Primary care. Making their marker

The performance indicators currently in use are not reliable for assessing individual GPs or identifying poor performers. The practice assessment visit used for GP registrars is probably the most objective system. Primary care groups boards should consider supplying individual GPs with information on their practice in a form which allows them to compare themselves with local colleagues.

Prevalence of asthma and 'probable' asthma in the Asian population in Blackburn, U.K

Local research had shown increased asthma admission rates in the Asian ethnic group in Blackburn, U.K. Patients also reported that asthma seemed to develop some years after first arrival in the U.K. A community prevalence survey of respiratory symptoms and asthma was undertaken in three practices with no special asthma interest. The questionnaire was administered by a Health Visitor and language link worker. Of the Asian patients in the practices, 96.6% were studied. The age distribution was similar to that of the local 1991 census. Of the patients, 181/1783 (10.2%) had diagnosed asthma but positive responses to individual questions suggested underdiagnosis of asthma. Asthma prevalence was higher in males up to age 20 (14.6% vs. 8.2%), and aged over 50 (16.5% vs. 10.5%), but higher in females aged 20-49 (5.6% vs. 9.2%). There were no correlations with social class or Jarman index, and no effect of country of origin or duration in the U.K. by multivariate analysis. The prevalence of diagnosed asthma at ages 5-9 and 10-14 was higher than in previous studies. Diagnosed asthma prevalence rates fell in the 20-49 age band but rose again in the over-50s. In all age groups the prevalence of asthma is probably underestimated. Asthma prevalence was not related to social factors. The data show that those born in the U.K. are more likely to describe regular symptoms and to be on regular treatment, but that for those born abroad there was an increasing rate of symptoms and medication use with increasing duration in the country. These observations confirm patient views but are explained by the age/sex distribution of those born in the U.K. compared to immigrants.

An unusual case of Creutzfeldt-Jakob disease

A patient with histopathologically verified sporadic Creutzfeldt-Jakob disease (CJD) presented initially with diplopia, sleep disturbances, and L-dopa-responsive parkinsonism. After more than a year of slow progression, he did not become demented, and failed to fulfill the clinical criteria for possible CJD. No clinical examinations currently proposed to detect CJD showed the disease. CJD should be in the differential diagnosis of "parkinson plus" syndromes until a different etiology has been found or a histopathologic examination performed.

The chemokine receptors CXCR3 and CCR5 mark subsets of T cells associated with certain inflammatory reactions

T cells infiltrating inflammatory sites are usually of the activated/memory type. The precise mechanism for the positioning of these cells within tissues is unclear. Adhesion molecules certainly play a role; however, the intricate control of cell migration appears to be mediated by numerous chemokines and their receptors. Particularly important chemokines for activated/memory T cells are the CXCR3 ligands IP-10 and Mig and the CCR5 ligands RANTES, macrophage inflammatory protein-1alpha, and macrophage inflammatory protein-1beta. We raised anti-CXCR3 mAbs and were able to detect high levels of CXCR3 expression on activated T cells. Surprisingly, a proportion of circulating blood T cells, B cells, and natural killer cells also expressed CXCR3. CCR5 showed a similar expression pattern as CXCR3, but was expressed on fewer circulating T cells. Blood T cells expressing CXCR3 (and CCR5) were mostly CD45RO+, and generally expressed high levels of beta1 integrins. This phenotype resembled that of T cells infiltrating inflammatory lesions. Immunostaining of T cells in rheumatoid arthritis synovial fluid confirmed that virtually all such T cells expressed CXCR3 and approximately 80% expressed CCR5, representing high enrichment over levels of CXCR3+ and CCR5+ T cells in blood, 35 and 15%, respectively. Analysis by immunohistochemistry of various inflamed tissues gave comparable findings in that virtually all T cells within the lesions expressed CXCR3, particularly in perivascular regions, whereas far fewer T cells within normal lymph nodes expressed CXCR3 or CCR5. These results demonstrate that the chemokine receptor CXCR3 and CCR5 are markers for T cells associated with certain inflammatory reactions, particularly TH-1 type reactions. Moreover, CXCR3 and CCR5 appear to identify subsets of T cells in blood with a predilection for homing to these sites.

