Multi-stage regulation, a key to reliable adaptive biochemical pathways

A general "multi-stage" regulation model, based on linearly connected regulatory units, is formulated to demonstrate how biochemical pathways may achieve high levels of accuracy. The general mechanism, which is robust to changes in biochemical parameters, such as protein concentration and kinetic rate constants, is incorporated into a mathematical model of the bacterial chemotaxis network and provides a new framework for explaining regulation and adaptiveness in this extensively studied system. Although conventional theories suggest that methylation feedback pathways are responsible for chemotactic regulation, the model, which is deduced from known experimental data, indicates that protein interactions downstream of the bacterial receptor complex, such as CheAs and CheZ, may play a crucial and complementary role.

A case-control study of risk factors for asthma in New Zealand children

OBJECTIVE

As in other English-speaking countries, asthma is a major and increasing health problem in New Zealand. This study examined the risk factors for asthma in children aged 7-9.

METHODS

Cases and controls were randomly selected from participants in the Wellington arm of the International Study of Asthma and Allergies in Childhood (ISAAC). Cases were children with a previous diagnosis of asthma and current medication use (n=233), and controls were children with no history of wheezing and no diagnosis of asthma (n=241).

RESULTS

After controlling for confounders, factors significantly associated with asthma were maternal (OR=3.36, 95% CI 1.88-5.99) and paternal asthma (OR-2.67, 95% CI 1.42-5.02), and male sex (OR=1.81, 95% CI 1.17-2.81). Children from social classes 5 and 6 or with unemployed parents (OR=2.32, 95% CI 1.22-4.44) were significantly more likely to have asthma than children in social classes 1 and 2. There was no significant association between having polio vaccination (OR=2.48, 95% CI 0.83-7.41), hepatitis B vaccination (OR=0.66, 95% CI 0.42-1.04) or measles/mumps/rubella vaccination (OR=1.43, 95% CI 0.85-2.41) and asthma.

CONCLUSIONS

This study has confirmed the associations of family history and lower socio-economic status with current asthma in 7-9 year old children. The role of vaccinations requires further research.

Heterogeneity stabilizes reciprocal altruism interactions

In considering the phenomena of reciprocal altruism few would dispute that there are differences in individual quality-in particular, that for some individuals, at least on occasion, the cost of doing favors will exceed the potential of future benefits. That is, at any given time, a typical population is heterogeneous with respect to the affordability of reciprocal altruism. However, methodological limitations of the traditional analytical framework-Single Type (symmetric) Evolutionary Game Theory-have restricted previous analytical efforts to addressing populations idealized in terms of their averages. Here we use the methods of Multitype Evolutionary Game Theory to analyse the role of individual differences in direct reciprocity interactions. Multitype analysis shows that non-idealized populations possess an ESS profile wherein individuals who cannot afford reciprocity (low-quality) defect, while individuals who derive net benefits from reciprocity (high-quality) cooperate. Furthermore, this cooperation is implemented via unmodified tit-for-tat (TfT) strategy. Hence, our results may help resolve a long-standing problem concerning the evolutionary stability of TfT in direct reciprocal altruism. Finally, this difference between idealized and real populations is not restricted to direct reciprocal cooperation. Previously (Lotem et al., 1999) we have demonstrated evolutionarily stable indirect reciprocal cooperation among high-quality individuals in heterogeneous populations.

Integrating counselling into general practice

BACKGROUND

General practice counselling has many significant differences to counselling in other settings. General practitioners have long term relationships with their patients involving physical as well as mental health care. General practitioners are often the first point of contact for distressed patients who may not perceive their problem to have a psychological basis. There are barriers to counselling including time management and cultural expectations of the consultation.

OBJECTIVE

To outline a practical biopsychosocial model for counselling in the general practice setting using the knowledge and skills unique to each GP. Theoretical and practical barriers to counselling commonly encountered in general practice are discussed.

DISCUSSION

Assessing the problem in a biopsychosocial format highlights strengths and skills the patient already possesses and involves consideration of physical sensations, emotions, behaviours, key relationships, family, social roles and resources. Counselling in general practice requires flexibility and an ability to adapt available resources to address patient needs in an individually appropriate way.

