Comparative scanning electron microscopy of third-instar Hypoderma spp. (Diptera: Oestridae)

Scanning electron microscope study of third-instar larvae of four species of Hypoderma revealed differences among species in the pattern of spination, spine morphology and morphology of the spiracular plates. These observations identify characters that enable the differentiation of Hypoderma actaeon and H. diana, parasitizing red deer (Cervus elaphus) in Europe, and provide additional characters for differentiating H. bovis and H. lineatum parasitizing cattle.

Clinical study of yoga techniques in university students with asthma: a controlled study

Adult asthmatics, ranging from 19 to 52 years from an asthma and allergy clinic in a university setting volunteered to participate in the study. The 17 students were randomly divided into yoga (9 subjects) and nonyoga control (8 subjects) groups. The yoga group was taught a set of breathing and relaxation techniques including breath slowing exercises (pranayama), physical postures (yogasanas), and meditation. Yoga techniques were taught at the university health center, three times a week for 16 weeks. All the subjects in both groups maintained daily symptom and medication diaries, collected A.M. and P.M. peak flow readings, and completed weekly questionnaires. Spirometry was performed on each subject every week. Analysis of the data showed that the subjects in the yoga group reported a significant degree of relaxation, positive attitude, and better yoga exercise tolerance. There was also a tendency toward lesser usage of beta adrenergic inhalers. The pulmonary functions did not vary significantly between yoga and control groups. Yoga techniques seem beneficial as an adjunct to the medical management of asthma.

Ambulatory surgery in the United States, 1995

OBJECTIVES

This report presents estimates of surgical and nonsurgical procedures performed on an ambulatory basis in hospitals and freestanding ambulatory surgery centers in the United States during 1995. Data are presented by types of facilities, age, sex, and geographic region. Major categories of procedures and diagnoses are shown by age, sex, and region.

METHODS

The estimates are based on data collected from the 1995 National Survey of Ambulatory Surgery conducted by the National Center for Health Statistics. The 1995 data were abstracted from 122,000 medical records in 489 hospitals and freestanding ambulatory surgery centers.

Traumatic myiasis of sheep in Europe: a review

The two most important fly species causing traumatic cutaneous myiasis of sheep in Europe are Wohlfahrtia magnifica (Diptera: Sarcophagidae), which causes a form of myiasis known as wound myiasis, mainly in southern and eastern Europe, and Lucilia sericata (Diptera: Calliphoridae), which causes sheep strike, mainly in the middle latitudes of Europe. Other calliphorid blow-flies play a role mainly as secondary agents of myiasis, but in northern latitudes the L. caesar/illustris group are primary agents. Infestation levels vary greatly from region to region depending on a wide range of factors related to the composition of the parasite fauna, the host, animal husbandry and control practices, climate and geography. In some areas of Europe there have been recent increases in the incidence of traumatic myiasis due to changes in some of the previously mentioned factors. However, in other areas the incidence of myiasis is apparently low. More studies are needed to resolve this unclear situation and to explain regional differences. A number of areas for future research are highlighted including predicting the impact of environmental change, population modelling and development of novel control strategies.

Long-term exposure to methotrexate induces immunophenotypic changes, decreased methotrexate uptake and increased dihydrofolate gene copy number in Jurkat T cells

Methotrexate (MTX) treatment of rheumatoid arthritis may require increasing doses to maintain clinical efficacy. An overall plateau of clinical response is reached after only six months of treatment. To study the immunologic, biochemical and genetic effects of MTX on T cells, the Jurkat T cell line was made MTX-resistant by serial addition of methotrexate sodium into culture medium. Cells proliferated and divided successfully in MTX concentrations ranging to 15 microM. MTX resistance of Jurkat T cells in vitro was accompanied by significantly (P < 0.05) decreased expression of CD2, CD3, CD4, CD28, and CD69, IL-2 production, and MTX uptake assessed by cell association or disassociation of 3[H]-MTX or fluoresceinated MTX (FMTX), respectively. In addition, there was DHFR gene amplification and increased levels of DHFR in all resistant cell lines. Both permanent and transient phenotypic changes developed in resultant cell lines exposed to increasing concentrations of MTX in vitro. Expression of CD4 and CD25 and sensitivity to MTX returned to near-parental levels after removal of MTX from culture medium, whereas expression of CD26 and MTX uptake were significantly increased. Expression of CD2, CD3, CD69 and IL-2 production as well as the DHFR levels did not return to the parental phenotype after removal from MTX. We conclude that MTX-cultured cells express depressed levels of cell-surface markers vital for T cell function and activation. The return of enhancement of these cell-surface markers critical to T cell activation suggests a possible mechanism for the severe flares experienced by rheumatoid arthritis patients when drug treatment is discontinued.

