Australian Antigen and Autoantibodies in Chronic Hepatitis

The sera of 110 patients with chronic hepatitis and adequate controls were examined for antibodies to smooth muscle (S.M.), mitochondria (M.), and for antinuclear factors by the immunofluorescence method, and for Australia (Au(1)) antigen by a modified micro-Ouchterlony immunodiffusion technique. Twelve out of 13 patients with primary biliary cirrhosis had M. antibodies, two had antinuclear factor, and none had Au(1) in their sera. In chronic aggressive hepatitis 23·5% of the sera contained antinuclear factor, 13% S.M. antibodies, 10·5% M. antibodies, and 22% Au(1) antigen. Of the 12 patients with chronic persistent hepatitis, one had antinuclear factor, one S.M. antibodies, and three Au(1) antigen.The most striking finding was a mutual exclusion between Au(1) antigen and M. and S.M. antibodies. None of the 33 patients with one or the other form of chronic hepatitis and M. or S.M. antibodies had Au(1) antigen; 22 out of 77 (28%) patients without such antibodies were positive.     

Decrease in the Incidence of Hepatitis in Dialysis Units associated with Prevention Programme

A prospective survey of hepatitis in more than two-thirds of the dialysis units in the United Kingdom since January 1968 shows that after a prevention and control programme was started in 1970 the rising incidence of hepatitis B was halted. The programme has continued, with a sustained decline in the incidence among patients from 4·9% in 1970 to 1·4% in 1972 and among staff from 1·3% in 1970 to 0·4% in 1972.     

Hepatitis B in retreat from dialysis units in United Kingdom in 1973. Public Health Laboratory Service Survey.

A prospective study of hepatitis in over two-thirds of the dialysis units in the United Kingdom has continued since 1968. After the introduction of a control and preventive programme in 1970 there was a sustained decline in the incidence of hepatitis B to the low level of 0-3% among patients and 0-1% among staff in 1973--a greater than tenfold decrease in four years. Comparisons with data from other countries suggest that the almost complete elimination of hepatitis B from dialysis units in the UK was due to the preventive programme.     

Prevalence of Hepatitis B Antigen and Antibody in Prostitutes

We investigated the prevalence of hepatitis B antigen (HBAg) and antibody (HBAb) in 293 prostitutes and in 379 pregnant women of similar age and of low socioeconomic level, who served as controls. HBAg was found in 4·4% of prostitutes and 3·4% of controls. The prevalence of HBAb was significantly higher (P <0·001) in prostitutes (56·7%) than in controls (24·5%). The prevalence of HBAb was clearly age-dependent in both groups. Evidence of hepatitis B virus infection significantly increased with the number of years in prostitution. The evidence of increased infection rates among prostitutes and their distribution support the hypothesis that hepatitis B infection is sexually transmitted.     

Is dialysis hypotension caused by an abnormality of venous tone?

The role of peripheral vascular tone in the development of hypotension induced by dialysis was investigated in eight patients undergoing haemodialysis with acetate or bicarbonate buffered fluid. Each patient had two sessions of dialysis with acetate fluid and two with bicarbonate fluid in the order acetate, bicarbonate, bicarbonate, acetate or bicarbonate, acetate, acetate, bicarbonate. Mean arterial blood pressure fell at a mean rate of 3·9 mm Hg/hour during dialysis with acetate fluid and 1·4 mm Hg/hour during dialysis with bicarbonate fluid. The rate of fall was significantly greater during dialysis with acetate fluid compared with bicarbonate fluid. Heart rate increased by a mean rate of 2·6 beats/min/hour during dialysis with both acetate and bicarbonate fluid. Vascular resistance in the forearm increased at a rate of 3·6 units/hour during dialysis with acetate fluid and 4·5 units/hour during dialysis with bicarbonate fluid, but the venous bed of the forearm dilated. The index of venous tone rose at a mean rate of 0·23 ml/100 dl over 40 mm Hg/hour during dialysis with acetate fluid and 0·20 ml/dl over 40 mm Hg/hour during dialysis with bicarbonate fluid.Inappropriate peripheral venodilatation may be important in the development of hypotension induced by dialysis.     

