How many illnesses does one emergency department visit represent? Using a population-based telephone survey to estimate the syndromic multiplier

INTRODUCTION

Syndromic surveillance monitors trends in nonspecific health indicator data to detect disease outbreaks in a timely manner; however, only a limited percentage of persons with mild illness might exhibit behaviors that could be detected by syndromic surveillance.

OBJECTIVES

The objectives of this study were to 1) examine the demographic characteristics of New Yorkers with recent flu-like or diarrheal illness, 2) describe behaviors associated with having flu-like illness, and 3) estimate the citywide burden for selected illnesses by calculating the syndromic multiplier (i.e., the number of citywide illnesses represented by each visit to an emergency department [ED]).

METHODS

A cross-sectional telephone survey of 2,433 adult residents of New York City (NYC) was conducted during March 19-March 31, 2003, and October 27-November 23, 2003. Respondents were asked about flu-like illness, behaviors related to flu-like illness, and diarrheal illness during the 30 days before the interview. Estimated numbers of citywide illnesses were compared with ED visits for flu-like and diarrheal illnesses that were recorded by the NYC syndromic surveillance system for the same periods.

RESULTS

Every ED visit for flu-like illness represented approximately 60 illnesses among city residents; every visit for diarrheal illness represented approximately 251 illnesses. Among adults who reported a recent flu-like illness, 53.2% purchased over-the-counter (OTC) medications; 32.6% reported missing school or work; 29.1% visited a physician; 21.4% called a physician for advice; 8.8% visited an ED; and 3.8% called a nurse or health hotline for advice. Of those who reported multiple behaviors, respondents most commonly reported purchasing OTC medications as their first response to a flu-like illness.

CONCLUSIONS

Population-based survey data can be used in conjunction with syndromic surveillance data to better understand the relation between nonspecific health indicators and the burden of certain illnesses in the community, and to assess the representativeness of different syndromic data sources.

Maintenance treatment with interferon for advanced ovarian cancer: results of the Northern and Yorkshire gynaecology group randomised phase III study

A randomised phase III trial was conducted to assess the role of interferon-alpha (INFalpha) 2a as maintenance therapy following surgery and/or chemotherapy in patients with epithelial ovarian carcinoma. Patients were randomised following initial surgery/chemotherapy to interferon-alpha 2a as 4.5 mega-units subcutaneously 3 days per week or to no further treatment. A total of 300 patients were randomised within the study between February 1990 and July 1997. No benefit for interferon maintenance was seen in terms of either overall or clinical event-free survival. We conclude that INF-alpha is not effective as a maintenance therapy in the management of women with ovarian cancer. The need for novel therapeutics or strategies to prevent the almost inevitable relapse of patients despite increasingly effective surgery and chemotherapy remains.

Intelligence and achievement of children referred following sexual abuse

OBJECTIVE

Little is known about the prevalence of intellectual and academic problems in sexually abused children. Such problems may have significant implications for their management. This study examined the prevalence of such problems in a population of Australian children referred for sexual abuse evaluation. The study also assessed the clinical utility of the Parents' Evaluation of Developmental Status (PEDS) questionnaire as a screening tool for learning and developmental problems in this population.

METHODS

Over a 12-month period, children referred for sexual abuse evaluation to the Mater Children's Hospital Child Protection Unit were enrolled and background demographic and abuse related data collected. The children then completed standardized psychometric assessments. Their parents completed Child Behavior Checklists (CBCL) and PEDS questionnaires. Day care providers and schoolteachers completed the corresponding Caregiver or Teacher Report Forms (TRF).

RESULTS

A total of 21 of the 35 eligible children completed the assessment during the study period. Mean scores for intelligence and academic achievement were within the average range. However, three (14%) of the tested children were intellectually impaired and three (14%) showed academic underachievement. Sixty-two per cent of children had problems in the clinical range on the CBCL and 33% on the TRF. The PEDS showed a sensitivity of 64%, specificity of 60% with a positive predictive value of 77%.

CONCLUSION

In this population of referred children, over one quarter showed problems with intellectual impairment or academic under achievement. Most of these children were not receiving learning support at school. A high index of suspicion is therefore required when assessing sexually abused children for comorbid intellectual and learning problems.

Patient characteristics and quality of life among a sample of Australian chronic pain clinic attendees

BACKGROUND

Multidisciplinary chronic pain management programs have proliferated widely in recent decades. The clinical characteristics of patients attending these clinics are becoming the subject of increased research. Recent European data suggests that patients attending these clinics report very low quality of life.

AIMS

The present study profiles an Australian population in terms of demographics, clinical characteristics and quality of life, as measured by the Short Form 36 Quality of Life Questionnaire (SF-36).

