Patients' perspectives on the burden of recurrent genital herpes

The purpose of this study was to quantify the impact of recurrent genital herpes (RGH) on health-related quality of life, healthcare resource and workplace productivity. This was a cross-sectional survey conducted in 5 countries (Australia, Denmark, Italy, The Netherlands and UK). Patients with a confirmed history of RGH completed the MOS 36-Item Short Form Health Survey (SF-36) and the Recurrent Genital Herpes Quality of Life questionnaire (RGHQoL). Questionnaires addressing frequency of access to healthcare services and workplace productivity were also completed and patients' medical history was obtained. Scores for 6 of the 8 domains of the SF-36 were significantly lower (P<0.001) i.e. worse, compared with scores for the normal population. The RGHQoL score was significantly lower in patients experiencing more frequent or more severe recurrences. Forty-five per cent of patients estimated that their work effectiveness was reduced by between 25% and 50% due to genital herpes symptoms.

Volunteer-based universal newborn hearing screening program

OBJECTIVE

To evaluate efficacy and costs of a volunteer-based universal newborn hearing screening program.

METHODS

The Lucile Packard Children's Hospital at Stanford newborn hearing screening program database was reviewed. Results and costs of the hearing screens were analyzed.

RESULTS

Hearing screens were performed on 5771 newborns treated in the well-baby nursery and nine infants from this population were identified with hearing loss, seven of whom had no risks factors for hearing loss. Using volunteers to perform the first-line screen with the automated auditory brainstem response (AABR) technology, 91% of infants registered for screening were evaluated prior to discharge. An additional 4% of infants were screened as outpatients. If an infant failed the AABR on two occasions, he or she was rescreened with the AABR or transient evoked otoacoustic emissions by a licensed audiologist, often while the infant was still in the hospital. Using this algorithm, 5% of infants tested in the well-baby nursery needed additional follow-up as an outpatient. Cost analysis of this volunteer-based program reveals a per/baby screening cost of $27.41.

CONCLUSIONS

A volunteer-based hearing screening program is a viable option for hearing screening in well-baby nurseries but does not result in significant cost savings during the first 2 years of the program.

A prospective, randomized comparison of the use versus non-use of topical corticosteroids after laser in situ keratomileusis

OBJECTIVE

To evaluate the benefit and safety of topical corticosteroids after laser in situ keratomileusis (LASIK).

DESIGN

Prospective, randomized, double-masked clinical trial.

PARTICIPANTS

A consecutive series of 1747 eyes in 897 patients desiring surgical correction of myopia from plano to -16 diopters (D) with up to 6 D of astigmatism.

INTERVENTION

Patients were randomly assigned to topical corticosteroids or artificial tears.

MAIN OUTCOME MEASURES

The primary outcome measure was stability of refraction. Secondary outcome measures were differences in best-corrected visual acuity, decrease in spherical refractive myopia, improvement in uncorrected visual acuity, predictability of achieved corrections versus planned corrections, evaluation of postoperative haze, preservation of best-corrected visual acuity, intraocular pressure, and incidence of complications and adverse events.

RESULTS

No difference was found between the groups for refractive accuracy, best-corrected or uncorrected visual acuity, or safety. Topical corticosteroids were associated with a prolonged period of refractive regression in moderate to high myopes (-7.25 to -16.00 D) (P = 0.01). Increased haze was noted at the 1 week examination for eyes not receiving topical steroids (P = 0.008); however, in most cases this was clinically insignificant. Thirty-six eyes (2.1%) required supplemental topical corticosteroids unrelated to reoperation. Two eyes received these on the first postoperative day and 15 at the 1-week examination.

CONCLUSIONS

Topical corticosteroids did not seem to play any beneficial role in routine postoperative treatment after LASIK, and they were associated with decreased stability of refraction in more highly myopic eyes. Eyes that require additional topical corticosteroids are easily identified at either the initial postoperative examinations or during the course of routine postoperative care.

Detection of leukemic cells in the CD34(+)CD38(-) bone marrow progenitor population in children with acute lymphoblastic leukemia

Successful autologous hematopoietic stem cell (HSC) transplantation in childhood acute lymphoblastic leukemia (ALL) requires the ability to either selectively kill the leukemia cells or separate normal from leukemic HSC. Based on previous studies showing that more than 95% of childhood B-lineage ALL express CD38, this study evaluated whether normal CD34(+)CD38(-) progenitors from children with B-lineage ALL could be isolated by flow cytometry. CD34(+) cells from bone marrow samples from 10 children with B-lineage ALL were isolated at day 28 of treatment, when clinical remission had been attained. The CD34(+) progenitor cells were flow cytometrically sorted into CD34(+)CD38(+) and CD34(+)CD38(-) populations. The absolute numbers of CD34(+)CD38(-) cells that could be isolated ranged from 401 to 6245. The cells were then analyzed for the presence of clonotypic rearrangements of the T-cell receptor (TCR) Vdelta2-Ddelta3 locus. Only patients whose diagnostic marrow had an informative TCR Vdelta2-Ddelta3 rearrangement were included in this study. Detection thresholds were typically 10(-4) to 10(-5) leukemic cells in normal marrow. In 6 of 10 samples analyzed, the sorted CD34(+)CD38(-) cells had no detectable Vdelta2-Ddelta3 rearrangements. In 4 cases, the clonotypic leukemic Vdelta2-Ddelta3 rearrangement was detected in the CD34(+)CD38(-) population, indicating that the putative normal HSC population also contained leukemic cells. The data indicate that although most childhood ALL cells express CD34 and CD38, leukemic cells are also frequently present in the CD34(+)CD38(-) population. Therefore, strategies to isolate and transplant normal HSC from children with ALL will require a more stringent definition of the normal HSC than the CD34(+)CD38(-) phenotype. (Blood. 2001;97:3925-3930)

Percutaneous core biopsy of the breast: correlates of anxiety

RATIONALE AND OBJECTIVES

The authors performed this study to investigate the level of patient anxiety immediately preceding breast biopsy and examined potential clinical and demographic correlates of anxiety.

