Aggressive squamous cell carcinomas developing in patients receiving long-term azathioprine

We report three patients who developed unusually aggressive squamous cell carcinomas after receiving long-term azathioprine treatment for dermatological disorders. Two patients gave a history suggestive of moderate to excessive sun exposure, and the third suffered from chronic actinic dermatitis. Hence, ultraviolet light damage may have been a significant cofactor in the development of these malignancies. Careful follow-up is necessary in patients who are taking azathioprine long term, and who have previously been excessively exposed to ultraviolet light (UVL), or in whom future exposure is likely to be excessive. We suggest that strict sun avoidance measures are followed by patients on long-term azathioprine, or that alternatives to azathioprine therapy are considered, especially in individuals inherently at risk of UVL damage, and in those already showing clinical signs of such damage.

The effects of caring on health: a community-based longitudinal study

This paper begins with a critical review of studies which have examined the effects of caring on health. Most are shown to suffer from defects in sampling and design, so that the evidence for detrimental effects is suggestive rather than conclusive. The substantive part of the paper then utilizes data on a cohort of 55-year-olds to compare the health of carers with the health of non-carers and to examine changes in caring and health over a 3-year period. The comparison yields no systematic evidence of the deleterious effects of caring on health; indeed, if there is a tendency in the accumulated data, it is in the opposite direction i.e. that carers report better health and functioning than non-carers. It is suggested that part of the explanation relates to selection and self-selection and the longitudinal data reveals high volatility in caring status, even over a short time period. The paper goes on to examine sub-groups of carers considered to be at greater risk. There is no evidence that their health is compromised but the authors acknowledge weaknesses in the data and argue for a specially designed study. The paper concludes with a discussion of the findings and their implications for research, policy and practice.

Patterns of class inequality in health through the lifespan: class gradients at 15, 35 and 55 years in the west of Scotland

Data confirming the existence of social inequalities in health have continued to accumulate since the Black Report reported class inequalities across a broad range of causes of mortality, with an increasing emphasis on indicators of morbidity and current health status. Although evidence of continuing inequalities mounts, elucidation of underlying mechanisms generating and maintaining such inequalities has been more elusive, and much of the debate has oscillated from the very broad to the very specific. In this paper, the class patterning of a range of non-fatal indicators of health are modelled in an attempt to outline first the adequacy of models of linear relationships for this range of measures, and secondly, the extent to which these are generalizable across a series of age/sex subgroups and across different domains of health. Data are presented here for representative community samples of men and women in adolescence, early- and late-midlife. While orderly relationships between social class and health were seen for the majority of the measures considered; the detailed patterns show considerable diversity. Thus for some aspects of health, notably height (itself often heralded as a broad indicator of health and early life experience), common class gradients were observed for both sexes at each of the stages of the life course examined. For others (notably mental health and presence of chronic illness), gradients were evident in later life but not in adolescence. Others still showed sex but not age differences in class patterning (typically measures of body shape), or no clear patterns (notably blood pressure and consultations with general practitioners). The current analysis draws attention to the consistency of gradients in early- and late-midlife, which are apparent despite the marked increase in the burden of poorer health which manifests between these life stages for almost all indicators of health (an exception being mental health). The challenges which this presents for understanding the mechanisms and processes which have been candidate explanations for social inequalities in health are discussed.

How sick is the West of Scotland? Age specific comparisons with national datasets on a range of health measures

The Central Clydeside Conurbation (CCC) has relatively high mortality rates. This paper examines whether it also has relatively high rates of ill health, using data from three cohorts (aged 15, 35 and 55 in 1987/88) in the West of Scotland. Comparisons on a range of self-reported physical and mental health indicators, anthropometric measures, blood pressure, and respiratory function were made with comparable age groups in ten British or Scottish national studies. The older two cohorts in the CCC exhibited relatively high rates of longstanding and limiting longstanding illness and the youngest cohort had relatively poor psychosocial health, compared to their age peers elsewhere. Fewer differences were found in blood pressure, anthropometric measures or respiratory function although older CCC residents were slightly shorter than in Britain as a whole and had slightly poorer respiratory function. Central Clydesiders in the late 1980s were generally in poorer health than those of the same sex and similar age elsewhere in the UK, but the extent of the disadvantage varied across different dimensions of health, and was not as marked as some stereotypes of the West of Scotland would suggest.