Left ventricular volume in patients with heart failure and Cheyne-Stokes respiration during sleep

In patients with congestive heart failure (CHF), elevated, left ventricular (LV) volume might lead to pulmonary congestion and hypocapnia, which would create a predisposition to the development of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA). In addition, because LV volume affects cardiac output, it should influence the lengths of hyperpneas. We therefore evaluated LV volumes and transcutaneous PCO2 (PtcCO2) during wakefulness and stage 2 sleep in 16 patients with CHF due to nonischemic dilated cardiomyopathy (NIDC). Data were then compared between those with (n = 7) and those without CSR-CSA (n = 9). LV end-diastolic volume (LVEDV) was significantly higher in patients with than those without CSR-CSA (585 +/- 118 versus 312 +/- 41 ml, p < 0.05). Compared with patients without CSR-CSA, those with CSR-CSA had lower mean stage 2 sleep PtcCO2 (36.3 +/- 2.2 versus 41.2 +/- 1.2 mm Hg, p < 0.05) and a lesser change in PtcCO2 from wakefulness to stage 2 sleep (-0.4 +/- 0.3 versus 2.0 +/- 0.4 mm Hg, p < 0.001). Among patients with CSR-CSA, hyperpnea length was inversely related to LVEDV (R = 0.769, p = 0.043) owing to the direct relationship of cardiac output to LVEDV (R = 0.791, p = 0.034). We conclude that CSR-CSA in patients with CHF due to NIDC is associated with increased LV volumes possibly through the direct or indirect influence of LV volume on PaCO2 and cardiac output.

Liabifity and accountability in psychotherapy supervision : a review, survey, and proposal

The contemporary climate of medical-legal liability, and of increasing expectations of accountability from agencies that pay for psychiatric services and training stipends, has created an atmosphere within which issues of liability and accountability should be constructively addressed. The authors conducted a nationwide survey of psychiatry residency training directors and asked them to estimate the awareness of their supervisors of liability issues pertinent to the supervision of psychiatric residents learning psychotherapy. While the training directors assume that their faculty supervisors, including volunteer faculty, are familiar with issues of accountability, very few make tangible efforts to provide this information. The authors found that patients are not routinely informed of the identity of supervisors, although the patients are usually informed that a therapist is in training. The authors propose practical interventions whereby residency training programs could address the issues of faculty members' awareness of their accountability, the education and training of supervisors, the documentation of supervisory sessions, and the attitudes and practices of psychotherapy trainees.

National Survey of Ambulatory Surgery: 1994

In 1994, 27.7 million surgical and nonsurgical procedures were performed during 18.4 million visits to ambulatory surgery settings. Eighty-five percent of the ambulatory procedures (23.4 million) were performed in hospital-based settings and 15 percent (4.3 million) were in freestanding settings. More than half of the ambulatory procedures were in three major categories: operations on the digestive system, the eye and the musculoskeletal system. The leading ambulatory procedures were extraction of lens (performed almost 2 million times), endoscopy of large intestine with or without biopsy (1.8 million) and insertion of prosthetic lens (1.6 million). Women had significantly more ambulatory surgery procedures than men. The ambulatory procedure performed most frequently on children under 15 was myringotomy. Also common for children were tonsillectomies and adenoidectomies. For those aged 15-44, frequently performed ambulatory procedures included endoscopies of large and small intestine; dilation and curettage of uterus; bilateral destruction or occlusion of fallopian tubes; and arthroscopy of knee. In the 45-64 year old group, endoscopies of large and small intestine were the most commonly performed ambulatory procedures. Extraction of lens and insertion of prosthetic lens were the leading ambulatory procedures for those 65 years and older, though endoscopies of large and small intestine were also performed frequently for this age group.

Use of the ganciclovir implant for treating cytomegalovirus retinitis secondary to immunosuppression after bone marrow transplantation

PURPOSE

To report a case in which we treated cytomegalovirus retinitis using an intravitreal ganciclovir sustained-release device in a patient negative for the human immunodeficiency virus, with a history of myeloproliferative syndrome with myelofibrosis and profound immunosuppression after allogeneic bone marrow transplantation.

METHODS

Case report. Review of medical records and fundus photographs.

RESULTS

After the ganciclovir device was implanted, the cytomegalovirus retinitis did not progress, and visual acuity improved. We removed the device 9 months after implantation.

CONCLUSIONS

The ganciclovir sustained-release device may be useful for treating cytomegalovirus retinitis in patients without the acquired immunodeficiency syndrome who are profoundly immunosuppressed and fail conventional intravenous therapy. If immune suppression is of limited duration, the device can be removed.

Wound myiasis of sheep in Hungary

In Hungary, 4388 sheep in six flocks were surveyed in June-August of 1992-1995 to gather basic data on wound myiasis, its incidence, the predominant fly species involved and the clinical manifestations of infestation. The pathogenesis and economic significance of wound myiasis, as well as the interrelation of breed and sex with infestation levels, were evaluated. Active wound myiasis was recorded in all flocks, in 17.6% (774/4388) of the inspected sheep. The incidence varied among flocks and inspections from 4.7% to 38.9%, but it was significantly greater in imported breeds (28.8%, 651/2257) than in indigenous breeds (5.8%, 123/2131). Lesions of wound myiasis were located more frequently on the external genital organs (in 87%, 673/774 of all cases) than on other body regions. Overall, significantly more males (74.3%, 61/82) than females (16.5%, 713/4306) were infested. With the exception of five cases (0.06% of the total), when larvae of Lucilia sericata (Diptera: Calliphoridae) were also found, Wohlfahrtia magnifica (Diptera: Sarcophagidae) was the only species identified in wounds in this study. Despite the fact that larvae of L. sericata were so rarely encountered in wounds, adults of L. sericata were much the more common of the two species observed around wounds, even those infested by W. magnifica. The vast majority of animals inspected had only one myiasis wound. Clinical signs depended on the body part affected. The most severe infestations, in terms of extent of wounds and numbers of visible larvae, were usually those of the vulva and prepuce. Wound consisted of from one up to six foci, each completely filled by larvae of W. magnifica. These foci were either isolated from each other or they merged into a large lesion. Larvae in any focus tended to be at the same stage of development, but, were wounds were very severe, a range of developmental stages was observed together, indicating that frequent restrikes of wounds occurred. The most common signs were restlessness, anxiety and reluctance to graze. The animals were obviously depressed when they suffered from severe infestations causing lameness or blindness. Some of the most severely affected animals displayed obvious loss of condition. However, overall, there was no significant difference between the mean bodyweights of a sample of infested (59.2 kg) and uninfested (60.9 kg) animals.

