The global AIDS pandemic. Toward a new vision of health

The AIDS pandemic has not been brought under control in any community or nation as its impact continues to worsen. The program-based strategy developed in the mid-1980s was important in placing AIDS on national and global agendas. From the laboratory and healthcare facilities will come many answers to the AIDS pandemic, some opening new prospects for effective prevention and care. The global fight against AIDS has now reached a critical stage in which complacency and loss of direction threaten the opportunity to effectively curb the course of the pandemic, mitigate its impact, and stimulate the emergence of a modern concept of health and society.

Periodontal treatment needs and oral hygiene among Ethiopian immigrants

Periodontal disease studies in developing countries over the past four decades indicate periodontitis to be a major problem, even in populations with relatively low caries rates. The aim of this study was to document levels of periodontal treatment needs, as well as oral hygiene levels for a large sample covering all ages of an Ethiopian Jewish population recently immigrated into Israel. Over 800 subjects from the total of 15,000 Ethiopians who immigrated were examined utilising the PTNS Index and the OHI-S Index. Results indicate that all the examined population was in need of oral hygiene instruction. Almost 80 per cent are in need of scaling and approximately 20 per cent are in need of more complex treatment such as surgery. Significant differences were found according to age. This could be attributed to the high OHI-S scores, ranging from 2.53 at age 0-12 to 4.82 at the 51+ age group, with a mean Debris Index of 2.12 for the total population. It is suggested that this population should be exposed immediately to preventive and treatment programmes to improve oral hygiene and decrease needs for future, costly periodontal treatment.

Trans fatty acids: a cause for concern?

The recommendation to reduce total and saturated fat is incorporated into the dietary guidelines for the general population in many western countries. In addition, dietary modification to reduce substantially the intake of saturated fats is a cornerstone of treatment in the hyperlipidaemias. Concern has recently been expressed regarding possible deleterious effects of trans isomers of unsaturated fatty acids on the lipoprotein profiles of both normo and hypercholesterolaemic persons. This review seeks to examine recent research in this area with a view to considering possible changes in the present dietary recommendations.

Dilated cardiomyopathy is associated with an increase in the type I/type III collagen ratio: a quantitative assessment

OBJECTIVES

The aim of this study was to quantify total collagen and the type I/type III collagen ratio and their localization in hearts with dilated cardiomyopathy.

BACKGROUND

Patients with dilated cardiomyopathy have an increase in intramyocardial fibrillar collagen. Types I and III are the main constituents and have different physical properties that may affect cardiac compliance.

METHODS

Nineteen hearts with dilated cardiomyopathy were studied (17 cardiac explants, 2 hearts obtained at autopsy) and compared with reference hearts. Total collagen was determined by hydroxyproline analysis. Collagen types I and III were analyzed using the cyanogen bromide method and immunohistochemical analysis followed by microdensitophotometric quantification. Localization of collagen types I and III was established at the light and electron microscopic levels. Immunoelectron microscopy provided information regarding their localization.

RESULTS

Total collagen and the collagen type I/type III ratio were increased in hearts with dilated cardiomyopathy (p < 0.05). Electron microscopy showed a diffuse increase in collagen fibrils in the endomysium; the perimysium showed an inhomogeneous increase. Collagen fibrils were thicker, and fibrous long-spacing collagen occurred in the endomysium. Immunoelectron microscopic findings confirmed an increase in type I collagen.

CONCLUSIONS

Hearts with dilated cardiomyopathy have a statistically significant increase in the collagen type I/type III ratio. The changes occur in the endomysium and perimysium, although with differences in distribution. These changes in intramyocardial collagen may be clinically relevant because they may affect cardiac rigidity and, therefore, eventually may render the heart less compliant. Further studies are needed to evaluate at what point in the course of the disease these changes appear.