Medilan: a hypoallergenic lanolin for emollient therapy

Lanolin has been used for thousands of years for its emollient properties. For the past two decades it has had an ill-deserved reputation as an important sensitizer. Medilan is an ultra-purified hypoallergenic medical grade lanolin that has been shown to cause almost zero sensitization. As well as its occlusive properties it has also been shown to penetrate the skin and help to store water in the stratum corneum. The hypoallergenic nature of Medilan combined with its soothing and hydrating properties make it a valuable ingredient in emollient preparations used to treat eczema and other dry skin conditions.

Indoor environment, atopy and the risk of the asthma in children in New Zealand

The objective of this study was to examine the relationship between the indoor environment, atopy and asthma in 7-9-year-old children. Cases and controls were randomly selected from children who participated in the International Study of Asthma and Allergies in Childhood (ISAAC) in Wellington, New Zealand. Cases were children with a previous diagnosis of asthma and current medication use (n = 233) and controls were children with no history of wheezing and no diagnosis of asthma (n = 241). Information was recorded about the indoor environment during the first year of life and currently. Dust was sampled from floors and beds and Der p 1 and Fel d 1 measured using enzyme-linked immunosorbent assays. Skin-prick tests were performed with eight common allergens. Sensitization to Dermatophagoides farinae (OR = 3.19; 95% CI 1.74-5.84), Dermatophagoides pteronyssinus (OR = 2.06; 95% CI 1.16-3.65) and cat (OR = 3.89; 95% CI 1.06-14.30) were independently associated with current asthma. The use of a sheepskin in the first year of life (OR = 1.91; 95% CI 1.11-3.33) was also independently associated with current asthma but current Der p 1 levels showed no association with current asthma. Exposures in early life may be more important than current exposures in determining asthma at age 7-9 years. Prospective studies are needed in New Zealand to determine the relative importance of early life exposures to Der p 1 and other risk factors for asthma.

Effects of immigration on the dynamics of simple population models

Many simple population models exhibit the period doubling route to chaos as a single parameter, commonly the growth rate, is increased. Here we examine the effect of an immigration process on such models and explain why in the case of one-dimensional ("single-humped") maps, immigration often tends to suppress chaos and stabilise equilibrium behaviour or cyclical oscillations of long period. The conditions for which an increase of immigration "simplifies" population dynamics are examined.

Complex dynamics and phase synchronization in spatially extended ecological systems

Population cycles that persist in time and are synchronized over space pervade ecological systems, but their underlying causes remain a long-standing enigma. Here we examine the synchronization of complex population oscillations in networks of model communities and in natural systems, where phenomena such as unusual '4- and 10-year cycle' of wildlife are often found. In the proposed spatial model, each local patch sustains a three-level trophic system composed of interacting predators, consumers and vegetation. Populations oscillate regularly and periodically in phase, but with irregular and chaotic peaks together in abundance-twin realistic features that are not found in standard ecological models. In a spatial lattice of patches, only small amounts of local migration are required to induce broad-scale 'phase synchronization, with all populations in the lattice phase-locking to the same collective rhythm. Peak population abundances, however, remain chaotic and largely uncorrelated. Although synchronization is often perceived as being detrimental to spatially structured populations, phase synchronization leads to the emergence of complex chaotic travelling-wave structures which may be crucial for species persistence.

Can mirrors alleviate visual hemineglect?

Following right hemisphere stroke, many patients display an indifference to objects and events in the left side of the world ('neglect'). Here, we describe a new technique that might help accelerate recovery from neglect. The patient sits at a table and a mirror is propped vertically on the patient's right side in the parasagittal plane, so that when the patient rotates his head rightward and looks into the mirror, he sees the neglected side of the world reflected in the mirror. Our question was: since the sensory information was now coming from the non-neglected left side, would this somehow make him overcome the neglect? In pilot experiments, two types of responses were seen: (a) In one subset of patients the presence of the mirror seemed to enhance the patients' awareness of the neglected field, so that they reached correctly for an object that was shown in the neglected field. Will repeated practice with this task accelerate recovery from neglect? (b) The second group of patients kept reaching into the mirror to grasp the reflection or kept groping behind the mirror ('mirror agnosia'). If the mirror was placed in the coronal position and the object placed behind their head, then some of these patients (from group B) reached correctly for the object. Quite apart from its obvious theoretical implications, we believe this technique might provide a new approach for the treatment of visual hemineglect.

