Parental experiences of a paediatric cochlear implant programme.

Although cochlear implantation is a well-established procedure in profoundly deaf children, very little research has investigated whether parents are satisfied with the treatment (including assessment, surgery and rehabilitation) or its outcome, and whether it has met their expectations. In this study, 44 parents of children who had received cochlear implants completed a confidential postal questionnaire. Results indicated that the majority of parents felt that the information they and their child received was both sufficient and appropriate. Many parents experienced more distress than they anticipated, but perceived their child as having experienced less physical discomfort than expected. Some suggestions for improving the service were made, but in general it was felt that little more could be done to inform our 'consumers', or to reduce levels of stress.

Can we predict which wheezy infants will continue to wheeze?

Early intervention strategies in infant wheezing will be dependent on the ability to predict persistence of disease. We undertook a prospective longitudinal study to determine which factors might be predictive for the persistence of wheeze. We examined a group of 107 children 3 to 36 mo of age with at least one atopic parent. Children were recruited within 12 wk of first wheeze. Factors assessed included: personal atopy (IgE > 1 SD above age-related normal and/or eczema and/or positive skin tests); parental atopy; number of siblings; age at first wheeze; sex; serum-soluble IL-2R; proliferation of peripheral blood mononuclear cells (PBMC) to beta-lactoglobulin and to D. pteronyssinus; production of IFN-gamma on stimulation of PBMC with beta-lactoglobulin and with D. pteronyssinus. A positive clinical outcome (child requiring prophylactic antiasthma treatment after 1 yr) was observed in 53 (49.5%) children. Predictor variables were assessed by univariate and multivariate logistic regression. Wheeze was more likely to be persistent in older, atopic children with biparental atopy. The model offering best prediction of persistent wheeze with least risk of including asymptomatic subjects was age at presentation + sIL-2R. Trials of early intervention strategies using a logistic regression equation based on this model for patient recruitment can now be designed.

Effect of lung volume reduction surgery on neuromechanical coupling of the diaphragm.

The mechanisms for symptomatic improvement following lung volume reduction surgery for emphysema are poorly understood. We hypothesized that enhanced neuromechanical coupling of the diaphragm is an important factor in this improvement. We studied seven patients with diffuse emphysema before and 3 mo after surgery. Patients showed improvements in 6-min walking distance (p = 0.002) and dyspnea (p = 0.04). The pressure output of the respiratory muscles, quantified as pressure-time product per minute (PTP/min), decreased after surgery (p = 0.03), as did PaCO2 (p = 0.02). Maximal transdiaphragmatic pressures (Pdi(max)) increased from 80.3 +/- 9.5 (SE) to 110.8 +/- 9.3 cm H2O after surgery (p = 0.03), and the twitch transdiaphragmatic pressure response to phrenic nerve stimulation (Pdi(tw)) increased from 17.2 +/- 2.4 to 25.9 +/- 3.0 cm H2O (p = 0.02); these increases were greater than could be accounted for by a decrease in lung volume. The contribution of the diaphragm to tidal breathing, assessed by relative changes in gastric and transdiaphragmatic pressures, increased after surgery (p = 0.008). Net diaphragmatic neuromechanical coupling, quantified as the quotient of tidal volume (normalized to total lung capacity) to tidal change in Pdi (normalized to Pdi(max)), improved after surgery (p = 0.03) and was related to the increase in 6-min walking distance (r = 0.86, p = 0.03) and decrease in dyspnea (r = 0.76, p = 0.08). In conclusion, lung volume reduction surgery effects an improvement in diaphragmatic function, greater than can be accounted for by a decrease in operating lung volume, and enhances diaphragmatic neuromechanical coupling.

Interference with testing for lysergic acid diethylamide.

We found a high rate (4.2%) of positive results for lysergic acid diethylamide (LSD) by Emit in 1898 urine samples that were submitted primarily from psychiatric patients for drugs-of-abuse (DOA) testing. Specimens that tested positive for LSD by Emit subsequently tested negative for LSD with two RIAs. Furthermore, LSD was not detected in randomly selected Emit-positive urine samples by gas chromatography-mass spectrometry. Normal urine samples tested positive for LSD by Emit when they were supplemented with therapeutic medications that were prescribed for patients with positive urine LSD results by Emit. These therapeutic drugs interfered specifically with the Emit assay for LSD, since other Emit DOA tests were not affected by these medications at the tested concentrations.

