HMO innovations. Video-enhanced medical advice; senior zoo walkers; Group Health Resource Line; enhancing health education programs through desktop publishing; home health beat; innovative school health partnership

The editors of HMO PRACTICE asked clinicians and health educators in HMOs across the country to submit reports on their unique, successful patient education programs. The following HMO Innovations testify to the wide range of new technologies, enterprising partnerships, and creative ideas that are shaping health education in HMOs today.

Repolarization inhomogeneities in ventricular myocardium change dynamically with abrupt cycle length shortening

BACKGROUND

In single heart cells, abrupt changes in stimulation rate elicit complex alterations in repolarization. The effects of rate change on dispersion of repolarization, however, have not been well characterized.

METHODS AND RESULTS

To determine the effects of abrupt cycle length (CL) shortening on spatial inhomogeneity of repolarization in a syncytium of ventricular cells, 124 action potentials were simultaneously recorded from Langendorff-perfused guinea pig hearts using high-resolution optical mapping with voltage-sensitive dye. The distribution of ventricular action potential durations (APDs) mapped during each cardiac cycle was used to calculate mean APD and repolarization dispersion index (DI), defined as the variance of the distribution. After abruptly shortening CL from 500 to 300 msec, mean APD declined exponentially in normoxic controls (by 23 +/- 3 msec, p less than 0.0001). This response was characterized by beat-to-beat oscillations of APD that were synchronized at all ventricular sites. After 30 minutes of hypoxia, mean APD decreased from 175.0 +/- 13.3 to 76 +/- 25.7 msec. However, during hypoxia, abrupt CL shortening lowered mean APD by only an additional 6 +/- 6 msec, and APD oscillations were no longer synchronized throughout the ventricle. In controls, beat-to-beat DI decreased significantly (-51.0 +/- 6.8%, p less than 0.01) by the sixth post-CL shortening beat and then recovered (by 15-20 beats). In contrast, DI failed to decrease during hypoxia (+7.1 +/- 23%). Two mechanisms for the transient decline of DI in controls were identified: synchronous APD oscillations and transient diminution of the apical-to-basal ventricular APD gradient.

CONCLUSIONS

These data demonstrate that inhomogeneity of ventricular repolarization, as measured by DI, changes dynamically with CL shortening. Furthermore, the hypoxic ventricle does not attenuate DI after abrupt CL shortening and thereby lacks a physiological response expected to diminish vulnerability to arrhythmias.

Serological monitoring of advanced breast cancer treated by systemic cytotoxic using a combination of ESR, CEA, and CA 15.3: fact or fiction?

A biochemical response index using the tumour markers ESR, CEA, and CA 15.3 in combination has been evaluated in 67 patients with systemic breast cancer treated by cytotoxic therapies; 55 patients were assessable using the three markers in combination. Changes in these three markers at 6-9 and 12-15 weeks showed a highly significant correlation with the UICC assessed response at 3 and 6 months (p less than 0.001); sensitivity 100 per cent, specificity 87 per cent. Comparison of survival in patients assessed biochemically or by UICC criteria showed no significant difference either for non-progression or progression. The advantages of the biochemical assessment are that it is objective and reproducible. This index has since been used successfully in directing systemic cytotoxics.

A prospective study of patient choice in treatment for primary breast cancer

One hundred and sixty-three patients with primary breast cancer were prospectively studied. Using recently developed selection criteria 91 patients were offered a choice of treatment. Forty-one chose to undergo conservation treatment and 47 chose to undergo simple mastectomy. In those women who were offered a choice of treatment there was a significant tendency for younger patients to choose breast conserving treatment.

Goserelin (Zoladex) in premenopausal advanced breast cancer: duration of response and survival

In premenopausal women with advanced breast cancer the luteinising hormone-releasing hormone agonist goserelin (Zoladex, ICI plc) will produce serum levels of oestradiol equivalent to those following surgical oophorectomy or the menopause. This paper reports our further experience of using this drug in 75 premenopausal patients with advanced breast cancer. In addition to response rates, duration of response is reported. An objective response was seen in 25 patients (33%), the median duration of which was in excess of 15 months. Seven patients (9%) showed a complete response to therapy; median duration greater than 37 months. There was no significant difference in time to disease progression (Lee-Desu statistic 18.26, 1 d.f., P = 0.43) and probability of survival (Lee-Desu statistic 3.41, 1 d.f., P = 0.07) between those patients assessed as having either static disease, or those showing a partial response at six months. Response to therapy correlates significantly with the oestrogen receptor status of the primary tumour (X2 = 20.59, 6 d.f., P less than 0.005). The modest side-effects, ease of administration and reversibility make this approach to therapy very attractive. This is to be remembered in that 53% of patients had disease progression whilst receiving goserelin. These patients thus avoided the unnecessary and irreversible morbidity associated with surgical oophorectomy. With the proven efficacy and minimal morbidity associated with goserelin we believe there is no current role for surgical oophorectomy in the management of premenopausal patients with advanced breast cancer.

