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.

Clinical and treatment correlates of access to Section 8 certificates for homeless mentally ill persons

OBJECTIVE

The study assessed how clients' housing preference and other variables were related to the acquisition of Section 8 certificates, facilitating independent living, for homeless persons with severe mental illness who were being served by an experimental assertive community treatment team.

METHODS

For 77 clients, demographic and clinical differences between receivers and nonreceivers of certificates were examined, and correlates of time from referral to the team to completion of the Section 8 application were analyzed. Reasons clients did not receive certificates and housing outcomes were summarized in relation to client preference.

RESULTS

The 34 clients who received certificates (44 percent) had significantly less psychopathology after three months than did nonreceivers and tended to have affective disorders rather than schizophrenia. Of the 43 nonreceivers, the two largest groups were 19 clients who did not want certificates and ten clients who wanted certificates but whom staff considered unable to live safely in an unsupervised apartment. The mean +/- SD length of time for application for a certificate was 5.7 +/- 5.8 months. Longer time to apply was significantly associated with having schizophrenia, having the team as a representative payee, and showing increased psychotic symptoms at referral and at three months.

CONCLUSIONS

The study suggests that it is possible to honor the housing preferences of the majority of homeless persons with severe mental illness if adequate resources are provided. However, staff may view persons who have schizophrenia and more symptoms as needing more supervision than those clients prefer. Homeless mentally ill persons may also take longer than more symptomatic persons to pursue independent living through a Section 8 certificate.

Langerhans' cell histiocytosis of the frontal bone

Two cases of Langerhans' cell histiocytosis of the frontal bone are presented. This condition was previously known as eosinophilic granuloma and rarely involves the orbit but may be associated with widespread and life-threatening disease. Clinical, radiological and histopathological features are presented. A discussion of the light and electron microscopic appearances, investigation and management follows.

An unusual pattern of growth disturbance of the hip in juvenile rheumatoid arthritis

OBJECTIVE

An unusual deformity in the hip in juvenile rheumatoid arthritis (JRA) consisting of a small femoral head in a capacious acetabulum has been described as an isolated finding, but no explanation as to the cause of the deformity has been proposed. We have also observed this deformity and the objective of this investigation was to determine the cause.

METHODS

In 1987, a review of hip disease in JRA was carried out at the Wellesley Hospital. Nine hips in 5 patients were identified as having a mismatch in size between the femoral head and acetabulum. Six of these hips came to surgery during the growth phase.

RESULTS

The 6 hips undergoing surgery between the ages of 16-19 showed an identical picture at the time of surgery. The pattern of pathology consisted of a femoral head devoid of articular cartilage and an acetabulum that showed an intact triradiate cartilage. Each of the 6 hips was treated with a resurfacing arthroplasty.

CONCLUSION

The femoral head grows in circumference by endochondral ossification of the articular cartilage. If the rheumatoid process destroys that articular cartilage, growth of the femoral head ceases. The intact triradiate cartilage permits continuing acetabular growth and the deformity of a small femoral head in a large capacious acetabulum results.

Characteristics and job satisfaction of nonphysician full-time family medicine faculty members

BACKGROUND

Nonphysician educators comprise a significant portion of the faculty in family medicine, yet little is actually known about this cohort of educators. This survey identifies and examines the population of nonphysician faculty.

METHODS

a questionnaire was sent to 859 nonphysician faculty teaching full time in 113 family medicine departments and 377 family medicine residency programs. The questionnaire was used to determine the composition, characteristics, and levels of job satisfaction of respondents. The responses of this nonphysician cohort were compared to responses of physician faculty who participated in a previous study.

RESULTS

Nonphysician faculty were more satisfied with the jobs they performed than they were with the recognition and rewards they received. Satisfaction levels of nonphysicians were significantly greater than their physician colleagues in the areas of research, clinical work, and administration. Physicians were significantly more satisfied than nonphysicians only in response to questions relating to teaching.

CONCLUSIONS

Further research is needed to determine how to optimally integrate nonphysicians into family medicine education and fully utilize their expertise.

Comparison of DSM-III-R diagnoses and a brief interview for substance use among state hospital patients

OBJECTIVE

Identifying substance use disorders in persons with mental illness is often difficult. In this study prevalence rates of substance use disorders among state psychiatric hospital patients were obtained by six different methods: DSM-III-R substance use diagnoses and five additional strategies based on frequency of use and past substance abuse treatment. Overlaps and differences between patients identified by the six methods were examined.

METHODS

Chart review and a structured substance use screening interview were used with a random sample of 20 percent (N = 474) of the population of the Maryland state hospital system. Comparisons focused on cohorts identified by two of the methods: DSM-III-R substance use diagnoses and recent regular use (any past period of daily or weekly use plus any use during the 30 days before hospitalization).