Analysis of the structural features of the C-terminus of GLUT1 that are required for transport catalytic activity.

C-terminally truncated and mutated forms of GLUT1 have been constructed to determine the minimum structure at the C-terminus required for glucose transport activity and ligand binding at the outer and inner binding sites. Four truncated mutants have been constructed (CTD24 to CTD27) in which 24 to 27 amino acids are deleted. In addition, point substitutions of R468-->L, F467-->L and G466-->E have been produced. Chinese hamster ovary clones which were transfected with these mutant GLUT1s were shown, by Western blotting and cell-surface carbohydrate labelling, to have expression levels which were comparable with the wild-type clone. Wild-type levels of 2-deoxy-D-glucose transport activity were retained only in the clone transfected with the construct in which 24 amino acids were deleted (CTD24). The CTD25, CTD26 and CTD27 clones showed markedly reduced transport activity. From a kinetic comparison of the CTD24 and CTD26 clones it was found that the reduced transport was mainly associated with a reduced Vmax. value for 2-deoxy-D-glucose uptake but with a slight lowering of the Km. These data establish that the 24 amino acids at the C-terminus of GLUT1 are not required for the transport catalysis. However, the point mutations of F467L and G466E (26 and 27 residues from the C-terminus) did not significantly perturb the kinetics of 2-deoxy-D-glucose transport. The substitution of R468L produced a slight, but significant, lowering of the Km. The ability of the truncated GLUt1s to bind the exofacial ligand, 2-N-4-(1-zai-2,2,2-trifluoroethyl)benzoyl-1,3-bis-(D-mannos- 4-yl-oxy) -2-propylamine (ATB-BMPA), and the endofacial ligand, cytochalasin B, were assessed by photolabelling procedures. The ability to bind ATB-BMPA was retained only in the CTD24 truncated mutant and was reduced to levels comparable with those of the non-transfected clone in the other mutant clones. Cytochalasin B labelling was unimpaired in all four mutated GLUT1s. These data establish that a minimum structure at the C-terminus of GLUT1, which is required for the conformational change to expose the exofacial site, includes amino acids at positions Phe-467 and Arg-468; however, these amino acids are not individually essential.

Remediation of pain-related memory bias as a result of recovery from chronic pain.

Cognitive biases are increasingly implicated as vulnerability factors in emotional and physical disorders. This issue is examined here in chronic pain sufferers using a recall memory paradigm. A sample of chronic pelvic pain patients undergoing hysterectomy and oophorectomy were assessed prior to the intervention, 8 weeks post-surgery, and again 6 months post-surgery. On each occasion patients were aurally presented four mixed lists of sensory, affective, neutral and gardening words, matched for frequency and length. No difference in the recall of neutral and gardening words was found, suggesting that selective memory for pain-related information cannot be attributed to superior recall of words belonging to a common semantic category. A clear pattern of more pain-related words being remembered before surgery, but better recall of non-pain-related words 6 months post-surgery when pain intensity ratings are significantly reduced, was evidenced. These results suggest that selective memory for pain-related words is more likely to be a secondary consequence of the long term experience of pain than a stable, enduring cognitive vulnerability factor.

Alterations in transmitral flow dynamics in patients with early mitral valve closure and aortic regurgitation.

