An epidemic of hepatitis B among injection drug users in a rural area

An epidemic of hepatitis B occurring in a rural area of Nova Scotia in 1988 and 1989 was investigated. This epidemic identified injection drug use (IDU) as the major determinant of transmission and was the first highly visible indication of IDU in rural Nova Scotia. Contact-tracing was used to identify 186 injection drug users (IDUs), of whom 153 (82%) were interviewed. Of 133 (72%) IDUs who underwent serological testing, 78 had serological evidence of hepatitis B infection. Using epidemiological criteria, 57 IDUs formed a cluster of hepatitis B infections. Using logistic regression techniques, age (O.R. = 1.1), the total number of IDU-contacts named (O.R. = 1.1), and the number of hepatitis B seropositive IDU-contacts named (O.R. = 1.3), were identified as risk factors predictive of an IDU being a cluster case. The characterization of this epidemic may be useful as a model for the spread of hepatitis B and other viral infections among IDUs in rural areas.

Life expectancy following dietary modification or smoking cessation. Estimating the benefits of a prudent lifestyle

OBJECTIVE

To evaluate the maximum benefits of dietary modification or smoking cessation to the life expectancy of North American adults.

DESIGN

Using a computer model, we estimated the change in life expectancy for men and women following risk factor modification. We then estimated the total number of adults who would be targeted by national guidelines and the total person-years of life that would be saved.

PATIENTS

Men and women aged 30 to 74 years who were free of coronary heart disease.

INTERVENTIONS

Smoking cessation or serum cholesterol-reducing diets with 8% to 10% saturated fat and 240 to 300 mg of daily cholesterol, respectively.

RESULTS

On average, dietary modification would reduce serum cholesterol levels from 0.45 mmol/L (17.4 mg/dL) to 0.75 mmol/L (29.1 mg/dL) in men and 0.12 mmol/L (4.6 mg/dL) to 0.55 mmol/L (21.4 mg/dL) in women, thereby increasing life expectancy by 0.03 to 0.4 year and 0.01 to 0.16 year, respectively. Smoking cessation would increase life expectancy from 2.59 to 4.43 years among men and from 2.6 to 3.68 years among women. Among adult Canadians, dietary modification would save 373,000 to 683,000 person-years of life. The majority of these benefits would occur among men who start dieting at ages 30 to 59 years. Smoking cessation would add more than 4 million person-years of life to the Canadian population. The relative impact of either intervention among American adults would be similar to these Canadian estimates.

CONCLUSIONS

Younger men, aged 30 to 59 years, might live slightly longer after dietary change, but among women and older men the average benefits would be negligible. The benefits of smoking cessation are more uniform across age and sex and are substantially greater than those predicted for dietary change.

Indications for transfer for childbirth in Inuit women at the Innuulisivik Maternity

The Innuulisivik Maternity is a northern-based service in Povungnituk, Quebec, which serves the Inuit women of the Hudson Coast. Although most women stay in the North for childbirth, others are transferred south. This paper will describe the experience of the Innuulisivik Maternity, which uses committee-based risk assessment for transfer decisions. Data for the three-year period 1989-1991 were examined. Descriptive statistics were used to compare the observed differences in the distribution of several variables according to birthplace. Data were available for 411 women. Three hundred fifty (85.2%) of the births occurred at Innuulisivik: 44 (10.7%) women were transferred and 17 (4.1%) were nursing station births. In 80% of transfers, clinical conditions were identified which in themselves usually require transfer. Premature labor was prevalent in the transfer group. The data demonstrate that risk scoring by consensus is a viable option for northern birthing units. Finally, logistical and cultural factors should be included for meaningful risk assessment in the North.

Routine immunologic tests in systemic lupus erythematosus: is there a need for more studies?

OBJECTIVE

To evaluate the sensitivity, specificity, and likelihood ratios of anti-dsDNA, C3, C4, and Clq binding tests for predicting flares in systemic lupus erythematosus (SLE) and to evaluate the conflicting results reported in the recent literature.

METHODS

Test results from 9 to 3 months preceding 83 flares among 53 patients from a cohort study of 202 patients with SLE were assessed for their ability to predict renal and nonrenal flares and all flares combined. A flare was defined as a 6 point rise in a modified SLE Disease Activity Index.

RESULTS

For all 4 tests, sensitivity approximated 50% and specificity was less than 75%. For anti-dsDNA, Clq binding, and C4, both positive and negative likelihood ratios were close to 1.0, suggesting little clinical value for routine testing. For C3, likelihood ratios for a positive test approximated 2.0, meeting the minimal level for clinical significance. Review of previous studies suggested that sample size, the use of a standardized disease activity measure to define a flare, the severity of the flare, and the study duration could not explain the discrepant results among studies. The 2 studies with testing every 4 to 6 weeks found that a rising anti-dsDNA predicted flares, while those with less frequent testing did not.