METHODS

Data were collected prospectively from consecutive patients presenting to a multidisciplinary chronic pain clinic at a major Sydney metropolitan teaching-hospital. Cross-sectional analysis of demographic and clinical characteristics and quality of life were then undertaken.

RESULTS

Descriptive analysis of demographics and clinical characteristics suggest a patient population group reporting significant pain severity and reduced quality of life. The comparison of SF-36 domain scores between clinic patients and Australian norm values indicates a greatly reduced score on all SF-36 domains for clinic patients. Pain clinic patients reported the most profound effect upon quality of life in the role physical, physical function and social function domains of the SF-36. Stepwise multiple regression indicated impaired coping ability and depressive disability as the most significant correlates of low quality of life.

CONCLUSION

Patients who attend chronic pain clinics are likely to report low quality of life with an inability to cope. These findings suggest that future intervention research should explore the impacts of behavioural and self-management interventions. Psychological distress and ability to cope could be used as indices of improvement.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

Feasibility and compliance of automated measurement of quality of life in oncology practice

PURPOSE

Systematic quality-of-life (QOL) assessment may have value in oncology practice by increasing awareness of a wide range of issues, possibly increasing detection of psychologic morbidity, social problems, and changes in physical status, and improving care and its outcomes. However, logistic problems are substantial. Automated systems solve many of these problems. We field-tested the feasibility and compliance that can be achieved using a computer touchscreen system in two consecutive studies.

PATIENTS AND METHODS

In study 1, a prospective cohort of 272 patients was offered QOL assessment at each clinic appointment for 6 months. In study 2, all patients (N = 1,291) were offered QOL assessment as part of clinic routine during a 12-week period.

RESULTS

In study 1, 82% of patients agreed to take part, but over time, compliance was poor (median, 40%; mean, 43%) and deteriorated with longer follow-up. In study 2, the overall compliance was greatly increased (median, 100%; mean, 70%), and compliance was retained over multiple visits. In study 1, compliance was better in younger patients, males, and socially advantaged patients, but was not affected by the presence of depression or anxiety, or QOL. In the second study, building on experience in the first study, data collection and storage in the computer system was excellent, achieving 98% of collected data stored in one center. In general, patients were comfortable with the computers and the approach. Data collection on the wards was more difficult and less complete than in clinics, especially for patients undergoing acute admissions.

CONCLUSION

Feasibility with higher compliance was demonstrated in study 2, in which the data collection was integrated into routine care, and can be improved with further technical initiatives and education of staff.

Thinking life is not worth living. A population survey of Great Britain

BACKGROUND

"Saving lives: our healthier nation" includes a target to reduce the death rate from suicide. Thoughts of suicide and feeling life is not worth living might be the first step in a pathway that can end in completed suicide. This study aims to identify factors associated with feeling life is not worth living amongst the household population of Great Britain, and to assess the strength of these associations after taking account of an individual's level of psychiatric morbidity.

METHODS

The 1993 OPCS National Psychiatric Morbidity Surveys of Great Britain assessed psychiatric morbidity using the Revised Clinical Interview Schedule amongst a stratified, clustered probability sample of 9830 subjects representative of the British private household population aged 16-64.

RESULTS

Of the sample 0.8 % (95 % CI 0.6 %-1 %) had thoughts of suicide in the week before interview and 3.1 % (95 % CI 2.7 %-3.5 %) reported thoughts of life not worth living in the week before interview. Psychiatric morbidity was most strongly associated with such thoughts. Ethnicity, marital status and low social support were strongly associated with such thoughts after adjusting for age, sex and psychiatric morbidity.

CONCLUSIONS

Reducing psychiatric morbidity in the population as a whole might also decrease the frequency of suicidal thoughts. Policies which improve social support at a population level might also have a large impact on prevalence of suicidal thoughts.

Analysis of postrevascularization syndrome after orthotopic liver transplantation: the experience of an Australian liver transplantation center

BACKGROUND/PURPOSE

We investigated the causes and examined patient outcomes following the postrevascularization syndrome (PRS) during orthotopic liver transplantation (OLTx).

METHODS

PRS was defined as a fall in the mean arterial pressure at 5 min after revascularization to less than 70% of the baseline and lasting for 5 min. Data from 100 adult patients who underwent OLTx between January 1998 and September 2000 were analyzed. Analyzed data included donor and recipient demographic data, recipient operative and postoperative courses, and recipient outcome.

RESULTS

Twenty-nine patients (29%) exhibited PRS during OLTx (PRS group). There was a higher incidence of older donors (>50 years) in the PRS group (48% vs 23%; P < 0.05). Postrevascularization hyperkalemia and metabolic acidosis were observed in both the PRS and non-PRS groups. Transaminase and lactate levels after revascularization were significantly higher in the PRS group ( P < 0.05). Alkaline phosphatase and gamma-glutamyl transpeptidase levels on day 7 tended to be higher in the PRS group; although the difference was not significant (p > or = 0.05). Serum creatinine was significantly elevated on day 7 in the PRS group ( P < 0.01).

