Domiciliary nebuliser therapy--a valuable option in chronic asthma and chronic obstructive pulmonary disease?

Domiciliary nebulisers are in widespread use for patients who have severe chronic airways disease, both asthma and chronic obstructive pulmonary disease (COPD). We report a study of the use of domiciliary nebulisers designed to assess practical problems and the value of such therapy in preventing hospital admissions. A total of 405 patients underwent a structured interview at home and their case records were reviewed. Technical performance of the nebuliser compressors was assessed. The mean (SD) age of those interviewed was 64.5 (12) years. 185 patients had a physician diagnosis of asthma, and 208 had COPD. 87% patients used their nebuliser at least once daily. Side effects, reported by 54%, were related to frequency of use and commoner in younger patients. 29 subjects (7%) died within 2 years of receiving their nebuliser. Among the survivors, the 2 year periods before and after supply of the nebuliser were compared. The percentage of patients requiring hospital admission for exacerbations of lung disease fell from 56% to 46% (p < 0.01) but the number and duration of admissions was unchanged. Those whose admission duration increased had more severely impaired spirometry when the nebuliser was supplied and had lower activity scores and higher breathlessness scores at the time of interview indicating more severe disease. Approximately half of the compressors were malfunctioning and patients' understanding of the principles of nebuliser treatment was poor. The provision of domiciliary nebuliser can influence hospital admission in patients with obstructive airways disease. There is also a need for improved patient education and for technical support which may require the development of a nurse-run nebuliser service.

Health and productivity of older workers

The purpose of this paper is to present a summary of a critical review of the literature on age, health, and work. The health of older workers is a concern to the extent that the productivity of older workers is considered to be a function of age-related health, the general conclusion being that age-related declines in health inevitably lead to decreased productivity. This paper investigates the implications of age-related physiological and psychological changes on the productivity of older workers, by focusing on a critical examination of the ways in which productivity has been conceptualized and operationalized. This paper concludes that the emerging concept of "work capacity" has the greatest potential for addressing the productivity issues of workforce aging. Implications for public and corporate policy and for further research are also examined.

Wealth, equity and health care: a critique of a "population health" perspective on the determinants of health. Critical Social Science Group

In this paper we examine the recent ascendancy of a "population health" perspective on the "determinants of health" in health policy circles as conceptualized by health economists and social epidemiologists such as Evans and Stoddart [Evans and Stoddart (1990) Producing health, consuming health care. Social Science & Medicine 31(12), 1347 1363]. Their view, that the financing of health care systems may actually be deleterious for the health status of populations by drawing attention away from the (economic) determinants of health, has arguably become the "core" of the discourse of "population health". While applauding the efforts of these and other members of the Canadian Institute for Advanced Research for "pushing the envelope", we nevertheless have misgivings about their conceptualization of both the "problem" and its "solutions", as well as about the implications of their perspective for policy. From our critique, we build an alternative point of view based on a political economy perspective. We point out that Evans and Stoddart's evidence is open to alternative interpretations--and, in fact, that their conclusions regarding the importance of wealth creation do not directly reflect the evidence presented, and are indicative of an oversimplified link between wealth and health. Their view also lacks an explicit substantive theory of society and of social change, and provides convenient cover for those who wish to dismantle the welfare state in the name of deficit reduction. Our alternative to the "provider dominance" theory of Evans and Stoddart and colleagues stresses that the factors or forces producing health status, which Evans and Stoddart describe, are contained within a larger whole (advanced industrial capitalism) which gives the parts their character and shapes their interrelationships. We contend that this alternative view better explains both how we arrived at a situation in which health care systems are as costly or extensive as they are, and suggests different policy avenues to those enunciated by Evans, Stoddart and their confrères.

Establishing a noise measurement protocol for neonatal intensive care units

OBJECTIVES

To compare three noise exposure measurement methods and determine the effect of location within the nursery, time of day, day of week, shift, and activities such as nursing shift change and physicians' rounds on noise measurements.

STUDY DESIGN

We performed a noise distribution survey, central site measurements, and quadrant area measurements in our nursery. The measurements made were sound pressure level and hourly LEQ, LMAX, and L10.

