Improved bowel function after gynecological surgery with epidural bupivacaine-fentanyl than bupivacaine-morphine infusion.

PURPOSE: To compare postoperative gastrointestinal recovery between continuous epidural bupivacaine-fentanyl and bupivacaine-morphine. METHODS: In a blinded, randomized, prospective trial, 60 women undergoing surgery for gynecologic cancer were studied. Anesthesia was provided by a combined general/epidural (L2-3 catheter) technique without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.1% with either morphine 0.05 mg x ml(-1) (BM) or fentanyl 5 microg x ml(-1) (BF). Visual Analogue Scale (VAS) scores for pain at rest and during movement, and the return of bowel function were collected for three days and the duration of hospitalization were noted. RESULTS: On POD-1, 18.5% of patients in the BM group had emesis compared with none in the BF group (P = 0.038) and fewer patients in the BM group tolerated clear oral fluids (11.1% BM vs 40.6% BF, P = 0.025). These differences became insignificant on POD-2 and 3. Median pain scores were comparable at rest and ranged from 10-20 in the BM group vs 0-20 in the BF group over the three days. Similarly, median pain scores with movement respectively ranged from 20-25 and 20-30 in the BF and BM groups. The mean duration of hospitalization was longer in the BM group (5.7 +/- 2.4) vs BF (4.5 +/- 1.2 days), P = 0.017. CONCLUSION: Epidural BM and BF provided equally effective postoperative analgesia at rest and during movement. Compared with BM, epidural BF is associated with less emesis and an increased ability to tolerate oral fluids on POD-1 and an overall shorter hospital stay.

Immunohistochemical retrieval of the principal HIV antigens p24, gp41, and gp120 in formalin fixed tissue: an investigation using HIV infected lymphoblasts and postmortem brain tissue from AIDS cases.

This paper describes the use of an autoclaving procedure followed by immunocytochemistry to enhance the detection of the human immunodeficiency virus (HIV) antigens p24, gp41, and gp120. This procedure greatly improved the detection rate of the p24 and gp41 HIV surface antigens in formalin fixed, paraffin wax embedded, HIV positive central nervous system (CNS) tissue while restricting staining to areas of the CNS showing evidence of neuropathology. However, the technique did not improve retrieval of the gp120 antigen in either HIV positive, formalin fixed CNS tissue or HIV infected T lymphoblasts. The inclusion of the high temperature autoclave step was validated using both HIV infected lymphoblasts and pre-adsorption of the specific antibodies with the appropriate recombinant HIV proteins. Using the methodology described here, formalin fixed CNS tissue from potential or known HIV positive cases can be processed reliably and safely. To ensure the reliability of this technique, it is recommended that an assessment of both the p24 and gp41 antigens is undertaken.

A malignant astrocytoma in a patient with AIDS: a possible association between astrocytomas and HIV infection.

We describe a malignant astrocytoma in a patient with AIDS confirmed at autopsy. The object of this report is to draw attention to a further example of an unusual tumour associated with HIV infection. This is the tenth case in the world literature and it is possible that this tumour is represented with a higher than expected frequency in this group of the population. This case and others add malignant astrocytoma to the differential diagnosis of an intracranial space occupying lesion in an AIDS patient.

Long terminal repeat enhancer core sequences in proviruses adjacent to c-myc in T-cell lymphomas induced by a murine retrovirus.

The transcriptional enhancer in the long terminal repeat (LTR) of the T-lymphomagenic retrovirus SL3-3 differs from that of the nonleukemogenic virus Akv at several sites, including a single base pair difference in an element termed the enhancer core. Mutation of this T-A base pair to the C-G C-G sequence found in Akv significantly attenuated the leukemogenicity of SL3-3. Thus, this difference is important for viral leukemogenicity. Since Akv is an endogenous virus, this suggests that the C-G in its core is an adaptation to being minimally pathogenic. Most tumors that occurred in mice inoculated with the mutant virus, called SAA, contained proviruses with reversion or potential suppressor mutations in the enhancer core. We also found that the 72-bp tandem repeats constituting the viral enhancer could vary in number. Most tumors contained mixtures of proviruses with various numbers of 72-bp units, usually between one and four. Variation in repeat number was most likely due to recombination events involving template misalignment during viral replication. Thus, two processes during viral replication, misincorporation and recombination, combined to alter LTR enhancer structure and generate more pathogenic variants from the mutant virus. In SAA-induced tumors, enhancers of proviruses adjacent to c-myc had the largest number of core reversion or suppressor mutations of all of the viral enhancers in those tumors. This observation was consistent with the hypothesis that one function of the LTR enhancers in leukemogenesis is to activate proto-oncogenes such as c-myc.

Analysis of the significance of two single-base-pair differences in the SL3-3 and Akv virus long terminal repeats.

Two single-base-pair differences between the long terminal repeats (LTRs) of the T-lymphomagenic murine retrovirus SL3-3 and nonleukemogenic Akv virus were tested for effects on activity of the LTRs. Evidence was obtained from electrophoretic mobility shift assays for the presence of at least one factor in both T and non-T cells that bound to the region of the viral enhancers that contained the differences. However, no significant differences in activity in expression assays were detected when the two base-pair differences were exchanged between the two LTRs. Therefore, they do not contribute to the higher activity of the SL3-3 LTR in T-lymphoma cell lines.

The forensic evaluation and treatment of children: ethics and values.

This article will review the history of ethics and values in the forensic evaluations and treatment of children. Topics to be discussed include paternalism, advocacy, parental responsibility, and legal doctrine of parens patriae. Various aspects of the treatment of children, including medications, behavior modification, and psychotherapy, are also examined for ethical considerations. Agency consultation in conflicts of ethics that are associated with public laws are also addressed. The ethical implications of the use of children in any research as research subjects is also addressed.

Models for psychiatry: icons or effigies?

Toulmin notes that a good model takes us beyond the phenomena from which we began [67]. It also tempts us. Models demand that we attempt to represent the dynamic relationships between variables. When we use them, we risk insulating our findings from empirical disproof [68]. Self-certifying myths, like articles of faith, need to yield to the demands of science. Psychiatric theory and practice need to yield to the demands of experience. We need to move away from ethereal assumptions to tangible mastery of the understanding of behavior. Freud, in The Interpretation of Dreams [69], writes, "Analogies of this kind are only intended to assist us in our attempt to make the complications of mental functioning intelligible. We are justified, in my view, in giving free rein to our speculations so long as we retain the coolness of our judgment and do not mistake the scaffolding for the building. We have been obliged to build. If we are not wholly in error, other lines of approach are bound to lead us into much the same region and the time may come when we shall find ourselves more at home in it!"

Relevance of modern neuropsychology to psychiatry.

This review of new developments in clinical neuropsychology is intended to acquaint the practicing psychiatrist with the current status of the field, focusing on its applicability to a variety of psychiatric situations. The approach of Luria is described in some detail, essentially because this represents one of the major formulations of the functional organization of the brain, which is now available for standardized assessment purposes as the Luria-Nebraska Neuropsychological Battery. At this juncture, it is relevant for psychiatry to gain familiarity with these new approaches, as an important adjunct to the diagnostic, therapeutic, and prognostic problems of brain damage in the psychiatric patient.