MATERIALS AND METHODS

The authors evaluated 102 women who were referred to a radiology breast clinic to undergo breast biopsy. The women were assessed with a self-report of demographic and medical items and the State Trait Anxiety Inventory (STAI) immediately before their biopsy. The STAI also was administered at 1 and 5 days after biopsy.

RESULTS

The participants' mean state anxiety T score as measured with the State Trait Anxiety Inventory was 71.1 (standard deviation, 7.2). Multiple regression analysis was performed to determine the correlates of state anxiety. The variables that showed the strongest correlation with state anxiety were trait anxiety, being concerned about the results of biopsy, education (less education was associated with more anxiety), age (an older age was associated with more anxiety), and number of relatives with breast cancer. Given the expected overlap (r = 0.55) between state and trait anxiety, a second regression analysis was performed that controlled for trait anxiety. The results of this analysis also identified age, being concerned about the results of the biopsy. and number of relatives with breast cancer as relevant correlates of state anxiety.

CONCLUSION

Overall, the results give some indication of the characteristics of women likely to be most anxious before biopsy. Future research should assess the effectiveness of different strategies for addressing situational anxiety.

Effects of environmental antiandrogens on reproductive development in experimental animals

Chemicals that act as androgen receptor (AR) agonists and antagonists or inhibit fetal steroidogenesis can induce reproductive malformations in humans and laboratory animals. Several environmental chemicals disrupt development in rats and/or rabbits at fetal concentrations at, or near, exposure levels seen in some segments of the human population. In rats, fetal tissues concentrations of 10-20 p.p.m. of the DDT metabolite, p,p'-DDE, are correlated with reproductive abnormalities in male offspring. These concentrations are similar to those measured in first-trimester human fetal tissues in the late 1960s. The pesticides vinclozolin, procymidone, linuron and DDT are AR antagonists. They reduce male rat anogenital distance, and induce areolas at relatively low dosages. Hypospadias, agenesis of the sex accessory tissues and retained nipples are seen in the middle dosages, while undescended testes and epididymal agenesis are seen in the highest doses. Phthalate esters (PE) inhibit testosterone synthesis during fetal life, but do not appear to be AR antagonists. Prenatal administration of a single low dose of dioxin (50-1,000 ng TCDD/kg) alters the differentiation of androgen-dependent tissues at p.p.t. concentrations, but the mechanism of action likely involves interaction with a hormone-like nuclear transcription factor, the hormone-like receptor AhR, rather than AR. p,p'-DDT and p,p'-DDE, vinclozolin and di-n-butyl phthalate affect reproductive function in rabbits when administered during prenatal and/or neonatal life. Cryptorchidism and carcinoma in situ-like (CIS) testicular lesions were seen in male rabbits treated during development with p,p'-DDT or p,p'-DDE. Extrapolation of effects from rodents to humans would be enhanced if future studies incorporate determination of tissue concentrations of the active metabolites. Knowledge of the tissue concentrations of the active toxicants also would provide an important link to in-vitro studies, which provide more useful mechanistic information when they are executed at relevant concentrations.

Impact of a multidisciplinary day program on disease and healthcare costs in children and adolescents with severe asthma: a two-year follow-up study

For patients whose asthma remains in poor control necessitating high utilization of medical services, a referral to a specialized "center of excellence" is often considered. A decade ago, we evaluated our pediatric asthma program of long-term hospitalization (median stay of 75 days) and found significant decreases in subjects' medical utilization following this intervention. In an effort to contain treatment costs, the former program was markedly altered to one of abbreviated stay with emphasis on family management of asthma. The purpose of the present study was to determine the outcome of children treated in the revised program with regard to disease severity, quality of life, and subsequent utilization of medical resources. Children with severe asthma who were admitted to the program and fulfilled study criteria were consecutively enrolled. Data was obtained concerning disease characteristics, treatment, and quality of life at admission, and at 1 and 2 years following discharge. Medical records for the year prior to program admission and for the 2 years following discharge were coded for medical care encounters. Ninety-eight children, aged 9 months to 18 years (mean age, 10.9 years), were enrolled. They participated in the program for a mean of 15.6 ( +/- 8 SD), median of 15.0, and range of 2-51 treatment days. The group showed significant improvement (P < 0.0001) from admission to 1- and 2-year follow-up in median corticosteroid use, asthma functional severity, perceived competence in asthma management, and quality of life for both caregiver and child. Medical record data showed significant improvement (P < 0.0001) at both 1- and 2-year follow-up in median number of corticosteroid bursts, emergency department visits, hospital days, and overall utilization of medical care encounters. A median total medical encounter cost/patient of $16,250 ($6,972-$25,714 interquartile range (IQR)) for the year prior to program participation was reduced to $1,902 ($505-$6,524 IQR) at 1-year and $690 ($185-$3,550 IQR) at 2- year follow-up (P < 0.0001). We conclude that multidisciplinary care in a short-term, outpatient, day treatment program can significantly contribute to improvement in asthma severity, quality of life, and reduction in healthcare costs.

