Blood pressure monitoring with home monitors versus mercury sphygmomanometer.

OBJECTIVE: To determine the accuracy of three automatic monitors (arm, wrist, finger) for blood pressure measurement manufactured by Omron compared with a standard mercury sphygmomanometer. PRIMRY END POINT: Difference in the mean blood pressure readings from each monitor; the secondary end point was difference in pulse readings. DESIGN: A single-visit, crossover trial tested each device twice on the left arm of each participant; the average of the two readings was recorded. The pulse readings from each monitor were also recorded. ANOVA was used to compare mean blood pressure readings and pulse readings from each device. RESULTS: A total of 55 persons (mean age 53 y; 36 women) met inclusion criteria and completed the study. The mean systolic and diastolic readings obtained from the electronic arm unit were comparable to the mercury readings (124.4/78.02 vs. 129.45/77.87 mm Hg, respectively; p > 0.05 for both readings). The mean results obtained from the wrist and finger monitors differed significantly from those of the mercury readings (145.44/89.58 and 113.94/69.07 mm Hg, respectively; p < 0.05 for both monitors compared with control). No difference was measured in the mean pulse readings between the comparisons (p = 0.72). The absolute difference in systolic and diastolic blood pressure readings from control varied the least wih the arm monitor. CONCLUSIONS: Compared with the mercury sphygmomanometer, the arm monitor was the most accurate in measuring blood pressure. The wrist and finger monitors resulted in statistically significant mean systolic and diastolic differences compared with the mercury sphygmomanometer.

Abbreviated scale for the assessment of psychosocial status in pregnancy: development and evaluation.

BACKGROUND: Data from five existing psychosocial scales were used to develop an abbreviated scale for the assessment of psychosocial status during pregnancy. METHODS: Scales were self-administered by 842 black and 381 white low-income multiparous women at risk for poor pregnancy outcome. Trait anxiety (Speilberger), self-esteem (Rosenberg), mastery (Pearlin), and depression (CES-D) were assessed at 24-26 weeks' gestation; subjective stress (Schar) was assessed at 30-32 weeks' gestation. The 59 pooled items were examined for redundancy and the discernment of primary factors using principal factor analysis. Regression analysis was used to determine if the resulting abbreviated scale (28 items) would provide information similar to that obtained with the 59 item pool (full scale) in predicting gestational age (GA), birth weight (BW), fetal growth restriction (FGR), and preterm delivery (PTD). RESULTS: The abbreviated scale was highly correlated (r = 0.97) with the 59-item pool and the six factors isolated were generally compatible with the major characteristics assessed by the five original scales. The distribution of FGR and PTD by scale quartile was similar for the abbreviated and the combined scales. Logistic regression analysis of scores for all women revealed that poor (high) scores on both the full (p = 0.0151) and the abbreviated scales (p = 0.0131) were positively associated with FGR, but not with PTD. In linear regression analysis poor (high) scores on both the full (p = 0.0024) and the abbreviated scale (p = 0.0019) were negatively related to BW, but not to GA. When data for black and white women were examined separately, the two scales provided comparable information. CONCLUSIONS: The abbreviated psychosocial scale provided information similar to that obtained with 59 pooled items in predicting GA, BW, FGR, and PTD.

The relationship between the hypothalamic-pituitary adrenal axis and oral-induced immunosuppression.

The effects of hypophysectomy on the immune response in mice orally immunized with sheep red blood cells (SRBC) was investigated. Hypophysectomized and sham-operated animals display elevated serum levels of SRBC-specific IgG. In addition, splenic lymphocytes obtained from hypophysectomized mice (i) exhibit an enhanced blastogenic response to SRBC, (ii) present with a lower frequency of T (thy 1.2+) cells and produce more total IgG polyclonal antibody in culture in comparison to splenic lymphocytes obtained from non-operated (control) mice. Peyer's patch (PP) and mesenteric lymph node (MLN) lymphocytes from hypophysectomized animals secreted elevated levels of total IgG compared to saline-treated controls. The culture supernates of splenic lymphocytes obtained from hypophysectomized, sham-operated, and control animals contain interleukin-2 suppressive factors as determined using the CTLL-2 cell line. The suppressive effect mediated by the lymphocyte culture supernates is less apparent on interleukin-4-mediated CTLL-2 proliferation. The culture supernates from PP lymphocytes obtained from hypophysectomized mice contain potent interleukin-2 suppressive factors while PP lymphocyte culture supernates from sham-operated and control mice displayed no suppressive activity. Likewise, culture supernates from MLN lymphocytes of hypophysectomized, sham-operated, and control mice possessed no suppressive factors for interleukin-2- or interleukin-4-mediated CTLL-2 proliferation. Taken together, the identification of suppressive factors in the lymphocyte culture supernates along with the enhanced blastogenic response and serum anti-SRBC IgG levels in hypophysectomized mice suggests neuroendocrine pathways regulate oral-induced tolerance.

