Where do developing World clinicians obtain evidence for practice: a case study on pneumonia

There are few data on the practice of evidence based medicine in the developing world, nor on the actual sources of evidence that clinicians use in practice. To test the hypothesis that there was variation between and within developing countries in the proposed management of a patient with hospital acquired pneumonia, and that part of the variation can be explained by the sources of evidence used. Questionnaire responses to hypothetical case history. Investigators from 6 centres within the International Clinical Epidemiology Network (INCLEN) in China, Thailand, India, Egypt, and Kenya. Doctors chosen to represent primary and secondary hospital practice in the regions of the study centres. Investigations and initial treatments which would be ordered for a hypothetical 60-year-old woman who develops pneumonia 5 days after hospital admission, whether local data on antibiotic sensitivities are available and where information would be obtained to guide management. Chest x-ray and sputum gram stain/culture were consistently the most commonly ordered investigations, there being much greater variation in the initial treatment choices with either penicillin, a third-generation cephalosporin or aminoglycoside being the most popular choice. Textbooks were the commonest form of information source, and access to a library, textbooks and journals were statistically significantly associated with appropriate choice of investigations, but not treatment. Access to local antibiotic sensitivities was associated with appropriate initial treatment choice. Improving access to information in the literature and to local data may increase the practice of evidence-based medicine in the developing world.

Meiosis in holocentric chromosomes: orientation and segregation of an autosome and sex chromosomes in Triatoma infestans (Heteroptera)

The meiotic behaviour of the X chromosome and one autosomal pair of the heteropteran Triatoma infestans was analysed by means of C-banding plus DAPI staining. At first metaphase, the X univalent is oriented with its long axis parallel to the equatorial plate, which suggests a holocentric interaction with the spindle fibres. After this initial orientation, kinetic activity is restricted to one of both chromatid ends. The election of the active chromatid end is random and it is independent of the end selected in the sister chromatid. At second metaphase, the X and Y chromatids associate side by side forming a pseudobivalent. After that, the kinetic activity is again restricted to either of both chromosomal ends in a random fashion. At first metaphase, the fourth autosomal bivalent shows two alternative random orientations depending on the chromosome end showing kinetic activity (DAPI positive or opposite). At second metaphase, half bivalents are oriented with their long axis parallel to the equatorial plate. Three different segregation patterns are observed. The kinetic activity can be localised: (i) in the end with the DAPI signal (46.9%), (ii) in the opposite end (44.6%) or (iii) in one DAPI-positive end in one chromatid and in the opposite end in the other one (8.5%). The existence of the last pattern indicates that the same end can show kinetic activity during both meiotic divisions. Our results provide new information on the comparative meiotic behaviour of autosomes and sex chromosomes in holocentric systems.

Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem

BACKGROUND

Experimental studies have shown that administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to susceptible individuals can lead to the development of congestive heart failure (CHF). There have been few epidemiological investigations of the importance of this adverse effect.

OBJECTIVE

To estimate the relative risk of first admission to a hospital with CHF in recent users of NSAIDs, compared with nonusers, and to determine whether the estimated relative risk was increased in those with a history of heart disease and the extent to which the level of risk varied with the dose and half-life of the drugs consumed.

METHODS

We conducted a matched case-control study of the relationship between recent use of NSAIDs and hospitalization with CHF. Cases (n = 365) were patients admitted to hospitals with a primary diagnosis of CHF. Controls (n = 658) were patients without CHF who were admitted to the same hospitals as case patients. Structured interviews were used to obtain information on several study factors, including recent use of aspirin and other NSAIDs.

RESULTS

Use of NSAIDs (other than low-dose aspirin) in the previous week was associated with a doubling of the odds of a hospital admission with CHF (adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.3). Use of NSAIDs by patients with a history of heart disease was associated with an odds ratio of 10.5 (95% confidence interval, 2.5-44.9) for first admission with heart failure, compared with 1.6 (95% confidence interval, 0.7-3.7) in those without such a history. The odds of a first admission to a hospital with CHF was positively related to the dose of NSAID consumed in the previous week, and was increased to a greater extent with long half-life than with short half-life drugs. Assuming these relationships are causal, NSAIDs were responsible for approximately 19% of hospital admissions with CHF.

CONCLUSIONS

The burden of illness resulting from NSAID-related CHF may exceed that resulting from gastrointestinal tract damage. NSAIDs should be used with caution in patients with a history of cardiovascular disease.