Recurrent atypical fibroxanthoma of the cheek

We report a case of recurrent atypical fibroxanthoma (AFX) of the preauricular area that recurred after Mohs micrographic surgery. AFX is a benign cutaneous fibrohistiocytic tumor that is most commonly found in elderly patients. Although these tumors are benign, they may mimic spindle cell carcinoma, squamous cell carcinoma, and melanoma on histologic examination. AFX tumors rarely recur or metastasize. Wide excision is recommended for the achievement of the best results.

Perinatal exposure to the phthalates DEHP, BBP, and DINP, but not DEP, DMP, or DOTP, alters sexual differentiation of the male rat

In mammals, exposure to antiandrogenic chemicals during sexual differentiation can produce malformations of the reproductive tract. Perinatal administration of AR antagonists like vinclozolin and procymidone or chemicals like di(2-ethylhexyl) phthalate (DEHP) that inhibit fetal testicular testosterone production demasculinize the males such that they display reduced anogenital distance (AGD), retained nipples, cleft phallus with hypospadias, undescended testes, a vaginal pouch, epididymal agenesis, and small to absent sex accessory glands as adults. In addition to DEHP, di-n-butyl (DBP) also has been shown to display antiandrogenic activity and induce malformations in male rats. In the current investigation, we examined several phthalate esters to determine if they altered sexual differentiation in an antiandrogenic manner. We hypothesized that the phthalate esters that altered testis function in the pubertal male rat would also alter testis function in the fetal male and produce malformations of androgen-dependent tissues. In this regard, we expected that benzyl butyl (BBP) and diethylhexyl (DEHP) phthalate would alter sexual differentiation, while dioctyl tere- (DOTP or DEHT), diethyl (DEP), and dimethyl (DMP) phthalate would not. We expected that the phthalate mixture diisononyl phthalate (DINP) would be weakly active due to the presence of some phthalates with a 6-7 ester group. DEHP, BBP, DINP, DEP, DMP, or DOTP were administered orally to the dam at 0.75 g/kg from gestational day (GD) 14 to postnatal day (PND) 3. None of the treatments induced overt maternal toxicity or reduced litter sizes. While only DEHP treatment reduced maternal weight gain during the entire dosing period by about 15 g, both DEHP and DINP reduced pregnancy weight gain to GD 21 by 24 g and 14 g, respectively. DEHP and BBP treatments reduced pup weight at birth (15%). Male (but not female) pups from the DEHP and BBP groups displayed shortened AGDs (about 30%) and reduced testis weights (about 35%). As infants, males in the DEHP, BBP, and DINP groups displayed femalelike areolas/nipples (87, 70, and 22% (p < 0.01), respectively, versus 0% in other groups). All three of the phthalate treatments that induced areolas also induced a significant incidence of reproductive malformations. The percentages of males with malformations were 82% (p < 0.0001) for DEHP, 84% (p < 0.0001) for BBP, and 7.7% (p < 0.04) in the DINP group. In summary, DEHP, BBP, and DINP all altered sexual differentiation, whereas DOTP, DEP, and DMP were ineffective at this dose. Whereas DEHP and BBP were of equivalent potency, DINP was about an order of magnitude less active.

Precisely positioned nucleosomes are not essential for c-fos gene regulation in vivo

Chromatin architecture plays a decisive role in many aspects of transcription regulation. We have tested the role of specific chromatin structures in c-fos gene regulation, using a gene transfer system based on episomes derived from the Epstein-Barr virus (EBV). This system reproduces in several respects the chromatin structure and regulation of the chromosomal c-fos gene. Using this approach, we first demonstrate that the pausing of RNA polymerase II downstream of the transcriptional start site does not require precisely positioned nucleosomes. Indeed, changing the pattern of MNase hypersensitive sites along the transcribed sequence does not perturb RNA polymerase II pausing or the regulation of the c-fos gene. Next, we show that a putative nucleosome positioned between the SIE/SRE elements (-300) and the CRE/TATA elements (-36) is not necessary for activation by a variety of inducers. Accordingly, total or partial deletion of the putative nucleosome sequence does not disturb c-fos regulation while the two regulatory sites flanking the nucleosome sequence remain hypersensitive to MNase. As described in this paper, EBV episomes are useful vectors to critically examine the role of the chromatin structure in gene transcription for human cells.

Organization and conservation of the GART/SON/DONSON locus in mouse and human genomes

The SON gene, which maps to human chromosome 21q22.1-q22.2, encodes a novel regulatory protein. Here we describe the organization of the Son locus in the mouse genome. The mouse Son gene spans a region of approximately 35 kb. The coding region is more than 8 kb in length and has been completely sequenced. The gene is organized into 11 coding exons and 1 noncoding 3'UTR exon, with over 70% of the coding region residing in one 5.7-kb exon. The gene contains at least one alternative exon, N/C exon 1, which can be used, by splicing, to generate a truncated form of the SON protein. Further investigation of the mouse Son locus has identified the genes directly flanking Son. The glycinamide ribonucleotide formyltransferase gene, Gart, is encoded 5' of Son in a head-to-head arrangement, with the start of both genes lying within 899 bp. Sequence comparison with the expressed sequence tagged database identified a novel gene within 65 bp of the 3' end of Son, which we have named Donson. In this unusually compact gene cluster, we have found overlap in the pattern of expression between Gart, Son, and Donson. However, at least two of these genes have very different functions. While GART is involved in purine biosynthesis, we find that SON shows the characteristics of "SR- type" proteins, which are involved in mRNA processing and gene expression.

