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Trends in lignin modification: a comprehensive analysis of the effects of genetic manipulations/mutations on lignification and vascular integrity.

A comprehensive assessment of lignin configuration in transgenic and mutant plants is long overdue. This review thus undertook the systematic analysis of trends manifested through genetic and mutational manipulations of the various steps associated with monolignol biosynthesis; this included consideration of the downstream effects on organized lignin assembly in the various cell types, on vascular function/integrity, and on plant growth and development. As previously noted for dirigent protein (homologs), distinct and sophisticated monolignol forming metabolic networks were operative in various cell types, tissues and organs, and form the cell-specific guaiacyl (G) and guaiacyl-syringyl (G-S) enriched lignin biopolymers, respectively. Regardless of cell type undergoing lignification, carbon allocation to the different monolignol pools is apparently determined by a combination of phenylalanine availability and cinnamate-4-hydroxylase/"p-coumarate-3-hydroxylase" (C4H/C3H) activities, as revealed by transcriptional and metabolic profiling. Downregulation of either phenylalanine ammonia lyase or cinnamate-4-hydroxylase thus predictably results in reduced lignin levels and impaired vascular integrity, as well as affecting related (phenylpropanoid-dependent) metabolism. Depletion of C3H activity also results in reduced lignin deposition, albeit with the latter being derived only from hydroxyphenyl (H) units, due to both the guaiacyl (G) and syringyl (S) pathways being blocked. Apparently the cells affected are unable to compensate for reduced G/S levels by increasing the amounts of H-components. The downstream metabolic networks for G-lignin enriched formation in both angiosperms and gymnosperms utilize specific cinnamoyl CoA O-methyltransferase (CCOMT), 4-coumarate:CoA ligase (4CL), cinnamoyl CoA reductase (CCR) and cinnamyl alcohol dehydrogenase (CAD) isoforms: however, these steps neither affect carbon allocation nor H/G designations, this being determined by C4H/C3H activities. Such enzymes thus fulfill subsidiary processing roles, with all (except CCOMT) apparently being bifunctional for both H and G substrates. Their severe downregulation does, however, predictably result in impaired monolignol biosynthesis, reduced lignin deposition/vascular integrity, (upstream) metabolite build-up and/or shunt pathway metabolism. There was no evidence for an alternative acid/ester O-methyltransferase (AEOMT) being involved in lignin biosynthesis. The G/S lignin pathway networks are operative in specific cell types in angiosperms and employ two additional biosynthetic steps to afford the corresponding S components, i.e. through introduction of an hydroxyl group at C-5 and its subsequent O-methylation. [These enzymes were originally classified as ferulate-5-hydroxylase (F5H) and caffeate O-methyltransferase (COMT), respectively.] As before, neither step has apparently any role in carbon allocation to the pathway; hence their individual downregulation/manipulation, respectively, gives either a G enriched lignin or formation of the well-known S-deficient bm3 "lignin" mutant, with cell walls of impaired vascular integrity. In the latter case, COMT downregulation/mutation apparently results in utilization of the isoelectronic 5-hydroxyconiferyl alcohol species albeit in an unsuccessful attempt to form G-S lignin proper. However, there is apparently no effect on overall G content, thereby indicating that deposition of both G and S moieties in the G/S lignin forming cells are kept spatially, and presumably temporally, fully separate. Downregulation/mutation of further downstream steps in the G/S network [i.e. utilizing 4CL, CCR and CAD isoforms] gives predictable effects in terms of their subsidiary processing roles: while severe downregulation of 4CL gave phenotypes with impaired vascular integrity due to reduced monolignol supply, there was no evidence in support of increased growth and/or enhanced cellulose biosynthesis. CCR and CAD downregulation/mutations also established that a depletion in monolignol supply reduced both lignin contents supply reduced both lignin contents and vascular integrity, with a concomitant shift towards (upstream) metabolite build-up and/or shunting. The extraordinary claims of involvement of surrogate monomers (2-methoxybenzaldehyde, feruloyl tyramine, vanillic acid, etc.) in lignification were fully disproven and put to rest, with the investigators themselves having largely retracted former claims. Furthermore analysis of the well-known bm1 mutation, a presumed CAD disrupted system, apparently revealed that both G and S lignin components were reduced. This seems to imply that there is no monolignol specific dehydrogenase, such as the recently described sinapyl alcohol dehydrogenase (SAD) for sinapyl alcohol formation. Nevertheless, different CAD isoforms of differing homology seem to be operative in different lignifying cell types, thereby giving the G-enriched and G/S-enriched lignin biopolymers, respectively. For the G-lignin forming network, however, the CAD isoform is apparently catalytically less efficient with all three monolignols than that additionally associated with the corresponding G/S lignin forming network(s), which can more efficiently use all three monolignols. However, since CAD does not determine either H, G, or S designation, it again serves in a subsidiary role-albeit using different isoforms for different cell wall developmental and cell wall type responses. The results from this analysis contrasts further with speculations of some early investigators, who had viewed lignin assembly as resulting from non-specific oxidative coupling of monolignols and subsequent random polymerization. At that time, though, the study of the complex biological (biochemical) process of lignin assembly had begun without any of the (bio)chemical tools to either address or answer the questions posed as to how its formation might actually occur. Today, by contrast, there is growing recognition of both sophisticated and differential control of monolignol biosynthetic networks in different cell types, which serve to underscore the fact that complexity of assembly need not be confused any further with random formation. Moreover, this analysis revealed another factor which continues to cloud interpretations of lignin downregulation/mutational analyses, namely the serious technical problems associated with all aspects of lignin characterization, whether for lignin quantification, isolation of lignin-enriched preparations and/or in determining monomeric compositions. For example, in the latter analyses, some 50-90% of the lignin components still cannot be detected using current methodologies, e.g. by thioacidolysis cleavage and nitrobenzene oxidative cleavage. This deficiency in lignin characterization thus represents one of the major hurdles remaining in delineating how lignin assembly (in distinct cell types) and their configuration actually occurs.

