Rhinoscleroma mimicking nasal polyposis

Rhinoscleroma is increasing in incidence in the United States. It should be considered in patients who are immigrants from endemic countries and present with nasal polyposis that exhibits significant adherence to the nasal septum and relative sparing of the sinuses. Fluoroquinolones are emerging as the adjunctive antibiotic treatment of choice to complement surgical extirpation of the disease.

Stroke: who's counting what?

INTRODUCTION

Patients with stroke are often selected for epidemiological reporting and research using ICD-9-CM (ICD-9) diagnostic codes. This study addresses the accuracy of these codes in identifying patients with stroke.

METHODS

A sample of 279 patients with new stroke and 392 non-stroke (no evidence of new stroke) patients were identified by medical record review from 11 Veterans Affairs Medical Centers. Administrative records containing ICD-9-CM diagnoses were matched with this sample. Coding sensitivity and specificity were determined using individual ICD-9 codes and two coding algorithms.

RESULTS

Significant variation was found in the accuracy of cerebrovascular ICD-9-CM codes in identifying patients diagnosed with stroke. Two coding algorithms were identified with the following performance statistics based on the sampled populations: 1) 91-percent sensitivity, 40-percent specificity; and 2) 54-percent sensitivity, 87-percent specificity.

DISCUSSION/CONCLUSIONS

Variability in identifying patients with stroke using ICD-9 codes has been reported in the literature and confirmed. Two coding algorithms for maximizing sensitivity or specificity are proposed. Caution is urged when using ICD-9-coded administrative data to identify patients with stroke.

Kidney transplantation at the University of Miami

Of the 1,679 renal allografts performed at the University of Miami between January 1, 1979 and October 31, 1999, 1,154 were from cadaver donors (CAD), 515 were from living-related donors (LRD), and 10 were from living-unrelated donors. The 3 ethnic groups: Black Caribbean-African-American, Hispanic, and others were almost equally represented among recipients. Recipient ages ranged between 1-83 years. In the CAD group, HLA matching was emphasized so that no patient received a kidney with less than one DR match, and for the entire series a mean of 2.59 of 6 HLA antigens were matched between donors and recipients. Overall actuarial 20-year patient and graft survival rates were 65.3% and 30.7%, respectively, with 69.2% patient and 38.5% graft survival rates for LRD, and 65.6% patient and 29.0% graft survival rates for CAD recipients. Several factors adversely affected long-term graft outcome. African-Americans had an overall 20-year graft survival rate of 13.6% compared with 34% for non African-Americans (p < 0.001) (not dependent on patient survival). Diabetic patients had an overall 20-year graft survival rate of 13.5% versus 34.2% for non-diabetics (primarily dependent on patient survival). In the category of non African-American, non-diabetic patients under age 36 (n = 412), the 20-year patient survival rates in the LRD and CAD groups were 85.0% and 79.3%, respectively, and the graft survival rates were 55.7% and 46.5%, respectively. This differed markedly from the results for the entire series.

The DNA mismatch repair enzyme PMS1 is a myositis-specific autoantigen

OBJECTIVE

The specificity of the autoantibody response in different autoimmune diseases makes autoantibodies useful for diagnostic purposes. It also focuses attention on tissue- and event-specific circumstances that may select unique molecules for an autoimmune response in specific diseases. Defining additional phenotype-specific autoantibodies may identify such circumstances. This study was undertaken to investigate the disease specificity of PMS1, an autoantigen previously identified in some sera from patients with myositis.

METHODS

We used immunoprecipitation analysis to determine the frequency of autoantibodies to PMS1 in sera from patients with myositis, systemic lupus erythematosus, or scleroderma and from healthy controls. Additional antigens recognized by PMS1-positive sera were further characterized in terms of their susceptibility to cleavage by apoptotic proteases.