Cognitive function in UK community-dwelling African Caribbean and white elders: a pilot study

In recent years there has been interest in risk of cognitive impairment and dementia in populations of African origin. Little is known about this risk in older African Caribbean residents in the UK. One difficulty is lack of consensus over an adequate cognitive test battery for this community. Forty-five African Caribbean and 45 age and gender matched white community residents were recruited by household enumeration of an inner London electoral ward. These participants were administered the MMSE during a screening interview. Where possible, this was followed up by tests from the CERAD and CAMCOG neuropsychological batteries, a medical examination, and a structured interview with an informant. Based on these data, a psychiatrist blind to ethnicity independently rated 86 of these participants (41 of the African Caribbeans, all 45 of the whites) as cognitively normal, cognitively impaired, or demented. Of 41 African Caribbeans, 18 (44%) were rated as cognitively normal, 9 (22%) were rated as cognitively impaired, and 14 (34%) were rated as demented. Of the 45 whites, 39 (87%) were rated as cognitively normal, 4 (9%) were rated as cognitively impaired, and 2 (4%) were rated as demented. African Caribbeans scored significantly lower than whites in most cognitive test scores, which was not accounted for by their lower educational and occupational attainment, or their higher frequency of cardiovascular risk factors. African Caribbean elders in the UK appear to be at high risk of cognitive impairment and dementia. However, the influence of potential confounding factors such as socio-economic position and ill-health, and the effect of cultural test bias, cannot be ruled out.

Behavioural measurement of postoperative pain after oral surgery

The amount and type of postoperative analgesia prescribed depends on the clinician's judgement of the patient's need. Among other factors, this judgement is likely to be based on the patient's behaviour. The primary aim of this study was to investigate the validity of using behavioural measures to provide information about a patient's experience of pain during the early stages of recovery from oral surgery under general anaesthesia. Behavioural measures were not valid measures of acute postoperative pain, which suggests that while clinicians may build a better picture of a patient's experience of pain by including behavioural observation in their range of assessments, they should not rely on them when judging a patient's need for analgesia. The results also show differences between the sexes in their reaction to pain. Significantly more women than men showed signs of pain, despite little difference in self-rating pain scores.

Competence to stand trial: a neuropsychological inquiry

How might the deconstruction of the legal theory of competence be related to modern neuropsychological models of cognition? To address this question, we examined retrospectively the relationship between clinical judgments of competence of defendants committed to a maximum security psychiatric facility and their neuropsychological test scores on measures of intelligence, memory, attention, academics, and executive function. In addition, based on both neuropsychological and legal theory, we examined whether subtypes of memory, namely episodic and semantic, and intelligence, specifically social intelligence, would have special relevance to these clinical judgements of competence. Results indicated that in relation to the defendants recommended as incompetent to stand trial (IST), defendants recommended as competent to stand trial (CST) scored significantly higher on summary indexes of psychometric intelligence, attention, and memory, especially verbal memory, but not significantly higher on tests of academics or executive function. Moreover, CST defendants scored significantly higher than did IST defendants on selective tests of episodic memory and social intelligence, but not on measures of semantic memory. Partial correlation also revealed a significant relationship between the likelihood of an IST recommendation and lower scores on tests of episodic memory and social intelligence, but not on measures of semantic memory. These findings illustrate the theoretical import of neuropsychological methods and concepts to the burgeoning nomological net known as competence.

Reconstructive surgery in children after meningococcal purpura fulminans

BACKGROUND/PURPOSE

Purpura fulminans (PF) is a serious, often life-threatening disease. As more children are surviving their disease, surgeons are presented with increasing numbers of multiple and complicated wounds as sequelae of PF. The purpose of this paper is to review the management of nine cases of PF, and present the reconstruction method in treating bilateral exposed elbow and knee joints.

METHODS

All cases of pediatric patients with PF and treated by the division of plastic and reconstructive surgery between 1986 and 1998 were reviewed.

RESULTS

Seven children (78%) had meningococcal PF, and one (11%) had PF after Haemophilus influenza septicemia. PF developed in one (11%) but with no growth in either blood or cerebrospinal fluid cultures. Five children (56%) required amputation procedures. Two children (22%) required knee disarticulation. Two patients (22%) had free myocutaneous flap transfers for bone coverage. One (11%) had PF involving the face.

CONCLUSIONS

Meningococcal PF is a rare, often life-threatening disease generally of childhood. More children are surviving their diseases but with devastating sequelae. Successful reconstructive treatment outcome of these children requires a multidisciplinary team approach involving multiple specialties. The goal is to preserve function, maintain maximal length, and salvage limbs when possible. Flexibility and innovation are necessary in treating these multiple and complicated wounds.

Myocardial infarction and coronary artery involvement in giant cell arteritis

PURPOSE

To describe the pathologic findings in an unusual case of giant cell arteritis that presented initially with visual loss and rapidly culminated in myocardial infarction.