Ambulatory surgery in the United States, 1994

OBJECTIVES

This report presents estimates of surgical and nonsurgical procedures done on an ambulatory basis in hospitals and freestanding ambulatory surgery centers in the United States during 1994. Data are presented by types of facilities, age, sex, geographic region, and disposition for ambulatory surgery visits. Major categories of procedures and diagnoses are shown by age, sex, and region.

METHODS

The estimates are based on data collected from the national Survey of Ambulatory Surgery, conducted for the first time in 1994 by the national Center for Health Statistics. The 1994 data were abstracted from 118,000 medical records in 494 hospitals and freestanding ambulatory surgery centers.

Probing conserved regions of the cytoplasmic LOOP1 segment linking transmembrane segments 2 and 3 of the Saccharomyces cerevisiae plasma membrane H+-ATPase

Genetic probing was used to examine conserved amino acid clusters in the first cytoplasmic loop domain (LOOP1) linking transmembrane segments 2 and 3 of the plasma membrane H+-ATPase from Saccharomyces cerevisiae. Deletion of the LOOP1 region in PMA1 resulted in a defective enzyme. Scanning alanine mutagenesis of conserved residues produced lethal cell phenotypes in 14 of 26 amino acids, suggesting major enzyme defects. Most viable mutants showed growth characteristics that were comparable to wild type. Two mutations, I183A and D185A, produced reduced growth rates, hygromycin B resistance, and low pH sensitivity, which are phenotypes associated with defects in the H+-ATPase. However, both mutant enzymes displayed near-normal kinetics for ATP hydrolysis in vitro. Localized random mutagenesis was also performed at sites Glu195, Val196, and Ile210, which all showed lethal phenotypes upon conversion to alanine. Amino acids with polar side groups could substitute for Glu195, while Val196 could not tolerate polar side group moieties. Nine mutations at Ile210 proved lethal, including K, R, E, P, H, N, V, G, and A, while functional enzyme was obtained with S, C, M, and L. Normal rates and extents of pH gradient formation were observed for all mutant enzymes, except I183A and D185A. Detailed analysis of the I183A enzyme indicated that it hydrolyzed ATP like wild type, but it appeared to inefficiently couple ATP hydrolysis to proton transport. In total, these results affirm that conserved amino acids in LOOP1 are important to H+-ATPase function, and purturbations in this region can alter the efficiency of energy coupling.

Cycle length of periodic breathing in patients with and without heart failure

Because apnea length during periodic breathing varies according to the preceding increase in ventilation and reduction in PaCO 2, differences in the cycle length of periodic breathing among patients with normal and impaired cardiac function might be explained by the influence of lung-to-carotid body circulatory delay, as reflected by lung-to-ear circulation time (LECT), on hyperpnea length rather than on apnea length. It was therefore hypothesized that circulatory delay is an important determinant of periodic-breathing hyperpnea length but not apnea length. To test this hypothesis, LECT, periodic-breathing cycle length, apnea length, and hyperpnea length were compared in 10 patients with idiopathic central sleep apnea (ICSA), whose cardiac function was normal, as opposed to 10 with Cheyne-Stokes respiration and central sleep apnea (CSR-CSA) in association with congestive heart failure (CHF). As compared with ICSA patients, cycle length was significantly longer in patients with CSR-CSA (37.3 +/- 3.0 s versus 59.0 +/- 4.9 s, p < 0.005). This difference was due to significantly longer hyperpnea length in the CSR-CSA patients (16.7 +/- 2.8 s versus 36.7 +/- 3.4 s, p < 0.001), since apnea length was similar in the two groups. In addition, LECT was longer in the CSR-CSA patients (24.3 +/- 2.0 s versus 10.3 +/- 1.0 s, p < 0.001), and correlated strongly with cycle length (r = 0.88, p < 0.001) and hyperpnea length (r = 0.90, p < 0.001) but not with apnea length. LECT correlated inversely with cardiac output (r = -0.72, p < 0.006), indicating that LECT is a valid measure of circulatory delay. Thus, circulatory delay is an important determinant of hyperpnea length but not of apnea length in patients with ICSA and CSR-CSA.

