Persistent cough in an adolescent

Jessica, a 14-year-old girl with a history of asthma, went to her pediatrician's office because of a persistent cough. She had been coughing for at least 3 months with occasional cough-free periods of less than a few days. The cough was nonproductive and was not accompanied by fever, rhinorrhea, or facial or chest pain. Jessica and her mother observed that the cough increased with exercise and typically was not present during sleep. She has used two metered-dose inhalers--albuterol and cromolyn--without any change in the cough pattern. For the past 5 years, Jessica has had mild asthma responsive to albuterol. She enjoys running on the cross-country team, soccer, and dancing. She is an average student and denies any change in academic performance. She has never been hospitalized or had an emergency department visit for asthma or pneumonia. There has been no recent travel or exposure to a person with a chronic productive cough, tobacco smoke, or a live-in pet. Jessica lives with her mother and younger sister in a 10-year-old, carpeted apartment without any evidence of mold or recent renovation. In the process of taking the history, the pediatrician noticed that Jessica coughed intermittently, with two or three coughs during each episode. At times, the cough was harsh; at other times, it was a quiet cough, as if she were clearing her throat. She was cooperative, without overt anxiety or respiratory distress. After a complete physical examination with normal findings, the pediatrician interviewed Jessica and her mother alone. Jessica's parents had been divorced for the past 6 years. She lived with her mother but visited her father, and his new family with two young children, every weekend. She spoke about this arrangement comfortably and said that she loved her father and mother but didn't like the tension she experienced at her father's home. "I don't like adults arguing when kids are around." When asked why she thought the cough persisted so long, she commented in a neutral tone, "I don't know. It's never been like this before." Jessica's pediatrician prescribed an inhaled steroid with the albuterol. When the cough did not respond after 1 week, he ordered a chest radiograph (normal) and a tuberculin skin test (purified protein derivative-negative), and he added montelukast (a leukotriene inhibitor) and monitored airway resistance with a peak flow meter. The cough persisted, and the peak flow recording showed normal airway resistance. At this time, Jessica's pediatrician suspected a conversion reaction and contemplated the next best therapeutic strategy.

Simulated blood levels of CF3I in personnel exposed during its release from an F-15 jet engine nacelle and during intentional inhalation

Of the agents under consideration for protecting unoccupied areas from fire, CF3I (trifluoroiodomethane) has physicochemical properties that give it potential as a "drop-in" replacement for halon 1301. One of the issues concerning the use of CF3I is the potential hazard to ground crews should an inadvertent discharge occur while workers are in or near an engine nacelle. A discharge test of CF3I was conducted on an F-15A jet to record CF3I concentration time histories at locations near the aircraft. The conditions of the discharges simulated an inadvertent ground discharge with the engine nacelle doors open and also with the doors closed. The use of three types of gas analysis instrumentation allowed gas sampling from several locations during the discharge tests. Concentrations measured at selected sensor locations were used as the input to a physiologically based pharmacokinetic model to simulate blood levels that would be attained by individuals inhaling CF3I at sensor locations. Blood levels reached during these exposures were compared with the blood level associated with the lowest observable adverse effect level (LOAEL) for cardiac sensitization to evaluate the possibility of safe egress. The highest blood concentrations simulated were twice the target blood concentration associated with cardiac sensitization. However, simulated blood concentrations of subjects who actually inhaled CF3I reached levels that were 100 times the target level without reported adverse effect. Thus, actual human data may supersede the use of the cardiac sensitization LOAEL obtained from animal studies.

Detection of episomal banana streak badnavirus by IC-PCR

A polymerase chain reaction (PCR) based strategy to detect episomal banana streak badnavirus (BSV) in banana and plantain plants that carry integrated BSV sequences was developed. Antisera used in immuno-capture polymerase chain reaction (IC-PCR) are capable of binding a large number of BSV serotypes. The primers used for PCR are capable of annealing to and amplifying across the aspartic protease-reverse transcriptase domain boundaries of both episomal and integrated BSV sequences and result in similar or identical sequence size fragments from either template. However, we show that under the conditions selected for IC-PCR, nuclear, mitochondrial or chloroplast genomic sequences are not amplified and thus only captured episomal BSV is amplified. IC-PCR is suitable for the large-scale screening of Musa for episomal BSV which is necessary for germplasm movement.

