Management of postoperative pain in maxillofacial surgery.

In this review we describe the evidence base for postoperative analgesia after maxillofacial surgery. We discuss the implications of poorly managed pain, risk factors for the development of severe pain, and pharmacological and non-pharmacological analgesic strategies to manage it.

Management of the airway in maxillofacial surgery: part 2.

Prediction of the difficulty of an airway is unreliable, and failure of one technique of management increases the likelihood of failure of subsequent interventions. Part 2 of this review describes strategies to avoid or mitigate the impact of failure, and the associated airway-related morbidity and mortality.

Management of the airway in maxillofacial surgery: part 1.

In part 1 of this review of management of the airway in maxillofacial surgery we discuss preoperative assessment of the airway, and the practical means to deal with difficulties. We review the evidence for videolaryngoscopy and flexible indirect laryngoscopy, together with surgical access to the airway including tracheostomy, cricothyroidotomy, and submental intubation.

First observation of African tigerfish Hydrocynus vittatus predating on barn swallows Hirundo rustica in flight.

A population of African tigerfish Hydrocynus vittatus from the Schroda Dam, actively prey on barn swallows Hirundo rustica in flight. This behaviour was discovered during a radio telemetry study and documented using a motion picture video camera. These results show that an avivorous diet is a part of the feeding biology of H. vittatus, and may occur in other populations.

Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD.

The effects of methylphenidate on the academic performance and classroom behavior of 45 adolescents with attention deficit hyperactivity disorder were studied. During a 6-week, placebo-controlled medication assessment in the context of a summer treatment program, participants received a double-blind, crossover trial of 3 doses of methylphenidate. Dependent measures included note-taking quality, quiz and worksheet scores, written language usage and productivity, teacher ratings, on-task and disruptive behavior, and homework completion. Group data showed positive effects of methylphenidate on academic measures; however, the greatest benefit came with the lowest dose. Although additional benefit did occur for some participants with higher doses, the largest increment of change usually occurred between the placebo and 10-mg dose. Many adolescents did not experience added benefit with increased dosages, and in some cases they experienced deterioration. Guidelines for assessment of medication effects are discussed.

Deoxynivalenol-induced immunomodulation of human lymphocyte proliferation and cytokine production.

Mycotoxins are a structurally diverse group of secondary metabolites produced by different genera of fungi, and include deoxynivalenol (DON), T-2 toxin, aflatoxin B1 (AFB1) and fumonisin B1 (FB1). Despite widespread human exposure and potent immunomodulation in animals, their effects on the human immune system remain to be defined. In this study, the effect of these toxins on human lymphocyte proliferation was evaluated using the MTT assay. Additionally, the effect of DON on cytokine profiles was measured. A 50% inhibition in cell proliferation was observed with a DON concentration of 216 ng/ml. T-2 toxin was more potent with 50% inhibition between 1 and 5 ng/ml. Negligible effects were observed with AFB1 and FB1, and a mixture of DON with either FB1 or AFB1 did not show any synergistic effects in this assay. Short-term treatment of PHA-stimulated lymphocytes with DON (100, 200 and 400 ng/ml) modulated the kinetics of IL-2, IL-4 and IL-6 production. IL-2 levels were up to 12-fold higher (P<0.05) in comparison to control levels at toxin concentrations of 200 and 400 ng/ml 72 h after treatment. IL-4 levels were only slightly elevated and IL-6 levels were slightly inhibited by these DON concentrations. The kinetics of cytokine production was followed for an extended period of 8-9 days at DON concentrations of 200 and 400 ng/ml. At the lower DON concentration (200 ng/ml), IL-2 levels were elevated 17-25-fold with a concomitant mild elevation in IFN-gamma. Consistent with earlier experiments, IL-6 levels were slightly suppressed by DON at this concentration. At 400 ng/ml, IL-2 levels were again significantly (P<0.05) elevated until 6 days post-treatment, while the effects on IL-4 and IL-6 were less marked. These data suggest DON has potent effects on human lymphocyte cytokine production which merit investigation in exposed human populations.

Television advertising of pharmacy medicines in the United Kingdom.

In the UK pharmacy is often promoted as the first port of call for minor ailments and the pharmacist's armamentarium of products is increasing as further products are reclassified from prescription only control. Non-prescription medicines in the UK can be advertised directly to the public but the advertisements must comply with the law. Some medicines, namely pharmacy can only be sold from pharmacies by, or under, the supervision of a pharmacist. This report describes the major findings of a postal survey of community pharmacists on the subject of advertising of pharmacy medicines and put them into context by outlining the legal and quasi-legal requirements. Further other studies concerning the advertising of non-prescription medicines are discussed in the context of requests for, and sales of, medicines available without a prescription.

