Biomedical subjects
Publications and source records attributed to J Lamont.
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Sjögren's syndrome (SS) is greatly under recognized in clinical practice, primarily for 2 reasons: its presentations are variable and often nonspecific and there are still no clear, uniform diagnostic criteria for this clinical entity. The prevalence, natural history, pathogenesis, and clinical taxonomy of SS are still not well understood. Potential criteria include both subjective symptoms and objective criteria such as measurements of salivary and tear flow, minor salivary gland biopsy, and an increasing variety of serological markers. Physicians often fail to appreciate the profound impact of SS on quality of life. Therefore, screening for SS should include questions exploring symptoms in terms of their effect on the patient's daily life. At present, there is no curative treatment for SS. For symptom relief, local treatments (such as artificial tears or oral topical sprays) are limited in their effects, whereas systemic treatment offers the advantage of addressing a wider range of symptoms. Controlled studies show that oral pilocarpine significantly improves sicca symptoms in the eyes, mouth, and other sites. Clinical experience to date suggests it is safe and well tolerated, with no serious adverse effects, tachyphylaxis, or drug to drug interactions of concern. The most frequent adverse effects are sweating, urinary frequency, diarrhea, and other parasympathomimetic effects, but these do not lead to substantial drug withdrawal rates. Patients should be forewarned that subjective improvement may lag behind improvement in objective measures. Because management often spans several specialties, coordination among them is essential. Dental, gynecological, and ophthalmological perspectives on diagnosis and management are discussed; the primary practitioner has the opportunity to play both a coordinating role and a direct role in early diagnosis and treatment.
In this study we describe the signature headbob displays of seven of the eight extant species of Cyclura iguanas using data collected from the field and from captive animals. We used phylogenetic comparative methods to estimate the ancestral states of several measures of the headbob displays, including number of headbobs and the duration of headbobs and inter-bob pauses. Divergence in the headbob display among species has been substantial, with some major changes occurring within only a few (about six) generations. Otherwise, results are consistent with those obtained previously for other lizards which suggest that there is an evolutionary limit on the total duration of headbob displays. Differences in the results obtained using different phylogenetic methods suggest that although estimates of ancestral states are reasonably robust to violations of evolutionary assumptions, we cannot determine the standard errors of those ancestral phenotypes accurately without more detailed information about the types of forces (e.g. selection, drift) underlying evolutionary change in these traits. In particular, within-species variation had a substantial impact on the standard errors of estimated ancestral states, and should be included in such estimations whenever possible. Finally, our results emphasize the importance of conserving behavioural as well as genetic diversity in trying to preserve endangered species for possible reintroduction into the wild. Copyright 1998 The Association for the Study of Animal Behaviour. Copyright 1998 The Association for the Study of Animal Behaviour.
The clinical syndrome "Bronchiolitis Obliterans Organising Pneumonia" (BOOP) has to be considered in patients with a flu-like illness since some weeks, fine crackles, and on chest X-ray bilateral patchy infiltrates. There is no response to antibiotics. BOOP is essentially idiopathic, but associations to other conditions exist. Lung function is often restrictive; biochemistry is not pathognomonic. BAL shows a mixed cellular pattern. The gold standard for pathologic diagnosis is open or thoracoscopic lung biopsy. However, a BOOP pattern or reaction is often seen on histologic specimens without the clinical-radiologic features of the BOOP-entity. Therapy consists of corticosteroids, which have to be prescribed for a long time at a rather high dose. Recurrence is frequent, but prognosis is good. Evolution to respiratory insufficiency and death is rare and may occur in rapidly progressive BOOP. This study reports on 11 cases (6 males/5 females) of clinical-pathological BOOP-syndrome (mean age 58 yrs, range 17-73 yrs), with an unexpectedly high mortality rate of 36% (4 cases). The disease was idiopathic in 7, and was associated with intake of amiodarone (in 1), with past Mycoplasma pneumonia (in 1) and with connective tissue disease (in 2). There was a history of a flu-like syndrome, cough and dyspnea of a mean duration of 4 months (range 1 week to 8 months). Lung function was mostly restrictive or/and obstructive with a diffusing capacity ranging between 47 and 95% predicted; there was hypoxia in about half of the patients. Chest X-ray and computed tomography (CT) scan showed a patchy consolidation with linear opacities (unilateral in 4 patients, bilateral in 5) and/or a ground glass pattern (in 4 patients), and a focal pseudo-tumoral lesion (in 1). Bronchoalveolar lavage showed a variable pattern of mixed, or eosinophilic or neutrophilic alveolitis. Histologic diagnosis was based on open lung biopsy (in 3), on thoracoscopic biopsy (in 2), on transbronchial biopsy (in 2), on wedge resection of the nodular lesion (in 1) and on postmortem lung biopsy (in 3). One patient recovered spontaneously, 1 remained cured after resection of the focal lesion, 7 were treated with 16-125 mg methylprednisolone (of whom 3 had a temporary flare-up during tapering the corticosteroids and 2 died after 1 and 3 months due to infectious complications), 2 died due to rapidly progressive BOOP.