CONCLUSION

While our study provided no major support for routine testing with anti-dsDNA, C3, C4, or Clq binding, additional longitudinal studies are needed to assess monthly testing of anti-dsDNA as a predictor of flare in SLE.

Radiographic damage in rheumatoid arthritis correlates with functional disability but not direct medical costs

OBJECTIVE

Few longitudinal data exist on the relationship between radiographic damage and self-reported functional disability and direct medical costs in rheumatoid arthritis (RA). We assessed these relationships.

METHODS

One hundred thirty patients with RA (at time of the first available radiograph, mean age 56.6 yrs, 16.9% male, mean disease duration 16.8 yrs) were followed for up to 13.4 years. Semiannually, they reported on functional disability (0 = no difficulty, 3 = unable to do), global severity (0 = very well, 100 = very poor), pain (0 = no pain, 3 = severe pain), and health services utilization through completion of the Stanford Health Assessment Questionnaire (HAQ). Concurrent hand radiographs were scored for erosions and joint space narrowing using the Genant method and a single score summing both erosions and joint space narrowing for both hands was calculated (0 = no damage, 200 = maximum damage). The univariate association of functional disability, global severity, pain, or direct medical costs with concurrent radiographic damage was assessed through Spearman correlations and hierarchical regression models. The hierarchical models permit exploitation of the between-patient and within-patient variation present in our longitudinal data.

RESULTS

At the time of the first available radiograph, mean (SD) levels of functional disability, global severity, and pain were 1.3 (0.7), 39.4 (21.0), and 1.1 (0.7), respectively. At entry into the study, the average radiograph score was 49.7 and upon leaving the study it was 66.9. Patients were followed an average of 6.7 years, with radiograph scores increasing at an average rate of 2.5 units/yr. The Spearman correlation [95% confidence interval (CI)] between average per-patient radiograph score and average per-patient HAQ disability index, average per-patient global severity, average per-patient pain score, and average per-patient direct medical costs was, respectively, 0.42 (0.26, 0.55), 0.23 (0.06, 0.39), 0.20 (0.03, 0.36), and 0.06 (-0.11, 0.23). The mean slope (95% CI) for disability on radiograph score was 0.0186 (0.0132, 0.0226), for severity on radiographs 0.1889 (0.1295, 0.2498), and for pain on radiographs 0.0057 (0.0027, 0.0084). As an example, over 10 years, a 25 unit (i.e., 50%) increase in radiograph scores would, on average, be associated with a 0.46 unit (i.e., 35%) increase in disability, a 4.72 unit (12%) increase in global severity score, and a 0.14 unit (13%) increase in pain, all expressed on the HAQ scales. There was little association between radiograph score and direct medical costs.

CONCLUSION

A clinically meaningful association exists between radiographic damage and self-reported functional disability, suggesting that interventions that slow radiographic progression may improve the patient's health status. Such a relationship was not observed between radiographic damage and direct medical costs.

Absence of an association of rheumatoid arthritis and diffuse idiopathic skeletal hyperostosis: a case-control study

OBJECTIVE

To compare the frequency of diffuse idiopathic skeletal hyperostosis (DISH), based on an evaluation of chest radiographs, in 2 populations of patients: those with and without rheumatoid arthritis (RA).

METHODS

Cases of RA were obtained from the Wichita Arthritis Center databank and controls from a private cardiology practice. Patients with RA and controls had to be older than 50 years and have a chest radiograph available. All radiographs were read, in haphazard order, by a single reader who classified them as definitely DISH, probably DISH (these 2 categories were considered as having DISH), uncertain, probably not DISH, and definitely not DISH (these 3 groups defined the absence of DISH). Logistic regression was used to investigate the probability of DISH while controlling for age and sex. Analyses were conducted to take into account the sensitivity and specificity of chest radiographs for the diagnosis of DISH.

RESULTS

Among 748 radiographs (357 RA and 391 controls), 29 were diagnosed as DISH (21 controls and 8 RA). The mean age for the RA group was 66.2 yrs (SD = 11.9 and 108 (30.2%) were men. Control subjects had a mean age of 69.6 yrs (SD = 11.4 and 139 (35.4%) were men. The DISH patients, compared with those without DISH, were more likely to be male (p = 0.004) and older (p < 0.001). After accounting for age and sex, the relative risk of DISH in RA versus the controls was 0.40 (95% confidence interval: 0.20 to 1.01). After taking into account the sensitivity and specificity in this population, the adjusted prevalence of DISH for the RA group was 1% (95% confidence interval: 0.1 to 3.7) and 3.1% (95% confidence interval: 0.2 to 7.9) for the control group.