Ten patients with severe aortic regurgitation (AR) and early diastolic mitral closure demonstrated by M-mode echocardiography (group I) were compared to 10 age-matched patients with severe AR and normal timing of mitral closure to quantify the accompanying alterations in transmitral flow dynamics assessed by pulsed Doppler echocardiography. Transmitral filling period expressed as a fraction of the time available for diastolic filling was significantly shortened in group I patients relative to group II patients (0.50 +/- 0.10 vs 1.04 +/- 0.09, p < 0.001) because early mitral closure truncated transmitral filling and obliterated the atrial contribution to left ventricular filling. The rapid diastolic filling period normalized for the time available for diastolic filling was also shortened for group I patients relative to group II patients (0.49 +/- 0.11 vs 0.64 +/- 0.19; p < 0.05). Early mitral closure in group I patients was functionally incomplete because 9 of the 10 patients had diastolic mitral regurgitation, which was not detected in any patients in group II (p < 0.001). Thus the group I patients with early mitral closure and severe aortic regurgitation had truncated transmitral inflow and diastolic mitral regurgitation. These patients had higher pulmonary capillary wedge pressures (32 +/- 6 vs 11 +/- 9 mm Hg; p < 0.001) and more severe functional limitation (p < 0.001) than group II patients.

Initial clinical evaluation of a wheelchair ergometer for diagnostic exercise testing: a technical note.

The purpose of this initial study was to evaluate a new wheelchair ergometer (WCE) and exercise test protocol for the detection of coronary artery disease in men with lower limb disabilities. Forty-nine patients (63 +/- 9 yr) completed WCE tests without complications. Peak heart rate was 84 +/- 15% (mean +/- SD) of age-predicted maximum and peak double product was 223 +/- 62 x 10(2). The specified target heart rate (> or = 80% age-predicted maximal) or a positive result was achieved in 76% of tests. Fourteen tests were rated positive, 21 as negative and 14 as nondiagnostic for exercise-induced ischemia. In 18 patients who underwent coronary angiography, the predictive value was 100% (10/10) for a positive, and 50% (2/4) for a negative WCE test result. These results suggest that WCE is a viable initial diagnostic option for some persons who cannot adequately perform treadmill or cycle ergometry exercise.

Word completion in chronic pain: evidence for schematic representation of pain?

Schematic representation of pain information was investigated in chronic pain patients, health professionals, and nonpatient controls. Under the guise of an English-language experiment, Ss were presented with 12 word stems to be completed with the first 2 English words that came to mind. Four of the stems could be completed with sensory pain words, 4 with effective, and 4 with words associated with pain or illness. All could be completed with at least 3 other nonpain words of equal or greater frequency. Results indicate that chronic pain Ss produced significantly more pain-related completions than control Ss and that in all 3 groups the types of pain words produced were related to the extent of personal experience of pain. The theoretical implications of these findings are discussed in relation to the organization of schema, implicit memory, and the activation of mental representations of pain (schema).

Transthoracic and transesophageal echocardiography for the evaluation of cardiac tumors, thrombi, and valvular vegetations.

Echocardiography is commonly used for the detection, assessment, and diagnosis of intracardiac masses. Since the introduction of M-Mode ultrasound in 1954, the subsequent development of two-dimensional Doppler, and transesophageal echocardiographic techniques have shown clinical efficacy in the evaluation of intracardiac pathology. The various presentations of cardiac tumors, thrombi, and valvular vegetations can pose a diagnostic challenge. In addition, once a diagnosis is established, data regarding risk stratification and prognosis are often required for further management. Echocardiography can serve these clinical needs.

The impact of volume on outcome in seriously injured trauma patients: two years' experience of the Chicago Trauma System.

The American College of Surgeons has stated that in considering the development of trauma systems it is important to ensure an appropriate volume of seriously injured patients be seen by each trauma center in order to achieve acceptable mortality rates. Clinical data supporting this recommendation are lacking. An analysis was performed on 1,643 seriously injured trauma patients to determine the relationship between volume and mortality rates. Three separate statistical methods were used: Pearson correlation coefficients, mortality odds ratios, and direct pairwise mortality comparisons. In addition, Tobit analysis was introduced as a method to analyze the relationship between volume and mortality. Mortality rates were adjusted for the confounding variable of serious head injury. Pearson correlation coefficients for volume vs. adjusted mortality was -0.65. Mortality odds ratios comparing the low-volume (less than 140 pts) trauma centers vs. the high-volume (greater than 200 pts) trauma centers was 1.3 for adjusted mortality rates (95% CI = 1.01-1.66; p = 0.04). Categorical analysis showed significantly different mortality rates in the centers before and after adjusting for patient mix. Tobit analysis showed the relationship between volume and mortality to be significant, accounting for 30-40% of the observed variation in mortality rates. In addition, Tobit analysis allowed construction of a model to predict mortality rates, given specific volumes of patients. Our data suggest that an inverse relationship exists between volume and mortality, and support the necessity of configuring trauma systems in a manner that will ensure designated trauma centers will see a high volume of seriously injured patients.