RESULTS

PMS1, a DNA mismatch repair enzyme, was identified as a myositis-specific autoantigen. Autoantibodies to PMS1 were found in 4 of 53 patients with autoimmune myositis (7.5%), but in no sera from 94 patients with other systemic autoimmune diseases (P = 0.016). Additional mismatch repair enzymes (PMS2, MLH1) were targeted, apparently independently. Sera recognizing PMS1 also recognized several other proteins involved in DNA repair and remodeling, including poly(ADP-ribose) polymerase, DNA-dependent protein kinase, and Mi-2. All of these autoantigens were efficiently cleaved by granzyme B, generating unique fragments not observed during other forms of cell death.

CONCLUSION

PMS1 autoantibodies are myositis specific. The striking correlation between an immune response to a group of granzyme B substrates (functioning in DNA repair and remodeling) and the myositis phenotype strongly implies that tissue- and event-specific biochemical events play a role in selecting these molecules for an autoimmune response. Understanding the role of granzyme B cleavage in this response is an important priority.

Moving out and moving on: some ethnographic observations of deinstitutionalization in an Australian community

Since the 1950s deinstitutionalization has taken place for people with mental illnesses in the Western world. The growth of community care and residential facilities, as well as planning and implementation of policies, has varied in timing and orientation. An appreciation of the process of change affecting people discharged to the community highlights their strength, resilience, and vulnerabilities. This paper outlines a two and a half year ethnographic qualitative study undertaken in Australia, where 47 long-stay psychiatric inpatients were discharged to the community. The process accompanied the amalgamation of two major psychiatric hospitals, resulting in the closure of one. Findings demonstrated slow but positive change for residents as they reintegrated into the community. A separate quantitative and economic study was undertaken alongside the qualitative study (for results see Hobbs, et al., 2000; Newton, et al, 2000; Lapsley, et al., 2000).

Donor bone marrow-derived chimeric cells present in renal transplant recipients infused with donor marrow. I. Potent regulators of recipient antidonor immune responses

BACKGROUND

Even though a number of transplant centers have adopted donor-specific bone marrow cell (DBMC) infusions to enhance donor cell chimerism, to date there has been no direct evidence linking chimerism with tolerance induction in human organ transplant recipients.

METHODS

Cells of donor phenotype were isolated 1 year postoperatively from the peripheral blood lymphocytes and iliac crest bone marrow of 11 living-related-donor (LRD) renal transplant recipients, who had received perioperative donor bone marrow cell infusions. These recipient-derived donor (RdD) cells were characterized phenotypically by flow cytometric analysis and functionally as modulators in mixed lymphocyte reaction (MLR) and cell-mediated lympholysis (CML) assays.

RESULTS

The yield of RdD cells ranged from 0.1 to O.9% of the starting material with the majority being TcRalphabeta, CD3 positive T cells, a substantial percentage of which coexpressed CD28. At 1 year posttransplant almost 50% of the LRD-kidney/DBMC recipients tested so far exhibited donor-specific unresponsiveness in MLR (7/17) and CML (6/13) reactions and this trend was further enhanced at 23 years. In the recipients with residual positive antidonor immune responses, the RdD cells inhibited recipient antidonor MLR and CML responses significantly more strongly than freshly isolated and similarly treated iliac crest bone marrow cells from the donor. RdD cells also inhibited the MLR of the recipient to third party allogeneic stimulator cells; however, this nonspecific effect was significantly weaker than specific inhibition. We also established long-term bone marrow cultures stimulated every 2 weeks with irradiated alogeneic feeder cells, that had similar functional properties thus possibly providing us with an in vitro correlate the RdD cells.

CONCLUSIONS

These results clearly support the notion that the infused donor cells play a positive role in the induction and/or maintenance of transplant tolerance.