Enzyme immunoassay using native envelope glycoprotein (gp160) for detection of human immunodeficiency virus type 1 antibodies

An enzyme immunoassay using the purified native gp160 for the detection of human immunodeficiency virus type 1 (HIV-1) antibody was developed. This assay was determined to be highly specific, since (i) 157 serum samples that were confirmed negative by Western blot (immunoblot) (WB) were negative, (ii) 41 serum samples from populations with medical conditions that might cause nonspecific assay reactivity were all negative, and (iii) all 15 serum samples that showed false-positive reactions in one or more commercial HIV-1 screening tests were negative. The assay gave 100% specificity with a randomly selected and unlinked panel of 1,000 serum samples from healthy blood donors. The sensitivity of the assay was assessed by testing 238 samples confirmed as HIV-1 antibody positive by a standardized WB assay. All 238 serum samples (100%) were reactive in the native gp160 assay. In a dilution panel of 14 weakly WB-positive serum samples, 7 samples reacted two-to fivefold more strongly in the gp160 assay than in a virus lysate-based assay; the remaining 7 samples gave comparable reactivities in the two tests. The reactivities of 13 of these 14 serum samples in the gp160 assay were higher than in a commercial enzyme immunoassay that uses a recombinant envelope protein as the antigen. The native gp160 assay was more sensitive to identify seroconversion. In a well-characterized panel of sequential blood samples from a seroconverter, the new assay detected antibodies at least one sample ahead of the other commercial assays tested.

Clinical experience with hyperthermia in conjunction with radiation therapy

The authors have reviewed the medical records of 421 sessions of hyperthermia treatments in 73 patients treated between 1987 and 1992 at the University Heights Cancer Center and the Indiana University Medical Center in Indianapolis, Ind. Temperatures attained during the course of therapy on each patient have been averaged and the results were evaluated for complete, partial, or no response. All patients had previously failed conventional radiation therapy, chemotherapy and surgery. Responses were defined as: (1) Complete response-lesions that completely disappeared during treatment and the response was sustained for a minimum of 6 months. (2) Partial response-lesions that underwent a reduction in size of greater than 50%. (3) No response-less than 50% reduction in tumor size during the course of treatment. Response varied somewhat according to histology and anatomical site of treatment; however, complete response was achieved in 45%, partial response in 48% (for an overall response of 93%), and no response in 7% of the patients. The response achieved varied with temperature attained and a minimum temperature of 40 degrees C for 40 min produced the greatest number of responses. Response to hyperthermia was directly related to the temperature achieved and the length of time the temperature was applied.

Prolonged and multipatient use of prefilled disposable oxygen humidifier bottles: safety and cost

OBJECTIVES

Multipatient use and prolonged use of prefilled disposable oxygen humidifier bottles (Aquapak 301, Respiratory Care, Inc., Arlington Heights, IL) were evaluated by performing microbiologic monitoring and a cost analysis on bottles used for varying numbers of patients and lengths of time.

METHODS

Humidifiers were hung for a maximum of one month. Monitoring was conducted in 6 different nursing areas. Quantitative cultures were done for aerobes and Legionella. Reusable humidifier bottles also were monitored.

RESULTS

Cultures were obtained from 1,311 disposable and 60 reusable humidifiers. No significant bacterial contamination was detected in the prefilled disposable oxygen humidifier units. Ten percent of the reusable bottles were contaminated by organisms associated with skin flora.

CONCLUSIONS

Multipatient use and increased duration of use of disposable humidifiers result in cost savings without increasing patient risk. Restricted multipatient use of prefilled disposable oxygen humidifier bottles for a period of one month is a safe and cost-efficient practice.