Neuropathologic findings associated with seizures in FVB mice

The FVB mouse is used extensively in transgenic research because of its defined inbred background, superior reproductive performance, and prominent pronuclei, which facilitate microinjection of genomic material. Seizures associated with a known mutation and seizure-susceptible inbred strains are well documented in mice; however, to the authors' knowledge, seizures in the FVB strain have not been evaluated. Affected nonmanipulated FVB/N (n = 5) and transgenic FVB/N mice generated, using eight unrelated transgenic constructs (n = 63), were submitted for pathologic examination. Most cases were detected during routine observations in animal rooms; however, seizure induction by tail tattooing, fur clipping, and fire alarms has been observed. The majority of mice were female (62 of 68), with mean age of 5.8 months (range, 2 to 16 months). Observations made during seizure presentation in 12 of 68 mice included facial grimace, chewing automatism, ptyalism with matting of the fur of the ventral aspect of the neck and/or forelimbs, and clonic convulsions that frequently progressed to tonic convulsions and death. Four mice were dead at presentation, with matting of the fur of the neck and forelimbs. The remainder of the mice had nonspecific signs of disease, such as lethargy, moribundity, or matting of the fur. Vendor and in-house animal health surveillance reports indicated that mice were seronegative to all murine pathogens. Results of gross pathologic examination were unremarkable. Microscopic findings were limited to the brain and liver. In all mice, neuronal necrosis was present in the cerebral cortex, hippocampus, and thalamus. Concurrent astrocyte hypertrophy, as evidenced by an increase in glial fibrillary acidic protein staining, was detected. Acute coagulative necrosis of centrilobular hepatocytes was present in the liver of some cases (19 of 68). Infective agents were not detected in selected brain specimens submitted for electron microscopy or in brain and liver specimens evaluated by use of special stains. Cytopathologic effect was not observed in 3T3, Vero, and BHK-21 cell lines inoculated with brain and liver specimens. The ischemic neuronal necrosis observed in these mice is consistent with lesions associated with status epilepticus in humans. The hepatocellular changes are interpreted to be agonal and associated with terminal hypoxia in seizuring animals. These results provide evidence of a previously unrecognized, often lethal epileptic syndrome in FVB mice that may have a major impact on transgenic research and other disciplines using this mouse strain.

Behavioral medicine, complementary medicine and integrated care. Economic implications

Health care concepts and practices are changing dramatically because of demographic and economic factors. The routine integration of behavioral and biomedical care is completely compatible with these changes and such integration would provide clinical and economic benefits to patients and to society.

Biliary elimination of oral 2,4-dichlorophenoxyacetic acid and its metabolites in male and female Sprague-Dawley rats, B6C3F1 mice, and Syrian hamsters

The role of biliary elimination in the metabolic disposition of 2,4-D was evaluated in male and female Sprague-Dawley rats, B6C3F1 mice, and Syrian hamsters. Following cannulation of the bile duct, an intragastric (ig) dose of 2,4-D (200 mg/kg) was administered and bile was collected at 30- or 60-min intervals for up to 6 h. Bile flow rates were constant in rats, increased in mice, and decreased in hamsters throughout the collection periods. Total recovery of radioactivity was greatest in male mice (about 7% of administered dose over 4 h). Female mice and rats of both sexes excreted about 3% over the same interval and male and female hamsters about 1%. About 71-88% of the activity in bile was parent compound. The glycine conjugate of 2,4-D was found in bile from mice, rats, and hamsters and the taurine conjugate in bile from mice. The only sex-dependent difference in the metabolite profile was in mice. Male mice excreted twice as much glycine conjugate as female mice. An additional minor metabolite (4-7%) was present in rat and mouse bile. This was tentatively identified as 2,4-D-glucuronide based on its hydrolysis by beta-glucuronidase. One more very minor metabolite (3%) was detected in rat bile but was not characterized due to its lability. The results of this study indicate that there are species-dependent differences in the biliary elimination of 2,4-D but not sex-dependent differences.

Cyclic neutropenia in Crohn's ileocolitis: efficacy of granulocyte colony-stimulating factor

A 40-year-old patient with long-standing Crohn's ileocolitis in remission experienced cyclic neutropenia with a periodicity of 14 days. He was not receiving immunosuppressive or myelosuppressive therapy. The patient had Staphylococcus aureus bacteremia resulting from central catheter infection, which was refractory to antibiotic therapy during the period of severe neutropenia. When granulocyte colony-stimulating factor (G-CSF) was administered, the cyclic neutropenia rapidly disappeared, the neutrophil and leukocyte counts normalized, and the sepsis resolved. When G-CSF therapy was discontinued, the leukocyte and absolute neutrophil counts again declined. With reinstitution of therapy, the leukocyte and absolute neutrophil counts recovered and normalized. Crohn's ileocolitis remained in remission during G-CSF therapy. This report confirms and extends one previous report of cyclic neutropenia associated with Crohn's disease and demonstrates in one patient the efficacy and safety of G-CSF on the hematologic, bacteriologic, and clinical manifestations of cyclic neutropenia associated with Crohn's disease.

