THE ESTABLISHMENT AND OPERATION OF A NERVE BLOCK CLINIC—One Year's Experience at the Los Angeles County Hospital

The Anesthesia Department at the Los Angeles County Hospital established a Nerve Block Clinic for the purpose of alleviating pain and providing helpful information for diagnosis in a number of diseases.During the first year of operation of this Nerve Block Clinic, over one thousand injections were made. The patients who received the injections were referred to the Nerve Block Clinic by staff members who had been apprised of the services offered.     

Comparing effectiveness of top-down and bottom-up strategies in containing influenza

This research compares the performance of bottom-up, self-motivated behavioral interventions with top-down interventions targeted at controlling an "Influenza-like-illness". Both types of interventions use a variant of the ring strategy. In the first case, when the fraction of a person's direct contacts who are diagnosed exceeds a threshold, that person decides to seek prophylaxis, e.g. vaccine or antivirals; in the second case, we consider two intervention protocols, denoted Block and School: when a fraction of people who are diagnosed in a Census Block (resp., School) exceeds the threshold, prophylax the entire Block (resp., School). Results show that the bottom-up strategy outperforms the top-down strategies under our parameter settings. Even in situations where the Block strategy reduces the overall attack rate well, it incurs a much higher cost. These findings lend credence to the notion that if people used antivirals effectively, making them available quickly on demand to private citizens could be a very effective way to control an outbreak.     

PSYCHIATRY IN A BATTLE ZONE

The authors describe the arrival and treatment of 164 severe chronic psychiatric patients who were displaced from the Serbian army‐controlled Jakes psychiatric hospital and off‐loaded on the afternoon of 28th of May, 1992 at the gates of the Psychiatry Clinic in Tuzla. Through analysis of their incomplete medical records, which arrived with the patients in Tuzla, and analysis of their activities during and after the war, they found that 83 of the patients (50%) were males and 147 (89.6%) were admitted to the Psychiatry Clinic in Tuzla. Of the patients, 86 (58.5%) were found to be Serbs. The majority of them were incapable of independent living and required ongoing medical and social care. They were from all regions of Bosnia‐Herzegovina, 81.6% had schizophrenia and 70 (47.6%) were over 50 years of age. For its humanitarian work, its contribution to peace and for the maintenance of the multi‐ethnic Bosnia‐Herzegovina, the Psychiatry Clinic in Tuzla received the Golden Award for Peace from the International Legion of Humanists in May 1998.     

Nerve growth factor mRNA in brain: localization by in situ hybridization

Nerve Growth Factor is a 118 amino acid polypeptide that plays an important role in the differentiation and survival of neurons. The recent discovery that a mRNA that encodes beta Nerve Growth Factor is present in brain suggests that the Nerve Growth Factor gene may not only regulate gene expression of peripheral but also of central neurons. To identify the site(s) of Nerve Growth Factor mRNA production in the brain and to determine which cells express the Nerve Growth Factor gene, the technique of in situ hybridization was employed. A 32P-labeled RNA probe complementary to Nerve Growth Factor mRNA hybridized to cells in the stratum granulosum of the dentate gyrus and the stratum pyramidale of the hippocampus. These observations identify for the first time cellular sites of Nerve Growth Factor gene expression in the central nervous system, and suggest that Nerve Growth Factor mRNA is produced by neurons.     

Vitamin B12 injections: considerable source of work for the district nurse.

Between June and September 1984, district nurses who worked in Coventry were asked to submit returns giving details of the patients for whom they administered vitamin B12 injections. Of 492 patients identified, 382 (78%) were receiving injections more frequently than the recommended three monthly dose of hydroxy-cobalamin. An extra 3751 injections are being administered a year. Four hundred and thirty (88%) of these patients have conditions for which the drug is of proven benefit, so the increased frequency of injections accounts for most of the observed excess. A total of 2000 hours a year of district nurse time is spent with these patients. The nursing service is under increasing strain. Changes in vitamin B12 prescribing alone could make between 600 and 1470 hours available for other patient needs.     

