A prospective randomised control study: reduction of children's pain expectation using a picture book during blood withdrawal.

OBJECTIVES: Blood drawings are very painful and stressful for children. In a prospective control group study we investigated if using a picture book could reduce the children's pain expectation. In addition, the children's pain experience and the observed pain behaviour was monitored. PATIENTS/METHODS: Block-randomization were used and 120 children at the age of 6-12 years who were visiting the general pediatric and coagulation outpatient clinics were included in this study. Pain expectation and experience were assessed with the Face-Pain-Scale-Revised and the pain behavior with the Faces-Legs-Activity-Cry-Consolability Scale. Multivariate covariance analysis was used for data analysis. RESULTS: The results showed that with statistical controlling the influence of the primary pain expectation (baseline) the pain expectation before blood withdrawal was reduced significantly (p=0.001) and effectively (ES=0.56) using the picture book. Children who received no local anaesthesia reported that they felt less pain during blood drawing after reading the picture book. The few children with local anaesthesia reported no benefit from the picture book. The observed use of local anaesthesia was very heterogeneous. CONCLUSIONS: The results recommend the usage of this picture book in everyday practice, if the use of local anaesthesia could not be used in an appropriate way.

Homozygous point mutations in platelet glycoprotein ITGA2B gene as cause of Glanzmann thrombasthenia in 2 families.

Glanzmann thrombasthenia (GT) is a rare autosomal recessive bleeding disorder characterized by quantitative and/or qualitative defects of the platelet glycoprotein (GP) IIb/IIIa complex. Physiologically, the integrin GPIIb/IIIa binds Von Willebrand factor and fibrinogen on activated platelets. GT is caused by genetic alterations in ITGA2B or ITGB3 (genes encoding GPIIb and GPIIIa).This study describes 2 siblings diagnosed with GT type I associated with homozygous point mutations in ITGA2B. All patients presented with typical bleeding disorder including moderate hematomas, petechiae, and mucocutaneous bleedings.Both siblings showed severely reduced platelet aggregation especially after stimulation with collagen and adenosine diphosphate. Absence of platelet GPIIb/GPIIIa complex was determined using flow cytometry. Molecular genetic analysis revealed 2 distinct homozygous point mutations in exon 18 of ITGA2B. Family 1 was identified with c.1878G>C and family 2 with c.1787T>C substitution. While the c.1787T>C mutation causes a single amino acid substitution p.I565T, the c.1878G>C mutation (p.Q595H) is predicted to induce a mRNA splicing anomaly.These mutations were identified as cause of GT type I in the described patients. Patients with GT should be documented in a prospective register to verify the correlation between the severity of bleeding symptoms and the pathogenic mutation. This can have effects on therapeutic decisions.

Depression and antidepressants and the elderly.

Depression is the most common emotional disorder of the elderly. The frequency of grief reaction and the confusion with dementia, hypochondriasis, and sleep disorders complicate both the diagnosis and treatment of depression in older patients. Further, these patients often take medications that can produce or aggravate depression. The choice of antidepressant is based largely on side effects. After evaluating the risk factors, the physician can select a drug on the basis of sedative, anticholinergic, or other side effects. Prior history of response to a particular drug and the physician's experience with particular drugs weight heavily in this decision. Lower initial doses of all medications should be used in the elderly, and dosage should be increased slowly, if possible. These guidelines, derived from clinical experience with tricyclic antidepressants, are presented as a foundation for selecting from the large number of "second generation" antidepressant drugs soon to be available.

Hypochondriasis in the elderly: a reaction to social stress.

Hypochondriasis in the elderly is often a preventable or reversible syndrome. It can become chronic if the patient finds no relief from social stress or becomes dependent upon medical services as a source of support. When this is recognized, psychotherapeutic intervention is necessary. Although no socioeconomic group is exempt, hypochondriasis in the elderly occurs more often among the lower social classes. Its higher prevalence in this group is attributable to the frequency and severity of social stress and the loss of alternative social opportunities. If psychotherapeutic intervention is necessary, the elderly hypochondriac patient should be helped to recognize social stress as a major source of the problem and to develop a realistic method of coping with it. Apparently the precipitating factors are often in the socioeconomic sphere; hence, social planners should be aware of this fact if the demands on the health care system are to be reduced.

Non-myelotoxic antitumour effects of L-dopa, buthionine sulphoximine and tamoxifen on neuroblastoma cells in vitro and in vivo.

The effects of three non-myelotoxic cancer drugs on the growth of neuroblastoma cells were investigated in vitro and in vivo: dihydroxyphenylalanine (L-dopa, a drug with selective toxicity for melanoma cells), DL-buthionine sulphoximine (BSO, a drug with radiosensitizing effects), and tamoxifen (a drug used in the treatment of human mammary carcinoma). In vivo these substances significantly reduced the weight of neuroblastoma tumour transplants in the mice (nude/nude) (P less than 0.05). A dose/effect relationship could be established. In vitro, the D50 was determined, using fibroblasts as controls. The growth of neuroblastoma tumours was inhibited by different mechanisms: L-dopa and its metabolite dopamine reduced the activity of tyrosinase, BSO reduced glutathione levels, and L-dopa and tamoxifen raised cAMP concentrations.

Changes in mouse skin cyclic nucleotides during chemical carcinogenesis and tumor response to treatment with BCG, L-Dopa and cyclic DBAMP.

During chemical carcinogenesis by 9, 10-dimethyl 1,2-benzanthracene the cyclic AMP and GMP content was measured in the skin of mice. The tissue of the developing skin tumor is characterized by an elevated cyclic GMP- and a lowered cyclic AMP level. Consequently the quotient of cyclic AMP and GMP is greatly lowered and is discussed as a crucial factor of cell derangement. Complete regression of the tumor is to be achieved by increasing the cyclic AMP levels by means of cyclic DBAMP and L-Dopa in 20% of the experimental animals. Additional stimulation by BCG of the unspecific immune defence has a favourable effect on tumor regression (about 50%). In a different type of tumor (solid Ehrlich carcinoma) it was possible after pretreatment of the mice with L-Dopa, cyclic DBAMP and BCG and after treatment following tumor injection to prevent tumor development in 67% of the animals.

Medtronic mosaic porcine bioprosthesis satisfactory early clinical performance.

BACKGROUND: The Medtronic (Minneapolis, MN) Mosaic porcine bioprosthesis is an investigational prosthesis which incorporates zero-pressure fixation, aortic root predilation, low profile stent, and alpha oleic acid antimineralization treatment. METHODS: From September 1994 to August 1996, 289 patients (mean age 70 years, range, 28 to 88 years) had 227 (78.5%) aortic valve replacements and 62 (21.5%) mitral valve replacements. Concomitant procedures were performed in 61.2% (139) of aortic valve replacements and 54.8% (34) of mitral valve replacements. Of the aortic valve replacement group 70 (30.8%) were in the 61 to 70 age group and 134 (59.0%) were 71 years or older. Of the mitral valve replacements, 23 (37.1%) were 61 to 70 years and 30 (48.4%) 71 years or older. RESULTS: The early mortality, overall, was 4.2% (12 of 289); for aortic valve replacement it was 4.0% (9) and for mitral valve replacement it was 4.8% (3). The late mortality for aortic valve replacement was 2.6% per patient-year (3 events, 1.3% of total) and for mitral valve replacement it was 3.3% per patient-year (one event, 1.6% of total). The reoperative rate for aortic valve replacement was 3.0% per patient-year (4), while there were no mitral valve replacement reoperations. The freedom from major thromboembolism was 97.3%+/-1.6% for aortic valve replacement and 94.7%+/-3.0% for mitral valve replacement at 1 to 1.5 years. The freedom from reoperation was 96.7%+/-1.7% for aortic valve replacement; there was no reoperation for mitral valve replacement. There were no cases of structural valve deterioration. In the aortic position the mean systolic gradient was low, approximately 11 mm Hg, across all sizes (range 8 to 12 mm Hg at 3 months and 10 to 13 mm Hg at 12 months). In the mitral position the mean diastolic gradient was approximately 5 mm Hg (range, 2 to 6 mm Hg) for all sizes 25 to 31 mm at the early and 1 year follow-up echocardiographic assessment. CONCLUSIONS: The early clinical performance and in vivo hemodynamics are encouraging.

The treatment of negative symptoms: a clinical and methodological study.

The primary objective of this study was to evaluate the efficacy, safety and tolerability of remoxipride (controlled release) versus haloperidol in patients with negative symptoms. The study comprised a multicentre, randomised, double-blind, parallel-group clinical trial. Two hundred and five patients were randomised to either remoxipride or haloperidol. Patients eligible for this study were aged 18-65 years, met the DSM-III-R diagnosis for chronic schizophrenia and the Positive and Negative Symptoms Scale (PANSS) criteria for predominant negative symptoms. There was a statistically significant reduction in the PANSS scores of at least 20% from baseline to last rating for 39 remoxipride (49.4%) and 45 haloperidol (47.6%) treated patients. There were no statistical differences found between the two treatment groups with respect to improvement of negative symptoms and adverse events. The PANSS data suggest that both remoxipride and haloperidol improve the cluster of negative symptoms concerned with social functioning. In addition, the design of the study provides a methodology that is appropriate to the study of primary negative symptoms in schizophrenia.

Elective aortocoronary bypass grafting in the elderly.

Operative mortality, postoperative morbidity and follow up data were analyzed retrospectively from 122 consecutive patients, over 65 years old undergoing elective aortocoronary bypass grafting for symptomatic relief of angina pectoris at the Plains Health Centre, Regina, Saskatchewan, from January 1980 to December 1985. There were two in-hospital deaths (operative mortality 1.6%). Definite perioperative myocardial infarction occurred in 12 patients (9.8%). The 120 survivors were followed for a mean of 32 months. There were three deaths during follow-up, giving a five-year probability of survival of 93%. Twenty-three clinical events (including deaths) occurred during follow-up, giving a five-year probability of event free survival of 72%. Ninety percent of patients say they are pleased with their operation. Seventy-eight percent are currently angina free. These data illustrate the effectiveness of aortocoronary bypass grafting in low risk elderly patients with symptomatic coronary artery disease.

Atenolol for the prevention of arrhythmias following coronary artery bypass grafting.

Seventy patients undergoing aortocoronary bypass grafting were randomized, double-blind, to receive either atenolol or placebo. There were 35 patients in each group. Patients received either atenolol 5 mg intravenously or matching placebo within 3 h of the completion of surgery. A second intravenous dose was administered 24 h following the first and then atenolol 50 mg orally or matching placebo was given for six days. Continuous Holter monitor recordings were obtained for the 24 h immediately preoperatively and continuously for eight days postoperatively. No patient received any antiarrhythmic drug preoperatively. Patients who required pharmacological intervention for the management of postoperative arrhythmias were withdrawn as treatment failures. Holter monitor analysis continued for 24 h following withdrawal of a treatment failure. All patients were analyzed according to the intention-to-treat principle. Both groups were comparable with respect to age, sex, severity of coronary artery disease, left ventricular ejection fraction, preoperative use of beta-blockers, bypass time, aortic cross-clamp time, number of grafts per patient and frequency of preoperative arrhythmias. Arrhythmia analysis was done manually. Supraventricular arrhythmias (atrial tachycardia, atrial fibrillation and atrial flutter) were classified as either mild (less than 0.5 mins, less than 140 beats/min), moderate (0.5 to 30 mins, 140 to 180 beats/min), or severe (longer than 30 mins, more than 180 beats/min). Ventricular arrhythmia analysis was performed with respect to isolated PVCs, couplets, triplets and episodes of nonsustained ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)

[In vitro and in vivo effect of thyroid hormones on the growth of neuroblastoma cells. I. The effect of triiodothyronine in vitro]. / In-vitro- und In-vivo-Wirkung von Schilddrüsenhormon auf das Wachstum von Neuroblastomzellen. I. Effekt von Trijodthyronin in vitro.

