Reactive hemophagocytic syndrome simulating acute hepatitis. A case due to hepatic peripheral T-cell lymphoma.

The reactive hemophagocytic syndrome may mimic acute hepatitis, as we report here. It should be considered when hepatitis is accompanied by high fever, progressive cytopenias, and weight loss, with or without adenopathy and striking lactate dehydrogenase elevation. Bone marrow, lymph node, or liver biopsy are necessary to confirm the diagnosis.

Progress in diagnosing and understanding chronic pain syndromes in children.

Chronic pain syndromes such as fibromyalgia and reflex sympathetic dystrophy constitute an increasing percentage of new patient referrals to pediatric rheumatology clinics. It is surprising then that so few studies have been published on these syndromes. This review focuses on the investigations that are central to our understanding of this difficult diagnostic area.

Is glycohemoglobin testing useful in diabetes mellitus? Lessons from the diabetes control and complications trial.

To address the question, Do laboratory tests cost money or save money? we have used as a model for discussion a common chronic disease, diabetes mellitus, and a widely used laboratory test, that for glycohemoglobin, a measure of long-term glycemia used to manage diabetic patients. Diabetes mellitus is serious, highly prevalent, and costly. In 1992, $1 of every $7 spent on health in the US was for diabetes, predominantly for treatment of the chronic complications of the disease.

A single administration of ethanol simultaneously increases c-fos mRNA and reduces c-jun mRNA in the hypothalamus and hippocampus.

We have previously demonstrated that a single administration of ethanol induces the expression of c-fos mRNA in the hypothalamic paraventricular nucleus (PVN). However, Fos protein must interact with a member of the Jun family to form functional heterodimers. To determine whether ethanol may have differential effects on c-fos and c-jun expression, we injected male rats acclimated to a 25 degrees C environment with ethanol (3 g/kg b.

The quality of ambulatory-based primary care: a framework and recommendations.

Unlabelled: GOAL OF THE FRAMEWORK: The goal of the framework described in this review article is to provide a comprehensive model for the development of quality improvement programs in ambulatory-based primary care currently being tested at the University of Missouri-Columbia. This review article assesses the past and present, and speculates on the future, of quality improvement in primary care through a comprehensive review of 30 years of literature.

Principle Conclusions: (1) Although much of the past literature in the quality area has been concentrated in hospital care, there is a strong tradition in ambulatory-based primary care.

Current options in gallstone management. What to do when symptoms are mild or absent.

Recent advances in our understanding of the natural history of gallstones and the introduction of new treatment options have dramatically altered the approach to gallstone management. Most patients with cholelithiasis are asymptomatic, and for them, expectant management is now recommended by many authorities. This approach may also be acceptable for some patients who have only occasional episodes of biliary colic.

The effect of teaching medical students on private practitioners' workloads.

Background: The costs in time and money of medical student education for family physicians in private practice is uncertain, with the literature containing conflicting reports.

Method: Questionnaires were mailed in 1992-93 to 56 primary care physicians who had taught third- or fourth-year students during the previous academic year in fulfillment of the students' required four-week family medicine preceptorships at the University of Missouri-Columbia School of Medicine.

Results: Forty-six physicians responded.

Mobilization of Ca2+ influx, but not of stored Ca2+, by extracellular ATP in rat submandibular gland acini.

To determine its effect on cytosolic Ca2+ levels (Ca2+i) and to assess its role as an autonomic cotransmitter, ATP was added to suspensions of rat pancreatic or submandibular gland acini loaded with fura-2. ATP had no effect on pancreatic acinar Ca2+i at either high (2.5 mM) or low (< 10 nM) extracellular Ca2+ concentrations (Ca2+o).

Characterization of glycogen-deficient glc mutants of Saccharomyces cerevisiae.