Cornelia de Lange syndrome. Otolaryngologic manifestations

Cornelia de Lange syndrome (CDLS) is characterized by multiple congenital malformations and mental retardation. New studies have documented otolaryngologic abnormalities. We examined 45 patients with CDLS. Virtually all had hearing loss, and most had impaired language development. Other otolaryngologic abnormalities, including external auditory canal stenosis and cleft palate, were also common. Because of the high incidence of otolaryngologic abnormalities, and the need for early intervention, it is important for otolaryngologists to recognize CDLS manifestations in the head and neck.

Terfenadine, a potent histamine H1-receptor antagonist in the treatment of grass pollen sensitive asthma

1. We have assessed the effect of a specific histamine H1-receptor antagonist, terfenadine, in the treatment of atopic asthmatics during the grass pollen season. 2. Eighteen mild, grass pollen sensitive asthmatics (10F, 8M, mean +/- s.e. mean age 34.7 +/- 5.6 years), all of whom were controlled on inhaled beta 2-adrenoceptor agonists alone, took part in a 9 week, double-blind, crossover study using terfenadine 180 mg three times daily and placebo. Throughout the study patients recorded peak expiratory flow rate (PEFR) twice daily, symptoms of cough, wheeze, breathlessness and chest tightness (scored 0-3), and their use of bronchodilators. Methacholine inhalation challenge tests were performed each week. Data were analysed by a method suitable for a two group, two period crossover trial with baseline measurements. 3. Terfenadine significantly reduced symptoms of cough by 76.9% (P less than 0.05) and wheeze by 46.9% (P less than 0.02). Symptoms of breathlessness and chest tightness were reduced by 16.8 and 30.3% respectively but these were not statistically significant. Morning and evening PEFR rose by 5.5 (P less than 0.001) and 6.2% (P less than 0.003) respectively on treatment with terfenadine and bronchodilator use fell by 40.3%. A progressive increase in methacholine sensitivity was seen in both treatment groups throughout the study but did not reach statistical significance. 4. We conclude that treatment with terfenadine during the grass pollen season in sensitive asthmatics reduced their symptoms and bronchodilator requirements and produced a modest improvement in their lung function without affecting the development of increased methacholine sensitivity that occurred during the grass pollen season.

De novo direct tandem duplication of the short arm of chromosome 7(p21.1-p14.2)

We report on a 6-year-old boy with moderate developmental retardation and unusual dermatoglyphics. Cytogenetic analysis demonstrated a duplication of chromosome sub-region 7p21.2-p14.2. Confirmation of the specific duplicated region was determined by quantitative Southern blotting by using a DNA fragment previously localized to the portion of chromosome 7 thought to be duplicated. This patient did not have the internal malformations seen with other dup(7p) patients.

Kinetics of N-[(4-chlorophenyl)amino]carbonyl-2,3-dihydro-1H-indene-5-sulfonamide (LY186641) in humans

The metabolism and disposition of LY186641, a diarylsulfonylurea with antineoplastic activity identified in preclinical tests, was determined in 21 patients who received 23 courses of orally administered drug. A linear correlation was found between the dose of drug administered and LY186641 peak plasma concentrations and LY186641 area under the curve measurements. Clearance (135 +/- 36 ml/h/m2), terminal half-life (31 +/- 11 h), and volume of distribution (10.2 +/- 2.8 liters) were independent of drug dose. No LY186641 was excreted in urine. Hydroxy and keto metabolites of LY186641 were identified in plasma and urine samples. Urinary excretion of these metabolites during the initial 48 h following drug administration accounted for 20% of LY186641 disposition. Plasma half-life of the hydroxy and keto metabolites was longer than that of parent drug (3.3 and 3.1 days, respectively). Plasma concentrations of parent drug correlated with the presence of methemoglobinemia, the dose-limiting toxicity found with LY186641.

