Relationship of functional health literacy to patients' knowledge of their chronic disease. A study of patients with hypertension and diabetes

BACKGROUND

Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described.

OBJECTIVE

To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment.

METHODS

We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics.

RESULTS

A total of 402 patients with hypertension and 114 patients with diabetes were enrolled. Mean (+/- SD) knowledge scores for patients with hypertension with inadequate (n = 189), marginal (n = 49), or adequate (n = 155) literacy were 13.2 +/- 3.1, 15.3 +/- 2.2, and 16.5 +/- 2.3, respectively (range, 4-20; P < .001). A total of 92% of patients with hypertension and adequate literacy levels knew that a blood pressure reading of 160/100 mm Hg was high compared with 55% of those in the lowest reading level (P < .001). Mean (+/- SD) knowledge scores for patients with diabetes with inadequate (n = 50), marginal (n = 13), or adequate (n = 51) literacy were 5.8 +/- 2.1, 6.8 +/- 1.9, and 8.1 +/- 1.6, respectively (range, 1-10; P < .001). A total of 94% of patients with diabetes and adequate functional health literacy knew the symptoms of hypoglycemia compared with 50% of those with inadequate literacy (P < .001).

CONCLUSIONS

Inadequate functional health literacy poses a major barrier to educating patients with chronic diseases, and current efforts to overcome this appear unsuccessful.

The comparative metabolism of the mollicutes (Mycoplasmas): the utility for taxonomic classification and the relationship of putative gene annotation and phylogeny to enzymatic function in the smallest free-living cells

Mollicutes or mycoplasmas are a class of wall-less bacteria descended from low G + C% Gram-positive bacteria. Some are exceedingly small, about 0.2 micron in diameter, and are examples of the smallest free-living cells known. Their genomes are equally small; the smallest in Mycoplasma genitalium is sequenced and is 0.58 mb with 475 ORFs, compared with 4.639 mb and 4288 ORFs for Escherichia coli. Because of their size and apparently limited metabolic potential, Mollicutes are models for describing the minimal metabolism necessary to sustain independent life. Mollicutes have no cytochromes or the TCA cycle except for malate dehydrogenase activity. Some uniquely require cholesterol for growth, some require urea and some are anaerobic. They fix CO2 in anaplerotic or replenishing reactions. Some require pyrophosphate not ATP as an energy source for reactions, including the rate-limiting step of glycolysis: 6-phosphofructokinase. They scavenge for nucleic acid precursors and apparently do not synthesize pyrimidines or purines de novo. Some genera uniquely lack dUTPase activity and some species also lack uracil-DNA glycosylase. The absence of the latter two reactions that limit the incorporation of uracil or remove it from DNA may be related to the marked mutability of the Mollicutes and their tachytelic or rapid evolution. Approximately 150 cytoplasmic activities have been identified in these organisms, 225 to 250 are presumed to be present. About 100 of the core reactions are graphically linked in a metabolic map, including glycolysis, pentose phosphate pathway, arginine dihydrolase pathway, transamination, and purine, pyrimidine, and lipid metabolism. Reaction sequences or loci of particular importance are also described: phosphofructokinases, NADH oxidase, thioredoxin complex, deoxyribose-5-phosphate aldolase, and lactate, malate, and glutamate dehydrogenases. Enzymatic activities of the Mollicutes are grouped according to metabolic similarities that are taxonomically discriminating. The arrangements attempt to follow phylogenetic relationships. The relationships of putative gene assignments and enzymatic function in My. genitalium, My. pneumoniae, and My. capricolum subsp. capricolum are specially analyzed. The data are arranged in four tables. One associates gene annotations with congruent reports of the enzymatic activity in these same Mollicutes, and hence confirms the annotations. Another associates putative annotations with reports of the enzyme activity but from different Mollicutes. A third identifies the discrepancies represented by those enzymatic activities found in Mollicutes with sequenced genomes but without any similarly annotated ORF. This suggests that the gene sequence is significantly different from those already deposited in the databanks and putatively annotated with the same function. Another comparison lists those enzymatic activities that are both undetected in Mollicutes and not associated with any ORF. Evidence is presented supporting the theory that there are relatively small gene sequences that code for functional centers of multiple enzymatic activity. This property is seemingly advantageous for an organism with a small genome and perhaps under some coding restraint. The data suggest that a concept of "remnant" or "useless genes" or "useless enzymes" should be considered when examining the relationship of gene annotation and enzymatic function. It also suggests that genes in addition to representing what cells are doing or what they may do, may also identify what they once might have done and may never do again.