RESULTS

The prevalence rates of substance use identified by the six strategies ranged from 23 percent to 55 percent. The recent-regular-use criteria identified 176 patients, and DSM-III-R diagnoses identified 111. The recent-regular-use criteria also identified a greater number of patients as likely to benefit from substance use treatment. Patients identified by both methods were significantly younger and more likely to be male and nonschizophrenic than patients without substance use disorders.

CONCLUSIONS

The need for substance use treatment may be underestimated if discharge planners consider only DSM-III-R diagnoses. A brief screen for recent regular use may be a better way to assess treatment needs in a state hospital population.

Purification of human leukotriene C4 synthase

Leukotriene (LT) C4 synthase, the enzyme that catalyzes the conjugation of LTA4 with reduced glutathione to form LTC4, was purified to homogeneity from the KG-1 myeloid cell line after solubilization of the microsomes utilizing a combination of 0.4% sodium deoxycholate and 0.4% Triton X-102. The solubilized enzyme was then applied to an S-hexyl-glutathione-agarose column that was eluted by the use of 7.5 mM probenecid. After removal of the probenecid by sequential concentration and dilution in an Amicon concentrator, the enzyme was additionally purified and concentrated by binding to and elution from approximately 75 mg of S-hexyl-glutathione-agarose. The enzyme was further resolved by electrophoresis with a nondenaturing Tris-glycine gel, and the LTC4 synthase activity was localized to slices 3 and 4. When the remainder of the eluate from the nondenaturing gel was precipitated by acetone and analyzed by 14% SDS/PAGE with silver staining, a single protein band of 18 kDa was associated with LTC4 synthase activity and was not present in the eluates of slices lacking activity. The overall recovery was 12.5%. In a separate preliminary purification, in which the yield was only approximately 1%, the eluates of the nondenaturing gel had also revealed a single protein of 18 kDa by SDS/PAGE, which was present only in the eluates with LTC4 synthase activity. These data identify LTC4 synthase as a protein of 18 kDa, a size consistent with its membership in the microsomal glutathione S-transferase family.

Increased asthma admission rates in Asian patients: Blackburn 1987

Asthma admissions for ages 1-44 for the year 1987 were studied to test the clinical impression that asthma admissions in ethnic Asians were more frequent than expected. Data on admissions was obtained from HAA statistics and from ward admission books. Population data was obtained from the 1981 Census with OPCS revisions and local epidemiological data of Asian births and new immigrant numbers. Admission rates per 1000 population were derived. Admissions were increased in Asian patients aged 1-4 years (odds ratio 1.18; 95% confidence interval 0.85-1.64) and 15-29 years (odds ratio 1.57; 95% confidence interval 0.83-2.98), but these increases were not significant. Admissions were significantly increased in Asian patients aged 5-14 (odds ratio 2.03; 95% confidence interval 1.32-3.12; 0.01 > P > 0.001) and 30-44 years (odds ratio 5.85; 95% confidence interval 3.66-9.35; 0.001 > P). The increased admission rate in Asians was not due to increased readmissions in the Asian ethnic group. The data supports the view that the difference in Asian admission rate may be due to a truly increased asthma prevalence in the Asian ethnic group.

A comparison of buccal nitroglycerin and sublingual nitroglycerin in the prophylaxis and treatment of exertional (situation-provoked) angina pectoris

Suscard is a buccally administered formulation which provides rapid introduction of nitroglycerin directly into the systemic circulation and, by virtue of its sustained-release properties, may confer protection against anginal attacks for several hours. Its efficacy has been established in angina pectoris and more recently its usefulness has been extended to include the management of unstable angina and acute heart failure. Buccal nitroglycerin combines the possibilities of short-term treatment and more extended prophylaxis. In a multicentre double-blind study the efficacy of buccal nitroglycerin and sublingual nitroglycerin were compared in patients with proven chronic stable exercise-induced angina as regards anginal attacks and capacity for physical activity. The conclusion is that the two formulations of nitroglycerin have a comparable effect in the treatment of acute attacks of angina pectoris. Buccal nitroglycerin has many advantages when used prophylactically. This is documented by less frequent anginal attacks and a more prolonged duration of effect resulting in an increased physical activity.

5-Fluorouracil and recombinant interferon alfa-2a: review of activity and toxicity in advanced colorectal carcinomas

Improved response rates in metastatic colorectal carcinoma recently have been observed for the combination of 5-fluorouracil (5-FU) and recombinant interferon alfa-2a (rIFN), compared to those obtained in historical trials of single-agent 5-FU. The mechanism of interaction between these agents has not been explored adequately but may relate to biochemical modulation of 5-FU by rIFN. Toxicities resulting from this combination have included fever, chills, myalgias, granulocytopenia, mucositis, diarrhea, skin rash, neurological symptoms, and hand-foot syndrome. Future studies of 5-FU with rIFN should investigate schedules aimed at reducing toxicity without compromising efficacy and also should explore mechanisms of enhanced activity.