Cytogenetic results of chorionic villus sampling: high success rate and diagnostic accuracy in the United States collaborative study

Cytogenetic results of first-trimester chorionic villus sampling are reported from seven U.S. medical centers. For 6033 patients who had a successful chorionic villus sampling procedure, the rate for obtaining a cytogenetic diagnosis was 99.6% with the direct method, long-term culture, or both. There were no incorrect sex predictions and no diagnostic errors involving trisomies 21, 18, or 13, sex chromosome aneuploidies, or structural abnormalities. There were no cases of normal cytogenetic diagnosis followed by birth of a cytogenetically abnormal infant. Three cases of unusual aneuploidies (tetraploidy, trisomy 16, and trisomy 22) detected by the direct method only were not confirmed by cytogenetic follow-up. Mosaic cytogenetic abnormalities were observed in 0.83% of all cases in which chorionic villus sampling was done but were confirmed by amniocentesis or in fetal tissues in only 7 of 30 cases (23.3%). Maternal cell contamination occurred in 1.9% of long-term cultures, although this did not present any cytogenetic diagnostic difficulties. Overall, a very high degree of laboratory success and diagnostic accuracy was observed with either cytogenetic method, although fewer predictive errors were observed with the long-term culture method and none were observed when both methods were used.

Ph-negative T cells in a patient with chronic myelogenous leukemia for twenty-eight years

The frequency of metaphases without a Philadelphia chromosome was determined in mitogen-stimulated cultures of peripheral blood mononuclear cells (PBMC) and purified T lymphocytes (93% CD2-positive) from a patient with chronic myelogenous leukemia (CML) for 28 years. The PBMC cultures contained few Ph-negative cells (8%), but they constituted 92% of the metaphases in T cell cultures, indicating few if any Ph-positive T cells in the patient's circulation. The results demonstrate that T cells derived from the leukemic clone may fail to replace the non-neoplastic population even when CML arises in childhood and the patient survives for many years. This raises questions concerning the normal role of the bone marrow as a source of T cells after infancy, and also whether Ph-positive lymphocytes may be at a disadvantage for growth.

Sensitivity to Parietaria pollen in the Southampton area as determined by skin-prick and RAST tests

The pollen of Parietaria species is a well-recognized and important inhalant allergen in the Mediterranean area. Parietaria judaica (Pellitory-of-the-Wall) is native to the U.K., flowering from June to September, but is not usually considered to be of any clinical importance by U.K. allergists. We skin tested 62 patients with a clinical history of summer seasonal respiratory symptoms and a control group of 11 patients with perennial respiratory symptoms only. Each was skin tested in duplicate with extracts of grass pollen, birch pollen, Parietaria pollen, Dermatophagoides pteronyssinus, Cladosporium, Alternaria, nettle pollen and negative and positive controls, and serum samples were collected for RAST assays for Parietaria and nettle. Eight of the 62 patients in the main group showed skin reactivity to Parietaria. Five of these eight had never visited the Mediterranean area and therefore it is possible that sensitization occurred in the U.K. Thirteen of the 62 patients were skin reactive to nettle but there was no correlation between skin reactivity to Parietaria and nettle. This supports a recent report that, despite their close botanical relationship, no antigenic cross-reactivity exists between the two species. No correlation was seen between skin reactivity and serum RAST activity to Parietaria or nettle. It is not known whether exposure to Parietaria pollen contributes to the seasonal symptoms of the patients found to be skin reactive. None of the 11 patients in the control group was skin reactive to Parietaria.

Acupuncture: an important treatment option

In recent years acupuncture has gained increasing acceptance in this country as a treatment option for certain painful conditions. At the same time, nurse practitioners are seeing greater numbers of Asian immigrants whose beliefs about health and illness are based on the theory of Chinese traditional medicine. This article provides an explanation of Chinese traditional medicine and the use of acupuncture in that context, so that nurse practitioners may take these beliefs into account when planning care for Asian clients. Information on the use of acupuncture from a Western health care perspective is also presented to give nurse practitioners an understanding of this treatment, which will enable them both to explain it to clients and to refer them for acupuncture when appropriate.