Phenotypic plasticity in skull and dental morphology in the prairie deer mouse (Peromyscus maniculatus bairdii)

Morphologists and systematists have long suspected that dietary consistency can affect skull and dental form in mammals. We examined plasticity of skull shape and tooth morphology in prairie deer mice (Peromyscus maniculatus bairdii) by feeding mice diets that differed in consistency but not nutritional quality. Shape differences were analyzed qualitatively and quantitatively, using both landmark-based morphometrics and traditional distance measurements. Mice fed a gruel made of laboratory chow soaked in water differed from those fed hard blocks of chow by a slight anterior shift in the incisor tips, a narrowed zygomatic plate, a reduction in size of the masseteric tubercles, an overall decrease in skull size in lateral view, and an increase in overall size in ventral view. Disparities between our results and previous studies may be due to the differences in behavior between the inbred, relatively inactive laboratory strains commonly used in experimental studies and the outbred, constantly active species used here. Also, in contrast to previous studies, the statistical analysis employed here took into account both family relationships of the animals and the large number of statistical comparisons performed. Failure to consider these factors would have resulted in an exaggerated estimate of the effects of diet on skull form and may taint other studies that have explored the same aspects of plasticity.

Referral delay in back pain patients on worker's compensation

Low back pain (LBP), a common illness that may progress to chronic disability, costs many billions for care, lost work, and compensation. Conventional medicine does not effectively restore chronic LBP patients to work; multidisciplinary rehabilitation does, but limited or delayed access risks unnecessary costs, additional morbidity, and permanent disability. The authors examine costs of delayed treatment for 23 disabled LBP patients in a rehabilitation program. Compensation costs average $26,159 per patient, a sum covering treatment for 3 patients. Additional medical and societal costs are estimated. Factors causing delay, such as economic incentives and ignorance about pain, and policies to remediate these problems, are discussed.

Behavioral medicine, clinical health psychology, and cost offset

The use of medical services is a function of several interacting psychological and social variables as well as a function of physical malfunction. The clinical significance of addressing patients' psychosocial issues has only occasionally been considered. However, the shift in health care economics toward health care maintenance is responsible for the increased interest in interventions in the domain of behavioral medicine and health psychology. Evidence is reviewed for 6 mechanistic pathways by which behavioral interventions can maximize clinical care and result in significant economic benefits. The rationale for further integration of behavioral and biomedicine interventions is also reviewed.

Molecular phylogenetics of oryzomyine rodents: the genus Oligoryzomys

Cytochrome b sequences (401 bp) were used to investigate the phylogenetic relationships of a group of South American rodents. The study focused on the tribe Oryzomyini (Family Muridae, Subfamily Sigmodontinae) and two of its genera, Oryzomys and Oligoryzomys, especially the latter. Genetic distances separating Oryzomys species average 19%, while those separating Oligoryzomys species are much smaller (mean 11%). When analyzed cladistically, cytochrome b sequences provide weak support for the monophyly of Oryzomyini, but strong evidence for paraphyly of Oryzomys. The cladogram supports the monophyly of Oligoryzomys; however, the branching pattern among its species suggests evolutionary relationships that conflict with hypotheses based on morphology and allozymes. In these taxa, sequences of nucleotides making up cytochrome b violate an important assumption of phylogenetic analysis, independence of characters. The implications of this finding are discussed for phylogeny reconstruction and the measurement of support for cladograms.

Behavioral medicine, clinical health psychology, and cost offset

The use of medical services is a function of several interacting psychological and social variables as well as a function of physical malfunction. The clinical significance of addressing patients' psychosocial issues has only occasionally been considered. However, the shift in health care economics toward health care maintenance is responsible for the increased interest in interventions in the domain of behavioral medicine and health psychology. Evidence is reviewed for 6 mechanistic pathways by which behavioral interventions can maximize clinical care and result in significant economic benefits. The rationale for further integration of behavioral and biomedicine interventions is also reviewed.