Forty-eight mutants of Saccharomyces cerevisiae with defects in glycogen metabolism were isolated. The mutations defined eight GLC genes, the function of which were determined. Mutations in three of these genes activate the RAS/cAMP pathway either by impairment of a RAS GTPase-activating protein (GLC1/IRA1 and GLC4/IRA2) or by activating Ras2p (GLC5/RAS2).

Differential effects of estrogen and progesterone on levels of POMC mRNA levels in the arcuate nucleus: relationship to the timing of LH surge release.

Beta-endorphin is thought to be an important inhibitor of LHRH neuronal activity and also to play a role in conveying information about changes in steroid levels to LHRH neurons. We have previously shown that the mRNA encoding the precursor of beta-endorphin, proopiomelanocortin (POMC), fluctuates during the estrous cycle with the most dramatic changes occurring on proestrus. POMC mRNA levels decline before the onset of LH surge release but then dramatically rise and remain elevated during the surge.

Prenatal ethanol exposure: changes in regional brain catecholamine content following stress.

Previous studies have shown that fetal ethanol exposure (FEE) may have long-term effects on the function of catecholaminergic neurons in different regions of the CNS. The present study is the first to examine the effects of FEE on regional brain catecholamine responses following acute stress (a single 60-min restraint stress), repeated stress (single periods of restraint stress on 1, 5, or 10 consecutive days), and recovery from stress (recovery for up to 60 min in the home cage following a single 60-min period of restraint stress). Both male and female offspring from FEE, pair-fed (PF), and ad libitum-fed control (C) groups were tested in adulthood to determine catecholamine content in the cortex, hypothalamus, and hippocampus.

Does problem-based learning work? A meta-analysis of evaluative research.

The purpose of this review is to synthesize all available evaluative research from 1970 through 1992 that compares problem-based learning (PBL) with more traditional methods of medical education. Five separate meta-analyses were performed on 35 studies representing 19 institutions. For 22 of the studies (representing 14 institutions), both effect-size and supplementary vote-count analyses could be performed; otherwise, only supplementary analyses were performed.

Primary osteoporosis. Methods to combat bone loss that accompanies aging.

Osteoporosis is a major public health problem in the United States. The key to its management is prevention by ensuring adequate amounts of calcium, vitamin D, and protein and exercise throughout life. When a significant amount of bone mass has been lost, therapeutic interventions are aimed at preventing further loss with use of antiresorptive agents (ie, estrogen, progestin, calcitonin, and bisphosphonates).

Structural basis for pathologic left ventricular hypertrophy.

Left ventricular hypertrophy (LVH) is a major risk factor associated with the emergence of symptomatic congestive heart failure. Cardiac myocyte excitation-contraction coupling has been the biochemical focus in the search for insights into the impaired contractility, relaxation, and stiffness of the hypertrophied myocardium. Although hypertrophied myocytes are the hallmark of LVH, other aspects of myocardial structure may be altered to impair pump function--specifically an abnormal accumulation of connective tissue (interstitial fibrosis).

Patient practice variation. A call for research.

This article presents a theoretic framework, "patient practice variation," currently missing from the investigations of medical care variation. Resource utilization, immediate, and long-term outcomes may be better explained by including utilities under control of the patient into small area variation studies. This especially may be important in the area of prenatal and maternal care and certain chronic diseases, such as diabetes.

Role of aldosterone in congestive heart failure.

Antialdosterone therapy in patients with secondary hyperaldosteronism due to myocardial failure must accomplish the following: (1) reduce or preferably normalize plasma aldosterone levels by blockade of excessive synthesis, (2) antagonize the renal and systemic effects of aldosterone at its receptor sites, and (3) minimize the presence of multiple stimuli to aldosterone secretion. Fulfillment of these goals likely requires the blockade of angiotensin II-induced aldosterone secretion (ie, angiotensin-converting enzyme inhibition) with an antagonist of aldosterone receptors (ie, spironolactone [Aldactone]). Despite the potential for hyperkalemia with this combined use of medications, particularly in patients with impaired renal function, such therapy is likely to attenuate the salt-acquisitive state that is characteristic of myocardial failure.

