Characteristics of patients with a regular source of care

This study was designed to describe patient characteristics associated with having a regular source of care among all patients who received care from large urban clinics in Manitoba over a three-year period (N = 298,222). Using administrative data, patients were classified as having a regular source of care if they made 75% or more of their total ambulatory visits to the same clinic. Overall, 44.2% of patients had a regular source of care. A logistic regression showed that children and adults aged 45 and older were more likely to have a regular source of care than patients aged 18-44. Moreover, patients with a regular source of care tended to live in more affluent neighbourhoods and were healthier than individuals with no regular source of care. Systemic changes might be needed to enhance continuity of care (e.g., mechanisms to enhance access) among vulnerable segments of the population like the poor.

Experiences at menopause of women in a non-English-speaking community: a qualitative study

CONTEXT

It is important that clinicians appreciate the link between physiological disturbances and cultural meanings. The community surrounding the Baker Medical Research Institute in Melbourne, Australia includes a substantial number of women from a Greek-speaking background who attend the Menopause Clinic.

OBJECTIVE

To demonstrate how qualitative methodologies can assist with the development of clinical services by employing them to elucidate the role of cultural variables in the ways in which Greek women view menopause, aging, illness and medicine.

DESIGN

This was a qualitative study employing in-depth interviews on five separate occasions over 2 years, analyzed with thematic and ethnographic content analysis.

PATIENTS

Subjects were 40 Greek-speaking women attending the Clinic, aged 45-60 years.

RESULTS

There is an intricate association between experiences of the menopause and family relationships, problems raised by immigration and the cultural dislocation caused by it, beliefs and theories of the body, religion, and traditional approaches to healing and medicine. Many women had experienced unfavorable or unsatisfactory encounters with medicine in the past, reflecting lack of understanding of the women's experiences and failures of communication about clinical assessments and recommended treatments. Traditional therapies were often used without advising doctors.

CONCLUSIONS

The study emphasizes the potential utility of qualitative research methods for improving clinical practice by elaborating the specific requirements of particular groups, and thereby allowing doctors to deliver services that are more acceptable to patients from both a cultural and an ethical point of view, and also more effective. The process established for the evolution of our clinic may serve as a model for other clinics seeking to direct themselves to the needs of particular social groups or communities.

Catheter angiography and angioplasty in patients with scleroderma

The objectives of this study were (i) to identify patterns of angiographic disease in scleroderma patients with and without other vascular risk factors and (ii) to define patients with scleroderma in whom angiography and angioplasty is useful. The records of 26 patients with scleroderma who underwent angiography and angioplasty over an 8-year period were reviewed. Angiographic disease patterns were assessed using a modified Brewster classification. Angiography of the upper limb demonstrated distal disease alone in 86% of patients, both with and without other vascular risk factors such as smoking. In the lower limb there was a highly significant association between the presence of other vascular risk factors and macrovascular disease potentially amenable to angioplasty, and conversely between the absence of other vascular risk factors and distal disease in the lower limb. Good early but poor late clinical results were achieved in three of five patients who underwent angioplasty. Angiography of the upper limb is likely to demonstrate distal disease alone, and angiography and angioplasty of the lower limb may be useful only if other vascular risk factors are present.

Assessing socioeconomic effects on different sized populations: to weight or not to weight?

OBJECTIVE

Researchers in health care often use ecological data from population aggregates of different sizes. This paper deals with a fundamental methodological issue relating to the use of such data. This study investigates the question of whether, in doing analyses involving different areas, the estimating equations should be weighted by the populations of those areas. It is argued that the correct answer to that question turns on some deep epistemological issues that have been little considered in the public health literature.

DESIGN

To illustrate the issue, an example is presented that estimates entitlements to primary physician visits in Manitoba, Canada based on age/gender and socioeconomic status using both population weighted and unweighted regression analyses.

SETTING AND SUBJECTS

The entire population of the province furnish the data. Primary care visits to physicians based on administrative data, demographics and a measure of socioeconomic status (SERI), based on census data, constitute the measures.

RESULTS

Significant differences between weighted and unweighted analyses are shown to emerge, with the weighted analyses biasing entitlements towards the more populous and advantaged population.

CONCLUSIONS

The authors endorse the position that, in certain problems, data analyses involving population aggregates unweighted by population size are more appropriate and normatively justifiable than are analyses weighted by population. In particular, when the aggregated units make sense, theoretically, as units, it is more appropriate to carry out the analyses without weighting by the size of the units. Unweighted analyses yield more valid estimations.

Women in hospital medicine: career choices and opportunities

A significant number of women now enter hospital medicine. However, many do not make the expected progression within the medical specialties. The Royal College of Physicians set up a working party to examine and collect evidence on the career choices and progression of women in the hospital medical specialties under its remit and published a report of this evidence. This article outlines the findings of the report and the implications for hospital medicine.

Cerumen composition by flash pyrolysis-gas chromatography/mass spectrometry

OBJECTIVE

To assess the chemical composition of cerumen by flash pyrolysis-gas chromatography/mass spectrometry.

STUDY DESIGN

Collected earwax specimens were fractionated into residue and supernatant by means of deoxycholate. This natural bile acid produces significantly better disintegration of earwax in vitro than do presently available ceruminolytic preparations, and also has demonstrated excellent clinical results in vivo to date.

PATIENTS

The sample for analysis was obtained from a patient with clinical earwax impaction.

RESULTS

The supernatant is composed of simple aromatic hydrocarbons, C5-C17 straight-chain hydrocarbons, a complex mixture of compounds tentatively identified as diterpenoids, and steroids, in particular cholesterol. The residue, on the other hand, produced simple aromatic compounds (including benzenes, phenols, and benzonitriles), C5-C25 straight-chain hydrocarbons, greater relative quantities of nitrogen compounds and phenol, and lesser importance of the (tentatively identified) diterpenoids.

CONCLUSIONS

Through the use of the detergent deoxycholate, squalene and a tentatively identified diterpenoid were revealed to be present in a free, unbound state, whereas some steroids and hydrocarbons appeared to be bound to a macromolecular structure by nitrogen linkages or other bonds. Additionally, this study reintroduces detergents as a viable method of earwax removal, specifically the bile acids.

Effect of systemic sclerosis on left ventricular long-axis motion and left ventricular mass assessed by magnetic resonance

The aim of this study was to assess the effect of scleroderma on left ventricular mass and subendocardial function using cardiovascular magnetic resonance (CMR) to determine parameters reflecting early dysfunction from fibrosis. Fifteen patients with a history of scleroderma had left ventricular mass measured with standard techniques and regional subendocardial contractile function assessed using myocardial velocity mapping in the basal short-axis plane with long-axis sensitized velocity mapping. Peak myocardial velocities in systole and diastole were measured to reflect systolic and diastolic function. The variance in the regional myocardial velocity, was determined as a parameter of function heterogeneity around the ventricle. The results were compared with 19 healthy volunteers without a history of cardiovascular disease. In 10 patients, pulmonary transfer factor was measured using a single-breath helium dilution technique. The duration of scleroderma correlated with left ventricular mass (r = 0.7, p < 0.05), the coefficient of variation of velocity (r = 0.63, p < 0.05), and inversely with the mean left ventricular diastolic long-axis velocity (r = -0.63, p < 0.05). There was also a correlation between left ventricular diastolic long-axis velocity and the pulmonary transfer factor (r = 0. 7, p < 0.05). Trends suggested differences between control subjects and scleroderma patients for mean systolic (64 vs. 49 mm/sec, p = 0.09) and diastolic (90 vs. 72 mm/sec, p = 0.07) velocities, as well as velocity variance (26 vs. 33, p = 0.09). In conclusion, there is a relationship between duration of scleroderma and both left ventricular mass and diastolic function, which may result from increased myocardial fibrosis. Trends suggest absolute differences in functional values with control subjects that reflect impaired diastolic and systolic function, with greater regional heterogeneity that is consistent with nonuniform collagen deposition, but a larger sample size is required to confirm this. CMR should be explored further as a technique for monitoring myocardial involvement in scleroderma noninvasively.

