Patient education programme on immunotherapy in multiple sclerosis (PEPIMS): a controlled rater-blinded study.

OBJECTIVE: To investigate the effectiveness of a multi-component evidence-based education programme on disease modifying therapies in multiple sclerosis. DESIGN: Controlled trial with two consecutive patient cohorts and a gap of two months between cohorts. SETTING: Three neurological rehabilitation centres. SUBJECTS: Patients with multiple sclerosis within rehabilitation. INTERVENTIONS: Control group (CG) participants were recruited and received standard information. Two months later, intervention group (IG) participants were recruited and received a six-hour nurse-led interactive group education programme consisting of two parts and a comprehensive information brochure. MAIN MEASURES: Primary endpoint was "informed choice", comprising of adequate risk knowledge in combination with congruency between attitude towards immunotherapy and actual immunotherapy uptake. Further outcomes comprised risk knowledge, decision autonomy, anxiety and depression, self-efficacy, and fatigue. RESULTS: A total of 156 patients were included (IG=75, CG=81). The intervention led to significantly more participants with informed choice (IG: 47% vs. CG: 23%, P=0.004). The rate of persons with adequate risk knowledge was significantly higher in the IG two weeks after the intervention (IG: 54% vs. CG: 31%, P=0.007), but not after six months (IG: 48% vs. CG: 31%, P=0.058). No significant differences were shown for positive attitude towards disease modifying therapy (IG: 62% vs. CG: 71%, P=0.29) and for disease modifying therapy status after six months (IG: 61.5% vs CG: 68.6%, P=0.39). Also no differences were found for autonomy preferences and decisional conflict after six months. CONCLUSION: Delivering evidence-based information on multiple sclerosis disease modifying therapies within a rehabilitation setting led to a marked increase of informed choices.

Seeking the best training model for difficult conversations in neonatology.

OBJECTIVES: We hypothesize that a formal simulation curriculum prepares neonatology fellows for difficult conversations better than traditional didactics. METHODS: Single-center neonatology fellowship graduates from 1999 to 2013 were sent a retrospective web-based survey. Some had been exposed to a Difficult Conversations curriculum (simulation group), others had not (no simulation group). The simulation group participated in one workshop annually, consisting of lecture, simulation, and debriefing. Scenarios were customized to year of training. Epoch comparisons were made between the simulation and no simulation groups. RESULTS: Self-rated baseline effectiveness at discussing difficult topics was not different. The simulation group reported more supervised family meetings and feedback after fellow-led meetings. Simulations were rated very positively. The simulation group reported increased comfort levels. Strategic pause and body positioning were specific communication skills more frequently acquired in the simulation group. In both groups, the highest ranked contributors to learning were mentor observation and clinical practice. In the simulation group, simulation and debriefing outranked didactics or other experiences. CONCLUSIONS: Simulation-based workshops improve communication skills in high stakes conversations. However, they do not substitute for mentor observation and experience. Establishing a structured simulation-based difficult conversations curriculum refines vital communication skills necessary for the high stakes conversations neonatologists direct in clinical practice.

Implementing a Neonatal Transport System With Simulation in Kosovo.

OBJECTIVE: Post-war Kosovar health care systems have reduced gaps in maternal and newborn health care. Coordinated neonatal transport programs may further improve survival and morbidities. METHODS: Transport care paradigms were tested using in situ (Kosovo) and ex situ (the United States) mobile immersive simulation. Patient demographics and outcomes were measured at the tertiary referral center. RESULTS: Four paired physician and nurse transport teams performed 7 simulated interfacility transports across Kosovo. In situ simulations revealed safety threats in facilities, ambulances, and team process. Ex situ observations reinforced roles and professionalism. For the first year after simulations, tertiary neonatal intensive care unit admissions were more premature (-2.4 weeks), smaller (-725 g), and out born (+12%). Mortality was higher (14.7% vs. 7.8%), hypothermia was lower (0.2% vs. 4.6%), and culture-positive sepsis was lower (15.7% vs. 42.9%). CONCLUSION: In situ augmented by ex situ simulation provided perspective and depth of understanding to implement a new care delivery paradigm. Simulations involving Kosovar health care providers across a network of facilities generated practical experience in nationwide neonatal transport, with temporal association to altered referral patterns at the tertiary care facility.