The management of neonatal rhinitis

Life-threatening upper airway obstruction secondary to neonatal rhinitis is a rare and poorly understood condition. Despite potential lethal effects, there has been no basic scientific research investigating the nature of this curious condition. This paper retrospectively reviews 8 patients suffering from neonatal rhinitis. Both the medical and surgical management of neonatal rhinitis and possible aetiological factors involved are discussed. Increasing clinical awareness of this condition may, therefore, serve as inspiration for future research of both an epidemiological and basic scientific nature.

Competing explanations for associations between marital status and health

This paper is based on baseline data from a survey of 1042 fifty-five year olds living in the Central Clydeside Conurbation, who constitute the eldest cohort of the 'West of Scotland Twenty-07 Study'--a longitudinal study of health and everyday life. The relationship between marital status and a number of measures of health and illness is explored. The paper examines which of four 'social causation' explanations--that married people have better health because they have more material resources, less stress, indulge in less risky health behaviour and have more social support--can actually account for the observed patterning. It finds that more risky health behaviour (measured by smoking and drinking), and 'objective' levels of social support, cannot account for very much of the effect of marital status on health measures; but that material resources, stress and perceived quality of social support could do so. However, elucidation of the direction of the relationships between these explanations and health measures, and indeed of the effect of health 'selection' into and out of marriage must await future sweeps of this longitudinal study.

Survivors of extreme prematurity--outcome at 8 years of age

Of 149 infants liveborn in a large maternity hospital in 1980 to 1982 and delivered between 24 and 29 completed weeks of gestation inclusive, 91 (61%) survived; 88 (97%) survivors were assessed at 8 years' corrected age; 77% of children were not disabled; disability was mild in 13%, moderate in 2% and severe in 4% of children. Although survival decreased with decreasing gestation, disability in survivors did not increase. An earlier assessment of the same children at approximately 2 years of age had been unduly pessimistic particularly for those born less than or equal to 26 weeks' gestation. The only other reports in the literature on outcome by gestation have all assessed the children in early childhood, and estimates of severe disability rates from these studies will probably also be too pessimistic. Since the rate of severe disabilities in infants of borderline viability is not much higher than in more mature infants the obstetrician should mainly consider survival chances for the fetus, and not be overly concerned with long-term neurological outcome, when making clinical decisions.

Persistent infection of rhesus macaques with a molecular clone of human immunodeficiency virus type 2: evidence of minimal genetic drift and low pathogenetic effects

In an attempt to generate a suitable animal model to study the infectivity and possible pathogenicity of human immunodeficiency viruses, we intravenously inoculated juvenile rhesus macaques and African green monkeys with a molecularly cloned virus, human immunodeficiency virus type 2 HIV-2sbl/isy, as well as with the uncloned HIV-2nih-z virus. Infection was monitored by virus recovery from the peripheral blood cells and by seroconversion against HIV-2 antigens measured by Western immunoblot, radioimmunoprecipitation, and enzyme-linked immunosorbent assay. We successfully infected two out of two macaques with the molecularly cloned virus and one macaque out of two with the HIV-2nih-z. No evidence of infection was seen in the African green monkeys with either virus. We followed the infected animals for 2 years. The animals remained healthy, although we observed intermittent lymphadenopathy and a transient decrease in the absolute number of circulating CD4+ T lymphocytes in both animals infected with the molecularly cloned virus. Virus isolation from the peripheral blood cells of the infected animals was successful only within the first few months after inoculation. Evidence of persistent infection was provided by the detection of proviral DNA by polymerase chain reaction analysis of the blood cells of the inoculated animals and by the stability of antiviral antibody titers. To evaluate the genetic drift of the proviral DNA, we molecularly cloned viruses which were reisolated 1 and 5 months postinoculation from one of these animals. Comparison of the DNA sequences of the envelope genes of both these isolates indicated that a low degree of variation (0.2%) in the envelope protein had occurred in vivo during the 5-month period. These data suggest that the use of HIV-2sbl/isy in rhesus macaques may represent a good animal model system to study prevention of viral infection. In particular, molecularly cloned virus can be manipulated for functional studies of viral genes in the pathogenesis of acquired immune deficiency syndrome and provides a reproducible source of virus for vaccine studies.