Serum and Urinary Folate in Liver Disease

During the active phase of viral hepatitis urinary folate loss was found to be 8·0 to 48·3 (mean 31·1) μg./day, compared with a normal urinary folate excretion of 0·1 to 18·0 (mean 9·5) μg./day. In cirrhosis and cardiac failure with congestive hepatomegaly the corresponding values were 25·8 to 55·0 (mean 35·7) μg./day and 2·5 to 61·6 (mean 26·9) μg./day, respectively. Urinary folate loss may be a significant factor in the aetiology of folate deficiency of chronic liver disease, particularly when dietary intake is poor.After prolonged dialysis in Visking casing urinary folate was almost totally dialysable, but an appreciable fraction of serum folate was not, even after 72 hours. The dialysable (free) folate fraction of serum and urine disappeared maximally during the first six hours'' dialysis, and was virtually cleared after 24 hours'' dialysis; clearance curves in normal individuals and in liver disease were comparable. The non-dialysable serum folate fraction was of similar magnitude in all subjects studied, in spite of marked variation in total folate, and probably represented protein-bound folate.     

One Year's Experience in a Ministry of Health Dialysis Centre

A 10-bed dialysis unit, opened at the London Hospital in 1968, admitted 37 patients during its first year of operation. The aims of the unit were to prepare patients for renal transplantation and to provide instruction for dialysis treatment at home. A total of 2,012 days were spent in hospital, the average intervals between admission, the first dialysis, and discharge being 23·8 and 20 days, respectively. The overall number of readmissions was 1·5 per patient. These figures, together with the increasing number of patients accepted for such treatment, indicate the considerable number of supporting hospital beds, as well as medical and technical staff, required to maintain a dialysis unit.     

Surgical Treatment of Severe Attacks of Ulcerative Colitis,with Special Reference to the Advantages of Early Operation

The management and outcome of 258 severe attacks of ulcerative colitis from 1952 to 1969 has been reviewed. If remission did not occur during an initial course of intensive medical treatment, including administration of corticosteroids, operation (generally ileostomy with proctocolectomy or subtotal colectomy) was performed. This took place some 12 to 17 days after admission as a rule during the years 1952-63, but usually within five to seven days from 1964 to 1969.Roughly half the attacks underwent spontaneous remission during the two periods, but the medical mortality was 4·8% in the former and 0·7% in the latter, the operative mortality 20·0 and 7·0%, and the overall mortality 11·3 and 4.5% respectively. The lowering of the mortality was particularly striking in severe first attacks and in severe attacks in patients over 60 years of age.Perforation of the colon was found in 21 cases, or nearly 20% of 112 patients coming to operation during attacks, being commoner in the first period (32·5%) than in the second (11·1%). The immediate mortality of all such operations was 11·6%; in cases with perforation it was 28·6%.Acute colonic dilatation was observed in 28 cases. All but one were treated by emergency colectomy, at which the colon was noted to be perforated in 11. The mortality of these operations was 18·5%.Follow-up of the 140 patients who survived without coming to operation during their attacks shows that 52 (37·1%) subsequently underwent surgical treatment either during further attacks or electively.Though all 258 attacks were thought at the time to be due to ordinary ulcerative colitis, subsequent pathological examination of operative specimens derived from 98 patients who came to urgent or subsequent operation during the 1964-9 period revealed that the lesion in the large bowel was Crohn''s disease in 17 instances.     

Is Screening for Cancer Worth While? Results from a Well-woman Clinic for Cancer Detection

1,768 women were screened for breast and cervical cancer in the year May 1968 to April 1969. Clinical examination followed the completion of a simple questionary. Investigations included thermography and mammography of the breast and cytology of the cervical and vaginal smears. Breast cancer was detected in 15 patients (0·85% or 8·5 per 1,000) and none was aware of any abnormality though 13 of the tumours were clinically palpable. Carcinoma in situ of the cervix was found in a further eight (0·45% or 4·5 per 1,000).     

Immigrant Mother and Her Child

The health risks of 1,164 immigrant Asian mothers and their babies in Bradford were compared with those of an indigenous group from obstetric data collected between 1965 and 1969. The average number of children for families in each group in 1969 were 3·31 and 2·33, respectively; 43·9% of 2,206 Asian mothers delivered in 1968-9 had less than a one-year interval between pregnancies. In 1965 the perinatal mortality rates for the two groups were 48·6 and 26·6, respectively, whereas in 1969 the corresponding figures were 26·8 and 25·5, respectively. Though the risks to maternal and child health of Asians are greater, Asian families are more stable and their children have a more secure upbringing than non-Asian children. However, Asian children need increased environmental stimulus in early childhood to prevent educational disadvantages at a later age.     

