An empirical comparison of rural and urban safety-net hospitals

This study compares the characteristics of rural hospitals with urban safety-net hospitals and with "other urban hospitals" (non-teaching, non-safety-net urban hospitals that provide mainstream care in the United States). The objective is to examine if there are similarities between rural and urban safety-net hospitals, both of which serve underserved populations. The authors also wish to study if there are areas in which rural and urban safety-net hospitals are closer together compared to "other" urban hospitals. Based on the results, some potential areas of cooperation between rural and urban safety-net hospitals are discussed.

Understanding the epidemic of HIV in South Africa. Analysis of the antenatal clinic survey data

OBJECTIVES

To investigate the magnitude and the time course of the HIV epidemic in the provinces of South Africa from the antenatal clinic HIV surveys.

DESIGN

We analysed the data on the provincial prevalences of HIV infection from 1990 to 1996 using maximum likelihood methods to determine the intrinsic growth rate and probable asymptotic prevalence of HIV among women attending antenatal clinics.

SUBJECTS

Women attending antenatal clinics and included in the national HIV prevalence surveys conducted by the Department of Health.

RESULTS

1. In KwaZulu-Natal the epidemic is likely to peak at a prevalence of about 23% (95% confidence interval (CI) 19-36%). 2. The intrinsic doubling time does not differ significantly among the provinces. 3. The average length of the intrinsic doubling time is 12.0 months (95% CI 11.3-12.8 months). 4. The force of infection is approximately 1.00/year at age 16 years and declines at a rate of about 5% per year of age above 16 years.

CONCLUSIONS

South Africa is likely to experience one of the worst HIV epidemics in Africa. The lack of statistically significant differences between the growth rates of the epidemic in the various provinces constrains the possible explanations that can be advanced to explain the time course of the epidemic and may in part be a consequence of migrancy. The intrinsic growth rate is higher than previous estimates and it is possible that in those provinces where the prevalence is still low it will eventually reach the same levels as in KwaZulu-Natal.

Corneal aberrations, monocular diplopia, and ghost images: analysis using corneal topographical data

Corneal irregularities can create conditions in which monocular diplopia, "ghost images," and multiple images of various types occur, thus degrading vision. For these secondary images to occur, corneal irregularities must create areas which form: (1) images which are displaced from the primary image; (2) sufficiently focused images; and (3) images which have sufficient contrast to be noticed in the presence of the primary image. Criteria necessary to satisfy these three conditions using measurable data are developed. The concept of a differential deflection field is introduced, and a method to create this field using corneal topography data is developed. It is shown how to use differential deflection field data to assess if conditions necessary for creating secondary images will occur in cases of corneal distortion.

Reduced Ca2+ uptake by mitochondria in pyruvate dehydrogenase-deficient human diploid fibroblasts

Physiological and pathological Ca2+ loads are thought to be taken up by mitochondria via a process dependent on aerobic metabolism. We sought to determine whether human diploid fibroblasts from a patient with an inherited defect in pyruvate dehydrogenase (PDH) exhibit a decreased ability to sequester cytosolic Ca2+ into mitochondria. Mobilization of Ca2+ stores with bradykinin (BK) increased the cytosolic Ca2+ concentration ([Ca2+]c) to comparable levels in control and PDH-deficient fibroblasts. In normal fibroblasts transfected with plasmid DNA encoding mitochondrion-targeted apoaequorin, BK elicited an increase in Ca2(+)-dependent aequorin luminescence corresponding to an increase in the mitochondrial Ca2+ concentration ([Ca2+]mt) of 2.0 +/- 0.2 microM. The mitochondrial uncoupling agent carbonyl cyanide p-(trifluoromethoxy)phenylhydrazone blocked the BK-induced [Ca2+]mt increase, although it did not affect the [Ca2+]c transient. Basal [Ca2+]c and [Ca2+]mt in control and PDH-deficient cells were similar. However, confocal imaging of the potential-sensitive dye JC-1 indicated that the percentage of highly polarized mitochondria was reduced from 30 +/- 1% in normal cells to 19 +/- 2% in the PDH-deficient fibroblasts. BK-elicited [Ca2+]mt transients in PDH-deficient cells were reduced to 4% of control, indicating that PDH-deficient mitochondria have a decreased ability to take up cytosolic Ca2+. Thus cells with compromised aerobic metabolism have a reduced capacity to sequester Ca2+.

Predicting depression in women: the role of past and present vulnerability

BACKGROUND

A prospective study, covering just over a 1-year period, sought to confirm an earlier finding that around 40% of women who experience a severe life event in the presence of two ongoing psychosocial vulnerability factors, (negative close relationships and low self-esteem) will develop a major depressive episode. Distal risk factors were examined to see if they improved prediction.