What is the potential for formal patient registration in Canadian primary care? The scale of 'informal registration' in Manitoba

OBJECTIVES

Registration of patients with a physician is increasingly being considered across Canada as part of a reform of the primary health care system. This study aims to determine how much 'informal registration' currently exists; that is, to identify the number/proportion of patients who, given existing utilization patterns, already receive the majority of their care from one practice, in order to assess the potential for formal registration.

METHODS

Administrative data were used to classify patients (n = 528,905) as being informally registered with a clinic if they received the majority of their care (75% or more of their total ambulatory visits) from the same practice over a three-year period (1994-1996). The proportion and number of informally registered patients were examined.

RESULTS

Substantial variability emerged across practices in the proportion of informally registered patients (15-68%) and the number of informally registered patients per physician (544-1378 patients per full-time equivalent physician). Informal registration was higher among rural practices (60%) than among urban practices (38%).

CONCLUSIONS

While formal registration of patients with physicians is increasingly being considered in Canada as a means to improve the primary care system, the potential disruption to both patients and physicians in moving towards registration should not be underestimated. The relatively low levels of existing informal registration suggest a need to enhance access by, for example, providing after-hours services.

Planning and executing simple movements: contributions of relative-time and overall-duration specification

In 3 experiments, the authors used a precuing protocol to examine the nature and cost of programming and the subsequent reprogramming of a movement's relative time and overall duration. Initial programming followed a fixed-order specification; knowledge of the necessary relative time was required before information regarding overall duration could be used in a manner that expedited response planning. In the case of reprogramming, however, when a modification had to be made in either the relative time or overall duration of the anticipated and already-prepared response, performers chose to completely reprogram the entire response. Complete reprogramming occurred even when the performer had correctly prepared the higher order relative-time component and only had to modify the overall duration of the movement. The data indicate that organizing movement timing before movement initiation is accomplished in a fundamentally different manner depending on whether the movement is being initially compiled or modified.

Serum TIMP-1, TIMP-2, and MMP-1 in patients with systemic sclerosis, primary Raynaud's phenomenon, and in normal controls

BACKGROUND

Excess tissue matrix accumulates in systemic sclerosis (SSc), accounting for both visceral and dermal fibrosis. It is suggested that decreased serum levels of matrix metalloproteinases (MMPs) or increased levels of tissue inhibitors of matrix metalloproteinases (TIMPs) may account for this matrix accumulation.

OBJECTIVE

To measure serum levels of tissue inhibitors of metalloproteinases, TIMP-1, TIMP-2, and collagenase-1 (MMP-1), in patients with diffuse cutaneous systemic sclerosis (dcSSc), limited cutaneous systemic sclerosis (lcSSc), primary Raynaud's phenomenon (RP), and in normal controls.

METHODS

Serum samples from patients with dcSSc (n=83), lcSSc (n=87), RP (n=80), and normal controls (n=98) were analysed using enzyme linked immunosorbent assays (ELISAs) for total TIMP-1, TIMP-2, and MMP-1. Results from each assay were analysed by the Kruskal-Wallis test. Dunn's multiple comparison post-test was then applied between groups.

RESULTS

TIMP-1 levels were significantly raised in dcSSc and lcSSc groups compared with the RP group and normal controls (p<0.01 to p<0.001). In the dcSSc group, TIMP-1 levels were significantly higher in early disease (<2 years) than in late stage disease (>4 years) (p<0.05). This was not found for the lcSSc group. Serum TIMP-2 and MMP-1 levels in dcSSc and lcSSc did not differ significantly from those in normal controls. Increased levels of TIMPs were not convincingly associated with organ disease. No assay result correlated with autoantibody status (anti-topoisomerase 1 (anti-Scl-70), anticentromere antibody, or anti-RNA polymerase). No significant differences in serum TIMP-1, TIMP-2, or MMP-1 levels were shown in the RP group compared with normal controls.

CONCLUSIONS

Raised TIMP-1 levels in the SSc groups support the hypothesis that matrix accumulation occurs in SSc at least in part owing to decreased degradation. Moreover, the variation in TIMP-1 levels between the early and late disease stages of dcSSc seems to reflect the early progressive course of dermal fibrosis seen clinically. The expected reduction in serum MMP-1 levels in the SSc groups was not found. This suggests that tissue matrix accumulation is due to increased inhibitors rather than to decreased MMPs.

Phase I/II trial of autologous stem cell transplantation in systemic sclerosis: procedure related mortality and impact on skin disease

BACKGROUND

Systemic sclerosis (SSc, scleroderma) in either its diffuse or limited skin forms has a high mortality when vital organs are affected. No treatment has been shown to influence the outcome or significantly affect the skin score, though many forms of immunosuppression have been tried. Recent developments in haemopoietic stem cell transplantation (HSCT) have allowed the application of profound immunosuppression followed by HSCT, or rescue, to autoimmune diseases such as SSc.

METHODS

Results for 41 patients included in continuing multicentre open phase I/II studies using HSCT in the treatment of poor prognosis SSc are reported. Thirty seven patients had a predominantly diffuse skin form of the disease and four the limited form, with some clinical overlap. Median age was 41 years with a 5:1 female to male ratio. The skin score was >50% of maximum in 20/33 (61%) patients, with some lung disease attributable to SSc in 28/37 (76%), the forced vital capacity being <70% of the predicted value in 18/36 (50%). Pulmonary hypertension was described in 7/37 (19%) patients and renal disease in 5/37 (14%). The Scl-70 antibody was positive in 18/32 (56%) and the anticentromere antibody in 10% of evaluable patients. Peripheral blood stem cell mobilisation was performed with cyclophosphamide or granulocyte colony stimulating factor, alone or in combination. Thirty eight patients had ex vivo CD34 stem cell selection, with additional T cell depletion in seven. Seven conditioning regimens were used, but six of these used haemoimmunoablative doses of cyclophosphamide +/- anti-thymocyte globulin +/- total body irradiation. The median duration of follow up was 12 months (3-55).

RESULTS

An improvement in skin score of >25% after transplantation occurred in 20/29 (69%) evaluable patients, and deterioration in 2/29 (7%). Lung function did not change significantly after transplantation. One of five renal cases deteriorated but with no new occurrences of renal disease after HSCT, and the pulmonary hypertension did not progress in the evaluable cases. Disease progression was seen in 7/37 (19%) patients after HSCT with a median period of 67 (range 49-255) days. Eleven (27%) patients had died at census and seven (17%) deaths were considered to be related to the procedure (direct organ toxicity in four, haemorrhage in two, and infection/neutropenic fever in one). The cumulative probability of survival at one year was 73% (95% CI 58 to 88) by Kaplan-Meier analysis.