Pulse vaccination strategy in the SIR epidemic model

Theoretical results show that the measles 'pulse' vaccination strategy can be distinguished from the conventional strategies in leading to disease eradication at relatively low values of vaccination. Using the SIR epidemic model we showed that under a planned pulse vaccination regime the system converges to a stable solution with the number of infectious individuals equal to zero. We showed that pulse vaccination leads to epidemics eradication if certain conditions regarding the magnitude of vaccination proportion and on the period of the pulses are adhered to. Our theoretical results are confirmed by numerical simulations. The introduction of seasonal variation into the basic SIR model leads to periodic and chaotic dynamics of epidemics. We showed that under seasonal variation, in spite of the complex dynamics of the system, pulse vaccination still leads to epidemic eradication. We derived the conditions for epidemic eradication under various constraints and showed their dependence on the parameters of the epidemic. We compared effectiveness and cost of constant, pulse and mixed vaccination policies.

Determinants of house dust mite allergen in homes in Wellington, New Zealand

OBJECTIVES

To measure levels of the major Dermatophagoidespteronyssinus allergen (Der p 1) in homes in Wellington, New Zealand, and to examine factors which affect these levels.

METHODS

As part of a study of risk factors for asthma among 474 8-10-year-old children, standard procedures were used to collect reservoir dust and to measure Der p 1 levels on the living room floor and child's bedroom floor and bedding. Der p 1 levels were analysed both as geometric mean microg/g of fine dust and as microg/m2. Questionnaires collected information about factors which might influence these levels, and an average relative humidity in the bed and on the bedroom floor was also measured.

RESULTS

Similar geometric mean levels of Der p 1 were found at each floor site - 25.5 microg/g (95% CI: 22.8-28.5) in the living room and 26.4 microg/g (95% CI: 23.7-29.3) on the child's bedroom floor. The geometric mean level of Der p 1 in the child's bed was 46.6 microg/g (95% CI: 42.3-51.3). After controlling for possible confounders, geometric mean living room and bedroom floor Der p 1 levels were significantly higher in households with older carpet than households with no carpets or newer carpets, and higher in the autumn. Households with three or more children had higher levels of Der p 1 than households with fewer children. Bedding levels were significantly higher in beds with kapok or inner sprung mattresses, or wool underlays and at relative humidities above the mean (51%).

CONCLUSION

The very high levels of house dust mite allergen (Der p 1) found in Wellington are likely to be due to a variety of life-style and climatic factors. However, the type and age of floor covering appears to be the single most important factor.

Dermatology nursing: planning for the future

In this article, the author outlines the factors which will influence the development of dermatology nursing services in the future. Nurses must be correctly prepared to develop the necessary new roles and how this could be achieved is discussed.

Progressive defect in biliary GSH secretion in streptozotocin-induced diabetic rats

This study examined the effect of streptozotocin-induced diabetes on biliary reduced glutathione (GSH) efflux. Biliary GSH efflux was measured before and after acivicin, an irreversible inhibitor of gamma-glutamyl transpeptidase (GGT). One week after streptozotocin treatment, liver GGT activity doubled in diabetic rats but was inhibited by approximately 90% after acivicin to levels comparable to controls. Despite maximal GGT inhibition, biliary GSH efflux in untreated diabetic rats decreased progressively to approximately 10% of control levels by week 4 and was partially restored by insulin. The mechanism for the decrease in biliary GSH efflux was not increased paracellular permeability. GSH transport kinetics, ATP-stimulated taurocholate, and oxidized glutathione (GSSG) transport in canalicular liver plasma membrane prepared from diabetic and control rats were similar. Inhibition of protein kinase C (PKC) with high-dose H-7 increased biliary GSH efflux in diabetic animals to near control basal levels. In conclusion, streptozotocin-induced diabetic rats exhibit a progressive impairment in biliary GSH transport. One of the responsible mechanisms is heightened PKC tone in diabetic animals.

