Shame subscale against the newly introduced Self-Conscious Affect and Attribution Inventory (SCAAI; Tangney, 1990) for shame and guilt dispositions. Fifty-nine college undergraduates completed randomly ordered personality inventories reflecting constructs theoretically relevant to the presence of shame and guilt proneness. Correlations between the affect measures and personality variables showed evidence of validity for all shame scales. The PFQ2 Guilt subscale also demonstrated construct validity when partialled for shame, but the SCAAI did not. Second, we tested hypotheses regarding the relative importance of shame and guilt to various symptom types (Symptom Checklist-90-Revised; Derogatis, 1983) using 71 college undergraduates. Both emotions were approximately equally related to all major symptom clusters, but there was some evidence for differential patterns of relative importance for shame and guilt to different symptoms.


Selective responsiveness of chronically ill children to assessments of depression. Many investigators have noted that depression is a common symptom among pediatric cancer patients. However, prevalence rates vary widely across studies. This variation in prevalence rates may be due, in part, to selective reporting of patients based on measures used and environmental cues. In this study, we evaluated 50 chronically ill pediatric patients (19 cancer and 31 diabetic patients) for their use of selective reporting of depression. Factors in the 2 x 2 design were Intervention (disclosure videotape and cartoon videotape) and Examiner (familiar examiner and unfamiliar examiner). In the Intervention manipulation, subjects were shown either a videotape prompting the child that self-disclosure was appropriate or a tape of a cartoon (control condition). In the Examiner manipulation, subjects were administered the experimental measures by either a familiar (parent) or unfamiliar (research assistant) examiner. Dependent variables were the Children's Depression Inventory (CDI; Kovacs, 1981), the Depression scale of the Roberts Apperception Test for Children (RATC; McArthur & Roberts, 1982), and a depression measure taken from the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983). As hypothesized, the Examiner x Intervention interaction revealed that children who did not view the disclosure videotape and who were tested by an unfamiliar examiner gave significantly lower self-reports of depression on the CDI than children in the other conditions. However, parent and child projective reports of depression did not vary as a function of experimental condition. The results are interpreted as selective responding on the part of pediatric patients. Limitations of assessing internal psychological states in children are discussed.


Mitotically unstable polyploids in the yeast Pichia guilliermondii. Attempts to obtain triploids or tetraploids of P. guilliermondii by sexual hybridization led to mitotically stable hybrids. However, their DNA content per cell was not higher than in diploids. The results of random spore analysis demonstrate that these hybrids were in fact aneuploids which obviously suffered drastic chromosome losses immediately after mating. This phenomenon could have been caused either by aneuploidy already present in the parental strains or it might have been due to a general inability of P. guilliermondii to maintain a polyploid genome.


Electrically induced protoplast fusion for ergosterol-producing yeast strain improvement. Electrofusion was employed for hybrid construction in ergosterol-producing yeast strains. Some fusion products proved to be hybrid with respect to ergosterol content and to remain stable over several generations.


Neighbour restoration: a possible explanation for some "broken" survival curves of UV-irradiated Escherichia coli K12 cells. Survival curves for UV irradiation of five non-filamenting strains of E. coli K12 decrease exponentially at moderate levels of radiation but are broken at high levels of radiation. That is, it appears a change in the slope of survival curves, featuring a tail. As this phenomenon was observed with strains bearing uvrA and recA mutations it must be independent of the products of these genes. Experiments with isolated surviving colonies and synchronized cultures eliminated genetic and phenotypic heterogeneity as reasons for the tails in the survival curves. UV survival increased 10- to 15-fold when UV-irradiated cells were plated either with cells unable to grow in the plating medium or with bacterial cell-free extracts. We suggest that factors related to the high cell densities used to obtain survival curves at high radiation levels (neighbour restoration) could be responsible for the survival increases, generating the tailed survival curves.


Immunoelectronmicroscopic study of the nucleoid structure of hydrogen bacteria. Electron microscopical studies of the nucleoid structure of hydrogen bacteria using ultrahin sections and spread DNA from bacterial cell lysates revealed a different DNA packaging in the cell. A compact state of the major part of DNA at all growth stages and stability of nucleosome-like structures were shown. The use of antibodies to HU protein of E. coli labelled by protein A-colloidal gold demonstrated the immunological relationship between HU protein of E. coli and histone-like proteins of Alcaligenes eutrophus and their possible role in the nucleosome-like DNA packaging in procariotic genome.


Selective isolation of fluorescent and nonfluorescent Pseudomonas species from Sohag Governorate (Upper Egypt). Three hundred and fourty nine isolates belonging to ten different species of Pseudomonas were isolated and identified from soil and water samples on four selective isolation media: Modified Trypticase soy agar (TSA), ACC-agar containing ampicillin-chloramphenicol-cycloheximide, Nitrate plus organic acid agar and Tryptophan substrate agar. The fluorescent species were P. putida (21.2% of the total Pseudomonas species), P. fluorescens (15.8%), P. aeruginosa (9.7%) and P. aureobaciens (2.6%), while the nonfluorescent species were P. stutzeri (12.4%), P. alcaligenes (11.2%), P. pseudoalcaligenes (9.5%), P. mendocina (8.3%), P. lemoignei (5.7%) and P. ruhlandii (3.4%). Modified TSA and ACC media were efficient for the isolation of both fluorescent and nonfluorescent species, whereas Nitrate and Tryptophan media were more selective for the isolation of nonfluorescent species. The optimum temperature for the isolation of different species ranged between 20 degrees and 37 degrees C.