Sodium-Dependent Azotobacter chroococcum Strains Are Aeroadaptive, Microaerophilic, Nitrogen-Fixing Bacteria

Na + -dependent strains of Azotobacter chroococcum were observed to have very low reactivities with the H 2 O 2 spot test for catalase. The cell extract of the representative Na + -dependent strain 184 contained a catalase specific activity that was 10-to 600-fold lower than those found in Na + -independent strains of A. chroococcum. Peroxidase and superoxide dismutase activities existed in all strains, although only certain Na + -dependent strains contained a peroxidase reactive with p -phenylenediamine. The activities of catalase and peroxidase in the Na + -dependent strain 184 were dependent on iron availability, which helped to explain the iron-dependent growth characteristic of this strain. The activities of these enzymes were not increased by subjecting the cells to increased aeration, nitrogen-fixing conditions, or paraquat. Strain 184 was found to be very sensitive to H 2 O 2 or paraquat, even under iron-sufficient conditions, and was difficult to recover quantitatively on solid plating media. Strain 184 was more susceptible to H 2 O 2 when grown under low-aeration, nitrogen-fixing conditions than when it was grown in the presence of NH 4 + . Low population densities of strain 184 grew in nitrogen-free medium under microaerophilic conditions, while more dense populations were able to fix nitrogen under aerobic conditions. Therefore, these bacteria appeared to be aeroadaptive, microaerophilic, nitrogen-fixing bacteria.

Historical communication: Philadelphia-positive chronic myelogenous leukemia followed for 27 years

The patient we studied was diagnosed as having chronic myelogenous leukemia (CML), possibly radiation-induced, in 1960 at age 9, and a Philadelphia chromosome was first demonstrated in the neoplastic cells in 1961. Her subsequent clinical course has been cyclic, requiring periodic therapy, but there has been no karyotypic progression. A study in 1987 continued to show the typical t(9;22) translocation as the only cytogenetic alteration, and concurrent molecular investigation of the neoplastic cells revealed a breakpoint cluster region rearrangement, also typical of CML. The chromosomal and molecular data provide no obvious explanation for her remarkably prolonged survival.

Maternal age-specific rates of 47,+21 and other cytogenetic abnormalities diagnosed in the first trimester of pregnancy in chorionic villus biopsy specimens: comparison with rates expected from observations at amniocentesis

Results are presented on chromosome analyses made on 4,481 embryos or fetuses studied through chorionic villus sampling (CVS) in whom there was no known bias to presence of a chromosome abnormality except advanced parental age. We excluded from the analysis most cases in which mosaicism was diagnosed or in which there were cytogenetic discrepancies among samples obtained from the conceptus. There remain 48 cases of 47,+21, 39 cases of other nonlethal abnormalities, and 12 lethal abnormalities diagnosed in 4,481 studied. A regression analysis (restricted to the 3,848 cases diagnosed in the 35-49-year maternal age interval) was done on rates of (1) 47,+21, (2) other abnormalities excluding lethals or (3) including them, and (4) all abnormalities excluding lethals or (5) including them. The model used was y = exp(bx + c), where y is the rate of abnormality, x is maternal age at time of CVS (the modal age of the procedure was 10 gestational weeks from the last menstrual period), and b and c were, respectively, (1) 0.288 and -15.527; (2) 0.272 and -15.173; (3) 0.253 and -14.141; (4) 0.282 and -14.753; and (5) 0.271 and -14.195. We also derived rates of abnormalities at the time of CVS that would be predicted from rates (of nonmosaics) at amniocentesis after adjustment for the difference in gestational age between the usual times that these two procedures are done. The difference between the numbers of abnormalities predicted on the basis of these adjusted amniocentesis rates and the numbers observed at CVS provides an estimate of the spontaneous loss of embryos and fetuses between the usual gestational ages of these procedures. In these data, for 47,+21 the estimated proportion lost is 21% but the result is not significant at the .05 level. For other abnormalities excluding lethals the estimated spontaneous loss is 29% (P approximately .05); including lethals it is 44%. For all abnormalities, excluding lethals, pooled together, the estimate is 24%; including lethals it is 33%. The last three values are all significant at the .05 level or lower. The observed rates of abnormalities at CVS would be approximately 10% to 15% higher if one pooled diagnosed mosaics with the nonmosaics, but the estimated proportion of spontaneous fetal loss would be lower.

Comparison of a positive expiratory pressure (PEP) mask with postural drainage in patients with cystic fibrosis

The use of a positive expiratory pressure (PEP) mask was compared with postural drainage in the treatment of 10 patients with cystic fibrosis. The patients were allocated randomly in a crossover fashion to the two regimens and evaluated initially by a physiotherapist and over a 4 week treatment period by use of a diary card. There was no significant difference in sputum production or change in lung function between each technique as assessed by the physiotherapist. Diary card evaluation also failed to demonstrate a difference in sputum production, symptom score or peak expiratory flow rate between the 4 week treatment periods. It was concluded that PEP mask therapy is an acceptable and effective alternative to postural drainage in interval therapy of patients with cystic fibrosis, although the patients have tended to revert to postural drainage during acute exacerbations.