[An integrated concept for contraception counseling and HIV prevention for young women: the Project Nécessaire]

PURPOSE

The aim of this study was to evaluate the effectiveness of the innovative project "Nécessaire" on sexual and reproductive health promotion. "Nécessaire" was developed for young women and carried out in the German-speaking part of Switzerland. The concept consisted of giving theoretical information in a brochure suitable for young women in its design combined with several items (such as condom, chewing gum, sticker) in a spongebag.

METHOD

Young women (n = 183) as well as professionals (n = 154) were asked to give their opinion on the "Necessaire" by filling in a semi-structured questionnaire. In addition, the product ordering was monitored over 7 months, in order to examine the use of the product by various institutions.

RESULTS

On the whole, the young women praised the product. They especially liked the brochure, which was made up like a diary written by a young woman called Rosa. According to their answers the combination of information and useful items stimulated the reflection on topics like sexuality, love, and prevention of sexually transmitted diseases. Critical voices pointed out the need for interventions aimed at young men, in order to make them more aware of their responsibility in contraception, HIV prevention and partnerships. The professionals generally would like to continue using the product in their work with young women. Many of them asked for more accompanying material with practical ideas for using the product. A similar product for young men and foreign youngsters was often asked for. The monitoring of the product ordering showed that schools and institutions such as youth centres evinced the greatest interest in the product. This contrasted with the results of a feasibility study conducted in advance. Although medical and advice centres indicated a need for a product to support professionals counselling young women, these institutions ordered relatively few kits.

CONCLUSION

Generally speaking the "Nécessaire" was well received by young women as well as by professionals. It not only informs on sexual health but also promotes preventive behaviour in daily life. The product was not used as an aid for counselling young women as much as was intended. It is suggested to promote the Nécessaire's use by taking specific measures like developing written material with practical ideas for professionals. In the case of developing a similar product for young men and migrants, their specific backgrounds and cultures should be taken into account and the material adapted accordingly.

Performance on the Modified Card Sorting Test by normal, healthy individuals: relationship to general intellectual ability and demographic variables

OBJECTIVES

The aim of this study was to obtain normative data for the Modified Card Sorting Test (MCST), and to examine the relationship between performance on this task, general intellectual ability and demographic variables.

DESIGN

A sample of 146 healthy individuals was tested with a demographic distribution (age, sex, socioeconomic class) similar to that of the British population.

METHODS

The MCST and the Wechsler Adult Intelligence Scales--Revised were administered to 146 people aged between 16 and 75 years.

RESULTS

Most people (56.6%) completed six categories, and many people made perseverative errors. Approximately 8% of the participants made over 50% perseverative errors. Performance on the MCST varied with age, years of education and general intellectual ability. Individuals with a Full Scale Intelligence Quotient (FSIQ) below 100 showed much more variability in performance than individuals with an FSIQ over 100. Detailed percentile norms for the performance on different indices of the test are presented.

CONCLUSIONS

The performance of individuals on the MCST is more closely associated with general intellectual ability than with demographic variables.

Squash procedure for protein immunolocalization in meiotic cells

Several techniques have been developed for protein immunolocalization in meiotic cells. However, most of them include treatments that lead to cell disruption and are only suitable for prophase-I cells. We describe a novel squash procedure of cell preparation for protein immunolabelling of different meiotic stages. This procedure is an alternative to both cryosectioning and whole spreading procedures. We present results obtained in mouse spermatocytes with three different antibodies: the MPM-2 mAb against mitotic phosphoepitopes, an anticentromere serum and a polyclonal serum against the SCP3 protein of the axial elements and lateral elements of the synaptonemal complex. The procedure was tested for single and double immunolabelling. With this technique a large number of cells at different meiotic stages can be analysed. Cell stages are easily identified and cell and chromosome structures are preserved. Thus, it allows the study of chromosome behaviour and the relationships between the different structural elements of the cell throughout meiotic divisions. Our procedure is also suitable for three-dimensional (3D) analyses and proved to be reliable in a wide range of systems including insects and mammals. In addition, the procedure may be interesting to obtain a rapid immunological diagnosis.