Evidence that badnavirus infection in Musa can originate from integrated pararetroviral sequences

When some virus- and disease-free Musa spp. (banana and plantain) are propagated by tissue culture, the resulting plants develop infections with banana streak badnavirus (BSV), a pararetrovirus. In sharp contrast to the virion DNA recovered from natural infections, the virion DNA from tissue culture-associated infections of different Musa spp. was highly similar if not identical. Although BSV does not employ integration during the infection cycle, BSV DNA was found to be integrated into the Musa genome. While one integration consisted of a partial BSV genome, a second contained more than one complete genome that was almost identical to BSV recovered from tissue culture-derived plants. The arrangement of this integrated BSV DNA suggests that it can yield an infectious episomal genome via homologous recombination. This report documents the first instance of integrated DNA of a nonintegrating virus giving rise to an episomal viral infection and identifies tissue culture as a possible trigger for the infection, raising the question of whether similar activatable viral sequences exist in the genomes of other plants and animals.

Integration of banana streak badnavirus into the Musa genome: molecular and cytogenetic evidence

Breeding and tissue culture of certain cultivars of bananas (Musa) have led to high levels of banana streak badnavirus (BSV) infection in progeny from symptomless parents. BSV DNA hybridized to genomic DNA of one such parent, Obino l'Ewai, suggesting integration of viral sequences. Sequencing of clones of Obino l'Ewai genomic DNA revealed an interface between BSV and Musa sequences and a complex BSV integrant. In situ hybridization revealed two different BSV sequence locations in Obino l'Ewai chromosomes and a complex arrangement of BSV and Musa sequences was shown by probing stretched DNA fibers. This is the first report of integrated sequences that possibly lead to a plant pararetrovirus episomal infection by a mechanism differing markedly from animal retroviral systems.

Cloning and sequence analysis of banana streak virus DNA

Banana streak virus (BSV), a member of the Badnavirus group of plant viruses, causes severe problems in banana cultivation, reducing fruit yield and restricting plant breeding and the movement of germplasm. Current detection methods are relatively insensitive. In order to develop a PCR-based diagnostic method that is both reliable and sensitive, the genome of a Nigerian isolate of BSV has been sequenced and shown to comprise 7389 bp and to be organized in a manner characteristic of badnaviruses. Comparison of this sequence with those of other badnaviruses showed that BSV is a distinct virus. PCR with primers based on sequence data indicated that BSV sequences are present in the banana genome.

The preliminary economic evaluation of health technologies for the prioritization of health technology assessments. A discussion

This paper critically evaluates methods for the preliminary economic evaluation of health technologies and the prioritization of health technology assessment projects. It reports on the literature, and considers methods currently employed and the purposes of preliminary appraisal. It concludes that a preliminary economic appraisal needs to be applied to the two main stages of the prioritization process; to have transparent criteria; to allow for an appropriate range of potential outcomes; to be practicable, flexible, and efficient; and to be relevant to the assessment of different research projects.

A community based study of vitamin A and vitamin E status of adolescent girls living in the Shire Valley, Southern Malawi

OBJECTIVE

To assess vitamin A and E status and anaemia in non-pregnant Malawian adolescent girls.

DESIGN

A cross-sectional study in rural village communities in the Shire Valley, Southern Malawi.

SUBJECTS

Adolescent girls, n = 118, aged between 10 and 19 y, 112 of whom were unmarried.

METHODS

Socio-demographic information was collected by questionnaire, heights and weights were measured. Vitamin A was assessed by the Modified Relative Dose Response (MRDR) test, in addition to serum retinol values. Blood samples were collected 4-5 h after administration of 3,4-didehydroretinyl acetate. Retinol and alpha-tocopherol levels were measured by HPLC. Serum retinol results for non-pregnant girls were compared with values for 43 adolescent pregnant girls which were available from a previous study.