Gene Expression Regulation, Plant↗

Continuous subacromial bupivacaine infusion for postoperative analgesia after open acromioplasty and rotator cuff repair: preliminary results.

Shoulder surgery is often associated with severe postoperative pain. Previous results in which single or continuous subacromial infiltration of local anesthetics was used as a method of postoperative pain relief have been contradictory. This study was initiated to evaluate the postoperative analgesic effect of a subacromial continuous 0.25% bupivacaine infusion at a rate of 6 mL/h after elective open shoulder surgery. We hypothesized that this procedure would improve postoperative analgesia while reducing morphine requirements. By use of a prospective, double-blind, randomized study design, 50 consecutive patients undergoing acromioplasty and rotator cuff repair surgery received a multiorifice catheter placed in the subacromial space. Twenty patients received 0.25% bupivacaine (group 1), and twenty-two patients received saline solution (group 2). The primary endpoints in the two groups were total morphine consumption administered by patient-controlled analgesia and the patient's subjective pain level evaluated by a visual analog scale during the first 48 postoperative hours. No major technical or pharmacologic side effects were noticed, and the indwelling pain catheter was well tolerated by all patients. There was no statistically significant difference (P < .05) either in total cumulative morphine consumption microg/48 h (73.2 +/- 43.1 vs 60.9 +/- 35.9) or in subjective pain perception 10-point visual analog scale (3.2 +/- 1.4 vs 3.1 +/- 1.5) between the two study groups. The continuous subacromial infiltration of 0.25% bupivacaine at a rate of 6 mL/h is concluded to be ineffective in providing pain relief supplementary to patient-controlled analgesia after open rotator cuff repair and acromioplasty surgery.

Adult↗

Angiotensin II receptor type 1 mRNA is upregulated in atria of patients with end-stage heart failure.

There is increasing evidence that pathological changes in the myocardium during chronic heart failure (CHF) are partly regulated through the activation of the renin-angiotensin system (RAS), an effect mediated by the angiotensin II type 1 receptor (AT1R). We examined the expression of cardiac AT1R mRNA in normal (atria, n=7; ventricle, n=3) and end-stage CHF human hearts (atria, n=8; ventricle, n=14). Tissue was snap-frozen immediately after explantation during orthotopic cardiac transplantation; control specimens were obtained from healthy donor hearts rejected for technical reasons. Northern blots of purified total mRNA from each tissue were hybridized with a random primed radiolabeled probe for the coding sequence of AT1R. Stringent conditions were used for both hybridization (5X SSC, 65 degrees C) and washing (0.5X SSC, 0.1% SDS, 65 degrees C) of the membrane. Left and right atrial tissue showed low levels of AT1R mRNA expression in the controls, with statistically significant upregulation of expression in tissue from pathological hearts; CHF atria 1.28+/-0.86 optical density (OD) units, control atria 0.56+/-0.31 OD units, P=0.05 (mean+/-s.d.). There were undetectable levels in ventricles from either control (2/2) or dilated hearts (7/7). The results were independent of the etiology of the heart failure and suggest that increased levels of atrial AT1R mRNA may occur in response to elevated atrial pressures in heart failure.