Obstetric outcome in women who present with a reduction in fetal movements in the third trimester of pregnancy

A complaint of decreased fetal movements is a common indication for the assessment of fetal well being. The aim of this study was to review the outcome of a group of women whose primary indication for referral was decreased fetal movements. Over a 20 month period, 435 patients were seen in the fetal assessment unit of an inner London teaching hospital, following a primary complaint of reduced fetal movements. Investigations included: the fetal abdominal circumference (AC), amniotic fluid volume (AFV), the umbilical artery pulsatility index (UAPI) derived from Doppler ultrasound waveforms and a computerised analysis of fetal heart rate (FHR) recordings or cardiotocograph (CTG). Outcome measures were: gestational age at delivery, Apgar score < 7 at 5 minutes, admission to the Special Care Baby Unit (SCBU), the need for delivery by an emergency cesarean section for fetal compromise (CSFC), and any perinatal deaths. A comparison of actual versus expected outcome for women with decreased fetal movement revealed the following relative risks, with the 95% confidence intervals (CI) in brackets; low 5 minute Apgar score 0.03 vs. 0.05 expected (CI = 0.01, 0.05), SCBU admission, 0.06 vs. 0.07 (0.04, 0.08), and preterm delivery, 0.08 vs. 0.11 (0.05, 0.10). Cesarean sections for fetal compromise, 0.07 vs. 0.053 (0.050-0.096). The addition of FHR monitoring to standard ultrasound assessment of well being did not appear to confer any added benefit. There were no fetal deaths. The outcome for pregnancies where the mother presents with decreased fetal movements in the third trimester is comparable with the outcome for the general population.

Proteasomal RNase activity in human epidermis

The proteasome is a cytoplasmic high-molecular-weight structure composed of several smaller protein and RNA subunits. It has been associated with non-lysosomal pathways of intracellular degradation, expressing multicatalytic proteinase activities and specific RNase activity. By standard methods, we have isolated andpartially purified proteasomes from human epidermis. We obtained the expected multiple 24-32 kDa subunits by SDS-PAGE, and evidence of RNA. Proteasomes degraded casein, as well as chromogens for t-PA and trypsin but not for chymotrypsin, these proteolytic activities overlap, but do not coincide with those observed in other organs. We found that human epidermal 28 S and 18 S rRNAs were degraded, but yeast RNA was not. By means of zymography, we demonstrated, for the first time, that RNase activity persists after dissociation of the proteasome on the gel and that it co-localizes to the same range of molecular weight subunits as the proteinase activity.

The effects of REM sleep-inhibiting drugs in neonatal rats: evidence for a distinction between neonatal active sleep and REM sleep

Neonatal active sleep (AS) has been considered to be homologous and continuous with rapid-eye-movement (REM) sleep in adult animals. We have recently proposed an alternative view that AS is an undifferentiated sleep state distinct from REM sleep. To test these opposing views on the relationship of AS and REM sleep, neonatal rats (P11, P14 and P20) were systemically injected with compounds that inhibit REM sleep in adults. Zimelidine (ZMI) and desipramine (DMI) are monoamine uptake inhibitors which increase synaptic concentrations of serotonin and norepinephrine, respectively. Serotonin and norepinephrine inhibit brainstem cholinergic neurons important in REM sleep generation. Atropine (ATR) is a muscarinic receptor antagonist that blocks the post-synaptic effects of cholinergic projections. Only DMI (5 mg/kg) suppressed AS at P11. ZMI (6 mg/kg) and ATR (6 mg/kg) did not suppress AS until P14. These data suggest that serotonergic and cholinergic regulation of AS are absent before P14. The fact that AS in P11 rats is not affected by cholinergic antagonists supports the hypothesis that AS and REM sleep represent different sleep states.

An approach to the neonate with sudden dysrhythmia: diagnosis, mechanisms, and management

The clinical course of a newborn can be rendered more complex by the sudden development of a disturbance in heart rhythm and conduction. The caregiver's ability to recognize a particular dysrhythmia and its most probable mechanism is crucial for optimal management. During the past 15 years, there has been significant progress in the understanding of the electrophysiologic basis of rhythm disturbances in the newborn period. This understanding has led to more precise diagnosis and effective treatment regimens for infants with dysrhythmias. Using recent case studies from one intensive care nursery as illustrations, this article discusses the clinical presentation and electrophysiologic mechanisms of three common forms of rhythm and conduction disturbance. The discussion pertains to disturbances of rhythm in association with tachycardia only. Emphasis is placed on the electrocardiographic diagnosis and clinical management of these infants.