Probing the cytoplasmic LOOP1 domain of the yeast plasma membrane H(+)-ATPase by targeted factor Xa proteolysis

The cytoplasmic domain linking transmembrane segments 2 and 3 (LOOP1) of the yeast H(+)-ATPase was probed by the introduction of unique factor Xa recognition sites. Three sites, I170EGR, I254EGR and I275EGR, representing different structural regions of the LOOP1 domain, were engineered by site-specific mutagenesis of the PMA1 gene. In each case, multiple amino acid substitutions were required to form the factor Xa sites, which enabled an analysis of clustered mutations. Both I170EGR and I275EGR-containing mutants grew at normal rates, but showed prominent growth resistance to hygromycin B and sensitivity to low external pH. The engineered I254EGR site within the predicted beta-strand region produced a recessive lethal phenotype, indicating that mutations G254I and F257R were not tolerated. Mutant I170EGR- and I275EGR-containing enzymes showed relatively normal Km and Vmax values, but they displayed a strong insensitivity to inhibition by vanadate. An I170EGR/I275EGR double mutant was more significantly perturbed showing a reduced Vmax and pronounced vanadate insensitivity. The I170EGR site within the putative alpha-helical stalk region was cleaved to a maximum of 10% by factor Xa under non-denaturing conditions resulting in a characteristic 81 kDa fragment, whereas the I275EGR site, near the end of the beta-strand region, showed about 30-35% cleavage with the appearance of a 70 kDa fragment. A I170EGR/I275EGR double mutant enzyme showed about 55-60% cleavage. The cleavage profile for the mutant enzymes was enhanced under denaturing conditions, but was unaffected by MgATP or MgATP plus vanadate. Cleavage at the I275EGR position had no adverse effects on ATP hydrolysis or proton transport by the H(+)-ATPase making it unlikely that this localized region of LOOP1 influences coupling. Overall, these results suggest that the local region encompassing I275EGR is accessible to factor Xa, while the region around I170EGR appears buried. Although there is no evidence for gross molecular motion at either site, the effects of multiple amino acid substitutions in these regions suggest that the LOOP1 domain is conformationally active, and that perturbations in this domain affect the distribution of conformational intermediates during steady-state catalysis.

Patients, carers and the medical profession: a co-operative approach

This article is reprinted (with minor editing) from the Queensland Council of Carers newsletter for members. The Council's Public Policy Forum, held in September 1994, raised problems faced by carers, some of which related to the relationship between patients, carers, and the medical profession. Their concerns were circulated to the Divisions of General Practice, who in turn delegated the author to contact the Queensland Council of Carers, with a view to improving co-operation and clarifying mutual expectations.

Genetic probing of the first and second transmembrane helices of the plasma membrane H(+)-ATPase from Saccharomyces cerevisiae

Structural features of the putative helical hairpin region comprising transmembrane segments 1 (TM1) and 2 (TM2) of the yeast plasma membrane H(+)-ATPase were probed by site-directed mutagenesis. The importance of phenylalanine residues Phe-116, Phe-119, Phe-120, Phe-126, Phe-144, Phe-159, and Phe-163 was explored by alanine replacement mutagenesis. It was found that substitutions at all positions, except Phe-120 and Phe-144, produced viable enzymes, although a range of cellular growth phenotypes were observed like hygromycin B resistance and low pH sensitivity, which are linked to in vivo action of the H(+)-ATPase. Lethal positions Phe-120 and Phe-144, could be replaced with tryptophan to produce viable enzyme, although the F144W mutant was highly perturbed. ATP hydrolysis measurements showed that Km was not significantly altered for most mutant enzymes, whereas Vmax was moderately reduced with two mutants, F144W and F163A, showing less than 50% of the normal activity. Double Phe-->Ala mutations in TM1 and TM2 were constructed to examine whether such substitutions would result in a higher degree of enzyme destabilization. Mutant F116A/F119A was viable and gave a normal phenotype, while F159A/F163A was not viable. Other double mutants, F116A/F159A and F119AF/159A, which are predicted to lie juxtaposed on TM1 and TM2, produced non-functional enzymes. However, a viable F119V/F159A mutant was isolated and showed hygromycin B resistance. These results suggest that double mutations eliminating 2 phenylalanine residues strongly destabilize the enzyme. A putative proline kink at Gly-122/Pro-123 in TM1 is not essential for enzyme action since these residues could be variously substituted (G122A or G122N; P123A, P123G, or P123F) producing viable enzymes with moderate effects on in vitro ATP hydrolysis or proton transport. However, several substitutions produced prominent growth phenotypes, suggesting that local perturbations were occurring. The location of Pro-123 is important because Gly-122 and Pro-123 could not be exchanged. In addition, a double Pro-Pro created by a G122P mutation was lethal, suggesting that maintenance of an alpha-helical structure is important. Other mutations in the hairpin, including modification of a buried charged residue, E129A, were not critical for enzyme action. These data are consistent with the view that the helical hairpin comprising TM1 and TM2 has important structural determinants that contribute to its overall stability and flexibility.

Efficacy of ivermectin and moxidectin injection against larvae of Wohlfahrtia magnifica (Diptera: Sarcophagidae) in sheep

The therapeutic efficacies of ivermectin (Ivomec injection, Merck Sharp & Dohme B.V.) and moxidectin (Cydectin 1% injection, American Cyanamid Company) were evaluated in sheep naturally infested with larvae of Wohlfahrtia magnifica. Sheep were randomly allocated to one of the 2 groups, each consisting of 19 animals. Sheep in one group received ivermectin and those in the other, moxidectin by subcutaneous injection at a dose of 0.2 mg/kg body weight. Evaluation was performed at 19, 24, 28, 39, 43, 48, 52, 63, 67, 72, 87, 96, 120, 144 and 168 h after treatment. At 144 and 168 h post-treatment, late third-instar larvae were collected from wounds of four sheep in both groups and from untreated, infested sheep. These larvae were reared in the laboratory to assess adult emergence. Neither ivermectin nor moxidectin was effective as a rapid acting treatment or as a long-term, or even short-term, prophylactic. Despite the treatment, 30-40% of sheep had live larvae at every evaluation. Although larvae disappeared from the wounds of some sheep in both groups after the treatment, the wounds in these animals failed to recover and were reinfested by larvae of W. magnifica. On day 7 post-treatment the trial had to be finished because the majority of treated sheep were severely infested by Wohlfahrtia maggots. The average number of infested sheep in the two groups and the number of adults that were produced from larvae collected from treated sheep indicate that ivermectin and moxidectin did not differ significantly in efficacy.