Lead and mercury mutagenesis: role of H2O2, superoxide dismutase, and xanthine oxidase

It has been suggested that reactive oxygen intermediates (ROIs) may have a role in the genotoxic effects of lead (Pb2+) and mercury (Hg2+), but there have not been any definitive studies demonstrating a causal relationship between the induction of ROIs by these metals and mutagenesis. We previously demonstrated, using the transgenic Chinese hamster ovary cell line AS52, that low concentrations (0.1-1 microM) of Pb2+ and Hg2+ are mutagenic. In the present study, using a novel histochemical computer-enhanced image analysis technique, we demonstrate that Pb2+ and Hg2+ induce the formation of H2O2 in AS52 cells by at least two distinct mechanisms. One is characterized by the rapid induction of H2O2 following treatment of cells with concentrations of Pb2+ or Hg2+ below 0.8 and 1 microM, respectively, while the second occurs in AS52 cells treated with concentrations of Pb2+ or Hg2+ greater than 0.8 and 1 microM, respectively. Pb2+ and Hg2+ (0.1-1 microM) had no effect on the activities of partially purified catalase, glutathione peroxidase, or glutathione reductase, important enzymes involved with antioxidant defense, but these metals stimulated the activities of copper-zinc superoxide dismutase (CuZn-SOD) and xanthine oxidase (XO). Allopurinol (50 microM), a specific inhibitor of xanthine oxidase, inhibited the induction of H2O2 by Pb2+ (0.8-1 microM) and Hg2+ (1 microM) and also inhibited Pb2+- and Hg2+-induced mutagenesis. These results demonstrate that Pb2+ and Hg2+ disrupt the redox status of AS52 cells by enhancing the activities of CuZn-SOD and XO. Furthermore, the results of these studies also demonstrate that there is a causal relationship between the induction of H2O2 by these metals and mutagenesis.

The relationship of patient reading ability to self-reported health and use of health services

OBJECTIVES

This study examined the relationship of functional health literacy to self-reported health and use of health services.

METHODS

Patients presenting to two large, urban public hospitals in Atlanta, Ga, and Torrance, Calif, were administered a health literacy test about their overall health and use of health care services during the 3 months preceding their visit.

RESULTS

Patients with inadequate functional health literacy were more likely than patients with adequate literacy to report their health as poor. Number of years of school completed was less strongly associated with self-reported health. Literacy was not related to regular source of care or physician visits, but patients in Atlanta with inadequate literacy were more likely than patients with adequate literacy to report a hospitalization in the previous year.

CONCLUSIONS

Low literacy is strongly associated with self-reported poor health and is more closely associated with self-reported health than number of years of school completed.

Antimutagenic and promutagenic activity of ascorbic acid during oxidative stress

Ascorbic acid (AA) has both antioxidant and prooxidant activities. However, there have not been any studies to elucidate the molecular mechanisms that determine whether AA functions as an anti- or a prooxidant during oxidative stress. The results of this study, using the Chinese hamster ovary cell line AS52 as a model system, demonstrate that there is a temporal relationship between the anti- and prooxidant activities of a physiologically relevant concentration of AA (50 microM) and oxidative stress. Treatment of cells with AA (50 microM) 24 hr prior to treatment of the cells with a radical generating system (RGS) results in a statistically significant inhibition of the cytotoxicity and mutagenicity associated with exposure of AS52 cells to oxidative stress. Conversely, cotreatment of cells with AA and the RGS results in a statistically significant increase in both the cytotoxic and mutagenic effects of oxidative stress when compared to cell populations exposed only to the RGS. The results, using a novel histochemical-computer image analysis system to detect hydrogen peroxide (H2O2), also demonstrate that there is a direct correlation between the ability of AA to decrease the levels of H2O2 in cells and the cytotoxic and mutagenic effects of oxidative stress. This study suggests that the time at which AA is administered in relation to exposure to oxidative stress has an impact on AA antimutagenic activity, and this may explain the conflicting results concerning the effectiveness of AA as a cancer chemopreventive agent.