CONCLUSIONS

Our results indicate that PRS following OLTx tended to be more common in liver allografts from older donors and was associated with posttransplantation liver and renal dysfunction.

Role of plant-derived omega-3 fatty acids in human nutrition

An international workshop on the role of plant-derived omega-3 fatty acids in human nutrition took place in Milan on February 9, 2000. The meeting was sponsored by the Nutrition Foundation of Italy and was organized by its Scientific Director, Dr. Andrea Poli. It was attended by experts in polyunsaturated fatty acids and human lipid nutrition. This is the first meeting devoted to the health aspects of alpha-linolenic acid, the omega-3 fatty acid contained in plant-derived edible products, as distinct from the more widely studied long-chain omega-3 products typically present in fish and fish-derived products. This report, which is based on updated scientific evidence presented and discussed at the workshop, was prepared by the international expert panel.

An analysis of consultations with the crowd doctors at Glasgow Celtic football club, season 1999-2000

OBJECTIVE

To analyse all clinical presentations to the crowd doctors at Scotland's largest football stadium over the course of one complete season.

METHODS

A standard clinical record form was used to document all consultations with the crowd doctors including treatment and subsequent referrals. The relevance of alcohol consumption was assessed.

RESULTS

A total of 127 casualties were seen at 26 matches, a mean of 4.88 per match. Twenty casualties were transferred to hospital, including one successfully defibrillated after a cardiac arrest. Alcohol excess was a major contributing factor in 26 cases.

CONCLUSIONS

The workload of the crowd doctors was very variable and diverse. The social problem of excessive alcohol consumption contributed considerably to the workload. The provision of medical facilities at football grounds means that attendance there is now one of the least adverse circumstances in which to have a cardiac arrest. The study confirmed previous impressions that more casualties are seen at high profile matches.

A voice for nurses in primary care

Primary care groups offer a new opportunity for practitioners in the community to broaden their experience--and share it with members of other professions.

Easing the path back to nursing practice

With staff shortages reaching crisis level, the government is keen to encourage back nurses who have taken a career break. For one nurse, this has worked well.

MAGE-F1, a novel ubiquitously expressed member of the MAGE superfamily

Most known members of the MAGE superfamily are expressed in tumors, testis and fetal tissues, which has been described as a cancer/testis or "CT" expression pattern. We have identified a novel member of this superfamily, MAGE-F1, which is expressed in all adult and fetal tissues tested. In addition to normal tissues, MAGE-F1 is expressed in many tumor types including ovarian, breast, cervical, melanoma and leukemia. MAGE-F1 is encoded on chromosome 3, identifying a sixth chromosomal location for a MAGE superfamily gene. The coding region of MAGE-F1 is contained within a single exon and includes a microsatellite repeat. Sequence analysis and expression profiles define a new class of ubiquitously expressed MAGE superfamily genes that includes MAGE-F1, MAGE-D1, MAGE-D2/JCL-1 and NDN. The finding that several MAGE genes are ubiquitously expressed suggests a role for MAGE encoded proteins in normal cell physiology. Furthermore, potential cross-reactivity to these ubiquitously expressed MAGE gene products should be considered in the design of MAGE-targeted immunotherapies for cancer.

Reducing falls risk

A multidisciplinary working group in a London hospital set up a questionnaire system to reduce patient falls. The framework it put in place is now a way of life at the hospital and could provide the basis for a wider Clinical Governance project.

Cell adhesion molecule expression in the cervix and myometrium during pregnancy and parturition

OBJECTIVE

To determine the expression and localization of cell adhesion molecules intercellular adhesion molecule-1 (ICAM-1), E-selectin, platelet-endothelial cell adhesion molecule (PECAM), and vascular cell adhesion molecule (VCAM) in the cervix and myometrium during pregnancy and labor.

METHODS

Biopsies of myometrium and cervix were obtained from non-pregnant women and from pregnant women before and after onset of spontaneous labor at term. Cell adhesion molecule mRNA expression was quantified using Northern blotting and cell adhesion molecule protein was localized using immunohistochemistry.

RESULTS

ICAM-1 mRNA was upregulated in the cervix (10-fold increase, P <.01) and myometrium (10.5-fold increase, P <.01) during labor. ICAM-1 was localized in the vascular endothelium and in leukocytes in the cervix and myometrium from all three groups of women. VCAM mRNA was upregulated in the cervix (2.5-fold increase, P <.01) during pregnancy and there was no further change during labor. VCAM localized weakly to the vascular endothelium in cervical and myometrial biopsies from pregnant and non-pregnant women. PECAM mRNA was significantly upregulated in myometrium during pregnancy (ninefold increase, P <.01) and did not change with the onset of labor. PECAM localized to the vascular endothelium in all cervical and myometrial biopsies and was identified on leukocytes. There were no significant changes in E-selectin mRNA expression in either tissue with pregnancy or parturition.