Does occupational exposure to argon laser radiation decrease colour contrast sensitivity in UK ophthalmologists?

The objects of the study were to determine: (1) whether United Kingdom ophthalmologists who used argon lasers had the elevation of colour-contrast thresholds previously discovered and (2) whether other users of argon lasers showed any unusual loss of colour vision. A total of 1072 UK ophthalmologists filled in a questionnaire about their professional use of lasers, the length of time spent operating, and their out-of-doors activities. Their colour vision was then tested by a new sensitive system, and if any abnormality was detected, a clinical eye examination was performed. The results were as follows: (1) Colour vision testing was shown to be reliable. Any self-selection bias was excluded. Test-retest variability was small. Normal results did not change during the survey. (2) A number of men with high red-green thresholds were discovered. Some were aware of their congenital insensitivity. The frequency of all such defects was less than the known incidence of congenital colour deficiency in the male population. (3) Additionally a number of high tritan (blue-yellow) thresholds were encountered, some associated with reported diabetes and hypertension. In other cases of this type, undetected or unacknowledged systemic disease may be present. (4) After making allowance for all these incidental causes of loss of colour vision, and for the effect of age on colour vision (which is very small) only four of the sample were > 2 SD above normal. (5) However, the average blue-yellow thresholds of ophthalmologists were slightly and highly significantly raised compared with normal, in the first year of the survey. During the second and third years, the mean thresholds declined to normal. Similar but less significant findings were found for protan thresholds. It is concluded that the enhanced safety precautions recently introduced are associated with a recovery of colour vision in this population, demonstrating that any changes to individuals were reversible. Colour vision screening has proved able to detect mild ocular abnormalities due to systemic and congenital disease.

Cardiovascular disease and sleep apnea

A number of novel and important observations have recently arisen that emphasize the interaction between sleep apnea and cardiovascular function. New evidence of a role for obstructive sleep apnea as an independent factor in the genesis of hypertension and nocturnal myocardial ischemia has been described. Advances have been made in the understanding of the acute impact of sleep-disordered breathing on hemodynamic function, and a better understanding of the interaction between sleep-disordered breathing and congestive heart failure is now emerging. There is now strong evidence that reversal of sleep-related breathing disorders by nasal continuous positive airway pressure leads to improvements in markers of cardiovascular outcome in selected patients with congestive heart failure. These findings augur well for the development of new diagnostic approaches and treatment strategies for patients with sleep apnea and coexisting cardiovascular disease.

Trapping the flies that cause myiasis: their responses to host-stimuli

A critical phase in the life cycle of the fly species that cause myiasis is host location by the adult females, whether by direct location of and contact with the host, or by indirect location through the selection of sites frequented by hosts. The stimuli to which these flies respond in host location, principally visual and olfactory, are discussed here in the context of their use to enhance the performance of trapping systems used in research, monitoring and control. The three major families of flies encountered in myiasis can be divided into two groups for comparison of host-location strategies: (1) Oestridae; and (2) Calliphoridae and Sacrophagidae. The former are all obligate parasites, the latter include obligate and primary facultative parasites. In the Oestridae, the majority of Cuterebrinae deposit their eggs at sites likely to be visited by the host, whereas the majority of Oestrinae, Hypodermatinae and Gasterophilinae deposit their eggs or larvae directly onto the host. It is presumed that most host location is, like that of haematophagous insects, by response to olfactory and visual cues released by healthy hosts, but the subject is very under-researched. In the Calliphoridae and Sacrophagidae, most species that cause myiasis deposit their eggs or larvae directly onto the host at some predisposing site, such as those caused by wounding, necrosis and/or bacterial contamination. Healthy hosts are much less attractive, even for obligate species such as Wohlfahrtia magnifica, which can invade undamaged tissues. The last decade has seen a renewed interest in the potential for using traps in control of myiasis, leading to significant advances in trap and bait efficiency. However, there is great potential for further research and development, particularly on the general responses of Oestridae to hosts and in the precise identification of the olfactory cues for Calliphoridae and Sarcophagidae.

Orientation of agents of wound myiasis to hosts and artificial stimuli in Hungary

The orientation of adults of the myiasis species Wohlfahrtia magnifica and Lucilia sericata to artificial visual stimuli (cloth targets) and olfactory stimuli ('swormlure-4', a potent screwworm attractant), was studied in sheep pastures near to Sárbogard in Hungary. Experiments with odour-baited cloth targets, enclosed in electrocuting grids, demonstrated that colour was an important factor influencing catches on targets: a black target caught most flies of both species, with other colours in the following order of effectiveness, blue > white > yellow. Wohlfahrtia magnifica did not respond to swormlure-4 in the strong manner that L.sericata did. The sex ratios of W.magnifica caught on targets (67.2% males) and hand-netted from fence posts (68.8% males) were similar and biased towards males, whereas that of L.sericata on targets was strongly biased towards females (15.6% males), indicating a fundamental difference in the response of these two myiasis species towards the swormlure-baited targets. The orientation of these two species towards hosts was also recorded together with that of a third species, Phormia regina. Electric nets placed beside infested sheep caught significantly more flies of all three species than those placed beside uninfested sheep or in the absence of sheep. The sex ratio of W.magnifica caught around infested sheep was the reverse of that on targets, with 68.5% females. Wohlfahrtia magnifica responded more strongly to healthy, uninfested sheep than did L. sericata and P.regina. The potential for use of targets both for population monitoring and control is discussed.