Orthopedic-Metabolic Collaborative Management for Osteoporotic Hip Fracture

Objective: Osteoporotic hip fractures are associated with increased morbidity, mortality, and secondary fractures. Although osteoporosis treatment can reduce future fracture risk, patients often do not receive it. We report results of a coordinator-less fracture liaison service in Israel addressing hip fracture patients. The primary endpoint was attending the Metabolic Clinic. Secondary endpoints included vitamin D measurement, calcium and vitamin D recommendations, initiation of osteoporosis treatment, and mortality 1-year post-fracture.Methods: This prospective study included 219 hip fracture patients who were compared with historical controls. Data on hospitalized patients were collected before and after implementation of a structured protocol for hip fracture patients, led by a multidisciplinary team, without a coordinator.Results: The study included 219 and 218 patients ≥60 years old who were operated on in 2013 and 2012, respectively. Metabolic Clinic visits increased from 6.4 to 40.2% after the intervention (P<.001). Among 14 patients who attended the Clinic in 2012, 85.7% began osteoporosis therapy; among 88 who attended in 2013, 45.5% were treated at the first visit. Vitamin D measurements and calcium and vitamin D supplementation increased postintervention (0.5–80.1%, P<.001; 30.8–84.7%, P<.001, respectively). Patients receiving osteoporosis medications had lower mortality rates than untreated patients (4.3% vs. 21.8%).Conclusion: An Orthopedic-Metabolic team implemented by existing staff without a coordinator can improve osteoporosis care for hip fracture patients. Yet, gaps remain as only 40% had Metabolic Clinic follow-up postintervention, and of these, only half received specific treatment recommendations. Hospitals are encouraged to adopt secondary fracture prevention protocols and continuously improve them to close the gaps between current management and appropriate metabolic assessment and treatment.Abbreviations: CHS = Clalit Health Services; CI = confidence interval; FLS = fracture liaison service; HMO = health maintenance organization; OR = odds ratio     

Oral health and treatment needs in a non-institutionalized elderly population: Experience of a dental school associated geriatric clinic

The purpose of this study is to report oral and dental findings in a population of independent geriatric patients, who were treated at the Geriatric Dental Clinic, School of Dental Medicine, Tel Aviv University. The study group consisted of 221 patients, 31.2% males and 68.8% females. The mean age was 75.3 years. Of the patients, 75% were edentulous. The most frequent complaint was pain associated with wear of dentures, and the most frequent mucosal lesion was traumatic ulcer (51%). Most dentures were of poor quality (77%). The mean denture age was 9.7 years, increasing as the patient's age increased. Denture hygiene was good in 59%, fair in 11% and poor in 30%. The mean number of visits at the Geriatric Clinic was 5.5 per patient.     

NGF induces activation of phospholipase C (membrane bound) in PC12 cells.

The aim of this work is to examine if the membrane-bound Phospholipase C system is correlated with the differentiative action of Nerve Growth Factor in PC12 cells. We found that the activity of membrane-bound Phospholipase C system increased with the presence of Nerve Growth Factor at two different phases. The early phase occurs during the first minutes after the formation of Nerve Growth Factor-receptor complex and it is completed within one hour. The later phase starts two hours after Nerve Growth Factor introduction and lasts for at least a total of 48 hours. The inositol-triphosphate levels measured in intact cells by radioimmunoassay show the same pattern of activation. We think that this dual response to Nerve Growth Factor could be due to either a double separated activation of the same enzyme or the presence of two different forms of membrane-bound Phospholipase C.     

Metabolic control analysis of developing oilseed rape (Brassica napus cv Westar) embryos shows that lipid assembly exerts significant control over oil accumulation

? Metabolic control analysis allows the study of metabolic regulation. We applied both single- and double-manipulation top-down control analysis to examine the control of lipid accumulation in developing oilseed rape (Brassica napus) embryos. ? The biosynthetic pathway was conceptually divided into two blocks of reactions (fatty acid biosynthesis (Block A), lipid assembly (Block B)) connected by a single system intermediate, the acyl-coenzyme A (acyl-CoA) pool. Single manipulation used exogenous oleate. Triclosan was used to inhibit specifically Block A, whereas diazepam selectively manipulated flux through Block B. ? Exogenous oleate inhibited the radiolabelling of fatty acids from [1-(14) C]acetate, but stimulated that from [U-(14) C]glycerol into acyl lipids. The calculation of group flux control coefficients showed that c. 70% of the metabolic control was in the lipid assembly block of reactions. Monte Carlo simulations gave an estimation of the error of the resulting group flux control coefficients as 0.27?±?0.06 for Block A and 0.73?±?0.06 for Block B. ? The two methods of control analysis gave very similar results and showed that Block B reactions were more important under our conditions. This contrasts notably with data from oil palm or olive fruit cultures and is important for efforts to increase oilseed rape lipid yields.     