Clinical characteristics of outpatients with chronic major depression

A cross-sectional evaluation of 243 unipolar, nonpsychotic outpatients with major depression was conducted. All subjects were diagnosed by RDC with SADS-L structured interviews. Diagnoses included RDC primary/secondary, RDC endogenous/nonendogenous and Winokur's family-history subtypes. Symptom severity was assessed by the 17-item Hamilton Rating Scale for Depression. Chronic depression was defined as the current episode of major depression lasting at least 2 years, corresponding to DSM-III-R and -IV criteria. Patients with chronic depression (n = 64) were compared with those with nonchronic depression (n = 179). Chronicity was not related to gender, symptom severity, prior length of illness, age at onset of illness, RDC endogenous/nonendogenous, RDC primary/secondary or Winokur's family-history subtypes. Those with chronic depression were older and had fewer major depressive episodes than the nonchronic group. That the chronic group had fewer total episodes of depression than the nonchronic group, but a similar age at onset, is consistent with the notion that patients in a current chronic episode have characteristically longer depressive episodes throughout the course of their illness. Those with chronic episodes may be subject to psychological, biological and/or sociocultural factors that preclude an earlier episode remission for these individuals.

Amaurosis fugax challenges: best met by multispecialty approach to management

1. Amaurosis fugax (AF) refers to transient, reversible loss of vision, typically monocular and of short duration. 2. Patients with AF present a diagnostic and therapeutic challenge, frequently requiring a multispecialty approach to management. It is important to determine whether or not there is an ocular cause of the problem. 3. In the absence of eye findings to explain the symptoms, the internist must direct the workup toward cardiogenic hypotension, migraine, carotid or vertebral-basilar artherosclerotic disease, cardiac embolic disorder, and other potential causes.

Multiple sclerosis is associated with alterations in hypothalamic-pituitary-adrenal axis function

In the LEW/N rat model, a decreased hypothalamic-pituitary-adrenal (HPA) axis response to inflammatory and immune mediators confers susceptibility to the development of a variety of inflammatory and immune diseases, including experimental allergic encephalomyelitis. In humans with optic neuritis, early intervention with steroids is associated with a decrease in the number of patients who go on to develop multiple sclerosis (MS). The current study was designed to determine whether patients with MS show evidence of a hypoactive HPA axis. Thirteen patients with MS were studied at baseline and with provocative tests of HPA axis function [ovine CRH, arginine vasopressin (AVP), and ACTH stimulation]. Compared to matched controls, patients with MS had significantly higher plasma cortisol levels at baseline. Despite this hypercortisolism and in contrast to patients with depression who had similar elevations in plasma cortisol levels, patients with MS showed normal, rather than blunted, plasma ACTH responses to ovine CRH, suggesting that the pathophysiology of hypercortisolism in MS is different from that in depression. Patients with MS also showed blunted ACTH responses to AVP stimulation and normal cortisol responses to high and low dose ACTH stimulation. Taken together, these findings are compatible with data from studies of experimental animals exposed to chronic inflammatory stress, which showed mild increased activation of the HPA axis with increased relative activity of AVP in the regulation of the pituitary-adrenal axis. These data do not support a role for hypocortisolism in MS once the disease is established.

El Niño Chaos: Overlapping of Resonances Between the Seasonal Cycle and the Pacific Ocean-Atmosphere Oscillator

The El Niño-Southern Oscillation (ENSO) cycle is modeled as a low-order chaotic process driven by the seasonal cycle. A simple model suggests that the equatorial Pacific ocean-atmosphere oscillator can go into nonlinear resonance with the seasonal cycle and that with strong enough coupling between the ocean and the atmosphere, the system may become chaotic as a result of irregular jumping of the ocean-atmosphere system among different nonlinear resonances. An analysis of a time series from an ENSO prediction model is consistent with the low-order chaos mechanism.

Coloured noise or low-dimensional chaos?

Devising a method capable of distinguishing a low-dimensional chaotic signal that might be embedded in a noisy stochastic process has become a major challenge for those involved in time-series analysis. Here a null hypothesis approach is used in conjunction with a known nonlinear predictive test, to probe for the presence of chaos in epidemiological data. A probabilistic set of rules is used to stimulate a historic record of New York City measles outbreaks, generally understood to be governed by a chaotic attractor. The simulated runs of 'surrogate data' are carefully constructed so as to be free from any underlying low-dimensional chaotic process. They therefore serve as a useful null model against which to test the observed time series. However, despite the assumed differences between the dynamics of measles outbreaks and the null model, a nonlinear predictive scheme is found to be unable to differentiate between their characteristic time series. The methodology confirms that, if there is in fact a chaotic signal in the measles data, it is extremely difficult to detect in time series of such limited length. The results have general relevance to the analysis of physical, ecological and environmental time series.