RESULTS

The noise distribution survey method was least useful because steady-state noise sources were the exception. Differences between central site and quadrant area measurements were minimal. There was no significant effect of time of day, shift change, or physician rounds on the noise measurements.

CONCLUSIONS

In an open nursery with excessive noise levels central site measurements over a relatively short time accurately reflect the noise exposure. A protocol for measuring noise exposure in the neonatal intensive care unit is appended.

HLA-G1 protein expression is not essential for fetal survival

HLA-G is a nonclassical, class I HLA gene that is primarily expressed by fetal cells at the maternal-fetal interface and is thought to play a key role in the induction of tolerance in pregnancy. This paper reports the identification of a single base pair deletion at position 1597 (1597delC) in exon 3 (encoding the alpha2-domain) of HLA-G on 20 of 272 (7.4 per cent) African American chromosomes, three of 102 (2.9 per cent) Hispanic chromosomes, and none of 134 Caucasian chromosomes. This relatively common frameshift mutation results in amino acid substitutions in all of the residues in the second half of exon 3 including the conserved cysteine at codon 164. An adult individual was identified who was homozygous for this 'null' allele, and a first trimester placenta that was homozygous for 1597delC had no detectable HLA-G1 protein. These data indicate that expression of HLA-G1 protein is not essential for fetal survival.

Pulp survival and hard tissue formation subsequent to dental trauma. A clinical and histological study of uncomplicated crown fractures and luxation injuries

Traumatic injuries in children and adolescents are a common problem, and the prevalence of such injuries has increased over the last 10-20 years. The purpose of the present investigation was to evaluate long-term results following uncomplicated crown fractures and luxations involving subsequent pulp canal obliteration. A total of 198 patients with 488 injured permanent teeth were available for clinical examination (15 year follow-up), of which 102 also answered a questionnaire and were interviewed before oral examination. Further, 82 permanent incisors presenting with pulp canal obliteration (PCO) were followed for a period of 7 to 22 yr. (mean 16 yr.). The histological evaluation of luxation injuries was performed on 123 primary teeth from 98 patients. In the experimental study (crown fractures), 64 monkey permanent maxillary and mandibular central incisors and canines were subjected to different treatment alternatives at the time of fracture. The findings in the follow-up study showed very little pulpal response to crown fracture and subsequent restorative procedures as long as there was no concomitant periodontal injury. Approximately every fourth resin composite restoration was rated unacceptable at the clinical examination. The interview showed that half of the individuals were dissatisfied with the color and/or anatomic form of the composite restoration. PCO was found in all luxation categories, and according to the survival curve, the 20-year pulp survival rate diagnosed with X-ray was 84%. Although the risk for pulp necrosis (PN) increased with time, routine endodontic intervention of teeth with ongoing PCO of the root canal did not seem justified. The histological study showed that changes in dentin were represented by occlusion of the dentinal tubules and deposition of tertiary dentin. The tertiary dentin were classified as either dentin-like, bone-like or fibrotic. In the experimental study, few changes were observed in the pulp 3 months after crown fractures, irrespective of treatment alternative.

Risks of silicosis in coalworkers exposed to unusual concentrations of respirable quartz

OBJECTIVES

To describe the radiographic changes in coalworkers exposed to unusual concentrations of respirable quartz during the 1970s, and to relate these to exposure measurements.

METHODS

Men who had worked at one Scottish colliery during the 1970s were invited to a health survey. Chest radiographs were taken from 547 subjects. Classifications of these films under the International Labour Organisation (ILO) 1980 scheme were related, by logistic regression, to existing data on individual men's exposures to respirable dust and quartz.

RESULTS

Taking the median of the three readers' results on profusion of small opacities, 203 men (38%) showed progression of at least one profusion category on the 12 point scale, from the various 1970s surveys to the follow up in 1990-1. A total of 158 men (29%) had a profusion of at least 1/0, and 47 (8.6%) of at least 2/1 at the follow up survey. Large opacities were recorded as present by at least two readers for 14 (2.6%) of the men. Profusion of small opacities was strongly related to exposures experienced in the 1970s, and more strongly for quartz than for the non-quartz fraction of the dust. Estimates of risk are presented over the range of quartz exposures experienced.