Pre-stroke socioeconomic status predicts upper limb motor recovery after inpatient neurorehabilitation.

BACKGROUND: Lower socioeconomic status (SES) is associated with higher mortality rates and the likelihood of receiving less evidence-based treatment after stroke. In contrast, little is known about the impact of SES on recovery after discharge from inpatient rehabilitation. The aim of this study was to investigate the influence of SES on long-term recovery after stroke. PATIENTS AND METHODS: In a prospective, observational, multicentre study, inpatients were recruited towards the end of rehabilitation. The 12-month follow-up focussed on upper limb motor recovery, measured by the Fugl-Meyer score. A clinically relevant improvement of ≥5.25 points was considered recovery. Patient-centric measures such as the Patient-reported Outcomes Measurement Information System-Physical Health (PROMIS-10 PH) provided secondary outcomes. Information on schooling, vocational training, income and occupational status pre-stroke entered a multidimensional SES index. Multivariate logistic regression models calculating odds ratios (ORs) and corresponding confidence intervals (CIs) were applied. SES was added to an initial model including age, sex and baseline neurological deficit. Additional exploratory analyses examined the association between SES and outpatient treatment. RESULTS: One hundred and seventy-six patients were enrolled of whom 98 had SES and long-term recovery data. Model comparisons showed the SES-model superior to the initial model (Akaike information criterion (AIC): 123 vs. 120, Pseudo R2: 0.09 vs. 0.13). The likelihood of motor recovery (OR = 17.12, 95%CI = 1.31; 224.18) and PROMIS-10 PH improvement (OR = 20.76, 95%CI = 1.28; 337.11) were significantly increased with higher SES, along with more frequent use of outpatient therapy (p = .02). CONCLUSIONS: Higher pre-stroke SES is associated with better long-term recovery after discharge from rehabilitation. Understanding these factors can improve outpatient long-term stroke care and lead to better recovery.KEY MESSAGEHigher pre-stroke socioeconomic status (SES) is associated with better long-term recovery after discharge from rehabilitation both in terms of motor function and self-reported health status.Higher SES is associated with significantly higher utilization of outpatient therapies.Discharge management of rehabilitation clinics should identify and address socioeconomic factors in order to detect individual needs and to improve outpatient recovery. Article registration: clinicaltrials.gov NCT04119479.

Infant heart-rate measurement and oxygen desaturation detection with a digital video camera using imaging photoplethysmography.

OBJECTIVE: To assess the feasibility of using an ordinary digital video camera to measure heart rate and detect oxygen desaturations in healthy infants. STUDY DESIGN: Heart rate and oxygen saturation were measured with a video camera by detecting small color changes in 28 infants' foreheads and compared with standard pulse oximetry measures. Multivariable regression examined the relationship between infant characteristics and heart-rate measurement precision. RESULTS: The average bias of camera heart-rate measures was -4.2 beats per minute (BPM) and 95% limits of agreement were ±43.8 BPM. Desaturations detected by camera were 75% sensitive (15/20) and had a positive predictive value of 20% (15/74). Lower birth-weight was independently correlated with more precise heart-rate measures (8.05 BPM per kg, [95% CI 0.764-15.3]). CONCLUSIONS: A digital video camera provides accurate but imprecise measures of infant heart rate and may provide a rough screening tool for oxygen desaturations.

Influence of clinical status on the association between plasma total and unbound bilirubin and death or adverse neurodevelopmental outcomes in extremely low birth weight infants.

OBJECTIVES: To assess the influence of clinical status on the association between total plasma bilirubin and unbound bilirubin on death or adverse neurodevelopmental outcomes at 18-22 months corrected age in extremely low birth weight infants. METHOD: Total plasma bilirubin and unbound bilirubin were measured in 1101 extremely low birth weight infants at 5 +/- 1 days of age. Clinical criteria were used to classify infants as clinically stable or unstable. Survivors were examined at 18-22 months corrected age by certified examiners. Outcome variables were death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss, and death prior to follow-up. For all outcomes, the interaction between bilirubin variables and clinical status was assessed in logistic regression analyses adjusted for multiple risk factors. RESULTS: Regardless of clinical status, an increasing level of unbound bilirubin was associated with higher rates of death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss and death before follow-up. Total plasma bilirubin values were directly associated with death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss, and death before follow-up in unstable infants, but not in stable infants. An inverse association between total plasma bilirubin and death or cerebral palsy was found in stable infants. CONCLUSIONS: In extremely low birth weight infants, clinical status at 5 days of age affects the association between total plasma bilirubin and death or adverse neurodevelopmental outcomes at 18-22 months of corrected age. An increasing level of UB is associated a higher risk of death or adverse neurodevelopmental outcomes regardless of clinical status. Increasing levels of total plasma bilirubin are directly associated with increasing risk of death or adverse neurodevelopmental outcomes in unstable, but not in stable infants.