Effective school-based mental health interventions: advancing the social skills training paradigm.

Psychotherapeutic interventions with children have not been as successful in practice as laboratory studies suggest. Two weaknesses frequently cited include the failure of treatment gains to generalize to other times and settings and the lack of individualization. Although social skills interventions have inherent appeal and appear appropriate to address many of the social and emotional problems encountered by children and youth, they have not demonstrated effectiveness despite their widespread use. This article outlines four steps to improve social skills interventions that take advantage of the unique environments of schools and increase the likelihood that social skills interventions can achieve individualization and generalization.

Changes in sensitivity of a human myeloid cell line (U937) to metal toxicity after glutathione depletion.

Glutathione (GSH) concentrations have been determined in the human myeloid cell line U937. The effects of modulating GSH concentration on sensitivity to metal toxicity has also been examined. Intracellular concentrations of GSH increased as the cells entered into the cell cycle, reaching a maximum level after 24 hours of cell culture, after which levels declined. Cell concentration was also observed to influence intracellular GSH concentrations. A reciprocal relationship was observed with higher maximum intracellular GSH concentrations being measured in cultures initiated with smaller cell number. The relative toxicity's determined for five metal chlorides were mercury > cadmium > cobalt > zinc > gold. Treatment of cells with N-acetylcysteine (NAC) increased intracellular GSH but had little effect on the absolute or relative toxicity's of the metals. Treatment of cells with L-buthionine-(S-R)-sulfoximine (BSO) depleted intracellular GSH and resulted in increased sensitivity of the cells to gold, 40 fold, cadmium 8 fold and mercury 3 fold.

Mental health services in schools: utilization, effectiveness, and consent.

The integration of education and behavioral health services in schools continues to evolve at a rapid pace. Proponents argue that school-based behavioral health programs have many benefits, including greater access to care and improved effectiveness as compared to clinic- or hospital-based services. While preliminary research is encouraging, in general the claims of school behavioral health are not supported by data. Some critics focus on negative aspects of school behavioral health. They claim that behavioral health is being forced upon students and can cite many examples of counseling and treatment administered to children without parental consent. Utilization, effectiveness, and consent are three topics that deserve a great deal of attention in this emerging field, and are the focus of this review.

Aurintricarboxylic acid inhibits apoptosis and supports proliferation in a haemopoietic growth-factor dependent myeloid cell line.

The actions of the nuclease inhibitor aurintricarboxylic acid (ATA) were investigated in the growth-factor dependent murine myeloid cell line NSF-60. NSF-60 cells proliferate in response to interleukin-3 (IL-3) and undergo apoptosis when deprived of exogenous IL-3, as demonstrated by the appearance of characteristic DNA 'ladders' following agarose gel electrophoresis. ATA, at concentrations between 5 and 25 microM, inhibited apoptosis in growth-factor deprived cells as demonstrated by inhibition of DNA fragmentation and increased cell survival. ATA at a concentration of 25 microM supported proliferation of the cell line in the absence of exogenous growth-factor. Both ATA and IL-3 increased protein phosphorylation in this cell line. ATA and IL-3 induced proliferation was inhibited by the kinase inhibitors genistein, staurosporine and H-7. These findings suggest that, in NSF-60, ATA is not acting exclusively as an endonuclease inhibitor and that protein phosphorylation is involved in the mechanism of action of ATA in this cell line.

Presence of a parasitic nematode (Eustrongylidies sp.) in brown trout (Salmo trutta) from a heavy metal contaminated aquatic ecosystem.

The Flåt Nickel mine at Evje in southern Norway was mined intensively between 1914 and 1945 with little regard for any potential environmental effect. Much of the ore extracted was smelted at a site adjacent to the river Otra south of Evje. Recent studies have revealed heavy metal pollution in the land surrounding the smelter and in water draining from the mine, leading to concern for the aquatic ecosystem in the river Otra. Brown trout were sampled from an uncontaminated lake nine kilometres upstream from the smelter, from the base of the Oddebekken (a tributary draining the mine water into the Otra), from sites immediately upstream and down stream of the smelter and from a site four kilometres down stream from the smelter. Fish from sites adjacent to the smelter and the base of the Oddebekken were smaller than those from the lake and down stream site. Fish from sites adjacent to the smelter and the base of the Oddebekken were more likely to be infected with parasitic nematode Eustrongylidies. At the population but not the individual level the presence of encapsulated parasitic larvae correlated with the concentrations of two metals, Ni and Cu, in fish.