Comparative metabolism of Mesoplasma, Entomoplasma, Mycoplasma, and Acholeplasma

Cytoplasmic fractions from species of the Mollicutes genera Entomoplasma, Mesoplasma, Mycoplasma, and Acholeplasma were assayed for NADH oxidase (NADH ox), ATP- and PPi-dependent phosphofructokinase (PFK), ATP- and PPi-dependent deoxyguanosine kinase (dGUOK), thymidine kinase (TK), TMP kinase (TMPK), glucose-6-phosphate dehydrogenase (G6Pde), lactate dehydrogenase (LDH), malate dehydrogenase (MDH), phosphoenolpyruvate carboxylase, hypoxanthine-guanine phosphoribosyl transferase, dUTPase, and uracil-DNA glycosylase (UNG) activities. Membrane fractions were also examined for NADH ox activity. These activities were used as indicators of the presence and relative activities of major Mollicutes metabolic and DNA repair pathways. This was the first study to determine the presence of these enzymes in members of the genera Entomoplasma and Mesoplasma. Using the data obtained, we constructed a preliminary scheme for distinguishing genera of the class Mollicutes on the basis of the results of signature functional enzyme assays. This scheme includes phylogenetic relationships deduced from rRNA analyses, but is more informative with respect to metabolic potential. The criteria used include the presence of PPi-dependent PFK, urease, dUTPase, and dGUOK activities. Entomoplasma ellychniae ELCN-1T (T = type strain), Entomoplasma melaleucae M-1T, Mesoplasma seiffertii F7T, Mesoplasma entomophilum TACT, Mesoplasma florum L1T, Mycoplasma fermentans PG18T, and Acholeplasma multilocale PN525T were similar in most respects. NADH ox activity was localized in the cytoplasm of these organisms. These strains had ATP-dependent PFK, MDH, LDH, ATP- and PPi-dependent dGUOK, and UNG activities, but not dUTPase or G6Pde activities. In contrast, Acholeplasma equifetale C112T, Acholeplasma oculi 19LT, Acholeplasma hippikon C1T, Acholeplasma modicum PG49T, and Acholeplasma morum 72-043T had membrane-localized NADH ox activity, PPi-dependent PFK, G6Pde, and dUTPase activities, and significantly lower MDH and LDH activities and exhibited a faster rate with PPi than with ATP in the dGUOK reaction. All of the members of the Mollicutes tested had hypoxanthine-guanine phosphoribosyl transferase, phosphoenolpyruvate carboxylase, and (except for Mesoplasma entomophilum TAC(T)) UNG activities. All of the Acholeplasma strains except Acholeplasma multilocale PN525T had TK, TMPK, and UNG activities. Mesoplasma entomophilum TAC(T) was distinguished by having no detectable dUTPase, UNG, TK, and TMPK activities, indicating that there is a severe restriction in or an absence of a synthetic route to dTTP. Our data also suggest that A. multilocale PN525T is a member of an unrecognized metabolic subgroup of the genus Acholeplasma or is not an Acholeplasma strain.

Literacy and contraception: exploring the link

OBJECTIVE

To describe what is known about the relation of literacy skills to contraceptive use and to suggest directions for future research. An overview of what is known about the literacy skills of Americans and the prevalence of inadequate functional health literacy is presented. Information about reading requirements for various methods of contraception and advice from health educators on dealing with low-literate populations are described.

DATA SOURCES

MEDLINE, PsychInfo, and ERIC searches for the last 20 years were completed using the terms literacy, literacy and health, family planning, health status, educational status, risk factors, contraception, and pregnancy.

METHODS OF STUDY SELECTION

The primary literature searches identified 125 articles. After reviewing abstracts for these articles, we excluded 79, because they contained no specific mention of literacy or educational status relating to contraception. TABULATION INTEGRATION, AND RESULTS: We were unable to identify and study specifically devoted to the relation between functional literacy and actual use of contraceptives. Forty-six with relevant background or related information were identified: literacy and health (19), adult literacy (nine), literacy and contraception (11), and literacy and family planning (seven). Over one-third of English-speaking and 62% of Spanish-speaking patients had inadequate or marginal functional health literacy in a study conducted at two urban public hospitals. Studies by health educators have demonstrated that information for many types of contraceptives is frequently above the patient's reading level. Available epidemiologic information on the relation between educational status and unplanned pregnancy is also presented.

CONCLUSIONS

Although no study has specifically addressed how functional health literacy affects contraceptive use, it is reasonable to hypothesize that functional health literacy influences contraceptive knowledge, attitudes, and behaviors. Future research should focus on the relation between functional health literacy and actual use of various contraceptives.