Adult↗

CLS competencies expected at entry-level and beyond.

OBJECTIVE: The study was undertaken to assess educators', practitioners', and managers' perceptions of the future job expectations of clinical laboratory scientists (CLSs) and their opinions on the skills that are expected of CLSs at entry-level and with experience. DESIGN: Survey participants were given a list of 44 competencies related to clinical laboratory science (CLS) practice and were asked whether they would expect a graduate of a respected CLS program to perform each competency in one of three educational categories: the first year of practice, with three to five years of experience but no additional education, or with three to five years of experience plus additional education. The competencies were subclassified into one of four major management functions: laboratory operations, human resource management, financial operations, or communications/consultation. Surveys also included eight Lickert-type questions designed to assess the respondents' opinions on the future job expectations of CLS practitioners. PARTICIPANTS: The sample for the survey included 280 directors of CLS educational programs, 600 managers randomly selected from the Clinical Laboratory Management Association (CLMA) membership, and 600 practitioners randomly selected from the American Society for Clinical Laboratory Science (ASCLS) membership. MAIN OUTCOME MEASURES: The percent of respondents selecting each educational category was tabulated and each competency was assigned to one educational category based onthe highest percent of respondents selecting that category. The means of the responses to the Lickert-type questions were calculated for all respondents and for each group of respondents (educators, managers, and practitioners). RESULTS: Response rates of 58% (educators), 28% (practitioners), and 39% (managers) were obtained. Of the 44 competencies in the survey, four were expected at career-entry, 17 were expected of CLS graduates with work experience but no additional education, and 23 were expected of CLS graduates with experience plus additional education. Competencies expected in the first year of practice were primarily scientific and technical. With three to five years of practice and no additional education, the expectations for practitioners were primarily in laboratory operations and communications/consultation areas. The majority of the human resource management and financial operations competencies were expected with three to five years of practice and additional education. All participants agreed that CLS staff-level practitioners need more management and administrative skills and that, in the future, CLS practitioners will spend less time performing laboratory tests and more time solving problems. CLS managers were more positive than CLS educators in response to statements asserting that CLT practitioners and non-certified personnel will have an increased role in the laboratory in the future. CONCLUSION: This study suggests that extensive laboratory operations and communication skills are expected of CLS graduates without any additional education beyond their CLS programs. CLS educators should adequately address those areas in the curriculum. Competence in other non-technical skills may not be expected without the benefit of post-baccalaureate education and in these areas, CLS programs can provide a foundation for future learning.

Analysis of Variance↗

Innovative Surgical Strategies: Minimally Invasive CABG and Off-pump CABG.

Minimally invasive coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCAB) have made up a significant facet of the recent attempts of surgical myocardial revascularization to evolve. Driven by an effort to limit the deleterious effects of cardiopulmonary bypass (CPB), along with a response to both the growing interests in performing procedures through smaller incisions and the successes of catheter-based therapies, these therapeutic options have found themselves moving into the future by resurrecting their past. Minimally invasive CABG is the procedure by which coronary grafting is performed through a small anterior thoracotomy, without the use of CPB. Although feasible, the inability to offer a more thorough degree of revascularization has limited the applicability of this procedure and, therefore, accounts for its overall minor contribution to the number of coronary revascularizations performed annually. Conversely, as the technical feasibility of performing complete revascularization without CPB has been achieved with OPCAB, its place as a mode of therapy remains uncertain. Several clinical trials have been performed to date with only a few being done in a prospective, randomized fashion. From this data has come a mix of information regarding either improvements or, at a minimum, no change in the rate of complications between CABG with, and without, CPB, while at the same time maintaining equivalent short-term graft patencies. The question remains, however, to which patient population is this approach to CABG optimal? Our practice has largely reserved OPCAB for those patients in whom manipulation of the aorta is considered not feasible due to severe calcification or in "high-risk" patients who are felt to be unable to tolerate the adverse physiologic effects of CPB. This makes up approximately 15% of our CABG population, roughly equal to the national average, with the remaining patients being revascularized with the assistance of CPB.