RESULTS

26.6% of non-pregnant girls had serum retinol values < 0.70 micromol/L; 40.2% had an MRDR ratio > 0.060. In 59.3%, serum tocopherol levels were < 11.5 micromol/L and the tocopherol/cholesterol ratio was < 2.2 in 23.9%. 11.3% had a haemoglobin > or = 12 g/dl. Vitamin A levels were significantly related to age, and younger girls were more likely to be deficient. Significant correlations were found between serum retinol, MRDR values and serum tocopherol. Girls with a low body mass index for age had tocopherol cholesterol ratios < 2.2. Low serum retinol values occurred significantly more often in stunted girls (P=0.01). Serum retinol values of adolescent pregnant girls were significantly lower than those of non-pregnant adolescents (P=0.002).

CONCLUSIONS

Vitamin A and E deficiency and anaemia were common in adolescent non-pregnant girls, and thought to partly result from increased growth requirements. Girls who become pregnant at an early age are at risk of depletion of their nutritional reserves. Measures to reduce nutritional deficiencies before the first pregnancy are needed.

Comparison of sequences of RNAs 3 and 4 of rice stripe virus from China with those of Japanese isolates

The sequences were determined of RNAs 3 and 4 of a Chinese isolate (Y) of rice stripe tenuivirus (RStV) and were compared with those of two RStV isolates (M and T) from Japan. Both RNAs of the Y isolate were longer than those of the M and T isolates. There was almost complete conservation in the 5' and 3' non-coding regions for each RNA between the isolates. The analogous ambisense coding regions for each isolate were exactly the same size and the sequences were highly conserved. The major differences were in the intergenic regions, the sizes of which accounted for the differences in size of each RNA of the three isolates. There were no obvious patterns of differences in comparisons of the two RNA over the three isolates. The significance of the similarities and differences in sequences of isolates of RStV separated by more than 3500 km is discussed.

Tryptophan, Tryptophan-Leucine, and BSA Adsorption at an Oil-Water Interface

Adsorption of the amino acid tryptophan, the peptide tryptophan-leucine and the protein bovine serum albumin (BSA) at buffered water-oleyl alcohol interfaces has been studied by ellipsometry. Tryptophan-leucine solutions showed a systematic change in ellipticity with concentration indicating an adsorption of 0.5 mg/m2 for a solution concentration of 1 g/L and evidence of saturation at that concentration. BSA showed an adsorption of 0.45 mg/m2 for a concentration of 3.5 g/L with no sign of saturation. There appeared to be little adsorption of tryptophan at the interface.

A decade of change for patients

Although expressing concern that the quality of care in the ESRD program will be negatively impacted by the changes occurring in health care delivery and oversight today, Peter Lundin cogently describes the past, current, and future state of ESRD care when he says, "I believe that the life-expectancy for all ESRD patients ... is markedly improved, but remains, as always, primarily determined by the skills and motivations of those providing care." I hope that the renal community will benefit from these patient views and perceived needs as they ponder ESRD care in the next decade.

Neurobiochemical changes from Taxol/Neupogen chemotherapy for metastatic breast carcinoma corresponds with suicidal depression

A patient under Taxol and granulocyte colony stimulating factor (G-CSF, Neupogen) treatment for metastatic breast carcinoma of the liver experienced repeated suicidal depression on days 10 and 11 of therapy. MRI and MRS were performed during the fifth and sixth cycles of chemotherapy on days 1 and 10. The MRI was normal in all four examinations. The MRS showed normal levels of metabolites on days 1 of therapy, with remarkable reproducible declines in neurobiochemicals myo-inositol (23-27%), choline (20-24%), creatine (10-14%) and glutamate/glutamine (22-39%) on day 10 of therapy. The neurobiochemical declines coincided with the patient's experience of suicidal depression. Patients reporting depression during standard cancer therapy may be experiencing previously undocumented chemotherapeutic neurobiochemical imbalances or neurotoxicity.