Foot blister risk factors in an ROTC summer camp population.

Data that establish risk factors for foot blister morbidity among ROTC cadets at summer camp are presented. The subjective blister attack rate was 42.1 per 100 cadets. Women had a relative risk of 1.6 that of men (p < 0.001). Cadets with a history of blisters in the 2 years before camp had an increased relative risk of blister formation. Cadets who reported wearing their boots less than 20 hours per week during the 2 weeks immediately before camp had elevated risk. Other factors are examined. These data suggest that the foot must become conditioned to its footwear to prevent blister formation.

Insulin administration to the eyes of normoglycemic human volunteers.

Animal studies have shown that insulin eyedrops containing an absorption-enhancing agent can have a significant effect on blood glucose levels. When formulated as a topical solution, insulin might potentially be used to treat or augment the treatment of diabetes mellitus in humans. We sought to investigate the feasibility of using insulin eyedrops in humans by studying the local toxicity and efficacy of insulin administered without surfactant to the eyes of healthy volunteers. A prospective, randomized, placebo-controlled, single-masked study was conducted in which 8 subjects were given 50 microliters of sterile normal saline containing varying insulin concentrations randomized to one eye, and 50 microliters of placebo (sterile normal saline) to the fellow eye. Subjective ocular irritation was evaluated, and the eyelids, conjunctiva, cornea, and anterior chamber were examined objectively with slit lamp biomicroscopy. Subjects were evaluated for 2 hours following administration of a single dose of insulin. There was no statistically significant difference (P > 0.05) in toxicity observed by any parameter evaluated between eyes receiving insulin and placebo. No systemic absorption of insulin was observed; blood glucose levels and serum immunoreactive insulin levels were unchanged. The results of this study suggest that single-dose insulin in concentrations up to 100 U/ml formulated in saline has no detectable clinical toxicity to the anterior structures of the human eye.

A longitudinal study of dental caries in the primary teeth of children who suffered from infant malnutrition.

A prospective, four-year longitudinal study of 209 Peruvian children was conducted to evaluate the effect of a single malnutrition episode occurring at infancy (i.e., < 1 year of age) on dental caries in the primary teeth. Children were recruited into the study at age 6-11 months after they had suffered from a malnutrition episode and were thus classified by anthropometry as either: (1) Normal; (2) Wasted (low weight for height); (3) Stunted (low height for age); or (4) Stunted and Wasted (S and W). Eruption of the primary teeth was significantly delayed in all malnourished children; however, the effect of stunting--that is, retarded linear growth--was more pronounced and lasted longer than that of wasting or acute malnutrition (i.e., 2.5 vs. 1.5 years, respectively). By age 4 years, children from group 4 (S and W) showed a significantly higher caries experience in the primary teeth than did those in any of the other three groups. In summary, this longitudinal study has confirmed previous studies in animals and indirect epidemiological evidence which had suggested a cause-effect relationship between early malnutrition and increased dental caries.