Cultural influences in community participation in health

The adoption of Primary Health Care in developing countries brought a new interest in the influence of cultural factors in community health programs. This paper traces the changes in the way that the role of culture has been analyzed in relation to community health issues and in particular with respect to 'community participation'. A look at recent perspectives shows that the fate of community health programs has come to be seen as relying more on structural factors in health care systems than on cultural factors within local communities. There has also been an increasing emphasis on political factors or power relationships within and between health agencies, governments, and various levels of national health care systems. These perspectives raise new questions for community health programs and the strategy of community participation.

Streptococcal lid necrosis in previously healthy children

Fulminant preseptal eyelid cellulitis developed in two previously healthy children, aged 17 months and 8 years, following minor trauma. Despite appropriate intravenous antibiotic therapy, lid necrosis with ulceration developed in both patients. In both cases group A beta-hemolytic Streptococcus was the causative agent. Spontaneous granulation of the ulcerated areas resulted in cicatricial defects, which in one case may require surgical correction. Neither child had a past history of susceptibility to infection. Group A beta-hemolytic Streptococcus has been known to cause lid gangrene, but almost all previously documented cases occurred in debilitated or elderly patients.

Dystonic tics in patients with Tourette's syndrome

Dystonic tics, in contrast to clonic tics, are relatively slow and temporarily sustained twisting, pulling, or squeezing movements producing briefly maintained abnormal postures. Because dystonic tics often present diagnostic difficulties, we studied these motor tics in 156 patients with Tourette's syndrome (TS). In addition to clonic motor and vocal/phonic tics, seen in all patients, 89 (57%) of them exhibited one or more dystonic tics. The most common dystonic tics were oculogyric deviations (43 patients), blepharospasm (23), and dystonic neck movements (11). Blinking (110) and facial twitching (86) were the most common clonic tics. Except for possibly a greater familial occurrence, a higher frequency of previous head trauma, and associated attention deficit disorder, the group of patients with dystonic tics did not significantly differ in any of the major clinical variables from those TS patients without dystonic tics. We conclude that dystonic tics are typical motor manifestations of TS and that patients with these motor tics are not different from those with more typical clonic tics.

Biokinetics of dietary RRR-alpha-tocopherol in the male guinea pig at three dietary levels of vitamin C and two levels of vitamin E. Evidence that vitamin C does not "spare" vitamin E in vivo

The net rates of uptake of "new" and loss of "old" 2R,4'R,8'R-alpha-tocopherol (RRR-alpha-TOH, which is natural vitamin E) have been measured in the blood and in nine tissues of male guinea pigs over an eight week period by feeding diets containing deuterium-labelled alpha-tocopheryl acetate (d6-RRR-alpha-TOAc). There was an initial two week "lead-in" period during which 24 animals [the "high" vitamin E (HE) group] received diets containing 36 mg of unlabelled (d0) RRR-alpha-TOAc and 250 mg of ascorbic acid per kg diet, while another 24 animals [the "low" vitamin E (LE) group] received diets containing 5 mg d0-RRR-alpha-TOAc and 250 mg ascorbic acid per kg diet. The HE group was then divided into three equal subgroups, which were fed diets containing 36 mg d6-RRR-alpha-TOAc and 5000 mg [the "high" vitamin C (HEHC) subgroup], 250 mg [the "normal" vitamin C (HENC) subgroup] and 50 mg [the "low" vitamin C (HELC) subgroup] ascorbic acid per kg diet. One animal from each group was sacrificed each week and the blood and tissues were analyzed for d0- and d6-RRR-alpha-TOH by gas chromatography-mass spectrometry. The LE group was similarly divided into three equal subgroups with animals receiving diets containing 5 mg d6-RRR-alpha-TOAc and 5,000 mg (LEHC), 250 mg (LENC) and 50 mg (LELC) ascorbic acid per kg diet with a similar protocol being followed for sacrifice and analyses. In the HE group the total (d0(-) + d6-) RRR-alpha-TOH concentrations in blood and tissues remained essentially constant over the eight week experiment, whereas in the LE group the total RRR-alpha-TOH concentrations declined noticeably (except in the brain, an organ with a particularly slow turnover of vitamin E). There were no significant differences in the concentrations of "old" d0-RRR-alpha-TOH nor in the concentrations of "new" d6-RRR-alpha-TOH found in any tissue at a particular time between the HEHC, HENC and HELC subgroups, nor between the LEHC, LENC and LELC subgroups. We conclude that the long-postulated "sparing" action of vitamin C on vitamin E, which is well documented in vitro, is of negligible importance in vivo in guinea pigs that are not oxidatively stressed in comparison with the normal metabolic processes which consume vitamin E (e.g., by oxidizing it irreversibly) or eliminate it from the body.(ABSTRACT TRUNCATED AT 400 WORDS)