Mutagenic potential of peripheral blood leukocytes: in vivo exposure to the carcinogen 7,12-dimethylbenz[a]anthracene, and the tumor promoter 12-O-tetradecanoylphorbol acetate followed by in vitro co-culture with AS52 cells

Co-culture of AS52 cells with peripheral blood leukocytes (PBLs), obtained from SENCAR mice topically treated with either tetradecanoyl-phorbol-13-acetate (TPA) or 7,12-dimethylbenz[a]anthracene (DMBA)-TPA, resulted in a 7-160-fold increase in the mutation frequency of the gpt gene in AS52 cells when compared to that induced by PBLs isolated from mice treated with either acetone or DMBA. This increase in mutation frequency was inhibited by the anti-oxidant (-)epigallocatechin gallate (EGCG). These results demonstrate that the AS52 cell line can be used as a mammalian mutagenesis model for the study of in vivo mechanism(s) of mutagenesis by leukocytes and also as a model for in vivo chemoprevention studies.

The health care experience of patients with low literacy

OBJECTIVES

To understand the difficulties that patients with poor reading ability have interacting with the health care system and to identify the coping mechanisms they use to deal with these problems.

DESIGN

Focus groups and individual interviews with patients who are illiterate and patients with low literacy.

SETTING

Two large, urban public hospitals.

PARTICIPANTS

Sixty patients with marginal to poor reading abilities as measured by the Rapid Estimate of Adult Literacy in Medicine were interviewed in focus groups or individual interviews.

MEASUREMENTS AND MAIN RESULTS

Patients with low literacy harbor a deep sense of shame, which is reinforced by hospital staff who become frustrated or angry when someone cannot complete a form or read instructions. Seeking medical care is intimidating for patients with low literacy because they cannot understand signs and registration forms. Many patients recounted serious medication errors resulting from their inability to read labels. To cope with these problems, the patients with low literacy rely heavily on oral explanations, visual clues, and demonstrations of tasks to learn new material. Most also use a friend or family member as a surrogate reader.

CONCLUSIONS

Patients with poor reading ability have important problems accessing the health care system, understanding recommended treatments, and following the instructions of providers. Because of their shame, patients with low literacy may be unwilling to disclose their problem to health care providers, and screening tests of reading ability may be necessary to identify those who need special assistance. Patients' coping mechanisms give insight into possible interventions that may improve their interactions with the health care system.

Short-course adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis: a Medical Research Council report

PURPOSE

This United Kingdom Medical Research Council (UK-MRC) study prospectively evaluated efficacy and long-term toxicity of adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis (NSGCTT).

PATIENTS AND METHODS

Eligible patients were those identified by the local histopathologist as having features confirmed in MRC surveillance studies to indicate an approximate 50% risk of relapse. Central histopathology review was undertaken. Chemotherapy consisted of two courses of cisplatin 100 mg/m2, bleomycin 30 mg weekly x 3, and etoposide 120 mg/m2 x 3, every 21 days (BEP).

RESULTS

One hundred fourteen eligible cases were enrolled. Median time of follow-up was 4 years, with 93 patients followed-up for at least 2 years. There have been two relapses, including one patient who did not have a germ cell tumor (GCT), according to the reference histopathologist. This patient is alive with active disease, the other has died. There was one death after a cerebrovascular accident during treatment. Assessment of fertility, lung function, and audiometry pretreatment and more than 9 months posttreatment indicated no clinically significant changes. A mean decrease in transfer factor coefficient (KCO) of 15% of the predicted value was noted, but no patient had symptomatic respiratory dysfunction.

CONCLUSION

There have been only two relapses among 114 cases of high-risk stage I NSGCTT treated with two courses of adjuvant BEP chemotherapy. The 95% confidence interval (CI) excludes a true relapse rate of more than 5%. Of 104 patients confirmed on histopathology review to have GCT, there has been only one relapse. Adjuvant chemotherapy is free from significant long-term toxicity, offering an effective alternative to surveillance or retroperitoneal lymph node dissection (RPLND) followed by surveillance, and may be preferred by some patients.