Some ecological and physiological studies on bacteria isolated from salt-affected soils of Egypt. Members of Bacillaceae, Rhizobiaceae, actinomycetes and others were isolated from cultivated and non-cultivated saline soils. The high population of bacteria and actinomycetes were almost coincided with the relatively high levels of organic matter whatever the degree of soil salinity. Bacillus stearothermophilus and B. subtilis were more frequently isolated than other Bacillus species. Most of Rhizobium isolates were salt tolerant being able to grow in media containing 3% and 6% NaCl. The abilities of different bacterial isolates to attack citrus pectin, soluble and insoluble forms of cellulose were also tested.


Coagulation autolysis in microorganisms and its relation to coagulase production. The phenomenon of coagulation autolysis was observed in two model microorganisms, i.e., a bacterial culture and an imperfect fungus. It was characterized by impairment of the cell membranes, followed by condensation and dehydration of the cytoplasm and long-term preservation of the cells in the form of coagulated cytoplasm. In this respect, it was similar to coagulation necrosis of human tissues. The autolysis in the microorganisms was accompanied by increase of their coagulase activity, the substrate specificity of the enzyme rather broad. The coagulase activity of the microorganisms was detected during the culture period between the lag-phase and the exponential growth phase, i.e., the phase of their active growth. It served as a signal to induce biosynthesis of peptidohydrolase and cleavage of proteins. We believe that the phenomenon of coagulation autolysis in these microorganisms is rather typical and can be considered as an adaptative reaction, inducing a cascade of events from synthesis of coagulase to overproduction of peptidohydrolases with proteolytic activity.


Ampicillin tolerance of Legionella pneumophila for counter-selection of transconjugants in heterospecific matings with Escherichia coli donors. Legionella pneumophila, the causative agent of Legionnaires' disease is sensitive to ampicillin. However, the slowly growing bacteria are not killed even by high doses of this antibiotic. This natural tolerance was used for counter-selection of trans-conjugants in heterospecific matings with Escherichia coli as donor. This approach is useful for gentic manipulations in Legionella, as it avoids the use of antibiotic-resistant variants, which have to be tested for full virulence before use.


The molecular clock ticks regularly in muroid rodents and hamsters. Extensive DNA sequence data are used to compare the rates of nucleotide substitution in the mouse, rat, and hamster lineages. A relative rate test using hamster sequences as references shows that the rates of synonymous and nonsynonymous substitution in the mouse and rat lineages are nearly equal and a test using human sequences as references shows that the rates in the mouse, rat, and hamster lineages are also nearly equal. Under the assumptions that the guinea pig lineage and the myomorph (mouse, rat, and hamster) lineage diverged 70-100 million years (Myr) ago and that the rate of nucleotide substitution has been constant in all these lineages since their divergence, the date of the mouse-rat split is estimated to be between 20 and 29 Myr ago, which is considerably older than the date (approximately 12 Myr) suggested by available rodent fossils and considerably younger than the date (approximately 35 Myr) suggested by Wilson and colleagues. The murid-hamster split is estimated to be 1.6 times older than the mouse-rat split.


Conservation of the mammalian RNA polymerase II largest-subunit C-terminal domain. We have isolated and sequenced a portion of the gene encoding the carboxy-terminal domain (CTD) of the largest subunit of RNA polymerase II from three mammals. These mammalian sequences include one rodent and two primate CTDs. Comparisons of the new sequences to mouse and Chinese hamster show a high degree of conservation among the mammalian CTDs. Due to synonymous codon usage, the nucleotide differences between hamster, rat, ape, and human result in no amino acid changes. The amino acid sequence for the mouse CTD appears to have one different amino acid when compared to the other four sequences. Therefore, except for the one variation in mouse, all of the known mammalian CTDs have identical amino acid sequences. This is in marked contrast to the situation among more divergent species. The present study suggests that there is a strong evolutionary pressure to maintain the primary structure of the mammalian CTD.


Evolution of the threonine-glycine repeat region of the period gene in the melanogaster species subgroup of Drosophila. The Threonine-Glycine (Thr-Gly) region of the period gene (per) in Drosophila was compared in the eight species of the D. melanogaster subgroup. This region can be divided into a diverged variable-length segment which is flanked by more conserved sequences. The number of amino acids encoded in the variable-length region ranges from 40 in D. teissieri to 69 in D. mauritiana. This is similar to the range found within natural populations of D. melanogaster. It was possible to derive a Thr-Gly "allele" of one species from that of another by invoking hypothetical Thr-Gly intermediates. A phylogeny based on the more conserved flanking sequences was produced. The results highlighted some of the problems which are encountered when highly polymorphic genes are used to infer phylogenies of closely related species.


Molecular phylogeny of some polychaete annelids: an initial approach to the Atlantic-Mediterranean speciation problem. The polychaete Eupolymnia nebulosa (family Terebellidae) displays two alternative modes of reproduction. In the Mediterranean, larvae are brooded in a mucous mass while in the Atlantic and English Channel, larvae follow a plank-tonic development. This paper attempts to discern whether this difference is expressed at the population, infraspecies, or species level. Specimens of E. nebulosa and representatives of a number of control species were sampled from Atlantic/English Channel and Mediterranean locations. Genetic sequencing of the Large-subunit ribosomal RNA 5' end of six representative species allowed one to infer the relative position of E. nebulosa within the Terebellidae and the position of the latter within the animal kingdom. The relative genetic distances calculated between the different species were also used to approach the speciation problem raised by the differences between the Mediterranean and Atlantic/English Channel population of E. nebulosa. The genetic distance between Mediterranean and Atlantic populations of both E. nebulosa and Lanice conchilega are of the same order, suggesting that differences between the populations of E. nebulosa are infraspecific.