Percutaneous phenol block of the musculocutaneous nerve to control elbow flexor spasticity

Twenty-three extremities in 17 brain-injured adults were prospectively studied to evaluate the effectiveness of percutaneous phenol blocks of the musculocutaneous nerve in controlling spasticity of the biceps and brachialis muscles. Twenty-one (93%) of the extremities improved after the initial injection. The mean resting position decreased from 120 degrees of flexion to 69 degrees. Elbow range of motion increased an average of 53 degrees. There were no complications. Two patients did not respond to the initial injection and required repeat nerve blocks. Concomitant phenol motor point block of the brachioradialis muscle further improved elbow motion. The mean duration of the block was 5 months. Follow-up averaged 21 months. This study indicates that percutaneous phenol injection of the musculocutaneous nerve provides reliable, temporary relief of spasticity in patients with potential for further neurologic improvement.

Inadequate barium enemas in hospitalized elderly patients. Incidence and risk factors

The likelihood of obtaining interpretable results is as important as sensitivity and specificity in selecting diagnostic tests. We reviewed medical and radiologic records of 140 consecutive inpatients over the age of 65 years who underwent a nonemergent barium enema. In 43 (31%) of these patients, the examination was incomplete or the results were uninterpretable. Thirteen patients could not retain the barium, and 27 patients had too much stool. Characteristics associated with an inadequate barium enema included confusion (adjusted odds ratio, 3.5), fever (adjusted odds ratio, 4.1), and cachexia (adjusted odds ratio, 2.7). Characteristics more common among subjects unable to retain barium than among subjects with too much stool were diarrhea (38% vs 18%) and fecal incontinence (31% vs 0%). The high frequency of inadequate results suggests that clinicians should consider whether a barium enema is the appropriate test in elderly patients with these characteristics, and, if so, what interventions may increase the chance for success.

Peripheral nerve injuries in the adult with traumatic brain injury

Fifty adult patients who sustained a traumatic brain injury (TBI) were screened for the presence of a peripheral nerve injury (PNI). All suspected patients had diagnostic electromyography performed in order to confirm the clinical findings. The incidence of PNI with TBI was 34%. A variety of nerve injuries were seen, the most frequent of which were ulnar nerve entrapment at the elbow (10%) and brachial plexus injuries (10%). No patient initiated a complaint that led to the diagnosis. In addition, all the neuropathies were missed prior to admission. The neuropathies commonly were found in the neurologically impaired extremity and associated with spasticity. The results of this study suggest that patients sustaining a TBI have a significant and higher incidence of PNI as a complication than previously reported.

Differential expression of Na+,K+-ATPase alpha- and beta-subunit mRNAs in rat tissues and cell lines

We have analyzed Na+,K+-ATPase (EC 3.6.1.3) alpha- and beta-subunit mRNA expression in rat tissues and cell lines derived from the rat central nervous system. Substantial differences in the tissue and developmental specificity of expression were found for the genes encoding three isoforms of the alpha subunit. Transcripts of the alpha 1-subunit gene were detected in all tissues tested, whereas alpha 2- and alpha 3-subunit mRNA species were expressed predominantly in brain. The pattern of expression of beta-subunit mRNA also was complex and tissue specific but was distinct from that of any of the alpha-subunit mRNAs. Cell lines derived from the rat central nervous system and the pheochromocytoma PC12 expressed the mRNAs for all three alpha-subunit isoforms, whereas beta-subunit mRNA was detected only in PC12 cells. The distinct expression patterns of rat Na+,K+-ATPase mRNAs suggest that different members of the ATPase family may have specialized functions.