METHODS

A population sample of 105 mainly working-class mothers with vulnerability and without depression were interviewed three times over a 14-month period to date the occurrence of severe life events and onset of major depression. Degree of vulnerability was assessed at first contact together with distal risk in terms of childhood neglect/abuse and any earlier episodes of depression.

RESULTS

Thirty-seven per cent of these vulnerable women became depressed in the study period. The majority experienced a severe life event, and of these, 48% had onsets. Contrary to expectation, risk was only a little less among those with just one of the two vulnerability factors. Two-thirds of women with an onset had been depressed in previous years. Although this was associated with increased risk, the effect was greatest for those who had experienced an episode before age 20. A relationship between childhood neglect/abuse and onset was entirely accounted for by such early depression.

CONCLUSION

An aetiological model of depression outlined in earlier research was confined with a new factor of teenage depression shown to increase risk of onset.

Bacterial overexpression of putative yeast mitochondrial transport proteins

Thirty-two genes have been identified within the genome of the yeast Saccharomyces cerevisiae which putatively encode mitochondrial transport proteins. We have attempted to overexpress a subset of these genes, namely those which encode mitochondrial transporters of unknown function, and have succeeded in overexpressing 19 of these genes. The overexpressed proteins were then isolated and tested for five well-characterized reconstituted transport activities (i.e., the transport of citrate, dicarboxylates, pyruvate, camitine, and aspartate). Utilizing this approach, we have clearly identified the yeast mitochondrial dicarboxylate transport protein, as well as two additional lower-magnitude transport functions (i.e., tricarboxylate and dicarboxylate transport activities). The implications of these results and the considerations relevant to this approach are discussed.

Reconstruction of the corneal shape with the MasterVue Corneal Topography System

This paper explains how the Humphrey MasterVue Corneal Topography System measures the corneal shape and explains what is meant by the various values presented. Covered are the geometrical concepts underlying the method, the necessary reconstruction steps, a description of the arc step reconstruction method used, a description of the cone of focus concept, and definitions of the presented power values.

Elevated homologous recombination activity in fanconi anemia fibroblasts

It is widely believed that Fanconi anemia cells possess a reduced ability to repair inter-strand DNA cross-links. While the mechanism through which inter-strand DNA cross-links are removed from mammalian chromosomes is unknown, these lesions are repaired via homologous recombination in lower eukaryotes and bacteria. Based on the hypothesis that a similar mechanism of DNA repair functions in mammalian somatic cells, we measured homologous recombination activity in diploid fibroblasts from healthy donors, and Fanconi anemia patients. Somewhat surprisingly, homologous recombination levels in nuclear protein extracts prepared from Fanconi anemia cells were nearly 100-fold higher than in extracts prepared from control cells. We observed a similar increase in the activity of a 100-kDa homologous DNA pairing protein in extracts from Fanconi anemia cells. Transfection studies confirmed that plasmid homologous recombination levels in intact Fanconi anemia cells were substantially elevated, compared with control cells. These results suggest that inappropriately elevated levels of homologous recombination activity may contribute to the genomic instability and cancer predisposition that characterize Fanconi anemia.

Tumor necrosis factor locus polymorphisms in rheumatoid arthritis

We examined six polymorphic elements in the tumor necrosis factor (TNF) locus and determined their allelic distribution in 98 Caucasian rheumatoid arthritis patients in comparison with 91 ethnically-matched controls. Polymorphic elements at four biallelic sites were distributed similarly between patients and controls, irrespective of the presence or absence of DR4. Differences were observed between the two groups at the TNFa and TNFe loci, but these were consistent with extended MHC haplotypes known to be present in rheumatoid arthritis patients. Therefore, this study suggests that there is little, if any, independent contribution of the TNF locus to the genetic background for rheumatoid arthritis susceptibility.

Drug use history and criminal behavior among 133 incarcerated men

The present study investigated the relationship between crime and substance abuse in a sample of 133 consecutively evaluated male prisoners. Using the Structured Clinical Interview for DSM-III-R, we assessed the prevalence of various forms of substance abuse in this population and attempted to judge whether substance abuse played a role in the index crime which has led to the present incarceration. In addition, we assessed whether there was a relationship between the nature of substance dependence and the type of crime committed, whether sexual, violent, or non-violent. Among the 133 prisoners, 95% obtained a diagnosis of dependence on one or more substances. Fifty-eight percent of the inmates reported that they were acutely intoxicated with one or more substances at the time they committed the index crime and an additional 6% were withdrawing from a substance at the time of the crime. There was no significant correlation between the type of substance abuse diagnosis and the type of crime committed. Similarly, there was no significant correlation between the number of individuals who reported they were intoxicated at the time of the offense and the type of crime committed.