Types and correlates of blood/injury-related vasovagal syncope

This study investigated by interview, the initial syncopal episode of 103 blood/injury-related vasovagal fainters in order to examine two competing hypotheses concerning their origins. Graham (Circulation, 23, 901-906, 1961) postulated that the faint resulted when sympathetic nervous system (SNS) activity ceased on termination of a threat, leaving parasympathetic nervous system (PNS) activation unopposed. Engel [Fainting (2nd edn), 1962; Annals of Internal Medicine, 89, 901-906, 1978] proposed that when in the face of threat with SNS activation, escape is blocked, the PNS becomes activated as the conservation-withdrawal response, leading to syncope. We found cases clearly conforming to each of these formulations as well as some with characteristics of both, and some who fainted in response to blood or injury but with no perception of threat. The Graham and Engel types did not differ in terms of fear or avoidance of blood, injury, or medically-related situations nor did they differ in the frequency with which their parents reported blood/injury-related syncopal episodes. It is proposed that both may be activated by a common psychological mechanism involving cessation of a defensive posture. In contrast, the non-threat fainters showed significantly less medically-related avoidance and had a greater percentage (94%) of parents with positive faint histories.

Reduction of fractured nasal bones; local versus general anaesthesia

This prospective study was designed to asses whether the results of reducing simple fractures of the nasal bones were different using local or general anaesthesia. Two consecutive groups of 50 patients had their fractures manipulated under (a) general, or (b) local anaesthesia. The results of reduction as assessed by the patients and surgeons were not significantly different between the 2 groups. The reoperation rate for nasal obstruction and external deformity was similar in the 2 groups. We suggest that fractured nasal bones may be reduced under local anaesthesia without detriment to the results. This represents a significant saving of hospital resources.

The metabolism and testicular toxicity of cyclohexylamine in rats and mice during chronic dietary administration

Cyclohexylamine hydrochloride has been given in the diet to mice and to Wistar and DA rats for 13 weeks, to provide a constant intake of 400 mg of the base/kg/day. Significantly decreased food intake and body weight gain were found in both strains of rats but not mice. The metabolism of [14C]cyclohexylamine was widely different in Wistar and DA rats and in rats and mice, and these differences were not altered appreciably by chronic intake for 13 weeks. The differences in metabolism resulted in marked and persistent differences in the concentrations of the hydroxylated metabolites in the plasma and testes of treated animals with Wistar much greater than DA much greater than mice. After 7 and 13 weeks testicular atrophy was demonstrated in both strains of rats given cyclohexylamine diet by a decrease in organ weight and by histological changes. DA rats appeared more sensitive to testicular toxicity from cyclohexylamine than Wistar rats, while mice showed no evidence of testicular damage. These data show that the development of testicular toxicity is not related to the extent of hydroxylation. The concentrations of cyclohexylamine in the plasma and testes of the treated animals were lower in mice than in either strain of rats despite a similar daily intake. This suggests that species differences in pharmacokinetics may contribute to the apparent difference in sensitivity to testicular toxicity.

Magnetic resonance imaging of pituitary and parasellar abnormalities

The ease, safety, accuracy, reliability, specificity, and sensitivity of the diagnosis of disorders of the sellar region all have been enhanced by MRI. This article demonstrates the normal anatomy and the wide array of pathology that can be visualized by MRI. Magnetic resonance has become the imaging modality of choice for most of the disorders within and about the sella.