Treatment of blepharospasm with medication, surgery and type A botulinum toxin

A total of 39 patients with essential blepharospasm and 2 patients with hemifacial spasm were treated with one or more forms of therapy. All patients underwent neurologic and ophthalmic assessment to rule out ocular causes of blepharospasm. Thirty-six patients were given a trial of various medications. Only one patient was successfully treated: her condition was markedly improved with pimozide after benztropine mesylate, clonazepam and amantadine hydrochloride had failed to help. Patients who did not respond to drug therapy were offered the option of undergoing eyebrow-eyelid muscle stripping surgery. The six patients who underwent surgery showed considerable improvement; however, side effects such as frontal anesthesia, exposure keratitis, lagophthalmus, scarring and eyelid malposition occurred, and three of the six had residual spasm. At this point type A botulinum toxin became available. A total of 27 patients (26 who did not respond to drug therapy, including the 3 with residual spasm after surgery, and 1 previously untreated patient) received type A botulinum toxin injections. Most experienced rapid relief from their spasms. The beneficial effects lasted weeks to months, and there were no major side effects. Treatment with type A botulinum toxin appears to be a safe and effective means of temporarily relieving blepharospasm. The long-term results with repeated injections are yet to be determined.

Psychoanalytic observations on the pathology of depressive illness: selected spheres of ambiguity or disagreement

This paper has two general sources: my own clinical psychoanalytic work extending over about four and one half decades; and consideration of certain outstandingly influential ideas in our literature: first, those of the pioneer contributors, and then those of certain more recent writers, whose views have sometimes exhibited important differences from those widely held in the past. I try to evaluate the two groups--in their occasional overlapping and important divergences, in relation to my own clinical experience. A certain general position of my own emerges from such process inevitably; but it is far from "revolutionary." Indeed, the contrary is more largely true. In extreme anticipatory condensation--what I do propose, from my own reflections, is the preeminent importance of an archaic characterological core in depressive illness.

Primary health care for whom? Village perspectives from Nepal

Over the last decade, many developing nations have embraced Primary Health Care (PHC) within their national health plans. PHC, in contrast to earlier approaches to national health development, emphasizes community participation and basic health care for the poorer segments of society. The research reported here finds that in the enthusiasm for the PHC concept in Nepal, important sociocultural processes have been overlooked. This paper describes the relationship between certain sociocultural factors and PHC activities in rural Central Nepal. It reveals a contradiction between the stated PHC intentions to address local interests and promote community participation on the one hand, and the actual approach taken on the other hand. Specifically it argues that PHC is encountering problems in Nepal for three reasons: (1) PHC fails to appreciate villagers' values and their own perceived needs. In particular, PHC is organized primarily to provide health education, whereas villagers value modern curative services and feel little need for new health knowledge. (2) PHC views rural Nepali culture only pejoratively as a barrier to health education. Alternatively, local cultural beliefs and practices should be viewed as resources to facilitate dissemination and acceptance of modern health knowledge. (3) In attempting to incorporate Nepal's traditional medical practitioners into the program, PHC has mistakenly assumed that rural clients passively believe in and obey traditional practitioners. In fact, clients play active roles and are themselves in control of the therapeutic process. Thus, instead of attempting to recruit traditional practitioners to do its work, PHC should recognize the precedent for community participation in Nepal's traditional medical system and develop the respect for villagers' own ideas and values that traditional practitioners already possess.

Inexpensive double-antibody fluoroimmunoassay for aminoglycoside antibiotics, phenytoin, and theophylline in serum

We describe simple, clinically useful double-antibody fluoroimmunoassays for amikacin, gentamicin, tobramycin, theophylline, and phenytoin. The fluorescent tracers were prepared by conjugation to fluorescein isothiocyanate; the antisera were raised in rabbits. A simple filter fluorometer and disposable culture tubes are used. The tracer, sample, and first and second antibodies are combined and incubated at room temperature for 30 min. A precipitation-acceleration buffer is added, the samples are centrifuged, and the fluorescence of the supernate is measured directly in the assay tube without decantation. Interferences, usually negligible, can be corrected for by use of a sample blank. Results compare favorably in performance with various commercially available RIA and enzyme immunoassays.

