Tuberculous otitis media -- a diagnostic dilemma

Tuberculous otitis media can provide a diagnostic challenge even to the most astute and experienced clinician. The rarity of the condition and its propensity to masquerade as commoner otological conditions further delays diagnosis and treatment. We present the case of a 22-year-old female who presented with chronic aural discharge, unilateral hearing loss and recurrent hemifacial paralysis. The paper highlights the difficulty in diagnosis and stresses the need for a high index of suspicion in cases resistant to the common methods of treatment.

Once-daily oral gatifloxacin versus oral levofloxacin in treatment of uncomplicated skin and soft tissue infections: double-blind, multicenter, randomized study

This was a double-blind, multicenter study in which 410 adults (> or =18 years of age) with uncomplicated skin and soft tissue infections (SSTIs) were randomized to receive either 400 mg of gatifloxacin orally once daily or 500 mg of levofloxacin orally once daily for 7 to 10 days. The study protocol called for four assessments-before and during treatment, at the end of treatment, and posttreatment. Efficacy evaluations included clinical response and bacterial eradication rates. Of 407 treated patients, 202 (108 women, 94 men) received gatifloxacin and 205 (111 women, 94 men) received levofloxacin. For clinically evaluable patients, the cure rates were 91% for gatifloxacin and 84% for levofloxacin (95% confidence interval [CI] for the difference, -2.0 to 15.2%). Clinical cure rates for microbiologically evaluable patients were 93% for gatifloxacin and 88% for levofloxacin (95% CI for the difference, -6.5 to 16.8%). The bacterial eradication rate was 92% for each group, with gatifloxacin eradicating 93% of the methicillin-susceptible Staphylococcus aureus isolates and levofloxacin eradicating 91% of them. Both drugs were well tolerated. Most of the adverse events were mild to moderate, and nausea was the most common adverse event in each treatment arm. Once-daily oral gatifloxacin (400 mg) is clinically efficacious and well tolerated compared with once-daily levofloxacin (500 mg) for the treatment of patients with uncomplicated SSTIs.

Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial

BACKGROUND

Recurrent herpes simplex labialis (HSL) occurs in 20% to 40% of the US population. Although the disease is self-limiting in persons with a healthy immune response, patients seek treatment because of the discomfort and visibility of a recurrent lesion.

OBJECTIVE

Our purpose was to determine whether docosanol 10% cream (docosanol) is efficacious compared with placebo for the topical treatment of episodes of acute HSL.

METHODS

Two identical double-blind, placebo-controlled studies were conducted at a total of 21 sites. Otherwise healthy adults, with documented histories of HSL, were randomized to receive either docosanol or polyethylene glycol placebo and initiated therapy in the prodrome or erythema stage of an episode. Treatment was administered 5 times daily until healing occurred (ie, the crust fell off spontaneously or there was no longer evidence of an active lesion) with twice-daily visits.

RESULTS

The median time to healing in the 370 docosanol-treated patients was 4.1 days, 18 hours shorter than observed in the 367 placebo-treated patients (P =.008; 95% confidence interval [CI]: 2, 22). The docosanol group also exhibited reduced times from treatment initiation to (1) cessation of pain and all other symptoms (itching, burning, and/or tingling; P =.002; 95% CI: 3, 16.5); (2) complete healing of classic lesions (P =.023; 95% CI: 1, 24.5); and (3) cessation of the ulcer or soft crust stage of classic lesions (P <.001; 95% CI: 8, 25). Aborted episodes were experienced by 40% of the docosanol recipients versus 34% of placebo recipients (P =.109; 95% CI for odds ratio: 0.95, 1.73). Adverse experiences with docosanol were mild and similar to those with placebo.

CONCLUSION

Docosanol applied 5 times daily is safe and effective in the treatment of recurrent HSL. Differences in healing time compared favorably with those reported for the only treatment of HSL that has been approved by the Food and Drug Administration.

Otology in ancient India

Sushrutra Samhita is essentially a multi-volume textbook reporting the surgical practices of ancient India. It covers all aspects of surgery. However, specific references are made to otorhinological conditions, their description and subsequent treatments often being described in some detail. In this paper we outline the structure of the document and attempt to explain its underlying philosophies. We highlight the specific references to otological diseases and their treatment and draw the obvious comparisons with modern otological practice.

Therapeutic studies with a new combination benzoyl peroxide/clindamycin topical gel in acne vulgaris

Three independent clinical studies were conducted in more than 1250 patients with moderate to moderately severe acne vulgaris to evaluate the efficacy and safety of a new combination gel that stably combines 5% benzoyl peroxide and 1% clindamycin. The results indicated that the benzoyl peroxide/clindamycin combination product was an effective treatment for reducing the inflammatory and noninflammatory lesions of acne vulgaris. In overall improvement as rated by the physicians and patients, the combination gel was superior to clindamycin alone, and in 2 of the 3 studies, to benzoyl peroxide alone. The antimicrobial activity of the combination gel was significantly (each P < .01) superior to that seen with topical application of its individual constituents, 5% benzoyl peroxide or 1% clindamycin, and was numerically better than that found with topical application of a 5% benzoyl peroxide/3% erythromycin combination product. As with benzoyl peroxide, dry skin was the most frequent side effect with use of the combination gel, with isolated incidences of other localized irritation. No other safety or tolerability concerns were identified.