Uncompensated care: hospitals' responses to fiscal pressures

This Data Watch examines the impact of hospital competition, the Medicare prospective payment system (PPS), and Medi-Cal selective contracting on the provision of uncompensated care by private hospitals in California during 1980-1989. It finds that hospitals subject to more intense competition and greater fiscal pressure from Medicare and Medi-Cal reduced their provision of uncompensated care relative to hospitals facing less pressure from these sources. We estimate that had hospitals not been subjected to increasing price competition from growth of managed care plans and financial tightening in public programs, they would have provided 36 percent more uncompensated care than was actually provided in 1989.

As good as anyone: antenatal shared care at an inner Sydney hospital

An exploratory survey design was used to assess satisfaction with antenatal care over a two-month period of women giving birth in an inner Sydney teaching hospital. Patients received obstetric services from private obstetricians, midwives, the hospital outpatient clinic, or 'shared care' between general practitioners and the outpatient clinic or birth centre. Insurance status and demographic information were collected across all groups. Shared care patients gave reasons why they chose that model of antenatal service. Ten per cent of women in the sample received shared care. Shared care patients were equally as satisfied as those in other modes of care in all but one factor--promptness of service (in which private obstetricians received higher ratings). They also judged shared care to have the advantages of being convenient, personal, and culturally appropriate. Significantly more patients in the shared care group were born overseas and they were less likely to hold private insurance. This paper discusses the results of the current study in the context of the Australian literature, explores some issues surrounding satisfaction research, and suggests further research arising from this work.

Clinical anatomy of the atrioventricular junctions

OBJECTIVES

This study reevaluated the anatomy of the areas anterior and posterior to the atrioventricular (AV) septal structures, previously said to represent anterior and posterior septal areas.

BACKGROUND

In descriptions of the locations of accessory AV pathways within the AV junctions, four regions have been recognized: the left and right free walls and the anterior and posterior septums. On the basis of known facts concerning cardiac structure, it is questionable whether these so-called septums are truly septal.

METHODS

Ten human hearts were dissected to elucidate the clinical anatomy of these purportedly septal regions, together with the overall arrangement of the AV junctions.

RESULTS

The true septal components of the AV junctions are the muscular and membranous AV septal areas. These separate the cavity of the right atrium from that of the left ventricle. The region previously designated as the anterior septum is part of the right parietal junction. It is contiguous with the membranous part of the septum but extends anteriorly and laterally from the septum as part of the supraventricular crest of the right ventricle ("crista supraventricularis"). In the region posterior to and beneath the mouth of the coronary sinus, only the most anterior extent, in continuity with the central fibrous body, is part of the muscular AV septum. The posterior extent of this area roofs over the diverging right and left ventricular walls and is filled in with fibroareolar tissue of the AV groove.

CONCLUSIONS

The larger part of the regions anterior and posterior to the true AV septal areas are not septal but are parts of the parietal AV junctions. An understanding of these anatomic relations is essential for those wishing to modify conduction across the AV junctions.

[Ischemic nephropathy]

Ischemic nephropathy encompasses renal insufficiency due to 3 different diseases, namely renal artery stenosis, so-called benign nephrosclerosis, and renal cholesterol embolism. All 3 disease entities may lead to a progressive loss of renal excretory function. If a patient presents with renal failure of unknown origin, renal artery stenosis should be looked for by color-coded duplex scanning or arteriography. The clinical presentation of benign nephrosclerosis in caucasians has no typical clues. Usually, a renal biopsy identifies this renal disorder in a patient with long-standing hypertension, moderate proteinuria and renal insufficiency. Cholesterol embolism typically affects several arterial trees, and is induced by arteriography in patients with arteriosclerosis of the aorta. The best treatment for ischemic nephropathy due to renal artery stenosis [conservative, angioplasty, surgery] is unknown because appropriately controlled trials are lacking. Invasive therapy should be considered in patients with bilateral renal artery stenosis or stenosis of a single functioning kidney, particularly if the affected kidney is not contracted. Arguments in favor of invasive therapy include the progressive nature of renal artery stenosis and the poor outcome of dialysis patients with this diagnosis as underlying renal disease.

