Family therapy in the treatment of adolescents

A family with an adolescent must transform itself from a predominantly nurturant unit to one that can tolerate and encourage the adolescent's need to separate. When an adolescent presents with symptoms that disrupt the developmental process, the clinician who is familiar with several models of family therapy is better able to select a therapeutic and cost-effective intervention. For family assessments, the authors recommend a biopsychosocial approach, which has replaced the outdated view that families cause psychiatric problems and which acknowledges the family as a potential source of healing. The authors describe several models of family therapy--Satir's communication model, the structural model of Minuchin, Bowen's cross-generational model, and psycho-education--and examine features of these approaches useful for working with adolescents. Illustrative vignettes and some guiding principles for matching model and problem are offered.

The use of electroconvulsive therapy in geriatric patients

The use of ECT has had a resurgence in the past decade as the promise of more effective and specific pharmacotherapy has been unfulfilled. This has been especially true in the elderly in whom ECT has been frequently demonstrated to be a safe and effective intervention. The decision to use ECT in an elderly patient is a complex one, based on the patient's illness, risks of the treatment compared with alternate or no treatment, and patient and family wishes. The list of dogmatic "absolute contraindications" for ECT has been replaced with a pragmatic philosophy looking at risk/benefit ratios. Such an attitude can only serve to enhance the quality of care clinicians provide their patients.

Unimpaired formation of hormone-stimulated inositol trisphosphate in human mesangial cells under hyperglycemic conditions

The relationship between bulk cellular myo-inositol content and phosphatidylinositol metabolism was evaluated in a human mesangial cell line under euglycemic and hyperglycemic conditions. Mesangial cells maintained in high glucose medium displayed a concentration-dependent fall in myo-inositol as measured by gas-liquid chromatography. Measurements of phosphatidylinositol, phosphatidylinositol 4-monophosphate and phosphatidylinositol 4,5-bisphosphate mass revealed slight but statistically insignificant increases in cells exposed to high glucose containing medium. CDP-diacylglycerol: myo-inositol 3-phosphatidylinositol transferase activity, measured in plasma membranes from mesangial cells grown under control and hyperglycemic conditions, was kinetically similar with Michaelis constants (Km values) for myo-inositol of 2.9 and 2.1 mM, respectively. Finally, hormone-stimulated intracellular calcium mobilization and myo-inositol 1,4,5-trisphosphate mass was measured from mesangial cells grown under normal and hyperglycemic conditions. Both intracellular calcium and inositol trisphosphate formation were unchanged in cells previously exposed to high glucose conditions (400 mg/dl) compared to cells grown under normal glucose concentration (100 mg/dl). These data indicate that bulk changes in myo-inositol induced by hyperglycemia are neither associated with alterations in basal levels of inositol containing glycerolipids nor with changes in hormone-stimulated calcium mobilization and inositol trisphosphate formation under conditions of short term changes in extracellular glucose.

Comparison of integrated systemic and emotionally focused approaches to couples therapy

This study compared couples receiving two marital therapy approaches and a control group over a 10-week treatment period. Integrated systemic therapy (IST) and an emotionally focused approach (EFT) were both found to be superior to the control and to be equally effective in alleviating marital distress, facilitating conflict resolution and goal attainment, and reducing target complaints at termination. IST couples, however, showed greater maintenance of gains from termination to 4-month follow-up on marital satisfaction and goal attainment. Clients' perceptions of how change occurred and issues related to the use of a team of observers in IST are discussed.

Effects of postmenopausal estrogen replacement on the concentrations and metabolism of plasma lipoproteins

BACKGROUND

Postmenopausal estrogen-replacement therapy may reduce the risk of cardiovascular disease, and this beneficial effect may be mediated in part by favorable changes in plasma lipid levels. However, the effects on plasma lipoprotein levels of postmenopausal estrogens in the low doses currently used have not been precisely quantified, and the mechanism of these effects is unknown.

METHODS

We conducted two randomized, double-blind crossover studies in healthy postmenopausal women who had normal lipid values at base line. In study 1, 31 women received placebo and conjugated estrogens at two doses (0.625 mg and 1.25 mg per day), each treatment for three months. In study 2, nine women received placebo, oral micronized estradiol (2 mg per day), and transdermal estradiol (0.1 mg twice a week), each treatment for six weeks. The metabolism of very-low-density lipoprotein (VLDL) and low-density lipoprotein (LDL) was measured by endogenously labeling their protein component, apolipoprotein B.