Objective assessment of hoarseness by measuring jitter

The objective measurement of hoarseness by measuring 'jitter' (the average percentage pitch-period variation between consecutive pitch-cycles) using an inverse filtering technique is described. Twenty-five patients with a variety of causes of hoarseness were studied, together with five individuals who had mild hoarseness induced by histamine challenge and 12 normal individuals. The mean severity of jitter in the patient group (9.8%) was significantly different from the normals. (1.04%) In addition, there was a significant correlation (R2 = 0.53; P < 0.0001) between jitter and subjective assessment of hoarseness. The mean values of jitter with histamine challenge before and after recovery (1.03%, and 1.18%) were significantly different (P < 0.0001) to the mean maximum value during the challenge (2.64%). These data suggest that jitter is an objective and repeatable measurement of hoarseness-even small changes in hoarseness in individual patients. It is likely to prove most effective for monitoring treatment response.

A combination benzoyl peroxide and clindamycin topical gel compared with benzoyl peroxide, clindamycin phosphate, and vehicle in the treatment of acne vulgaris

A topical gel combining 5% benzoyl peroxide and 1% clindamycin as phosphate was evaluated in a 10-week randomized double-blind trial involving 287 patients with moderate to moderately severe acne. The combination agent demonstrated significantly greater reductions in inflammatory lesions than either of its active constituents (5% benzoyl peroxide and 1% clindamycin) or vehicle when used alone. Significantly greater reductions in comedos and improvements, as measured by both physicians' and patients' global evaluations, were obtained with the combination agent than with clindamycin or vehicle. The reduction in comedos and the global improvements were similar between the combination agent and benzoyl peroxide. The combination agent was well tolerated; the incidence of dry skin was similar to that found with benzoyl peroxide, and other adverse events were similar to that with vehicle. The improved efficacy obtained with combination therapy was accompanied by a safety profile similar to that of either constituent used alone.

Snoring: recent developments

Despite limited evidence validating its efficacy, surgery to overcome snoring is commonly undertaken. This article looks at the development of snoring surgery to present day, highlighting its limitations and outlining current methods being used to target the surgery more effectively.

Adaptive female choice for middle-aged mates in a lekking sandfly

Most theoretical models of age-related mate choice predict that females should prefer older males because they have proven survival ability. An alternative view is that older males represent inferior mates because of negative genetic correlations between early and late fitness components, or because older males have traded off longevity against other fitness components, have accumulated deleterious germ-line mutations, or are less well adapted to current conditions than more recently born individuals. While numerous studies have reported female choice for older males, few have explicitly examined the fitness consequences of such a preference. We present evidence from a lekking sandfly, Lutzomyia longipalpis, showing that choosy females discriminate against older males and gain a fitness benefit from their choice. When permitted free choice from an aggregation consisting of males aged zero to two days (young), four to six days (middle-aged) and eight to ten days (old), females preferentially mated with middle-aged males, but all measures of female reproductive success were independent of male age. In contrast, when a second set of females was randomly assigned single virgin males of known age, the eggs of those paired to old mates exhibited lower hatching success than the eggs of females mated to young or middle-aged males. These results suggest that females avoid mating with older males because they represent poorer quality mates. Age-related differences in male quality may have a genetic basis, but could equally well arise through a phenotypic decline in sperm quality or sperm transfer ability with male age. The lack of evidence of female discrimination against older males from other studies may be because these did not explore the reproductive success of the full age range of males.

A modified spacer device for inhalational drug therapy for chronic bronchitis/asthma in laryngectomised patients

Following total laryngectomy, patients who need to continue their inhalational drug therapy for chronic pulmonary conditions experience a great deal of difficulty in administering the drugs. We describe a new spacer device to deliver inhalational drug therapy to laryngectomized patients which is simple to use and does not interfere with the patient's life style. The device involves a standard metered dose inhaler, a paediatric face mask and a small volume spacer. This device was used successfully in six laryngectomised patients for 12-18 months, who needed to continue their inhalational drug therapy for their pulmonary condition.

Does adenotonsillectomy cure hypoxaemia in children with sleep apnoea and congenital cardiac pathology?

INTRODUCTION

Adenotonsillectomy usually cures obstructive sleep apnoea in otherwise healthy children. When children, with congenital cardiac pathology, suffer sleep hypoxaemia following their corrective cardiac surgery, they are referred to an otolaryngologist for adenotonsillectomy. Hardly any studies have been published to show how effective this operation is for these children.

OBJECTIVE

To determine whether adenotonsillectomy significantly improves hypoxaemia in children with congenital cardiac pathology following corrective cardiac surgery.

METHODS

Thirty children with sleep apnoea (aged 2-8 years) were recruited. Fifteen children with congenital cardiac pathology (Gp I) and 15 children who were otherwise healthy (Gp II). All children were assessed pre-operatively and at 1 and 3 months post-operatively with transcutaneous oxygen saturation monitoring. Tonsillar size, base oxygen saturation level, apnoeic episodes and snoring were recorded. Sleep apnoea and snoring was graded on a 5 point scale from I (no apnoea/snoring) to V (severe apnoea and snoring).

RESULTS

All children had an initial sleep grade of IV or V. Tonsillar size did not appear to be a significant factor on sleep grade in Gp I and Gp II. The median base line oxygen saturation was 88 and 93%, respectively in Gp I and II pre-operatively and improved to 90.1 and 99.2%, post-operatively. Following surgery, snoring and sleep apnoea disappeared in group II. In group I, there was significant reduction in the number of apnoeic episodes at 3 months, but the majority of children were still snoring with hypoxaemic episodes.

CONCLUSION

This study shows that adenotonsillectomy significantly reduces the apnoeic episodes in children with cardiac pathology but does not abolish it. At 3 months after surgery there was significant overall improvement in the baseline oxygen saturation.