CONCLUSIONS

The quartz exposures experienced by some men at this colliery have caused considerable progression of radiographic abnormalities since exposure ended. The data accumulated offer opportunities for further more detailed analyses to inform debate on occupational limits for quartz exposures, both in collieries and in other industries where there is exposure to quartz in mixed dust.

A retrospective evaluation of traumatized permanent teeth

The purpose of this retrospective study (15 years follow-up) was to evaluate the long-term results of treatment to injured teeth following acute trauma. A total of 198 patients with 488 injured teeth were available for analysis. Uncomplicated crown fractures were restored with composite restorations in 106 teeth. 19% of the restorations had been replaced more than 10 times and at the final examination approximately 25% were rated as unacceptable, i.e. needing clinical treatment. Fixed prosthetic therapy had been provided for 106 teeth and endodontic treatment had been provided in 114. Colour changes appearing at late stage suggested obliteration, necrosis or endodontically treated teeth. Anterior composite restorations have been considered acceptable as semi-permanent restorations in patients of early school age (7-15 years), and may have been an advance on what was possible previously, but results of this clinical study suggest that they still do have major shortcomings. There remains a need for a simple, conservative method of restoring aesthetics to fractured and discoloured anterior teeth for clinical use in young patients of late school age.

Urodynamic and clinical effects of noninvasive and minimally invasive treatments in elderly men with lower urinary tract symptoms stratified according to the grade of obstruction

OBJECTIVES

We investigated the symptomatic and urodynamic effects of several noninvasive and minimally invasive treatment modalities to quantify these effects and to compare subjective and objective results within groups with various degrees of obstruction.

METHODS

In a prospective study at one center, 487 patients who completed a full screening program including urodynamic investigation started treatment with watchful waiting, terazosin, transurethral microwave thermotherapy, or laser treatment of the prostate; they were re-evaluated symptomatically and urodynamically after 6 months of therapy. The symptomatic and urodynamic results of 87 patients from another center who underwent transurethral resection of the prostate and who had their second urodynamic evaluation 6 months after surgery were also included.

RESULTS

In patients without bladder outlet obstruction (BOO), improvement in maximum flow and symptom scores with little change in the degree of obstruction was most apparent, whereas a decrease of detrusor pressure at maximum flow was observed mainly in patients with BOO. The urodynamic effect but not the symptomatic effect of treatments depended on the initial grade of BOO. Urodynamic changes were more marked in the minimally invasive treatment groups compared with the noninvasive treatment groups.

CONCLUSIONS

In symptomatic patients with benign prostatic hyperplasia, symptomatic improvement in the short term does not seem to depend on changes in urodynamic parameters. Future well-controlled studies focusing on the durability of symptomatic and urodynamic effects will be needed to illustrate the relative potential of urodynamic and other clinical parameters to predict a favorable response to current and innovative treatments.

Pulp calcifications in traumatized primary incisors. A morphological and inductive analysis study

The purpose of this study was to investigate histopathological changes in primary teeth following trauma, and to look for possible correlations between the morphology of pulpal calcification and clinical findings. The material consisted of 123 primary teeth from 98 Danish children aged 9-108 months (mean age 33.5 +/- 19.7 months) at the time of injury. The specimens were analyzed by means of light and scanning and transmission electron microscopy. Data from the clinical investigation and from predetermined ranked parameters from the histological analysis were processed in a computerized inductive analysis program. The results, describing patterns of co-variation, are presented as a decision tree. The most common diagnosis was intrusion luxation (54%). In 41% of all teeth, the degree of obliteration was less than 1/4 of the pulpal lumen. In most cases (79%), no denticles were visible. When present, 80% of the denticles had a bone-like appearance. Tissues occluding the pulpal lumen were either dentin-like (49%), bone-like (19%), or fibrotic (9%). It could be concluded that these varying responses could not be correlated with explicit clinical diagnoses. However, in certain combinations, histological parameters could be correlated to clinical findings.