The effect of triiodothyronine (T3) on the differentiation of cultured neuroblastoma (NB) cells was studied after 9 days of treatment with a dose of 10(-4) M/10(6) cells per day. Using phase contrast microscopy, 30-50% of NB cells showed formation of neurites as a morphological sign of cellular differentiation. The initial rise of the mitosis rate was followed by a plateau. Changes in cyclic nucleotide content, in the triphosphates and in the activity of the enzyme ornithine decarboxylase (ODC) were assessed in 2 human and 2 murine cell lines to serve as biochemical parameters of the cell differentiation induced by T3. Whereas the cAMP level increased significantly (3 to 7 fold compared with its initial value), the cGMP value dropped to 30 to 50% of that of the control group. ATP and GTP increased about 200%, the ODC showed a decrease of about 50%. The present studies show a biphasic effect of T3 on neuroblastoma cells: the initial rise of mitotic activity is followed by increased cell differentiation starting from day 4 of the treatment.

[In vitro and in vivo effect of thyroid hormones on the growth of neuroblastoma cells. II. The effect of thyroxine in vivo]. / In-vitro- und in-vivo-Wirkung von Schilddrüsenhormon auf das Wachstum von Neuroblastomzellen. II. Effeckt von Thyroxin in vivo.

We studied the effect of thyroxine (T4 0.050 mg/kg/d, i.p.), TSH (0.08 U/kg/d, i.p.) and hypothalamic peptide (HF; 1 mg protein/kg/d, i.p.) given alone or in combination, on the growth of murine (NB C-1300) and human (NB Park) neuroblastoma transplanted onto the nude mouse (nu/nu). Both T4 and TSH caused a significant increase (perchlorate a decrease) of the serum T3. Histologically, the T4 treatment was followed by partial tumor necrosis and a marked growth of connective tissue within the tumors; there was no significant change in tumor weight as compared to the control group. Treatment with HF alone or in combination with T4 inhibited in 30% the invasive growth of the neuroblastoma transplants and a fatty degeneration was found in 25% of the human NB-TX after 28 days of treatment. The measurement of the intratumoral content of the cyclic nucleotides showed a significant increase of the cAMP and a decrease of the cGMP. The morphological and biochemical alteration observed under treatment with thyroid hormone or analogues could possibly be applied for therapeutic purposes.

[Detection of the binding of 131I-meta-iodobenzylguanidine to structures of the plasma membranes of neuroblastoma cell lines]. / Nachweis der Bindung von 131J-Meta-Jod-Benzylguanidin an Strukturen der Plasmamembran von Neuroblastom-Zellinien.

In vitro studies of tumor tissue have shown that 131I-IBG is specifically bound to the plasma membrane-enriched fraction of two neuroblastoma cell lines (NA-2 and C-1300). NB C-1300 showed a slightly higher binding capacity than NB NA-2. It may be inferred from experiments performed with activators of the adrenergic and dopaminergic systems that binding of IBG to proteins on the plasma membrane which is physiologically important for binding of this guanidine derivative, is probable.

How mind, body, and environment influence nutrition in the elderly.

Eating habits, food preferences, and attitudes affecting nutrition in the elderly are the result of the interaction of numerous interpersonal and intrapersonal forces. The physiologic changes that accompany aging must be understood by the clinician and accepted by the elderly person. Social stress and other environmental factors can adversely affect nutritional status.