CONCLUSION

Despite a higher procedure related mortality rate from HSCT in SSc compared with patients with breast cancer and non-Hodgkin's lymphoma, the marked impact on skin score, a surrogate marker of mortality, the trend towards stabilisation of lung involvement, and lack of other treatment alternatives justify further carefully designed studies. If future trials incorporate inclusion and exclusion criteria based on this preliminary experience, the predicted procedure related mortality should be around 10%.

Consistent and variable practice conditions: effects on relative and absolute timing

The authors conducted the present experiments to resolve the discrepancy between studies in which relative-timing learning has been found to be enhanced by consistent practice conditions and contextual interference experiments in which relative-timing learning has been found to be enhanced more by random practice than by blocked practice. There were 40 participants in Experiment 1 and 48 in Experiment 2. The results of Experiment 1 extended previous findings: The learning of the relative-timing pattern was systematically enhanced by the degree to which the practice conditions promoted movement consistency (constant > blocked > serial > random). Experiment 2 provided evidence that the discrepancy between the relative-timing effects in the 2 groups of studies was a product of the way in which relative-timing goals and feedback were presented. When the feedback was presented as segment times, random practice resulted in generally more stable relative-timing patterns during acquisition than blocked practice did. Thus, in both experiments, the learning of the relative-timing pattern was enhanced by more stable relative-timing conditions during acquisition. Absolute-timing learning, as indexed by the transfer tests, was enhanced by serial or random practice as compared with constant or blocked practice, and was relatively unaffected by feedback conditions directed at the relative-timing pattern. In terms of motor programming theory, those findings are taken as additional evidence for the disassociation of memories supporting generalized motor program (GMP) performance, as indexed by relative timing, and parameter performance, as indexed by absolute timing.

The commonality and synchronicity of mental health nurses and palliative care nurses: closer than you think? Part two

This is the second of a two-part paper which explores the areas of commonality and synchronicity between palliative care (PC) nurses and mental health nurses. The authors argue that this commonality is best articulated under the headings: defining the needs of the client group, the role of the nurse in non-physical care, the nurse--client relationship, and the locus of control. They also argue that the differences between these groups of nurses are best articulated under the headings: facilitation/confrontation and the focus on physical care. Part one focused on the first three areas of commonality, whereas this paper focuses on the fourth commonality, the locus of control. It also focuses on key differences and the implications of such similarity. The paper highlights the practice, education and research implications of this alleged commonality. It suggests, given the evidence that clients perceive the therapeutic relationship as the vital and unique aspect of PC nursing, that those working within palliative care need to question whether or not RGN registration is an essential requirement, or whether those with other skills, such as psychiatric/mental health (P/MH) nurses, should be considered for such roles. It highlights the need for the provision of post-basic counselling courses and the potential value for PC nurses of receiving clinical supervision from P/MH nurses or mental health liaison nurses. Lastly, it posits that the research issues arising out of this alleged commonality centre on the potential impact such transitions in care delivery may have on the care delivered, on the nurses themselves and on the clients.

The commonality and synchronicity of mental health nurses and palliative care nurses: closer than you think? Part one

The role of the palliative care nurse emphasizes the need for holistic care, and as this role has developed it has become evident that palliative care nurses require skills which, arguably, not all registered general nurses possess; particularly, skills pertaining to the psychological, social and spiritual domains of the person. In order to identify the skills that such nurses may require, there may be merit in considering other specialities of nursing which pay particular attention to the psychological, social and spiritual domains of the person. Consequently, this two-part paper explores the areas of commonality and synchronicity between palliative care nurses and mental health nurses. The authors argue that this commonality is best articulated under the headings: defining the needs of the client group, the role of the nurse in non-physical care, the nurse--client relationship, and the locus of control. They also argue that the differences between these groups of nurses are best articulated under the headings: facilitation/confrontation, and the focus on physical care. Part one of this paper therefore focuses on the first three areas of alleged commonality, with part two focusing on the fourth commonality, the key differences and the implications of such similarity. Given these areas of similarity the authors argue there is a case for reconsidering if the RGN qualification is an essential requirement for working within palliative care or if those with other skills -- skills based on 'being with' rather than 'doing for' -- such as RMNs, should be thought of for such roles.

Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population

BACKGROUND

High rates of unprotected intercourse and illegal drug use have been reported among homeless adolescents. As a transient population with the potential to act as disease vectors from one location to another, incidence and prevalence of sexually transmitted infections in this population are of particular concern.

GOAL

To assess a homeless adolescent population for incidence and prevalence of Chlamydia trachomatis, herpes simplex virus type 2, hepatitis B virus, hepatitis C virus, HIV, and psychosocial correlates of the acquisition of sexually transmitted infections.

STUDY DESIGN

Longitudinal with assessments at baseline, 3 months, and 6 months (n = 536; 319 males and 217 females).

RESULTS

Baseline prevalence of C trachomatis was 4.17% for males and 6.30% for females. Prevalence of herpes simplex virus type 2 was 5.73% for males and 12.50% for females. Hepatitis B virus and hepatitis C virus prevalences were 3.60% and 5.0%, respectively. HIV seroprevalence was 0.3%. The incidence of sexually transmitted infections was significantly higher among females than among males (16.7% versus 9.8%) and was associated with inconsistent condom use and, for females, number of partners and sex with older partners. Incident hepatitis B virus and hepatitis C virus infection rates were 3.44% and 6.61%, respectively; both were associated with injection drug use.

CONCLUSIONS

Among females, the incidence of herpes simplex virus type 2 (> 25%) and C trachomatis (12%) was relatively high. Inconsistent condom use was the primary factor associated with a significantly greater risk of incident sexually transmitted infections. This was especially true for females with multiple partners. Homeless adolescents also are at high risk for hepatitis B virus and hepatitis C virus infection, primarily associated with self-reported injection drug use.

Caspase inhibitors improve survival in sepsis: a critical role of the lymphocyte

Sepsis induces lymphocyte apoptosis and prevention of lymphocyte death may improve the chances of surviving this disorder. We compared the efficacy of a selective caspase-3 inhibitor to a polycaspase inhibitor and to caspase-3-/- mice. Both inhibitors prevented lymphocyte apoptosis and improved survival. Caspase-3-/- mice shared a decreased, but not total, block of apoptosis. The polycaspase inhibitor caused a very substantial decrease in bacteremia. Caspase inhibitors did not benefit RAG-1-/- mice, which had a > tenfold increase in bacteremia compared to controls. Adoptive transfer of T cells that overexpressed the anti-apoptotic protein Bcl-2 increased survival. T cells stimulated with anti-CD3 and anti-CD28 produced increased interleukin 2 and interferon gamma by 6 h. Thus, caspase inhibitors enhance immunity by preventing lymphocyte apoptosis and lymphocytes act rapidly, within 24 h, to control infection.

Distribution of novel polymorphisms of the interleukin-8 and CXC receptor 1 and 2 genes in systemic sclerosis and cryptogenic fibrosing alveolitis

OBJECTIVE

To search for single-nucleotide polymorphisms in the interleukin-8 (IL-8) and IL-8 receptor CXCR-1 and CXCR-2 genes, and to compare their distribution among patients with systemic sclerosis (SSc) with fibrosing alveolitis (FASSc) or without fibrosing alveolitis (NFASSc), or patients with cryptogenic fibrosing alveolitis (CFA), and normal healthy subjects.