Journal Article↗

Liquid chromatographic determination of maleic hydrazide in technical and formulated products: collaborative study.

Fourteen collaborating laboratories assayed maleic hydrazide (MH), 6-hydroxypyridazin-3(2H)-one, in technical and formulated products by reversed-phase liquid chromatography (LC) with sulfanilic acid as an internal standard. The active MH in the samples (6 lots) ranged from 16% (expressed as the potassium salt) to 98% (MH in the technical). A small amount of 1 M KOH was added to the technical MH and analytical standards to create the potassium salt of the analyte which is soluble in water. Test samples and standards were extracted with water containing the internal standard before analysis by LC on a C8 column with an ion-pairing eluting solution and UV detection at 254 nm. The concentration of MH was calculated by comparing the peak area response ratios of the analyte and the internal standard with those in the analytical standard solution. Eleven laboratories weighed each test sample twice with single analysis. Three laboratories weighed each sample once and made duplicate injections on the LC system. The data were analyzed using the 11 laboratories' results. A second data analysis was done including all laboratory results using a Youden pair approach, selecting one of 2 duplicate assay values randomly for each laboratory and sample. In the first data analysis, the repeatability standard deviation ranged from 0.07 to 1.39%; reproducibility standard deviation ranged from 0.22 to 1.39%. In the second data analysis (using all laboratory data), repeatability standard deviation ranged from 0.09 to 0.86%; reproducibility standard deviation ranged from 0.22 to 1.31%.

Chemistry Techniques, Analytical↗

Phase I-II study of multiple daily fractions for palliation of advanced head and neck malignancies.

PURPOSE: To assess palliation of advance head and neck malignancies with the use of rapid hyper fractionation studies similar to the RTOG 85-02. MATERIALS AND METHODS: 37 patients with 39 lesions were entered into the non-randomized Phase I-II protocol, between 1984 and 1991. Previously untreated malignancies were present in 24 lesions, primary recurrent diseases in six patients, metastasis to the head and neck in five patients and skin primaries in the remaining two cases. At presentation 15 of 37 patients (or 17 of 39 lesions) were in operable due to poor medical status, eight patients were considered technically in operable due to extent of disease, 10 patients had distant metastasis and four patients refused surgery. The protocol uses twice a day fraction (370 cGy per fraction) for 2 consecutive days totalling 1,480 cGy per course. Three courses were given at 3-week intervals for a final tumor dose of 4,440 cGy in twelve fraction over 8-9 weeks. RESULTS: Eleven of 39 lesions had complete response; 19 lesions had partial response; 4 lesions had no response; 3 lesions progressed under treatment. Response could not be assessed in two patients. The average survival after completion of therapy was 4.5 months ranging from 2 weeks to 31 months. Palliation was achieved in 33 of 39 lesions. The acute reactions were minimal and no late or long term complications were noted. CONCLUSION: The absence of significant complications with reasonable response in the high rate of palliation suggests that this rapid hyper fractionation palliation study should be studied for further evaluation.

Actuarial Analysis↗

Surgical treatment for pulmonary metastases.

As the lungs are a filter for the entire circulation, they are a common site for metastatic disease. Although never proven by a prospective randomized trial, surgical resection is a widely accepted treatment for pulmonary metastases on the condition that a complete resection can be obtained. However, many patients will develop recurrent disease in the thorax despite the use of systemic chemotherapy, dosage of which is limited due to systemic toxicity. As isolated limb and liver perfusion, isolated lung perfusion is an attractive and promising surgical technique for the delivery of high-dose chemotherapy with minimal systemic toxicity. The use of biological response modifiers, like tumour necrosis factor, is also feasible. Isolated lung perfusion has proven to be highly effective in rat models of pulmonary metastases with a clear survival advantage. Lung levels are significantly higher after isolated lung perfusion compared to intravenous therapy without systemic exposure. Preliminary human studies have shown that isolated lung perfusion is technically feasible with low morbidity and without compromising the patient's pulmonary function. Further clinical research is necessary to determine its effect on pulmonary metastases in man, especially in case of unresectable disease or as adjuvant therapy after surgical resection.