The relevance of adjuvant therapy in primary carcinoma of the fallopian tube, stages I and II: irradiation vs. chemotherapy

INTRODUCTION

Primary carcinoma of the Fallopian tube (FTC) is a rare but extremely aggressive neoplasm. It must be expected to cause up to 40% of tumor-related deaths even in Stage I, and up to 57% in Stage II. Due to its rarity, there exist only a few and divergent reports on the value of adjuvant therapy. Therefore the present study aims at evaluating the influence of postoperative adjuvant therapy on FTC by studying the effects of irradiation and chemotherapy on the overall survival of patients in Stages I and II.

PATIENTS AND METHODS

We investigated 95 cases of FTC in Stages I (n = 66) and II (n = 29) in a retrospective multicenter study. Group I (n = 32) are patients who underwent a complete irradiation with cobalt or photon energies of 23 MV (administering a daily dose of 2 Gy resulted in a total of 45-52 Gy in the pelvic areas). Group II (n = 31) consists of those cases who received postoperative chemotherapy with platinum. Thirty-two women were excluded from this study because they had other chemotherapies, incomplete irradiation, or no adjuvant therapy at all.

RESULTS

Median survival time was 57 months in Group I patients (95% confidence interval 33-81 months), compared to 73 months (95% confidence interval, 68-78 months) in the chemotherapeutically treated Group II. This difference did not prove to be statistically significant (p = 0.476).If primary surgical therapy is included in the evaluation, and patients with total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) are compared to those with additional radical lymphadenectomy (TAH+BSO+lymph nodes), the latter group's overall survival essentially improves but fails to reach statistical significance. Their 5-year survival rate is 83% against 58% in the TAH+BSO group (p = 0.12).

CONCLUSION

Chemotherapy and irradiation are two adjuvant therapies that are similarly effective in FTC of Stages I and II, with chemotherapy being preferred at the present time. Primary surgical treatment, however, is of crucial impact on the prognosis of FTC.

Practice-related functional activation changes in a working memory task

The effects of practice on the functional anatomy of a visuospatial working memory (VSWM) task were studied using functional Magnetic Resonance Imaging (fMRI). Functional imaging was conducted as subjects completed a moderate (Experiment 1) or extensive (Experiment 2) amount of practice on a delayed-match-to-sample task. While improvement in task performance was seen with practice, the task's dependence upon VSWM did not change. Activations in frontal (inferior, middle, and precentral gyri and superior frontal sulcus), parietal (intra-parietal sulcus, inferior parietal lobule, and precuneus) and cingulate (anterior and posterior) regions were observed as were bilateral insular and occipital activations. With the exception of the posterior cingulate, practice produced activation decreases in these regions, thus providing little evidence for a re-organization of the functional neuroanatomy. Fewer regions passing statistical criteria were observed at the end of practice relative to early in practice. Regions that were lost were mostly posterior (occipital and precuneus) but also included the left middle frontal gyrus, left precentral gyrus, and right insula suggesting that a more precise VSWM functional map can be observed once processes specific to encountering a novel task are removed. Little further activation changes were observed after extensive practice. These results suggest, minimally, that practice effects should be considered so as to avoid incorrectly attributing functional activation to a cognitive process of interest. Further, these data show that the dynamics of functional change can be tracked while a task is being learned and as an important cognitive process becomes more skilled.

(-)-Spiro[1-azabicyclo[2.2.2]octane-3,5'-oxazolidin-2'-one], a conformationally restricted analogue of acetylcholine, is a highly selective full agonist at the alpha 7 nicotinic acetylcholine receptor

Neuronal nicotinic acetylcholine receptors are members of the ligand-gated ion channel receptor superfamily and may play important roles in modulating neurotransmission, cognition, sensory gating, and anxiety. Because of its distribution and abundance in the CNS, the alpha 7 nicotinic receptor is a strong candidate to be involved in some of these functions. In this paper we describe the synthesis and in vitro profile of AR-R17779, (-)-spiro[1-azabicyclo[2.2. 2]octane-3,5'-oxazolidin-2'-one] (4a), a potent full agonist at the rat alpha 7 nicotinic receptor, which is highly selective for the rat alpha 7 nicotinic receptor over the alpha 4 beta 2 subtype. Preliminary SAR of AR-R17779 presented here indicate that there is little scope for modification of this rigid molecule as even minor changes result in significant loss of the alpha 7 nicotinic receptor affinity.