Migrancy, masculine identities and AIDS: the psychosocial context of HIV transmission on the South African gold mines

Levels of HIV infection are particularly high amongst migrant workers in sub-Saharan Africa. This paper presents a case study of one such vulnerable group of migrants-underground workers on the South African gold mines-and highlights the psychosocial context of HIV transmission in the mining setting. On the assumption that social identities serve as an important influence on peoples' sexual behaviour, the study examines the way in which miners construct their social identities within the parameters of their particular living and working conditions. It also identifies some of the key narratives used by miners to make sense of their experience in the realms of health, ill-health, HIV and sexuality. Masculinity emerged as a leading narrative in informants' accounts of their working life, health and sexuality, and the paper examines the way in which the construction of masculine identities renders miners particularly vulnerable to HIV. The implications of these findings for HIV educational interventions are discussed.

Fringe boundaries coincide with Notch-dependent patterning centres in mammals and alter Notch-dependent development in Drosophila

In both vertebrate and invertebrate development, cells are often programmed to adopt fates distinct from their neighbors. Genetic analyses in Drosophila melanogaster have highlighted the importance of cell surface and secreted proteins in these cell fate decisions. Homologues of these proteins have been identified and shown to play similar roles in vertebrate development. Fringe, a novel signalling protein, has been shown to induce wing margin formation in Drosophila. Fringe shares significant sequence homology and predicted secondary structure similarity with bacterial glycosyltransferases. Thus fringe may control wing development by altering glycosylation of cell surface and/or secreted molecules. Recently, two fringe genes were isolated from Xenopus laevis. We report here the cloning and characterization of three murine fringe genes (lunatic fringe, manic fringe and radical fringe). We find in several tissues that fringe expression boundaries coincide with Notch-dependent patterning centres and with Notch-ligand expression boundaries. Ectopic expression of murine manic fringe or radical fringe in Drosophila results in phenotypes that resemble those seen in Notch mutants.

The refractive group

Spherocylindrical optical elements can be decomposed into a sphere-equivalent component and two cross-cylinder components, oriented at 45 degrees to one another. These components in turn can be represented with a simple matrix formalism. This matrix formalism allows it to be seen that the components also form members of an eight element group, designated the refractive group. The structure of this group is developed including its algebra and its representation with Cayley diagrams. The group is identified as the eight element dihedral group, D4, and is compared to another well-known eight element group, the quaternion group. An example is given using the group formal algebra to develop the transfer equations for spherocylindrical wavefronts. Certain properties of propagating spherocylindrical wavefronts, such as nonrotation of cylinder axes, are seen to come directly as consequences of the group properties.

Cardiac allograft rejection: do trough cyclosporine levels correlate with the grade of histologic rejection?

BACKGROUND

The introduction of cyclosporine to heart transplantation immunosuppressive protocols has been associated with an improvement in the long- and short-term survival rates. The ideal dose of cyclosporine that maximizes its immunosuppressive properties and minimizes its toxicity has remained an enigma since its introduction. This study was undertaken to evaluate which range of cyclosporine levels provided the most effective protection against graft rejection.

METHODS

We studied the correlation between cyclosporine levels and histologic grade of rejection, cardiac function, and renal function by retrospectively analyzing the results of 1407 individual whole blood cyclosporine trough levels. One hundred seven heart transplant recipients were studied within 2 years of undergoing transplantation. As a historical comparison, we also studied 146 individual trough cyclosporine levels from a subgroup of patients (n = 14) who had acute cellular rejection with graft dysfunction or failure. We correlated trough cyclosporine levels with the histologic severity of cellular rejection, cardiac function (right cardiac catheterization), and serum creatinine in both groups. The correlation was performed within patient's own data rather than between patient groups to avoid interpatient variations.

RESULTS

The mean cyclosporine level was significantly higher (206 ng/ml) when the patients had grade 0 cellular rejection in comparison to grade 3A, with a mean cyclosporine level of 173 ng/ml (p = 0.005). Patients with graft dysfunction or failure had higher mean cyclosporine level (230 ng/ml) when they had no rejection compared with 3A rejection with a mean cyclosporine level of 153 ng/ml (p = 0.001). Furthermore, lower cyclosporine levels were associated with graft dysfunction. There was no correlation between serum creatinine and cyclosporine levels (r = 0.059, r2 = 0.351%).

CONCLUSION

We conclude that cyclosporine trough levels above 200 ng/ml in the first 2 years after heart transplantation are associated with reduced cellular rejection without deleterious effects on renal function.