Outcome in infants of birth weight 500 to 999 g: a continuing regional study of 5-year-old survivors

During 1979 and 1980, 351 infants of birth weight 500 to 999 g were born in the State of Victoria: 89 (25.4%) survived to the age of 2 years corrected for prematurity, and 83 were fully assessed by a multidisciplinary team; partial data were obtained on the remainder. At the age of 5 years, corrected for prematurity, 85/89 (96%) were evaluated by a multidisciplinary team, although not all children could be fully evaluated by the psychologists. Reports were available for another three children; one child was untraced. Of the survivors able to be classified at 5 years, 59/82 (72%) had no functional handicap. Functional handicaps was severe in 16 (19%), moderate in four (5%), and mild in three (4%). Functional handicaps were present in 50% (8/16) of outborn survivors compared with the 23% (15/66) for the inborn survivors (P = 0.02). Cerebral palsy was diagnosed in eight children at 5 years and in 12 children at 2 years. The diagnosis was stable for the children not ambulant at 2 years; five of seven 2-year-old children with mild cerebral palsy had "outgrown" the diagnosis by 5 years, but ataxic cerebral palsy was not identified in one child until 5 years. Six children were blind; four had severe sensorineural or mixed deafness, one more than at 2 years. Of 82 children assessed according to identical criteria for functional handicap at both 2 and 5 years, 52 (63%) remained in the same category at 5 years, three (4%) were judged to be more severely handicapped, and 27 (33%) were less severely handicapped. The 2-year evaluation of extremely low birth weight children often proved to be unduly pessimistic, for many showed improvement or recovery from functional handicaps and impairments by 5 years of age.

The mechanism underlying sudden death from electric shock

Much has been written on the effects of electric shock on the body. However, in those cases in which victims become pulseless and therefore die suddenly, the underlying event has assuredly been ventricular fibrillation. In this condition of the heart, all of the muscle fibers of the ventricles, the main pumping chambers, contract and relax randomly and pump no blood. Simple protracted cardiac arrest, in this circumstance, is most unlikely. It generally is believed that only low-frequency alternating current can induce ventricular fibrillation; this assumption is invalid, because a single pulse of current applied to the body, as well as high-frequency current, can induce ventricular fibrillation. The important variables are the type and magnitude of the current and the manner in which it is applied to the body. To date, the current pathway has received too little attention. This article reviews the various mechanisms by which a single shock or a train of pulses can induce ventricular fibrillation.

Relationship of growth and psychoneurologic status of 2-year-old children of birthweight 500-999 g

There were 257 liveborn infants of birthweight 500-999 g born in one tertiary centre in the 5 1/4 years commencing January 1977; 86 (33.5%) survived to 2 years of age, corrected for prematurity and 83/86 (96.5%) were fully assessed. The prevalence of cerebral palsy was 10/83 (12%) and 17/83 (20%) had a major impairment. The distribution of weights and heights for 2-year-old boys and girls was significantly lower than for the standard population, as was the head circumference distribution for boys; the distribution of the Mental Developmental Index (Bayley Scales) was not related to the head circumference or body weight at two years or to head-circumference/bodyweight or height ratios. At birth measurements of weight, length and head circumference were under the 3rd percentile for 13/86 (15%), 9/86 (10.5%) and 9/86 (10.5%) respectively. By 2 years of age, weight, length and head circumference were under the 3rd percentile in 23/83 (27.7%), 26/83 (31.3%) and 4/83 (4.8%) respectively. 12 children who were SGA at birth were fully assessed at 2 years; the group of 6, who continued with poor postnatal weight gains (under the 3rd percentile) had the highest rate of major impairment but included were the only extremely SGA twins and the only two major malformations in the study. We found no association of other health problems or unfavourable social factors with poor postnatal growth or impaired outcome.

The elderly as underconsulters: a critical reappraisal

This paper reconsiders the evidence for underconsultation among the elderly. Earlier evidence from studies of unreported illness is reassessed and new data are presented for the ratio of self-reported illness to number of consultations. It is concluded that underconsultation among the elderly is exaggerated and that there are implications for screening and case-finding. It is suggested that attention should be directed towards a combination of self-referral and multi-tiered screening for low contact and high risk groups.