Transcriptional activation by tetracyclines in mammalian cells.

A transcriptional transactivator was developed that fuses the VP16 activation domain with a mutant Tet repressor from Escherichia coli. This transactivator requires certain tetracycline (Tc) derivatives for specific DNA binding. Thus, addition of doxycycline to HeLa cells that constitutively synthesized the transactivator and that contained an appropriate, stably integrated reporter unit rapidly induced gene expression more than a thousandfold. The specificity of the Tet repressor-operator-effector interaction and the pharmacological characteristics of Tc's make this regulatory system well suited for the control of gene activities in vivo, such as in transgenic animals and possibly in gene therapy.

Improved metabolic control after 12-week dietary intervention with low glycaemic isomalt in patients with type 2 diabetes mellitus.

The polyol isomalt (Palatinit) is a very low glycaemic sugar replacer. The effect of food supplemented with isomalt instead of higher glycaemic ingredients like sucrose and/or starch hydrolysates on metabolic control in patients with type 2 diabetes was examined in this open study. Thirty-three patients with type 2 diabetes received a diet with foods containing 30 g/d isomalt instead of higher-glycaemic carbohydrates for 12 weeks. Metformin and/or thiazolidindiones were the only concomitant oral antidiabetics allowed during the study. Otherwise, the participants maintained their usual diet during the test phase, but were instructed to refrain from additional sweetened foods. Before start, after 6 weeks and 12 weeks (completion of the study), blood samples were taken and analysed for clinical routine parameters, metabolic, and risk markers. Thirty-one patients completed the study. The test diet was well accepted and tolerated. After 12 weeks, significant reductions were observed for: glycosylated haemoglobin, fructosamine, fasting blood glucose, insulin, proinsulin, C-peptide, insulin resistance (HOMA-IR), and oxidised LDL (an atherosclerosis risk factor). In addition, significant lower nonesterified fatty acid concentrations were found in female participants. Routine blood measurements and blood lipids remained unchanged. The substitution of glycaemic ingredients by isomalt and the consequent on reduction of the glycaemic load within otherwise unchanged diet was accompanied by significant improvement in the metabolic control of diabetes. The present study is in agreement with findings of previous reported studies in human subjects demonstrating beneficial effects of low glycaemic diets on glucose metabolism in patients with diabetes mellitus type 2.

Clinical Macrosystem Simulation Translates Between Organizations.

INTRODUCTION: Simulation has become an integral tool in healthcare facility redesign. Immersing clinical experts into their future environment has demonstrated benefits for transition planning. This study evaluates translation of a proven macrosystems testing protocol, TESTPILOT, to an organization with limited simulation experience. METHODS: An experienced TESTPILOT team guided Woman's Hospital Baton Rouge's simulation preparation for their new neonatal intensive care unit. Metrics included participant evaluations, latent safety threats (LST), and clinician surveys. Latent safety threats recorded during debriefings were addressed by workflow committees. Clinicians were surveyed at four time points for readiness and preparedness on 24 key processes. RESULTS: The local team invested nearly 750 hours into learning and implementing seven simulations that participants rated positively. Most of the 305 LST were minor issues. Surveys at baseline (42% of staff), postsim (18%), pretransition (26%), and postmove (29%) demonstrated strong internal consistency. System readiness lagged behind staff preparedness (P < 0.007); both were higher after simulations (P ≤ 0.001) but at no other interval. Critical laboratory notification, rounding structure, team coverage, and feedback were still evolving as of move day (P < 0.02). DISCUSSION: Macrosystems testing using simulation identifies LST, improves process, and prepares staff. The methodology is implementable in organizations with limited prior exposure. Woman's Hospital Baton Rouge accrued essential skills to model and orchestrate an immersive neonatal intensive care unit and then drive effective multidisciplinary debriefings. Staff immersed in the new environment began to articulate their jobs before moving in. The trajectory of system readiness improvement corroborated LST correction. Future research is needed to determine the extent of simulation required for different organizational structures.