Subjective aspects of patients with traumatized teeth. A 15-year follow-up study

The aim of this study was to obtain detailed information about adults who suffered trauma to the teeth as children. A total of 102 patients took part. The patients answered a questionnaire and were interviewed before the oral examination. Thirty-nine per cent of the patients reported dissatisfaction either with the color and/or anatomic form of the traumatized teeth or reconstruction. Most of the individuals did not remember having received any information about prognosis for the traumatized teeth. Twenty-one per cent of the patients remembered pain during treatment, and 25% remembered only the behavior and attitudes of the dental team. It can be concluded that all dental treatment in children with traumatized teeth must be carried out as painlessly as possible, and the dental team should minimize discomfort during the treatment. Good knowledge about traumatology and management can reduce stress and anxiety for both the patient and the dental team.

Genetically variable triplet repeats in a RING-finger ORF of Helicoverpa species baculoviruses

Nucleotide sequence analysis of the Helicoverpa zea S-type nucleopolyhedrovirus (HzSNPV) genomic interval between the polh and iel genes has revealed an open reading frame (HOAR ORF) that contains a complex A 1-T rich triplet repeat region (RAT-repeats). HOAR ORF is predicted to encode an acidic, arginine residue rich. 712 aa protein, with a C3HC4 (RING-finger) zinc binding motif. RAT-repeats, distributed over 450 bp. consist of GAT. AAT, and GTT codons, correspond to Asp, Asn and Val residues which display an extreme codon bias not seen with nine other genes of this virus. A survey of four other (field) isolates of Helicoverpa sp. NPVs confirms a high incidence of mutation in the RAT-repeat region. A 158-bp conserved block, homologous to the pe38-ien promoter of AcMNPV, was identified upstream of HOAR ORF. The sub-region of the genome in which HOAR ORF is located is susceptible to rearrangement.

Does ibuprofen affect bilirubin-albumin binding in newborn infant serum?

Intravenous ibuprofen is being studied in sick, premature infants for the prevention of intraventricular haemorrhage and closure of the ductus arteriosus. We tested the effect of ibuprofen on bilirubin-albumin binding in adult and newborn infant serum by measuring the free ibuprofen concentration in the presence of bilirubin (reverse displacement method). At clinically appropriate ibuprofen concentrations the free fraction of bilirubin is increased by a factor of 4. Ibuprofen may increase the risk of bilirubin encephalopathy when used in sick, premature infants.

Population genetic studies of HLA-G: allele frequencies and linkage disequilibrium with HLA-A1

HLA-G is a class I gene that is expressed in the extravillous cytotrophoblast. Although the function of this gene is still unknown, its expression at the maternal-fetal interface suggests that HLA-G may play a key role in the induction of tolerance during pregnancy. Preliminary to our studies of the effects of HLA-G polymorphisms on pregnancy outcome, we have defined HLA-G alleles in the Hutterites. We report here the presence of nine HLA-G alleles that differ with respect to nucleotide sequences, including four groups of alleles that differ with respect to amino acid sequences, and striking linkage disequilibrium between HLA-G and HLA-A alleles. The levels and sites of polymorphism in HLA-G suggest that this gene had a unique evolutionary history and may perform nonclassical functions at the maternal-fetal interface.

Delivering the goods, showing our stuff: the case for a constructivist paradigm for health promotion research and practice

This article argues that there has been a tendency to empower the "conventional" positivist paradigm in health promotion research, often at the expense of confounding or ignoring much of health promotion practice. This article argues further that a "constructivist" research paradigm not only has the potential to resolve some of the tensions between research and practice in health promotion but also is inclusive of knowledge generated by the conventional paradigm. The usefulness of a constructivist paradigm is demonstrated through the use of four practice-based case examples drawn from actual community-based health promotion efforts. The congruence of a constructivist paradigm with the health promotion principles of empowerment and community participation are discussed. Finally, this article argues for the acceptance of the legitimacy of knowledge generated from the constructivist paradigm and concludes that this paradigm is more suited to the goals of current health promotion.

Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors

Little long-term data are available on the frequency by which pulp canal obliteration (PCO) subsequent to trauma leads to pulp necrosis (PN). In this study, 82 concussed, subluxated, extruded, laterally luxated, and intruded permanent incisors presenting with PCO were followed for a period of 7 to 22 yr (mean 16 yr). At final clinical examination, 51% of the observed teeth responded normally to electric pulp testing (EPT). An additional 40% of the teeth although not responding to EPT were clinically and radiographically within normal limits. Yellow discoloration was a frequent finding. During the observation period, periapical bone lesions suggesting PN developed in seven teeth (8.5%). Twenty-yr pulp survival rate was 84%, as determined from life-table calculations. There was no higher frequency of PN in obliterated teeth subjected to caries, new trauma, orthodontic treatment, or complete crown coverage than intact teeth. Although the incidence of PN in teeth displaying PCO seems to increase over the course of time, prophylactic endodontic intervention on a routine basis does not seem justified.

Costs and benefits of cervical screening. II. Is it worthwhile reducing the screening interval from 5 to 3 years?

A reduction in screening interval from 5 years to 3 years would greatly increase the cost of the programme, but would save few extra lives. The cost per life saved would be around 250,000 Pounds at 1995 prices, or around 8000 Pounds per life per year saved. There would in addition be human costs for the women screened. The opportunity cost of reducing the interval may be too great, since it is likely that the Health Service would achieve greater health benefits by investing the funds in other health care activities.

Costs and benefits of cervical screening. I. The costs of the cervical screening programme

In 1991, the average total Health Service cost of a cervical smear, including follow up at the colposcopy clinic, was almost 22.70 pounds in the Perth and Kinross district of Scotland. The average cost per colposcopy clinic visit was 30 pounds. The main cost elements were in general practice (55% of total) and the laboratory (33%), and most of the cost was for staff time.

Costs and benefits of cervical screening. III. Cost/benefit analysis of a call of previously unscreened women

A population-based cervical screening programme issued invitations to women with no record of a previous smear. This call was very good value, at 5780 Pounds per life saved or 159 Pounds per life-year saved at 1991 prices. The first priority for the cervical screening service should be comprehensive coverage.

Psychological sequelae of mountain accidents: a preliminary study

Studies of the victims of road traffic accidents and of violent crime have shown that a significant minority continue to display mood disorders and posttraumatic symptoms one year later; however, few studies have been conducted on victims of other kinds of accident. Thirty-one subjects admitted to hospitals after a mountain accident in the Scottish Highlands were followed up at 3-month intervals over 9 months to determine the prevalence of psychological sequelae; a variety of questionnaires were used to measure mood and other psychological effects. A large minority experienced at least mild depression and other negative consequences at follow-up, despite relatively minor physical injuries; subjects who experienced intrusive thoughts and avoidance of accident-related phenomena demonstrated the least recovery.

PCR analysis of oilseed rape cultivars (Brassica napus L. ssp. oleifera) using 5' -anchored simple sequence repeat (SSR) primers

Primers complementary to simple sequence repeats (SSRs) and with variable three-base 'anchors' at their 5' end, were used in PCR analyses to compare pooled DNA samples from various Brassica napus and B. rapa cultivars. Amplification products were resolved on polyacrylamide gels and detected by silver-nitrate staining. The resulting banding patterns were highly repeatable between replicate PCRs. Two of the primers produced polymorphisms at 33 and 23 band positions, respectively, and could each discriminate 16 of the 20 cultivars studied. Combined use of both primers allowed all 20 cultivars to be distinguished. The UPGMA dendrogram, based on the cultivar banding profiles, demonstrated clustering on the basis of winter/spring growth habit, high/low glucosinolate content, and cultivar origin (i.e. the breeder involved). Intracultivar polymorphism was investigated using a minimum of ten individuals for each cultivar and was found to vary considerably between cultivars. It is concluded that anchored SSR-PCR analysis is a highly informative and reproducible method for fingerprinting oilseed rape populations, but that intra-cultivar variation should be investigated before using banding profiles from pooled samples for the identification of individuals.