Ethics of early prevention in schizophrenia

OBJECTIVE

To represent a cross-section of current thinking on the ethics of early (primary) prevention in schizophrenia.

METHOD

Ethical considerations presented at the First Australian Schizophrenia Prevention Conference, Sydney, March 1999, particularly from the final session on 'Ethics', are recorded here together with complementary referenced material.

RESULTS

Ethical concerns arise in the arenas of research over clinical priorities; screening ethics, including stigma, confidentiality, informed consent and support required through waiting periods; and the ethics of prolonged assessments in the absence of disorder, the right not to know and the possible ethical prematurity or otherwise of screening for schizophrenia.

CONCLUSIONS

There are several legitimate ethical concerns that must be understood and addressed by those undertaking the developing of primary preventive measures in schizophrenia. Such measures must still be regarded as more experimental the further ahead the measures are undertaken from the onset of the disorder. Anticipatory ethical guidelines should be developed to inform such research.

Eustachian tube endoscopy in patients with chronic ear disease

OBJECTIVES/HYPOTHESIS

A paucity of research exists on trans-eustachian tube endoscopy to evaluate the status of the eustachian tube. Fuller examination of the role of the eustachian tube in chronic ear disease is needed, particularly because the eustachian tube has been implicated in the chronicity and pathogenesis of chronic ear disease. Therefore the purpose of this study was to evaluate the eustachian tube, based on observations from trans-eustachian tube endoscopy.

STUDY DESIGN

Twenty-two adult patients with chronic ear disease gave informed consent to participate in a prospective, trans-eustachian tube endoscopic investigation.

METHODS

Flexible, fiberoptic, nonarticulating (outside diameter of 0.5 mm) and articulating (outside diameter of 1.0 mm) endoscopes (coherent fused bundle of 3,000 pixels) were employed. The eustachian tube endoscopy was performed under general endotracheal anesthesia as the initial part of a larger, otological surgical procedure for chronic ear disease. The endoscope was passed from the middle ear (transtympanic approach) to the nasopharynx.

RESULTS

The 0.5-mm endoscope passed entirely through the eustachian tube from the tympanic orifice into the pharyngeal orifice in 16% of the cases. Stenotic blockage occurred at the infundibulum in 37%, isthmus in 42%, and fossa of Rosenmuller in 5% of cases. The eustachian tube mucosa was abnormal in 64% of cases. The risk for abnormal eustachian tube mucosa was four times greater for persons with long-standing disease (> or = 20 y) than for persons without long-standing disease (<20 y). The mean therapeutic efficiency of ossicular reconstruction was higher for the subgroup with normal than for the subgroup with abnormal eustachian tube mucosa.

CONCLUSIONS

The findings of trans-eustachian tube endoscopy provide objective evidence concerning eustachian tube status in persons with chronic ear disease and have implications for the timing of surgical intervention (ossicular reconstruction).

The impact of laparoscopy and laparoscopic ultrasonography on the management of pancreatic cancer

HYPOTHESIS

Laparoscopy and laparoscopic ultrasonographic (LAPUS) examinations combined with a biopsy of the pancreatic lesion contribute significantly in the determination of resectability of pancreatic cancer.

DESIGN

A prospective evaluation of the impact of laparoscopy and LAPUS on surgical decision making in patients with pancreatic cancer.

SETTING

A general community hospital; the department of surgery serves as referral for pancreatic surgery.

PATIENTS

During a 36-month period, 94 patients with pancreatic lesions were prospectively examined. Twenty-seven patients were found to have advanced disease. The remaining 67 patients were examined by laparoscopy and LAPUS to determine the resectability of the pancreatic tumor.