CASE REPORT

After the death of the patient, a complete autopsy was performed, including bilateral enucleation. All specimens, including a temporal artery biopsy completed before the patients death, were processed for routine paraffin histology and initially stained with hematoxylin and eosin. Elastic stains were subsequently used on specimens of temporal and coronary artery. The patient presented with loss of vision in the right eye. The clinical diagnosis was anterior ischemic optic neuropathy, secondary to temporal arteritis. The temporal artery biopsy was positive. Despite high-dose corticosteroid administration, the patient progressed to neurologic impairment, and subsequently to a fatal myocardial infarction.

DISCUSSION

Previous reports of temporal arteritis with coronary involvement are summarized. Myocardial infarction may be a more common early complication of temporal arteritis than appreciated previously. This important complication can occur despite administration of high-dose corticosteroid therapy.

Administration of potentially antiandrogenic pesticides (procymidone, linuron, iprodione, chlozolinate, p,p'-DDE, and ketoconazole) and toxic substances (dibutyl- and diethylhexyl phthalate, PCB 169, and ethane dimethane sulphonate) during sexual differentiation produces diverse profiles of reproductive malformations in the male rat

Antiandrogenic chemicals alter sexual differentiation by a variety of mechanisms, and as a consequence, they induce different profiles of effects. For example, in utero treatment with the androgen receptor (AR) antagonist, flutamide, produces ventral prostate agenesis and testicular nondescent, while in contrast, finasteride, an inhibitor of 5 alpha-dihydrotestosterone (DHT) synthesis, rarely, if ever, induces such malformations. In this regard, it was recently proposed that dibutyl phthalate (DBP) alters reproductive development by a different mechanism of action than flutamide or vinclozolin (V), which are AR antagonists, because the male offsprings display an unusually high incidence of testicular and epididymal alterations--effects rarely seen after in utero flutamide or V treatment. In this study, we present original data describing the reproductive effects of 10 known or suspected anti-androgens, including a Leydig cell toxicant ethane dimethane sulphonate (EDS, 50 mg kg-1 day-1), linuron (L, 100 mg kg-1 day-1), p,p'-DDE (100 mg kg-1 day-1), ketoconazole (12-50 mg kg-1 day-1), procymidone (P, 100 mg kg-1 day-1), chlozolinate (100 mg kg-1 day-1), iprodione (100 mg kg-1 day-1), DBP (500 mg kg-1 day-1), diethylhexyl phthalate (DEHP, 750 mg kg-1 day-1), and polychlorinated biphenyl (PCB) congener no. 169 (single dose of 1.8 mg kg-1). Our analysis indicates that the chemicals discussed here can be clustered into three or four separate groups, based on the resulting profiles of reproductive effects. Vinclozolin, P, and DDE, known AR ligands, produce similar profiles of toxicity. However, p,p'-DDE is less potent in this regard. DBP and DEHP produce a profile distinct from the above AR ligands. Male offsprings display a higher incidence of epididymal and testicular lesions than generally seen with flutamide, P, or V even at high dosage levels. Linuron treatment induced a level of external effects consistent with its low affinity for AR [reduced anogenital distance (AGD), retained nipples, and a low incidence of hypospadias]. However, L treatment also induced an unanticipated degree of malformed epididymides and testis atrophy. In fact, the profile of effects induced by L was similar to that seen with DBP. These results suggest that L may display several mechanisms of endocrine toxicity, one of which involves AR binding. Chlozolinate and iprodione did not produce any signs of maternal or fetal endocrine toxicity at 100 mg kg-1 day-1. EDS produced severe maternal toxicity and a 45% reduction in size at birth, which resulted in the death of all neonates by 5 days of age. However, EDS only reduced AGD in male pups by 15%. Ketoconazole did not demasculinize or feminize males but rather displayed anti-hormonal activities, apparently by inhibiting ovarian hormone synthesis, which resulted in delayed delivery and whole litter loss. In summary, the above in vivo data suggest that the chemicals we studied alter male sexual differentiation via different mechanisms. The anti-androgens V, P, and p,p'-DDE produce flutamide-like profiles that are distinct from those seen with DBP, DEHP, and L. The effects of PCB 169 bear little resemblance to those of any known anti-androgen. Only in depth in vitro studies will reveal the degree to which one can rely upon in vivo studies, like those presented here, to predict the cellular and molecular mechanisms of developmental toxicity.

The management of diabetes at primary level in South Africa: the results of a facility-based assessment

Diabetes is a widespread condition in South Africa and is often managed at primary level health facilities. This study aimed to assess the quality of diabetes management using a rapid assessment approach, focusing on three indicators as proxy measurements of quality: the regularity of blood glucose level (BGL) measurement; the percentage of patients whose BGLs were within 'acceptable' limits (under 10.0 mmol/l) on at least 75% of visits; the rate at which action was taken in response to high BGLs. Five sites were included in the study, including public and private, doctor- and nurse-based facilities. A total of 128 records were examined. Only 33% of all records were found to be well-managed according to the study criteria. None of the individual facilities were found to have more than 40% of patients achieving BGLs within the study limits. Some obstacles to good glycaemic control were costs to patients, transport problems, a lack of health education and shortcomings in clinical expertise. Policy implications and recommendations are suggested.

Evaluation of rural ambulance services

The evaluation of ambulance services in a rural area of South Africa is described. The approach is affordable and could be applied in other countries. As well as providing valuable information it involves health workers in planning, motivates them to improve service delivery, and lends support to their requests for increased resources.