CONCLUSION

We confirmed the increase in frequency of DISH with increasing age and male sex, but failed to support an increased association of DISH with RA.

Selection of subjects for hospital-based epidemiologic studies based on outward manifestations of disease

Selection of controls with the same outward manifestations of disease as the case group has been proposed as a means of avoiding selection bias in hospital-based case-control studies. The same strategy, however, can lead to selection bias in registry-based case-control studies that use control diseases with similar manifestations whose diagnoses might have been associated with the exposure. Matching exposed and unexposed subjects by outward manifestation of disease can be used in cohort and cross-sectional studies aiming at decreasing selection bias. This strategy in these study designs may lead to overmatching, but this will not bias the relative-risk estimates. Efficiency considerations in applying this strategy require further investigation.

Dissociation of T8+ cell-mediated cytolytic and suppressor functions in young adults

In the normal young adult population, in vitro levels of polyclonally-induced IgG secretion by mononuclear cells (MNCs) vary widely amongst individuals. Levels of IgG secretion correlate with functional suppressor activity of T8+ cells but not with their proportion within the MNCs either prior to culture, or as found in this study, at the end of the culture period. The current study also demonstrates a lack of correlation between T8+ cell-mediated suppressor (Ts) function and a second predominantly T8+ cell-mediated function, alloantigen-directed cytolytic (Tc) activity. Whether this dissociation between Ts and Tc functions reflects quantitative differences in subsets contained within the T8+ population or qualitative differences in the mechanisms required for induction or generation of Ts and Tc remains to be established.

Subcutaneous phaeohyphomycosis caused by Amesia atrobrunnea in Kuwait

The recently described genus Amesia encompasses four species but only Amesia atrobrunnea (=Chaetomium atrobrunneum) is known to be pathogenic to humans. Here, we describe a case of subcutaneous phaeohyphomycosis in Kuwait in an apparently immunocompetent patient diagnosed by direct microscopy of the infected tissue and culture. The identity of A. atrobrunnea was established by typical morphological characteristics and by sequencing of internally transcribed spacer (ITS) region and D1/D2 domains of rDNA. To the best of our knowledge, this is the first report documenting etiologic role of this species in causing a locally invasive subcutaneous infection.

Antimalarial drug utilization by women in Ethiopia: a knowledge-attitudes-practice study

A survey was undertaken between December 1991 and February 1992 to assess the knowledge, attitudes, and practices with respect to malaria of 300 women from six randomly selected rural communities in central Ethiopia. A total of 85% were able to recognize one or more of the common symptoms of the disease; however, the modes of transmission were generally misunderstood and only 23% believed that transmission could be prevented. More women preferred to obtain antimalarials from government clinics rather than from private drug shops, mission clinics, unofficial suppliers of injections, open markets, or from leftover sources. Under-5-year-olds were identified as the most malaria-vulnerable group and given priority for treatment; severity of illness was the principal determinant in seeking treatment. Decisions about treatment were generally made jointly by both parents. Knowledge about the transmissibility of malaria decreased with increasing distance from a health unit (odds ratio: 0.48; 95% confidence interval: 0.27, 0.86). A logistic regression analysis indicated that literacy and village were the most important variables associated with knowledge about preventing malaria.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Background

Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards.

Methods

Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated.

Results

There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy.

Conclusion

Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity

OBJECTIVE

Differences have been described between patient and physician assessments of well being in several chronic illnesses, and these differences may affect outcome. Disagreement may lead to dissatisfaction and to behaviors with dangerous consequences. We describe and identify predictors of patient-physician differences on ratings of disease activity in systemic lupus erythematosus (SLE).

METHODS

Data collected on 154 patients included age, education, disease duration, and patient and physician global assessments of lupus activity on a 10 cm visual analog scale (VAS), the Health Assessment Questionnaire (HAQ), the Medical Outcome Study Short-Form 36 (SF-36), the Systemic Lupus Disease Activity Index (SLEDAI), the Systemic Lupus Activity Measure (SLAM-R), and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Multiple linear regression models were performed using patient VAS scores, physician VAS scores, and patient minus physician VAS scores as the dependent variables, and age, disease duration, selected SF-36 and SLAM-R subscales, and SDI as independent variables.

RESULTS

Patients were 90% female and 80% Caucasian, with a mean education of 13 +/- 2.8 years and a mean age of 43.1 +/- 13.6 years. The overall mean disease duration was 10.5 +/- 7.8 years. Physicians overscored patients by 2.5 cm in 6% of the cases and patients overscored physicians in 16% of the cases. The best multivariate model to predict overall differences included SF-36 mental health and SLAM-R kidney scores.

CONCLUSION

Patient-physician differences may result from a divergence in focus. Patients score lupus activity based on their psychological status, while physicians rely more heavily on the physical effect of the disease.