Clinical consultations in an aboriginal community-controlled health service: a comparison with general practice

Clinical consultation at Danila Dilba, an Aboriginal community-controlled health service in Darwin, were compared with consultations in Australian general practice. We described 583 consultations, using a questionnaire based on the International Classification of Primary Care. The methods were similar to those of the Australian Morbidity and Treatment Survey (AMTS) of consultations in Australian general practice undertaken by the University of Sydney Family Medicine Research Unit. Compared with Australian general practice consultations, consultations with Danila Dilba were more complex: more young patients, more new patients, more home visits, more problems managed, more new problems and more consultations leading to emergency hospital admission. Skin infections, diabetes mellitus, chronic alcohol abuse, rheumatic heart disease (or rheumatic fever) and chronic suppurative otitis media were much more commonly managed at study consultations at Danila Dilba than at consultations with general practitioners in the AMTS. Nearly all patients saw an Aboriginal health worker first, and nearly half the consultations were with Aboriginal health workers alone. The results suggest possible limitations of fee-for-item Medicare funding of Aboriginal community-controlled health services compared with existing block grant funding.

Malnutrition and microcephaly in Australian aboriginal children

OBJECTIVE

To examine the association between malnutrition and microcephaly in the first two years of life.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Royal Darwin Hospital (a tertiary referral centre); 157 of 165 previously studied Aboriginal children aged under two years who were admitted with diarrhoea between May 1990 and April 1991. Birth weight, birth length, birth head circumference, admission head circumference and admission nutritional status were examined. Nutritional status was categorised according to World Health Organization (WHO) criteria for wasting (thinness) and stunting (shortness). Microcephaly on admission was defined as a head circumference less than the second percentile on Australian reference charts. Small-for-gestational-age (SGA) and birth microcephaly were defined as being less than the tenth percentile for an Australian hospitalised population, corrected for gestational age at confinement. Low birth weight (LBW) was defined as less than 2500 g.

MAIN OUTCOME MEASURE

Microcephaly on admission.

RESULTS

Of the 157 children, 76 (48%) were wasted, 36 (23%) stunted and 37 (24%) microcephalic on admission. A total of 26 (17%) children had been of LBW, 17 (11%) SGA and 21 (13%) microcephalic at birth. On univariate analysis, microcephaly on admission was associated with wasting (crude odds ratio [OR], 3.91; 95% confidence interval [CI], 1.6-9.7; P < 0.005), but not stunting. There were no significant associations between microcephaly on admission and LBW, being SGA, microcephaly at birth, age or sex. With multivariate analysis, birth head circumference was significantly associated with microcephaly on admission (adjusted OR, 3.62; 95% CI, 1.28-10.23; P < 0.05), as was wasting (adjusted OR, 4.38; 95% CI, 1.88-10.20; P < 0.001).

CONCLUSIONS

Wasting was significantly associated with microcephaly, independent of intrauterine growth retardation (as measured by being SGA) and LBW. As malnutrition in critical periods of both intra- and extrauterine development may have irreversible effects on intellectual potential and behaviour, the emphasis on improved nutrition must begin during pregnancy, and should continue in infancy and early childhood.

Hypercoagulability in venous and arterial thrombosis

The term "hypercoagulability" is used to describe patients who are at increased risk for thrombosis because of inherited defects in their anticoagulant pathways or because of various predisposing causes. About one in five patients of European descent who present with venous thromboembolism have a specific genetic defect in their anticoagulant pathway. In these patients, anticoagulant prophylaxis is indicated at times of high risk, such as after surgery. Prolonged anticoagulant therapy may be required in patients with recurrent or life-threatening thromboemboli, but decisions about this are best made on an individual basis. Patients who present with arterial thrombosis usually develop their disease as a complication of atherosclerosis. However, these patients also have a form of hypercoagulability, manifested primarily by high fibrinogen levels and elevated factor VII activity. Evidence increasingly indicates that these and other hemostatic markers may help in the assessment of patients at risk for coronary heart disease.