CONCLUSION

Cell adhesion molecule expression changes in human cervix and myometrium during pregnancy and parturition. At least part of these changes are attributable to expression by leukocytes infiltrating these tissues.

Docetaxel-carboplatin as first line chemotherapy for epithelial ovarian cancer

A prospective, non-randomized, multicentre, open, dose-finding study of a carboplatin-docetaxel (C-D) combination as first-line chemotherapy in FIGO stage Ic-IV epithelial ovarian cancer. C-D was given 3-weekly for 6 planned cycles, with a 3-day prophylactic dexamethasone regimen (8 mg b.i.d.). 139 eligible patients (Pts) (median age 56 years, range 28-85) were given a total of 750 cycles of chemotherapy in 5 cohorts: Co1, 32 pts, 169 cycles (C at AUC 5 + D 60 mg/m(2)); Co2, 22 pts, 122 cycles (5 + 75), Co3, 29 pts, 156 cycles (6 + 75), Co4, 27 pts, 146 cycles (7 + 75), Co5, 30 pts, 157 cycles (6 + 85). 110 patients (79%) completed 6 cycles; 17 (12%) stopped due to toxicity. 104 patients (75%) had CTC grade IV neutropenia, and 5 patients (4%) had this associated with fever. There were 2 probable treatment-related deaths. Only 8 patients (6%) experienced grade II-III neurotoxicity (all sensory; no motor > grade I). The maximum tolerated dose was reached in cohorts 4 and 5, and the dose limiting toxicities were myelosuppression and diarrhoea. The overall response rate for the study was 66% (49/74); CA125 response was 75% (70/93). Median progression-free survival was 16.6 months (95% CI 13.3-19.1). Recommended doses are carboplatin AUC 5 (via(51)Cr EDTA) or AUC 6 (if calculated) plus docetaxel 75 mg/m(2). A randomized trial comparing this regimen with carboplatin-paclitaxel has just completed recruitment.

Sublingual morphine may be a suitable alternative for pain control in children in the postoperative period

The purpose of this pilot study was to compare the effects of sublingual morphine with intravenous morphine in the treatment of postoperative pain following adenotonsillectomy in children. Twenty-nine children scheduled for adenotonsillectomy were randomly assigned to group 1 (n=14) receiving 0.1 mg x kg(-1) sublingual morphine and group 2 (n=15) 0.1 mg x kg(-1) intravenous morphine followed by 1 mg x kg(-1) diclofenac rectally in both groups after induction of anaesthesia. Postoperatively, time to first eye opening, sedation score, pain score, time for further analgesia requests and incidence of nausea and vomiting were recorded. There was no statistical significant difference in any of these parameters between the two groups. The results suggest that sublingual morphine may be a suitable alternative to various other routes of opioid administration in children, but further investigations of the sublingual route of administration of opioids in children are required.

Teens' images of smoking and smokers

The authors used qualitative and quantitative data to identify and interpret specific images teens have about smoking and smokers. Qualitative data were collected in 1996 from 793 teenagers participating in 125 focus groups at eight different sites across the United States. Most focus groups were homogeneous with respect to gender, ethnicity, and smoking status. Ages ranged from 12 to 18 years, and about half of the participants were female. The majority of participants (62%) were white and African American, the remainder (38%) were Hispanic, American Indian, and Asian/Pacific Islander. Groups were comprised of smoking and nonsmoking teens. Focus group activities were used to elicit image-related discussions about attitudes, beliefs, and perceptions of smoking. Investigators identified seven consistent and distinctive image themes: Appearance (smoking is dirty and unattractive), Activity (nonsmokers have busy, active lives), Drugs and sex (smokers are substance abusers and are sexually active), Rebellion (smokers belong to rebellious groups), Affect (smokers are depressed, angry, and stressed-out), In control (nonsmokers have self-control and are independent), and Pride (nonsmokers are proud of themselves, their families, and their heritage). A large scale, multi-site qualitative research approach can increase understanding of teen smoking. The identification of distinctive images of smoking can help researchers develop more sophisticated models of the processes of teen smoking than currently exist.

Non-accidental fractures in infants: risk of further abuse

OBJECTIVES

To look for features of non-accidental fractures in infants aged under I year and assess the risk of subsequent morbidity and mortality.