RESULTS

In study 1, the conjugated estrogens at doses of 0.625 mg per day and 1.25 mg per day decreased the mean LDL cholesterol level by 15 percent (95 percent confidence interval, 11 to 19 percent; P less than 0.0001) and 19 percent (95 percent confidence interval, 15 to 23 percent; P less than 0.0001), respectively; increased the HDL cholesterol level by 16 percent (95 percent confidence interval, 12 to 20 percent; P less than 0.0001) and 18 percent (95 percent confidence interval, 14 to 22 percent; P less than 0.0001), respectively; and increased VLDL triglyceride levels by 24 percent (95 percent confidence interval, 8 to 40 percent; P less than 0.003) and 42 percent (95 percent confidence interval, 26 to 58 percent; P less than 0.0001), respectively. In study 2, oral estradiol increased the mean concentration of large VLDL apolipoprotein B by 30 +/- 10 percent (P = 0.05) by increasing its production rate by 82 +/- 18 percent (P less than 0.01). Most of this additional large VLDL was cleared directly from the circulation and was not converted to small VLDL or LDL. Oral estradiol reduced LDL cholesterol concentrations by 14 +/- 3 percent (P less than 0.005), because LDL catabolism increased by 36 +/- 7 percent (P less than 0.005). The oral estradiol increased the HDL cholesterol level by 15 +/- 2 percent (P less than 0.0001). Transdermal estradiol had no effect.

CONCLUSIONS

The postmenopausal use of oral estrogens in low doses favorably alters LDL and HDL levels that may protect women against atherosclerosis, while minimizing potentially adverse effects on triglyceride levels. The decrease in LDL levels results from accelerated LDL catabolism; the increase in triglyceride levels results from increased production of large, triglyceride-rich VLDL.

A comparison of three desktop chemistry analyzers for the pediatric practice

Three desktop chemistry analyzers most frequently utilized in physicians' offices are compared for performance and precision: the DT60 (Kodak), Vision (Abbott), and Reflotron (Boehringer-Mannheim). The manufacturers' instructions were followed for all the reagents, calibrators and controls provided with each analyzer used. Precision, stability, dynamic range, interferences, and comparison of analyses of 50-100 patient samples with standard laboratory instruments were evaluated. Within-run precision on all three instruments was acceptable, the coefficient of variation (% CV) ranging from 0.8-5.4% and run-to-run precision CV of 1.1-7.3%. Within-run precision for glucose, blood urea, nitrogen, cholesterol and sodium for an experienced technologist, a clerk without any laboratory experience and a physician with no recent laboratory training were compared: the total CV varied between 1.1 and 6.3%. There are differences in the way bilirubin and hemoglobin interfere with the chemistries on the analyzers. Instrument size, available analyses, reagent cost and ease of operation were also assessed. The data suggest that all three analyzers performed well and would be suitable for the pediatric office setting.

Idiopathic trigeminal pain associated with gustatory stimuli

We present a unique case of a patient with facial pain evoked by gustatory stimuli. Pain was typically evoked by application of sucrose to the ipsilateral anterior 2/3 of the tongue, but not to the contralateral aspect. Pain was referred to the maxillary tuberosity area and, when stronger, to the infraorbital and supraorbital regions. Sucrose was most effective in eliciting pain, whilst saline, citric acid and water had a minimal effect. Spatial or temporal summation of gustatory stimuli was associated with stronger pain of longer duration and shorter latency. Some of the pain characteristics were similar to those of idiopathic trigeminal neuralgia. Thus, pain was elicited by innocuous ipsilateral stimuli, referred out of the stimulus zone, persisted beyond the period of stimulation and could be controlled with carbamazepine. We proposed a central neural mechanism for pain induction with convergence between gustatory stimuli afferents and pain pathways in the trigeminal system.