Snoring and obstructive sleep apnoea (OSA) both seem at least to be associated with narrowing of the upper airway and sleep-induced loss of muscle-tone. Mandibular advancement splints (MAS) have been proposed as a relatively simple method to increase oro- and hypo-pharyngeal dimensions thereby increasing the size of the airway. However, data on their effectiveness are conflicting and there are no clear indications as to which design is most effective or when they should be used. The effects of two designs of splint (types A and B) have been evaluated in 14 and nine subjects, respectively, using the Epworth Sleepiness Score (ESS) and domiciliary sleep monitoring on separate nights. Both splints reduced the median ESS (type A from 12 to 4.5; P = 0.003, type B from 7 to 4; P = 0.005). The apnoea-hypopnoea index was not affected by type A, but was reduced from 7.1 to 0.8; P = 0.005 by type B splints. There was evidence of a small improvement in overnight oxygen saturation for type B splints (P = 0.02). The splints were well tolerated and continued to be used nightly by 18 subjects. Mandibular advancement splints may offer a simple and effective alternative for the treatment of snoring and mild OSA in selected patients. Splint design may have considerable bearing on efficacy.
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OBJECTIVE: To examine whether changes in menstrual cycle length occurred in women who received 20 mg of fluoxetine per day and women who received 60 mg of fluoxetine per day as compared with women who received placebo. METHODS: A two-cycle, single-blind placebo phase was followed by a six-cycle double-blind phase. Only placebo nonresponders were randomized to one of three treatment arms: placebo, fluoxetine 20 mg/day, or fluoxetine 60 mg/day. Cycle length was established using a prospective daily calendar. Cycle-length data from women who completed at least three treatment cycles were used in this analysis. Cycle-length change was defined a priori as cycle lengthening or shortening of 4 days or more (1 or more standard deviations from the mean change between baseline cycles). RESULTS: Eleven of the 62 women receiving 60 mg of fluoxetine per day and seven of the 70 women receiving 20 mg of fluoxetine per day but only one of the 61 women in the placebo group demonstrated cycle-length change at the end of the first treatment cycle (P = .011). In total, 15% of the women in the fluoxetine 60 mg/day group demonstrated a cycle-length change during two of the three observed cycles compared with 6% of the women in the fluoxetine 20 mg/day group and 3% of the women in the placebo group (P = .048). Women with cycle-length changes demonstrated either shortening or lengthening only. There were no differences between the number of women with changes in either direction. CONCLUSION: Cycle-length change occurred more frequently in the fluoxetine 60 mg/day group than in the fluoxetine 20 mg/day or placebo groups. The effects of selective serotonin reuptake inhibitors on menstrual cycle length are mostly unknown and warrant careful monitoring in women of reproductive age, who are the prime consumers of these medications.
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Some women experience premenstrual mood symptoms that severely disrupt their lives and relationships. These women often require pharmacologic treatment. Selective serotonin reuptake inhibitors, particularly daily fluoxetine, have been proven superior to placebo in several randomized controlled trials. Twenty-four women with confirmed premenstrual dysphoric disorder (PMDD) and with a history of affective disorders or alcoholism were treated with fluoxetine 20 mg/day (continuous), and 24 women with PMDD and no psychiatric history were treated with fluoxetine 20 mg/day for 14 days premenstrually only (intermittent). Both groups received treatment for three menstrual cycles. Sixteen women (66.7%) in the continuous dosing group and 18 women (75.0%) in the intermittent group were classified as treatment responders. Intermittent dosing of fluoxetine seems to be effective and mostly free of side effects in women with PMDD and, therefore, may offer an attractive treatment option for a disorder that is itself intermittent.