The use of remifentanil in general anaesthesia for caesarean section in a patient with mitral valve disease

We report the use of remifentanil as part of a general anaesthetic technique for a patient with mixed mitral valve disease, asthma and pre-eclampsia presenting for an emergency Caesarean section. The use of remifentanil was associated with stable haemodynamic variables during general anaesthesia. No clinically significant respiratory depression was noted in the neonate.

Tissue-specific chromatin structure at the hepatocyte growth factor/scatter factor gene promoter

Hepatocyte growth factor/scatter factor (HGF/SF) is a recently characterised molecule with many remarkable functions. Its involvement in important processes such as cell proliferation, cell migration, morphogenesis and organ development implies that its activity should be tightly regulated. To understand the molecular mechanisms controlling HGF/SF transcription, we have analysed DNaseI hypersensitive sites (DHS) along rat and human HGF/SF genes in various tissues and cell types. We identified five DHS along the rat gene, two in the 5'-flanking region and three in the first intron. These sites are only found in rat tissues and rat cell lines, which express HGF/SF. The strongest hypersensitive site map to a region that corresponds to the promoter by start site analysis. A single tissue-specific DHS is present in human cell lines that express HGF/SF and corresponds to the promoter region. Our results suggest that chromatin accessibility plays a major role in the regulation of HGF/SF transcription regulation.

Developmental expression of GABA(A) receptor subunit mRNAs in individual hippocampal neurons in vitro and in vivo

The GABA(A) receptor is a heterooligomeric protein complex composed of multiple receptor subunits. Developmental changes in the pattern of expression of 11 GABA(A) receptor subunits in individual rat embryonic hippocampal neurons on days 1-21 in culture and acutely dissociated hippocampal neurons from postnatal day (PND) 5 rat pups were investigated using the technique of single-cell mRNA amplification. We demonstrate that multiple GABA(A) receptor subunits are expressed within individual hippocampal neurons, with most cells simultaneously expressing alpha1, alpha2, alpha5, beta1, and gamma2 mRNAs. Further, relative expression of several GABA(A) receptor subunit mRNAs changes significantly in embryonic hippocampal neurons during in vitro development, with the relative abundance (compared with beta-actin) of alpha1, alpha5, and gamma2 mRNAs increasing 2.3-, 2.7-, and 3.8-fold, respectively, from days 1 to 14, and beta1 increasing 5-fold from days 1 to 21. In situ hybridization with antisense digoxigenin-labeled alpha1, beta1, and gamma2 RNA probes demonstrates a similar increase in expression of subunit mRNAs as embryonic hippocampal neurons mature in vitro. Relative abundances of alpha1, beta1, and gamma2 subunit mRNAs in acutely dissociated PND 5 hippocampal neurons are also significantly greater than in embryonic day 17 neurons on day 1 in vitro and exceed the peak values seen in cultured neurons on days 14-21, suggesting that GABA(A) receptor subunit mRNA expression within individual hippocampal neurons follows a similar, if somewhat delayed, developmental pattern in vitro compared with in vivo. These findings suggest that embryonic hippocampal neuronal culture provides a useful model in which to study the developmental regulation of GABA(A) receptor expression and that developmental changes in GABA(A) receptor subunit expression may underlie some of the differences in functional properties of GABA(A) receptors in neonatal and mature hippocampal neurons.

Management guidelines for progressive chronic renal failure. New Zealand Nephrologists Consensus Group

Consensus guidelines are provided for the conservative management of adult patients with chronic and progressive renal failure, together with a brief review of the evidence relating to various treatable complications. Blood pressure control, diet, hyperlipidaemia, calcium and phosphate metabolism, anaemia and acidosis are considered.

Merkel cell carcinoma arising after therapeutic immunosuppression

Azathioprine and cyclosporin have been used as immunosuppressants for many years, but long-term use has also been associated with neoplasia. We report three cases of rapidly fatal Merkel cell carcinoma in patients who had been treated with azathioprine for many years either for rheumatoid arthritis or following organ transplantation. Two of these patients had also received cyclosporin. We suggest that Merkel cell carcinoma may be seen more commonly in immunosuppressed patients than in the normal population and that the oncogenic potential of azathioprine and cyclosporin should be borne in mind when prescribing these drugs.

Iontophoresis of poly-L-lysines: the role of molecular weight?

PURPOSE

(1) To determine the extent of iontophoretic transport as a function of molecular weight (MW) of the penetrant; and (2) to visually and quantitatively characterize the iontophoretic transport pathways (follicular (F) versus nonfollicular (NF) of the fluorescently-labeled poly-L-lysines employed.

METHODS

A series of fluorescently-labeled poly-L-lysines (FITC-PLLs) [4 KDa, 7 KDa and 26 KDa] were used to study the extent and distribution of iontophoretic skin penetration as a function of MW using laser scanning confocal microscopy (LSCM).

RESULTS

It was found that, relative to the passive controls, and under the electrical conditions considered, iontophoresis greatly enhanced the penetration of the 4 KDa analog, slightly elevated the delivery of the 7 KDa FITC-PLL, but had no effect on the transport of the larger 26 KDa FITC-PLL. Quantitative analyses of LSCM images revealed that iontophoresis increased transport via F pathways only slightly more than that through NF pathways for the 4 KDa and 7 KDa FITC-PLL molecules.