Venous thrombosis revisited

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in hospitalized patients. For many years, stasis in the deep veins of the legs has been recognized as being a necessary but not a sufficient cause of thrombosis. The recent demonstration of the high prevalence of a mutation at Arg506 in the factor V gene ('factor V Leiden') in patients presenting with VTE has emphasized the protective role of activated protein C in neutralizing thrombin, and has highlighted the importance of genetic factors in the pathogenesis of venous thrombosis. For many if not most patients, the prothrombotic stimulus of a surgical operation with the accompanying stasis may be a sufficient cause for VTE if endogenous anticoagulant mechanisms are impaired. In populations with a high prevalence of the FV:Q506 allele there is now a strong case for screening individuals for the mutant gene if they have a personal or family history of VTE, especially before surgery, during pregnancy or before prescribing oral contraceptives.

Venous thrombosis and the "Wessler test"

The Wessler test in animals has been used extensively for over 40 years as a laboratory measure of in vivo hypercoagulability. The test, in which induced hypercoagulability is combined with local venous stasis, has contributed significantly to our understanding of the pathogenesis of venous thrombosis and pulmonary embolism. In addition, the Wessler test has proved invaluable for assessing the thrombogenicity of various blood products, as well as for assaying the effectiveness of heparin and heparin fractions.

How complete is a transurethral resection of the prostate?

OBJECTIVE

To determine the completeness of transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

The prostate volume of 432 patients was measured by transrectal ultrasonography (TRUS) before they underwent a TURP performed by one of three consultant urological surgeons. The prostate tissue collected at resection was weighed, multiplied by 1.2 to compensate for 'shrinkage', and the amount of tissue removed expressed as a percentage of the pre-operative prostate volume determined by TRUS (resection ratio). The patients were categorized into groups based on pre-operative prostate size.

RESULTS

The mean weight of prostate tissue resected was 25.6 g. Resection ratios increased with prostate size, with the largest occurring in prostates of 71-110 g. The surgeon did not resect more than 50% of the gland volume in any group.

CONCLUSION

This study counters the theory that a complete resection of the prostate is routinely achieved. The endoscopic appearances probably imply a complete resection of the adenoma but a considerable volume of the gland remains. This has important implications for the detection of prostate carcinoma at TURP and for the staging of the disease.

Human Rh D monoclonal antibodies (BRAD-3 and BRAD-5) cause accelerated clearance of Rh D+ red blood cells and suppression of Rh D immunization in Rh D- volunteers

The use of prophylactic anti-D to prevent Rh D immunization in Rh D- women and subsequent hemolytic disease in Rh D+ infants is widespread, but has led to shortages of the anti-D Ig. With the aim of substituting monoclonal anti-D for Rh D prophylaxis, we have compared the abilities of monoclonal and polyclonal anti-D to clear Rh D+ red blood cells (RBCs) infused into Rh D- male volunteers and to suppress Rh D immunization. Two human monoclonal antibodies (MoAbs), BRAD-3 (IgG3) and BRAD-5 (IgG1), produced from stable Epstein-Barr virus-transformed B-lymphoblastoid cell lines, were selected because of their proven in vitro activity in promoting RBC lysis in antibody-dependent cell-mediated cytotoxicity assays. RBC clearance was assessed by intravenous injection of 3 mL of 51chromium-labeled D+ RBCs into 27 volunteers 48 hours after intramuscular injection of monoclonal or polyclonal anti-D. Further 3-mL injections of unlabeled D+ cells were administered at 6 and 9 months to induce immunization. Blood samples were taken throughout the 12-month period of study for the serologic detection of anti-D. The mean half-life (t50%) of RBCs in 7 recipients of 300 micrograms BRAD-5 (5.9 hours) was similar to that in 8 recipients of 500 IU polyclonal anti-D (5.0 hours), whereas D+ cells were cleared more slowly in some of the 8 subjects injected with 300 micrograms BRAD-3 (mean t50% 12.7 hours) and in 1 individual administered 100 micrograms BRAD-3 (t50% 41.0 hours). The rate of RBC clearance in both groups administered 300 micrograms monoclonal anti-D correlated with the amount of antibody bound per cell, determined by flow cytometry. There was no evidence of primary immunization having occurred in any subject after 6 months of follow-up. Five of 24 subjects produced anti-D after one or two further injections of RBCs, confirming that they were responders who had been protected by the monoclonal or polyclonal anti-D administered initially. Four of these responders were recipients of monoclonal anti-D (3 BRAD-3, 1 BRAD-5). One individual who received BRAD-5 produced accelerated clearance of D+ RBCs at the third unprotected RBC challenge but did not seroconvert. This study shows that the human MoAbs BRAD-3 and BRAD-5 can prevent Rh D immunization, and indicates that they may be suitable replacements for the polyclonal anti-D presently used in prophylaxis of Rh D hemolytic disease of the newborn.(ABSTRACT TRUNCATED AT 400 WORDS)