METHODS

Fifty control subjects were screened for potential polymorphisms by using polymerase chain reaction in association with sequence-specific primers incorporating mismatches at the 3' end. The novel polymorphisms were subsequently examined in British Caucasian subjects, including 194 healthy controls, 71 patients with CFA, and 128 patients with SSc who were further subdivided into 78 FASSc patients and 50 NFASSc patients.

RESULTS

Three novel biallelic polymorphisms were identified in the IL-8 gene (all in noncoding areas of the gene), 1 was found in the CXCR-1 gene (resulting in a conservative amino acid change), and 3 were observed in the CXCR-2 gene, of which the first resulted in a silent codon change and the others were in the 3' untranslated area of exon 3. Compared with controls, a significant increase in the frequency of the CXCR-2 +785 CC homozygote and of the CXCR-2 +1208 TT homozygote was found in the SSc patients (37% versus 22% [P = 0.01] and 33% versus 17% [P = 0.003], respectively). A subgroup analysis revealed this association to be significant both in the FASSc patients and in the NFASSc patients.

CONCLUSION

This report describes an association between SSc and 2 polymorphisms occurring close to each other in the CXCR-2 gene. This finding and its functional significance need to be confirmed and analyzed in future studies.

Scleromyxedema: response to high-dose intravenous immunoglobulin (hdIVIg)

We report 2 patients with scleromyxedema, both associated with IgG-lambda paraproteinemia, who were treated with high-dose intravenous immunoglobulin (hdIVIg) 2g/kg per month. The response to treatment was assessed using an objective skin scoring system initially established for patients with scleroderma. This system grades the overall severity of the induration and the reduction in mobility of the skin. Both patients initially had a dramatic response to treatment which was sustained in one patient. The first patient, a 30-year-old black man, showed a reduction in skin scores from 36/60 to 11/60 over a 3-month period, during which time he had 3 infusions of hdIVIg. After an unplanned 2-month break from treatment, severe neuromuscular complications developed. These improved initially with more frequent infusions of hdIVIg but oral corticosteroids were required to treat worsening myopathy. Unfortunately, the initial response to hdIVIg has not been sustained and his skin scores at 1 year returned to baseline. The second patient, a 60-year-old white man, showed a similarly dramatic reduction in skin scores from 36/60 to 15/60 over a 3-month period after having received only 2 infusions of hdIVIg. There has been sustained improvement after 10 months of therapy and the interval between hdIVIg infusions has been increased to 10 weeks without deterioration. HdIVIg may be an effective treatment for some patients with scleromyxedema, a rare condition with few effective treatments and a poor prognosis.

A two-stage, genome-wide screen for susceptibility loci in primary Raynaud's phenomenon

OBJECTIVE

To identify chromosomal regions containing genes involved in the susceptibility to primary Raynaud's phenomenon (RP).

METHODS

Six extended families with multiple individuals affected with primary RP (n = 37) were examined for linkage in a 2-stage, whole-genome screen, using a total of 298 microsatellite markers.

RESULTS

Multipoint, nonparametric linkage analysis identified 5 areas of possible linkage, with a nominal level of significance of P < or = 0.05. Analysis of a finer map of markers in these regions defined the regions of linkage as 21.4 cM on 6q13-6q23.3 (D6S261; P = 0.0004), 10.2 cM on 7p22-7p15 (D7S664; P = 0.014), 1.6 cM on 9p23-9p22 (D9S156; P = 0.0075), 5.1 cM on 17p13.1-17p12 (D17S1791; P = 0.036), and 11.8 cM on Xp11.4-Xp11.23 (DXS8054; P = 0.006). Three potential candidate genes map to these regions: the beta subunit of the muscle acetylcholine receptor and the serotonin 1B and 1E receptors.

CONCLUSION

These results provide evidence of the presence and location of genes that are involved in the genetic susceptibility to primary RP.

Distribution of novel polymorphisms of the interleukin-8 and CXC receptor 1 and 2 genes in systemic sclerosis and cryptogenic fibrosing alveolitis

OBJECTIVE

To search for single-nucleotide polymorphisms in the interleukin-8 (IL-8) and IL-8 receptor CXCR-1 and CXCR-2 genes, and to compare their distribution among patients with systemic sclerosis (SSc) with fibrosing alveolitis (FASSc) or without fibrosing alveolitis (NFASSc), or patients with cryptogenic fibrosing alveolitis (CFA), and normal healthy subjects.

METHODS

Fifty control subjects were screened for potential polymorphisms by using polymerase chain reaction in association with sequence-specific primers incorporating mismatches at the 3' end. The novel polymorphisms were subsequently examined in British Caucasian subjects, including 194 healthy controls, 71 patients with CFA, and 128 patients with SSc who were further subdivided into 78 FASSc patients and 50 NFASSc patients.

RESULTS

Three novel biallelic polymorphisms were identified in the IL-8 gene (all in noncoding areas of the gene), 1 was found in the CXCR-1 gene (resulting in a conservative amino acid change), and 3 were observed in the CXCR-2 gene, of which the first resulted in a silent codon change and the others were in the 3' untranslated area of exon 3. Compared with controls, a significant increase in the frequency of the CXCR-2 +785 CC homozygote and of the CXCR-2 +1208 TT homozygote was found in the SSc patients (37% versus 22% [P = 0.01] and 33% versus 17% [P = 0.003], respectively). A subgroup analysis revealed this association to be significant both in the FASSc patients and in the NFASSc patients.

CONCLUSION

This report describes an association between SSc and 2 polymorphisms occurring close to each other in the CXCR-2 gene. This finding and its functional significance need to be confirmed and analyzed in future studies.

Primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type in a patient with primary biliary cirrhosis

Primary lymphoma of the liver is rare. Recently, marginal zone B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) type have been described in the liver. Most of these cases occurred without known underlying liver disease, while others were seen in patients with chronic hepatitis. A case of primary hepatic MALT lymphoma in a patient with primary biliary cirrhosis was reported recently. Some authors have proposed that chronic persistent immunogenic stimulation causes development of acquired MALT and subsequently MALT lymphoma, based on the observation of MALT lymphoma in association with infectious agents, such as Helicobacter pylori and hepatitis C virus, and autoimmune diseases, such as Hashimoto thyroiditis and Sjögren syndrome. Primary biliary cirrhosis is a chronic, progressive, cholestatic liver disease characterized by destruction of intrahepatic small to medium-sized bile ducts; this disease is mediated by a cytotoxic T-cell reaction. The prolonged immune activation in primary biliary cirrhosis may play a role in the lymphomagenesis of hepatic MALT lymphoma. We describe another case of primary hepatic MALT lymphoma, which was found incidentally in a patient with end-stage primary biliary cirrhosis. This case further supports the role of immunogenic stimulation in the pathogenesis of this particular low-grade B-cell lymphoma.

Primary hepatic marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type in a patient with primary biliary cirrhosis

Primary lymphoma of the liver is rare. Recently, marginal zone B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) type have been described in the liver. Most of these cases occurred without known underlying liver disease, while others were seen in patients with chronic hepatitis. A case of primary hepatic MALT lymphoma in a patient with primary biliary cirrhosis was reported recently. Some authors have proposed that chronic persistent immunogenic stimulation causes development of acquired MALT and subsequently MALT lymphoma, based on the observation of MALT lymphoma in association with infectious agents, such as Helicobacter pylori and hepatitis C virus, and autoimmune diseases, such as Hashimoto thyroiditis and Sjögren syndrome. Primary biliary cirrhosis is a chronic, progressive, cholestatic liver disease characterized by destruction of intrahepatic small to medium-sized bile ducts; this disease is mediated by a cytotoxic T-cell reaction. The prolonged immune activation in primary biliary cirrhosis may play a role in the lymphomagenesis of hepatic MALT lymphoma. We describe another case of primary hepatic MALT lymphoma, which was found incidentally in a patient with end-stage primary biliary cirrhosis. This case further supports the role of immunogenic stimulation in the pathogenesis of this particular low-grade B-cell lymphoma.

