Pleuropulmonary disease due to pergolide use for restless legs syndrome.

Pergolide is an ergot-derived dopamine agonist used in Parkinson's disease and, increasingly, in restless legs syndrome. We report a patient with a 2.5-year history of weight loss, pleuropulmonary fibrosis, and exudative pleural effusion that developed insidiously while taking this medication. The extensive and invasive workup that preceded the diagnosis highlights the difficulty in attributing such a process to a drug reaction. This is the second report of such a reaction to pergolide, which is one of the increasing number of ergot-derived compounds in common clinical use.

Cost effectiveness of acute imipramine therapy versus two imipramine maintenance treatment regimens for panic disorder.

OBJECTIVE: To examine the medical costs and effectiveness of acute treatment with imipramine versus acute treatment plus 2 different maintenance therapies for panic disorder. METHODS: A clinical decision model was constructed to estimate 18-month costs and outcomes associated with these treatment scenarios based on the medical literature and clinician judgment. The clinical parameters and outcomes for the model were derived from a series of systematic clinical trials with imipramine utilising uniform dosage procedures and validated response criteria. Costs were calculated based on standardised treatment regimens. The outcome measures were 18-month medical costs, quality-adjusted life years (QALYs) and costs per QALY gained. A sensitivity analysis was performed to explore the impact of treatment withdrawals on outcomes. STUDY PERSPECTIVE: US mental healthcare system. RESULTS: Over 18 months, the total costs (1997 values) and QALYs associated with half-dose maintenance therapy (imipramine 1.1 mg/kg/day) [$US3377; QALYs = 0.991] and full-dose maintenance therapy (imipramine 2.25 mg/kg/ day) [$US3361; QALYs = 0.991] were almost identical; both were cost saving compared with acute imipramine therapy (2.25 mg/kg/day) with no maintenance treatment ($US3691; QALYs = 0.979). Whether patients withdrawing from treatment were considered to have continued to respond to treatment or to have relapsed, the half-dose and full-dose maintenance treatments were still cost saving compared with acute treatment alone. CONCLUSIONS: The results indicate that imipramine maintenance treatment is cost effective compared with acute imipramine treatment for patients with panic disorder. The basic findings and conclusions are not affected after modifying model assumptions for clinical response in patients withdrawing from treatment.

An evidence-based interactive computer program to assist physicians in counseling smokers to quit.

Computerized expert systems offer the promise of increasing the frequency and efficiency of physician counseling of smokers to quit by collecting pertinent data and presenting it to physicians in a useful manner to guide and inform the counseling session. This article explores one such program that collects patient information, before the physician visit, that is pertinent to counseling smokers as described in the Agency for Health Care Policy and Research's Smoking Cessation Guidelines and supported in the medical literature. The program uses the information collected to produce two reports: one for the physician to use during the visit and the other for the patient as a means of supplementing and reinforcing the counseling message. Pilot data are presented from volunteers and primary care patients.

Development and evaluation of a coordinated, ambulatory rheumatology experience for internal medicine residents.

OBJECTIVE: To develop a compulsory ambulatory rotation in rheumatology for internal medicine residents and to evaluate the educational effect of this rotation. METHOD: All year 2 residents in the program participated in the rotation. The perceived quality of the learning experience was assessed by resident self-evaluation using a visual analog scale. Residents used a similar scale to rate their confidence in managing common rheumatologic problems. A validated multiple choice test was used to measure pre- and post-rotation knowledge of rheumatology and skill in interpreting bone radiographs. RESULTS: On a 1 (no learning) to 5 (superior learning) scale, the mean rating of the rheumatology learning experience was 4.7 +/- 0.5. Residents' confidence in clinical skills significantly increased as well. Scores on the post-rotation rheumatology knowledge test increased 15% compared with pre-rotation scores (P < 0.0001). Confidence and skills in interpreting bone radiology films also significantly improved (P < 0.0001 for both items). CONCLUSION: A relatively brief, subspecialty ambulatory rotation can be developed to expose all residents to a rheumatology curriculum. Such a rotation can increase their confidence, knowledge, and skills in important domains of outpatient rheumatology.

Provocation of hypotension and pain during upright tilt table testing in adults with fibromyalgia.

OBJECTIVE: Fibromyalgia is a common but poorly understood problem characterized by widespread pain and chronic fatigue. Because chronic fatigue has been associated with neurally mediated hypotension, we examined the prevalence of abnormal responses to upright tilt table testing in 20 patients with fibromyalgia and 20 healthy controls. METHODS: Each subject completed a symptom questionnaire and underwent a three stage upright tilt table test (stage 1:45 minutes at 70 degrees tilt; stage 2, 15 minutes at 70 degrees tilt with isoproterenol 1-2 micrograms/min; stage 3, 10 minutes at 70 degrees tilt with isoproterenol 3-4 micrograms/min). An abnormal response to upright tilt was defined by syncope or presyncope in association with a drop in systolic blood pressure of at least 25 mm Hg and no associated increase in heart rate. RESULTS: During stage 1 of upright tilt, 12 of 20 fibromyalgia patients (60%), but no controls had an abnormal drop in blood pressure (P < 0.001). Among those with fibromyalgia, all 18 who tolerated upright tilt for more than 10 minutes reported worsening or provocation of their typical widespread fibromyalgia pain during stage 1. In contrast, controls were asymptomatic (P < 0.001). CONCLUSION: These results identify a strong association between fibromyalgia and neurally mediated hypotension. Further studies will be needed to determine whether the autonomic response to upright stress plays a primary role in the pathophysiology of pain and other symptoms in fibromyalgia.