METHODOLOGY

A retrospective analysis of 99 children aged under 1 year who presented to the Mater Children's Hospital, Brisbane, between January 1990 and December 1993, and were found to have a fracture. The 99 infants were divided into non-accidental and accidental groups. Comparison was made between the two groups for age, sex and type of fracture. Deaths, subsequent injuries and child protection notifications until March 1997 were compared between groups.

RESULTS

Of the 99 infants with fracture (64 males, 35 female), the skull and femur were the most prevalent sites of fracture. Twenty-six infants had fractures assessed as non-accidental. This group was younger but did not differ significantly in gender or site of fracture. Infants aged under 4 months had a significantly greater risk of their fracture being non-accidental (P = 0.0007). Subsequent substantiated child protection notifications occurred in nine of the non-accidental group and in one of the accidental group (P = 0.000001). There was no significant difference in the rate of subsequent notifications between those infants with abuse who were removed from their carers and those not removed. Subsequent injuries presenting to hospital occurred in 17 of the accidental group and three of the non-accidental group (P = 0.20). There were no deaths.

CONCLUSION

Infants aged under 1 year with fractures have a high prevalence of abuse. The risk of abuse as cause for the fracture is greater in those aged under 4 months. Infants with non-accidental fractures have a high risk of further abuse even with intervention.

Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy--a randomized trial

OBJECTIVE

To determine the effect of the method of tonsillectomy on postoperative pain in pediatric patients.

DESIGN

Prospective, randomized, single-blind, controlled clinical trial.

SETTING

A university pediatric hospital in Aberdeen, Scotland.

PATIENTS

A volunteer sample of 54 children, aged 3 to 12 years, with recurrent tonsillitis or symptomatic adenotonsillar hypertrophy. Two patients withdrew consent.

INTERVENTIONS

Twenty-six children underwent a nonelectrical (ie, cold) dissection tonsillectomy with cold steel instruments, 5 of whom also had adenoidectomy by curettage. Monopolar diathermy forceps were used for tonsillar bed hemostasis. Twenty-four children had electrocautery (ie, hot) dissection tonsillectomy, 7 of whom underwent adenoidectomy by curettage without a suction coagulator.

MAIN OUTCOME MEASURES

Postoperative analgesic consumption, time to regain normal diet and activity levels, and complications.

RESULTS

Patients who underwent hot dissection tonsillectomy showed no difference in time to first drink or analgesic use within the first 24 postoperative hours compared with children undergoing cold nonelectrical dissection tonsillectomy. The hot dissection tonsillectomy group took 7.5 (95% confidence interval [CI], 1-14.1) more doses of analgesics than the cold dissection group over the next 12 days (P<.05). The hot dissection tonsillectomy group took 2.5 more days than the cold dissection tonsillectomy group to regain normal diet (P<.05). Thirteen children (54%; 95% CI, 34-74) in the hot dissection tonsillectomy group and 6 (23%; 95% CI, 7-39) in the cold dissection tonsillectomy group sought outpatient care for throat pain, otalgia, poor diet, pyrexia, and/or bleeding (P<.05). Throat pain delayed in onset or of prolonged duration affected 9 children (38%; 95% CI, 19-57) in the hot dissection tonsillectomy group as opposed to 3 children (12%; 95% CI, 0-24) in the cold dissection tonsillectomy group (P<.05).

CONCLUSION

Hot dissection tonsillectomy increases morbidity in pediatric patients in the recovery period following hospital discharge.

Detection of Leptospira spp. in the aqueous humor of horses with naturally acquired recurrent uveitis

Leptospiral organisms have long been presumed to be associated with the presence of equine recurrent uveitis. This project was undertaken to determine the presence of Leptospira spp. in the aqueous humor of horses with uveitis to determine if there was an association with inflammation. Thirty horses were determined to have recurrent uveitis based on clinical evaluation or history. Sixteen horses were judged clinically and historically to be free of uveitis and were used as controls. Aqueous humor samples were cultured and evaluated by PCR for the presence of Leptospira DNA. Serum was collected and evaluated for the presence of antibodies against five serovars in a leptospirosis panel. Twenty-one of 30 horses with recurrent uveitis and one of 16 uveitis-free horses were positive by PCR for the presence of Leptospira DNA. Six of these 21 horses with uveitis were culture positive for leptospires from the aqueous humor. Serologic results did not correlate well with the presence of Leptospira DNA or organisms in the aqueous humor. Leptospira spp. are present in a high percentage of horses with naturally occurring recurrent uveitis.

Peripherally inserted central catheter program

The peripherally inserted central catheter (PICC) is a safe and less costly option to centrally inserted, tunneled, or implanted central vascular access devices. Support for PICC services and reports of results vary among organizations. A comprehensive PICC Program, guided by the Center for Advanced Nursing Practice's Evidence-Based Practice Model, was designed and implemented with successful outcomes. Key program components include administrative, education, clinical practice, and data monitoring to enhance best practice.