The role of anticodon bases and the discriminator nucleotide in the recognition of some E. coli tRNAs by their aminoacyl-tRNA synthetases. The T7 polymerase transcription system was used for in vitro synthesis of unmodified versions of the E. coli tRNA mutants that insert asparagine, cysteine, glycine, histidine, and serine. These tRNAs were used to qualitatively explore the role of some anticodon bases and the discriminator nucleotide in the recognition of tRNA by aminoacyl-tRNA synthetases. Coupled with data from earlier studies, these new results essentially complete a survey of all E. coli tRNAs with respect to the involvement of anticodon bases and the discriminator nucleotide in tRNA recognition. It is found that in the vast majority of tRNAs both of these elements are significant components of tRNA identity. This is not universally true, however. Anticodon sequences are unimportant in tRNA(Ser), tRNA(Leu), and tRNA(Ala) while the discriminator base is inconsequential in tRNA(Ser) and tRNA(Thr). The significance of these results for origin-of-life studies is discussed.


The specificity of yolk protein uptake in cyclorrhaphan diptera is conserved through evolution. Yolk proteins are transported from the hemolymph into the oocytes of insects during vitellogenesis by receptor-mediated endocytosis. Since other hemolymph proteins, both native and foreign, are not accumulated in the oocyte, the process of uptake is selective for yolk proteins. Peptide domains within the yolk proteins must therefore be involved in receptor recognition. With the long-term aim of identifying these domains and to open the possibility of understanding the molecular basis of receptor-mediated endocytosis of yolk proteins, we began investigating how well this mechanism has been conserved in evolution. We studied the uptake of yolk proteins from 13 different Drosophila species and five other dipteran species, namely, Calliphora erythrocephala, Sarcophaga argyrostoma, Musca domestica, Lucilia servicata, and Protophormia terrae-novae, into the ovaries of Drosophila melanogaster and Drosophila funebris. The results from these experiments showed that in all cases the foreign yolk proteins were taken up by the host ovaries, indicating that the mechanism and peptide domains of the yolk proteins involved in recognition of the receptor have been well conserved in dipteran evolution.


Genetic distance and species formation in evolving populations. We compare the behavior of the genetic distance between individuals in evolving populations for three stochastic models. In the first model reproduction is asexual and the distribution of genetic distances reflects the genealogical tree of the population. This distribution fluctuates greatly in time, even for very large populations. In the second model reproduction is sexual with random mating allowed between any pair of individuals. In this case, the population becomes homogeneous and the genetic distance between pairs of individuals has small fluctuations which vanish in the limit of an infinitely large population. In the third model reproduction is still sexual but instead of random mating, mating only occurs between individuals which are genetically similar to each other. In that case, the population splits spontaneously into species which are in reproductive isolation from one another and one observes a steady state with a continual appearance and extinction of species in the population. We discuss this model in relation to the biological theory of speciation and isolating mechanisms. We also point out similarities between these three models of evolving populations and the theory of disordered systems in physics.


Temporal effects of inhaled histamine and methacholine aerosols on the pulmonary mechanics of thoroughbred horses. This paper presents a method for on-line determination of pulmonary mechanics in standing, non-sedated horses during and following inhalation of aerosolized drug solutions. This method was used to evaluate the temporal effects of inhaled histamine and methacholine aerosols on pulmonary mechanics in 18 Thoroughbred horses. The following were concluded from this study. The extremely large between-breath variation, for all variables used to evaluate pulmonary mechanics in the horse, limits the usefulness of these variables for modeling the non-specific pulmonary responses to inhaled stimulants on a breath-by-breath basis. Following the implementation of averaging techniques to control the variation of these response variables, respiratory rate appears to be affected most predictably by inhalation of non-specific bronchoconstrictors. In the 18 subjects studied, the response of respiratory rate to inhaled histamine and methacholine aerosols was well described by a complex function consisting of exponential treatment and post-treatment phases in 10 and six of the subjects, respectively. Large intra-individual variation of the non-specific response to these stimulants in repeated studies of some subjects, suggests that differences in responses on a particular day may be due to inter-day variations in minute ventilation or baseline airway caliber.


Fever and acute phase response induced in dwarf goats by endotoxin and bovine and human recombinant tumour necrosis factor alpha. Tumour necrosis factor (TNF), a polypeptide produced by mononuclear phagocytes, has been implicated as an important mediator of inflammatory processes and of clinical manifestations in acute infectious diseases. To study further the potential role of TNF in infectious diseases, recombinant Escherichia coli (E. coli) derived human (r.HuTNF-alpha) and bovine TNF (r.BoTNF-alpha) were intravenously (i.v.) administered in dwarf goats. Rectal temperature, heart rate, rumen motility, plasma zinc and iron concentrations, and certain other blood biochemical and haematological values were studied and compared with the changes seen after E. coli endotoxin (LPS) was administered (dose: 0.1 microgram/kg i.v.). Following a single injection of 4 micrograms/kg of r.BoTNF-alpha, shivering and biphasic febrile response were observed, accompanied by tachycardia, inhibition of rumen contractions, drop in plasma zinc and iron concentrations, lymphopenia, and neutropenia followed by neutrophilia. The i.v. administration of a single injection of 4 micrograms/kg r.HuTNF-alpha induced shivering and biphasic febrile responses, accompanied by anorexia and a similar drop in plasma trace metal concentrations when compared with r.BoTNF-alpha-treated goats. The TNF-alpha-induced symptoms were essentially the same as those that occurred after LPS administration. However, the time of onset of these changes after the injection of TNF-alpha was significantly shorter than after LPS. Moreover, the r.BoTNF-alpha induced a longer lasting neutrophilic leucopenia, less neutrophilia, and a more persistent lymphopenia than after LPS injection. Neither r.BoTNF-alpha nor LPS caused severe haemo-concentration. Furthermore, no cross-tolerance between r.BoTNF-alpha and LPS could be demonstrated. We conclude that both r.BoTNF-alpha and r.HuTNF-alpha induce many of the physiologic, haematologic and metabolic changes that characterize the acute phase response to LPS. The overlapping biological activities of r.BoTNF-alpha, r.HuTNF-alpha and LPS in dwarf goats may indicate that both recombinant tumour necrosis factors have some homology with caprine TNF-alpha.