Widening regional inequality in premature mortality rates in Manitoba

OBJECTIVE

To describe regional trends in premature mortality in Manitoba.

DESIGN

Comparison of all-cause and cause-specific mortality of persons less than age 75 in 11 Regional Health Authority populations over two time periods: 1985-89 and 1990-94.

RESULTS

The provincial premature mortality rate declined over the two time periods (4.00/1,000 to 3.72/1,000). Declines were also observed in 9 of 11 regional populations. Premature mortality increased, however, in the 2 regional populations with the highest mortality rates in the first observation period.

CONCLUSION

Declining premature mortality in low mortality populations and rising premature mortality in high mortality populations has resulted in a widening of regional mortality rates in Manitoba. Recent policy initiatives in many provinces, including the devolution of authority for the management and delivery of health services and the implementation of population need-based funding formulas to share health care resources among regional health authorities, if implemented, have the potential to partially mitigate the processes producing these widening regional health inequalities.

A randomised controlled trial of a community intervention to prevent adolescent tobacco use

OBJECTIVE

Experimental evaluation of comprehensive community wide programme to prevent adolescent tobacco use.

DESIGN

Eight pairs of small Oregon communities (population 1700 to 13 500) were randomly assigned to receive a school based prevention programme or the school based programme plus a community programme. Effects were assessed through five annual surveys (time 1-5) of seventh and ninth grade (ages 12-15 years) students.

INTERVENTION

The community programme included: (a) media advocacy, (b) youth anti-tobacco activities, (c) family communications about tobacco use, and (d) reduction of youth access to tobacco.

MAIN OUTCOME MEASURE

The prevalence of self reported smoking and smokeless tobacco use in the week before assessment.

RESULTS

The community programme had significant effects on the prevalence of weekly cigarette use at times 2 and 5 and the effect approached significance at time 4. An effect on the slope of prevalence across time points was evident only when time 2 data points were eliminated from the analysis. The intervention affected the prevalence of smokeless tobacco among grade 9 boys at time 2. There were also significant effects on the slope of alcohol use among ninth graders and the quadratic slope of marijuana for all students.

CONCLUSION

The results suggest that comprehensive community wide interventions can improve on the preventive effect of school based tobacco prevention programmes and that effective tobacco prevention may prevent other substance use.

The development of a health policy for the Army

This paper describes the development of the Army Health Policy (AHP), which is a key component of the Army Human Resources Strategy (AHRS). The work on the AHP provided an opportunity for a fundamental review of the delivery of health support to the Army. The AHP will provide the strategic framework by which the Army will ensure the health of its workforce and, where appropriate, their dependents. The methodology used for this work may be a useful model for the development of a health policy for occupational populations.

Autologous haematopoietic stem cell transplants for autoimmune disease--feasibility and transplant-related mortality. Autoimmune Disease and Lymphoma Working Parties of the European Group for Blood and Marrow Transplantation, the European League Against Rheumatism and the International Stem Cell Project for Autoimmune Disease

This ongoing multicentre prospective phase I/II trial enrolled 74 consecutive patients from 22 centres worldwide with severe autoimmune disease, 35 with rheumatological disorders, 31 with neurological, five with haematological and three with vasculitides. They were treated with autologous peripheral blood or bone marrow transplants according to predetermined criteria. Two patients died after mobilisation before transplant. Seventy-two patients were given 73 transplants, seven bone marrow, and 66 mobilised peripheral blood stem cell transplants. The graft was manipulated to remove T and/or B cells in 43 cases. All 73 transplants engrafted. Five patients died of transplant-related complications: two from bleeding, three from infections. Two patients died of progressive disease. The transplant-related mortality at 1 year of 9% (1-17%; 95% CI) is comparable to the transplant-related mortality of 6% (3-9%; 95% CI) in patients transplanted during the same period in Europe for non-Hodgkin's lymphoma in sensitive relapse (P = 0.39). Sixty patients are evaluable for response, 40 patients (65%) showed some improvement in their disease. Haematopoietic stem cell transplants are feasible for patients with severe refractory autoimmune disease. Transplant-related mortality is comparable to results in patients with non-Hodgkin's lymphoma in responsive relapse. Two-thirds of the patients show at least some response. These preliminary data are promising. Although associated with considerable risk, randomised trials comparing autologous stem cell transplants to conventional therapy are warranted.

Retrospective analysis of the adequacy of oral contrast material for computed tomography scans in trauma patients

BACKGROUND

This study examined the adequacy of oral contrast (OC) in adult trauma patients, the differences in the incidence of pathology and other patient characteristics related to OC adequacy, and the incidence of OC-associated emesis.

METHODS

The cases of 129 adult trauma patients were reviewed from January to December 1996 for utilization of OC, administration time, time to computed tomography (CT), and emesis within 4 hours. CT films were reviewed for adequacy of OC (AC = adequate contrast, IC = inadequate contrast) and pathology.

RESULTS

Data are presented as median and range, or percentage and 95% confidence interval (CI). Pathology was found in 24% (CI 17% to 31%) and was not associated with AC. OC administration to CT was 14 minutes (0 to 139). IC was present for 60% (CI 52% to 69%). Subjects with IC had higher injury severity scores. 10% (CI 5% to 15%) with OC had emesis.

CONCLUSION

OC is not necessary for diagnostic accuracy, and may contribute to patient morbidity or discomfort.

Neonatal Marfan syndrome: a case report

A case of neonatal Marfan syndrome is presented. The patient was noted to have cardiomegaly and tricuspid regurgitation on antenatal ultrasound scan. She was born with long, slender fingers and toes, an aged appearance and non-paralytic hypotonia. Echocardiogram revealed a dilated right atrium, right ventricle, dysplastic tricuspid valve and severe tricuspid regurgitation. She subsequently died of severe heart failure. Post-mortem examination showed the pathological features of lobar emphysema and cystic medial necrosis of the aorta. These features supported the diagnosis of neonatal Marfan syndrome. Nucleotide sequencing showed substitution of G by A at codon 1032 in exon 25 located in the long arm of chromosome 15. This resulted in the substitution of a cysteine by a tyrosine. A de novo mutation is suggested by the absence of affected family members.

An assessment of the potential for repatriating care from urban to rural Manitoba

OBJECTIVES

Following the closure of Manitoba hospital beds, the Manitoba government adopted a strategy of shifting hospital care from more expensive urban hospitals to less expensive rural facilities. With this project, Manitoba Centre for Health Policy and Evaluation (MCHPE) studied the implications of the stated policy of "repatriation."

RESEARCH DESIGN

The project first involved examining population-based patterns of hospital utilization to define hospital service areas for 10 large rural hospitals. Three different hospital service area definitions were developed for use in sensitivity testing. Rates of overall use of hospital services, indicators of need for health care, and patterns of use of urban facilities are compared for these hospital service areas. Using a large rural hospital as a benchmark, patterns of adult surgical, adult medical, pediatric, and obstetric care were examined for the hospital service areas. Number and percent of cases provided by the index hospital and by urban hospitals were compared, to assess the feasibility and the potential impact of redirection of care to the benchmark level.