Frequency of Salmonella typhimurium the year after a massive outbreak.

In 1985, Illinois experienced a large milkborne outbreak of Salmonella typhimurium with over 16,000 cases. During this year, 49.4% of United States and 86.4% of Illinois salmonellae were S. typhimurium. In 1986, 1133 microbiologically confirmed and serotyped cases of salmonellosis were reported in the City of Chicago, comprising 37% of the 3034 cases reported for the State of Illinois. The most frequent serotypes were S. typhimurium (21.3%), Salmonella heidelberg (18.2%), Salmonella enteritidis (10.7%), and Salmonella braenderup (7.7%), similar to the state as a whole. Nationally, excluding Illinois, the most frequent serotypes in 1986 were S. typhimurium (26.1%), S. enteritidis (14.7%), and S. heidelberg (13.0%). S. braenderup comprised 0.9% of the non-Illinois total. Regional variations in the epidemiology of salmonellae are probable and may reflect detected or undetected outbreaks. Within a year of the nation's largest Salmonella outbreak, there was no trace of any effect on the frequency of isolation of Salmonella spp.

Lymphocyte function in patients treated with monoclonal anti-T3 antibody for acute cadaveric renal allograft rejection.

We are participating in a multicenter trial testing the efficacy of a murine monoclonal antihuman peripheral T lymphocyte antibody (OKT3.PAN) as immunosuppressive therapy for the treatment of acute cadaveric renal allograft rejection. Although clinical data indicate that administration of this antibody clears the circulating lymphocyte pool of T3-positive cells, some in vitro studies have called into question whether the antibody is indeed lymphocytotoxic. Other in vitro data suggest that the antibody is a potent mitogen. To address these problems and investigate the effect of the antibody on T cell function, we have studied spontaneous blastogenesis, response to the lectins phytohemagglutinin (PHA) and concanavalin A (ConA), and response to donor-specific and non-donor-specific alloantigen in a one-way MLC in 9 patients treated with anti-T3 for acute rejection and 9 steroid-treated controls. Patients cells were harvested with standard techniques and studied after transplantation, but prior to acute rejection, on days 3 and 12 of therapy and 1 week after cessation of therapy. All patients received baseline immunosuppression with azathioprine and steroids. Acute rejection was reversed with alpha T3 antibody (5 mg i.v./day-1 X 14 days) in 8 of 9 patients and in 6 of 9 steroid-treated controls. Spontaneous blastogenesis was not enhanced by anti-T3 nor did it rise during therapy. PHA and Con A responsiveness were dramatically and significantly depressed by therapy with anti-T3 or steroids on days 3 and 12. Although PHA responsiveness rebounded past baseline 1 week after monoclonal therapy, it was depressed compared with the steroid-treated patients. On the other hand, Con A responsiveness was still significantly depressed one week after monoclonal therapy compared with prerejection values or with controls. Response to donor-specific and to non-donor-specific alloantigen was significantly depressed with anti-T3 therapy compared with steroid controls, and it did not rise during therapy. Donor-specific responses tended to be slower in returning to pretreatment values in the OKT3 patients compared with steroid controls. In summary: (1) Anti-T3 antibody did not enhance spontaneous blastogenesis in patients treated for acute rejection; (2) Con A and PHA responses were dramatically depressed by anti-T3 therapy and returned to baseline following different time courses; (3) Non-donor-specific alloresponse and, more important, donor-specific alloresponse, was more depressed--and for longer periods--by anti-T3 than by conventional steroid anti-rejection therapy.(ABSTRACT TRUNCATED AT 400 WORDS)