An electromyographic study of elbow motion during postexercise muscle soreness

Postexercise muscle soreness was induced in the elbow flexors of human volunteer subjects through the use of a regimen of eccentric contractions. Physical examination before and 48 h after the exercise included measurements of range of elbow motion at the elbow and of arm diameter. Electromyographic (EMG) observations, utilizing fine wire electrodes introduced into each of the elbow flexors, were carried out before and 48 h after the exercise. These observations included resting EMG levels, EMG activity under various isometric loads, and activity during active and passive extensions. The soreness induced was accompanied by a reduction in resting elbow angle while the subjects stood with arms relaxed at their sides, decreased range of both flexion and extension of the elbow, and swelling of the arm. EMG measurements showed no increase in EMG activity as the sore arms were extended passively at the elbow, indicating that the extra resistance to extension associated with the soreness was not a result of stretch receptor-induced activity in the flexors. The results rule out the possibility that neuromuscular activity is responsible for the restriction of motion and are consistent with the idea that edematous changes within the perimuscular connective tissue alter the elastic behavior of the muscles and cause restriction of motion.

Outcome in infants with birth weight 500 to 999 gm: a regional study of 1979 and 1980 births

During 1979 and 1980, 351 infants weighing 500 to 999 gm were born in the State of Victoria, Australia; 89 (25.4%) survived to 2 years of age. Survival was better for tertiary center births (29%) than for those born elsewhere (17%). Multidisciplinary teams reviewed 83 of the survivors at 2 years of age postterm; some data were available for the other six children. Overall, 22.5% of infants had severe functional handicap, 29.2% had either moderate or mild handicap, and 48.3% had no handicap. Severe functional handicap was present in 50% of outborn infants; this was significantly more common than in those born in tertiary centers (15.5%), and the Bayley Mental Developmental Index was also significantly lower in outborn infants. The prevalence of cerebral palsy (13.5%), bilateral blindness (3.4%), and severe sensorineural deafness (3.4%) did not differ significantly in the inborn and outborn infants. Singleton inborn infants of appropriate weight for gestational age had significantly less severe functional handicap (9.1%), compared with 37.5% for the group of infants who were either small for gestational age or one of multiple births. Six of the 18 outborn infants could have been transferred in utero, and improvements in immediate neonatal care were possible in seven other infants.

Active mobility of the extremities in older subjects

The purposes of this study were to expand the data base of active range of motion (ROM) in the upper and lower extremities of older persons measured by goniometry and to determine if differences exist related to age, sex, and physical activity. Active ROM was measured with a clinical goniometer in 28 joint motions of the upper and lower extremities of the right side in 60 older subjects. Thirty men and 30 women were equally divided in two age groups of 60 to 69 and 75 to 84 years of age. Multivariate analysis of variance showed no significant differences in ROM that were attributable to sex and age. In univariate tests, however, 12 motions were significantly different (p less than .05) between the sexes, but only in 4 motions was the difference greater than intertester error. Physical activity, as assessed by a questionnaire and a rating scale, was not related to specific changes of joint range. Within the older subjects, however, a significant relationship between ROM and age or ROM and physical activity cannot be assumed. These results suggest that a data base of normative values is needed for older individuals.

Comparison of polyadenylic acid and oligouridylic acid messenger RNA associated proteins

Various subclasses of messenger ribonucleoprotein particles were prepared from free cytoplasmic and polysome fractions of rat liver on the basis of the homopolymeric content of the constituent RNA's. Two major proteins were evident in the free cytoplasmic preparations: the poly(A)-binding protein was the major constituent of polyadenylated components and a 60 kilodalton protein was the major protein in oligouridylated components. In addition to the poly(A)-binding protein, the polysome fractions contained a 74 kilodalton protein that was present in all subclasses of particles. With both free cytoplasmic and polysome preparations, chromatography on columns of poly(U)-sepharose separated poly-adenylated mRNP's largely on the basis of the length of the poly(A) tract; mRNP's containing short poly(A) tracts (fragment distribution centered on 34 residues) were not retained by the columns, presumably because of the interaction of the poly(A) with poly(A)-binding protein.