A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome

Surgery is the definitive treatment for carpal tunnel syndrome. Conservative treatments, such as wrist splinting and steroid injections, are also effective for the relief of carpal tunnel symptoms, but their use remains controversial because they only offer long-term relief in a minority of patients. A prospective study was performed to assess the role of steroid injections combined with wrist splinting for the management of carpal tunnel syndrome. A total of 73 patients with 99 affected hands were studied. Patients presenting with known medical causes or muscle wasting were excluded. Diagnosis was made clinically and electrodiagnostic studies were performed only when equivocal clinical signs were present. Each patient received up to three betamethasone injections into the carpal tunnel and wore a neutral-position wrist splint continuously for 9 weeks. After that period, symptomatic patients received an open carpal tunnel release, and those who remained asymptomatic were followed up regularly for at least 1 year. Patients who relapsed were scheduled for surgery. At a minimum follow-up of 1 year, seven patients (9.6 percent) with 10 affected hands (10.1 percent) remained asymptomatic. This group had a significantly shorter duration of symptoms (2.9 months versus 8.35 months; p = 0.039, Mann-Whitney test) and significantly less sensory change (40 percent versus 72 percent; p = 0.048, Fisher's exact test) at presentation when compared with the group who had surgery. It is concluded that steroid injections and wrist splinting are effective for relief of carpal tunnel syndrome symptoms but have a long-term effect in only 10 percent of patients. Symptom duration of less than 3 months and absence of sensory impairment at presentation were predictive of a lasting response to conservative treatment. It is suggested that selected patients (i.e., with no thenar wasting or obvious underlying cause) presenting with mild to moderate carpal tunnel syndrome receive either a single steroid injection or wear a wrist splint for 3 weeks. This will allow identification of the 10 percent of patients who respond well to conservative therapy and do not need surgery.     

Use of vitamin B12 injections among elderly patients by primary care practitioners in Ontario

BACKGROUND: Excess use of parenteral vitamin B12 has been reported from audits of clinical practices. The authors assessed the use of vitamin B12 injections in patients aged 65 years and over in Ontario. METHODS: A cross-sectional analysis was conducted that included all elderly people covered by the Ontario Health Insurance Plan who received insured services from general practitioners or family physicians (GP/FPs). For each practice the proportion of elderly patients who received regular vitamin B12 injections between July 1996 and June 1997 was calculated. The frequency of injections was determined for each patient receiving regular B12 replacement. RESULTS: Of the 1,196,748 elderly patients (mean age 74.8 [standard deviation 6.8], 58.0% female) treated by 14,177 GP/FPs, 23,651 (2.0%) received regular B12 injections. The rate of B12 injections per patient, standardized for age and sex, varied between practices (range 0%-48.6%). Although no authoritative sources support the practice, 3303 (19.8%) of the 16,707 patients receiving long-term parenteral therapy had, on average, overly frequent injections (more than 1 injection every 4 weeks). For 76 (12.3%) of the 617 practices with 10 or more patients receiving regular vitamin B12 injections, the mean injection frequency was greater than once every 4 weeks. The proportion of patients in these 617 practices who received overly frequent injections varied extensively (0%-100%). INTERPRETATION: Our findings indicate that some primary care physicians in Ontario administer unnecessary vitamin B12 injections to elderly patients.     

Peripheral neuropathy following intentional inhalation of naphtha fumes.

Two adolescent native Canadians who presented with peripheral neuropathy secondary to the abuse of volatile hydrocarbons are described. They were initially thought to have been sniffing leaded gasoline fumes, but public health investigation revealed that they had been sniffing naphtha fumes. Naphtha contains a significant amount of n-hexane, a known inducer of neuropathy. Nerve conduction studies and nerve biopsy confirmed the diagnosis of naphtha abuse. These cases emphasize the need to specifically identify the formulation of hydrocarbons being abused.     