Safety and efficacy of pasireotide in dumping syndrome-results from a phase 2, multicentre study.

BACKGROUND: Dumping syndrome is a prevalent complication of oesophageal and gastric surgery characterised by early (postprandial tachycardia) and late (hypoglycaemia) postprandial symptoms. AIM: To evaluate efficacy and safety of the somatostatin analogue, pasireotide in patients with dumping syndrome after bariatric or upper gastrointestinal cancer surgery. METHODS: A single-arm, open-label, multicentre, intrapatient dose-escalation, phase 2 study with 4 phases: screening, 3-month SC (subcutaneous), 3-month IM (intramuscular) and 6-month optional extension IM phase. Primary endpoint was the proportion of patients without hypoglycaemia (plasma glucose <3.3 mmol/L [60 mg/dL] during an oral glucose tolerance test, OGTT) at the end of 3-month SC phase. A ≥50% response rate was considered clinically relevant. RESULTS: Forty-three patients with late dumping were enrolled; 33 completed the 3-month SC phase and 23 completed the 12-month study. The proportion of patients without hypoglycaemia at month 3 (primary endpoint) was 60.5% (26 of 43; 95% confidence interval, 44.4%-75.0%). Improvement in quality of life was observed during SC phase, which was maintained in the IM phase. The proportion of patients with a rise in pulse rate of ≥10 beats/min during OGTT reduced from baseline (60.5%) to month 3 (18.6%) and month 12 (27.3%). Overall (month 0-12), the most frequent (>20% of patients) adverse events were headache (34.9%); diarrhoea, hypoglycaemia (27.9% each); fatigue, nausea (23.3% each); and abdominal pain (20.9%). CONCLUSION: These results suggest that pasireotide is a promising option in patients with dumping syndrome after bariatric or upper gastrointestinal cancer surgery.

Effects of sample dilution, peroxidase concentration, and chloride ion on the measurement of unbound bilirubin in premature newborns.

OBJECTIVES: To assess the effects of sample dilution, peroxidase concentration, and chloride ion (Cl(-)) on plasma unbound bilirubin (B(f)) measurements made using a commercial peroxidase methodology (UB Analyzer) in a study population of ill, premature newborns. DESIGN AND METHODS: B(f) was measured with a UB Analyzer in 74 samples at the standard 42-fold sample dilution and compared with B(f) measured at a 2-fold sample dilution using a FloPro Analyzer. B(f) was measured at two peroxidase concentrations to determine whether the peroxidase steady state B(f) (B(fss)) measurements were significantly less than the equilibrium B(f) (B(feq)), in which case it was necessary to calculate B(feq) from the two B(fss) measurements. B(f) was also measured before and after adding 100 mmol/L Cl(-) to the UB Analyzer assay buffer. RESULTS: B(feq) at the 42-fold dilution was nearly 10-fold less than but it correlated significantly with B(feq) at the 2-fold dilution (mean 8.2+/-5.2 nmol/L versus 73.5+/-70 nmol/L, respectively, p<0.0001; correlation r=0.6). The two UB Analyzer B(fss) measurements were significantly less than B(feq) in 42 of 74 (57%) samples, and Cl(-) increased B(feq) in 66 of 74 (89%) samples by a mean of 82+/-67%. CONCLUSIONS: B(fss) measured by the UB Analyzer at the standard 42-fold sample dilution using assay buffer without Cl(-) and a single peroxidase concentration is significantly less than the B(feq) in undiluted plasma. Accurate B(f) measurements can be made only in minimally diluted serum or plasma.

Distinct roles for spinophilin and neurabin in dopamine-mediated plasticity.