High level expression of the envelope glycoproteins of the human immunodeficiency virus type I in presence of rev gene using helper-independent adenovirus type 7 recombinants

The effect of rev (art/trs) gene on the level of HIV-1 envelope (env) expression using recombinant adenovirus was investigated. Recombinant adenoviruses expressing either the envelope or the rev gene of the human immunodeficiency virus type 1 (HIV-1) were constructed by inserting the gene into an expression cassette. The expression cassette contained the adenovirus type 7 major late promoter, followed by leader 1 of the adenovirus tripartite leader and a portion of intron between leaders 1 and 2, leaders 2 and 3, and a hexon polyadenylation signal. The cassette was then inserted at the terminal region between the E4 and ITR regions of the adenovirus 7 genome with a concomitant E3 region deletion (80-87 m.u.). A549 cells infected with the recombinant virus containing the env gene produced the envelope glycoproteins gp160, gp120, and gp41. HIV-1 envelope gene expression was greatly enhanced (20- to 50-fold) in the cells that were simultaneously infected with the recombinant adenovirus containing the rev gene as measured by ELISA and Western blotting. Interestingly, this effect was observed despite the lack of the 5' down splice site for rev and seems to be post-transcriptional. Another recombinant adenovirus which contains both the rev and the env genes was constructed by inserting the rev gene in the deleted E3 region and the env gene in the terminal cassette. This double recombinant virus expressed high levels of env antigen in A549 cells similar to those attained upon co-infection with two separate recombinant viruses containing the rev or env gene. Furthermore, the rev gene nucleotide sequence could be altered without altering the amino acid sequence and its sequences truncated by 17 amino acids from the C-terminus had no effect of rev function.

An interdisciplinary psychoeducation program for schizophrenic patients and their families in an acute care setting

A psychoeducation program in an acute care inpatient psychiatric setting involves schizophrenic patients and their families in a range of educational interventions that are responsive to their particular strengths and vulnerabilities. Patients receive one-on-one instruction about their illness from a psychiatrist and the nursing staff and learn community living skills in classes and tutorials conducted by occupational therapists. Families discuss ways of coping with the patients' illness in a series of meetings with a social worker, and they attend workshops led by a team of clinicians and an administrator, who advise them of current perspectives on the illness and its management and about how to negotiate the mental health system. A mental health library keeps staff, family, and patients abreast of recent literature about schizophrenia. The authors believe the program prepares patients to live in the community better than do programs whose goals are limited to symptom reduction or crisis intervention.

Renal histology of mucocutaneous lymph node syndrome (Kawasaki disease)

Renal involvement is well described in patients with mucocutaneous lymph node syndrome (MCLNS), or Kawasaki disease and is manifested by mild azotemia, hematuria, pyuria or cylinduria, and more often, proteinuria. Renal morphology during the acute stages of the illness has never been reported. In this paper we describe the renal histopathologic changes in a child with MCLNS. The glomerular histopathologic findings suggest immune complex damage to the kidney as a possible mechanism of nephrotoxicity in MCLNS. Presence of kidney lesions, which speak in favor of the injurious role of immune complexes in MLCNS may be relevant to the understanding of the pathogenesis of the vascular lesions that are characteristic of this disease.

Self-insured health plans

Nationwide, 8 percent of all employment-related health plans were self-insured in 1984, which translates into more than 175,000 self-insured plans according to our latest study of independent health plans. The propensity of an organization to self-insure differs primarily by its size, with large establishments more likely to self-insure. In the overwhelming majority of cases, the self-insured benefit was hospital and/or medical. Among employers who self-insure, 23 percent self-administer, and the remaining 77 percent hire a commercial insurance company, Blue Cross/Blue Shield plan, or an independent third-party administrator to administer the health plan.

Intratracheal thyroid: an unusual cause of upper airway obstruction in a newborn

The proper management of upper airway obstruction requires prompt recognition, correct diagnosis, and appropriate treatment. Of all the causes of upper airway compromise, intratracheal thyroid is one of the least common, especially in the newborn. The majority of cases reported involve adults or adolescents, mostly in European countries. The English literature has fewer cases, none involving a newborn. The authors report a case they believe to be the first example in the English language of obstructing intratracheal thyroid in a newborn. The authors' experience and literature review of this rare anomaly are presented in an effort to acquaint others with this often unthought of cause of airway compromise.