Consumption of non-steroidal anti-inflammatory drugs and the development of functional renal impairment in elderly subjects. Results of a case-control study

AIMS

The aim of the present study was to explore the level of risk associated with community use of non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

We carried out a matched case-control study of the relationship between recent use of NSAIDs and the presence of functional renal impairment present at the time of hospitalisation with a range of clinical problems. Cases (n = 110) were consecutive patients admitted acutely to hospital who had serum creatinine levels greater than or equal to 0.15 mmol l(-1) , which improved by 20% or more within the next 14 days, or prior to discharge from hospital. Controls (n= 189) were subjects of the same sex and age (to within 5 years) as the cases, who were admitted to the same hospital, who had normal serum creatinine levels (<0.12 mmol l(-1) throughout their hospital stay. Information on a number of study factors, including recent use of aspirin and other NSAIDs, was obtained by structured interview.

RESULTS

Overall, there was a weak association between consumption of NSAIDs (including non-prophylactic aspirin) and the development of functional renal impairment-adjusted odds ratios (OR) with use of NSAIDs in the previous week or in the previous month: OR 1.5 (95% CI 0.80, 2.9) and 1.8 (95% CI 0.97, 3.4) respectively. In subjects with a previous history of renal disease the adjusted OR was 6.6 (0.75, 57.8) and in those with a history of gout or hyperuricaemia the OR was 7.2 (1.3, 40.2). There was a weak positive relationship between the dose of drug consumed in the previous week and the odds of functional renal impairment. The relationship between risk and published figures for drug half-lives (t1/2) was stronger. The odds ratio increased from 1.2 (95% CI 0.61, 2.4) with a t1/2 < or = 4 h, to 4.8 (1.5, 15.8) with a t1/2 of < or = 12 h (P=0.012, test for trend). This relationship remained statistically significant after adjustment for a number of clinical variables and the dose of drug ingested.

CONCLUSIONS

NSAIDs are an important cause of functional renal impairment in subjects with renal disease or a history of gout or hyperuricemia. The half-life of the drug is more important than the ingested dose in determining the risk of this outcome. Long half-life drugs should be avoided in individuals who are at risk of developing renal impairment.

Improved quality of life with megestrol acetate in patients with endocrine-insensitive advanced cancer: a randomised placebo-controlled trial. Australasian Megestrol Acetate Cooperative Study Group

PURPOSE

To investigate the effect of two doses of megestrol acetate (MA) compared with placebo on quality of life (QoL) and nutritional status (NS) in patients with advanced endocrine-insensitive cancer.

PATIENTS AND METHODS

Two hundred forty patients were randomised to double-blind MA 480 mg/day, MA 160 mg/day, or matching placebo for 12 weeks. Nutritional status (including weight, skinfold thickness and midarm circumference) and QoL (using 6 linear analogue self-assessment (LASA) scales) were assessed at randomisation and after four, eight and 12 weeks. A QoL ranking incorporating QoL and death was also used ranging from 1 = dead to 5 = much better QoL.

RESULTS

One hundred seventy-four patients were assessable at week four, 136 at week eight and 103 patients at week 12. Patients receiving MA reported substantially better appetite (P = 0.001), mood (P = 0.001) and overall quality of life (P < 0.001), and possibly less nausea and vomiting (P = 0.08) than patients receiving placebo, based on a test for trend. A larger benefit was seen with the higher dose which (unlike the lower dose) was significantly better in pairwise comparisons with placebo for appetite, mood and overall QoL (each P < or = 0.001). Despite some missing data on QoL scores, QoL ranking was available on 227 (95%) of patients with significantly higher QoL ranking associated with MA (P = 0.002). Improvements in QoL occurred early within four weeks and were sustained. No statistically significant differences were observed in NS measurements, including weight (P = 0.29). Side effects of therapy were minor and did not differ significantly across treatments.

CONCLUSION

Megestrol acetate given at 480 mg/day is useful palliation in patients with endocrine-insensitive advanced cancer. It improves appetite, mood and overall quality of life in these patients, although not through a direct effect on nutritional status.