CONCLUSIONS

Although in theory a significant percentage of care delivered to rural residents by Winnipeg hospitals might be redirected to rural institutions, the project raised issues of feasibility. Moreover, it identified that most of the redirected cases could be accommodated within existing capacity.

Using population-based data to enhance clinical practice guideline development

OBJECTIVES

Working with the College of Physicians and Surgeons of Manitoba, and using tonsillectomies as a basis of inquiry, MCHPE examined surgical rates and patterns of practice. This project had three major aims: to review whether current patterns of delivery provide optimal care; to enhance the development of clinical guidelines; and to inform and influence physician practice.

RESEARCH DESIGN

Both a population-based method of inquiry (which permits comparisons across population groups) and a provider-based approach (which offers insights into differences in the nature of care offered by different types of hospitals and physicians) were used.

MEASURES

Synergies between these two approaches offered useful insight into aspects of quality and efficiency of care.

RESULTS

Consistent with other jurisdictions, there was a high degree of variability across regions. However, there were also a number of surprising findings, including high rates of surgery in females, in older children, and among residents of rural areas. Data analysis raised a number of quality-of-care issues related to small caseload volumes, performance of procedures in very young children, and patterns of postoperative care in rural hospitals. The analyses provided impetus for addressing these issues in the guideline and suggested that the target audience for intervention should be rural physicians rather than urban specialists.

CONCLUSIONS

This project demonstrated that data analysis can provide a powerful adjunct to the development and implementation of clinical practice guidelines.

Managing health services: how the Population Health Information System (POPULIS) works for policymakers

OBJECTIVES

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for answering such questions as: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served? or do they have poor health outcomes despite being well served? Does high utilization represent overuse? or is it related to high need? More specifically, this system provides decision makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and countries, utilization review within a single hospital, and longitudinal research on health reform. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

The population's use of pharmaceuticals

OBJECTIVES

In this study, population-based analysis is used to study the extent to which characteristics such as age, sex, socioeconomic status, and region of residence are associated with different patterns of pharmaceutical use. It also includes an examination of whether pharmaceutical use is responsive to differential health needs across the population.

RESEARCH DESIGN

Indicators of access, intensity of use, and total expenditures are used to describe Manitobans' use of pharmaceutical agents, consistent with the POPULIS framework.

MEASURES

Several rate-based measures have been developed for this purpose: the number of residents who are pharmaceutical users; the number of prescriptions dispensed; the number of different drugs dispensed; the total number of defined daily doses (DDDs) dispensed; and expenditures for pharmaceuticals. The DDD measurement provides a cumulative assessment of total drug use (i.e., across multiple drug categories) and is a useful indicator of a population's total drug exposure.

RESULTS

Patterns of use of pharmaceuticals follow patterns similar to those patterns in earlier POPULIS studies on health care access, intensity, and expenditures. In areas where health is generally poorer, a greater number of prescriptions are dispensed. The highest use of pharmaceuticals also was found in the lower-income quintiles and among those at greatest socioeconomic risk, traditionally those with the poorest health status.

CONCLUSIONS

This kind of population-based pharmaceutical information can help monitor the effectiveness of policy initiatives, as well as serve to better manage pharmaceutical use within the health care system.

Liposome-mediated NGF gene transfection following neuronal injury: potential therapeutic applications

We have systematically investigated the therapeutic potential of cationic liposome-mediated neurotrophic gene transfer for treatment of CNS injury. Following determination of optimal transfection conditions, we examined the effects of dimethylaminoethane-carbamoyl-cholesterol (DC-Chol) liposome-mediated NGF cDNA transfection in injured and uninjured primary septo-hippocampal cell cultures and rat brains. In in vitro studies, we detected an increase of NGF mRNA in cultures 1 day after transfection. Subsequent ELISA and PC12 cell biological assays confirmed that cultured cells secreted soluble active NGF into the media from day 2 after gene transfection. Further experiments showed that such NGF gene transfection reduced the loss of chol- ine acetyltransferase (ChAT) activity in cultures following calcium-dependent depolarization injury. In in vivo studies, following intraventricular injections of NGF cDNA complexed with DC-Chol liposomes, ELISA detected nine- to 12-fold increases of NGF in rat CSF. Further studies showed that liposome/NGF cDNA complexes could attenuate the loss of cholinergic neuronal immunostaining in the rat septum after traumatic brain injury (TBI). Since deficits in cholinergic neurotransmission are a major consequence of TBI, our studies demonstrate for the first time that DC-Chol liposome-mediated NGF gene transfection may have therapeutic potential for treatment of brain injury.

Adding up provincial expenditures on health care for Manitobans: a POPULIS project. Population Health Information System

OBJECTIVES

Using the POPULIS framework, this project estimated health care expenditures across the entire population of Manitoba for inpatient and outpatient hospital utilization, physician visits, mental health inpatient, and nursing home utilization.

RESEARCH DESIGN

This estimated expenditure information was then used to compare per capita expenditures relative to premature mortality rates across the various areas of Manitoba.

RESULTS

Considerable variation in health care expenditures was found, with those areas having high premature mortality rates also having higher health care expenditures.

Secondary analysis of survey data: a research method with potential for occupational therapists

The secondary analysis of previously collected survey data can assist occupational therapists to focus research, make policy decisions and test theory. In this paper the authors outline the process of carrying out a secondary analysis using existing survey data. Steps include selecting the research question, and then locating, appraising, acquiring and analysing the data. To illustrate this process, the authors examined the relationships between accidents and mobility impairments among older adults using data previously collected in the National Population Health Survey. Finally, some further examples of occupational therapy research carried out using secondary analysis of survey data are considered.

Double-blind, randomised, placebo-controlled, dose-finding study of oral ibandronate in patients with metastatic bone disease

BACKGROUND

Bisphosphonates are an important component of the treatment of metastatic bone disease but more potent, oral formulations are required to improve the effectiveness and convenience of treatment. An oral formulation of the new bisphosphonate, ibandronate (BM 21.0955) has recently been developed.

PATIENTS AND METHODS

One hundred ten patients with bone metastases (77 breast, 16, prostate, 3 myeloma, 14 others) were recruited from a single institution to this double blind placebo-controlled evaluation of four oral dose levels (5, 10, 20 and 50 mg) of ibandronate. No changes in systemic anti-cancer treatment were allowed in the month before commencing treatment or during the study period. After an initial four-week tolerability phase, patients could continue on treatment for a further three months without unblinding; patients initially allocated to placebo received ibandronate 50 mg. The primary endpoint was urinary calcium excretion (UCCR). Bone resorption was also assessed by measurement of pyridinoline (Pyr), deoxypyridinoline (Dpd), and the N-terminal (NTX) and C-terminal (Crosslaps) portions of the collagen crosslinking molecules.