Protein phosphatase 1 plays a major role in the governance of excitatory synaptic activity, and is subject to control via the neuromodulatory actions of dopamine. Mechanisms involved in regulating protein phosphatase 1 activity include interactions with the structurally related cytoskeletal elements spinophilin and neurabin, synaptic scaffolding proteins that are highly enriched in dendritic spines. The requirement for these proteins in dopamine-related neuromodulation was tested using knockout mice. Dopamine D1-mediated regulation of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate receptor activity was deficient in both striatal and prefrontal cortical neurons from neurabin knockout mice; in spinophilin knockout mice this deficit was manifest only in striatal neurons. At corticostriatal synapses long-term potentiation was deficient in neurabin knockout mice, but not in spinophilin knockout mice, and was rescued by a D1 receptor agonist. In contrast, long-term depression was deficient in spinophilin knockout mice but not in neurabin knockout mice, and was rescued by D2 receptor activation. Spontaneous excitatory post-synaptic current frequency was increased in neurabin knockout mice, but not in spinophilin knockout mice, and this effect was normalized by D2 receptor agonist application. Both knockout strains displayed increased induction of GluR1 Ser(845) phosphorylation in response to D1 receptor stimulation in slices, and also displayed enhanced locomotor activation in response to cocaine administration. These effects could be dissociated from cocaine reward, which was enhanced only in spinophilin knockout mice, and was accompanied by increased immediate early gene induction. These data establish a requirement for synaptic scaffolding in dopamine-mediated responses, and further indicate that spinophilin and neurabin play distinct roles in dopaminergic signal transduction and psychostimulant response.

Extension of host range of Rhizobium leguminosarum bv. trifolii caused by point mutations in nodD that result in alterations in regulatory function and recognition of inducer molecules.

The positive activation of several nodulation genes in strain ANU843 of Rhizobium leguminosarum biovar trifolii is mediated by the product of the nodD gene and by the interaction of NodD with plant-secreted inducer and anti-inducer compounds. We have mutagenized the nodD gene of strain ANU843 with nitrosoguanidine and have found that the ability of the mutated nodD products to interact with inducer and anti-inducer compounds is affected by the amino acid sequence in at least two key regions, including a novel area between amino acids 77 and 123. Several novel classes of mutants were recognized by phenotypic and molecular analysis of the mutant nodD genes. Classes 1 and 4 mutants were able to induce nodA expression independently of the addition of inducer and anti-inducer compounds and were unable to mediate autoregulation of the nodD gene. Classes 2 and 3 mutants retained several properties of the wild-type nodD, including the ability to interact with inducer and anti-inducer compounds and the capacity to autoregulate nodD expression. In addition, class 2 mutants showed an inducer-independent ability to mediate nodA expression to 10-fold higher levels over control strains. The class 3 mutant showed reactivity to compounds that had little or no inducing ability with the wild-type nodD. An alteration in NodD function was demonstrated with classes 2 and 3 mutants, which showed greatly enhanced ability to complement a Tn5-induced mutation in the nodD1 gene of strain NGR234 and to restore nodulation ability on the tropical legume siratro. Mutants of nodD possessing inducer-independent ability to activate nod gene expression (classes 1, 2, and 4) were capable of extending the host range of R. l. bv. trifolii to the nonlegume Parasponia. DNA sequence analysis showed that single base changes were responsible for the altered phenotypic properties of five of six mutants examined. Four of the six mutations affected amino acid residues in a putative receiver domain in the N-terminal end of the nodD protein.

Radiographic examination of the small bowel. An application of odds ratio analysis to help attain an appropriate mix of small bowel follow through and enteroclysis in a working-clinical environment.

RATIONALE AND OBJECTIVES: Simplifying data collection and analysis should promote utilization management in review of examinations of the small bowel in the general practice. METHODS: A case control format with the generation of an odds ratio to answer sets of binary questions derived from annual examination data is shown. The positive examination results applied were compared with the literature as a cross-checking mechanism. The examination identified as most likely to be positive was recommended prospectively in a protocol for the following year. Two of 5 years are illustrated to emphasize the development of the methodology. RESULTS: Application of this model in testing its validity, since 1990 at Madigan Army Medical Center, allows for the generation of a new protocol each year to prospectively improve clinical definition. CONCLUSIONS: A 5-year analysis of small bowel examination protocols, subdivisions, and odds ratios, will be forthcoming. The 2 years illustrated show how strongly our practice was influenced in using enteroclysis or in using the small bowel follow through as the examination of choice in the various clinical categories of small bowel disease: (1) practice was influenced by protocol and (2) outcome was steered toward positive examinations.