Exercise, potassium, and muscle deconditioning post-thoracic organ transplantation

Although muscle deconditioning appears to significantly limit peak exercise performance post-thoracic organ transplantation, few confirmatory data exist. Potassium (K+) regulation during exercise may reflect muscle deconditioning, since both peak plasma K+ concentration ([K+]) and the increase in plasma [K+] relative to energy expenditure (delta [K+]/W) are reduced in healthy individuals after training. This study compares delta [K+]/W during graded exercise and the change in [K+] (delta [K+]) during both exercise and recovery in 12 heart transplant (HT) recipients, 14 lung transplant (LT) recipients, and 7 healthy subjects. Plasma [K+] was determined from arterial blood sampled at rest; during the final 15 s of each power output; and at 1, 2, and 5 min postexercise. Peak oxygen consumption was significantly lower (P < 0.0001), whereas delta [K+]/W was significantly higher (P < 0.002) among the HT and LT groups. When delta [K+] during recovery was expressed relative to delta [K+] detected during activity, no difference at 1, 2, or 5 min postexercise was detected, although the absolute fall in plasma [K+] was greater among the healthy subjects in the 1st min (P < 0.0001). The rate of delta [K+] during recovery appears to reflect the rise seen during activity in all groups. These results suggest that [K+] regulation is altered during exercise in both HT and LT recipients and may reflect muscle deconditioning.

Violence in patients with narcissistic personality pathology: observations of a clinical series

This paper presents clinical observations on a group of nine patients whose action consisted of either the commission of violent acts or of seriously threatening behaviors suggestive of precursors to violence. A cluster of common features was observed to be present to some degree in all patients: (1) significant narcissistic personality pathology, (2) recent narcissistic injury, (3) inability to acknowledge or express affect related to this injury, (4) some history of impulsiveness when stressed, and (5) the availability of a weapon. Discussion is presented that the clinician's ability to predict the potential for violence may be enhanced by special attention to these features.

Ophthalmomyiasis in Kuwait: first report of infections due to the larvae of Oestrus ovis before and after the Gulf conflict

We report for the first time four cases of ophthalmomyiasis due to the larvae of Oestrus ovis in Kuwait, before and after Operations Desert Shield and Desert Storm. The larvae were easily removed under local anaesthetic. The symptom complex of acute foreign body sensation, irritation, redness, lacrimation and photophobia resolved rapidly. Ophthalmic antibiotic and corticosteroid drops were also instilled and recovery was uneventful. The ophthalmomyiasis may not always be associated with contact with sheep-rearing per se. Medical personnel should therefore be aware that in cases of what might appear initially as acute, non-specific catarrhal conjunctivitis, patients with the persistent symptom complex should be re-examined to exclude ophthalmomyiasis due to the larvae of O. ovis in endemic areas.

Long-stay patients in short-stay hospitals

In 1980 and 1990, only 4-5 percent of patients in short-stay hospitals were hospitalized for more than 3 weeks. The number of discharges and days of care for these long-stay patients were lower in 1990 as compared with 1980, but they continued to use more than a quarter of all hospital days in 1990. Long-stay patients were more likely than all patients to be 65 years of age and over and have Medicare as their expected principal source of payment. For long-stay and all patients, private insurance covered smaller proportions of discharges and days of care, and Medicaid covered larger proportions in 1990 than in 1980. Long-stay patients were more likely than all patients to be discharged dead or transferred to other hospitals or nursing homes. Long-stay and all patients were more likely to be transferred at discharge in 1990 than in 1981. The Northeast Region had a larger proportion of long-stay patients than of all patients, and that proportion increased from 1980 to 1990. The proportion of long-stay discharges and days of care in the Midwest decreased during this period. In 1980 and 1990, more than 50 percent of the discharges and days of care for long-stay patients were for diseases of the circulatory system, mental disorders, neoplasms, or injury and poisoning. Despite the overall decreases in hospital use by long-stay patients, their discharges and days of care increased significantly from 1980 to 1990 for diagnoses such as septicemia, psychoses, and miscellaneous complications of surgical and medical care. Over time, decreases were seen in long-stay discharges and days of care for a variety of diagnostic categories, including malignant neoplasm of trachea, bronchus, and lung; diabetes mellitus; and fracture of the neck of the femur. Long-stay patients had a higher rate of procedures per 1,000 discharges in 1990 than in 1980, and a higher rate than all patients in both years. Approximately half of all the procedures performed on long-stay patients in 1980 and two-thirds in 1990 were miscellaneous diagnostic and therapeutic procedures, operations on the cardiovascular system, or operations on the digestive system. The rates of numerous procedures, especially diagnostic tests, increased for long-stay and all patients from 1980 to 1990.