Animals↗

Uterine artery embolization in the treatment of symptomatic uterine fibroid tumors (EMMY trial): periprocedural results and complications.

PURPOSE: Uterine artery embolization (UAE) is an emerging treatment for symptomatic uterine fibroid tumors. This study was performed to evaluate the periprocedural results of the UAE procedure and identify risk factors for technical failure, fever after UAE, pain, and other complications. MATERIALS AND METHODS: As part of a multicenter, randomized trial to compare UAE versus hysterectomy in patients with symptomatic uterine fibroid tumors, 81 patients underwent UAE. Univariate and multivariate analyses were used to identify predictors for technical failure, postprocedural fever, complications as defined by the Society of Interventional Radiology (SIR), and pain scores. RESULTS: The technical failure rate according to SIR guidelines was 5.3% (95% CI, 2.3%-10.1%). The procedural failure rate was 17.3% (95% CI, 9.8%-27.3%). Bilateral failure occurred in four of 81 patients and unilateral failure occurred in 10 of 81 patients. Technical failure occurred mainly as a result of difficult anatomy (3.7%) or absence of the uterine artery (3.1%). The overall complication rates were 28.4% during the patients' hospital stay and 60.5% for the 6 weeks after discharge. The risk of technical failure was found to increase in the presence of a single fibroid tumor (odds ratio [OR], 6.21; 95% CI, 1.65-23.41; P = .007) and/or a small uterine volume (<500 cm(3); OR, 10.8; 95% CI, 1.25-93.36; P = .03). The amount of embolization material was associated with the onset of fever after UAE (OR, 2.05; 95% CI, 1.09-3.87; P = .027), major complications (OR, 5.68; 95% CI, 2.05-15.75; P = .001), and high pain scores (OR, 1.97; 95% CI, 1.08-3.58; P = .027). CONCLUSIONS: The procedural failure rate for UAE was higher than those reported by others, mainly as a result of difficult anatomy and absence of a uterine artery in some cases. The risk of procedural failure was increased for patients with single fibroid tumors and/or small uterine volumes. A clear dose-effect response was revealed between the amount of embolization material used and the risk for postprocedural fever, major complications, and severe pain.

Adult↗

Selection of novel mediators of E2F1-induced apoptosis through retroviral expression of an antisense cDNA library.

The E2F1 transcription factor is an essential mediator of p53-dependent and p53-independent apoptosis as part of an anti-tumour safeguard mechanism. In this study, a functional so-called technical knockout (TKO) approach was applied to Saos-2ERE2F1 cells that conditionally activate E2F1 by the addition of 4-hydroxytamoxifen to search for p53-independent pro-apoptotic E2F1 targets. The approach was based on random inactivation of genes after retroviral transfer of an antisense cDNA library enriched of E2F1-induced genes, followed by the selection of Saos-2ERE2F1 cells that survive in the presence of the apoptotic stimulus. We identified 13 novel E2F1 target genes encoding proteins of known cellular function, including apoptosis and RNA binding. FACS analysis revealed that E2F1-induced apoptosis was significantly attenuated in cell clones containing the antisense cDNA fragments of these genes, demonstrating their participation in E2F1 death pathways. Moreover, inactivation of the target genes resulted in a clear increase of cell viability (>80%) in response to E2F1 activation compared with controls (approximately 30%). Four genes showed an increase in expression intensity in the presence of cycloheximide, suggesting a direct effect of E2F1 on gene transcription, whereas one gene was identified as an indirect target. Our data provide new insight in the regulation of E2F1-induced apoptosis.

Apoptosis↗

The efficacy of direct current stimulation for lumbar intertransverse process fusions in an animal model.