RESULTS

Two patients did not receive any trial medication thus, 108 patients were evaluable for safety. Ninety-two patients were evaluable for efficacy. A dose dependent reduction was observed in both UCCR and collagen crosslink excretion. At the 50 mg dose level, the percentage reductions from baseline in UCCR, Pyr, Dpd, Crosslaps and NTX were 71%, 28%, 39%, 80% and 74% respectively. One or more gastrointestinal (GI) adverse events occurring in the first month of treatment were reported by six (30%), seven (33%), nine (39%), nine (41%) and eleven (50%) patients at the placebo, 5, 10, 20 and 50 mg dose levels respectively. One patient (20 mg dose) developed radiographically confirmed oesophageal ulceration. GI tolerability may have been adversely affected by concomitant administration of non-steroidal anti-inflammatory agents. Nine (8%) patients stopped treatment within the first month due to GI intolerability but these patients were evenly distributed across the five treatment groups. There was no difference in non-GI adverse events between groups.

CONCLUSIONS

Oral ibandronate has potent effects on the rate of bone resorption at doses which are generally well tolerated. Further development is appropriate to evaluate the effects of long-term administration in the prevention of metastatic bone disease and the management of established skeletal metastases.

Intraoperative clinical practice and risk of early complications after cataract extraction in the United States, Canada, Denmark, and Spain

OBJECTIVE

To examine variation in intraoperative clinical practice and rates of adverse events after cataract surgery across four different healthcare systems.

DESIGN

Multicenter cohort study.

PARTICIPANTS

Patients were recruited from ophthalmic clinics in the United States (n = 75); in the Province of Manitoba, Canada (n = 12); in Denmark (n = 17); and the City of Barcelona, Spain (n = 10). In all, 1420 patients undergoing first eye cataract surgery were enrolled, with preoperative, perioperative, and postoperative clinical data collected on 1344 patients (95%).

MAIN OUTCOME MEASURES

Occurrence of 23 specified intraoperative and early postoperative adverse events was measured. Four-month postoperative visual acuity outcome also was measured.

RESULTS

Phacoemulsification was performed in two thirds of the extractions in the United States and Manitoba, in one third in Denmark, and in 3% in Barcelona (P < 0.001). More than 96% of extractions in North America and Denmark were performed with the patient under local anesthesia, whereas general anesthesia was used for 38% of extractions in Barcelona (P < 0.001). Rates of intraoperative adverse events were 11% to 12.8% in Manitoba, Denmark, and Barcelona and significantly lower in the United States (6%), mainly because of a lower rate of capsular rupture (P < 0.01). Significantly higher rates of early postoperative events were seen in the United States (18.8%) and Manitoba (20.4%) compared to Denmark (7.9%) and Barcelona (5%) (P < 0.001). The differences among sites in rates of events could not be explained by differences in recorded patient characteristics or surgical techniques. The occurrence of perioperative events was significantly associated with a worse 4-month visual outcome.

CONCLUSION

The observed variation in clinical practice might represent a general trend of a slower diffusion of new medical technology in Europe compared with that of North America. Rates of intraoperative and early postoperative events varied significantly across sites.

Circulating type I collagen degradation products: a new serum marker for clinical severity in patients with scleroderma?

Systemic sclerosis (SSc; scleroderma) results in the excessive deposition of extracellular matrix components in affected organs. This is partly due to enhanced synthesis; however, the role of degradative processes in this disease is still poorly understood. Sera of 32 patients with SSc (22 with the diffuse, 10 with the limited form) and of six patients with morphoea were assessed using radioimmunoassays for the cross-linked carboxy terminal telopeptide of type I collagen (ICTP) and for the amino terminal propeptide of type I procollagen (PINP) reflecting type I collagen degradation and synthesis, respectively. In 27 of the 32 patients with SSc, the concentration of ICTP was above the upper limit of the normal value (4.6 micrograms/L) and the mean level was clearly elevated at 7.92 micrograms/L. The ICTP concentration correlated with the skin score measuring the extent of the lesions, whereas no such correlation was found for PINP. The ICTP antigen in serum, studied by immunoblotting, had a molecular weight of about twice that of the trypsin-generated fragment isolated from human bone collagen. The mean concentration of serum PINP was 43.9 micrograms/L and no patient exceeded the upper limit of the normal range (80 micrograms/L). We report here for the first time that the concentration of the type I collagen degradation product ICTP in serum shows a close correlation with the extent of skin fibrosis in patients with SSc. We conclude that the increased deposition of type I collagen in this disease is accompanied by an increased turnover of this molecule, indicating a more complex derangement of synthetic and degradative processes than previously acknowledged.

Variation in indications for cataract surgery in the United States, Denmark, Canada, and Spain: results from the International Cataract Surgery Outcomes Study

BACKGROUND/AIMS

International comparisons of clinical practice may help in assessing the magnitude and possible causes of variation in cross national healthcare utilisation. With this aim, the indications for cataract surgery in the United States, Denmark, the province of Manitoba (Canada), and the city of Barcelona (Spain) were compared.

METHODS

In a prospective multicentre study, patients scheduled for first eye cataract surgery and aged 50 years or older were enrolled consecutively. From the United States 766 patients were enrolled; from Denmark 291; from Manitoba 152; and from Barcelona 200. Indication for surgery was measured as preoperative visual status of patients enlisted for cataract surgery. Main variables were preoperative visual acuity in operative eye, the VF-14 score (an index of functional impairment in patients with cataract) and ocular comorbidity.

RESULTS

Mean visual acuity were 0.23 (USA), 0.17 (Denmark), 0.15 (Manitoba), and 0.07 (Barcelona) (p < 0.001). When restricting the sample to eyes with normal retina and macula, no significant difference between United States and Denmark was observed (p > 0.05). Mean VF-14 scores were 76 (USA), 76 (Denmark), 71 (Manitoba), and 64 (Barcelona) (p < 0.001).

CONCLUSION

Similar indications for cataract surgery were found in the United States and Denmark. Significantly more restricted indications were observed in Manitoba and Barcelona. Possible explanations for the results are discussed, including differences in sociodemographic characteristics, access to care, surgeons' willingness to operate, and patient demand.

Visual outcomes of cataract surgery in the United States, Canada, Denmark, and Spain. Report From the International Cataract Surgery Outcomes Study

OBJECTIVE

To compare visual outcomes obtained following cataract surgery in 4 sites in North America and Europe where considerable differences in the organization of care and patterns of clinical practice have been previously described.

METHODS

Patients scheduled for first eye-cataract surgery and aged 50 years or older were enrolled consecutively in a prospective multicenter study that collected clinical and patient interview data preoperatively and postoperatively. From the United States, 772 patients were enrolled; from the Province of Manitoba (Canada), 159; from Denmark, 291; and from the City of Barcelona (Spain), 200. Preoperative and 4-month postoperative visual acuity was obtained for 92% of the patients (n = 1291).

RESULTS

The mean 4-month postoperative visual acuity of eyes operated on varied significantly across the 4 sites (P < .001) and had the following Snellen decimal fraction measurements: 0.49 in Barcelona, 0.65 in Denmark, 0.66 in Manitoba, and 0.74 in the United States. However, while crude visual acuity outcome figures varied significantly, no significant difference was observed across the 4 sites regarding the risk of poorer visual outcome after controlling for differences in age, preoperative visual acuity, and general health status for patients with no ocular comorbidity. Older age, poorer preoperative visual acuity, poorer preoperative general health status, and coexisting ocular comorbidity were predictors of a poorer visual outcome.

CONCLUSION

A previously identified variation in treatment modalities across the 4 sites did not seem to affect patients' visual acuity outcomes.