Nickel, cobalt, zinc and copper levels in brown trout (Salmo trutta) from the river Otra, southern Norway.

The Flåt Nickel mine at Evje in southern Norway was mined extensively from 1914 to 1945 with little regard for any potential environmental effect. Much of the ore extracted was smelted at a site adjacent to the river Otra south of Evje. Recent studies have revealed heavy metal pollution in the land surrounding the smelter and in water draining from the mine leading to concern for the aquatic ecosystem in the river Otra. Brown trout were sampled from an uncontaminated lake 9 km upstream from the smelter, from the base of the Oddebekken (a tributary draining the mine water into the Otra), from sites immediately upstream and down stream of the smelter and from a site 4 km down stream from the smelter. Fish from sites adjacent to the smelter and the base of the Oddebekken were smaller than those from the lake and down stream site. Concentrations of the metals were highest in fish sampled where the mine water entered the Otra and gradually decreased in fish further down the river. Fish from the uncontaminated lake had the lowest level of metals.

Ontogeny of humoral immunity in northern elephant seal (Mirounga angustirostris) neonates.

Northern elephant seal (NES) serum concentrations of total immunoglobulin (Ig) G, an IgG sub-class, and an IgM-like protein were determined by capture immunoassay using three monoclonal antibodies with specificities for Ig of members of the Phocidae pinniped family. These assays were calibrated for use with NES sera using affinity column purified Ig. Concentrations of these Ig populations were estimated in adult female sera sampled at two time points during the lactation period, as well as sera from their pups collected during the first 5 weeks after birth. In pups, concentrations of the IgM-like protein was found to increase rapidly post-partum. In some individuals, values reached mean concentrations within 10-14 days. In addition, rapid increases in pup total IgG and IgG sub-class concentrations were also observed. Collectively, these findings suggest that the majority of post-partum increases in serum Ig can be accounted for by de-novo synthesis.

Incidence and predictors of axillary metastasis in T1 carcinoma of the breast.

BACKGROUND: The relatively low incidence (6 to 31 percent) of axillary metastasis in patients with T1 carcinoma of the breast (20 mm or smaller) has led some surgeons to question routine axillary lymphadenectomy (ALND) for patients with no palpable axillary metastases and T1 tumors. This study was undertaken to determine the incidence and predictors of axillary lymph node metastasis in patients with T1 carcinoma of the breast and evaluate the role of sentinel lymphadenectomy (SLND) in this context. STUDY DESIGN: All patients with T1 invasive carcinoma of the breast treated at the John Wayne Cancer Institute between January 1988 and June 1994 were prospectively studied. The study population was comprised of 259 women who had ALND. Of these patients, 114 were part of a pilot study examining the efficacy of SLND. RESULTS: Of the 259 women, 69 (27 percent) had axillary metastasis. Hematoxylin and eosin staining identified nodal involvement in 13 percent of patients with T1a and T1b tumors (10 mm or less) and in 30 percent of patients with T1c tumors (p = 0.002). Other factors such as age, hormone receptor status, presence of ductal carcinoma in situ, histology, ploidy, and S-phase were not significant predictors of involvement. A sentinel node was identified in 73 patients: this node accurately predicted axillary status in 72 patients, was the only positive node in nine of 16 patients with axillary involvement, and was 100 percent predictive of axillary status when the primary tumor was 10 mm or less. Retrospective immunohistochemical staining revealed an additional seven patients with positive sentinel nodes. With this technique, even T1a lesions had a 15 percent incidence of axillary metastasis. CONCLUSIONS: Tumor size is the only accurate predictor of axillary metastasis in patients with T1 carcinoma of the breast. The significant incidence of axillary involvement from T1 tumors mandates accurate staging, even when the tumor is 10 mm or less in size. Examination of a sentinel lymph node may accurately predict axillary metastasis.

Leucocyte interleukin-1-like activity in the common seal (Phoca vitulina) and grey seal (Halichoerus grypus).

Interleukin-1 (IL-1) is an important cytokine with predominantly proinflammatory activities, which have been characterized in many mammals. This study showed the production of IL-1-like bioactivity by cultured seal leucocytes. Increasing concentrations of lipopolysaccharide (LPS) (0-1 micrograms/ml) stimulated an increase in measurable IL-1-like activity in cell culture supernates. This activity increased for the first 24 h after LPS stimulation and the substance responsible had an apparent molecular weight of 17 kDa on gel filtration, similar to that described for other species. Specificity of the bioassay used was confirmed by blocking the bioactivity with an IL-1 receptor antagonist (IL-1 ra).