PIP: The study was conducted from 1986 through 1990 among 209 children residing in Canto Grande, a poor community located north of Lima, Peru. The children were recruited as infants, aged 6-11 months, from the outpatient population of the Canto Grande Health Center, or from two other hospitals. All children were of full-term gestation and normal birth weight ( 2500 g). Each child was assigned to 1 of 4 study groups ascertained by weight and height measurements, with the National Center for Health Statistics standards used as the reference: 1) normal; 2) wasted, indicating current acute malnutrition; 3) stunted, indicating past or chronic malnutrition; and 4) stunted and wasted, indicating malnutrition soon after birth. The data, composed of 2700 examinations, were analyzed by the Statistical Analysis System (SAS) General Linear Models (GLM) program for computation of ANOVA tables. The mean numbers of teeth at ages 1 and 1.5 years for normal children were significantly higher than those of the children who were either wasted, stunted, or stunted and wasted as infants. At age 2, normal children had significantly more teeth in the mouth than did stunted children and stunted and wasted children. At age 2.5, the number of teeth in the normal children was still significantly higher than in stunted children. At age 4, all 4 groups had their full 20 teeth. At age 4, children who were stunted and wasted during infancy showed a significantly higher number of decayed, extracted, and filled teeth (def) compared with that of the other 3 groups. When grouped into 4 def categories of low, moderate, high, and very high caries experience, the distribution of the 4th group was distinctly different from that of the other 3 groups. 17.2% of stunted and wasted children had a very high caries experience (i.e., def 13) at age 4, significantly higher than that in any of the other 3 groups (i.e., normal 9.8%, wasted 4.4%, and stunted 3.6%, respectively; p 0.001).

Thyroid function and other clinical chemistry parameters in subjects eating iodine-enriched eggs.

Iodine-enriched (IE) eggs are produced by chickens fed a diet containing kelp. These eggs, which contain an average of 711 micrograms iodine/egg, have been reported to reduce plasma cholesterol in humans and laboratory animals. A modified form of these eggs is under consideration for marketing in the United States. 104 hyperlipidaemic subjects were placed on a low-fat diet for 12 wk. Between wk 4 and 12, approximately half of the subjects were randomized to a dietary control group (n = 53) or a group who ingested one IE egg/day in addition to this diet (n = 51). Some subjects in both groups continued in the study for an additional 4-8 wk. No significant adverse clinical effects were observed or reported, with the exception of one subject who reported an allergic-like reaction soon after beginning egg ingestion. All clinical chemistry values remained within normal limits, and comparisons between the egg group and controls were not significant. Three subjects (two in the egg group and one in the control group) had elevated thyroid stimulating hormone levels during the experimental period. All thyroid function tests remained within normal limits in the remaining subjects. Thus, ingestion of one IE egg of the type used in our study appears to be relatively safe and devoid of clinically significant, short-term adverse effects in healthy individuals.

Identification of high intraocular pressure responders to topical ophthalmic corticosteroids.

To locate suitable candidates to study the intraocular pressure (IOP) effects of new ocular steroids, healthy volunteers must be challenged with topically applied steroids to verify that such individuals are indeed high "steroid responders"; that is, they respond with IOP elevations of at least 5 mmHg during a 4- to 6-week challenge with the topically applied steroid. We used first-degree offspring of individuals with primary open-angle glaucoma to develop a model to identify high steroid responders to topical ophthalmic prednisolone. We conducted a prospective, randomized, open-label, placebo-controlled study of prednisolone phosphate 1.0% in which 13 subjects received either topical prednisolone phosphate 4 times daily to the right eye and placebo to the left eye, or vice versa. Baseline evaluations occurred on study Day 0, and follow-up examinations were on Days 7, 14, 21, 28, 35, and 42. The medications were administered continuously for 6 weeks or until the IOP rose > or = 10 mmHg. After the effect of diurnal variation in IOP was taken into account, 4 of the 13 subjects (31%) had a maximum elevation in IOP of 4 mmHg or less, 7 subjects (54%) showed maximum elevations in IOP of 5 to 9 mmHg, and 2 subjects (15%) had a maximum IOP elevation of > or = 10 mmHg. Thus, a cumulative total of 9 subjects (69%) had IOP elevations of at least 5 mmHg and could be classified as moderate to high steroid responders. This model should become useful as a productive source of subjects for studies evaluating the effect on IOP of new ocular steroids.

Pharmacokinetics and bioavailability of the RRR and all racemic stereoisomers of alpha-tocopherol in humans after single oral administration.