RESULTS

Laparoscopy and LAPUS contributed new, additional data in 40 patients (60%). Advanced disease was found in 30 patients, precluding curative resection. The study indicated potentially resectable tumors in 37 patients (55%), including 3 defined by conventional imaging studies as probably unresectable, and these patients were operated on with the intention of curative resection. Thirty-three patients underwent resection, and 4 (6%) were found to have nonresectable disease and form the false-positive group of the study. A summary of the results shows that the study resulted in a change of the decision regarding surgical intervention in 24 patients (36%) and avoided unnecessary laparotomies in 21 (31%). The study had a sensitivity of 100%, a specificity of 88%, and a false-positive rate of 6%. The positive predictive value of the study is 89%, and the negative predictive value is 100%.

CONCLUSIONS

Although rather invasive procedures that require general anesthesia and hospitalization, laparoscopy and LAPUS significantly contribute to the staging of patients with potentially resectable pancreatic cancer, avoiding unnecessary explorative laparotomies. These procedures should be performed in all patients with potentially resectable pancreatic cancer before explorative laparotomy.

Practice-related functional activation changes in a working memory task

The effects of practice on the functional anatomy of a visuospatial working memory (VSWM) task were studied using functional Magnetic Resonance Imaging (fMRI). Functional imaging was conducted as subjects completed a moderate (Experiment 1) or extensive (Experiment 2) amount of practice on a delayed-match-to-sample task. While improvement in task performance was seen with practice, the task's dependence upon VSWM did not change. Activations in frontal (inferior, middle, and precentral gyri and superior frontal sulcus), parietal (intra-parietal sulcus, inferior parietal lobule, and precuneus) and cingulate (anterior and posterior) regions were observed as were bilateral insular and occipital activations. With the exception of the posterior cingulate, practice produced activation decreases in these regions, thus providing little evidence for a re-organization of the functional neuroanatomy. Fewer regions passing statistical criteria were observed at the end of practice relative to early in practice. Regions that were lost were mostly posterior (occipital and precuneus) but also included the left middle frontal gyrus, left precentral gyrus, and right insula suggesting that a more precise VSWM functional map can be observed once processes specific to encountering a novel task are removed. Little further activation changes were observed after extensive practice. These results suggest, minimally, that practice effects should be considered so as to avoid incorrectly attributing functional activation to a cognitive process of interest. Further, these data show that the dynamics of functional change can be tracked while a task is being learned and as an important cognitive process becomes more skilled.

Non-Invasive detection of respiratory effort-related arousals (REras) by a nasal cannula/pressure transducer system

STUDY OBJECTIVES

The published AASM guidelines approve use of a nasal cannula/pressure transducer to detect apneas/hypopneas, but require esophageal manometry for Respiratory Effort-Related Arousals (RERAs). However, esophageal manometry may be poorly tolerated by many subjects. We have shown that the shape of the inspiratory flow signal from a nasal cannula identifies flow limitation and elevated upper-airway resistance. This study tests the hypothesis that detection of flow limitation events using the nasal cannula provides a non-invasive means to identify RERAs.

DESIGN

N/A.

SETTING

N/A.

PATIENTS

10 UARS/OSAS and 5 normal subjects

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

All subjects underwent full NPSG. Two scorers identified events from the nasal cannula signal as apneas, hypopneas, and flow limitation events. Two additional scorers identified events from esophageal manometry. Arousals were scored in a separate pass. Interscorer reliability and intersignal agreement were assessed both without and with regard to arousal. The total number of respiratory events identified by the two scorers of the nasal cannula was similar with an Intraclass Correlation (ICC) =0.96, and was essentially identical to the agreement for the two scorers of esophageal manometry (ICC=0.96). There was good agreement between the number of events detected by the two techniques with a slight bias towards the nasal cannula (4.5 events/hr). There was no statistically significant difference (bias 0.9/hr, 95%CI -0.3-2.0) between the number of nasal cannula flow limitation events terminated by arousal and manometry events terminated by arousal (RERAs).

CONCLUSION

The nasal cannula/pressure transducer provides a non-invasive reproducible detector of all events in sleep disordered breathing; in particular, it detects the same events as esophageal manometry (RERAs).

Influence of cigarette-smoking on the result of the triple test

The aim was to establish whether the risk of trisomy 21 in women smokers undergoing triple test differs to women nonsmokers, whether increased smoking changes the hormonal values, and if the cessation of smoking at the beginning of pregnancy has any influence on the triple test. 1,854 pregnant women were interviewed regarding their smoking habits at the time of the triple test. They were divided into 5 groups: (a) nonsmokers; (b) smokers before pregnancy; (c) 1-5 cigarettes; (d) 6-10; (e) 11 or more. MOM values of AFP, E3 and beta-HCG and Down risk calculated by the triple test were compared within the 5 groups. Increasing smoking was associated with a reduction in MOM values of beta-HCG. Smokers were significantly less likely to be counseled for karyotyping (cut-off level 1:250) than nonsmokers. The values of women who stopped smoking at the beginning of pregnancy were not different to nonsmokers. The results suggest the benefits of inclusion of smoking habits for the calculation of the triple test.

Impact of hysteroscopy on disease-free survival in clinically stage I endometrial cancer patients

Recent data strongly suggest tumor cell dissemination of endometrial carcinoma cells in the course of fluid hysteroscopy. In patients who had endometrial cancer which was (except for peritoneal cytology) confined to the uterus, the disease-free survival (DFS) of 135 patients who underwent hysteroscopy prior to staging laparotomy was compared with the DFS of 127 patients without hysteroscopy. After a median follow-up of 23 months, 10 patients experienced tumor recurrence. Although there was a trend towards a higher incidence of positive peritoneal cytology at laparotomy in patients who underwent hysteroscopy, this difference did not achieve statistical significance (P = 0.47). For 5 years, the DFS was 92.4% in patients with hysteroscopy and 84.7% in patients without hysteroscopy before laparotomy (log-rank, P = 0.782). Our data therefore suggest a similar short-term DFS in endometrial cancer patients with and without hysteroscopy prior to laparotomy.

[Laparoscopic ultrasound in predicting resectability of cholangiocarcinoma]

Cholangiocarcinoma accounts for about 1% of all malignant tumors. They are difficult to diagnose because of their small size and their location. Although surgical resection is the best therapeutic approach, most patients undergo unnecessary exploratory laparotomy due to incorrect preoperative diagnosis. We present our experience with laparoscopic ultrasound (LU) in the evaluation of cholangiocarcinoma and determination of tumor spread and vascular involvement. Of 25 patients referred for surgery, 6 were excluded following LU and were referred instead for palliative treatment. Diagnosis of the tumor was successful in 92%, and vascular involvement was diagnosed in 46%. LU should be an integral diagnostic test in the evaluation of choriocarcinoma.

Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators

BACKGROUND

The Bypass Angioplasty Revascularization Investigation (BARI) included 4039 patients with multivessel coronary artery disease; 1829 consented to randomization, and 2010 did not but were followed up in a registry. Thus, we can evaluate the outcome of physician-guided versus random assignment of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG).

METHODS AND RESULTS

We compared the baseline features and outcomes for PTCA and CABG in the overall registry and its predesignated subgroups. We assessed the impact of treatment by choice versus random assignment by comparing the results in the registry with those of the randomized trial. Statistical adjustments for differences in baseline characteristics were made. Within the registry, nearly twice as many patients were selected for PTCA (1189) as CABG (625); mortality at 7 years was similar for PTCA (13.9%) and CABG (14.2%) (P=0.66) before and after adjustment for baseline differences between patients selected for PTCA versus CABG (adjusted RR, 1.02; P=0.86). In contrast to the randomized trial, the 7-year mortality rate of treated diabetics in the registry was equally high (26%) with PTCA or CABG. Seven-year mortality was higher for patients undergoing PTCA in the randomized trial than in the registry (19.1% versus 13.9%, P<0.01) but not for those undergoing CABG (15.6% versus 14.2%, P=0.57). The adjusted relative mortality risk for PTCA in the randomized versus registry population was 1.17 (P=0.16).

CONCLUSIONS

BARI physicians were able to select PTCA rather than CABG for 65% of registry patients who underwent revascularization without compromising long-term survival either in the overall population or in treated diabetics.

Quantitative FISH analysis and in vitro suspension cultures of erythroid cells from maternal peripheral blood for the isolation of fetal cells

Several techniques for the enrichment of nucleated fetal red blood cells present in maternal blood have been reported. Here we describe the use of a quantitative fluorescence in situ hybridization (FISH) method and in vitro suspension cultures of erythroid cells from newborn cord blood and maternal peripheral blood. Together with a rapid high performance liquid chromatography (HPLC) method, that allows us to determine as few as 100 cells containing haemoglobin F (HbF), we have scrutinized the reported enrichment methods for fetal nucleated cells in peripheral maternal blood. One hundred FISH analyses on maternal peripheral blood were performed. The method comprises a cell lysis method for depletion of red cells with minimal losses of nucleated cells, uniform numbers of cells (750 000 cells each) on microscopic slides, and inclusion of internal controls to monitor the efficacy of hybridization. Twenty-six cultures of pure erythroid progenitor cells from maternal peripheral blood were analysed for the expansion of fetal cells. To generate these in vitro cultures, nucleated cells from 10-20 ml of peripheral blood from 26 pregnant women were grown in media containing growth factors and hormones to yield over 10(7) of immature erythroid cells within two weeks. Of those, 13 cultures were from pregnancies with confirmed male fetuses. A total of approximately 8x10(8) maternal cells were added into tissue culture medium for these 13 cultures, resulting in about 2x10(8) nearly pure erythroid cells after two weeks. Whereas fetal cells, alone or added into cultures of peripheral blood, grow rapidly and can be detected quantitatively, we could not find any fetal cells in cultures from maternal blood. Likewise, in 7.5x10(7) peripheral blood cells probed by FISH analysis (half of which were from pregnancies with male fetuses) no single Y chromosome was detected. In summary, suspension cultures of erythroid cells can be established routinely and easily. With the quantitative FISH technique used, 750 000 cells per slide can be screened reliably for cells with Y chromosomes. However, the stringent quality-criteria and most elaborate methods indicate that fetal cells in maternal peripheral blood can not be found using the current technology.

Deinstitutionalisation for long-term mental illness: an ethnographic study

OBJECTIVE

Deinstitutionalisation of seriously mentally ill people in the developed world, including Australia, has occurred since the middle of this century. Evaluation of the effects of this change on the lives of individuals is of paramount importance to ensure that policies are acceptable and effective. Increasingly, multifaceted studies are considered essential for comprehensive health research. The qualitative aspect of this study complements the clinical and economic components.

METHOD

An ethnographic approach enabled contextual, qualitative data to be gathered from within the social world of 47 hospital residents as they moved to the community. A social anthropologist acting explicitly as a participant observer undertook fieldwork over two and a half years both pre- and post-discharge. Qualitative data were collected, stored and analysed separately from quantitative and economic data.

RESULTS

Ethnographic findings generally supported and, in many cases, mirrored clinical results. Of the total cohort of 47 patients transferred to the community, the 40 who continue to live outside of hospital all reported a preference for community living. The importance of freedom and simple liberties cannot be underestimated as factors that enabled this resilient group of people to work creatively through difficult periods.

CONCLUSION

Properly planned and resourced deinstitutionalisation not only maintains people with a prolonged mental illness outside of hospital, it also enhances their quality of life. Subjective descriptive material focusing on personal experiences adds meaning to quantitative research data allowing health professionals to more fully understand the implications of health policy on the lives of individuals.