Shame and health literacy: the unspoken connection

Illiteracy is a well known national crisis, yet relatively little research has focused on how low literacy affects patients' health care experiences. The purpose of this study was to determine the relationship between shame and low functional literacy in the health care setting. It hypothesized that many patients with low literacy may not admit they have difficulty reading because of shame. Patients who presented for acute care at a large, public hospital in Atlanta, Georgia were interviewed. A total of 202 predominately indigent African-American patients completed a demographic survey, the Test of Functional Health Literacy in Adults (TOFHLA) and answered questions about difficulty reading and shame. Of the 202 patients interviewed, 42.6% had inadequate or marginal functional health literacy. Patients with low literacy were more likely to be male (P < 0.05), have less than a high school education (P < 0.01) and be over the age of 60 (P < 0.01). Of those patients with low literacy, 67.4% admitted having trouble reading and understanding what they read. Almost 40% (n = 23) of patients with low functional literacy who acknowledged they have trouble reading admitted shame. Of the 58 patients who had low functional health literacy and admitted having trouble reading, 67.2% had never told their spouses, and 53.4% had never told their children of their difficulties reading. Nineteen percent of patients had never disclosed their difficulty reading to anyone. Many patients with reading problems are ashamed and hide their inability to read. Shame is a deeply harbored emotion that plays an important role in understanding how low literate patients interact with health care providers. Further research is needed to understand how providers should deal with the shame associated with low literacy.

Mutagenesis of AS52 cells by low concentrations of lead(II) and mercury(II)

Little is known at the molecular level concerning the genotoxic effects following the acute exposure of eukaryotic cells to low concentrations of lead (II) or mercury (II). There have been conflicting reports concerning the mutagenic potential of these heavy metals, and there have not been any studies performed to determine the molecular mechanism(s) by which these metals are mutagenic. The Chinese hamster ovary cell line, AS52, contains a stably integrated single functional copy of the Escherichia coli xanthine-guanine phosphoribosyltransferase (gpt) gene. Mutations in the gpt gene confer resistance to 6-thioguanine (TG). There was little effect on viability, as measured by relative cloning efficiency, of AS52 cells exposed to lead (II) or mercury (II) up to concentrations of 0.5 microM and 0.3 microM, respectively. However, higher concentrations of the metals caused a significant increase in cell death. There was also a dose-dependent increase in the isolation of mutants resistant to TG in treated cells when compared to non-treated controls. Concentrations of the metals as low as 0.1 microM caused a significant increase in the number of mutants resistant to TG when compared to the number of spontaneous mutants obtained in nontreated controls. While the molecular mechanism(s) by which lead and mercury (II) are genotoxic is unknown, the results of this study demonstrate that low concentrations of lead (II) and mercury (II) are mutagenic in eukaryotic cells.

Artificial radiation menopause: where are the ovaries?

For ovarian ablation using radiotherapy, the pelvis is irradiated using generous fields sizes, as the position of the ovaries is uncertain. To assess the variation in ovarian position, we reviewed 81 sequential CT examinations of the pelvis performed in women under the age of 50 years. Women with pelvic malignancy or previous pelvic surgery were excluded from the analysis, leaving 30 eligible women. One or both ovaries could be clearly identified in 23 of these patients; in 19 (83%), the ovaries were located within the upper two-thirds of a ring defined by the sacroiliac joints, the bony side wall of the pelvis and the symphysis pubis. The ovaries were located outside this ring in four (17%) women. Ovarian position did not appear to be influenced by parity, uterine orientation, the degree of bladder filling or faecal loading within the rectum. The treatment volume for artificial radiation menopause has been variably defined; the upper part of the pelvis may not be included. The results from this retrospective study suggest that the treatment volume should extend from the inferior border of the fifth lumbar vertebra down to a level traversing the middle of the femoral heads and 1 cm lateral to the pelvic side walls.

The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills

OBJECTIVE

To develop a valid, reliable instrument to measure the functional health literacy of patients.

DESIGN

The Test of Functional Health Literacy in Adults (TOFHLA) was developed using actual hospital materials. The TOFHLA consists of a 50-item reading comprehension and 17-item numerical ability test, taking up to 22 minutes to administer. The TOFHLA, the Wide Range Achievement Test--Revised (WRAT-R), and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered for comparison. A Spanish version was also developed (TOFHLA-S).

SETTING

Outpatient settings in two public teaching hospitals.

PATIENTS

256 English- and 249 Spanish-speaking patients were approached. 78% of the English- and 82% of the Spanish-speaking patients gave informed consent, completed a demographic survey, and took the TOFHLA or TOFHLA-S.