The plasma and red blood cell pharmacokinetics and bioavailability of the natural source (RRR, d) and all racemic (all rac, dl) stereoisomers of alpha-tocopherol were studied in 12 men in a double-blind randomized crossover study. Subjects were administered two 400-mg soft-gelatin capsules of either RRR or all rac alpha-tocopherol. Plasma alpha-tocopherol concentrations were determined by high-performance liquid chromatography at various time intervals for up to 96 hours postadministration. Pharmacokinetic modeling of the data showed that alpha-tocopherol was absorbed after a 2 to 4 hour lagtime and maximum plasma concentration occurred from 12 to 14 hours postadministration. There were no significant differences in the Ka, t1/2 a, beta, or t1/2 beta between RRR and all rac. Mean plasma alpha-tocopherol concentrations were greater for RRR than all rac from 10 to 96 hours postadministration and significantly greater at 24 hours (P < .05). The red blood cell alpha-tocopherol concentration from the RRR preparation was significantly greater than from the all rac preparation from 24 to 96 hours postadministration with Cmax for RRR (4.8 micrograms/mL) significantly greater than for all rac (4.0 micrograms/mL, P < .05). The RRR AUC0-96 for both plasma and red blood cells were significantly greater than the all rac AUC0-96 (P < .05) indicating a greater bioavailability of RRR versus all rac alpha-tocopherol. This difference in overall bioavailability was apparently not due to a single pharmacokinetic component.

Immunoregulatory properties of (+)-pentazocine and sigma ligands.

(+)-Pentazocine, phencyclidine, and other sigma ligands including 1,3-di-(o)-tolylguanidine (DTG), (+)-1-propyl-3-(3-hydroxyphenyl) piperidine [(+)-PPP] and haloperidol were investigated for their potential immunoregulatory properties. High concentrations (10(-5) M) of DTG and haloperidol were found to suppress in vitro murine splenocyte natural killer activity while equivalent concentrations of (+)-pentazocine, (-)-pentazocine and (+)-PPP were without effect. In a reciprocal fashion, lower doses (10(-9) M) of DTG enhanced natural killer activity. Sigma ligands were also found to affect in vitro polyclonal immunoglobulin production following mitogen stimulation. Specifically, high concentrations (10(-6) M) of haloperidol significantly (P < 0.001) suppressed pokeweed mitogen (PWM)-stimulated IgG and IgM production, yet enhanced lipopolysaccharide (LPS)-stimulated IgM production by murine splenocytes. Lower concentrations (10(-8) to 10(-10) M) enhanced (two- to fourfold) PWM-induced IgM production and LPS-stimulated IgG and IgM production. At high concentrations (10(-6)), (+)-pentazocine suppressed (P < 0.01) LPS-induced polyclonal IgG and IgM but enhanced (P < 0.01) PWM-induced IgM production. Both DTG and (-)-pentazocine (10(-8) to 10(-10) M) significantly augmented (two- to threefold) LPS-stimulated murine splenocyte production of polyclonal IgM. Intracellularly, (-)-pentazocine (10(-9) M), haloperidol (10(-7) M), DTG (10(-7) M) and (+)-PPP (10(-5) to 10(-9) M) enhanced forskolin (10(-6) M)-induced cAMP production in splenic lymphocytes while (+)-pentazocine was without effect. Collectively, the data suggest functional and biologically relevant sigma receptors on cells of the immune system.

Phentolamine but not propranolol blocks the immunopotentiating effect of cold stress on antigen-specific IgM production in mice orally immunized with sheep red blood cells.

The effect of cold stress on immunocompetence was investigated in mice intragastrically intubated with sheep red blood cells. Cold stress was found to consistently augment total IgG and IgM production by splenic lymphocytes. In addition, antigen-specific IgM production by cultured splenic lymphocytes obtained from cold stressed animals was enhanced compared to unstressed mice. However, serum levels of total and antigen-specific immunoglobulins were suppressed or unaltered following cold stress. The alpha-adrenoceptor antagonist, phentolamine, could block the effects mediated by cold stress while the beta-adrenoceptor antagonist, propranolol, potentiated the action of cold stress. Taken together, the data indicate cold stress-mediated enhancement in immunoglobulin production by orally immunized animals takes place through the activation of alpha-adrenergic pathways. The results also suggest alpha- and beta-adrenergic pathways independently regulate antibody production following oral administration of antigen. These observations illustrate the integrative nature of the immune and neuroendocrine systems.