STUDY DESIGN: Posterolateral lumbar intertransverse process fusion using a rabbit model with autologous bone graft and direct current stimulation was compared with fusion achieved by using autologous bone graft alone. OBJECTIVES: To determine the efficacy of direct current electrical stimulation for the posterolateral lumbar intertransverse process fusion technique by using a 20-microA current and the more recently developed 60-microA current delivered by an implantable direct current stimulator. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated a positive effect of direct current electrical stimulation on posterior spinal fusion techniques. However, until recently, the environment of an intertransverse fusion was not well simulated. The current research examined the posterolateral lumbar intertransverse process fusion technique with direct current electrical stimulation using a rabbit model. This appears to parallel human fusion techniques more closely and allows for lower cost and technical ease. METHODS: In this study, 44 adult New Zealand white rabbits underwent an L5-L6 intertransverse process fusion. All the fusions used an autologous bone graft obtained from bilateral posterior iliac crests. A device was implanted in all the rabbits subcutaneously, and they were divided randomly into three groups: a sham or nonfunctioning group, a 20-microA low-current stimulator group, and a 60-microA higher-current stimulator group. Spinal fusion was evaluated radiographically, histologically, and manually as well as by biomechanical testing 5 weeks after surgery. RESULTS: Radiographic grades, manual palpation, biomechanical strength, and stiffness showed an increasing trend from sham or inactive stimulator groups to low-current and then to high-current stimulator groups. Histologic analysis revealed that the higher-current stimulator showed that, statistically, the healing response of the host tissue to the autograft had increased significantly, as compared with the sham. CONCLUSIONS: Direct current electrical stimulation is efficacious in improving both the healing rate and strength in this posterolateral lumbar fusion model. In addition, it appears that this effect is enhanced by increasing the stimulation current from 20 microA to 60 microA.

Animals↗

Operant conditioning of primate spinal reflexes: the H-reflex.

The study of primate memory substrates, the CNS alterations which preserve conditioned responses, requires an experimental model that fulfills two criteria. First, the essential alterations must be in a technically accessible location. Second, they must persist without input from other CNS regions. The spinal cord is the most technically accessible and readily isolated portion of the primate CNS. Recent work has demonstrated that the spinal stretch reflex (SSR), the initial, wholly segmental response to muscle stretch, can be operantly conditioned and suggests that this conditioning may produce persistent spinal alteration. The present study attempted similar operant conditioning of the H-reflex, the electrical analog of the SSR. The primary goals were to demonstrate that spinal reflex conditioning can occur even if the muscle spindle is removed from the reflex arc and to demonstrate conditioning in the lumbosacral cord, which is far preferable to the cervical cord for future studies of neuronal and synaptic mechanisms. Nine monkeys prepared with chronic fine-wire triceps surae (gastrocnemius and soleus) electromyographic (EMG) electrodes were taught by computer to maintain a given level of background EMG activity. At random times, a voltage pulse just above M response (direct muscle response) threshold was delivered to the posterior tibial nerve via a chronically implanted silicon nerve cuff and elicited the triceps surae H-reflex. Under the control mode, reward always followed. Under the HR increases or HR decreases mode, reward followed only if the absolute value of triceps surae EMG from 12 to 22 ms after the pulse (the H-reflex interval) was above (HR increases) or below (HR decreases) a set value. Monkeys completed 3,000-6,000 trials/day over study periods of 2-3 mo. Background EMG and M response amplitude remained stable throughout data collection. H-reflex amplitude remained stable under the control mode. Under the HR increases mode (5 animals) or HR decreases mode (4 animals), H-reflex amplitude (EMG amplitude in the H-reflex interval minus background EMG amplitude) changed appropriately over at least 6 wk. Change appeared to occur in two phases: an abrupt change within the first day, followed by slower change, which continued indefinitely. Change occurred in all three triceps surae muscles (medial and lateral gastrocnemii and soleus). Under the HR increases mode, H-reflex amplitude rose to an average of 213% of control, whereas under the HR decreases mode it fell to an average of 68% of control. The results demonstrate that the H-reflex can be operantly conditioned.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

Treatment is an art to which science can contribute: the 2nd James Rankin Oration.

Working models-beliefs-are an essential element of behaviour. Clients' models and non-scientific treatment models, need to be respected. It is contended that, practically and theoretically, scientific models have little validity or relevance for understanding and managing addictive behaviour. The WHO model of drug use, with two added elements (the self and the functions of choice and decision making; and random variation of neurophysiological activities), is used as an example. The scientific method consists of dissecting a complex phenomenon into simpler parts, testing hypotheses about these parts, collecting and summating the data, and applying the conclusions to individual cases. It is presumed that if we know enough about a person then we can predict their future behaviour, including response to therapeutic interventions. Four major arguments are produced against that presumption. The scientific method depends upon the use of meaningful numbers (representing discrete, replicable categories) and its results are presented in statistical formats (with limited individual relevance). Measurement in the behavioural sphere is neither precise nor objective. This is critical with complex interactive systems (such as the WHO model) in which an apparently insignificant change in input can result in dramatic changes in output. Progress may have been made technically, e.g. to reduce relapse, but therapy remains an art. In future, scientific endeavours should be complemented by attention to other disciplines.