Exceptional chromosomal mutations in a rodent population are not strongly underdominant

The observation of karyotypic uniformity in most species has led to the widespread belief that selection limits chromosomal change. We report an unprecedented amount of chromosomal variation in a natural population of the South American marsh rat Holochilus brasiliensis. This variation consists of four distinct classes of chromosomal rearrangements: whole-arm translocations, pericentric inversions, variation in the amount of euchromatin, and variation in number and kind of supernumerary (B) chromosomes. Twenty-six karyotypes are present among 42 animals. Observations of the natural population over a 7-year period and breeding experiments with captive animals indicate that heterozygous individuals suffer no detectable reduction in fitness. This is at odds with a central assumption in current models of chromosomal speciation and provides a firm rejection of the view that selection necessarily restricts chromosomal change.

An Assessment of the Performance and Requirements for "Adiabatic" Engines

A review of research on low heat rejection engines, on cooperative efforts in the United States and abroad to incorporate ceramics in intermittent combustion engines, and on the use of ceramics in these engines is presented. The reduction of heat loss from the combustion chamber of diesel engines improves fuel efficiency only 3 or 4 percent. Some other gains may be possible from a smaller cooling system, recovery of exhaust energy, and improvements in aerodynamics. It is judged that designs of low heat rejection engines will have the greatest initial impact on armored combat vehicles. Organization, coordination, planning, and cooperation on R&D for the use of ceramics in intermittent combustion engines appear to be greater abroad than in the United States.

Three studies of the psychologic changes in chronic headache patients associated with biofeedback and relaxation therapies

Three separate, but similar, studies are described in which the psychologic effects (depression, anxiety, and overall degree of psychosomatic distress) of nonpharmacologic treatment (relaxation and/or biofeedback training) for three kinds of chronic headache (tension, migraine, and mixed migraine and tension) were evaluated. Results showed consistently (across all three studies) significant reductions in depression and trait-anxiety associated with receiving treatment, regardless of headache type or treatment outcome. The significant reduction for overall degree of psychosomatic distress was not differentially related to receiving treatment and thus could have been due to prolonged monitoring of headaches or test-retest regression effects.

Management of Minor Medical Problems and Trauma: General Practice or Hospital?

An assessment of the problems for which 1000 consecutive patients attended an accident and emergency department of a district general hospital showed that 54.2% could have been treated by a general practitioner. Amongst 150 patients attending hospital for minor problems between the hours of 09:00 and 19:00 on weekdays, the main reason given for not going to a GP was their impression that only in hospital could the required treatment be provided. A postal survey of 50 GPs found that they tended to avoid regularly handling certain specified minor problems which often present to hospital. The current trend away from the community management of such problems is discussed. It is suggested that improving patient education and GPs' incentives, while decreasing list sizes and expanding the primary care team, may encourage the management by GPs of trivial trauma and minor medical problems.

Muscle enzyme profile, diet, and flight in South American bats

Activities of four catabolic enzymes (citrate synthase, hexokinase, 3-hydroxyacyl-CoA dehydrogenase, and phosphorylase) were measured in the pectoralis muscles of 10 species of South American bats, representing four families. The pattern of enzyme activities in these tissues suggests that these muscles differ qualitatively with other mammalian and avian muscles in two respects. First, the muscles of all 10 bat species were much more highly oriented toward fat metabolism and away from glucose metabolism than in any previously measured skeletal muscle. Second, the species were divided into two major groups with respect to hexokinase activity. Primarily frugivorous species had hexokinase activities about 2-3 times as high as insectivorous species. It is suggested that the weight restrictions of flight limit glycogen storage and thus bias muscle metabolism toward fat. However, the extent to which pectoralis muscles have the capacity for glucose oxidation appears to be dependent on the intake of dietary glucose.

Effect of calcium and phosphate on bicarbonate and fluid transport by proximal tubules in vitro

Previous studies in living animals have suggested that variations in the serum concentrations of calcium and phosphate directly affect renal tubular bicarbonate transport. To examine this area more directly, we measured the bicarbonate and the fluid transport in isolated rabbit proximal convoluted and straight tubules perfused in vitro. The concentration of calcium in the perfusate was varied between 0 and 5 mM and in the bath between 0.5 and 5 mM. In proximal convoluted tubules, 5 mM calcium in the perfusate and bath caused a significant increase in the rate of bicarbonate absorption, and removal of calcium from the perfusate inhibited both bicarbonate and fluid absorption. The concentration of phosphate in the perfusate and the bath was varied from 0.25 to 5 mM. In both convoluted and straight tubules, there was no significant change in bicarbonate or fluid absorption with changes in the ambient phosphate concentration. We conclude that changes in calcium concentration have significant effects on bicarbonate transport by proximal convoluted tubules but that wide variations in the concentration of phosphate have no significant effect on bicarbonate, sodium, or fluid transport by proximal tubules in vitro.