Evaluation of motivating factors for selecting optometric residency education.

There are now more than 50 accredited optometric residency programs. We sought to learn the primary motivating factors for selecting residency education beyond the traditional 4-year professional program. Questionnaires addressing this issue were sent in May 1990 to directors of all Council on Optometric Education (COE)-accredited residency programs for distribution to currently participating residents. Of the 81 existing residency positions, 61 questionnaires (75 percent) were returned. Three residents (5 percent) accepted positions in residency programs because they had no definite practice plans following graduation. One resident (2 percent) could not take state board examinations and elected to enter a residency program until licensure could be obtained. Fifty-three (85 percent) selected residency education to enhance their clinical skills, and five residents (8 percent) cited other reasons, such as to prepare for a career in optometric education, to enhance long-term career objectives, and to mature. For 50 (83 percent) of the respondents, residency education was their first choice following graduation from optometry school. We conclude that optometric residency education is highly valued as a source of enrichment of clinical skills.

Review of recent pneumococcal infections with attention to vaccine and nonvaccine serotypes.

Conflicting data on the efficacy of the pneumococcal vaccine have continued to evolve. One important aspect of vaccine efficacy is related to the percentage of disease-causing serotypes contained in the vaccines. If disease-causing serotypes were to vary from place to place and population to population, vaccine efficacy would be variable and difficult to assess. We reviewed the literature on serotypic distribution of pneumococcal infection. Percentage of disease-causing serotypes covered by the 14-valent vaccine varied significantly from one study to another. Differences in age, hospital type, and source of isolation showed statistically significant serotypic distribution.

Nosocomial infections in long-term facilities.

We studied the incidence and prevalence of hospital-acquired infections in our intermediate-care units and the Nursing Home Care Unit at the Veterans Administration Medical Center, Johnson City, TN over a 4-year period (1980 through 1983). The global infection rate was 3.86 per 1,000 patient care days. The lower respiratory tract was the most common site of infection, followed by urinary tract infections, skin infections, bacteremia, wound infections, and infections at other sites. The prevalence study conducted by monthly visits over a 1-year period showed similar results. All of our patients were elderly males with multiple underlying diseases and poor performance status. The high incidence of nosocomial infections in chronic-care facilities relates to the poor functional assessment of the patients, which may increase the susceptibility of these patients to develop infections, mainly lower respiratory and cutaneous infections.

Infectivity and antigenicity reduction rates of human rotavirus strain Wa in fresh waters.

The rates of inactivation of human rotavirus type 2 (strain Wa) (HRV-Wa) and poliovirus type 1 (strain CHAT) were compared in polluted waters (creek water and secondary effluent before chlorination) and nonpolluted waters (lake water, groundwater, and chlorinated tap water). Viral infectivity titers were determined by plaque assays, while HRV-Wa antigenicity also was monitored by an enzyme-linked immunosorbent assay. Both viruses persisted longest in lake water and shortest in tap water. The actual inactivation times (i.e., times required for two-log10 reductions of initial viral titers) for the two viruses were significantly different in all waters except tap water. With the exception of the groundwater and secondary effluent results, the HRV-Wa inactivation times in the fresh waters tested were significantly different. Owing perhaps to aggregation, HRV-Wa appeared less susceptible to the effects of chlorine than previously reported for this virus and for the simian rotavirus SA11. HRV-Wa displayed prolonged survival in lake water and groundwater exceeding that previously reported for the SA11 virus. The HRV-Wa infectivity reduction rate (ki) was significantly correlated with the water pH (i.e., as pH increased, ki increased). The water pH may have influenced viral aggregation and thereby HRV-Wa susceptibility to other virucidal factors in the water. Enzyme-linked immunosorbent assay results showed similar inactivation patterns with the most significant reduction in HRV-Wa antigenicity occurring in polluted waters and tap water. In all waters, particularly tap water, infectivity declined at a faster rate than antigenicity. It is proposed that HRV-Wa can be used as a model for future studies of rotaviral persistence in the aquatic environment.

Comparison of arteriography and noninvasive techniques for the diagnosis of carotid artery disease. A statistical analysis of 140 patients.

The carotid arteriograms of 140 patients are compared to noninvasive studies performed on the same group using a SAS statistical package for correlation and identity of information obtained. Chi-square and gamma is calculated for all pairs using total number of arteries and also individual sides of the neck. These reveal significant relationship and identity of information for the arteriograms and the Echoflow (continuous wave Doppler imaging) (Diagnostic Electronic Corp.; Lexington, MA). Discrepancies found between the two groups are a higher frequency of normal findings in the arteriograms and a higher frequency of significant stenoses in the Echoflow group. Differences in frequency of occlusion as a diagnosis are difficult to explain because of the time interval between exams. Other noninvasive studies--OPG, wave-form analysis, supraorbital directional flow--showed poor or no correlation and were unreliable for surgical decisions. A comparison of x-ray interpretations (original report, review interpretation, calculated lumen) reveals statistical identity, although there was a 10 per cent variation in those classified as normal and significant stenosis. No attempt was made to determine whether arteriography or Echoflow was more accurate.

Prognostic indicators including DNA histogram type, receptor content, and staging related to human breast cancer patient survival.

Primary tumors from breast cancer patients were evaluated for the biochemical presence of three steroid cytosolic receptors and by DNA histogram analysis using flow cytometry. These parameters were compared with the histological and staging diagnoses and the patients' survival over a 36-month period. A total of 74 patients with primary breast tumors were evaluated. The breast samples invariably demonstrated a peak population of diploid G0/1 cells which contained 2C amounts of DNA, as determined by mixing experiments using normal human breast tissues or trout erythrocytes as fixed standards. The tumors were classified into five DNA histogram types based on their DNA index distributions established by flow cytometry. These results showed that 21% of the tumors were diploid and indistinguishable from the diploid population of normal breast cells, 8% were hypodiploid, 11% were hypertetraploid, 8% were multiploid, and the remaining 52% were hyperdiploid. The DNA index values varied from 0.78 (hypodiploid) to 2.60 (hypertetraploid). The percentages of S-phase cells were lowest in the diploid and hypertetraploid tumors and highest in the hypodiploid tumors. Among the 24 patients who died during the 36-month follow-up, 92% (22 of 24) were classified in one of the aneuploid groups. Three high-risk groups identified on the basis of survival after 36 months were distinguished: hypodiploid (50% survival); multiploid (43% survival); and hyperdiploid (50% survival). Rates of survival in the diploid and hyperdiploid groups were 87 and 71%, respectively. The hypodiploid group was distinguished by having the lowest mean estrogen cytosolic receptor value [26 +/- 13 (S.D.) fmol/mg], progesterone cytosolic receptor value (13 +/- 15 fmol/ mg), and androgen cytosolic receptor value (less than 1 +/- 1 fmol/mg). In contrast, the diploid tumors had some of the highest receptor values, with mean estrogen cytosolic receptor value equal to 102 +/- 114 fmol/mg, progesterone cytosolic receptor value equal to 74 +/- 110 fmol/mg, and androgen cytosolic receptor value equal to 65 +/- 80 fmol/mg. The lowest survival rates (17% after 36 months) occurred in patients over 67 years of age who had aneuploid tumors, compared to 100% survival in patients over 67 years of age with diploid tumors. Our results demonstrate the value of using flow cytometry and steroid receptor values as supplements to histopathology for the characterization of subgroups of mammary cancer patients. The ability to identify patients with a good prognosis compared to those at high risk of recurrence and death will be valuable in the design of future prospective treatment studies.

A comprehensive power-analytic investigation of research in medical education.

A total of 230 major articles in volumes 55 through 57 of the Journal of Medical Education were reviewed for a comprehensive power-analytic investigation of research in medical education. Three statistical power determinations were made for each of 2,220 reported tests of significance, and the average power for detecting a range of possible treatment effects was calculated for each of the 100 studies subsequently included in the analysis. Among other findings, fully 91 percent of the 100 articles analyzed had less than a 50-50 chance of detecting a "small" treatment effect. Average power figures from similar surveys in other disciplines demonstrate that the problem of low statistical power is not unique to research in medical education. Additionally, the practical consequences of low statistical power are outlined, and workable guidelines for reporting the information necessary for the independent evaluation of published studies are provided.