Manipulation of the fractured nose: a comparison of local infiltration anaesthesia and topical local anaesthesia

Reduction of simple nasal fractures under local anaesthetic is now an accepted practice. The anaesthetic is usually administered using an external percutaneous approach, coupled with topical intranasal cocaine. Topical local anaesthetic with intranasal cocaine is an alternative method. Fifty-four adult patients with simple displaced nasal fractures were randomised to three different groups prior to fracture reduction in the outpatient department. Group A received external local infiltration, Group B received topical EMLA cream whilst Group C received topical AMETOP gel. All patients received topical intranasal cocaine. The cosmetic result and airway patency were comparable in all groups. However, patients in group A perceived the procedure as significantly more painful than the patients of groups B and C. Despite the increased procedure time, we recommend topical anaesthesia as the method of choice to reduce simple nasal fractures in the outpatient department. It offers a similar outcome, whilst being significantly less painful than external infiltration.

Cyclooxygenase-2 inhibition by rofecoxib reverses naturally occurring fever in humans

Cyclooxygenase (COX) exists as constitutive (COX-1) and inducible (COX-2) isoforms. Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen and diclofenac inhibit both COX-1 and COX-2. The role of COX-2 in the genesis of fever in monkeys and humans was examined with use of the specific COX-2 inhibitor rofecoxib. Rofecoxib was administered to monkeys made febrile by 6 microg/kg intravenous lipopolysaccharide. Induced pyrexia was followed by oral rofecoxib (1 or 3 mg/kg), diclofenac (3 mg/kg), or vehicle. Rofecoxib and diclofenac rapidly reversed the elevated temperature (P < .05 versus vehicle for 3 mg/kg rofecoxib and diclofenac at 70 to 90 minutes after dosing). A single-dose, parallel-group, double-blind randomized trial was conducted in 94 patients with fever caused by a viral-type illness. Mean baseline temperature was similar for all groups (-38.5 degrees C). Patients received oral doses of 12.5 mg rofecoxib, 25 mg rofecoxib, 400 mg ibuprofen, or placebo and the mean +/- SE change in oral temperature at 4 hours after dosing was -0.97 degrees C +/- 0.11 degrees C, -1.19 degrees C +/- 0.09 degrees C, -1.20 degrees C +/- 0.11 degrees C, and 0.01 C +/- 0.17 C, respectively (P < .001 for active treatments versus placebo). Specific inhibition of COX-2 by rofecoxib results in antipyretic activity in monkeys and humans comparable to dual COX-1/COX-2 inhibitors such as diclofenac or ibuprofen. The data support the hypothesis that it is the COX-2 isoform that is primarily involved in the genesis of fever in humans.

A multicenter, investigator-blinded, randomized comparison of oral levofloxacin and oral clarithromycin in the treatment of acute bacterial sinusitis

A multicenter, investigator-blinded, randomized, parallel-group study was conducted to compare oral levofloxacin 500 mg once/day for 14 days with clarithromycin 500 mg twice/day for 14 days in the treatment of acute bacterial sinusitis. Of 216 adult outpatients randomized to treatment, 190 were evaluable for efficacy. The primary efficacy measure was clinical response, based on resolution of signs and symptoms 2-5 days after therapy. A secondary efficacy measure was relapse rate 1 month after therapy. Among evaluable patients, clinical success rates (cured or improved) were 96.0% and 93.3% for levofloxacin (L) and clarithromycin (C), respectively (95% CI -9.2%, 3.7%). The confidence interval (CI) for treatment difference (C-L) included zero and its upper limit was less than 15%, indicating that levofloxacin was as effective as clarithromycin. In all, 4.1% of patients receiving levofloxacin and 7.2% receiving clarithromycin had a relapse of symptoms 1 month after therapy (95% CI-12.2%, 3.2%). Long-term success (initial success, absence of relapse at 1 month, no further antibacterial therapy 2-5 days after therapy) was 79.2% in the levofloxacin group and 76.4% in the clarithromycin group (95% CI -14.7%, 9.0%). Based on investigator-assessed treatment-emergent adverse events, overall tolerability of the drugs was similar, except for a higher frequency of taste perversion and diarrhea in the clarithromycin group. Levofloxacin had an advantage over clarithromycin based on two quality-of-life (QOL) parameters: number of times taking other drugs for targeted medical conditions and mean total cost of these drugs. No statistical significance was found in other QOL variables. These findings suggest that the efficacy and tolerability of levofloxacin 500 mg once/day are comparable with those of clarithromycin 500 mg twice/day in the treatment of acute bacterial sinusitis.

A role for pheromones in mate choice in a lekking sandfly

There is increasing evidence to suggest that pheromone-mediated communication may play an important role in mate choice in many insects. We investigated the possible role of pheromones in mate choice in the lekking sandfly, Lutzomyia longipalpis, and explored whether males or females display any behavioural traits that predict patterns of male mating success. Pairs of virgin males were introduced into a small mating chamber and allowed to interact for approximately 10 min prior to the introduction of a single virgin female. The trial continued until the female copulated with one of the males. We recorded trials on video for later analysis. After a successful copulation, we determined the quantity of pheromone remaining in the glands of both males and measured the size of the pheromone glands and tergites. We corrected behaviours and measurements for body size (tergite width). Mated males had significantly more pheromone present in their glands after a trial than unmated males. Males differed in how much time they invested in wing fanning. Members of each pair of males spent similar amounts of time wing fanning but mated males and males with more residual pheromone spent more time wing fanning than their counterparts throughout the trial. The time spent wing fanning and the amount of residual pheromone were not correlated, however. A male's ability to win fights did not relate to his reproductive success. Finally, a female was equally likely to wing-fan directly at, or walk away from, either male in a given pair. The possible relationships between the amount of pheromone released and the residual pheromones left in the glands, and the level of male wing fanning and pheromone productivity, are discussed. Copyright 1998 The Association for the Study of Animal Behaviour.