Methotrexate in rheumatoid arthritis: when NSAIDs fail.

Methotrexate has become the agent of choice for rheumatoid arthritis that does not respond to nonsteroidal anti-inflammatory drugs. In appropriately selected patients and with diligent monitoring, methotrexate in low weekly doses is effective and has a much better safety profile than was originally perceived.

Routine serologic screening for syphilis in hospitalized patients: high prevalence of unsuspected infection in the elderly.

BACKGROUND AND OBJECTIVES: To evaluate the potential yield of routine serologic testing for syphilis in hospitalized patients. STUDY DESIGN: Sera from consecutive patients admitted to an inpatient general medical service of a Baltimore hospital were tested using the RPR and FTA-ABS tests for syphilis. Two hundred ninety-one (149 males and 142 females) of 344 patients (85%) hospitalized during the study period participated, with ages ranging from 17 to 98 years. Seventy-seven percent of participants were African-American. Results of serologic tests for syphilis and human immunodeficiency virus were correlated with questionnaire responses. Associations were sought between results of serologic testing and demographic characteristics, medical problems, and a history of syphilis. RESULTS: No patient had an admitting diagnosis of syphilis. Thirty-seven patients (13%) had both reactive RPR and FTA-ABS tests. Although serologic evidence of syphilis was significantly associated with age older than 50 years and with a history of syphilis, 59% of patients with both reactive RPR and FTA-ABS tests did not give a history of syphilis. Ten percent of patients were HIV seropositive; however HIV seropositivity was not significantly associated with serologic evidence of syphilis. CONCLUSION: Unsuspected latent syphilis was common in this population. Routine serologic screening for syphilis should be considered in some hospitals.

Immunocompetence as a measure of the biological effects of sewage sludge pollution in fish.

1. Dab, Limanda limanda, exposed to nominal concentrations of 0 (control), 0.0032% (low) and 0.032% (high) sewage sludge in seawater for 12 weeks, were assessed for their immunological competence. 2. No effect upon total blood leucocyte and erythrocyte numbers was found, although significantly fewer thrombocytes were seen in the high-exposure group. 3. A decreased serum protein level was found in the high exposure group, but lysozyme and immunoglobulin levels showed non-significant differences between the groups. 4. Melano-macrophage centres were also affected in the high-exposure dab, which had increased numbers in the spleen and kidney. No effect upon spleen weights or oxygen free radical production by splenocytes was noted. However, oxygen free radical production by kidney leucocytes was inhibited in the low-exposure dab.

Different secretory pathways of renin from mouse cells transfected with the human renin gene.

Mammalian cells in culture, transfected with human renin gene, can provide a useful tool for studying renin biosynthesis and secretion. We transfected fibroblast cells (mouse L929 and Chinese hamster ovary cells) and pituitary tumor cells (mouse AtT-20) with the human renin gene and a selectable plasmid (pSV2Neo). Transfected fibroblasts synthesize prorenin only. Prorenin is secreted by fibroblasts constitutively and the secretion is not influenced by 8-bromo-cAMP. On the other hand, transfected AtT-20 cells synthesized both prorenin and mature active renin. Transfected AtT-20 cells release prorenin by constitutive secretion but mature renin is secreted by a regulated mechanism since the secretion of the former is not influenced by 8-bromo-cAMP but the release of the latter is significantly stimulated. Our studies demonstrate that human renin may be secreted by at least two cellular pathways: prorenin by a constitutive pathway and mature renin by a regulated pathway. These transfected cells may provide useful models for studies of human renin synthesis, processing, and secretion.

Subpopulation of alveolar macrophages inhibits superoxide anion production by macrophages.

Pig alveolar macrophages are a heterogeneous population of cells. Three subpopulations or bands exist when the whole population is separated according to density. Band 1 cells are the least dense cells and constitute 9% of the total population. Bands 2 and 3 represent 44 and 47% of the total population. The three subpopulations generate superoxide anions, although to varying degrees. Band 3 cells are the most active, while band 1 cells are the least active. The amount of superoxide anions released in a mixed population of bands 1, 2, and 3 cells was less than the sum of that produced from each band assayed separately. Band 1 cells were found to inhibit by 47% the production of superoxide anions by band 3 cells. Conditioned medium from band 1 cells contains a heat-sensitive, nondialyzable, soluble factor responsible for this inhibition.

Genetics of exopolysaccharide production by mucoid Pseudomonas aeruginosa.

The secretion of the exopolysaccharide, alginate, is believed to contribute to the predilection for persistence of P. aeruginosa in respiratory tract infections of cystic fibrosis patients. To understand more about the pathway of alginate biosynthesis, we have cloned a gene, alg-50, which is involved in alginate biosynthesis. The alg-50 gene was physically mapped on a DNA fragment from P. aeruginosa by deletion analysis and transposition mutagenesis. The alginate trait is unstable, and another clone was found which may contain genes involved in this phenomenon. The two uronic acid components in alginate can vary, and a gene was cloned which increases the L-guluronate concentration of alginate produced by P. aeruginosa.