Differential aging: an exploratory approach using cluster analysis

This article uses cluster analysis to identify different patterns of personal resources within a random sample of the well, elderly population. Ten such patterns or natural groupings are identified and their implications for coping and successful aging are discussed. It is apparent that there are a number of ways both of aging well and aging badly, and that these patterns cannot be predicted solely on the basis of structural data. The article poses a number of questions on the performance of cluster members over time and draws attention to the importance of longitudinal data.

Outcome of extremely low birth-weight infants in relation to the hospital of birth

There were 351 liveborn infants of birth-weight 500-999 g born in the State of Victoria in the years 1979 and 1980; 89/351 (25.4%) survived to the age of 2 years: 42 (47.2%) survivors were of gestational ages of 24 to 26 weeks and 47 (52.8%) were born at 27 to 32 weeks' gestation. Survival of these extremely low birth-weight infants was significantly better (71/245, 29%) for births in tertiary centres compared with those born elsewhere (18/106, 17%). Of the 351 livebirths, 69.8% occurred in 1 of the 3 tertiary centres. All 89 survivors were traced; 84 (94.4%) were assessed at the age of at least 2 years by a multidisciplinary team. Three children had been fully assessed at 1 year of age and paediatric reports were available for 2 children. The quality of survival of children born in tertiary centres was significantly better than those transferred to a tertiary centre after birth; the prevalence of serious functional handicap was 72.2% (13/18) for outborn children compared with 22.5% (16/71) for those born in tertiary centres. The prevalence of serious functional handicap in the inborn survivors was lowest (9/55, 16.4%) in singleton births who had been of appropriate birth-weight for gestation. A review of the 18 surviving outborn infants' records indicated that 6 (33.3%) could have been transferred to a tertiary centre in utero and for the 12 infants where birth in a tertiary centre was not feasible, improvements in the early neonatal care were possible in another 7 infants.

Reappearance of epidermal Langerhans cells after PUVA therapy

Epidermal Langerhans cells (LC) disappear during photochemotherapy (PUVA) with 8-methoxypsoralen (8-MOP) and long wavelength ultraviolet (UV-A) radiation. The time course of their disappearance during treatment and their reappearance after its completion was followed. Langerhans cells lost ATPase activity before they disappeared by ultrastructural criteria: thus 90% of ATPase-stained cells had disappeared after seven treatments (2 weeks) whereas it was only after fifteen treatments (5 weeks) that they were seen to be reduced on electron microscopy. Their numbers remained low throughout the course of treatment but they had returned to normal by 3 weeks after cessation of therapy. Since PUVA lamps also emit traces of medium wavelength UV (UV-B) the separate effects of UV-A and UV-B in the presence and absence of 8-MOP were examined. Within the dose range normally used for therapy, the LC disappeared only with the combination of UV-A and 8-MOP.

Collaborative study of very-low-birth-weight infants. Correlation of handicap with risk factors

Two large maternity services studied consecutive inborn infants (birth weight range, 500 to 1,500 g) born between 1977 and 1978. The multidisciplinary team members used identical assessment methods and documentation. Of 259 long-term survivors, 252 (97.3%) were seen at 2 years of age. Survival rates for hospitals 1 and 2 were 68.5% and 69.0%, respectively. Cerebral palsy rates for hospitals 1 and 2 were 11.8% and 11.2%, respectively. Major handicaps (cerebral palsy, mental developmental index [MDI] on the Bayley scales less than 69, epilepsy, deafness, or blindness) occurred in 30 (18.6%) and 17 (17.3%) of hospitals 1 and 2 survivors, respectively. Both cerebral palsy and developmental delay (MDI below 75 without severe or moderate cerebral palsy) were significantly correlated with a number of perinatal variables, but none were common to the two hospitals. Of the 30 children with cerebral palsy, 15 (50%) were not ventilated, and 28 (93%) had a five-minute Apgar score greater than 4; there was no indication that selective treatment to prevent cerebral palsy was possible.