Journal Article↗

[Quality of dispensation of prescription medication from the patients' point of view].

A cross-sectional survey investigated quality relevant aspects of the most common distribution channels (pharmacies, self-dispensing physicians) for prescription drugs in Switzerland. A self-administered questionnaire focusing on consumers' behaviour, perception and priorities regarding the process of dispensation of prescriptive medication was mailed to a random sample of 3000 patients, aged 18 years or older, with regular intake of prescriptive medication. Chi-square analysis was performed on 1058 responses. 60% of the respondents received their medication mainly or exclusively from pharmacies and 40% from self-dispensing physicians. In German-speaking Switzerland 53% of participants received their prescription drugs exclusively or mainly from self-dispensing physicians, compared to only 10% in the French-speaking area (p = 0.00). This distribution confirms the existing differences in regulation of self-dispensation in these regions. Most of the patients took 2-4 prescriptive drugs a day. The French Swiss received slightly more prescriptive medication than the German Swiss (p = 0.05). 45% of the participants, especially women and people using a pharmacy, reported additional, usually occasional over-the-counter medication. Provision of technical information (41%), friendliness (19%), and the availability of drugs (19%) were valued most important when receiving prescription drugs and 96% of the participants were satisfied with the service. In consequence, the participants were strongly bound to their source of drug supply. Some 80% received instructions for use there. However, only half were informed about the purpose of the medication, drugs' side effects, or possible drug interactions. Physicians provided such information more often than pharmacy staff. This observation may be attributable to the double role played by the self-dispensers, who provide medical care and at the same time hand out the drug. In conclusion, patients' satisfaction is achieved equally by both medication channels. However, there is a need to improve counselling to ensure excellence in the supply of drugs.

Adult↗

[The incidence of wound healing disorders in heart surgery].

In a five-year retrospective study we investigated the wound infection rate after median sternotomy in 2805 adult patients on whom elective surgery had been performed with extracorporeal circulation. On the basis of 14,700 apparently relevant data from 101 patients with wound healing disturbances at the sternotomy site, both the significance of predisposing risk profiles and the prevalence of nosocomial pathogens were evaluated. The control group was formed by 100 patients selected at random. The results were checked for statistical significance using the X2 test for alternative characters; the significance level was set at alpha = 5%. The infection rate observed in our group was 3.6%, which was assigned to 5 internally defined degrees of severity. Cases of healing by second intention were caused to 93% by coagulase-negative staphylococci and staphylococcus aureus. Factors leading to a decrease in oxygenation of the wound area (low-output syndrome, rethoracotomy), diabetes, obesity and the duration of wound drainage were accompanied by a significantly more frequent occurrence of wound healing disturbances. On the other hand, perfusion-technical parameters, operation duration, revascularisation techniques (IMA/ACVB), pulmonary conditioned hypoxemias and the end-of-year desinfection usual in our clinic had no influence on wound healing. Seasonal fluctuation of the epidermal microclimate appear to be responsible for the prevalence and virulence of the pathogen strains in the clinic environment. The preventive measures used in cardiosurgical clinics do not yet represent a fully developed prophylaxis against exposure to nosocomial pathogens.

Adult↗

Technical note: effect of corticotropin-releasing hormone on adrenocorticotropic hormone and cortisol in steers.