Enhancing the usability of safety software for microcomputers

With the proliferation of microcomputers, increasing effort is being made to write programs dealing with occupational safety and health. So as to assure the widespread use of this material, it is important that it be prepared in a manner easy to use. Ignoring this consideration may cause the potential users to be repelled by it from the start, or that its use will be difficult and error-prone. This article dwells on some of the points that need to be borne in mind when writing such software to make it easy and pleasant to use. Additionally, a project, carried out by the author, is described, which makes use of a free-form program access approach, as opposed to a purely menu-driven one. Two potential extensions of this approach are then described.

Serotonin-activated adenylate cyclase and the possible role of cyclic AMP in modulation of buccal muscle contraction in Aplysia

The possible role of cyclic AMP in mediating opposite modulatory effects of serotonin (5-HT) on Aplysia buccal mass muscles E1 and E2 was examined. Serotonin enhances E1 contractions and inhibits E2 contractions. Adenylate cyclase in membranes of both E1 and E2 is stimulated approximately 180% by 10(-6) M 5-HT and 300% by 10(-3) M 5-HT. Dibutyryl cyclic AMP and 8-benzylthio cyclic AMP mimicked the effect of 5-HT on E1 but had no effect on E2. Theophylline (Th) and isobutylmethylxanthine (IBMX) mimicked the effect of 5-HT on E1 at high concentrations. Concentrations of Th and IBMX low enough not to have any direct effect on contraction increased both the magnitude and duration of the effect of 5-HT on E1 contraction. Neither Th nor IBMX had a direct effect on E2 contraction, although Th produced a small increase in the effect of 5-HT on E2. These data are consistent with the hypothesis that cyclic AMP mediates the enhancement effect of 5-HT on E1 contraction. Other mechanisms probably mediate the effect of 5-HT on E2 contraction.

The practice of occupational safety and health--facing the twenty-first century

As a result of the increasing need for the services of occupational safety and health staff, with the concomitant costs, on the one hand, and rapid developments in the field of microcomputers, on the other, it was felt that a new conceptualization of safety practice, integral with computer use, was in order. To meet this objective, a microcomputer software package for interactive use by all levels of occupational safety and health practitioners, was prepared. The experience has indicated to the author that this is a viable and worthwhile approach, giving promise of enhancing the performance capabilities of lower level staff, and saving the time and effort of highly qualified practitioners.

Campylobacter enteritis in infants and young children

Campylobacter has recently been recognized as a common pathogen of the intestinal tract in pediatric practice. We report on 21 patients who were diagnosed as having enteritis due to Campylobacter jejuni infection. The most common symptom was diarrhea, accompanied by fever, vomiting and abdominal pain. The in vitro sensitivity test demonstrated the efficacy of aminoglycosides, chloramphenicol and erythromycin in the treatment of this disease. All the patients were symptom-free when discharged from the hospital.

Phase II trail cisplatin in refractory childhood cancer: Children's Cancer Study Group Report

A total of 114 children with solid tumors refractory to conventional therapy were evaluated for response and/or toxic effects after receiving cisplatin at doses of 3.0-4.5 mg/kg with aggressive hydration and mannitol diuresis every 3 weeks; a minimum of two courses was required for evaluation of response (110 patients). Objective responses were noted in 18 patients: rhabdomyosarcoma (three), Wilm's tumor (three), osteogenic sarcoma (three). Ewing's sarcoma (two), neuroblastoma (one), undifferentiated sarcoma (one), hepatoblastoma (one), ovarian teratoma (one), hepatocellular carcinoma (one), embryonal carcinoma of the mediastinum (one), and thymoma (one). Twenty-six patients had some evidence of renal toxicity. Asymptomatic hearing loss was commonly found when audiometry was performed (eight of 18 patients tested). Eight additional patients had symptomatic hearing problems--tinnitus or hearing loss. Myelosuppression was mild. Hypomagnesemia and/or hypocalcemia were common but only one patient had symptoms. Cisplatin, administered at a dose of 3.0 mg/kg with aggressive hydration and mannitol diuresis, is reasonably well-tolerated. Its role in the therapy for those tumors against which it shows activity remains to be determined.