Pharmacokinetics and preliminary observations of behavioral changes following administration of midazolam to dogs. The pharmacokinetics of midazolam were investigated following intravenous and intramuscular administration of 0.5 mg of midazolam hydrochloride/kg of body weight to five healthy mixed-breed dogs. One dog also received the same dose of midazolam by oral and rectal routes. The disposition of midazolam following intravenous administration was characterized by very rapid and relatively extensive distribution followed by rapid elimination. Mean (+/- SD) apparent volume of distribution was 3.0 +/- 0.9 l/kg, mean elimination half-life was 77 +/- 18 min, and clearance was 27 +/- 3 ml/kg/min. Following intramuscular administration, absorption was rapid and complete. A mean peak midazolam concentration of 549 +/- 121 ng/ml was reached within 15 min, and systemic availability was over 90% in each dog. Oral administration to one dog resulted in peak midazolam concentrations within 10 min and a systemic availability of 69%. Rectal administration to the same dog yielded very low systemic availability. Midazolam was extensively bound to canine plasma proteins, with the unbound fraction representing less than 4% of the total plasma midazolam concentration. Plasma samples were also assayed for the presence of the major metabolites, 1-OH and 4-OH midazolam. Neither metabolite were detected, probably as a result of rapid elimination of these compounds by hepatic glucuronidation. Behavioral responses to administration of midazolam included initial signs of profound weakness, ataxia and transient agitation followed by a period of quiesence. A normal behavior pattern returned within 2 h of midazolam administration.


Vancomycin kinetics in plasma and synovial fluid following intravenous administration in horses. Vancomycin hydrochloride was infused intravenously (i.v.) over a 30-min period in five horses at doses of 6.6, 11.0 and 15.4 mg/kg. Vancomycin concentration in plasma and synovial fluid samples was measured using a polarization immunoassay. A pharmacokinetic model was developed to accommodate the special features of the present study. The data were described by a two compartment open model with synovial fluid as an additional compartment in exchange with plasma. Minimum inhibitory concentration (MIC) and minimum bacterial concentration (MBC) were measured for Staphylococcus aureus and Enterococcus sp. using isolates from hospital patients. Based on the pharmacokinetic model and MIC/MBC data, a practical therapeutic protocol for vancomycin administration was established at doses of 4.3-7.5 mg/kg given as a 1-h infusion every 8 h.


Evaluation of antibiotics for racing pigeons (Columba livia var. domestica) available in The Netherlands. Antibiotics and chemotherapeutics marketed for use in racing pigeons (Columba livia var. domestica) were evaluated by comparing the dosages and indications given by the manufacturers with the data obtained by pharmacokinetic, bacteriological and efficacy studies. This comparison showed that only three of the recommended dosages and indications of the 60 formulations marketed in The Netherlands are scientifically sound and in accordance with the literature. It is to be expected that the majority of the antimicrobials for pigeons will not satisfy the requirements for final registration as a pigeon therapeutic under the Dutch Veterinary Medicines Act of 1985. Several factors affecting drug availability are discussed, such as the different routes of administration and the influence of food. The public health aspects of the consumption of medicated pigeons is also discussed. Although there is no legislation with regard to this subject, a recommended withdrawal time of 10 days for the majority of the antimicrobials seems advisable.


Beta-endorphin-induced inhibition of rumen contractions in sheep. The effect of hypothalamic de-efferentiation. In conscious sheep, beta-endorphin (1 and 2 micrograms/kg) administered into the third cerebral ventricle caused psychomotor excitability and a significant inhibition of the frequency of rumen contractions. The amplitude of the first rumen contractions, following immediately after the end of endorphin infusion, and the average amplitude of primary rumen contractions were also inhibited. De-efferentiation at the level of the hypothalamus prevented both the inhibitory effect of beta-endorphin on the frequency of rumen contractions and the drug-induced psychomotor excitability. However, de-efferentiation did not prevent beta-endorphin-induced inhibition of the mean amplitude of rumen contractions. The character of pathohistological changes induced by de-efferentiation showed descending degenerative changes of the nerve tracts connecting the hypothalamus with the pons and the medulla oblongata. These results, together with previously published evidence, do suggest that de-efferentiation at the level of the hypothalamus causes degeneration of inhibitory descending opioid-noradrenergic pathways connecting the hypothalamus with the gastric centres in the medulla oblongata.


Distribution studies of theophylline: microdialysis in rat and horse and whole body autoradiography in rat. After intravenous administration of theophylline, microdialysis has been used for studying the non protein bound theophylline concentration in blood and in lung tissue in the rat as well as in two horses. The distribution pattern of 14C-theophylline in the rat was also investigated. When the distribution of theophylline was completed the time course of free drug in the interstitial fluid in lung tissue was in good agreement with the total concentration-time profile in plasma in both species. In the rat the free concentration of theophylline in the lung was slightly lower than the free concentration in the blood from 40 to 300 min. The in vivo protein binding in blood was 48.8 +/- 6.2% in the rats (n = 9) and 8-25% in the horses (n = 2). The whole body autoradiography study in rat showed that the concentration of radioactivity in the lung followed the blood concentration very closely up to 24 h after injection. The effect of theophylline in the lung can be assumed to be related to the plasma concentration of theophylline, since the concentration-time profile in plasma reflects the time course in the lung.