OBJECTIVE: To identify factors associated with increased risk of immediate complications from induced abortion. DESIGN: Retrospective analysis of a provincial database. SETTING: All Ontario general hospitals in which abortions are performed and all free-standing abortion clinics in Ontario. POPULATION: Women in Ontario aged 15 to 44 years who underwent an induced abortion in the province (without concurrent sterilization) between Jan. 1, 1992, and Dec. 31, 1993. OUTCOME MEASURES: Recording of complications at the time of the procedure, gestational age, type of procedure, place of abortion (hospital or clinic), and patient's age, parity and history of previous abortion (spontaneous or induced). RESULTS: During the study period 83 469 abortions were performed that met our inclusion criteria. Immediate complications were reported in 571 cases (0.7%). Multivariate logistic regression analysis revealed that, after other variables were controlled for, the patient's age, parity and history of previous abortions (spontaneous or induced) were not significant risk factors for immediate complications; however, gestational age, method of abortion and place of abortion were significant risk factors (p < 0.001). The odds ratio (OR) for having a complication from abortion was 1.3 (95% confidence interval [CI] 1.02 to 1.63) between 9 and 12 weeks, compared with having one after abortion at 9 weeks or earlier, and increased to 3.3 (95% CI 2.23 to 5.00) after abortion between 17 and 20 weeks. Compared with surgical dilatation and curettage (D&C), instillation of saline and instillation of prostaglandins were more likely to be associated with immediate complications (OR 24.0, 95% CI 13.22 to 43.70, and OR 11.7, 95% CI 6.43 to 21.18, respectively), whereas both suction D&C and insertion of a laminaria tent were less likely to be associated with immediate complications (OR 0.4, 95% CI 0.26 to 0.67, and OR 0.3, 95% CI 0.19 to 0.52, respectively). Compared with women who had an abortion in a free-standing clinic, the risk for immediate complications was greater among those who had an abortion in a hospital, especially a teaching hospital (OR 1.9, 95% CI 1.38 to 2.58), a nonteaching hospital with 200 to 399 acute care beds (OR 3.1, 95% CI 2.27 to 4.21) and a nonteaching hospital with fewer than 200 acute care beds (OR 5.9, 95% CI 4.04 to 8.64). CONCLUSION: The risk of immediate complications from induced abortion is very low. Unlike in previous studies, the woman's age, parity and history of previous spontaneous or induced abortions were not found to be risk factors. However, advancing gestational age and procedures involving instillation of saline or prostaglandins were predictive factors of immediate complications.
A generic, rapid and sensitive enzyme linked immunosorbent assay (ELISA) test has been developed which allows large-scale simultaneous testing of synthetic corticosteroids viz., flumethasone, dexamethasone and betamethasone. This assay can be directly applied to diluted urine samples (1 + 9) without hydrolysis of glucuronide or sulfate conjugates or any other treatment of samples. The polyclonal antibody was obtained by immunizing sheep with a flumethasone derivative linked to human serum albumin. This polyclonal antibody displayed high-reactivity with several synthetic corticosteroids whilst endogenous corticosteroids such as cortisol gave very low cross-reactivity (< 0.5%). Sensitivities obtained in this assay were 2.5, 3.1 and 12.5 ng ml-1 for flumethasone, dexamethasone and betamethasone, respectively. The ability of this assay to detect several synthetic corticosteroids was demonstrated by testing urine samples from horses to which the drugs had been administered.