Placental delivery of arachidonic and docosahexaenoic acids: implications for the lipid nutrition of preterm infants

Arachidonic (AA) and docosahexaenoic (DHA) acids are major components of cell membranes and are of special importance to the brain and blood vessels. In utero, the placenta selectively and substantially extracts AA and DHA from the mother and enriches the fetal circulation. Studies indicate that there is little placental conversion of the parent essential fatty acids to AA and DHA. Similarly, analyses of desaturation and reductase activity have shown the placenta to be less functional than the maternal or fetal livers. There appears to be a correlation with placental size and plasma AA and DHA proportions in cord blood; therefore, placental development may be an important variable in determining nutrient transfer to the fetus and, hence, fetal growth itself. In preterm infants, both parenteral and enteral feeding methods are modeled on term breast milk. Consequently, there is a rapid decline of the plasma proportions of AA and DHA to one quarter or one third of the intrauterine amounts that would have been delivered by the placenta. Simultaneously, the proportion of linoleic acid, the precursor for AA, rises in the plasma phosphoglycerides 3-fold. An inadequate supply of AA and DHA during the period of high demand from rapid vascular and brain growth could lead to fragility, leakage, and membrane breakdown. Such breakdown would predictably be followed by peroxidation of free AA, vasoconstriction, inflammation, and ischemia with its biological sequelae. In the brain, cell death would be an extreme consequence.

Inter-ethnic differences in youth tobacco language and cigarette brand preferences

OBJECTIVE

To describe and understand variations in cigarette brand preferences between adolescents from varying ethnic and gender groups around the US.

DESIGN

A qualitative study where adolescents, both smokers and nonsmokers, were interviewed individually in depth.

SETTING

Schools and recreation centers in four sites: urban Maryland (Baltimore), urban Texas (Houston), rural Alabama and rural New Mexico.

PARTICIPANTS

121 adolescent volunteers 13-19 years of age, representing African American, white, American Indian and Hispanic ethnic groups, from both genders.

RESULTS

Considerable geographic and ethnic variation exists in terminology used by youth to refer to cigarettes and to their use. Clear patterns in brand preference by ethnic group were found that follow patterns of targeted marketing by ethnicity. White teens preferred Marlboro brand cigarettes, while African-American teens who smoke preferred Newports. Hispanic and American Indian teens were more likely to smoke Marlboro or Camel cigarettes. Hispanic teens were most likely to mention low price as a reason for choosing a particular brand or to state that the brand does not matter. Tobacco advertisements targeting ethnic groups and the use of promotional items to encourage teen smoking were also recognized as factors influencing brand preferences.

CONCLUSIONS

These findings have implications for the design of intervention programs aimed at curbing teen smoking. When working with teens who already smoke, using youth language to target messages at perceived characteristics of commonly used brands may be more effective and meaningful than talking about cigarette use in general. Another implication of this work is to shed light on what impact an advertising ban would have on teen brand preferences, brand loyalty, and prevalence of smoking.

Respiratory chain complex I deficiency: an underdiagnosed energy generation disorder

OBJECTIVE

To define the spectrum of clinical and biochemical features in 51 children with isolated complex I deficiency.

BACKGROUND

Mitochondrial respiratory chain defects are one of the most commonly diagnosed inborn errors of metabolism. Until recently there have been technical problems with the diagnosis of respiratory chain complex I defects, and there is a lack of information about this underreported cause of respiratory chain dysfunction.

METHODS

A retrospective review of clinical features and laboratory findings was undertaken in all diagnosed patients who had samples referred over a 22-year period.

RESULTS

Presentations were heterogeneous, ranging from severe multisystem disease with neonatal death to isolated myopathy. Classic indicators of respiratory chain disease were not present in 16 of 42 patients in whom blood lactate levels were normal on at least one occasion, and in 23 of 37 patients in whom muscle morphology was normal or nonspecific. Ragged red fibers were present in only five patients. Tissue specificity was observed in 19 of 41 patients in whom multiple tissues were examined, thus the diagnosis may be missed if the affected tissue is not analyzed. Nine patients had only skin fibroblasts available, the diagnosis being based on enzyme assay and functional tests. Modes of inheritance include autosomal recessive (suggested in five consanguineous families), maternal (mitochondrial DNA point mutations in eight patients), and possibly X-linked (slight male predominance of 30:21). Recurrence risk was estimated as 20 to 25%.

CONCLUSION

Heterogeneous clinical features, tissue specificity, and absence of lactic acidosis or abnormal mitochondrial morphology in many patients have resulted in underdiagnosis of respiratory chain complex I deficiency.