Life threatening airway obstruction: a hazard of concealed eating disorders

The ingestion of unusual objects is not uncommon in florid mental illness. Less common is the accidental ingestion of a foreign body which has been used to induce vomiting. A case is reported of complete dysphagia that resulted from impaction of a plastic fork in the hypopharynx. The patient had been attempting to induce vomiting and, as a result of the presentation, was found to be suffering from a previously concealed eating disorder (bulimia). Self induced vomiting is one criterion for the diagnosis of bulimia and a review of the literature indicates that accidental ingestion of large foreign bodies is an increasingly familiar hazard of occult bulimia.

Localized amyloidosis of the parotid gland: a case report and review of the localized amyloidosis of the head and neck

BACKGROUND

Localized amyloidosis in the head and neck is a rare and benign process.

METHODS

We present the first case report in the literature of localized amyloidosis of the parotid glands and also comprehensively review the literature regarding localized amyloidosis of the head and neck.

RESULTS

Amyloidosis affecting the head and neck region is uncommon and is mostly in the form of localized amyloidosis. Larynx is the commonest site of involvement and accounts for 0.2% to 0.5% of benign laryngeal tumors. Laryngeal involvement could be either diffuse subepithelial deposition or discrete tumor nodules. Although localized amyloidosis occurs much more frequently in the oral cavity and pharynx, only seven cases of nasopharyngeal amyloidosis and eight cases of nasal septum amyloidosis have been reported. There is no documentation to suggest that localized amyloidosis can progress to systemic amyloidosis. Local surgical excision is the treatment of choice for laryngeal amyloidosis and laser excision is probably the best.

CONCLUSION

While localized amyloidosis of the head and neck region is rare, it should be recognized, understood, evaluated, and properly treated.

Norgestimate and ethinyl estradiol in the treatment of acne vulgaris: a randomized, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of a triphasic, combination oral contraceptive (OC), (norgestimate-ethinyl estradiol), in comparison with placebo in the treatment of moderate acne vulgaris.

METHODS

Two hundred fifty women were enrolled in a multicenter, randomized, double-blind, placebo-controlled clinical trial to evaluate the effectiveness of norgestimate-ethinyl estradiol in the treatment of acne vulgaris. Subjects were 15-49 years old and had moderate acne vulgaris. Each month for 6 months, subjects received either 3 consecutive weeks of active OC treatment followed by 1 week of inactive drug, or 4 consecutive weeks of color-matched placebo tablets. Efficacy was assessed by facial acne lesion counts, the investigator's global assessment, and the subject's self-assessment. Hormone levels were also measured.

RESULTS

Despite the large placebo effect inherent in an acne trial (due to, for example, careful skin care, frequent office visits, regression to the mean), of the 164 subjects who completed the study without major protocol deviations, the OC group was significantly better than the placebo group for all primary efficacy measures: inflammatory lesions (mean reduction, 51.4% compared to 34.6%; P = .01), total lesions (mean reduction, 46.4% compared to 33.9%; P = .001); investigator's global assessment (83.3% compared to 62.5%; P = .001). Free testosterone decreased significantly and sex hormone-binding globulin increased significantly in the OC group, but remained unchanged in the placebo group.

CONCLUSION

A triphasic combination of norgestimate and ethinyl estradiol is an effective treatment for moderate acne vulgaris in women with no known contraindication to OC therapy.

General practitioner consultations after a paediatric tonsillectomy

General Practitioner (GP) consultations were audited in paediatric patients who have undergone an elective tonsillectomy on our unit over a 6 month period. As there is no formal follow-up, it is the department's practice to discuss with the patients the problems to expect following the operation. This is reinforced with a tonsillectomy advice sheet. An initial audit of GP consultations was performed by a telephone survey of the relevant GP. This revealed an attendance rate of 41%. Following the implementation of a change in management (chewing gum was added to the post operative care instructions) a subsequent audit of 91 children was performed. A marked reduction in the GP attendance was observed. We now routinely recommend the use of chewing gum in the post-operative period after tonsillectomy to our patients.

Butenafine 1% cream in the treatment of tinea cruris: a multicenter, vehicle-controlled, double-blind trial

BACKGROUND

Butenafine hydrochloride, a potent antifungal agent related to the allylamines, has been used in Japan for treating various cutaneous mycoses including tinea cruris.

OBJECTIVE

We compared the safety and efficacy of butenafine hydrochloride and its vehicle when used once daily for 2 weeks to treat tinea cruris.

METHODS

Patients (n = 93) with tinea cruris and a positive potassium hydroxide examination and mycologic culture were enrolled. Of the 76 patients assessed for efficacy, 37 applied butenafine and 39 applied vehicle once daily for 2 weeks. Assessments were made at the end of the 2-week treatment period and 4 weeks after the end of treatment.

RESULTS

Patients in the butenafine group had a higher mycologic cure rate by day 7 (66% vs 13%, p < 0.0001), with marked improvement 4 weeks after the end of treatment (81% vs 13%, p < 0.0001). They also had a higher rate of effective treatment at day 7 (29% vs 5%, p < 0.01) and at 4 weeks after treatment (73% vs 5%, p < 0.0001). Adverse events definitely related to butenafine treatment were limited to one case of burning sensation after application.

CONCLUSION

Butenafine applied once daily for 2 weeks is effective in treating tinea cruris. The proportion of patients cured increased between the end of treatment and 4 weeks after treatment.