TGF-beta1 binding protein-like modules of fibrillin-1 and -2 mediate integrin-dependent cell adhesion

Human fibrillin, a major component of the extracellular matrix, exists as two highly homologous forms (fibrillin-1 and -2). Several modules of fibrillin are homologous to TGF-beta1 binding protein. Two of these modules, D25 (the 25th module of fibrillin-1 and -2 D segment) and D12 (the 12th module of fibrillin-2 D segment) contain the cell adhesion motif arginyl-glycyl-aspartyl (RGD). The ability of RGD to mediate adhesion to D25-1 and D12-2 was investigated using bacterially expressed fusion proteins. Human skin fibroblasts and murine L-cells were used in microassays of cell attachment and cell spreading on fibrillin fusion-protein substrata. Dose-dependent experiments and competitive inhibition by soluble RGD-containing peptides demonstrated that D25-1 and D12-2 mediate RGD-dependent cell adhesion. These results provide evidence for a cell adhesion function of fibrillin-2. Inhibition with anti-integrin antibodies showed that alpha(v) and beta3 integrins mediate adhesion to D25-1, while alpha3, alpha(v) and beta1 are involved in adhesion to D12-2. Binding of different receptors may elicit distinct cell signalling supporting the hypothesis that fibrillin-1 and fibrillin-2 have distinct roles.

Cross-cultural differences in the reporting of global functional capacity: an example in cataract patients

OBJECTIVES

Patient-based health status measures have an important role to play in the assessment of health care outcomes. Among these measures, global assessments increasingly have been used, although the understanding of the performance of these indicators and the determinants of patients responses is underdeveloped. In this study, the performance of a single-item global indicator of visual function in cataract patients of four international settings was compared.

METHODS

Visual acuity and ocular comorbidity was assessed by patients' ophthalmologist using Snellen-type charts in patients referred for a first cataract surgery in the United States, Manitoba (Canada), Denmark, and Barcelona (Spain). Patients also were interviewed by telephone and asked to report overall trouble with vision on a single-item indicator ("great deal," "moderate," "a little," "none") and to complete the Visual Functioning Index (VF-14), a scale of visual function ranging from 0 (worst function) to 100 (best level of function), along with other questions including the degree the patient was bothered by symptoms as measured by the Cataract Symptom Score (CSS). A total of 1,407 patients completed the clinical examination and the preoperative interview.

RESULTS

Distribution of overall trouble with vision varied across the sites, with the proportion of patients reporting a great deal of trouble ranging from 21.7% to 37.9%. In all sites, patients reporting more trouble with vision tended to show a poorer age-adjusted and sex-adjusted visual acuity. The proportion of patients reporting great deal of trouble with vision was higher in the groups with worse visual acuity (P < 0.001). In multivariate analysis, after controlling for clinical and sociodemographic factors, the patients from Manitoba (OR = 0.32, 95% CI = 0.20, 0.51) and those from Barcelona (OR = 0.33, 95% CI = 0.20, 0.56) were less likely to report a great deal of trouble with their vision (P < 0.01) than the Danish and US patients. No such differences were found among the US patients from three sites.

CONCLUSIONS

There is international variation in the self-reporting of global vision-related functional capacity that is not explained by clinical or sociodemographic factors, which may be because of cultural differences. International comparisons of patient-based health outcomes should not rely only on single-item indicators until there is convincing evidence of their cross-cultural equivalence.

Minority women and tobacco: implications for smoking cessation interventions

Quitting smoking is the single most important preventive health behavior a woman can perform to significantly reduce her chances of morbidity and premature mortality. Minority women are an extremely important population to target for smoking cessation intervention. Rates and risk factors for cardiovascular diseases and cancer are markedly higher among women of certain minority groups. In addition, smoking prevalence rates in women of some ethnic groups are elevated relative to the majority population of women, and specific groups have displayed slower rates of decline in smoking. Furthermore, minority women tend to have less access and appear to be less responsive to smoking cessation programs aimed at the majority culture. Thus, consideration of the practical and cultural needs of ethnic minority women is imperative when designing smoking intervention programs. This article describes the smoking behaviors of African-American, American Indian and Native Alaskan, Asian and Pacific Islander, and Hispanic women smokers, in order to gain a greater understanding of the treatment needs of these women. Information on prevalence rates and smoking patterns, barriers to quitting, and findings from intervention studies within each population are reviewed as well as recommendations for smoking cessation treatment.

Anxiety and depression in patients receiving implanted cardioverter-defibrillators: a longitudinal investigation

OBJECTIVE

The implantable cardioverter-defibrillator (ICD) has dramatically improved survival rates following sudden cardiac death episodes. However, researchers have devoted little attention to the psychosocial consequences of living with the device. The current study used a longitudinal design to evaluate the impact of adaptation to the ICD on incidence and severity of anxiety and depression.

METHOD

ICD recipients were administered standardized anxiety and depression questionnaires as well as questions evaluating quality of life related to the ICD in two consecutive yearly assessments. A preliminary evaluation of potentially important theoretical variables, such as the perceived predictability and controllability of shock onset was also conducted.

RESULTS

One-third of the study population (N = 38) had clinically significant levels of anxiety, depressed mood, and fear of symptoms of autonomic arousal. These negative affective states persisted over time, with 40 to 63 percent of subjects continuing to have ongoing difficulties over a one-year time period. Anxiety about the ICD firing was closely associated with the occurrence of depression, while avoidance of activities was associated with anxiety. "Worry" about the ICD and a belief that ICD firing can be predicted were associated with anxiety sensitivity.

CONCLUSIONS

Depressive and anxiety states in ICD recipients may be frequent, clinically significant, and resistant to spontaneous resolution. Early signs of anxiety and depression in ICD recipients should be evaluated. Implications for future research are discussed.

Activation of tissue inhibitor of metalloproteinases-3 (TIMP-3) mRNA expression in scleroderma skin fibroblasts

Excessive accumulation of fibrillar collagens is a hallmark of the cutaneous fibrosis in both systemic and localized scleroderma. Turnover of the collagenous extracellular matrix is dependent on the balance between collagenolytic matrix metalloproteinases and their specific inhibitors. We have examined the expression of the novel, matrix associated tissue inhibitor of metalloproteinases-3 (TIMP-3) in normal and scleroderma skin fibroblasts in culture and in vivo. The levels of TIMP-3 mRNA were elevated up to 2.5-fold in five of seven systemic sclerosis fibroblast strains, whereas TIMP-1 mRNA expression was elevated up to 1.8-fold in two and TIMP-2 mRNA expression up to 1.8-fold in two systemic sclerosis strains. Using in situ hybridization, TIMP-3 mRNA was detected in seven of 12 localized scleroderma skin samples, specifically in fibroblasts within fibrotic collagen fibers or in the vicinity of inflammatory cells. TIMP-1 mRNA was detected in three of eight scleroderma skin samples in fibroblasts adjacent to inflammatory cells. The expression of TIMP-3 mRNA by systemic sclerosis and normal skin fibroblasts was enhanced to a similar extent (by 8.6- and 8.1-fold, respectively) by transforming growth factor-beta, and suppressed down to 34 and 54%, respectively, by tumor necrosis factor-alpha. Specific activation of TIMP-3 gene expression in scleroderma skin fibroblasts in culture and in vivo suggests a role for TIMP-3 in the pathogenesis of dermal fibrosis via inhibition of turnover of fibrotic dermal extracellular matrix, possibly due to upregulation of TIMP-3 expression by transforming growth factor-beta.