Recruiting adolescents into qualitative tobacco research studies: experiences and lessons learned

An increasing barrier to the development and implementation of effective youth smoking prevention and cessation programs involves recruiting adolescents into research studies. Even for non-intervention studies, issues of consent, confidentiality, and motivation to participate are important considerations. In 1996, 11 Prevention Research Center sites across the country conducted qualitative research using focus groups to explore ethnic differences in smoking among adolescents. The diversity in strategies used to interest, motivate, and retain potential focus group subjects provided a rich data set for information about effective strategies and challenges to recruitment. This article presents an overview of recruitment methods used in a multi-site qualitative study on adolescent tobacco use, reports on successful and less successful strategies, and provides recommendations for future recruitment.

Dietary magnesium supplementation attenuates ethanol-induced myocardial dysfunction

Hypomagnesemia is positively correlated with a number of cardiovascular abnormalities and recent evidence suggests that magnesium supplementation prevents ethanol-induced development of hypertension. The purpose of our study was to assess whether dietary magnesium supplementation effectively reverses or attenuates chronic ethanol-induced cardiac dysfunction, both at the tissue and the cellular level. Therefore, the influence of dietary magnesium supplementation during chronic ethanol ingestion on the mechanical properties of cardiac muscle was studied using isolated papillary muscles and ventricular myocytes from rat heart. In addition, the acute effects of ethanol on cardiac muscle from animals chronically exposed to ethanol in the absence and presence of dietary magnesium supplementation were also examined. Chronic ethanol exposure caused significant cardiac, hepatic, and renal enlargement, increased systolic blood pressure, and produced hypomagnesemia. After chronic ethanol exposure, the baseline force generating capacity of papillary muscles was markedly depressed and was associated with a significant slowing in the maximum velocities of contraction and relaxation. By contrast, in isolated myocytes, long-term ethanol exposure increased the extent of cell shortening associated with a significant reduction in the duration of relengthening and an increase in both the maximum velocities of shortening and relengthening. Dietary magnesium supplementation among animals chronically ingesting ethanol effectively normalized heart size, systolic blood pressure, and reduced plasma ethanol concentration. Magnesium supplementation also attenuated chronic ethanol-induced depression of contractile force and increased the extent of cell shortening. As expected, acute ethanol exposure caused a dose-dependent inhibition of both isometric force and isotonic shortening associated with a decrease in the intracellular calcium transient. However, the extent of the acute ethanol-induced reduction in isometric force and isotonic shortening was always slightly greater among preparations from animals chronically exposed to ethanol. Dietary magnesium supplementation normalized the acute inhibitory action of ethanol on isometric force, isotonic shortening, and the intracellular calcium transient. Our results suggest that dietary magnesium supplementation may attenuate chronic ethanol-induced alterations in baseline myocardial mechanical function and normalize the cardiac response to acute ethanol exposure.

Sleep Deprivation in social phobia and generalized anxiety disorder

BACKGROUND

Sleep deprivation has been shown to improve depressive symptoms in some patients with major depressive disorder, but it has not been tested in patients with generalized anxiety disorder (GAD) or social phobia (SP).

METHODS

To determine if sleep deprivation altered anxiety or depressive symptoms in patients with GAD (n = 7) or SP (n = 8), we sleep deprived patients and normal controls (n = 18) for one night.

RESULTS

On one measure of anxiety, GAD patients improved compared with controls, but there were otherwise no significant change differences between controls and SP or GAD patients.

CONCLUSIONS

The lack of benefit is consistent with previous findings that sleep deprivation provides no benefit to patients with other anxiety disorders. Sleep deprivation may be a biological intervention that distinguishes anxiety from affective disorders.

Socioeconomic deprivation and health in Glasgow and the west of Scotland--a study of cancer incidence among male residents of hostels for the single homeless

STUDY OBJECTIVE

To determine the incidence of cancer among homeless men in Glasgow.

DESIGN

Descriptive study of cancer incidence in a defined, though individually unidentifiable, population cohort.

SETTING

Glasgow and the West of Scotland Region.

PARTICIPANTS

Male residents of 10 hostels for the single homeless in Glasgow, open for all or part of the period 1975-93. Estimated total man-years of risk 21,820.

MAIN RESULTS

After adjusting for age and socioeconomic deprivation, the proportional incidence ratio (PIR) of tumours of the oral cavity and pharynx in hostel residents was over twice what would be expected in the male population as a whole (PIR 2.37, 95% CI 1.41, 4.00). Cancers of the oesophagus and larynx were also overrepresented (PIR 1.63 and 1.74 respectively). Estimated age standardised incidence ratios were greater than would be expected for the most socioeconomically deprived areas of the west of Scotland for tumours of the oral cavity and pharynx, larynx, oesophagus, and lung (2.39, 1.87, 1.61, and 1.23 respectively).