Spontaneous retropharyngeal haematoma attributable to Epstein-Barr virus infection

Life-threatening sequelae of Epstein-Barr virus infection are uncommon but may present as: local pharyngeal manifestations, splenic rupture, neurological and haematological disorders and altered hepatic function. We present a case of retropharyngeal haematoma with posterior hypopharyngeal wall necrosis, thrombocytopenia and altered clotting function as a result of Epstein-Barr virus infection. A review of the literature on retropharyngeal haematoma reveals this to be the only recorded case which can be directly attributed to Epstein-Barr virus infection.

Alzheimer's disease and apolipoprotein E genotype in Western Australia: an autopsy-verified series

OBJECTIVE

To determine the relationship between the apolipoprotein E epsilon 4 allele and autopsy-verified Alzheimer's disease (AD) in an Australian population.

DESIGN

Retrospective case-control study.

SETTING

Royal Perth Hospital, Perth, Western Australia (a tertiary referral hospital).

SUBJECTS

50 subjects with "definite" AD (according to the histological and clinical criteria of the Consortium to Establish a Registry for Alzheimer's Disease [CERAD]) and 30 control subjects who had died from a non-neurological disease were randomly selected from the hospital's neuropathology register.

OUTCOME MEASURES

Histological grading of brain sections stained with the modified Bielschowsky stain according to the criteria of CERAD; number (burden) of neuritic plaques; apolipoprotein E genotype (APOE).

RESULTS

Frequency of the epsilon 4 allele was significantly higher in the AD group (37%) than in the control group (2%) (chi 2 = 25.8; P < 0.00001). In the AD group, 50% of subjects were heterozygous for the epsilon 4 allele and 12% were homozygous, while in the control group one subject was heterozygous for the allele and none were homozygous. No association was seen between the epsilon 4 allele and neuritic plaque burden in the hippocampus, entorhinal cortex, middle frontal gyrus or inferior parietal lobule in subjects with AD.

CONCLUSIONS

Our findings confirm an association between the epsilon 4 allele and autopsy-verified AD. The epsilon 4 allele may be an important risk factor for susceptibility to AD in the general Australian population.

Psychology of computer use: XXXI. Relating computer users' stress, daily hassles, somatic complaints, and anxiety

The relation of computer users' stress, measured by the Computer Hassles Scale, and global stress, measured by the Daily Hassles Scale, with stress reactions, measured by the somatization-anxiety items of the SCL-90, was investigated in a college sample (N = 101). Computer hassles ratings were correlated .54 with daily hassles ratings and .57 with somatization-anxiety ratings. Daily hassles ratings were correlated .74 with somatization-anxiety ratings. These results provide important evidence on convergent validity for the Computer Hassles Scale as a measure of computer users' stress.

Building Internet accessible medical education software using the World Wide Web

We describe work to enhance existing software protocols and develop a suite of new software utilities based upon a set of standards known as the World Wide Web (WWW). Specifically, we have developed an effective X-windows based WYSIWYG WWW browser/editor and a prototype for integrated wide-area authentication and authorization support for delivery and maintenance of WWW service. These software development activities, along with parallel work in content development, are empowering individuals to better use the Internet as a resource to easily author, publish, and access materials. As an illustrative application, we describe one Web-based self-instructional unit designed to increase users' knowledge of hazardous substances in the environment. This on-line monograph was adapted from a series of paper-based case studies developed by the Agency for Toxic Substances and Disease Registry of the U.S. Department of Health & Human Services. The on-line version illustrates many of the innovative features provided by the Web, and demonstrates how such materials can significantly impact medical education at all levels.

Variation of isozyme patterns among Arachis species

The genus Arachis contains a large number of species and undescribed taxa with patterns of genetic variation that are little understood. The objectives of this investigation were to estimate genetic diversity among species of Arachis by utilizing electrophoretic techniques and to establish the potential for use of isozymes as markers for germplasm introgression. One-hundred-and-thirteen accessions representing six of the seven sections of the genus were analyzed for isozyme variation of 17 enzymes. Section Rhizomatosae species were not included because they produce very few seeds. Seeds were macerated and the crude extract was used for starch-gel electrophoretic analyses. Although the cultivated species has few polymorphic isozymes, the diploid species are highly variable and two-to-six bands were observed for each isozyme among accessions. Because of the large number of isozyme differences between A. hypogaea and A. batizocoi (the presumed donor of the B genome), this species can no longer be considered as a progenitor of the cultivated peanut. Seed-to-seed polymorphisms within many accessions were also observed which indicate that germplasm should be maintained as bulk seed lots, representative of many individuals, or as lines from individual plants from original field collections. The area of greatest interspecific genetic diversity was in Mato Grosso, Brazil; however, the probability of finding unique alleles from those observed in A. hypogaea was greatest in north, north-central, south and southeast Brazil. The large number of polymorphic loci should be useful as genetic markers for interspecific hybridization studies.

Selection of human anti-hapten antibodies from semisynthetic libraries

Semisynthetic human Fab libraries were constructed, displayed on the surface of filamentous phage and selected for binding to three hapten conjugates. A number of Fabs were isolated and characterized with respect to affinity and specificity. Fabs exhibited affinities of between 80 and 29 nM, as determined by surface plasmon resonance, for the conjugate on which they were selected. Conservation of Asp101 in the third heavy-chain complementarity determining region (HCDR3) appears to be important in the construction of synthetically diverse repertoires.