An examination of narcissistic personality traits as seen in a military population

Various studies examining the prevalence of personality disorders in civilian inpatient and outpatient populations have consistently found narcissistic personality disorder to be one of the least common. In striking contrast to this, a recently published study showed narcissistic personality features to be among the most common personality features in a military outpatient clinic population. This paper examines several possible explanations for this finding. This surprisingly high relative incidence of narcissistic personality features may be related to a self-selection bias on the part of persons choosing a military career. Narcissistic personality traits may confer adaptive advantage in certain military professional roles. Kohut's theory of specific transference requirements in individuals with narcissistic character structure serves as a useful explanatory model for these findings.

Attracting adult New World screwworm, Cochliomyia hominivorax, to odour-baited targets in the field

A field study in Libya investigated aspects of Cochliomyia hominivorax behaviour relevant to the operation of a target-based control system. Flies were readily caught by electrified targets, but only when baited with the attractant 'swormlure-4'. Target size (0.25-1 m2) did not affect catch, but black targets caught twice as many flies as red ones. Omitting the most volatile component of swormlure-4, dimethyl disulphide, significantly reduced catches of both sexes of C.hominivorax in wind-orientated traps, but only reduced the capture of females significantly on targets. A new polythene sachet dispenser for odours was tested; four to six such sachets filled with swormlure-4 less dimethyl disulphide gave an equivalent catch to one of the standard bottle plus wick dispensers using the same attractant, although they dispensed odour at about half the rate. From direct observations, fewer than 40% of flies contacted the target for more than 10 s on any one visit. From catches on an intermittently-active electrocuting grid, it was calculated that there is a c. 40% rate of multiple contacts of flies with the target.

A case of subcortical grey matter heterotopia presenting as bipolar disorder

A case of previously diagnosed bipolar disorder was found to be associated with unilateral subcortical grey matter heterotopia, cortical hemiatrophy, midline shift, and ventriculomegaly on magnetic resonance imaging (MRI). The patient responded to pharmacotherapy with lithium carbonate and carbamazepine. This case dramatically illustrates the need for neuroimaging in psychiatric patients with apparently "functional" affective illness.

Psychiatric evaluation of self-referred and non-self-referred active duty military members

This study examined 300 cases of active duty Air Force members seen in an Air Force medical center outpatient mental health clinic over a 1-year period. Comparisons were made between self-referred and non-self-referred (commander-directed) patients across several areas, including chief complaints/referral reasons, diagnoses, personality features, dispositions, and numbers of therapy sessions. Results showed significantly different distributions of types of chief complaints, dispositions, and treatment sessions between the two groups, and provided relative proportions of personality types distributed within each group. The dual roles of the military mental health practitioner, as provider for both the organization and the patient, are discussed.

Urticarial vasculitis: a histopathologic and clinical review of 72 cases

BACKGROUND

Urticarial vasculitis is a subset of vasculitis characterized clinically by urticarial skin lesions and histologically by necrotizing vasculitis.

OBJECTIVE

A review of patients with urticarial vasculitis was undertaken to further characterize the clinical and histologic findings and to differentiate this disorder from urticaria and other types of cutaneous vasculitis.

METHODS

Seventy-two cases of biopsy-proven urticarial vasculitis were selected for a review of medical records, laboratory data, and histologic findings. Fifty cases of simple urticaria were also reviewed for purposes of comparison.

RESULTS

Systemic symptoms in patients with urticarial vasculitis included angioedema in 30 patients (42%), arthralgias in 35 (49%), pulmonary disease in 15 (21%), and abdominal pain in 12 (17%). Twenty-three patients (32%) had hypocomplementemia. Forty-six of 72 patients (64%) had lesions that lasted more than 24 hours, 23 of 72 (32%) had painful or burning lesions, and 25 of 72 (35%) had lesions that resolved with purpura. Sixteen biopsy specimens from the 23 patients with hypocomplementemia showed dermal neutrophilia in addition to the perivascular infiltrate. Of the 23 patients with hypocomplementemia, 20 (87%) had fluorescence of the blood vessels and 16 (70%) had fluorescence of the basement membrane zone as determined by routine direct immunofluorescence.

CONCLUSION

Patients with hypocomplementemia were more likely to have systemic symptoms such as urticaria that resolved with purpura, arthralgias, abdominal pain, and chronic obstructive pulmonary disease. The histologic pattern associated with hypocomplementemia is interstitial neutrophilic infiltrate of the dermis and an immunofluorescent pattern of immunoglobulins or C3 in the blood vessels and along the basement membrane zone.

Large asymptomatic antrolith of the maxillary sinus. Report of a case

A case of an unusually large antrolith of the maxillary sinus is presented. Because of the size of the mass, benign neoplasms were considered in the differential diagnosis. Surgery was the treatment of choice, and recurrence of the lesion is not expected.

Coeliac disease and malignancy of the duodenum: diagnosis by endoscopy, successful treatment of the malignancy, and response to a gluten free diet

A patient presented with subtotal villous atrophy and a malignant duodenal tumour of uncertain histogenesis. He was successfully treated by resection and chemotherapy and the small bowel mucosa recovered on a gluten free diet. The tumour was diagnosed at upper gastrointestinal endoscopy when barium studies and abdominal computed tomography were normal, thus making this one of the earliest coeliac malignancies diagnosed.