Efficacy of intra-lesional injections of meglumine antimoniate once a week vs. twice a week in the treatment of cutaneous leishmaniasis caused by L. tropica in Iran: A randomized controlled clinical trial

Treatment of Cutaneous leishmaniasis (CL) is based on using antimoniate derivatives; patients’ compliance for systemic injections is low due to the pain and systemic complications. In this randomized open trial, the efficacy of intra-lesional (IL) injections of meglumine antimoniate (MA) once a week vs. twice a week in the treatment of Anthrpoponothic CL caused by L. tropica was studied. Eligible volunteer patients were selected according to inclusion/exclusion criteria. The included patients were randomly allocated to receive IL-MA injections once a week or twice a week. The primary outcome was set as complete healing of the lesion(s), and defined as complete re-epithelialization and absence of induration in the lesions. A total of 180 parasitologicaly proven CL patients caused by L. tropica were recruited, 90 patients were treated with weekly IL-MA and 90 patients received IL-MA twice a week. The complete cure was 87.9% vs. 89.2% in the group received weekly and twice a week IL-MA injections, respectively (P = 0.808). Patients’ compliance was acceptable and side effects were limited to a few local allergic reactions to MA. Median time to healing was significantly shorter in patients who received IL-MA twice a week (median ± SE) 37±3.8, (CI: 29.6–44.4) days compared to whom received IL-MA once a week 60±2.3, (CI: 55.6–64.5) days (P< 0.001), however the number of injections was higher in group who received IL-MA twice a week (12 vs. 9 injections). In conclusion, the rate of cure in the group of CL patients with IL-MA twice a week was not significantly different from the group who received IL-MA once a week shorten, but the duration of healing was shorter in the group who received IL-MA twice a week while the group received more injections so is recommended to use IL-MA once a week due to the fact the compliance is acceptable with limited side effects.Clinical Trial Registration: IRCT20081130001475N13; https://en.irct.ir/.     

Intrapericardiac injections of algogenic chemicals excite primate C1-C2 spinothalamic tract neurons

Extracellular potentials of 38 C1-C2 spinothalamic tract (STT) neurons in anesthetized monkeys (Macaca fascicularis) were examined for responses to intrapericardiac injections of an algogenic chemical mixture (adenosine, 10(-3) M; bradykinin, prostaglandin E(2), serotonin, histamine, each 10(-5) M). Chemical stimulation of cardiac/pericardiac receptors increased activity of 21 cells, decreased activity of 5 cells, and did not change activity of 12 cells. Cells excited by chemical stimuli received input from noxious mechanical stimulation of somatic fields; most receptive fields included the neck, inferior jaw, or head areas. Nerve ablations in 11 cells excited by intrapericardiac chemicals showed that cardiac input activated by algogenic chemicals traveled primarily in vagal afferent fibers to C1-C2 segments; phrenic or cardiopulmonary sympathetic inputs were predominant in 2 of 11 cells. These results supported the concept that activation of cardiac vagal afferents might lead to the production of referred pain sensation in somatic fields innervated from high cervical segments.     

Etiology and resistance patterns of respiratory isolates in Kenyan adults with AIDS from slum population

We investigated regularly swabs of adults dispenzarised at Mary Immaculate Clinic of Trnava University in Nairobi providing free health care for about 50 000 population of Mukuru Slums. 20 patients who were treated for AIDS by our clinic (those who started HAART before Free National AIDS Cooperation Programme - NASCOP) were assessed after 1, 2 and 3 years (18 of 20 completed the survey, other 2 loss of follow up, probably died. Exposure to other molecules can select resistant mutants. Previous exposure to TMP/SMX was similar in both groups and therefore was not responsible for the difference between resistance patterns.     

Enfuvirtide administration in HIV-positive transgender patient with soft tissue augmentation: US evaluation

Enfuvirtide is a large protein that should be injected subcutaneously to ensure an appropriate absorption. Here we report the case of a transgender HIV-positive patient receiving enfuvirtide with an individualized background regimen of antiretroviral drugs, who had previously undergone liquid silicone oil injections. We performed US scan to detect silicone-free areas for following enfuvirtide injections. US can be useful in the correct management of those patients with liquid silicone oil soft tissue augmentation who require subcutaneously injected drugs.     