Evaluation of anthelmintics, antiprotozoal drugs and ectoparasiticides for racing pigeons (Columba livia var. domestica) available in The Netherlands. Anthelmintics, antiprotozoal drugs and ectoparasiticides specially marketed for use in racing pigeons (Columba livia var. domestica) were evaluated by comparing dosages and indications given by the producers with data obtained from efficacy studies or empirical data. Of a total of 63 products, 59% were in accordance with the literature. Fifty-nine percent of the dosages and indications of anthelmintics were in accordance with scientifically obtained data, while for trichomonacides, coccidiostats and ectoparasiticides the figures were 47%, 59% and 100% respectively. Public health aspects of the consumption of medicated pigeons are discussed.


In vitro nitroimidazole resistance of Trichomonas gallinae and successful therapy with an increased dosage of ronidazole in racing pigeons (Columba livia domestica). Six out of eight different Trichomonas gallinae strains isolated from racing pigeons proved to be resistant to the nitroimidazole drugs ronidazole, carnidazole and metronidazole. The minimal cytocidal concentration of ronidazole was determined in in vitro experiments. Moreover, a therapeutic dose for ronidazole was determined for the control of trichomoniasis in pigeons from which the resistant T. gallinae strains were isolated. It was a 5-fold increase of the recommended ronidazole dosage which eliminated the infection in affected pigeons.


Effect of dietary nitrogen intake on gentamicin disposition in sheep. The effect on gentamicin pharmacokinetics of a diet high (HP) (120 g/day) or low (LP) (25 g/day) in digestible proteins was studied in sheep. Gentamicin sulphate (4 mg/kg) and inulin (40 mg/kg) were administered by the intravenous route to six ewes of local Moroccan breed. The serum gentamicin concentrations were consistently higher in ewes that received a LP diet. Clearance was 0.93 +/- 0.13 ml/mm/kg in the LP group and 1.64 +/- 0.40 ml/mm/kg in the HP group. The volume of distribution at steady state (Vss) was lower in the LP group (11% of body weight) than in the HP group (21.8% of body weight). These diet-linked variations in pharmacokinetic parameters were also obtained in the disposition of inulin following the intravenous administration of a single dose. This suggests that the protein content of the diet modifies the distribution of body water and kidney function. The therapeutic, toxicological and hygienic implications of these modifications are discussed.


Effect of water deprivation on absorption (oral, intramuscular) and disposition of ampicillin in sheep. The effects of a 72 h water deprivation on the absorption--intramuscular (i.m.) and oral and disposition of ampicillin, inulin and para-aminohippuric acid (PAH) were investigated in six sheep. After intravenous (i.v.) administration of ampicillin sodium (10 mg/kg), the water deprivation decreased slightly the initial volume of distribution (0.082 +/- 0.033 vs. 0.055 +/- 0.030 l/kg) but not the steady state volume of distribution. The plasma clearance was significantly decreased (6.21 +/- 1.94 vs. 3.90 +/- 1.92 ml/min/kg) and the mean residence time (MRT) was increased from 22.25 +/- 4.91 to 33.36 +/- 8.16 min. After i.m. administration of ampicillin sodium (20 mg/kg), ampicillin concentrations were systematically higher after a 3-day period of water deprivation than during the control period but the muscular absorption rate was not modified. After oral administration of ampicillin trihydrate (1 g in toto) plasma concentrations were much lower and more persistent than after an i.m. administration and the systemic availability remained low whatever the hydration status. Influences of water deprivation on ampicillin disposition were linked to adaptation of renal function as assessed by inulin and PAH clearances. The therapeutic relevance of the results are discussed for a better definition of dosage regimens for sheep reared in arid environments.


Quantification of percutaneous absorption of metronidazole and levamisole in the fire-bellied toad (Bombina orientalis). Spot-on application has proved to be an effective way to reach therapeutic doses of metronidazole and levamisole in fire-bellied toads. The percutaneous absorption of metronidazole and levamisole was quantified, using an aqueous solution of 1.008 mg/ml of metronidazole and an aqueous solution of 3.767 mg/ml of levamisole. High Performance Liquid Chromatography (HPLC) analysis of the percutaneous absorption revealed that of the amount applied, 75% of metronidazole and 90% of levamisole was absorbed. This resulted during 3 days of application in dosages of 23 mg/kg BW of metronidazole and 94 mg/kg BW of levamisole. Of the absorbed substances, 48% of metronidazole and 9% of levamisole were excreted in urine and faeces as unmetabolised substances.


The sequence of panic symptoms.

The sequence of panic symptoms. For phenomenological elucidation of panic attacks, 26 patients with panic attacks were requested to name the panic symptoms in order of their occurrence and specify the patterns of their abatement. Panic symptoms were found to be classifiable into three categories: early symptoms consisting of dizziness or faintness, palpitations, and sweating; intermediate symptoms dyspnea, nausea or abdominal distress, flush or chills, chest pain or discomfort, shaking, and choking; late symptoms paresthesias, fear of dying, and fear of going crazy. Panic symptoms disappeared in 61.6% irrespective of the sequence of their occurrence. Twenty-one patients were interviewed about the experience of nocturnal panic attacks, and 23.8% experienced them. These findings suggest that fear is caused by sudden physical abnormality triggered by some biological factors.


Differences between two questionnaires for assessment of typus melancholicus, Zerssen's F-list and Kasahara's scale: the validity and relationship to DSM-III-R personality disorders. We examined the validity in various settings of two questionnaires for assessment of Typus melancholicus, F-list and Kasahara's scale, and characterological differences between the questionnaires, based on data in 69 patients with unipolar depression and 386 normal controls without a history of depression. The questionnaires were performed on both groups. In addition, a diagnosis of DSM-III-R personality disorders was done for the patient group. Our results demonstrated that Kasahara's scale has much more stable validity in various settings for distinction between personalities of the two groups, and that high scorers in Kasahara's scale have more obsessionality and less personality instability than those in F-list. Such differences between the questionnaires suggested that a direct international comparison of premorbid personality of unipolar depressive patients is needed.