Meiotic behaviour of holocentric chromosomes: orientation and segregation of autosomes in Triatoma infestans (Heteroptera)

The meiotic behaviour of the holocentric chromosomes of the heteropteran species Triatoma infestans has been analysed by means of orcein staining and C-banding on squashed spermatocytes. We have focused our analysis on chromosome 3, which shows a large distal heterochromatic band at one of the ends of both homologues. At metaphase I, and independently of the chiasma position, two alternative orientations have been observed: either the heterochromatic or the euchromatic ends of both homologues are directed to opposite poles. At anaphase I, the kinetic activity is restricted to the same chromosome end (euchromatic or heterochromatic) of each homologue. The frequencies of these two alternatives are not random and differ significantly among the five individuals analysed. However, the euchromatic ends present kinetic activity at a higher frequency than the heterochromatic ends. At metaphase II, half-bivalents also show the kinetic activity restricted to either of the chromosome ends (euchromatic or heterochromatic). The frequencies of each alternative are inverted in anaphase II compared with those scored in anaphase I. Accordingly, those ends that present kinetic activity at anaphase I segregate reductionally during the first meiotic division and equationally during the second meiotic division. These results provide sound evidence on the meiotic behaviour of holocentric chromosomes, as regards the absence of chiasma terminalization and the modes of orientation and segregation.

Management of hormone-resistant prostate cancer: an Australian trial

The management of metastatic prostate cancer that has relapsed after initial hormonal manipulation remains a major problem, with the majority of patients dying within 12 months. Their clinical course is frequently characterized by progressive debilitation, pain, and other tumor-related symptoms. A phase II, non-randomized multicenter clinical trial was carried out in Australia in 1985-1986 to assess the efficacy and toxicity of mitoxantrone. Substantial anticancer activity was shown against hormone-refractory prostate cancer, indicated by reduction in tumor-related symptoms, improvement in quality of life indices, and a median survival of 10 months in patients with a heavy tumor burden. Although it is not possible to equate this nonrandomized series more fully with current experience since routine prostate-specific antigen measurement was not performed, the median survival of 10 months was equivalent to or better than the survival times reported from most other institutional reports of the time. Even more importantly, however, major improvements were noted in such subjective indices as reduction in pain, weight gain, and performance status. Toxicity was also acceptable, with the major side effect being asymptomatic myelosuppression.

The osmium tetroxide-p-phenylenediamine procedure reveals the chromatid cores and kinetochores of meiotic chromosomes by light and electron microscopy

We analyzed first-metaphase meiotic chromosomes of the grasshopper Chorthippus jucundus by two different methods, i.e., a silver impregnation technique and the osmium tetroxide-p-phenylenediamine (Os-PPD) procedure. The former was applied on squashed testes previously fixed in ethanol-acetic acid, whereas for Os-PPD the material was not subjected to any previous extraction treatment but was fixed in OsO4, treated with PPD, and embedded in Epon 812. Both techniques revealed chromatid cores and kinetochores regardless of the processing of the material (squashed or sectioned). Unstained Os-PPD sections were analyzed by light microscopy and transmission electron microscopy (TEM). The Os-PPD technique provided a high contrast of chromatid cores and kinetochores in relation to the chromatin, which revealed a low electron density. To determine the Os-PPD reaction mechanism, the PAS procedure, as well as scanning electron microscopy (SEM) backscattering and SEM X-ray microanalysis, was performed on sections. By use of the Os-PPD-PAS procedure, glycol groups formed by oxidation of osmium bound to aromatic substrates were detected in chromatid cores and kinetochores by brightfield and fluorescence microscopy. A high Z contrast was detected in these structures by backscattered electron imaging. SEM X-ray microanalysis showed osmium and phosphorus to be the main elements present on the chromatid cores. Taking into account the known reactivity of OsO4 and the present results, the possible participation of nucleic acids as well as proteins in the Os-PPD reaction mechanism and in the composition of chromatid cores and kinetochores is discussed.

The quantitation of coupled bead antibody by enzyme-linked immunosorbent assay

Quantitation of antibody coupled to a derivatized polystyrene bead through a bifunctional cross linker can be accomplished by a competitive enzyme-linked immunosorbent assay (ELISA) method. This sensitive method is less subject to interference than other protein assay methods such as bicinchoninic acid (BCA) or Lowry. The competitive ELISA method consists of incubating the coupled bead with a (20/80) weight ratio of goat anti mouse kappa alkaline phosphatase/goat anti mouse kappa (GAMKAP/GAMK) for 1.5 hours at 37 degrees C, washing, adding p-nitrophenyl phosphate (PNPP) substrate, and reading the absorbance at 405/450 nm. A standard curve is established with radiolabeled antibody beads for microgram quantitation.