Antral nodularity, fold thickness, and narrowing. Signs on the upper gastrointestinal series that may indicate chronic active gastritis secondary to Helicobacter pylori.

RATIONALE AND OBJECTIVES: The purpose of this retrospective study was to investigate any association between the classic radiographic findings of nonerosive gastritis on the upper gastrointestinal (GI) series (antral nodularity, fold thickening, and narrowing) and histologically proven gastritis secondary to Helicobacter pylori. METHODS: The authors reviewed the histopathologic results of 31 patients who had upper GI barium examinations with the findings listed above who presented with dyspepsia. These patients were compared with 30 dyspeptic patients who had radiographically normal antrums. RESULTS: Twenty (64.5%) patients had chronic active gastritis and tested positive for H pylori organism, 5 (16.1%) were normal, 5 (16.1%) had inflammation but were negative for H pylori, and 1 (3.2%) had an insufficient amount of tissue. The barium upper GI series was 66.7% sensitive and 69.4% specific for chronic active gastritis secondary to H pylori (P = 0.0002 Fisher's exact test), with a positive predictive value of 64.5% and a negative predictive value of 83.3%. CONCLUSIONS: The differential diagnosis for antral nodularity, fold thickening, and narrowing is extensive. However, because of the common histopathologic diagnosis of chronic active gastritis secondary to H pylori in patients with these radiographic findings, the radiologist must remember to include this infectious cause of gastritis in the interpretive report. If the antrum is normal on the upper GI series, other causes should be considered.

Computed tomographic enteroclysis: one methodology.

RATIONALE AND OBJECTIVES: Computed tomography (CT) is limited in the assessment of partial small bowel obstruction (SBO). Enteroclysis is preferred but gives little direct information about the bowel wall, mesentery, or remote findings. Preliminary results of a combined CT enteroclysis (CT-E) methodology are reported. METHODS: Forty-eight patients with suspected partial SBO underwent a water soluble contrast enteroclysis followed immediately by CT. Pump rates at fluoroscopy and CT were 75 to 100 cc/min unless a high-grade obstruction was encountered at fluoroscopy. Shrake's criteria for complete, high-grade or low-grade partial SBO were used. RESULTS: The calculated dose per patient was 27 rad for CT-E as opposed to 32 rad with traditional enteroclysis. Site specific sensitivity and specificity for low-grade partial SBO, were 82.1% and 87.5%. One death was encountered in a patient with diffuse abdominal metastatic disease and complete obstruction. This was caused by vomiting and aspiration secondary to tube placement alone, CT-enteroclysis having been aborted. CONCLUSIONS: Computed tomographic enteroclysis is a diagnostic option for evaluation of low-grade partial SBOs. Pitfalls with this technique are encountered in decompressed torsions and hernias.

Double contrast upper gastrointestinal barium examination with biopsy versus endoscopy with biopsy in dyspeptic patients.

RATIONALE AND OBJECTIVES: The financial restrictions of the managed care environment require reconsideration of the barium upper gastrointestinal examination as a diagnostic tool for gastritis patients. However, a greater sensitivity and specificity for gastritis is needed. A prospective study was performed comparing barium examinations with gastric biopsies to endoscopy with biopsy. METHODS: Forty adult patients underwent upper gastrointestinal barium examination with gastric biopsies obtained under fluoroscopy through a nasogastric tube. Twenty-seven patients gave consent for subsequent endoscopy with biopsy. Both sets of biopsies were compared, as were the interpretations of the radiographs and visual appearances. RESULTS: For barium examinations with gastric biopsies, sensitivity for gastritis was 94% and specificity was 100%, using endoscopic biopsies as the gold standard. CONCLUSIONS: In addition to endoscopy with biopsy, the upper gastrointestinal barium examination with biopsy is another option of sufficient sensitivity and specificity for consideration by clinicians in their workup of patients with gastritis.

Fluoroscopic-guided in vivo gastric mapping for assessment of gastric carcinoma.