A simple in vitro test to calculate the dose of heparin required to achieve optimal in vivo anticoagulation during surgery has been assessed in 15 patients who subsequently underwent vascular surgery. Heparin was added to four aliquots of patients blood in vitro to give five solutions with heparin concentrations ranging from 0-0.8 units/ml of plasma. The activated partial thromboblastic times (APTT) of each of these samples was then measured and the natural log (ln) of the APTT calculated. The natural log of the APTT in vitro was then plotted against the in vitro heparin concentration. From this linear correlation the concentration of heparin required to achieve an APTT 2.5 times the normal in vitro (Hc) for the 15 different patients was calculated and ranged from 0.4-0.75 units/ml (median 0.47). Based on an estimate of the plasma volume (PV), the bolus dose of heparin given intravenously to each patient to produce an equivalent anticoagulant response in vivo was calculated (Hc x PB). Heparin boli administered ranged from 1000-2000 units (median 1500). The mean in vivo APTT achieved was 77% of the predicted value (range 62%-123%). Such an estimation of an in vivo response, by means of an in vitro test, should help to more accurately predict the effects of heparin in vivo and individualise anticoagulation dosage.
The serine proteinase inhibitor, aprotinin, significantly reduces transfusion requirements during open heart surgery. Whether this benefit is associated with an increased tendency to thrombosis has not been studied. We investigated the effect of aprotinin in an experimental arterial thrombosis model. In 17 male Sprague-Dawley rats, the infrarenal aorta was replaced with 1.0-mm diameter PTFE grafts of varying lengths. The time to graft occlusion, recorded by palpation, Doppler ultrasound and a distal bleeding test, was 20.2 +/- 1.8 min, 35.8 +/- 6.1 min and 43.7 +/- 6.6 min for grafts of 10, 7.5 and 5.0 mm respectively (r = -0.98, p less than 0.05). Following PTFE graft placement 24 Sprague-Dawley rats were given saline (n = 6), aprotinin (n = 6), heparin (n = 6), and heparin + aprotinin (n = 6). The time to occlusion was significantly prolonged in the aprotinin group (71.7 +/- 20.4 min vs. 20.2 +/- 1.8 min, p less than 0.05). The time to thrombosis for heparin + aprotinin and heparin alone was also significantly prolonged (p less than 0.05). Prothrombin times (PT) were 21.9 +/- 3.0 s for control, 29.4 +/- 6.2 s for aprotinin, 40.7 +/- 2.5 s for heparin and 39.9 +/- 14.5 s for heparin + aprotinin (p less than 0.05 vs. control for all values). Bleeding time was not prolonged with aprotinin (3.0 +/- 0.9 min vs. 2.9 +/- 0.7 min). The bleeding time was 18.9 +/- 4.1 min for heparin + aprotinin and 22.5 +/- 2.3 min for heparin alone (p less than 0.05 vs. control for both values).(ABSTRACT TRUNCATED AT 250 WORDS)
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Results of prothrombin time tests for the control of oral anticoagulant therapy, when using automated blood coagulation instruments (coagulometers), may not be the same as those obtained when using manual methods, and variation in coagulometer performance may affect clinical interpretation of data. The haematology advisory committee of the Institute of Medical Laboratory Sciences has recommended that coagulometers should be used for determination of prothrombin times only if it can be demonstrated that the results are valid when compared with those of a standardised manual method. A protocol for the evaluation of coagulometers, and details of the procedures, are given in this report, the main emphasis of which is on the assessment of instruments for determination of the International Normalised Ratio. Guidelines are also provided for the general use of machines of this type and for the assessment of safety. The principles of the protocol are applicable to other automated tests of blood coagulation.
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In the research reported here, the authors examined the relation of 82 medical students' feelings about sex to their level of sexual knowledge, willingness to treat patients with sexual concerns, and participation in an elective sex education course. The results showed that the erotophobic students (those with negative feelings about sexuality) had significantly lower levels of sexual knowledge and were significantly less likely to participate in an elective human sexuality course than the erotophilic students (those with positive feelings about sexuality). Moreover, the erotophobic students who took part in the sexuality course benefited from it less than did the erotophilic students as measured by their willingness to treat patients with sexual concerns. Finally, although the students overall were relatively knowledgeable about sex and were relatively willing to treat patients with sexual concerns, troubling gaps in specific sexual knowledge and in willingness to treat patients with certain sexual concerns (such as acquired immune deficiency syndrome) were identified. Medical schools need to structure sex education in ways that take account of students' ambivalent feelings about sex and need to provide sex education that increases both sexual knowledge and willingness to treat patients with sexual concerns.