Postcardiac-event elderly: effect of exercise on cardiopulmonary function

1. The findings of this study contradicted those of previous studies in the areas of respiratory rates, conditioning, and the effect of exercise on diastolic blood pressure. 2. This study indicates that the heart's requirement for oxygen at a given MET load (a unit of energy cost-related to workload) is significantly reduced in elderly cardiac-event patients following a 6-week conditioning program; thus, a similar program would appear to provide cardioprotective effects to this population. 3. This study demonstrated that, as a result of physical conditioning, heart rate, systolic blood pressure, and rate-pressure product showed significant beneficial reductions which would allow elderly postcardiac-event patients to function more effectively in daily activities.

A cross-over pharmacokinetic and thrombogenicity study of a prothrombin complex concentrate and a purified factor IX concentrate

A prospective cross-over study was carried out on 19 patients with haemophilia B. comparing the pharmacokinetics of a purified factor IX concentrate prepared by metal chelate affinity chromatography (9MC) with a conventional three-factor prothrombin complex concentrate (9A). The highly purified factor IX concentrate was shown to have a half-life comparable to the PCC; the in vivo recovery of the purified concentrate was significantly greater than that of the complex (P < 0.01). The 20% change in the value of the International Standard for Factor IX Concentrate, introduced in 1988, might have been expected to lower the recovery values. However, the in vivo recovery for both concentrates was somewhat higher than reported previously, particularly in the older literature. In nine patients, serial assays for fibrinopeptide A, prothrombin fragment F1+2 and thrombin-antithrombin complexes (TAT) were performed to assess the potential thrombogenicity of the two concentrates. Evidence was obtained that there was significantly less activation of coagulation following administration of purified factor IX (9MC), as compared to the activation that occurred after the PCC.

Immediate and delayed apoptotic cell death mechanisms: UVA versus UVB and UVC radiation

The mechanism of cell death induced by the different waveband regions of ultraviolet radiation (UVR), i.e., UVA1 (340-400 nm), UVB (290-320 nm) and UVC (200-290 nm) was investigated, using equilethal doses (90% reproductive death) on L5178Y-R murine lymphoma cells. To distinguish between necrosis and apoptosis, the following endpoints were monitored over time using flow cytometry and transmission electron microscopy: percentage of remaining cells, membrane permeabilized cells, dead cells, apoptotic cells, and ultrastructural changes. All waveband regions of UVR were found to cause apoptosis as opposed to necrosis. However, UVA1-induced immediate (0-4 h) apoptosis, while UVB- or UVC-induced delayed apoptosis (<34 h). Moreover, the membrane permeability changes that only result from exposure to UVA1 radiation, especially to red blood cells, suggests that the immediate apoptotic mechanism involves membrane damage. Therefore, the results suggest that there are three death mechanisms available to one cell type: necrosis, immediate apoptosis, and delayed apoptosis (or programmed cell death).