Inexpensive double-antibody fluoroimmunoassay for aminoglycoside antibiotics, phenytoin, and theophylline in serum

We describe simple, clinically useful double-antibody fluoroimmunoassays for amikacin, gentamicin, tobramycin, theophylline, and phenytoin. The fluorescent tracers were prepared by conjugation to fluorescein isothiocyanate; the antisera were raised in rabbits. A simple filter fluorometer and disposable culture tubes are used. The tracer, sample, and first and second antibodies are combined and incubated at room temperature for 30 min. A precipitation-acceleration buffer is added, the samples are centrifuged, and the fluorescence of the supernate is measured directly in the assay tube without decantation. Interferences, usually negligible, can be corrected for by use of a sample blank. Results compare favorably in performance with various commercially available RIA and enzyme immunoassays.

Hierarchy and food in Nepalese healing rituals

An analysis of food transactions in a Nepalese village provides an interpretation of the cultural place of illness within high caste Hindu traditions. In several realms of village social life, rules of food transfer simultaneously mark hierarchical relationships between people and symbolize an interdependency among them. In these contexts, food transactions stress the importance of preserving hierarchy, reinforcing interdependence, and thereby maintaining a social framework within which exchanges of goods and services can harmoniously take place. But in the realm of illness, food use and references to food suggest conflicts or breakdowns in these kinds of interdependent relationships and ordered exchanges. I suggest that there is a fundamental conflict in village society since the local concern with human interdependency is set in a milieu of a sharply perceived scarcity of valued resources. This conception that human beings are interdependent for access to scarce goods introduces an element of danger into the system of exchange and opens a potential for disharmony in social relations. A cultural recognition of this danger is again reflected in the use of food, specifically in illness ideology and curing rituals. In this examination, illness emerges as the culturally apprehended outcome of some inevitable conflicts in the village social order.

Some thoughts on the "here and now" in psychoanalytic technique and process

This paper consists of a series of reflections on the "here and now" in analysis, stimulated by recent renewed interest in the subject. The subject is considered briefly in historical perspective. In addition to the central issue of transference interpretation, a broader conception of current process is briefly examined. The entire "here and now" complex is viewed as dynamically indispensable to the effective reconstruction of the past. The critical role of the transference neurosis is stated. Certain dynamic and technical desiderata are developed. The importance of adequate attention to the patient's "reality" is emphasized in its multiple references.

Remarks on certain unique conditions of human aggression (the hand, speech, and the use of fire)

I have tried to single out for study, from the limitless complexity of human physical and mental life, three decisively fundamental elements, which, individually and synergistically, in biological and psychological spheres, have contributed importantly to the distinctiveness of human aggressive behavior and psychology and their transformations. These are: (1) the remarkable development of the human hand; (2) the primordial role of human speech, especially in drive economy; (3) the purposive utilization of fire. The pervasive dynamic importance of human orality and its vicissitudes, in relation to its phylogenetic background, has been stressed throughout. In this connection, the revolutionary role of fire has been brought into drive-economic relationship with the other two critical human instrumentalities. It is suggested that in its myriad roles, ranging from cooking to the prodigious function of sacrifice in human history and psychology, the decisive position of the role of fire in the emergence and development of homo sapiens may conceivably include a significant "overdetermining" position among the multiple elements conditioning the appearance of human speech and language.

Effects of Three Conditions of Administration on Bem Sex Role Inventory Scores

In order to assess the validity of the technique employed in selecting items for the Bern Sex Role Inventory (BSRI) 58 male and 62 female undergraduates took the BSRI under three different sets of instructions. Both males and females were able to produce extremely masculine and extremely feminine BSRI profiles which differed (p < .01) from their own BSRI profiles. The results support Bem's (1974) assertion that the BSRI Masculinity and Femininity scales are comprised of items which are consistent with widely held sex-role sterotypes.

Some problems and potentialities of present-day psychoanalysis

In a critical review of the current historical situation of psychoanalysis and its unique problems, the author considers a variety of specific but interacting factors. The potentialities for advance as therapy and science, their interrelationship, and the possible channels for such advance are examined. The social, clinical, and scientific importance of derivative 'psychotherapies' and of rationally flexible boundaries of 'indication' are discussed. As differentiated from rational conservatism, the phenomenon of analysts' irrational resistance to potential change in basic tenets of technique or theory is held to be a critically formidable impediment to the further development of psychoanalysis.