CONCLUSIONS

It is visually apparent that the iontophoretic transport pathways taken are importantly determined by the physicochemical properties (including size and charge) of the penetrant. The results presented here demonstrate an inverse dependence of iontophoretic delivery upon the MW of the penetrant.

Nurse managed occupational health services without on-site clinical care delivery: a case example

1. In this program management/community network model of occupational health services, the occupational health nurse is responsible for managing program development and implementation, with vendors providing the clinical services. 2. Occupational health nurses' primary areas of responsibility are occupational health, disability case management, ergonomics, and health promotion. 3. Successful management of program outcomes requires the occupational health nurse to continually assess employee/business needs, maintain communication with employees and management, and partner with the environmental, health, and safety team, other functional work groups, and vendors. 4. Effective management of contracts becomes critical to the process beginning with clear service requirements through the delivery of quality services.

Burden and outcomes of hospitalisation for congestive heart failure

OBJECTIVE

To describe the hospital burden and health outcomes associated with admission for congestive heart failure (CHF).

DESIGN AND SETTING

Descriptive follow-up study in a tertiary-level metropolitan teaching hospital.

PATIENTS

Acute adult inpatients with a clinical diagnosis of CHF for more than 24 hours admitted to Westmead Hospital, Sydney, during the four months from September 1993 to January 1994. At baseline, 122 patients were assessed; 88 patients were assessed at four-month follow-up.

INTERVENTIONS

Usual clinical care.

MAIN OUTCOME MEASURES

Length of stay; hospital bed-days; readmissions; mortality; health related quality of life (SF-36); patient knowledge.

RESULTS

The average age of subjects was 73.4 years. Many were using informal domiciliary care before admission. Mean length of stay for the baseline admission was 13.8 days, accounting for 7.6% of hospital separations and 1683 hospital bed-days, or 4.2% of bed-days for all inpatients aged 65 years and over. Fifteen patients were readmitted for CHF during the following four months, with a total of 26 CHF-related admissions. Twenty-one patients (17.2%) died during the course of the study. Quality of life at baseline was poor compared with population normative data, with a slight improvement among survivors at four-month follow-up. Patient knowledge of CHF was poor in a subsample survey (n = 24).

CONCLUSIONS

CHF represents a significant burden to patients (through morbidity and mortality), their carers (through provision of daily care), and hospitals (through multiple admissions for acute decompensation). It is difficult to monitor the hospital burden of CHF using routine data sources.

Clients entering drug abuse day treatment: 18-month outcomes

Clients who entered and remained in day treatment for at least 2 weeks (N = 66) were interviewed at 6, 12, and 18 months after baseline. Follow-up rates for each time point ranged from 58% to 68%, and 30 clients (45%) were interviewed at every time point. Those who were consistently followed (N = 30) did not differ from those who were not consistently followed (N = 36) on demographics or on outcome variables measured at baseline. Comparison of mean outcome scores across time using MANOVA indicated significant changes from baseline to 6 months in the areas of alcohol, drug, legal, and social problem severity, and these changes were maintained up to 18 months postadmission. Outcomes reflecting psychiatric symptoms and employment also changed over time, but exhibited different patterns of change. Results are confounded by treatment received, since many respondents also participated in residential treatment during follow-up. Day treatment can serve clients having a range of substance abuse problems, and can act as a bridge to traditional residential treatment. Randomized clinical trials, where clients receive only one or the other type of treatment, are needed to assess the effectiveness of day treatment alone.

Antigen heterogeneity in advanced colorectal and breast cancer

The association of several monoclonal antibody defined tumour-associated antigens with colorectal and breast carcinoma tissues was investigated by immunocytochemistry. The antigens included CEA and the related antigen, NCA (NCA-1), modified blood group substances (Le(y) hapten), a tumour glycolipid antigen and the MUC1 mucin. The molecular expression of these antigens in tumour cell membranes was analysed by identification of antigens in detergent extracts by SDS-PAGE analysis and Western blotting. The capacity of viable tumour tissue to release these antigens as soluble components into short term tissue culture supernatants was further examined. The findings provide a basis for the defining those membrane-associated antigens which would be appropriate targets for monoclonal antibody based targeted therapies in colorectal and breast cancer.

Indicators and research methods for rapid assessment of a tuberculosis control programme: case study of a rural area in South Africa

SETTING

An evaluation of the Tuberculosis Control Programme (TBCP) of KaNgwane, a rural, previously designated 'homeland' of South Africa, was performed in 1990.

OBJECTIVE

The evaluation is presented as a case study to illustrate a proposed methodology for rapid, comprehensive, management oriented TBCP research.

DESIGN

The components of the TBCP were categorised into direct TBCP activities, management processes and integration of the TBCP into Primary Health Care (PHC). The methods used to evaluate indicators for each of these components included: policy analysis, interviews with staff and patients, observation of in-patient and ambulatory patient care, record reviews and a household survey.

RESULTS

The regional scope of the study yielded a wealth of useful information at a managerial level. Detailed, quantitative information was obtained, allowing for the identification of weaknesses in the TBCP and the targeting of appropriate action. Particularly problematic aspects were: the health information collection, case-finding and case-holding, health education and coordination and supervision. Comparative analyses between different health wards helped identify particular areas of weakness. Both illustrative results and methodological limitations are presented. The methodology used is related to previous South African TB health service research and to the emerging field of rapid assessment methods.