Stomach cancer in transgenic mice expressing human papillomavirus type 16 early region genes from a keratin promoter

Certain human papillomaviruses (HPVs) have been implicated as important contributory factors in the development of cervical carcinoma and other epithelial malignancies. In order to investigate the role of papillomavirus early gene expression in epithelial oncogenesis in vivo, we produced transgenic mice expressing HPV-16 early region genes from the promoter of the bovine keratin 6 gene. Spliced transcripts were detected in the tongue, forestomach, glandular stomach, female reproductive tract and tail skin of these mice. This expression was initially asymptomatic. However, at increasing frequency after approx. 100 days, solitary glands within the gastric mucosa became colonized with small dysplastic cells. Later this abnormal cell population spread within the glandular mucosa, invaded the submucosa and outer muscular wall of the stomach, and commonly metastasized to local lymph nodes and the liver. The appearance and staining characteristics of the tumours suggested their classification as malignant carcinoids, originating from the neuroendocrine enterochromaffin-like cells. Expression of HPV mRNAs was increased in the tumours, though it remained comparable to that in forestomach and tongue. The mean age at tumour presentation was 246 days in males and 352 days in females, all transgenic mice in eight independent lines were similarly susceptible. This study confirms the oncogenicity of HPV-16 early region genes, and establishes a model system in which to investigate mechanisms of malignant progression and possible therapeutic strategies for HPV-associated tumours.

A practical intervention to address ear and lung disease in Aboriginal primary school children of central Australia

Australian Aboriginal populations have an extremely high prevalence of lung disease and ear disease. In addition to an improvement in socio-economic conditions, implementation of strategies to address the problem, within the limitations of present conditions, is needed. A 5 month trial was conducted to investigate the effectiveness of a school-based intervention programme involving nose blowing, deep breathing and coughing combined with exercise performed daily. This was a community-based trial, designed to give priority to cultural and ethical considerations, to be non-intrusive and to utilize local skills and resources. Results of the trial showed that signs of upper and lower respiratory tract disease and pulmonary function measurements were statistically significantly improved. Hearing levels showed no statistically significant change. The programme met with a good response from children and teachers. This study does suggest that this strategy may help address the existing problems of lung and ear disease in Aboriginal primary school children, providing some immediate benefits within the limitations of the present socio-economic conditions.

Regional differences in LV collagen accumulation and mature cross-linking after myocardial infarction in rats

To determine the extent of and any regional differences in remodeling response of the extracellular matrix (ECM) to myocardial infarction (MI), moderate-to-large transmural infarcts were surgically produced in left ventricular (LV) free wall of rats. Animals were killed 13 wk after surgery. In comparison to age-matched controls, infarction was associated with an overall increase in heart weight, which included hypertrophy of both the right ventricle and LV. Although the remaining viable myocardium in LV free wall was significantly reduced, the interventricular septum was hypertrophied some 30% compared with control tissues (247 +/- 9 vs. 189 +/- 8 mg). Collagen concentration more than doubled in remaining viable free wall (8.92 +/- 0.59 vs. 3.95 +/- 0.25 mg/100 mg, P < 0.0001), and a smaller but still highly significant 27% increase occurred (P < 0.01) in the more remote septum. Degree of covalent cross-linking of collagen fibrils as assessed by hydroxylysylpyridinoline (HP) concentration also revealed regional differences in response of the ECM to infarction. Although HP concentration was increased 60% in viable free wall (P < 0.05) post-MI, it was unchanged in the septum. With respect to collagen characteristics of the transmural infarct per se, the scar exhibited still further increases in both collagen and HP concentrations compared with the already elevated values for these two parameters in viable free wall. The results indicate that any evaluation of the remodeling response of viable myocardium post-MI must include not only the myocyte but also the ECM, the principal component of which is collagen.