The Effect of Urography on Renal Function in Patients with Multiple Myeloma

Reports in the medical literature of seven patients with multiple myeloma who died of acute renal failure following intravenous urography prompted a study of 39 patients with multiple myeloma who were subjected to intravenous urography at the Cleveland Clinic from 1940 to 1959. Four developed acute renal failure and two died within three weeks. All four revealed evidence of renal damage, or insufficiency, or both prior to urography. Thirty-five patients, 15 of whom had renal damage, had no untoward reaction to intravenous urography. These observations suggest that urography is associated with a small but definite risk in patients who have multiple myeloma and renal involvement.     

Impact of a Reference Center on Leprosy Control under a Decentralized Public Health Care Policy in Brazil

ObjectiveWe evaluated the profile of patients referred to the Fiocruz Outpatient Clinic, a reference center for the diagnosis and treatment of leprosy in Rio de Janeiro, RJ, and analyzed the origins and outcomes of these referrals.MethodsThis is an observational retrospective study based on information collected from the Leprosy Laboratory database at Fiocruz, Rio de Janeiro, RJ, Brazil. A total of 1,845 suspected leprosy cases examined at the reference center between 2010 and 2014 were included. The originating health service referrals and diagnostic outcomes were analyzed as well as the clinical and epidemiological data of patients diagnosed with leprosy.ResultOur data show that the profile of the patients treated at the Clinic has changed in recent years. There was an increase in both the proportion of patients with other skin diseases and those who had visited only one health service prior to our Clinic. Among the total 1,845 cases analyzed, the outcomes of 1,380 were linked to other diseases and, in 74% of these cases, a biopsy was not necessary to reach a diagnostic conclusion. A decrease in new leprosy case detection among our patients was also observed. Yet, among the leprosy patients, 40% had some degree of disability at diagnosis.ConclusionThe results of the present study demonstrated the importance of referral centers in support of basic health services within the decentralization strategy. But, the success of the program depends on the advent of new developmental tools to augment diagnostic accuracy for leprosy. However, it should be emphasized that for new diagnostic methods to be developed, a greater commitment on the part of the health care system regarding research is urgently needed.     

Continuous narcotic infusions for relief of postoperative pain.

Relief of acute pain after surgery or trauma is still inadequate in many centres, most patients being treated with intermittent intramuscular injections of narcotic analgesics. Over the past three years continuous intravenous narcotic infusions have been used at this hospital to treat postoperative pain; recently a system has been devised whereby an hourly dose is given and the dispenser recharged every hour. The method used is cheap and reliable, and signs of overdosage may be easily checked by nursing staff. Side effects rarely occur. Fifty patients who had received intravenous infusions after undergoing major abdominal surgery were sent a questionnaire to assess postoperative pain, and the results were compared with those from 50 matched controls who had received intramuscular injections. Of those who replied, only four patients who had received the infusion had found the pain distressing compared with 13 controls. Continuous narcotic infusions are most effective in relieving postoperative pain and may be given cheaply and reliably.     

A malaria vaccine based on the polymorphic block 2 region of MSP-1 that elicits a broad serotype-spanning immune response

Polymorphic parasite antigens are known targets of protective immunity to malaria, but this antigenic variation poses challenges to vaccine development. A synthetic MSP-1 Block 2 construct, based on all polymorphic variants found in natural Plasmodium falciparum isolates has been designed, combined with the relatively conserved Block 1 sequence of MSP-1 and expressed in E.coli. The MSP-1 Hybrid antigen has been produced with high yield by fed-batch fermentation and purified without the aid of affinity tags resulting in a pure and extremely thermostable antigen preparation. MSP-1 hybrid is immunogenic in experimental animals using adjuvants suitable for human use, eliciting antibodies against epitopes from all three Block 2 serotypes. Human serum antibodies from Africans naturally exposed to malaria reacted to the MSP-1 hybrid as strongly as, or better than the same serum reactivities to individual MSP-1 Block 2 antigens, and these antibody responses showed clear associations with reduced incidence of malaria episodes. The MSP-1 hybrid is designed to induce a protective antibody response to the highly polymorphic Block 2 region of MSP-1, enhancing the repertoire of MSP-1 Block 2 antibody responses found among immune and semi-immune individuals in malaria endemic areas. The target population for such a vaccine is young children and vulnerable adults, to accelerate the acquisition of a full range of malaria protective antibodies against this polymorphic parasite antigen.