The meaning of basic symptoms for the genesis of the schizophrenic nuclear syndrome. In the Bonn Transition Sequences study, the development of the Schneiderian first rank symptoms in their exact chronological order was studied from the first symptomatological precursors up to the complete forms of the respective psychotic final phenomena. At their onset, subjective experiences of preexisting disorders of perception, thinking, speech and memory, of cognitive control of action and of proprioception were found. These four groups of initial deficiencies developed via certain intermediate phenomena into first rank symptoms. The analysis of these transition sequences revealed three phases with different generating factors each. Altogether, the results showed that and how the gap between the deficiency findings of the biologically oriented research in schizophrenia and the diagnostically relevant changes in experience can be bridged.


Relevance of ethology to psychiatry.

Relevance of ethology to psychiatry. The interactions between ethology and psychiatry were reviewed. The ethological methods have provided more objective and theory-free observation techniques than the traditional psychiatric methods. The evolution-based ethological viewpoints afford some fundamentally new and more comprehensive approaches in understanding psychiatric conditions. The ethological theory has many concepts in common with various other schools of psychiatry, and thus is expected to act as a bridge to integrate them to lead to a more comprehensive psychiatric theory system. Ethology has not explored its potential in therapy, but may be useful, especially in terms of prevention and social psychiatry.


Three-year follow-up studies on heart rate variability in nursing home residents. The coefficient of variation of the R-R interval (CV value) of nursing home residents was investigated twice during a three-year period. The initial CV value of the deceased during the period was significantly lower than that of the survivors. Among the survivors, residents without chronic cerebrovascular disease mainly showed a decrease in their CV values during the period.


A study of common carotid arterial blood flow volume of nursing home residents. Ninety-seven nursing home residents were divided into 2 groups according to whether they had had an episode of stroke or not. Each group was classified into 3 subgroups: prolonged bed rest, walking with aids or walking by themselves. They were investigated for both the carotid blood flow volume and the modified Stockton geriatric rating scale (SGRS). In chronic stroke residents, the total blood flow volume of prolonged bed rest residents was lower than that who can walk by themselves. In residents without stroke, the total blood flow volume of prolonged bed rest residents was lower than the other 2 subgroups. The total blood flow volume was significantly correlated with the scores of 3 factors of the modified SGRS.


Left hypofrontality correlates with blunted affect in schizophrenia. Regional cerebral blood flow (rCBF) during the resting state was measured using the 133Xe inhalation technique in 39 patients diagnosed as having schizophrenic disorder according to the DSM-III criteria and 30 age- and sex-matched healthy volunteers. All the patients were receiving neuroleptic medication. The bilateral hemispheric mean flow values in the schizophrenic patients decreased significantly and the relative flow distribution reduced significantly only in the left frontal region compared to the controls. The lower the left frontal blood flow in schizophrenics, the more pronounced were the negative symptoms including blunted affect, avolition-apathy and inattention. These results suggest that the negative symptoms in schizophrenics are related to left frontal lobe dysfunction.


Age-related changes in occipital alpha rhythm of adults with Down syndrome. A power spectral analysis was performed on occipital EEGs recorded from 36 Down Syndrome (DS) subjects aged 15 to 54 and compared with two control groups; 47 healthy volunteers (Control) and 42 mentally retarded people without DS (MR). The frequencies of occipital alpha rhythms of DS showed a significant inverse correlation with chronological age, while Control and MR did not. The average frequencies of DS were significantly low even in the youngest age-group in comparison with those of Control, and also decreased in the age-groups of 35 and older compared with MR. It was considered that a slowing of alpha rhythm was a manifestation of premature aging that occurred in the underdeveloped brains of DS.


Auditory brain stem response (ABR) in anorexia nervosa. Auditory brain stem responses were recorded in 20 patients with anorexia nervosa and 10 normal control subjects. Twenty patients were studied during two phases of illness, 1) anorexia nervosa group with under weight (U-AN group), and 2) anorexia nervosa group with recovered normal weight (N-AN group). Absolute latencies, interwave latencies, absolute amplitudes, and amplitude ratios were investigated. A nonsignificant difference was found among these groups as far as the latencies were concerned. Both the patients in the U-AN group and those in the N-AN group had significantly smaller amplitude ratios (III/I, IV.V/I) and absolute amplitude (V) than did the control subjects. Furthermore, a nonsignificant difference was found between the U-AN group and the N-AN group. It suggests that some dysfunction might exist in the region of the brain stem.


A long-term observation on a case of epilepsy with occipital continuous spikes. We have reported a 38-year-old female who did not show clinical seizures during continuous spikes in the left occipital area over a period of 18 years. As to the neurological findings, visual disturbance, optic nerve atrophy and right hemianopsia were almost always present. The low density area distributing from the left occipital area to the left temporal one on the CT revealed to be porencephaly. From the clinical findings obtained in this case, the lesion responsible for the occipital continuous spikes could be ascribed to be functional abnormality of the visual pathway connecting the left lateral geniculate body with the left occipital cortex.