Psychology of computer use: XXIX. Measuring computer users' stress: the Computer Hassles Scale

Measurement of computer users' stress was based on the Computer Hassles Scale. 65 questionnaires were returned from 113 mailed to users of accounting information systems who worked for manufacturing companies. Correlations were calculated for the total sample and subsamples divided by gender. The analysis indicated that persons with college degrees experienced greater computer users' stress than those who were without. Those persons who reported more computer hassles experienced more somatic complaints which indicated that the computer hassles were stressful. There were no significant mean differences between women and men on computer hassles or somatic complaints. The correlations of computer hassles with somatic complaints differed by gender. Women's computer hassles were significantly correlated .61 with somatic complaints, but men's computer hassles were not significantly correlated (r = .18) with somatic complaints. The gender differences suggest that there is a complex relationship between stressors (computer hassles) and stress reactions (somatic complaints).

Molecular profile of an antibody response to HIV-1 as probed by combinatorial libraries

A large number (33) of human Fab fragments reacting with HIV-1 surface glycoprotein gp120 have been generated by selection from a combinatorial IgG1 kappa library displayed on the surface of phage. The library was prepared from a long term asymptomatic HIV-seropositive donor. Analysis of the sequences from these Fabs shows the heavy chains can be placed in groups, many of which contain intraclonal variants, almost certainly corresponding to chains used in vivo. Further variants can be accessed via chain shuffling experiments in which a given light chain is recombined with a library of heavy chains. Heavy chain promiscuity, i.e. the ability of heavy chains to pair with different light chains with retention of antigen binding, is dependent on the particular heavy chain considered and probably excludes the identification of in vivo light chain partners. The antibodies examined here are primarily to the CD4 binding site on gp120 and broadly reflect the serum profile of the donor. The antibodies show evidence of extensive somatic modification indicative of an antigen-driven response. The heavy chain CDR3 regions of the antibodies show a remarkably conserved extended length. A number also show strong sequence conservation in CDR3 against a background of considerable diversity in the rest of the VH gene supporting a central role for this region in antigen recognition.

The Centennial Patient Care Program: binding patient, student, and clinician-teacher in a learning triad

The University of Chicago is building a technology-based clinical environment to provide a longitudinal experience for patients and medical students. This environment uses an open systems, computer communication and information support network to forge an interactive education and care relationship between patient, medical student, and clinical faculty mentor. The project proactively addresses some of the most important activities required to reform both the health care and medical education systems: anchoring patient care in a generalist setting; educating medical students in outpatient medicine; fostering primary care as a career choice; and using medical informatics as a tool rather than as an end in itself. Moreover, the project effectively deploys concepts such as patient-centered education, student-based learning, and mentored teaching experiences. This paper reports the curricular, pedagogical, and technological motivations and framework under which the project was designed, and describes the process that a patient-student-clinician/teacher triad will experience as participants in this program.

Human monoclonal Fab fragments derived from a combinatorial library bind to respiratory syncytial virus F glycoprotein and neutralize infectivity

Respiratory syncytial virus (RSV) is the most important cause, throughout the world, of severe viral lower respiratory tract illness in young children. Antibodies are known to mediate resistance to RSV infection and illness. We have isolated a number of human monoclonal Fab fragments to RSV F glycoprotein from a combinatorial antibody library expressed on the surface of phage. One of these neutralized a wide range of virus isolates, 10 subgroup A and 9 subgroup B isolates, with a titer (60% neutralization) of approximately 0.1-1.0 micrograms/ml. Another Fab neutralized diverse isolates at a concentration somewhat higher. These human Fab fragments show great promise for use in the prophylaxis or therapy of serious RSV lower respiratory tract disease. For intramuscular or intravenous administration, whole antibodies will be required, whereas for aerosol application, F(ab')2 or Fab fragments may suffice.

Recombinant human Fab fragments neutralize human type 1 immunodeficiency virus in vitro

A panel of 20 recombinant Fab fragments reactive with the surface glycoprotein gp120 of human type 1 immunodeficiency virus (HIV-1) were examined for their ability to neutralize MN and IIIB strains of the virus. Neutralization was determined as the ability of the Fab fragments to inhibit infection as measured in both a p24 ELISA and a syncytium-formation assay. One group of closely sequence-related Fab fragments was found to neutralize virus in both assays with a 50% neutralization titer at approximately 1 micrograms/ml. Another Fab neutralized in the p24 ELISA but not in the syncytium assay. The other Fab fragments showed weak or no neutralizing ability. The results imply that virion aggregation or crosslinking of gp120 molecules on the virion surface is not an absolute requirement for HIV-1 neutralization. Further, all of the Fab fragments were shown to be competitive with soluble CD4 for binding to gp120 and yet few neutralized the virus effectively, implying that the mechanism of neutralization in this case may not involve receptor blocking. The observation of a preponderance of high-affinity Fab fragments with poor or no neutralizing ability could have implications for vaccine strategies.

Prenatal determination of demographic and attitudinal factors regarding feeding practice in an indigent population

Demographic and attitudinal factors influencing the decision to breast- or bottle-feed were evaluated early in pregnancy by survey of 307 women in a low-risk prenatal obstetric clinic at a publicly funded hospital in Houston, Texas. Subjects responded to 17 demographic and 24 attitudinal questions. Racial classification revealed blacks 36.4%, whites 29.2%, and hispanics 30.8%. Twenty-five percent of the completed surveys were in Spanish. Of the total sample, 26.7% planned to breast-feed, 48.2% planned to bottle-feed, and 25.1% planned to do both. Multiple logistic regression analysis revealed six prominent independent risk factors for bottle-feeding. The most significant variable was lack of support for breast-feeding from a significant other (husband, mother, other relative, or friend), which had a odds ratio (OR) of 456.3. Other attitudinal variables achieving independent significance were disagreement with the statements "breastfeeding protects against disease" (OR = 4.0), "breasts were made for breastfeeding" (OR = 8.0), and "I want to know more about breastfeeding" (OR = 120.0). Significant demographic variables identified were completion of less than 12th grade (OR = 32.1), and age less than 35 years (OR = 43.3). These findings indicate the influence of significant others in the decision to breast-feed and suggest that future educational programs should require their inclusion if the prevalence of breast-feeding in this population is to be increased.

Attitudes and education of pediatric house staff concerning breast-feeding

Pediatricians are expected to offer information and advice on breast-feeding to expectant and lactating mothers, but the educational experience for pediatric residents may not adequately prepare them for this responsibility. To examine knowledge and confidence regarding breast-feeding gained by pediatric house staff during their residency, a survey was administered to pediatric residents in a large, hospital-based training program. Of 108 program residents, 87 (81%) participated. Forty-one percent of the respondents were postgraduate level I (PL-I), 29% were PL-II, and 30% were PL-III. There was no evidence that PL-III residents were more competent or comfortable with routine breast-feeding counseling or intervention than their PL-I counterparts. Residents who had breast-fed, those with spouses who had breast-fed, and those with children of their own had the greatest knowledge and confidence base in several areas, such as their ability to teach breast-feeding techniques and to treat cracked nipples. They were also more familiar with different types of breastpumps. There were no significant differences among those who were or were not breast-fed as a child nor among men versus women. Residency programs must provide comprehensive education on breast-feeding to prepare future pediatricians to meet the needs of patients and their parents.

Antibody redesign by chain shuffling from random combinatorial immunoglobulin libraries

A number of experiments on the shuffling of heavy and light chains from antibodies of defined specificity for the transition-state analogue hapten nitrophenyl phosphonamidate are described. The experiments report on the promiscuity of heavy and light chains in binding antigen and the feasibility of antibody redesign by this shuffling process. The concepts of incestuous and extraclonal promiscuous association are described. Shuffling opens the possibility of generating panels of antibodies with related specificity but of distinct idiotypic composition that may have significance in the use of human monoclonal antibodies in therapy.

Psychology of computer use: XXIII. Validating a measure of computer-related stress

Prediction of the final grade in a computer course using the Computer Technology Hassles Scale, a measure of computer-related stress, was investigated. A sample of 154 university students enrolled in computer courses completed questionnaires covering demographic data, information on computer use, the Computer Technology Hassles Scale, and somatic complaint items of the Hopkins Symptom Checklist. Pearson correlations indicated scores on the Computer Technology Hassles Scale were significantly associated .27 with somatic complaints, -.24 with computer-course grades, and -.18 with self-rated computer knowledge. Regression analysis indicated that self-rated computer knowledge and scores on the Computer Technology Hassles Scale significantly predicted computer-course grade.

Temperature response to acetaminophen and risk of occult bacteremia: a case-control study

A case-control study of 34 children with occult bacteremia was conducted to test the hypothesis that nonresponse to acetaminophen (decrease less than or equal to 0.8 degrees C) is a risk factor for occult bacteremia. Febrile children visiting the emergency center from May 1986 to October 1987 were monitored for occult bacteremia. Inclusion criteria were age 2 months to 6 years, temperature greater than or equal to 38.9 degrees C, and having a blood culture. Exclusion criteria were serious acute or chronic illness, sponging for fever reduction, current therapy with antibiotics or steroids, and admission to the hospital. Records of 3892 febrile children were reviewed. Of these, 2101 (54%) had a blood culture and 1028 (26%) were eligible. All patients (positive blood culture) were matched with two control subjects (negative blood culture). Patients and control subjects had similar age, gender, ethnicity, height of initial temperature, time to second temperature, and dose of acetaminophen. The estimated risk of occult bacteremia for nonresponders was 9.2 (95% confidence interval 2.7, 32.0). We conclude that children who do not respond to acetaminophen by at least a 0.8 degrees C decrease in temperature have an increased risk of occult bacteremia. However, achieving a response to acetaminophen does not eliminate the possibility that the child has occult bacteremia.

Putting a premium on medical staffs. A novel way to insure physician liability (and loyalty)

The physician malpractice insurance crisis is having an adverse financial impact on both hospitals and their medical staffs. Innovative hospitals are exploring ways to create insurance arrangements to cover the professional liability of their medical staffs. Hospital risk managers often have theorized that if the same insurer covered both hospitals and their staff physicians, providers and their patients would benefit. These programs--often referred to as "channeling" or "channeled programs"--use a common risk management program, common claims administration, and a common claims defense for insured hospitals and their medical staffs, reducing costs, unfavorable verdicts, and, thus, premiums. Unfortunately only a few commercial carriers now offer such a program. Some hospitals and systems have therefore turned to "captive" insurance companies to provide the benefits of a channeled program. Hospitals or systems and their medical staffs can establish a captive (i.e., a controlled insurance company designed to insure its owners and their affiliates) either offshore (typically in a tax-free jurisdiction such as the Cayman Islands, Barbados, or Bermuda) or onshore (typically in a state with facilitating legislation). The Tax Reform Act of 1986, together with the Liability Risk Retention Act of 1986, generally tips the regulatory balance in favor of onshore captives by allowing these entities to operate as risk retention groups (RRGs).