Continuous Intravenous Infusion of Small Doses of Insulin in Treatment of Diabetic Ketoacidosis

Continuous intravenous infusion of small amounts of insulin has been used in the management of a series of patients with diabetic ketoacidosis. In 13 patients with a plasma glucose level on admission of 725 mg/100 ml (± 80 S.E. of mean) and an arterial pH of 7·07 ± 0·05 a mean loading dose of 6·5 ± 0·82 units of soluble insulin was administered intravenously, and thereafter a sustaining infusion of 6·5 ± 0·82 U/hr was continued until ketosis was corrected and the plasma glucose fell below 300 mg/100 ml. The total insulin dose needed to achieve this was 39·2 ± 6·6 units given over a 3 to 10-hour period. Plasma insulin was measured in patients who had not previously received insulin and the mean level at an infusion rate of 4 U/hr was 75·6 ± 8·0 μU/ml. Plasma glucose fell at a regular rate of 101 ± 11 mg/100 ml/hr, and ketosis improved in parallel. Plasma potassium was well maintained throughout treatment. This regimen of treatment was clinically effective and simple to follow.     

Coronary Care Unit in a General Medical Ward

A five-bedded coronary care unit has been set up within a general medical ward without the provision of extra medical or nursing staff. During 30 months 1,000 patients were admitted. Sixty-three developed cardiac arrest; 28 were resuscitated successfully initially; and 18 were eventually discharged. The corresponding figures for the 28 patients with ventricular fibrillation treated by direct current defibrillation were 20 and 12 respectively. The mortality rate during the first three days (the usual length of stay in the unit) was 8·9% compared with 9·7% after transfer to the general ward. It is suggested that these results are comparable with those from more highly staffed purpose-built units.     

Biological Availability of Digoxin from Lanoxin Produced in the United Kingdom

Though established quality control standards were maintained, the bioavailability of digoxin from Lanoxin tablets produced in the United Kingdom fell in 1969, and was restored in 1972. After 1·5 mg doses of representative batches, tablets made between 1969 and 1972 produced mean values for area under the 50 hours plasma concentration/time curve of 36·6 ng/ml/hr and four-day urinary excretion of 340 μg, compared with respective values of 67·5 ng/ml/hr and 696 μg for recently produced tablets.After 0·5 mg doses of four recent independently produced batches of Lanoxin tablets no significant between-batch difference was found for area under the plasma concentration/time curve or cumulative urinary excretion.Absorption of digoxin from batches of Lanoxin manufactured since May 1972 is uniform and consistent. Content uniformity is an inadequate measure of tablet quality, and consistent digoxin bioavailability cannot be ensured by existing regulations.     

Effects of Dementia-Care Mapping on Residents and Staff of Care Homes: A Pragmatic Cluster-Randomised Controlled Trial

Background

The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention.

Methods

Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents’ neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects.

Results

34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI −2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects.

Conclusions

Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect.

Trial Registration

Dutch Trials Registry NTR2314.     

Hepatitis with Australia antigenemia following renal transplantation

Over a seven-year period 18 of 125 patients who underwent renal transplantation developed hepatitis. Acute hepatic necrosis occurred in two, chronic aggressive hepatitis progressing to posthepatitic cirrhosis in eight, chronic persistent hepatitis in five, acute hepatitis with recovery in two and cholestatic hepatitis in one. Hepatic failure was the cause of death in four and a major contributing factor in three. Fifteen of the 18 were of blood Group A. After renal transplantation Australia antigen (Au) was present in the blood of 12 of the 15 patients with hepatitis who were tested and in one of 38 patients without clinical evidence of liver disease. Once present, Au persisted in all patients but one. Particles measuring 210 to 250 Å, characteristic of Au, were seen in liver cells by electronmicroscopy in nine of the 10 patients examined who had hepatitis with Australia antigenemia, but they were not seen in the two patients studied with Au-negative hepatitis.     

Hepatitis-associated antigen in sporadic cases of acute viral hepatitis

Serum specimens collected during the period from September 1970 to April 1971 from hospitalized patients and apparently healthy staff members at risk were tested for the presence of hepatitis-associated antigen (HAA) by the parallel use of three techniques: the complement fixation test, crossover-electrophoresis and immuno-electronmicroscopy.Out of a total of 204 persons investigated 63 (30.9%) were found to harbour the antigen. The HAA-positive sera originated almost exclusively from sporadic cases of acute viral hepatitis (clinically diagnosed as “infectious hepatitis” or “serum hepatitis”). The great majority of the hepatitis cases studied had a history of drug addiction.     