RESULTS

The TOFHLA showed good correlation with the WRAT-R and the REALM (correlation coefficients 0.74 and 0.84, respectively). Only 52% of the English speakers completed more than 80% of the questions correctly. 15% of the patients could not read and interpret a prescription bottle with instructions to take one pill by mouth four times daily, 37% did not understand instructions to take a medication on an empty stomach, and 48% could not determine whether they were eligible for free care.

CONCLUSIONS

The TOFHLA is a valid, reliable indicator of patient ability to read health-related materials. Data suggest that a high proportion of patients cannot perform basic reading tasks. Additional work is needed to determine the prevalence of functional health illiteracy and its effect on the health care experience.

Appraisal of a glycopeptide cloaking strategy for a therapeutic oligopeptide: glycopeptide analogs of the renin inhibitor ditekiren

Among the limitations to the practical therapeutic oligopeptide are low oral availability, indifferent aqueous solubility, and an astonishing efficient sequestration and biliary elimination by a multi-capacity liver transporter. Given the purposed use of N- and O- linked saccharides as functional appendages of eukaryotic peptides and proteins, a strategy of glycopeptide mimicry was examined for the oligopeptide renin inhibitor, ditekiren. The anticipation was that the saccharide would impart significant aqueous solubility, and might impact beneficially on the remaining two limitations. Execution of this approach was achieved by the removal of the (dimethylethoxy)carbonyl amino terminus of ditekiren, and its substitution by Boc-L-asparagine N-linked mono- and disaccharides. Potent hypotensive activity, as measured by a human renin-infused rat assay, is observed for virtually all of these structures (N-linked beta-pyranose D-N-acetyglucosaminyl, D-glucosaminyl, D-N-acetylgalactosaminyl, D-mannosyl, D-galactosyl, D-maltosyl, D-cellobiosyl, D-chitobiosyl, but not L-fucosyl). The basis for this dramatic improvement (relative to ditekiren in the same assay) is the diversion of the peptide clearance from rapid liver biliary clearance to slower urinary clearance (Fisher, J. F.; Harrison, A. W.; Wilkinson, K. F.; Rush, B. R.; Ruwart, M. J. J. Med. Chem. 1991, 34, 3140). Guided by the human renin-infused rat hypertension assay, an evaluation of the linker-saccharide pairing was made. Loss of hypotensive activity is observed upon substitution of the Boc-L-asn by Boc-D-asn, and by removal of the Boc amino terminus of the glycopeptide. Potent hypotensive activity is preserved by replacement of the Boc-L-asn linker by succinate, malate, tartrate, and adipate linkers. With the longer adipate spacer, attachment of the saccharide to the P-3 phenylalanine--with omission of the P-4 proline--retains activity. These data suggest value to the glycopeptide guise for preserving the in vivo activity, and for the beneficial manipulation of pharmacodynamics, of this renin inhibitory oligopeptide. This strategy may have general applicability.

Case report: the pulmonary lesions of chickenpox pneumonia--revisited

Infection with the varicella zoster virus can include pulmonary complications. These may cause such minor symptomatology as to go unrecognized and unimaged. We describe a case of active chickenpox pneumonia that mimicked pulmonary metastases and was detected incidentally by means of computed tomography in a man with a past history of testicular teratoma.

Mutagenic effect of mercury (II) in eukaryotic cells

Acute exposure of KB and Chinese hamster ovary cells (AS52) to low concentrations of mercury (II) results in a dose dependent binding of mercury to DNA. This binding of mercury (II) to the DNA occurs at concentrations of mercury that have little if any effect on glutatione levels or on superoxide dismutase activity. Mutational studies with AS52 cells demonstrated that concentrations (0.1 to 0.4 microM) of mercury (II) which were not cytotoxic caused an increase (1.7 to 3.1) in the frequency of mutations in the gpt gene when compared to non-treated controls. These results suggest that there may be risks associated with exposure to non-cytotoxic levels of mercury (II).

Obstacles predicting lack of a regular provider and delays in seeking care for patients at an urban public hospital

OBJECTIVE

To determine the correlation among obstacles to medical care, lack of a regular source of care, and delays in seeking care.

DESIGN

Cross-sectional survey of patients presenting for ambulatory care during a 7-day period. Multiple logistic regression models were used to identify obstacles independently associated with outcome variables.

SETTING

Urban public hospital.

PATIENTS

A total of 3897 disadvantaged and predominantly minority patients.

MAIN OUTCOME MEASURES

Lack of a regular source of medical care and delay in seeking medical care for a new problem.