RATIONALE AND OBJECTIVES: The authors seek to determine if a new method of combining fluoroscopy and nasogastric biopsy can demonstrate the existence and boundary limits of a known gastric carcinoma or its premalignant conditions. The study is performed in hopes of avoiding unnecessary surgery or limiting resection. METHODS: Two cases are presented to illustrate the technique. The first had a known gastric carcinoma; the other had adenomatous change in the antrum. After topical anesthesia was applied, a nasogastric tube with a coaxial biopsy forceps was inserted. Multiple biopsies were taken in a designed geographic pattern and sent to pathology. The patient with known carcinoma received a total gastrectomy. The specimen was sectioned in the same regions as the biopsies to validate mapping technique. RESULTS: Pathology results for sectioned stomach were nearly identical to the biopsies showing the technique can accurately map the stomach. No adenomatous change in the antrum or other sections of the stomach was observed in the second case. This resulted in the patient being spared gastric resection. CONCLUSIONS: Fluoroscopic-guided gastric mapping can aid in determining the boundaries of a known carcinoma or premalignant conditions. Additional cases and follow-up are necessary.

Using sector endoluminal ultrasound to identify the normal pancreas when axial computed tomography is falsely positive.

RATIONALE AND OBJECTIVES: Little has been reported on the ability of endoluminal ultrasound (EUS) to identify a normal pancreas after an abnormal axial computed tomogram (CT). Many clinicians still use axial technology, as opposed to helical or spiral CT, which differ in scanning speed. Spiral CT and EUS are considered equal in their ability to diagnose pancreatic tumors. Although this is not the case with axial CT, the complementary role by EUS has not been defined. This study reports on the ability of EUS to identify the "true-negative" pancreas deemed abnormal by axial CT. METHODS: Sixty-five consecutive patients suspected of having a small pancreatic lesion were studied by comparing axial CT and EUS examinations, using each patient as his or her own control. Identification of a normal pancreas was reviewed using surgery, biopsy, and long-term clinical follow-up as the standard of truth. RESULTS: Thirty-three patients were documented as having small pancreatic lesions; the remaining 32 were normal. The sensitivity and specificity, respectively, were 91% and 41% for axial CT and 88% and 88% for EUS. The positive and negative predictive values, respectively, were 61% and 82% for CT and 88% and 88% for EUS. The statistical differences between axial CT and EUS were significant. CONCLUSION: An axial CT positive for a small pancreatic mass requires confirmation with additional imaging before invasive management. The specificity of EUS--twice that of CT--is strong evidence that EUS can fulfill this role. Review of the literature supports the conclusion that EUS should be required in the workup of small pancreatic lesions identified at axial CT.

Reduction of acidurance of streptococcal growth and glycolysis by fluoride and gramicidin.

The acidurance of glycolysis by intact cells of Streptococcus mutans GS-5, Streptococcus salivarius ATCC 25925, and Streptococcus sanguis NCTC 10904 was found to be highly dependent on membrane functions affected by gramicidin, which increases the proton permeability of cell membranes. Plots of % glucose utilized during two hours against suspension pH values for cells suspended in 100 mM phosphate buffer plus 1 mM MgCl2 plus 13.9 mM glucose indicated, for 50% glucose utilization, pH values of 5.0 for S. mutans, 5.7 for S. salivarius, and 6.2 for S. sanguis. Gramicidin treatment shifted these values to 6.0, 6.3, and 6.9, respectively. Growth of S. mutans and S. salivarius in complex media proved to be more acid-sensitive than was glycolysis, and in batch cultures, there was a well-defined, post-growth phase of glycolysis. Minimum pH values for growth and for glycolysis in medium with excess glucose were approximately 4.8 and 4.4, respectively, for S. mutans, and 4.9 and 4.3 for S. salivarius. S. sanguis was less aciduric and showed little differential acid sensitivity, with minimum pH values of about 5.2 for both growth and glycolysis. Fluoride acted to eliminate the differences in acidurance of growth and glycolysis for S. mutans or S. salivarius and to render both processes more acid-sensitive. Thus, glycolysis was more fluoride-sensitive than was growth. Growth was found to be acid-limited in media with initial glucose levels greater than 0.2, 0.3, and 0.5% (weight/volume) for S. sanguis, S. mutans, and S. salivarius, respectively, and to be glucose-limited at lower levels.(ABSTRACT TRUNCATED AT 250 WORDS)