The objective of this study was to determine an appropriate exogenous dose of bovine corticotropin-releasing hormone (bCRH) to stimulate the physiological effects of the hypothalamic-pituitary-adrenal axis in steers as a method to test the sensitivity of the pituitary and adrenal gland. Twenty 14-mo-old Holstein-Friesian steers were blocked by weight (443.7+/-2.5 kg) and randomly allotted to receive either saline (control) or bCRH (0.1, 0.3, 1.0, or 1.5 microg/kg BW). Animals were housed in a slatted-floor facility (n = 5 per pen). Indwelling jugular catheters, for both the administration of bCRH and blood collection, were fitted on d -1 of the experiment. Saline and bCRH were administered i.v. at time 0. Serial blood samples were collected at -15, 0, 15, 30, 45, 60, 75, 90, 105, 120, 135, 150, 165, and 180 min relative to time 0. Following administration of 0.1 microg of bCRH/kg BW, the peak ACTH response was not significantly different from pretreatment baseline concentrations (mean concentrations as measured at -15 and 0 min before bCRH administration). Mean ACTH concentrations from 0 to 180 min following 0.1 microg of bCRH/kg BW were not significantly different (P = 0.177) from controls. Administration of 0.3, 1.0, and 1.5 microg of bCRH/kg BW increased (P < 0.05) peak ACTH above pretreatment concentrations, and mean ACTH from 0 to 180 min for these treatments were greater (P < 0.05) than for controls. Peak cortisol responses to all bCRH treatments were greater (P < 0.05) than those to pretreatment concentrations. Mean cortisol concentrations from 0 to 180 min were greater (P < 0.05) in all bCRH-treated steers than in controls, but there were no significant differences among the bCRH treatments. The ratio of mean cortisol to mean ACTH for all bCRH doses tested differed (P < 0.05) from control values, indicating reactivity of the adrenals. In conclusion, bCRH challenge may be a useful method for testing the sensitivity of the hypothalamic-pituitary-adrenal axis in steers subjected to stressful husbandry conditions, and a minimum dose of 0.3 microg of bCRH/kg BW is required to stimulate physiological effects of stressor hormones.

Adrenocorticotropic Hormone↗

[Therapy of highly malignant non-Hodgkin lymphoma with high-dose chemotherapy and stem cell transplantation].

Patients with intermediate or high-grade non-Hodgkin's lymphoma are rarely cured of their disease after the failure of conventional therapy. High-dose chemotherapy followed by transplantation of either autologous marrow (ABMT) or peripheral stem cells (PBSCT) offers such patients a new possibility of cure. To patients younger than 60 years and without contraindications high-dose chemotherapy should be offered in case of relapse and bad prognosis. The PARMA-study demonstrated, that high-dose chemotherapy with subsequent autologous stem cell transplants is superior to conventional chemotherapy for relapsing patients. However high-dose chemotherapy in first complete or partial remission followed by ABMT and PBSCT as post-remission therapy for adult NHL has yielded only similar results randomized to those achieved with conventional chemotherapy in several prospectively studies. This approach should be limited to patients with bad prognostic factors (high-intermediate or high-risk groups according to the International Prognostic Factor Project). The success of ABMT and PBSCT in treating these diseases mandates exploration of the best high-dose chemotherapy, the use of autologous or allogenic bone marrow resp. peripheral stem cell for haematopoietic reconstitution and technical aspects such as purging of tumor cells, the short- and long-term transplant-related mortality continues to be a major concern.

Adult↗

Randomized controlled trial of intraputamenal glial cell line-derived neurotrophic factor infusion in Parkinson disease.

OBJECTIVE: Glial cell line-derived neurotrophic factor (GDNF) exerts potent trophic influence on midbrain dopaminergic neurons. This randomized controlled clinical trial was designed to confirm initial clinical benefits observed in a small, open-label trial using intraputamenal (Ipu) infusion of recombinant human GDNF (liatermin). METHODS: Thirty-four PD patients were randomized 1 to 1 to receive bilateral continuous Ipu infusion of liatermin 15 microg/putamen/day or placebo. The primary end point was the change in Unified Parkinson Disease Rating Scale (UPDRS) motor score in the practically defined off condition at 6 months. Secondary end points included other UPDRS scores, motor tests, dyskinesia ratings, patient diaries, and (18)F-dopa uptake. RESULTS: At 6 months, mean percentage changes in "off" UPDRS motor score were -10.0% and -4.5% in the liatermin and placebo groups, respectively. This treatment difference was not significant (95% confidence interval, -23.0 to 12.0, p = 0.53). Secondary end point results were similar between the groups. A 32.5% treatment difference favoring liatermin in mean (18)F-dopa influx constant (p = 0.019) was observed. Serious, device-related adverse events required surgical repositioning of catheters in two patients and removal of devices in another. Neutralizing antiliatermin antibodies were detected in three patients (one on-study and two in the open-label extension). INTERPRETATION: Liatermin did not confer the predetermined level of clinical benefit to patients with PD despite increased (18)F-dopa uptake. It is uncertain whether technical differences between this trial and positive open-label studies contributed in any way this negative outcome.

Adult↗