Multivariate analyses of CT findings in typical schizophrenia and atypical psychosis. In order to investigate the brain morphological differences between typical schizophrenia and atypical psychosis, the brain CTs of 41 patients with typical schizophrenia, 27 patients with atypical psychosis (ATP), and 20 controls were examined. The schizophrenics had larger values for 9 CT indices, i.e., interhemispheric fissure (IHF) index, VBR, 2 lateral ventricles (L-V) and 3rd ventricle (III-V) indices, and 4 sylvian fissure (SF) indices, while the values of ATP patients for 3 SF indices were greater than for the controls. Moreover, the schizophrenics had greater III-V and L-V indices than the ATP patients. The correlation matrix of CT indices indicates that the III-V index correlated well with the other CT indices, whereas the VBR, IHF and right SF indices did not. Therefore, it was speculated that there might be 3 subgroups, each of which has a main focus of alteration in the above-mentioned regions. Therefore, all the cases were divided by means of a cluster analysis into 5 groups. Group I, which contained mainly normal controls, and Group II, which consisted mainly of atypical psychosis patients, had no abnormal CT findings. Group III, which comprised mainly ATP patients and paranoid type schizophrenics, had right SF enlargement. Group IV, which showed significant IHF enlargement, and the residue group, which had larger VBR and significant left SF enlargement, consisted mostly of schizophrenics. Thus, our results suggest that the classification by CT data corresponds on the whole to our clinical diagnosis, according to which schizophrenic psychosis is divided into typical schizophrenia and atypical psychosis, and that each of the two psychosis groups may be further classified into distinct subgroups.


Immunoglobulin kappa/lambda ratios in migraine and tension-type headache. The possibility of immunological mechanisms causing headaches has been proposed in the past. To investigate the immunological system activation in patients with chronic headaches, we evaluated the kappa/lambda ratios of immunoglobulins in 40 patients with migraine and 49 patients with tension-type headache. Nineteen healthy volunteers composed the control group. The serum kappa and lambda levels of immunoglobulins were determined by using the enzyme-linked immunosorbent assay (ELISA) techniques. The kappa/lambda ratios of IgG in the patients with tension-type headache were significantly higher than those in the controls. The kappa/lambda ratios of IgA and IgM in the patients with headaches were higher than those in the controls, but they were not statistically significant. The total concentrations of IgG, IgA and IgM were significantly higher in the patients with migraine. In the patients with tension-type headache, the total concentrations of IgG and IgA were significantly higher than those in the controls. The high levels of kappa/lambda ratios of IgG in the patients with tension-type headache and the increase in the total concentrations of immunoglobulins in the patients with migraine and tension-type headache, observed in this study, suggest that the humoral immunological system activation might exist, and it might be related to the etiology of tension-type headache and migraine.


Periodic leg movements in sleep with restless legs syndrome: effect of clonazepam treatment. Fifteen patients with restless legs syndrome underwent whole-night polysomnographic recordings before and during clonazepam treatment. The treatment with 0.5 to 1.5 mg clonazepam improved subjective complaints of all the 15 patients. All the patients presented periodic leg movements on the polysomnograms before the treatment. The clonazepam treatment significantly decreased the total numbers of leg movements and the numbers of leg movements per hour without affecting the mean intermovement interval.


An autopsied case of interferon encephalopathy. A 78-year-old male with renal carcinoma was treated with a high dose infusion of interferon-alpha (IFN-alpha) for eight months. The patient had evidence of organic brain syndrome such as dysfunction of memory, slowing of behavior, and development of mental confusion that appeared eight months after the treatment. MRI at the time of mental confusion revealed diffuse white matter lesions. Neuropathologic findings were compatible to Binswanger's disease and Senile Dementia of Alzheimer Type (SDAT), Preexisting neurologic abnormalities including intracerebral arteriosclerosis and cerebral atrophy may increase susceptibility to unacceptably severe IFN neurotoxicity.


An autopsied case of dentatorubropallidoluysian atrophy with atypical pathological features. This is a report of an autopsied case of dentatorubropallidoluysian atrophy (DRPLA) with atypical neuropathological findings. The patients was a 31-year-old female. Her clinical symptoms were epileptic seizures, cerebellar ataxia, choreoathetosis and dementia. A neuropathological examination revealed the fibrillary gliosis in various areas of the CNS and severe degeneration in the cerebellar cortex and nucleus fasciculi dorsalis in addition to a marked degeneration of the dentatorubropallidoluysian systems. The present case is diagnosed neuropathologically as DRPLA associated with the findings of chronic diphenylhydantoin intoxication and epileptic brain damage.


Antiepileptic effects of MK-801, a noncompetitive NMDA-receptor antagonist, in the low-frequency kindling model of epilepsy. We assessed the acute effect of MK-801 (0.05-0.7 mg/kg), a noncompetitive NMDA-receptor antagonist, on hippocampus-kindled seizures induced with low-frequency (2 Hz) electrical stimulations. MK-801 dose-dependently increased the seizure threshold (PNT, the number of stimulating pulses required for the triggering of epileptic after discharge), whereas most of the previous studies which assessed the effect of MK-801 on kindled seizures could not detect the elevation of seizure threshold by MK-801. In addition MK-801 decreased the severity of induced seizures at low doses at which previous studies could not detect the antiepileptic effect of MK-801, suggesting that the low-frequency kindling technique might be a more sensitive and reliable model of epilepsy than the conventional high-frequency kindling technique.


[Pneumonectomy for destroyed lung or chronic tuberculous empyema]. Fourteen patients underwent pneumonectomy for destroyed lung or tuberculous empyema at the Shimada Municipal Hospital from September 1980 to December 1985. Mean age was 61 and ten patients were males. Cough and sputum (in 12 cases) and hemosputum or hemoptysis (in 8 cases) were common complaints. Three patients had complications in the immediate postoperative period: hemorrhagic shock, pulmonary embolism and contralateral pneumothorax. They were treated conservatively. The postoperative course was uneventful in the other patients and all complaints were reduced or disappeared. And lung function improved in 3 cases with chronic empyema compressing the mediastinum. In conclusion, pneumonectomy is one of the radical operation for destroyed lung or chronic tuberculous empyema with low pulmonary function and complaints. And the critical level are 40% of %VC and 25% of FEV1.0/pr. %VC in preoperative pulmonary function.