Australia (Hepatitis-Associated) Antigen in Patients Attending a Venereal Disease Clinic

A total of 1,650 patients attending the venereal disease department at St. Mary''s Hospital, London, have been tested for Australia antigen. Twenty-three positive results were obtained, or 1·39%, which is more than 10 times the rate noted by others in blood donor populations in the U.K. and U.S.A. The positive rates among female patients and European male heterosexual patients were 0·36% and 0·19% respectively. High rates were obtained for homosexual patients (3·8%) and non-European heterosexual patients (3·1%). The reasons for the higher rates found in these groups merit further study.     

The isolation of neurophysin-I and -II from bovine pituitary neurosecretory granules separated on a large scale from other subcellular organelles. Demonstration of slow equilibration of neurosecretory granules during centrifugation in a sucrose density gradient

1. An improved procedure for the isolation of neurosecretory granules from the posterior lobe of the bovine pituitary gland is described. 2. Of the total oxytocic and pressor activities present in the original tissue 80% was sedimentable. 3. The granules were separated from mitochondria by prolonged centrifugation in a sucrose density gradient. During a sedimentation period of 5hr. the granules moved progressively into denser regions of the gradient and the mitochondria remained at the top. 4. The biological activities of the granules were measured: the oxytocic activity was 11·56±1·63 and the pressor activity was 15·60±3·91 units/mg. of protein. 5. A protein was isolated from a lysate of granules prepared from 40 pituitary glands. Amino acid analysis showed that it consisted of a mixture of neurophysin-I and neurophysin-II in equal proportions. It accounted for 60% of the soluble granule protein and for 50% of the total granule protein. 6. The neurophysins present in the granules are associated with 19·1 units of oxytocic and 21·1 units of pressor activity/mg. of protein. 7. Starch-gel electrophoresis revealed the presence of both neurophysins in extracts of 15 pituitary glands studied individually. 8. We conclude that the polypeptide hormones, oxytocin and [8-arginine]-vasopressin, are normally closely associated with the two neurophysins within neurosecretory granules of the pituitary gland.     

Serologic studies in viral hepatitis]

Comparative studies of sera from 710 patients with viral hepatitis and contacts were made during the 1958-1973 period for hepatitis antigens (Au antigen and the Botevgrad antigen). The percentage of virus hepatitis in patients positive for the Au and the Botevgrad antigens varied in different years. The percentage of those positive for the Au antigen ranged from 50 in 1958 to 8.8 in 1970-1971, while for the Botevgrad antigen--it ranged from 32.6 in 1962-1963 to 6.1 in 1966. In case of contacts, mostly in the 7-14 age group the sera positive for the Au antigen were found in a low percentage (2.09 percent) of cases; as to the Botevgrad antigen, 20 persons were found positive during various epidemics (55 percent). Simultaneous presence of both antigens was found in 4 of the 710 patients with virus hepatitis (0.56 percent), and in 2 of 431 contacts (0.46 percent).     

Response of Asthmatics to Isoprenaline and Salbutamol Aerosols Administered by Intermittent Positive-pressure Ventilation

The bronchodilator and cardiac effects produced by aerosols of 0·5% isoprenaline and of 0·25, 0·5, and 1% salbutamol administered in 40% oxygen by intermittent positive-pressure ventilation were compared in 24 asthmatic patients. Isoprenaline and salbutamol in concentrations of 0·5% were equipotent in peak bronchodilator effect; salbutamol was superior in total bronchodilator effect and duration of average effect, but the peak bronchodilator effect occurred earlier after isoprenaline. Significantly greater tachycardia was produced by 0·5% isoprenaline than by the same concentration of salbutamol. The 0·25, 0·5, and 1% concentrations of salbutamol had about the same peak bronchodilator effect, but there was a stepwise increase in total effect and duration of average effect in relation to the concentration used. A similar stepwise increase in heart rate was also noted, but with all concentrations this was significantly less than with 0·5% isoprenaline. It was concluded that a 0·5% solution of salbutamol, which provided maximal bronchodilatation without important tachycardia, was therapeutically superior to the other three treatments.