RESULTS

The majority (61.6%) of patients reported no regular source of care. Of 2341 patients reporting a new medical problem, 48.4% waited more than 2 days before seeking medical care. No health insurance (adjusted odds ratio [OR], 2.2; 95% confidence interval [CI], 1.89 to 2.61), no transportation (OR, 1.44; 95% CI, 1.23 to 1.70), exposure to violence (OR, 1.21; 95% CI, 1.08 to 1.45), and living in a supervised setting (OR, 1.50; 95% CI, 1.00 to 2.25) were independent predictors of lack of a regular source of care. No insurance (OR, 1.24; 95% CI, 1.02 to 1.51), no transportation (OR, 1.45; 95% CI, 1.19 to 1.77), and less than a high school education (OR, 1.22; 95% CI, 1.08 to 1.49) were independent predictors of delaying care for a new medical problem.

CONCLUSIONS

Obstacles in addition to lack of insurance impede provision of medical care to disadvantaged patients. The adoption of universal health care coverage alone will not guarantee access to appropriate medical care.

Pilot studies of 2 and 1 course carboplatin as adjuvant for stage I seminoma: should it be tested in a randomized trial against radiotherapy?

PURPOSE

Underpinned by increased confidence in cure of metastatic seminoma by chemotherapy during the past 12 years, three management strategies for Stage I seminoma have been evaluated by six collaborating centers within the Anglian Germ Cell Tumor Group. This paper evaluates the efficacy of surveillance, prophylactic radiotherapy and adjuvant chemotherapy, and discusses these differing management approaches.

METHODS AND MATERIALS

Patients were recruited into the study between 1982 and 1992. There was no randomization between treatment groups. Seventy-nine patients received prophylactic radiotherapy (median follow-up = 51 months), 67 patients had surveillance alone (median follow-up = 61 months) and 78 patients were treated with adjuvant single agent platinum (median follow-up = 44 months). Fifty-three of these patients received two courses of platinum (median follow-up = 51 months) and 25 patients received one course (median follow-up = 29 months, range 22-72 months).

RESULTS

There were 18 (27%) recurrences on surveillance, five (6%) after radiotherapy, one (1%) after two courses of adjuvant single agent platinum and none after one course of carboplatin. There was one death from testis cancer after radiotherapy and none after adjuvant chemotherapy treatments. Two patients died with drug resistant disease after relapse on surveillance. There was one death from a myocardial infarction after prophylactic radiotherapy and one death from suicide in the surveillance group. A retrospective quality of life questionnaire reviewing the incidence of early and late toxicity revealed no major differences though they suggest that those treated with one course adjuvant carboplatin had somewhat less sickness and an earlier return to work.

CONCLUSION

Single agent carboplatin appears well tolerated and is an effective adjuvant treatment for Stage I seminoma. A multicenter randomized trial of the different treatment modalities is required to further evaluate its use.

Efficacy and toxicity of vinblastine, bleomycin, and methotrexate with involved-field radiotherapy in clinical stage IA and IIA Hodgkin's disease: a British National Lymphoma Investigation pilot study

PURPOSE

To assess the efficacy and toxicity of vinblastine, bleomycin, and methotrexate (VBM) chemotherapy with involved-field radiotherapy in clinical stage IA and IIA Hodgkin's disease.

PATIENTS AND METHODS

Thirty eligible patients with clinical stage IA or IIA Hodgkin's disease, at intermediate risk of relapse, were enrolled into a prospective multicenter pilot study. They received two cycles of VBM chemotherapy, followed by involved-field radiotherapy and then four further cycles of VBM. The median follow-up duration from the start of treatment is 30 months.

RESULTS

All 26 patients with assessable disease showed an objective response after two cycles of VBM (nine complete responses, 17 partial responses). By the completion of treatment, 27 patients were in complete remission; two had stable residual masses, which have not progressed at 26 and 34 months of follow-up; and one patient who died of treatment-related sepsis was in complete remission at that time. Two relapses have occurred, 19 and 28 months after starting VBM. Cough and dyspnea developed in 14 of 30 patients, and were associated with impairment of pulmonary function tests. Three episodes of neutropenic sepsis were recorded.

CONCLUSION

VBM with involved-field radiotherapy is an effective treatment for early Hodgkin's disease. However, the associated toxicity, both pulmonary and hematologic, is severe, making the regimen unsuitable for routine use.