Retinal age pigments generated by self-assembling lysosomotropic detergents.

A universal biomarker of cellular ageing in eukaryotic postmitotic cells is the appearance over time of autofluorescent lysosomal residual bodies called age pigments or lipofuscin granules. Their role in the process of cellular ageing has been debated without resolution. Neither the identity nor mechanism of formation of the fluorophores has been definitively determined.

Evidence for the phosphorylation of dopamine by striatal tissue from rat brain.

Methods were developed for the chemical phosphorylation of dopamine and for the isolation of phosphorylated dopamine from acidic extracts of rat brain. The developed methods were applied to provide evidence that striatal tissue from rat brain can phosphorylate dopamine to yield dopamine-3-monophosphate ester and dopamine-4-monophosphate ester.

Vasoactive hormones and autocrine activation of capillary exchange barrier function.

Capillary barrier function is subject to changes in Starling forces via hemodynamic status (hydrostatic pressure) or protein milieu of fluids bathing the wall (oncotic pressure). Venular function is sensitive to inflammatory mediators leading to white cell sticking, fluid and formed element extravasation, and flow disruption. Thus, we hypothesized that vasoactive hormones and autocrines alter preferentially the venular-capillary (VC) barrier.

The trypsin-sensitive RVER domain in the capsid proteins of minute virus of mice is required for efficient cell binding and viral infection but not for proteolytic processing in vivo.

Analysis of a series of mutations in the trypsin-sensitive RVER region of the amino terminal domain in the capsid proteins (VP1 and VP2) of the autonomous parvovirus, minute virus of mice (MVM), demonstrates that this sequence is not essential for proteolytic processing of VP2 into VP3 in vivo, but specific amino acids within this domain are important for viral infection. Analysis of the most deficient of these mutants, VP(delta 2842-2863), a 7-aa deletion of aa 159-165 in VP1 and 17-23 in VP2, has identified at least two steps in MVM infection in which this domain is important. VP(delta 2842-2863) was 3-fold defective in binding to murine A9(2L) cells and, when an equivalent amount of virus was bound to cells, additionally 10-fold deficient compared to wild-type in initiating a productive infection.

Polyps in the colon. Answers to key questions.

Adenomatous polyps in the adult colon and rectum are of great clinical importance because they can undergo malignant degeneration. Size and histologic type are useful in predicting the likelihood of malignancy. In most cases, biopsy is required to distinguish small adenomas (< 1 cm) from hyperplastic polyps, which do not undergo malignant degeneration.

Selective activation of murine V beta 8.2 bearing T cells by Pseudomonas exotoxin A.

We have determined that Pseudomonas aeruginosa exotoxin A (PE) can selectively stimulate the proliferation of V beta bearing T lymphocytes. Murine thymocytes were fractionated by selective agglutination with peanut agglutinin (PNA) and the PNA- thymocytes, which represent mature thymocytes, were shown to be responsive to PE stimulation. In addition, mature peripheral T lymphocytes (nylon wool nonadherent splenocytes) were also observed to respond to PE stimulation.

Involvement of tyrosine kinase and protein kinase C in platelet-activating-factor-induced c-fos gene expression in A-431 cells.

In A-431 cells, platelet-activating factor (PAF) induces the expression of c-fos and TIS-1 genes in both the absence and the presence of cycloheximide in a structurally specific and receptor-coupled manner. We have now investigated the molecular mechanisms of this response, particularly in relation to the role of protein kinases. Pretreatment of cells with genistein or methyl-2,5-dihydroxycinnamate (tyrosine kinase inhibitors) or staurosporine (a protein kinase C inhibitor) for 20 min abolished the c-fos expression induced by PAF.

Physician staffing of small rural hospital emergency departments: rapid change and escalating cost.

We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage.