A biopsychosocial model of pain and depression in rheumatoid arthritis: a 12-month longitudinal study

OBJECTIVE

To cross-validate a biopsychosocial model using physical disability, helplessness and passive coping to predict depression and pain in rheumatoid arthritis (RA).

METHODS

Clinical and psychological measures were collected from 157 RA patients at three time points over a period of 12 months. Path analysis was used for cross-sectional and longitudinal prediction of depression and pain.

RESULTS

Helplessness and passive coping were found to be significant mediators of the relationship between the physical disability and future depression and pain. Cross-sectionally, the predictive model could account for 52-94% of the variance of pain and 37-71% of the variance of depression. Longitudinally, the predictive model could explain 29-43% of the variance of pain and 21-33% of the variance of depression.

CONCLUSIONS

These results suggest that physical disability, helplessness and passive coping have a significant impact on the levels of pain and depression experienced by RA patients.

Practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the Quality Standards Subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons

OBJECTIVES/METHODS

To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures by systematic review and analysis of the literature since 1990.

RESULTS

One intention-to-treat Class I randomized, controlled trial of surgery for mesial temporal lobe epilepsy found that 58% of patients randomized to be evaluated for surgical therapy (64% of those who received surgery) were free of disabling seizures and 10 to 15% were unimproved at the end of 1 year, compared with 8% free of disabling seizures in the group randomized to continued medical therapy. There was a significant improvement in quantitative quality-of-life scores and a trend toward better social function at the end of 1 year for patients in the surgical group, no surgical mortality, and infrequent morbidity. Twenty-four Class IV series of temporal lobe resections yielded essentially identical results. There are similar Class IV results for localized neocortical resections; no Class I or II studies are available.

CONCLUSIONS

A single Class I study and 24 Class IV studies indicate that the benefits of anteromesial temporal lobe resection for disabling complex partial seizures is greater than continued treatment with antiepileptic drugs, and the risks are at least comparable. For patients who are compromised by such seizures, referral to an epilepsy surgery center should be strongly considered. Further studies are needed to determine if neocortical seizures benefit from surgery, and whether early surgical intervention should be the treatment of choice for certain surgically remediable epileptic syndromes.

The tolerance of three transgenic subterranean clover (Trifolium subterraneum L.) lines with the bxn gene to herbicides containing bromoxynil

A bxn gene, coding for the nitilase enzyme that catalyses the detoxification of the herbicide bromoxynil, was inserted into subterranean clover (Trifolium subterraneum L. subsp. yanninicum). The agronomic characteristics of 3 transgenic lines (BXN 5, 7, 10) and their response to herbicides containing bromoxynil, were compared with that of the non-transgenic parent, cv. Gosse, in 1 glasshouse and 2 field experiments.The application of bromoxynil at 1.5 L/ha resulted in a 50% reduction in the spring herbage yield of the non-transgenic control but no reduction in BXN 5 and 7. The level of the phyto-oestrogens, genistein and biochanin A, in the leaf tissue were low in Gosse and the 2 transgenic lines, BXN 7 and 10, but the level of genistein increased significantly (P < 0.05) from 0.85% in Gosse to 1.43% dry weight in BXN 5, and biochanin A increased from 0.35% in Gosse to 0.73% in BXN 5. The application of the herbicides bromoxynil, bromoxynil+MCPA, and Jaguar (bromoxynil+diflufenican) at the cotyledon stage in a glasshouse study significantly reduced the leaf area of the non-transgenic Gosse, but did not reduce the leaf area of the 3 transgenic lines. When applied at the 4–5 leaf stage, the leaf area of Gosse was again reduced by all the herbicides, but only the bromoxynil+MCPA treatment reduced the leaf area of the transgenic lines relative to the control. The application of bromoxynil or Jaguar at the 4–5 leaf stage depressed the herbage yield of Gosse by about 62% compared with 0–24% in the 3 transgenic lines. In the field studies, BXN 5 and 10 had similar seed yields to Gosse in the absence of herbicide application, but the seed yield of BXN 7 was significantly less than the other 2 transgenic lines. The level of hard-seed in BXN 7 was also lower at 25% compared with 55–57% in the other transgenic lines and Gosse.These findings stress the need to carefully assess the agronomic qualities of transgenic lines prior to release as although tolerance to bromoxynil may be greatly increased by the bxn gene, other important agronomic characteristics, such as seed yield, hardseededness, and isoflavone content, may change as result of the gene or transformation process.

Totally implantable vascular access devices for cystic fibrosis

BACKGROUND

Totally implantable vascular access devices are widely used in people with cystic fibrosis to provide intermittent venous access for therapeutic infusions. Their use is associated with some complications such as thrombosis, embolism and infection.

OBJECTIVES

To assess if totally implantable venous access devices are a safe and effective route for providing venous access for intermittent administration of intravenous antibiotics in people with cystic fibrosis, also to assess strategies to reduce possible complications of totally implantable venous access devices (e.g. anticoagulants to reduce the risk of thrombosis).

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Date of the most recent search: May 2003.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials which compared the use of totally implantable venous access devices in people with cystic fibrosis to other means of vascular access, trials which compared the different types of these devices against each other and trials which assessed strategies to reduce complications of these devices.

DATA COLLECTION AND ANALYSIS

No relevant trials were identified.

MAIN RESULTS

No trials were included in this review.

REVIEWER'S CONCLUSIONS

Totally implantable vascular access devices are widely used in people with cystic fibrosis to provide intermittent venous access for therapeutic infusions. Reports of their use in people with cystic fibrosis suggest that they are safe and effective. These reports also suggest that certain interventions might reduce the risk of complications; however, it is disappointing that these reports have not been assessed by randomised controlled trials. This systematic review identifies the need for a multicentre randomised controlled trial assessing both efficacy and possible adverse effects of totally implantable venous access devices in cystic fibrosis.

UK laboratory intercomparison on internal dosimetry

A laboratory intercomparison for internal dose assessment from a variety of intake scenarios is described. This is the first UK intercomparison using the revised ICRP Human Respiratory Tract and biokinetic models. Four United Kingdom laboratories participated and six cases were assessed. Overall, the agreement in internal dose assessments between laboratories was considered satisfactory with 79% of the assessed committed effective doses, e(50), for cases within a band of +/- 40% of the median value. The range (highest/lowest) in e(50) estimated by the laboratories was smallest (1.2) for a case involving inhalation of 137Cs. The range was greatest (6.0) for a case involving a wound with, and possible inhalation of, 238Pu, 239Pu and 241Am; the variation between laboratories in assessment of intakes could not be considered to be satisfactory in this case. Judgements on the most appropriate data to use in estimating intakes, choice of parameter values for use with the ICRP models and allowing for the effects of treatment with DTPA were important sources of variability between laboratories.

Practical system to detect and assess consequences of radioactivity in a wound

Any wound received within the controlled areas of Dounreay could potentially be contaminated with plutonium and/or uranium isotopes. Wounding bypasses the body's natural barriers to foreign objects, such as the skin and the lining of the alimentary canal. Therefore a relatively low intake can potentially result in a high committed effective dose. The likelihood of contamination of a wound with either plutonium or uranium is low. The decision-making process for dealing with wounds has been continually reviewed and updated by the approved dosimetry service (ADS) at Dounreay. Each wound is considered on an individual basis by the ADS in order to decide what follow-up actions, if any, are necessary. The aim of the process is to maximise the probability that a significant intake is detected, while targeting resources in an appropriate manner.

High rate of Bartonella henselae infection in HIV-positive outpatients in Johannesburg, South Africa

The emerging opportunistic pathogen Bartonella henselae has a wide range of clinical presentation, which includes, particularly, bacillary angiomatosis. This non-random pilot survey of outpatients attending HIV clinics in Johannesburg, South Africa, sampled 188 patients, in whom there was a 10% prevalence of Bartonella bacteraemia, as determined by nested polymerase chain reaction.

Paediatric trauma: when it is not an accident

A portion of childhood trauma seen in any emergency department will be non-accidental in origin. Child abuse is a world-wide phenomenon that transcends race, religion, colour and socio-economic status. Any aspect of child abuse is likely to interfere with the child's normal social, cognitive and spiritual development. A variety of injuries may be seen in the abused child and the emergency nurse is placed in a strategic position to identify and intervene in these cases. This paper aims to review some of the current research and literature, specifically in regard to physical child abuse, risk factors, presentation patterns and links with domestic violence.

4-aminopyridine poisoning of crows in the Chicago area

Poisoning of crows with the avicide 4-aminopyridine is reported. Seven crows had frequent vocalization and nervous signs; 6 died. Postmortem examination of 4 found evidence of trauma and corn-based bait present in the gastrointestinal tract. The bait contained 4-aminopyridine, a rapidly fatal nervous system toxin. When utilized by pest control professionals using manufacturer's recommendations, 4-aminopyridine has little risk of direct or relay toxicosis to non-target species. Treatment of exposed individuals involves symptomatic care and control of seizures.

Material-specific lateralization in the medial temporal lobe and prefrontal cortex during memory encoding

Numerous observations in patients with unilateral lesions of the medial temporal lobe (MTL) and the prefrontal cortex indicate that memory processes are lateralized according to content. Left-sided lesions interfere with verbal memory processes, whereas right-sided lesions interfere with visuospatial (non-verbal) memory processes. However, functional imaging studies have resulted in contradictory data, some studies showing lateralization in the prefrontal cortex determined by stage of processing (encoding versus retrieval) and others suggesting that lateralization is dependent on the type of material. Few studies have examined this issue in the MTL. In order to test the hypothesis that the lateralization of encoding processes in the MTL and frontal regions is dependent on the verbalizability of the material, we performed behavioural and functional imaging studies. We demonstrated differing verbalizabilities of three classes of non-verbal stimuli (scenes > faces > abstract patterns) using a dual-task verbal interference behavioural paradigm. A functional neuroimaging study of encoding was carried out using these three types of stimuli, plus words. During whole-brain functional MRI at 1.5 T, eight normal right-handed adults were presented with alternating blocks of novel and repeated stimuli under intentional memory encoding conditions. Verbal encoding resulted in left-lateralized activation of the inferior prefrontal cortex and the MTL. Pattern encoding activated the right inferior prefrontal cortex and the right MTL. Scenes and faces resulted in approximately symmetrical activation in both regions. The data indicate that the lateralization of encoding processes is determined by the verbalizability of stimuli.

A randomized, double-blind, placebo-controlled study of itraconazole capsules for the prevention of deep fungal infections in immunodeficient patients with HIV infection

OBJECTIVES

To determine whether systemic or deep fungal infections can be prevented, a double-blind, placebo-controlled, phase III trial of itraconazole prophylaxis was undertaken in HIV-infected patients.

METHODS

HIV-1 infected patients with CD4 counts < 300 cells/microL were treated with itraconazole (200 mg per day) or matching placebo and followed for 2 years. Development of deep fungal infections, episodes of mucocutaneous candidiasis, change in CD4 count, survival and safety data were collected at each study visit.

RESULTS

Three hundred and seventy-four patients received study medication, 187 were given itraconazole and 187 matching placebo. Time to development of deep fungal infection did not differ between groups, in an intention to treat analysis. Low CD4 cell count and prior use of Pneumocystis carinii pneumonia (PCP) prophylaxis were significantly associated with a more rapid development of deep fungal infection (P = 0.044 and 0.017, respectively). Itraconazole treatment significantly reduced the incidence of oral candidosis (25% vs. 48% P < 0.001) and time to development of oral candidosis (508 vs. 413 days, P < 0.001) but not the number of deep fungal infections (11 vs. 13). Survival did not differ significantly between groups (nine vs. 14 deaths). CD4 counts decreased significantly over time in both study arms. Adverse events did not differ between groups; 20% vs. 23% stopped study medication due to an adverse experience.

CONCLUSIONS

Although itraconazole prophylaxis significantly reduced the number and time to development of oral candidosis, too few episodes of deep fungal infection were noted to determine whether itraconazole prophylaxis was effective for this condition. Chronic itraconazole treatment is well tolerated in HIV-infected patients with marked immunodeficiency.

Rare single system diseases

There are many rare conditions to be found in textbooks of respiratory paediatrics which are often difficult to place in to any standard form of classification. The expertise of any single paediatrician or centre in the management of such problems is inevitably limited, and so treatment is never "evidence based" but depends on individual experience and information contained in case reports or small series in the literature. The investigation and management of such cases is often complex and should be performed in large regional centres. In this article we will discuss pulmonary alveolar microlithiasis, disorders of the lymphatic system, lymphoid bronchiolitis and pulmonary langerhans cell histiocytosis.

Complete genome sequence of Pseudomonas aeruginosa PAO1, an opportunistic pathogen

Pseudomonas aeruginosa is a ubiquitous environmental bacterium that is one of the top three causes of opportunistic human infections. A major factor in its prominence as a pathogen is its intrinsic resistance to antibiotics and disinfectants. Here we report the complete sequence of P. aeruginosa strain PAO1. At 6.3 million base pairs, this is the largest bacterial genome sequenced, and the sequence provides insights into the basis of the versatility and intrinsic drug resistance of P. aeruginosa. Consistent with its larger genome size and environmental adaptability, P. aeruginosa contains the highest proportion of regulatory genes observed for a bacterial genome and a large number of genes involved in the catabolism, transport and efflux of organic compounds as well as four potential chemotaxis systems. We propose that the size and complexity of the P. aeruginosa genome reflect an evolutionary adaptation permitting it to thrive in diverse environments and resist the effects of a variety of antimicrobial substances.

Dimerization-dependent block of the proapoptotic effect of p75(NTR)

The biochemical mechanism by which neurons become dependent on neurotrophins for survival is unknown. We found previously that the common neurotrophin receptor, p75(NTR), is a mediator of neurotrophin dependence and that this effect requires a novel type of domain dubbed a neurotrophin dependence domain. We report here that, in contrast to other proapoptotic receptors such as Fas, apoptosis induction by p75(NTR) requires monomerization, with dimerization inhibiting the effect. Blocking the proapoptotic effect of the monomer by dimerization requires a distinct domain that lies at the carboxyterminus of p75(NTR). These results define a novel type of domain required for inhibiting apoptosis induction by p75(NTR).

Cloning and characterization of dRFX, the Drosophila member of the RFX family of transcription factors

The RFX family of transcription factors is characterized by a unique DNA binding domain. Five genes have been isolated in mammals, one gene in Caenorhabditis elegans and in the yeasts Schizosaccharomyces pombe and Saccharomyces cerevisiae. Whereas the roles of the RFX genes are beginning to be understood in yeasts, no clear function has been reported in multicellular organisms, except for RFX5, the most divergent member of the family. To study the physiological role of RFX transcription factors using an alternative multicellular model, we report the isolation and characterization of the Drosophila RFX gene (dRFX). The fruit fly protein shares highly conserved domains with the mammalian factors RFX1 to 3 and is more closely related to this subgroup. It binds DNA with the same target specificity as mammalian factors RFX1 to 3. dRFX is located on chromosome III and we characterized the entire locus. dRFX expression was analyzed during embryogenesis. dRFX mRNAs are detected only in the peripheral nervous system and in the brain of the embryo.

Refractive-index and element-spacing effects on the spectral behavior of infrared frequency-selective surfaces

Transmission and reflection characteristics of inductive-mesh frequency-selective surfaces were measured in the 4-12-microm range. Specific issues investigated include the effect of interelement spacing on the location and width of the resonance and the influence of superstrate and substrate refractive indices on the spectral response of the structure.

Two liquid medium systems, mycobacteria growth indicator tube and MB redox tube, for Mycobacterium tuberculosis isolation from sputum specimens

Two manual liquid medium systems, the Mycobacteria Growth Indicator Tube (MGIT) and MB Redox tube systems, were evaluated in comparison to the radiometric BACTEC-460 semiautomated system for recovery of Mycobacterium tuberculosis from sputum specimens. The highest level of recovery, from a total of 77 culture-positive specimens, occurred with the BACTEC-460 system (92.2%), followed by the MB Redox tube (80.5%) and the MGIT (63.6%) systems. The shortest time to detection was observed also among the cultures in BACTEC-460: a mean of 12 days to a growth index (GI) of 10 and 15 days to a GI of 500. The mean times for the other systems were 16 days for the MB Redox tube system and 17.4 days for the MGIT system. The proportion of cultures grown after more than 3 weeks of incubation was only 2.8 or 8.4% in BACTEC-460 (for a GI of 10 or 500) but 17.7% in MB Redox and 22.5% in MGIT. Despite these differences in comparison to the BACTEC-460 system and some differences between the MGIT and MB Redox tube systems, either of the two manual liquid medium systems presents a reasonable alternative to the BACTEC-460 system, especially for laboratories with a limited workload, and a valuable element in the laboratory protocol, in conjunction with solid media, for obtaining rapid detection of growth from about 80% of culture-positive specimens and for better overall recovery of M. tuberculosis.

Investigation of the child with interstitial lung disease

Many disorders can affect the pulmonary interstitium in children. Although individual interstitial lung diseases are rare, the range of conditions encountered is wide. Interstitial disease is also seen increasingly as a consequence of the treatment of children having other primary problems including cancer, immunodeficiency and haemotological diseases, as well as in recipients of solid organ and bone marrow transplants. The management and prognosis of individual conditions is highly variable, thus it is essential to search for a precise diagnosis in every patient. High resolution computerised tomography (HRCT) and other less invasive investigations may be helpful in the management of patients. However, it is unusual to be able to make a firm diagnosis without a lung biopsy.

Non-nominal HIV surveillance: preserving privacy while tracking an epidemic

OBJECTIVE

To enhance HIV surveillance within a non-nominal provincial testing system.

METHODS

Confirmatory HIV tests from a provincial laboratory were analyzed during 1995 and 1996. Enhancements included elimination of repeat positive tests for the same individual using automated matching of non-nominal identifiers and nurse call-back of health care providers, completion of missing information through call-back and connection of providers with resources for patient care.

RESULTS

Forty-seven percent of 2,683 reactive HIV tests were identified as duplicates for the same individual, meaning that 1,401 people tested positive for the first time. From laboratory test data to enhanced unduplicated data after call-back, the proportion of tests for which risk and ethnic information was unknown dropped from 37% to 11% and from 64% to 18% respectively (p < 0.0001).

CONCLUSIONS

Enhanced non-nominal surveillance for HIV is a practical means of marrying the needs of public health for epidemiological information and the rights of patients to privacy.

Intracranial hypotension presenting with severe encephalopathy. Case report

A patient with severe and protracted symptoms from intracranial hypotension is described. The patient's presentation was marked by diffuse encephalopathy and profound depression of consciousness. This case report expands the presently known clinical spectrum of this uncommon and generally benign illness. The clinical and laboratory findings typically observed in the syndrome of intracranial hypotension are outlined. The pathophysiological mechanisms of the phenomenon are briefly discussed. Intracranial hypotension is a potentially severe illness with specific treatments that are distinct from the treatment of most neurological diseases. Three cardinal features--postural headache, pachymeningitis, and descent of midline cerebral structures--should prompt the diagnosis.

Endoscopic intracorporal abdominoplasty: a review of 85 cases

The specialty of plastic surgery has witnessed an explosion of novel procedures with the advent of endoscopy. Surgeons are making more aggressive attempts to reduce the length of scars and subsequent morbidity associated with traditional "open" procedures. Our purpose is to present a new technique of endoscopic abdominoplasty that has largely replaced traditional "full open" techniques at our institution. Since 1985, 85 patients have undergone a procedure that we call the endoscopic intracorporal abdominoplasty. This technique combines traditional abdominal wall liposuction with endoscopic intracorporal plication of the rectus fascia by using a series of horizontal mattress sutures. The procedure is performed using three 1-cm incisions and a series of midline and lateral skin nicks. These 85 patients were compared with 25 patients who underwent traditional open abdominoplasty with anterior plication of the rectus fascia. Average length of surgery was 127 minutes compared to 149 minutes with the open techniques. Length of hospitalization at our institution was 1 postoperative day compared to an average of 3 days with open techniques. No drains were used with the endoscopic techniques, and all of the open procedures had two drains placed. The perioperative rate of morbidity for the intracorporal abdominoplasty was 15 percent (13 of 85 patients) and with the open abdominoplasty cases it was 24 percent (6 of 25 patients). Our conclusion is that the endoscopic intracorporal abdominoplasty reduces operative scars and effectively plicates the rectus fascia, thereby reducing abdominal wall laxity. It has a rate of morbidity in a skilled laparoscopist's hands no greater than with traditional open abdominoplasty.

Novel methods for studying new antiepileptic drug pharmacology

A number of new antiepileptic drugs act by indirect mechanisms and thus produce effects that may not best be measured by traditional blood studies of the drugs and their metabolites. Study of the indirect action of these drugs on GABA-mediated inhibition by microdialysis and nuclear MR spectroscopy has proved more relevant. These new investigative techniques may also prove valuable as compounds affecting glutamate or other excitatory neurotransmitters are developed.

The challenges and benefits of job sharing in palliative care education

This article examines the authors' experience of job sharing a post in palliative care education. It discusses the concept of job sharing and examines factors such as power sharing, compatibility and other people's perception of the job sharing role. Effective communication is identified as a key issue. Benefits such as reduced professional isolation, increased job satisfaction and the opportunity to offer the knowledge and skills of two people are highlighted. The authors identify the factors which they consider to be crucial to the success of job sharing.

Enhanced methionine levels and increased nutritive value of seeds of transgenic lupins (Lupinus angustifolius L.) expressing a sunflower seed albumin gene

With the aim of improving the nutritive value of an important grain legume crop, a chimeric gene specifying seed-specific expression of a sulfur-rich, sunflower seed albumin was stably transformed into narrow-leafed lupin (Lupinus angustifolius L.). Sunflower seed albumin accounted for 5% of extractable seed protein in a line containing a single tandem insertion of the transferred DNA. The transgenic seeds contained less sulfate and more total amino acid sulfur than the nontransgenic parent line. This was associated with a 94% increase in methionine content and a 12% reduction in cysteine content. There was no statistically significant change in other amino acids or in total nitrogen or total sulfur contents of the seeds. In feeding trials with rats, the transgenic seeds gave statistically significant increases in live weight gain, true protein digestibility, biological value, and net protein utilization, compared with wild-type seeds. These findings demonstrate the feasibility of using genetic engineering to improve the nutritive value of grain crops.

The Centre for Palliative Care Education and Research

This article describes the role and function of the Centre for Palliative Care Education and Research at the University of Central England in Birmingham. The authors describe the development of the centre, which is a multidisciplinary venture in collaboration with Cancer Relief Macmillan Fund and palliative care providers throughout the west Midlands. Current educational and research initiatives are identified and some future challenges indicated.

Embryonal adenoma of the kidney: a report of two cases

Embryonal (metanephric) adenoma of the kidney, like Wilms' tumor, exhibits small monomorphic, blue cells arranged as vague, tubular rosettes. Unlike Wilms' tumor, which requires chemotherapy or multi-modality therapy for optimal management, the available evidence indicates that embryonal adenoma is most likely cured by simple enucleation or nephrectomy. Two women, age 54 (Case 1) and 78 (Case 2), respectively, underwent needle biopsy for a radiologically well circumscribed renal lesion with associated hematuria. The cellular smears contained vague rosette-like arrangement of small, blue cells with scant cytoplasm and evenly distributed, fine, nuclear chromatin. In cell blocks, these cells were arranged as compact, primitive, tubular rosettes or rare, moresolid clusters. Assuming that the absence of undifferentiated blastema and primitive glomeruli represented a sampling error, a diagnosis suggesting of Wilms' tumor was made in Case 1. At nephrectomy, despite extensive sampling, the typical triphasic Wilms' morphology and anaplastic or necrotic areas were not seen. In the presence of architectural monotony, the diagnosis in Case 1 was amended to embryonal adenoma. Case 2 was cytologically diagnosed as embryonal adenoma of the kidney and is being followed conservatively. In our opinion, the presence of monotypic architecture at cytology/histology is very helpful in differentiating renal embryonal (metanephric) adenoma from Wilms' tumor.

Counterurbanisation and rural depopulation revisited: landowners, planners and the rural development process

"This paper reopens the debate between Weekley (1988) and Rowsell (1989) over why pockets of depopulation have persisted within parts of rural Britain which have experienced net growth through counterurbanisation. It argues that Weekley has not fully appreciated the context for local population losses, namely the emergence of a new structural relationship between people, households, and dwellings, and the growing tension between production and consumption interests in rural locales. Moreover, the paper disputes claims that depopulation is triggered by the actions of either the landowner or the planner. Drawing on case study material informed by critical realism, it argues that planners and landowners have been drawn into an asymmetrical power relationship. This has tended to buttress landed interests and, in so doing, reproduce mechanisms which protect the less populous communities from growth and change."

Physician reactions to the health care revolution. A grief model approach

The American health care reform revolution has brought about major changes in the practice of medicine. As integral components of the health care system, physicians have felt the full impact of most of these changes. Change often involves losses for those affected, and, in this case, physicians are no exception. Many physicians have experienced losses of financial security, social status, independent clinical decision making and resource utilization, the practice option of independent private practice, hospital governance power, freedom of choice in specialty selection and geographic practice location, physician collegiality, continuity of patient relationships, and autonomy. We use Kübler-Ross' grieving model to help understand physician responses to their losses inherent in health care system reform. The grieving stages of denial, anger, bargaining, depression, and acceptance are applied to these physician responses and suggestions given to help physicians through this grieving process.

Spatial heterogeneity of soil water around single roots: use of CT-scanning to predict fungal growth in the rhizosphere

Whole-body computed tomography X-ray scanning (X-ray CT) of wheat, cotton and radish growing in pots containing 350 g of a white sand: clay mixture produced images from which digital data of the volumetric water content were obtained. The volumetric water contents were spatially heterogeneous around the root and altered with the depth at which the image was taken. Data represent a 'snapshot in time' of the soil around single roots in a living soil-plant system. The volumetric water contents of soil around seedlings were assessed for the growth of two soil-borne fungi, Gaeumannomyces graminis var. tritici and Rhizoctonia solani. The heterogeneity of water content was biologically significant: water contents around the roots of wheat, radish and cotton were of a great enough range to suggest the existence of heterogeneous sites in the rhizosphere which might favour or restrict fungal growth. In soil surrounding wheat roots, the most favourable regions for the growth of G. graminis were nearest the root, suggesting that the inner rhizosphere might be more amenable to the growth of this pathogenic fungus than the outer region of the rhizosphere, and the bulk soil. The technique of X-ray CT enables spatial examination of the response of soil water to environmental treatments of the soil-root system, and the non-destructive observation of the effect of the spatial heterogeneity of volumetric water content upon fungal growth in the soil, over time and at a range of depths.