Risk groups and selective case finding in an elderly population

As the preventive approach gains ground in the care of the elderly there is increasing interest in screening or case-finding. Given the impracticability of visiting all those over a certain age, most GPs and health visitors concentrate on those considered to be at greatest risk of medical and social deterioration. This paper draws on data from a random sample of the elderly population of Aberdeen to examine the nature and extent of 'risk' experienced by those falling into a number of conventionally defined risk groups. It shows that few of these groups are comprehensively disadvantaged and most are inefficient for selective case-finding. An alternative approach based on answers to a carefully selected set of screening questions is shown to be more efficient, and suggestions are offered for further improvements.

Infants born before 29 weeks gestation: survival and morbidity at 2 years of age

In a collaborative study involving two hospitals with large maternity services, 166 liveborn infants of gestational age from 24 to 28 weeks were born in the calendar years 1977 and 1978. Of these infants, 75 (45.2%) died either in hospital or after discharge home. At the age of 2 years, 16 (9.6%) of the cohort had a major handicap [cerebral palsy, Mental Developmental Index (MDI) under 69, deafness or blindness]. An additional 20 children (12.0%) had significant developmental delay (MDI 69 to 84, -2 to -1 SD below mean) and 53 (31.9%) were considered to be free of these handicaps. Psychological assessments were not performed on two survivors (1.2%) but reliable reports indicated that they were free of major handicaps. Long-term survival increased in a stepwise fashion from 9.1% at 24 weeks to 68.5% at 28 weeks gestation, and there was a trend for major handicap and significant developmental delay to decrease in incidence with increasing maturity. Of the 58 children who had presented by the vertex 42 (72.4%) were free of significant handicap; however, of the 31 children in whom there had been either a breech presentation or a transverse lie, only 11 (35.5%) were free of significant handicap (chi 2 = 9.69, P less than 0.01). The mode of delivery (vaginal or caesarean section) did not significantly affect the handicap rate in the survivors.

Changing outcome over 13 years of very low birthweight infants

The survival prospects for infants of birthweight less than or equal to 1500 g born in recent years have improved. Evidence for a corresponding decrease in long-term morbidity of survivors is conflicting but recent reports from some centers indicate that high morbidity rates are occurring. Until additional satisfactory reports are available on the outcome of very low birthweight (VLBW) infants born after 1975, preferably from a community or region, uncertainty will continue. The outcome of three cohorts of VLBW infants, born in the Royal Women's Hospital, Melbourne between 1966 and 1978 is reported; more than 90% of each cohort were fully assessed, aged 2-8 years. There were 169 long-term survivors from the first cohort (1966-1970 births) and 72 from the second cohort (1973-74 births); survival rates were 37.1% and 37.3% respectively; however, for the 1977-78 births, there were 161 survivors, a significant increase to 68.3%. In the first cohort, 32.7% had one or more visual defects and 3.9% were blind but visual morbidity decreased progressively in cohorts 2 and 3; 3% of the second cohort and 1.2% of the third cohort were blind. There was a trend for a decrease in severe sensorineural deafness. Cerebral palsy increased progressively, respectively 2.6%, 4.5% and 11.9% in the first, second and third cohorts. There was a significant increase in the mean Mental Developmental Index of the Bayley Scales at the age of 2 years from 75.38 for the 64 children born in 1966-70 compared with 90.96 for 150 children in the 1977-78 cohort. Although there had been an increase in upper social class families in the more recent cohort, improvement in test scores was still highly significant when higher social classes (1-3 Congalton Scale) were excluded. However, there was no significant improvement in the 6 year psychological test scores of the first and second cohorts. There was a steady increase in occurrence of cerebral palsy. Significance associations in the 1977-78 cohort were found with only 2 perinatal variables (use of theophylline and necrotizing entercolitis). Furthermore, 17 (89.5%) of children had a five-minute Apgar score greater than 5 and 14 (73.7%) did not require ventilatory support: Prevention of cerebral palsy by selective treatment in the delivery room or nursery was not feasible for prediction of this condition was not possible from perinatal risk factors.