CONCLUSIONS

The incidence of many cancers is known to be higher in lower socioeconomic groups. Within the lowest deprivation category, there is evidence from this study for a further excess risk among homeless men for cancers of the oral cavity and pharynx, oesophagus, larynx, and lung. Improvements in general health care are urgently needed for this particularly vulnerable section of the population.

Dialogue. Resource allocation: to those in the greatest need or those who will benefit most?

The behavioral healthcare community seeks universal coverage for mental health and addiction treatment services at parity with coverage for other medical conditions. To achieve this goal, our field must accept and work within realistic financial limits. The time has come to establish a framework for "rational rationing" of behavioral healthcare resources. What are the priorities? How should resources be equitably shared? Should we sacrifice people with mild and moderate disabilities and illness in order to spend most of our dollars on people who are severely impaired? Our first writer, Dr. Daniels, warns us that there are no moral tenets upon which we can easily or comfortably hang our hats, as he shares the current perspective of medical bio-ethics. Dr. Sabin is a practicing psychiatrist at Harvard Pilgrim Health Care. He highlights the Oregon health Plan as one example of political fortitude and wisdom in resolving healthcare resource allocation challenges. Mac Crawford, chairman of the board and chief operating officer of Magellan Health Services, is in one of the most influential positions in private sector integrated behavioral services delivery. He stresses the importance of managed care and clinical process standardization as fundamental requirements for the rational allocation of resources. One additional note: The lack of a consumer voice in this Dialogue is an unfortunate consequence of the mismatch between submissions received and our publication deadlines. It was our intention to present the perspective of a prominent individual from the growing field of consumer and family advocacy. We apologize for the lack of this perspective, which may have extended this discussion to the practical implications of this abstract question of resource allocation.

Characterization of the detergent insolubility of the T cell receptor for antigen

Aggregation of cell surface receptors plays an important role in signal transduction in many receptor systems. In the T cell receptor (TCR), as in many other cell surface receptors, this aggregation results in insolubility in certain nonionic detergents. We have characterized this insolubility for TCR, and we show it is not preexisting in HPB-ALL cells but increases with increasing TCR aggregation. It is not likely to be due to a direct interaction with cellular cytoskeletal elements, as it is not affected by inhibitors of actin or tubulin polymerization. It may be due to interaction with detergent-resistant membrane domains that have been found in various cell types and contain tyrosine kinases, the earliest known participants in TCR signal transduction. This aggregation-dependent insolubility occurs as rapidly as the anti-TCR antibody binds, so the kinetics are consistent with an involvement in signal transduction. It is not, however, dependent on signal transduction, as inhibitors of tyrosine kinases do not inhibit the insolubility. Insolubility is also enhanced by preaggregation of CD4, an important T cell surface molecule which also associates with the tyrosine kinase p56lck.

Role of adenosine in the ethanol-induced potentiation of the effects of general anesthetics in rats

Acetate, derived from ethanol metabolism in the liver, is released into the circulation and utilized in many tissues including the brain. The subsequent metabolism of acetate results in the production of adenosine that has a number of effects in the central nervous system. The purpose of the present studies, therefore, was to investigate the contribution of metabolically generated adenosine to the ethanol-induced potentiation of the inhalational agents isoflurane and sevoflurane. Changes in the anesthetic requirement for isoflurane and sevoflurane were determined in rats using the tail-clamp procedure. Both ethanol and sodium acetate reduced anesthetic requirement for isoflurane and sevoflurane in a dose-dependent fashion. The effect of acetate on anesthetic requirement was completely blocked by the administration of the adenosine receptor blocker, 8-phenyltheophylline. The ethanol-induced reduction in anesthetic requirement, however, was only partially blocked by 8-phenyltheophylline. Direct intracerebroventricular (i.c.v.) administration of the water-soluble adenosine receptor blocker, 8-sulfophenyltheophylline, also completely blocked the effect of acetate and partially blocked the effect of ethanol. This i.c.v. administration demonstrates that the actions of ethanol and acetate on anesthetic requirement are a central nervous system effect. The i.c.v. administration of the adenosine A1 receptor subtype agonist, R-phenylisopropyl adenosine, potentiated the anesthetic effects of isoflurane and suggests that the A receptor mediates the observed potentiation of anesthetic effect. This is further supported by the concomitant administration of 5-N-ethylcarboxamido adenosine, a non-selective adenosine agonist, with the selective A1 antagonist, 8-cyclopentyltheophylline, showing A1 receptor potentiation of anesthetic requirements. The studies show that (1) acetate potentiates the anesthetic effects of the inhalational anesthetics, sevoflurane and isoflurane; (2) acetate contributes in part to the effect of ethanol on anesthetic potency through metabolically generated adenosine; (3) these effects are likely mediated via adenosine A1 receptor subtypes.