[Influence of bronchoscopic examinations on the statistics of tuberculosis incidence]. The frequency of the modes of bacteriological examinations other than direct sputum smear were observed for a total of 955 "smear-positive" pulmonary tuberculosis cases which were notified at 7 health centres in the Metropolitan and suburban areas during 1986-1990. Of them 21 cases (2.2%) were examined for the specimens obtained by bronchofiberscopic procedures, and in 4 cases (0.4%) gastric juice was taken. The proportion of the non-sputum positivity as seen above was higher in females than in males, but it was uniform across all age group. Non-cavitary cases showed higher proportion of the non-sputum positivity than cavitary cases. There was wide variation in the frequency of these aggressive modes of examination among health centres, probably indicating the difference in the extent to which hospitals are interested in these modes of examination in each health center area. In addition to the above observed cases, there were 60 cases with direct smear positive finding of mycobacteria other than tuberculosis (MOTT). They account for 5.9% of all of 1,015 new notifications of AFB-smear positive cases. It is possible that these non-sputum "smear positive" cases, as well as the MOTT-smear positive cases may be underestimated in our study, because of the notification form not necessarily requesting to enter the type of bacteriological examinations. They may contribute to the recent upward trend of incidence rate of smear positive tuberculosis in Japan to a considerable extent.(ABSTRACT TRUNCATED AT 250 WORDS)


[Ultrasonographic findings of abdominal tuberculous lymphadenitis]. Five patients with abdominal tuberculous lymphadenitis were studied by ultrasound. The final diagnosis of tuberculosis was based on open biopsy in 2 patients, neck lymph node biopsy in 1, needle biopsy under ultrasound control in 2. Low-echoic and iso-echoic abdominal lymph nodes were seen in all patients and a mixed echoic lymph node was found in one of them. Enlarged, round or oval, lymph nodes were conglomeratically observed along the common hepatic artery, in the hepatoduodenal ligament and along the abdominal aorta. The size of the lymph node was found to be 20-70 mm. In one case, compression of the portal trunk and the common bile duct due to a large lymph node was observed, and arterioportography showed hepatopetal collateral veins. In the other case, multiple mass lesions in the liver and the spleen were observed. In the 4 patients who were observed by ultrasound at 2 months after anti-tuberculosis therapy, enlarged lymph nodes decreased and 3 of them changed from low-echo to iso-echo in the echo pattern. Of the 4 patients who were followed for more than 4 months, lymph nodes disappeared in 2 at 4 months and in one at 12 months. The remaining patient showed residual nodes which decreased in half at 8 months. Ultrasound is now used commonly in the examination of the abdomen, and there are cases of abdominal lymph nodes swelling due to varied diseases. In this study, there were no characteristic ultrasonographic findings in abdominal tuberculous lymphadenitis. So, it is difficult to diagnose the cause of abdominal lymph node swelling by only ultrasound.(ABSTRACT TRUNCATED AT 250 WORDS)


[A case of pulmonary tuberculosis associated with severe respiratory failure, DIC and intractable bilateral pneumothoraces]. We had a sixty-five year old male patient who suddenly complained of dyspnea and fever with pulmonary tuberculosis, severe respiratory failure, disseminated intravascular coagulation (DIC) and intractable bilateral pneumothoraces. From the first hospital day severe hypoxemia which did not respond to conventional oxygen therapy developed with a diffuse ill-defined reticulo-nodular shadow in the plain chest x-ray film. On the 2nd hospital day mechanical ventilation with 2cmH2O PEEP was introduced. Antituberculous agents as well as corticosteroids were started suspecting acute interstitial pneumonia with pulmonary tuberculosis and adult respiratory distress syndrome (ARDS). Medication was followed by the treatment of Gabexate mesilate and heparin against DIC on laboratory data. Though clinical findings and pulmonary infiltrate on chest x-ray film transiently improved, right pneumothorax occurred suddenly on the 6th day followed with left pneumothorax on the 36th day. Tube drainage of both pleural spaces and repeated instillation of thrombin-rich oxycel cotton via bronchofiberscope failed to stop air leakage. He ultimately expired on 49th hospital day. At postmortem lung had multiple bilateral bulla several of which ruptured to the pleural site and caseating necrotic area containing bacilli positively stained with Ziehl-Nielsen stain in the bilateral upper lobe. No typical caseating necrotic lesion, however, was found in the other lung tissue. Therefore, it seemed to show a chronic phase of diffuse alveolar damage (DAD).


[A case of severe juvenile pulmonary tuberculosis associated with malnutrition in special reference to nutritional assessment]. We reported a case who had suffered from severe pulmonary tuberculosis in association with severe malnutrition. A 19-year-old man was admitted complaining of high fever, productive cough and body weight loss. Before admission, he worked as a cook for long hours a day and had meals irregularly. On admission, he was cachexic. Coarse crackles were auscultated on the both lung field, and the liver was enlarged. Chest X-ray revealed multiple ringed and mottled shadows mainly in bilateral upper and middle lung field. Laboratory examination revealed inflammatory reaction defined by an increase of white blood cells, accelerated erythrocyte sedimentation rate and positive CRP, impairment of liver function and cell-mediated immunity, hypoxemia and restrictive lung dysfunction. Ziehl-Neelsen stain of sputum showed a large number of acid fast bacilli. The assessment of his nutritional status showed decrease in anthropometric measurements, visceral proteins and the Fischer ratio, which suggested that he was in the status of protein-calorie malnutrition in association with amino acid imbalance. He was treated with nutritional therapy in addition to antituberculous drugs, which improved his clinical symptoms, laboratory data and nutritional assessment. These results suggested the importance of nutritional assessment and nutritional therapy based on it.