Knee-length versus thigh-length graduated compression stockings in the prevention of deep vein thrombosis

Graduated compression stockings can reduce the incidence of deep vein thrombosis by 60 per cent1, by providing a decreasing compression gradient from the ankle towards the thigh. There is both theoretical and clinical evidence that compression of the thigh as well as the calf does not give extra benefit2,3. Although regarded as safe, improperly used stockings are not without risk. Problems are usually due to areas of localized high pressure, especially under ‘rucked up’ constricting bands of stocking. This is particularly so in the presence of ischaemia; manufacturers state that ischaemia is a contraindication to stocking use. Cases of arterial thrombosis have been reported4, as well as more frequent skin necrosis, when stockings have been used in the presence of reduced arterial blood supply5.

African-American adolescents residing in high-risk urban environments do use condoms: correlates and predictors of condom use among adolescents in public housing developments

OBJECTIVE

African-American adolescents living in high-risk inner-city environments have been disproportionately affected by the epidemics of human immunodeficiency virus (HIV) and other sexually transmitted diseases. Understanding the factors that influence the use of condoms by adolescents is critical for developing effective behavioral interventions. The present study examined the demographic, psychosocial, and behavioral correlates of condom use among African-American adolescents residing in public housing developments in an HIV epicenter (San Francisco) and prospectively evaluated the stability of these significant cross-sectional variables to predict consistent condom use.

DESIGN

A prospective study.

SETTING

Two public housing developments in San Francisco.

PARTICIPANTS

African-American adolescents and young adults between 12 and 21 years of age were recruited though street outreach and completed a theoretically derived research interview assessing HIV-related knowledge, attitudes, and behaviors. After a 6-month period, adolescents completed a follow-up interview similar to the baseline measure. Among adolescents reporting sexual activity in the 6 months before completing the baseline interview (n = 116), logistic regression analysis evaluated the influence of demographic, psychosocial, and behavioral factors on consistent condom use.

RESULTS

Adolescents who had high assertive self-efficacy to demand condom use (adjusted odds ratio [OR], 11), perceived peer norms as supporting condom use (OR, 4.2), had greater impulse control (OR, 3.7), were male (OR, 4.7), and were younger (OR, 2.9) were more likely to report consistent condom use. Frequency of sexual intercourse was inversely related to condom use; adolescents with higher numbers of sexual episodes were less likely to use condoms consistently. Prospective analyses identified the baseline level of condom use as the best predictor of condom use at the 6-month follow-up. Adolescents who were consistent condom users at baseline were 7.4 times as likely to be consistent condom users during the follow-up period. Of those adolescents changing their frequency of condom use during the follow-up interval, significantly more engaged in risky behavior; 33.3% changed from consistent to inconsistent condom use, whereas 20.6% changed from inconsistent to consistent use (OR, 1.6).

CONCLUSIONS

The findings suggest that HIV prevention programs need to be implemented early, before high-risk behaviors are established and may be more difficult to modify.

Child and adolescent psychiatry: toward the twenty-first century

The history of child and adolescent psychiatry is reviewed, from its beginning in the Hull House movement in Chicago a century ago through subsequent social and scientific transformations. The field's relationships to academic medicine, to progress in the basic sciences, and to child advocacy are described. Current challenges to the field, including the gaps in and barriers to care, the emergence of for-profit enterprises, and the lack of consensus regarding health care regulation, are discussed in terms of the evolving social mission of the profession. Priorities for the next century are identified.

A new educational approach for supporting the professional development of third-year medical students

This paper describes a new course designed to support the professional development of third-year medical students. The course runs through the clinical clerkships, and has several additional features: it includes a multidisciplinary faculty; it is centrally based in the medical school; it addresses students' values and attitudes in addition to their knowledge and skills; and it makes use of small-group learning methods, and faculty, student, and group continuity during the year. The curriculum, which addresses ethical, social, and communicative issues in medicine, plus the evaluation of students and of the course, are described.