Prevalence of dental caries among Ethiopian emmigrants

Studies have documented the prevalence of caries in developing countries. The current study adds to this body of knowledge. Of the total Ethiopian Jewish population who emmigrated to Israel in 1991, a sample of over 800 individuals was randomly selected representing all age groups. DMF-T and DMF-S scores were recorded, as well as percentages of caries free individuals. Results indicated that almost no fillings or crowns had been provided to the study population. The Missing 'M' component was low as was the Decay 'D' component, although this increased with increasing age, ranging from 0.33 D-T at the 0-12 age group to 2.46 at the 51+ age group. In the permanent dentition 88.4 per cent of those 0-12 years of age were caries free and 74.5 per cent were caries free in both the primary and permanent dentition. Almost 59 per cent of the 13-20 years olds were caries free and 32.8 per cent of those 21-50 years old. Only 16.7 per cent were caries free at age 51+ years old. The data indicate a relatively low prevalence of both coronal and root caries, and an effort has to be made to keep these figures low for years to come mainly by diet and dental health education.

Nutrient intake and haematological status of vegetarians and age-sex matched omnivores

OBJECTIVE

The study was designed to investigate the nutritional intake and haematological status of adult vegetarians.

DESIGN

Cross-sectional comparison of vegetarians and age/sex-matched omnivores.

SETTING

Free-living community subjects.

SUBJECTS

Fifty vegetarians were recruited by local advertisement. Each vegetarian selected their own age/sex-matched 'friend' control.

OUTCOME MEASURES

Each subject completed a 12 day dietary record. Haemoglobin, red cell indices, and serum ferritin, B12 and folate were measured.

RESULTS

Protein, saturated fat and vitamin D intake were significantly lower in the vegetarians, particularly in the vegans. Dietary fibre was higher in the vegetarians, and intake of calcium and zinc was similar. Mean (SD) iron intake in the vegetarians and vegans of 16.8 (4.8) mg/day was significantly greater than that of the omnivores: 14.6 (4.3) mg/day (P = 0.02). All the iron consumed by the vegetarians was non-haem; for the omnivores 10% was haem iron. Serum ferritin concentrations were significantly lower in male vegetarians than omnivores; mean (SD): 36.6 (36.0) and 105.4 (78.7) ng/ml, respectively, P < 0.01; and significantly more had values below 12 ng/ml (P < 0.001), despite having higher iron intakes which exceeded the Recommended Nutrient Intake (RNI). Female vegetarians also had lower ferritin concentrations than omnivores; mean (SD) 13.6 (7.5) compared to 33.6 (54.3) ng/ml, P < 0.01, but similar numbers of women had values below 12 ng/ml (42% and 39%). The vegans all had B12 intakes below the RNI; and 35% of the long-term vegetarians and vegans had serum vitamin B12 concentrations below the reference range.

CONCLUSION

Although the vegetarians had diets nearer to the recommended diet with a lower fat and salt content, a significant number need advice to improve their haematological status. Recommended intakes of iron may also need to be higher for vegetarians, particularly men.

Metabolic effects of alterations in meal frequency in hypercholesterolaemic individuals