Variations in the natural history and survival of patients with supratentorial low-grade astrocytomas

Data from 55 consecutive patients with low-grade astrocytomas treated between 1982 and 1990 were analyzed to determine specific outcome factors, including time to recurrence, incidence of anaplastic transformation, and survival. Gender, type of symptoms, contrast enhancement, and timing of radiation therapy were not significant in determining outcome. Patients who had symptoms for > 2 years and underwent gross-total resection of the tumor, with age as a continuous variable, were associated with significantly longer time to recurrence and survival. Within the population of patients with low-grade astrocytomas, patients with chronic epilepsy clearly had the best prognoses. There were no tumor recurrences or deaths in 27 patients with chronic epilepsy, regardless of the extent of surgery and without the use of radiotherapy. Ten-year survival was 100% for 31 patients who underwent gross-total tumor resection, regardless of the length of preoperative symptoms. Immediate postoperative radiotherapy did not prolong the time to recurrence, reduce the incidence of transition to more malignant tumors at recurrence, or increase the length of survival when compared with delayed radiotherapy. Because recurrence with a high-grade lesion caused 92% of the mortality in our series, the benefit in patients who underwent aggressive surgery seems to result from a significant decrease in the risk of recurrence when compared with patients who underwent anything less than gross-total resection. Our data also suggest that variability in the natural history of low-grade astrocytomas has a strong influence in determining survival and that tumors associated with chronic epilepsy are much less likely to become more malignant over time.

Accumulation of a sulphur-rich seed albumin from sunflower in the leaves of transgenic subterranean clover (Trifolium subterraneum L.)

A gene encoding a sulphur-rich, sunflower seed albumin (23% cysteine plus methionine) was modified to contain the promoter for the 35S RNA of cauliflower mosaic virus, in order to obtain leaf expression in transgenic plants. In addition, a sequence encoding an endoplasmic reticulum-retention signal was added to the 3' end of the coding region so as to stabilize the protein by diverting it away from the vacuole. The modified gene was introduced into subterranean clover (T. subterraneum L.) and its expression was detected by northern and western blots and by immunogold localization. The albumin was accumulated in the lumen of the endoplasmic reticulum, and, among six independent, transformed lines, it accumulated in the leaves of T0 transgenic plants at varying levels up to 0.3% of the total extractable protein. The level of accumulation of the sunflower albumin increased with increasing leaf age, and in the older leaves of the most highly expressing plants of the T1 generation it reached 1.3% of total extractable protein. Expression of the SSA gene was stable in the first and second generation progeny. These results indicate that there is potential for significantly improving the nutritional value of subterranean clover for ruminant animals such as sheep by expressing genes that code for sulphur-rich, rumen-stable proteins in leaves.

Scleroderma and watermelon stomach

Two patients with scleroderma (systemic sclerosis, SSc) and chronic blood loss secondary to gastric vascular ectasia--"watermelon stomach"--are presented. These cases exemplify the condition of gastric vascular ectasia and highlight the increasingly recognized association with autoimmune antibodies and connective tissue disease such as SSc. In both cases the onset of gastric blood loss coincided with the clinical manifestations of sclerodactyly by months, suggesting some temporal relationship. Although a number of different treatment modalities are available, and discussed in this report, both cases required gastrectomy.

Variants of Kaposi's sarcoma in Southern Africa. A retrospective analysis (1980-1992)

All types of Kaposi's sarcoma (KS) are represented in the Southern African region. We present a retrospective analysis of patients with KS, treated and followed up at the Johannesburg General Hospital over a 12-year period (1980-1992). One hundred and nineteen patients with KS, divided into four groups according to their etiology (classical; endemic African; renal transplant recipients; epidemic AIDS-related) were analyzed. Choice of treatment (radiotherapy or chemotherapy) was individualized and based on clinical criteria, extent of disease and severity of symptoms. Kaposi's sarcoma showed a very high response rate to radiation therapy, regardless of variant, radiation modality or schedule. Chemotherapy was also effective in the more aggressive pattern of endemic African KS. Epidemic Kaposi's sarcoma showed the same poor outcome as demonstrated by its Western counterpart. We conclude that radiation therapy can provide excellent palliation with only minimal side-effects in all variants of KS seen in Southern Africa.