Disposition of an immunoglobulin intravenous preparation in very low birth weight neonates

To assess the disposition, tolerance, and toxicity of an intravenous preparation of immunoglobulin (IGIV) in very low birth weight (VLBW) neonates, we administered single doses of 500 or 750 mg/kg to 20 neonates with birth weights between 750 and 1500 g during the first week of life. The infusion of this product was well tolerated. Modest changes in hemoglobin, hematocrit, and total hemolytic complement occurred as expected. Hepatic toxic effects were not detected. Mean peak IgG concentrations were 1564 and 1316 mg/dL for the high-dose and low-dose groups, respectively. Mean IgG concentrations were very similar for both groups on postinfusion days 1, 4, 7, 14, 21, and 28. IgG concentrations remained above 300 mg/dL in seven of 10 infants in each group by day 21, and in six of the high-dose group and seven of the low-dose group by day 28. Mean elimination half-lives were 22.6 and 22.8 days in the high-dose and low-dose groups, respectively. These data provide a basis for assessment of potential efficacy of IGIV in the prevention of late-onset infection in VLBW neonates.

Quantitative gas chromatographic headspace determination of choline in adult and infant formula products

A gas chromatographic headspace method has been developed for the determination of choline in liquid and powder formula products. Choline undergoes the Hofmann elimination reaction during a 24 h, 120 degrees C alkaline digestion. Volatile trimethylamine (TMA) is produced and equilibrates between the liquid and vapor phase (headspace). A 50 microL headspace sample is chromatographed on a 28% Pennwalt 223-4% KOH column, with flame ionization detection. Choline is indirectly quantitated by comparing sample TMA peaks with peaks for a reference standard. Ethyl ether is used as an internal standard. Compared with previous methods, this procedure offers improved precision (7.7-9.6% relative standard deviation (RSD], accuracy, and specificity of both free and bound forms of choline. Estimated analysis rate using manual injection is 160 samples/week, requiring 35 work-hours. Automation of this procedure, using a commercially available headspace analyzer, resulted in a further improvement in precision (1.60-6.91% RSD) and a throughput of 400 samples/week.

Hyperprolactinemia and male infertility

Four patients suffering from oligospermia and infertility were found to have slightly to moderately elevated serum prolactin levels consistently. Their testicular biopsy specimens showed varying degrees of impairment of spermatogenesis ranging from hypospermatogenesis to complete absence of germ cells. The usual known causes of hyperprolactinemia, such as pituitary or suprasellar tumors, hypothyroidism, intake of certain medications that deplete the dopamine levels of the hypothalamus or block the action of dopamine on the pituitary, were absent. These patients are described in view of recent clinical and experimental reports implicating hyperprolactinemia as a cause of male infertility.

Response of patients with amyotrophic lateral sclerosis to testosterone therapy: endocrine evaluation

Four men with amyotrophic lateral sclerosis (ALS) were treated with 200 mg of intramuscular testosterone weekly. Endocrine evaluation, using a gonadotropin-releasing hormone infusion test, indicated the expected degree of suppression of pituitary luteinizing hormone and follicle-stimulating hormone production. These data suggest that testosterone's (androgen) interaction with its receptors in the hypothalamic-pituitary axis is normal in patients with ALS.

Parameters of response to clompiphene citrate in oligospermic men

Twenty oligospermic young men have undergone a 6-month trial of intermittent low dose clomiphene therapy. Three-fourths of the patients enjoyed an increase in semen quality and 8 patients impregnated their wives. Plasma luteinizing hormone, follicle-stimulating hormone and testosterone levels increased in all patients on clomiphene. Development of stringent criteria for the use of clomiphene citrate should result in a conception rate of more than 50 per cent in selected patients. Hypotheses concerning the mechanism of therapeutic response to clomiphene included the induction of higher levels of testosterone locally around the germinal epithelium and the induction of increased follicle-stimulating hormone levels.

Comparison of healing following periodontal surgery with and without dressings in humans

Seven patients with chronic moderate to severe generalized periodontitis requiring periodontal flap surgery were selected for study. Internally beveled full thickness, apically positioned flaps with osseous recontouring were performed in 20 quadrants. Half the quadrants received a noneugenol dressing, and the other half were left undressed. Fluid Index, Gingival Index, inflammatory index, pocket depth and patient comfort were studied up to 16 weeks postoperatively. Results showed no difference in these parameters between quadrants where periodontal dressings were or were not used following surgery. The patients reported more pain and discomfort and the pain and discomfort was more severe postoperatively when the dressing was used. The results of this study suggest that a surgical dressing serves no useful purpose when periodontal flap surgery is performed.

Direct inhibition of Leydig cell function by estradiol

Suppression of plasma testosterone levels from a mean of 760 ng/dl to a mean of 295 ng/dl could be induced in normal young adult men 24 h after a single injection of 2 mg aqueous 17 beta-estradiol. Maximum suppression to 123 ng/dl was noted 36 h after estradiol administration. Neither LH nor FSH levels were similarly affected. After administration of 5000 IU hCG to a similar group of subjects, daily blood samples were obtained for testosterone and estrogen. Maximum testosterone levels of 2060 ng/dl (basal, 784 ng/dl) were seen 96 h after hCG administration. Maximum estrogen levels of 13 pg/ml (basal 73 pg/ml) were seen 36 h after hCG administration. The testosterone response to hCG could be attenuated by preceding hCG administration with an injection of 17 beta-estradiol. These results can be explained by the concept of enzyme inhibition; estrogen acts directly on the Leydig cell to effect changes in the activities of certain enzymes important for testosterone synthesis. Whether endogenous estrogen production by the Leydig cell may be important in this postulated short loop feedback is as yet unclear.

Mucha-Habermann's disease in children: treatment with erythromycin

Safe therapeutic measures for Mucha-Habermann's disease in children are lacking. Three patients with the disease were treated with erythromycin for systemic effect. Although the series is small and uncontrolled, this approach seemed effective. An anti-inflammatory mechanism related to inhibition of chemotaxis is speculated.