It has been suggested that the metabolic consequences of a given diet may depend in part on the frequency with which meals are eaten. To investigate the effects of meal frequency on plasma lipid metabolism, 16 free-living hypercholesterolaemic men and women consumed their usual diet as 3 or 9 meals/day in random order for 4 weeks. Dietary macronutrient intake and body weight remained similar on the 2 regimens. Fasting plasma lipids were measured after 2, 3 and 4 weeks on each regimen and there were no significant differences in the fasting concentrations of plasma total, LDL, and HDL cholesterol, triglycerides, apolipoprotein A-I and B and the ratio of total: LDL and LDL:HDL cholesterol (HDL-C) on the two diets. The mean (+/- S.D.) fasting total cholesterol was 6.73 +/- 0.74 and 6.81 +/- 0.88 mmol/l on 3 and 9 meals/day, respectively and LDL-C was 4.77 +/- 0.66 and 4.87 +/- 0.78 mmol/l, respectively. There was also no significant variation in the response of plasma triglycerides or serum insulin to a high fat meal following a 3 week adaptation to regimens of 3 and 9 meals/day. Finally the 24 h urinary output of C-peptide was similar on each diet. The consumption of isoenergetic diets as 3 and 9 meals/day did not influence fasting plasma lipid levels, C-peptide excretion or the plasma triglyceride response to a high fat meal of a group of free living hypercholesterolaemic subjects.

Risk of death from cancer and ischaemic heart disease in meat and non-meat eaters

OBJECTIVE

To investigate the health consequences of a vegetarian diet by examining the 12 year mortality of non-meat eaters and meat eating controls.

DESIGN

Prospective observational study in which members of the non-meat eating cohort were asked to nominate friends or relatives as controls.

SETTING

United Kingdom.

SUBJECTS

6115 non-meat eaters identified through the Vegetarian Society of the United Kingdom and the news media (mean (SD) age 38.7 (16.8) years) and 5015 controls who were meat eaters (39.3 (15.4) years).

MAIN OUTCOME MEASURES

Standardised mortality ratios for cancer, ischaemic heart disease, and total mortality in the two cohorts and death rate ratio in the non-meat eaters compared with meat eaters after adjustment for potentially confounding variables.

RESULTS

Standardised mortality ratios (taking the value among the general population as 100) for ischaemic heart disease were 51 (95% confidence interval 38 to 66) for meat eaters and 28 (20 to 38) for non-meat eaters (P < 0.01). Values for all cancers were 80 (64 to 98) and 50 (39 to 62) for meat eaters and non-meat eaters respectively. After adjustment for the effects of smoking, body mass index, and socioeconomic status death rate ratios in non-meat eaters compared with meat eaters were 0.72 (0.47 to 1.10) for ischaemic heart disease and 0.61 (0.44 to 0.84) for all cancers.

CONCLUSIONS

The reduced mortality from cancer among those not eating meat is not explained by lifestyle related risk factors, which have a low prevalence among vegetarians. No firm conclusion can be made about deaths from ischaemic heart disease. These data do not justify advice to exclude meat from the diet since there are several attributes of a vegetarian diet apart from not eating meat which might reduce the risk.

Fatty acid composition of erythrocytes and plasma triglyceride and cardiovascular risk in Asian diabetic patients

The excess of coronary heart disease in Indian Asians compared with Europeans is unexplained by conventional risk factors, although the high prevalence of diabetes may play a part. To explore the contribution of diet we compared the fatty acid composition of erythrocyte membrane phospholipid and plasma triglyceride in 36 Gujarati Asians and 24 Europeans with non-insulin-dependent diabetes. Erythrocytes from Asian subjects contained higher proportions of linoleic, dihomogammalinolenic, and arachidonic acids, and lower proportions of oleic and n-3 series fatty acids; triglycerides contained higher linoleic and lower oleic acid levels. For example, mean percentage (SE) of oleic acid (18:1n-9) in erythrocytes was 16.7 (0.2) in Asians and 20.5 (0.6) in Europeans (p = 0.0001), and total n-6:n-3 ratio was, respectively, 12.8 (0.7) and 6.7 (0.7) (p = 0.0001). A high dietary intake of linoleic acid may not be cardioprotective unless balanced by significant intakes of oleic and n-3 series fatty acids, at least in diabetic Indian Asians. By itself, the conventional recommendation to substitute polyunsaturated for saturated fat in the diet may be inadequate to reduce thrombogenesis, and the overall balance of fatty acids, including monounsaturates, should be considered.