CONCLUSIONS

A rapid but comprehensive review of a TBCP can be done if indicators and research methods are carefully selected and record systems are functional. If record systems are not functional, the non-record review methods still offer substantial information on many indicators and one or two quantitative indicators (e.g. case holding) could be selectively measured through reviewing a sample of records.

Assessment of five serum marker assays in patients with advanced breast cancer treated with medroxyprogesterone acetate

This study concerns five different tumour marker assays examined in the context of 94 patients with advanced breast cancer treated in a prospectively randomised trial of different doses of medroxyprogesterone acetate (MPA). MPA was administered at doses of 500 or 1000 mg daily and clinical evaluation of patients was carried out according to UICC criteria. Carcinoembryonic antigen (CEA) was selected as a standard marker, with three assays for MUC1 mucins (epithelial mucin core antigens (EMCA), EMCA2 and BR-MA immunoradiometric assay) differing in antibody specificities for different mucin epitopes. An additional novel assay for soluble cytokeratin was also evaluated as an example of an independent marker with a different nature and biology. Sensitivity of individual assays ranged between 44 (EMCA2) and 69% (cytokeratin) and the use of two assays in combination led to sensitivities as high as 84% (cytokeratin+BR-MA). The proportion of patients found to be assessable by each assay ranged between 51 (EMCA2) and 76% (cytokeratin). Of those patients whose marker changes were assessable, those receiving the higher dose of MPA displayed significant falls in marker levels after 12 weeks of treatment. This effect was not observed in patients receiving 500 mg. The change in cytokeratin levels in patients undergoing high dose MPA therapy proved to be most marked. Using the cytokeratin assay, 91% (of 23 patients) of patients with progressive disease showed at least a 25% rise in serum marker levels. Of these, 66% showed increases before disease progression was detected clinically with a mean lead time of 14 weeks. There was very little difference between the responses of the five tumour marker assays in patients with stable or responding disease, the proportion of these patients with stable or falling tumour marker levels ranging between 58% (CEA) and 77% (EMCA). We conclude that the cytokeratin assay has an application in monitoring response to therapy and predicting tumour progression in advanced breast cancer patients with assessable tumour marker profiles, especially if used in combination with a MUC1 mucin assay.

Myositis and fasciitis associated with group A beta hemolytic streptococcal infections: development of a rabbit model

Group A streptococci produce a variety of clinical symptoms ranging from minor pharyngeal infections to life-threatening soft-tissue disease. A rabbit model is described for induction of myonecrosis and fasciitis with group A beta-hemolytic streptococci. Group A streptococcal infections have shown remarkable virulence in recent years, resulting in severe local tissue destruction and life-threatening toxicity. After subcutaneous injection into the thigh of 20 ml broth containing 10(5) to 10(9) cfu/ml, initial soft tissue infection rapidly progressed to rhabdomyolysis. The response of the rabbits to the infection was consistent with the human response.

Utilisation of primary curative services in Diepkloof, Soweto

A study was undertaken to compare characteristics of attenders at primary curative services in Diepkloof, Soweto, and their reasons for the utilisation thereof. A structured questionnaire was administered to a sample of patients attending a provincial clinic and two general practitioners (GPs) in the Diepkloof area. The demographic characteristics, utilisation characteristics and reasons for choosing the service are compared. The most important characteristic determining choice of primary care was an individual's access to medical aid: 14% of clinic attenders compared with 67% of GP attenders. Other significant differences between the service users were employment and income. Perceived quality of care, attitude of health workers, distance to the service, availability of credit, waiting time, and the type of illness were also important determinants of choice of service. Methodological issues with regard to the heterogeneity of GP practices and ways of dealing with attitudinal data from a facility-based survey are illustrated.

Asking questions: a management tool

The occupational health nurse manager does not have all the answers. In using a democratic style of leadership with well qualified professionals, the technique of questioning can be invaluable in clarifying the issue, brainstorming solutions, developing a course of action, and monitoring success. The personal rewards to the occupational health nurse manager will include a reputation for being an effective listener, a problem solver, and a valued member of the company's management team.

Isoniazid prophylactic therapy for tuberculosis in HIV-seropositive patients--a least-cost analysis

The expected upsurge in the number of new cases of tuberculosis resulting from the HIV/AIDS epidemic prompted an examination of the feasibility of prevention strategies to limit the increase in clinical tuberculosis. A computer spreadsheet model was developed to estimate the costs and benefits that would result from isoniazid chemoprophylaxis for tuberculosis in a hypothetical cohort of 100,000 HIV-seropositive people in South Africa over a period of 8 years. At a 50% prevalence of tuberculosis infection among those at high background risk, and 5-10% among those at low risk, there would have been 34,000 cases of active tuberculosis in the cohort and their contacts if no prophylactic therapy had been used. On the other hand, a chemoprophylaxis policy would have meant only 12,200 cases of tuberculosis, if a patient compliance rate of 68.5% had been assumed. Such a policy would have prevented 21,800 cases of active tuberculosis. The estimated total discounted cost of a chemoprophylaxis programme would have been R51.3 million. In the absence of preventive therapy the discounted cost of treating patients with active tuberculosis would have been R91.9 million over the 8-year period. Therefore, if the benefits of chemoprophylaxis were defined in terms of averted health care costs, such a policy would have resulted in net savings of R40.6 million. This study did not estimate losses in production associated with tuberculosis treatment or the value of preventing tuberculosis per se, though such indirect costs would have increased the benefit of the prevention programme.(ABSTRACT TRUNCATED AT 250 WORDS)