Medicaid-financed residential care for persons with mental retardation

Two sources of Medicaid support for persons with mental retardation and related conditions (MR/RC) are examined, the intermediate care facility for the mentally retarded (ICF/MR) program and the home and community-based services (HCBS) waiver. Results indicate that Medicaid support through the ICF/MR program has shown little recent growth in terms of number of persons served, although expenditures continue to increase. Medicaid's HCBS waiver is being used increasingly by States to support residential placement because of its greater flexibility and more individualized approach relative to ICF/MR care. Use of Medicaid to finance care for persons with MR/RC varies considerably across States.

[Production, purification and action mechanism of interferon]

Interferon-alpha is in clinical use for approximately 10 years. Large-scale cell culture and genetic technology had to be developed in the seventies in order to provide sufficient amounts of pure substance for meaningful clinical studies and analysis of modes of action. For its specific effects interferon-alpha has first to bind to specific receptors on the cell membrane. The resulting trans-cytoplasmic signals induce a series of biochemical and cellular events, directly or indirectly responsible for anti-tumor or anti-viral effects. Essential initial events are the induction of synthesis of several new proteins such as 2',5'-oligo-A-synthetase, protein-kinase P1 and major histocompatibility-complex antigens (MHC). Further effects comprise a modulation of the cell cycle, cytostatic effects, induction of differentiation as well as modulation of oncogene expression. Finally immunomodulating effects with effects on the monocyte/macrophage system, natural killer cells and indirectly cytotoxic T-cells have been noted. These effects are illustrated by clinical examples such as chronic viral hepatitis, hairy-cell leukemia and chronic myelogenous leukemia.

Prevalence of Clostridium difficile on a mixed-function ward for the elderly

We studied the prevalence of Clostridium difficile over a period of 2 months on a mixed-function geriatric ward. Seven (14%) of the 49 patients were long-stay but the remainder were in hospital for acute illness or required a short period of active rehabilitation. Although 69% patients had recently received antibiotics, from only two (4%) was C. difficile isolated from their faeces. Our results show that C. difficile is not endemic in patients on all geriatric wards as has been previously suggested.

Synthesis and antiviral activity of monofluoro and difluoro analogues of pyrimidine deoxyribonucleosides against human immunodeficiency virus (HIV-1)

A range of 2'-fluoro and 2',3'-difluoro analogues of pyrimidine deoxyribonucleosides have been synthesized and evaluated against human immunodeficiency virus (HIV-1) in a human lymphoblastoid cell line. Among these compounds, 1-(2,3-dideoxy-2-fluoro-beta-D-threopentofuranosyl)cytosine (12), 2',3'-didehydro-2',3'-dideoxy-2'-fluorocytidine (35), 1-(2,3-dideoxy-2,3-difluoro-beta-D-arabinofuranosyl)cytosine (41), and 3'-deoxy-2',3'-didehydro-2'-fluorothymidine (45) were found to have significant antiviral activity, with IC50 values of 0.65, 10, 10, and 100 microM, respectively. The structure-activity relationships are discussed.

Effect of reduced phytate wheat bran on zinc absorption

The rise in plasma zinc after the ingestion of 765 mumol (50 mg) elemental zinc was measured over 6 h in three groups of healthy subjects who, in a second test, also consumed a standard wheat bran, a reduced phytate, high fibre processed bran or rice-based, low phytate, low fibre breakfast cereal (Rice Krispies). Standard bran, reduced phytate bran and Rice Krispies all significantly decreased the area under the plasma zinc time curve (AUC) compared to the zinc alone test. The AUC obtained with standard bran was significantly lower than that after reduced phytate bran (mean +/- s.e.: -5.9 +/- 2.7 vs 18.5 +/- 4.2 mumol.h/l, P less than 0.001). The percentage reductions in AUC produced by the test meals were: standard bran 106.4 +/- 2.4, reduced phytate bran 75.9 +/- 4.8, Rice Krispies 46.3 +/- 10.4 per cent, P less than 0.01). Histidine, taken with standard bran in a small subgroup of subjects, tended to improve zinc absorption but the difference was not statistically significant.

Synthesis and antiviral activity of phosphonoacetic and phosphonoformic acid esters of 5-bromo-2'-deoxyuridine and related pyrimidine nucleosides and acyclonucleosides

Phosphonoacetic acid (PAA, 1) was coupled with various acyclonucleosides, 2'-deoxyuridines, cytidines, and arabinosyluracils, with 2,4,6-triisopropylbenzenesulfonyl chloride (TPS) or dicyclohexylcarbodiimide (DCCI) as condensing agents, to give a range of phosphonate esters. The carboxylic ester linkage of PAA to the 5'-position of 5-bromo-2'-deoxyuridine (BUdR, 3) was achieved via the mixed anhydride formed from (diethylphosphono)acetic acid and trifluoroacetic anhydride. Phosphonoformic acid (PFA, 2) was coupled with BUdR by using the DCCI method to give the phosphonate ester. Of these compounds only phosphonate esters in the 2'-deoxyuridine series showed significant activity against herpes simplex virus types 1 and 2. The BUdR-PAA derivative and the BUdR-PFA derivative were highly active, especially the latter, which was more active than the parent nucleoside BUdR against the type 2 virus. The active compounds may exert their effects by extracellular or intracellular hydrolysis to the corresponding antiviral agents, but an intrinsic component of antiviral activity may also be involved.