Improved axillary staging of breast cancer with sentinel lymphadenectomy.

OBJECTIVE: The authors evaluated the effect of intraoperative lymphatic mapping and sentinel lymphadenectomy (SLND) on the axillary staging of patients with carcinoma of the breast. SUMMARY BACKGROUND DATA: The accurate staging of patients with breast cancer is essential to guide management and determine prognosis. The authors previously reported the feasibility and accuracy of SLND in breast carcinoma. Sentinel lymphadenectomy identifies the first ("sentinel") axillary lymph node draining the site of a primary tumor; because this node is the most likely site of axillary metastasis, histopathologic examination of the sentinel node correlates well with examination of the entire axillary contents. The current study compares SLND with standard axillary lymphadenectomy (ALND) for the staging of breast carcinoma. METHODS: The incidence of axillary node metastasis and micrometastasis in SLND and ALND specimens from patients undergoing operative treatment of a primary breast carcinoma was compared prospectively. Multiple sections of each sentinel lymph node in SLND specimens were examined by hematoxylin and eosin (H&E) staining and by immunohistochemical techniques using antibodies to cytokeratin. One or two sections of each nonsentinel lymph node in ALND specimens were examined by routine H&E staining. RESULTS: One hundred thirty-four patients underwent ALND (ALND group), and 162 underwent successful SLND followed by completion ALND (SLND group). Both groups were similar with respect to age (median, 55 and 54 years, respectively), palpable primary tumors (54.5% and 59.3%, respectively), palpable axillary nodes (5.2% and 7.4%, respectively), size of primary tumor (median, 1.5 cm in each group), and total number of axillary lymph nodes examined (median, 19 and 21, respectively). The number of patients with axillary metastasis was 39 (29.1%) in the ALND group and 68 (42.0%) in the SLND group (p < 0.03). Of these, 4 of 39 (10.3%) ALND patients (3.0% of all ALND patients) and 26 of 68 (38.2%) SLND patients (16.0% of all SLND patients) had micrometastasis (< or = 2 mm), a highly significant difference (p < 0.0005) CONCLUSIONS: Sentinel lymphadenectomy with multiple sectioning and immunohistochemical staining of sentinel nodes increases the accuracy of axillary staging in breast cancer and can identify significantly more patients with lymph nodes metastases, especially micrometastases, than can ALND with routine histopathologic processing of lymph nodes.

Identification, characterisation, and measurement of immunoglobulin concentrations in grey (Haliocherus grypus) and common (Phoca vitulina) seals.

Concentrations of macroglobulin, total gammaglobulin, and a gammaglobulin subclass were measured in grey and common seals. In pups, immunoglobulin M (IgM) was found to rise rapidly, concentrations reaching adult values by approximately 14 days postpartum. Total IgG concentrations increased more slowly, only approaching 50% of juvenile and adult male values by 30 days after birth. Concentrations of the IgG subclass did not change significantly postpartum. Total IgG concentrations measured in adult female grey seals sampled during lactation were found to be lower than in males and juveniles. This apparent immunosuppression may be associated with pregnancy.

Serum interleukin-8 in inflammatory bowel disease.

To investigate the relationship between serum concentrations of interleukin-8 (IL-8) and disease activity in inflammatory bowel disease, serum IL-8 concentrations were measured by enzyme-linked immunosorbent assay (ELISA) in 93 patients. Interleukin-8 levels were compared with plasma interleukin-6 (IL-6) levels in 80 of these patients. Interleukin-8 levels were also measured in ten patients with active Crohn's disease, before and after treatment with a defined formula polymeric diet. Of these patients, 70 out of 93 IL-8 concentrations were below the detection limit of the assay. Levels were higher in patients with active ulcerative colitis (median < 20 pg/mL, 75th centile value = 190) compared with inactive disease (median and 75th centile value < 20; P < 0.05). Interleukin-8 concentrations correlated with a combined score for disease severity and extent (P = 0.01). Thirty-eight per cent (8/20) of patients with active Crohn's disease also had high levels of IL-8 but there was no significant difference between active and inactive disease. There was no correlation between serum IL-8 and plasma IL-6; on the contrary, very few patients had raised blood levels of both cytokines. In the diet treated group, serum IL-8 fell significantly after treatment (median = 37 pg/mL, range < 20-4615 before treatment, median < 20, range < 20-104 after treatment; P = 0.03). The results suggest that although IL-8 may be involved in the inflammatory process in inflammatory bowel disease, it is a poor marker of disease activity.