Kinetics of splenocyte interleukin-4 production after injury and lethal endotoxin challenge

Cytokine aberrations may contribute to sepsis-associated mortality after trauma. We have previously documented that IL-10 (a Th-2 cytokine) is downregulated after tissue trauma, and the administration of exogenous IL-10 improved survival and anti-IL-10 antibody increased lethality in a murine injury-lethal endotox-emia model. IL-4 activates the Th-2 subset of T cells, and functions in a paracrine manner to inhibit proinflammatory cytokine synthesis. The purpose of this study was to investigate the kinetics of IL-4 production in this murine trauma-sepsis model. Mice (n = 50) were randomized to five groups: Control, Femur Fracture (FFx), FFx-lipopolysaccharide (LPS), FFx-LPS-IL10, and FFx-LPS-Anti-IL10. LPS (400 micrograms ip) was administered 4 days after FFx to induce lethal sepsis. IL-10 (0.5 microgram ip) or anti-IL-10 (100 micrograms IP) was administered at resuscitation, 30 min after LPS. IL-4 production was measured in ex vivo splenocyte culture supernatants at 24-hr intervals. Splenocyte IL-4 production was significantly upregulated in the FFx-LPS group that received anti-IL-10; maximal IL-4 production was on Day 5, with a greater than sevenfold increase compared to all other groups. A transient early rise in IL-4 production was noted in the FFx-LPS group that received exogenous IL-10; however, a subsequent rapid decline was documented. Treatment with anti-IL-10 antibody after FFx injury and septic challenge with LPS is associated with an upregulation of splenocyte IL-4 synthesis, as well as an increase in mortality in this murine model. IL-4 and IL-10 interaction postinjury may profoundly influence monocyte activation, cell-mediated immunity, and the subsequent host immune response to infection.

Blockade of CD28/B7 co-stimulation by mCTLA4-Hgamma1 inhibits antigen-induced lung eosinophilia but not Th2 cell development or recruitment in the lung

We have studied the role of the CD28/B7 co-stimulatory pathway in the development of a Th2-type lung immune response. Mice injected two or three times intraperitoneally with ovalbumin in alum adjuvant and then re-exposed to the same antigen by intranasal (i.n.) inoculation show infiltration of the lung tissue and appearance in the broncho-alveolar lavage (BAL) fluid of significant numbers of eosinophils and lymphocytes, in a pattern which is reminiscent of asthmatic inflammation. The accumulation of eosinophils in the airways is completely dependent on interleukin (IL)-5 secretion by CD4+ T cells. We have used mice transgenic for a soluble form of murine CTLA-4 (mCTLA4-Hgamma1) which binds to B7 molecules on antigen-presenting cells, thereby preventing their interaction with T cell-expressed CD28. mCTLA4-Hgamma1-transgenic mice immunized intraperitoneally and challenged i.n. with ovalbumin failed to generate any eosinophil infiltration, suggesting that little or no IL-5 was secreted in the lungs of these mice. In contrast with the complete lack of eosinophils, the numbers and phenotypes of infiltrating lymphocytes were comparable in the lungs of mCTLA4-Hgamma1-transgenic and normal mice. Also, lung lymphocytes from immunized mCTLA4-Hgamma1-transgenic and normal mice could be shown to secrete comparable amounts of IL-4 and IL-5 when stimulated in culture in the absence of mCTLA4-Hgamma1. We conclude that mCTLA4-Hgamma1 can efficiently block the production of IL-5 during in vivo responses and inhibit eosinophil recruitment, but that it does not block the development of CD4+ T cells into Th2 cells with the potential to secrete IL-5.

Spinal osteomyelitis presenting with a life-threatening pleural empyema

STUDY DESIGN

This case report illustrates a rare presentation of spinal osteomyelitis that initially manifested as a life-threatening pleural empyema leading to misdiagnosis.

OBJECTIVES

A high index of suspicion is required to make the correct diagnosis of spinal osteomyelitis, especially with unusual presentations. Appropriate antibiotic management should be commenced immediately the diagnosis is made.

SUMMARY OF BACKGROUND DATA

A review of the literature reveals five previous cases of vertebral osteomyelitis associated with pleural effusions. In three of these, the effusions were reactive and sterile. There is only one previous case of a pleural empyema related to primary spinal osteomyelitis. There also is one case report of vertebral osteomyelitis presenting as a mediastinal abscess.

METHODS

A case is presented of a man thought to have bronchogenic carcinoma with a destructive vertebral metastasis who was sent for palliative radiation therapy. A life-threatening pleural effusion subsequently developed, and after additional investigation, he was found to have spinal osteomyelitis with a pleural empyema.

RESULTS

The empyema was drained through an indwelling chest tube, and the patient was administered appropriate antibiotics. He made a complete and uneventful recovery.

CONCLUSIONS

The case illustrates a rare presentation of spinal osteomyelitis. It exemplifies the dictum that if a malignant disease is suspected, every effort has to be made to establish a histologic diagnosis to prevent inappropriate management and the potentially devastating consequences of an incorrect diagnosis. It also high-lights the difficulties in diagnosis of vertebral osteomyelitis with empyema. With correct management, the prognosis is excellent.