Comparison of bacterial and fungal adherence to vaginal exfoliated epithelial cells and human vaginal epithelial tissue culture cells

The adherence of four bacterial species and Candida albicans to a new in vitro tissue culture model of human vaginal stratified squamous epithelium was investigated and compared with in vitro adherence to vaginal exfoliated cells. Gardnerella vaginalis, group B streptococci, Lactobacillus sp., and C. albicans adhered well to both exfoliated and tissue culture cells. Similarly, a piliated fecal isolate of Escherichia coli, but not a nonpiliated vaginal isolate of E. coli, adhered well to both cell types. Adherence of the piliated E. coli was markedly inhibited by preincubation of bacteria with D-mannose. No inhibition of adherence by D-mannose of G. vaginalis, nonpiliated E. coli, and C. albicans was demonstrated. Scanning electron microscopy of tissue cultures showed nonuniform distribution of adherent microorganisms with diminished adherence in areas of active mitosis and proliferation and increased adherence to mature flat cells, often in the process of desquamation.

Cimetidine secretion by rabbit renal tubules in vitro

Cimetidine, a drug in widespread use in the treatment of peptic ulcer disease, is eliminated primarily via urinary excretion. We examined cimetidine transport by rabbit proximal straight tubules perfused in vitro. [3H]Cimetidine in the bath was actively secreted into the tubule lumen. There was a curvilinear relationship between the rate of cimetidine secretion and the concentration of bath cimetidine. Cimetidine secretion was inhibited by hypothermia and ouabain. Quinine, tolazoline, probenecid, phloridzin, creatinine, p-aminohippurate, and cimetidine sulfoxide inhibited cimetidine secretion in a dose-related manner. At low cimetidine concentrations lumen-to-bath transport rates were only 11-18% of bath-to-lumen secretory rates. High performance liquid chromatographic analysis of collected tubular fluid showed a predominance of cimetidine and a small amount of cimetidine sulfoxide in ratios similar to those of the bath. These studies show that cimetidine is actively secreted into the lumen of rabbit proximal straight tubules in vitro. Secretion probably occurs via the organic base and to a lesser extent the acid transport systems.

Comparison between bacteriophage typing and serotyping for the differentiation of Bacillus sphaericus strains

Eleven bacteriophages were isolated using mosquito pathogenic strains of B. sphaericus as hosts. The phage morphology and host range on five DNA homology groups including 16 mosquito pathogenic and 32 non-pathogenic strains were determined. the same bacterial strains were studied serologically for their flagellar agglutination by antisera representing eight serotypes: six antisera prepared against the reference strains for the DNA homology groups and two others against selected mosquito pathogenic strains. Two new serotypes have been determined among the non-pathogenic strains. Both phage typing and serotyping identified subgroups within the IIA homology group which contains the mosquito pathogens. The same bacterial strains were found in the subgroups established by both methods. These subgroups often paralleled difference in the level of toxicity of the strains for mosquito larvae.

PTH inhibition of bicarbonate transport by proximal convoluted tubules

These studies examined the effect of parathyroid hormone (PTH), dibutyryl cyclic AMP DBcAMP, and 8-bromo-cyclic AMP BrcAMP on HCO3- transport by rabbit superficial proximal convoluted tubules perfused in vitro. Bicarbonate was estimated as total CO2 measured microcalorimetrically. At slow perfusion rates with 25 mM HCO3- in the perfusate and bath, PTH (0.1 U/ml in the bath) caused the total CO2 in tubular fluid to rise from 10.2 to 19.9 mM. The hormone had no effect on the total CO2 concentration in tubules perfused with HCO3(-)-free perfusates. With HCO3(-) in the perfusate and bath, PTH reduced the rates of fluid and total CO2 absorption to 57 and 48% of control values, respectively. PTH had no effect on the rates of fluid absorption and total CO2 secretion when HCO3(-)-free perfusates were used. The effects of DBcAMP and BrcAMP (10(-7) M in the bath) were similar to those of PTH. 5'-AMP (10(-6) M in the bath) did not alter the total CO2 concentration of tubular fluid when the tubules were perfused at slow rates with HCO3- in the perfusate and bath. Ouabain (10(-5) M in the bath) caused the total CO2 concentration in tubules perfused at slow rates with HCO3--free perfusates to rise from 8.9 to 12.7 mM. PTH caused no further change in the total CO2 concentration in the presence of ouabain.

Comparative studies of the mosquito-larval toxin of Bacillus sphaericus SSII-1 and 1593

Two strains of Bacillus sphaericus. SSII-1 and 1593, were bioassayed for toxic activity against second-instar larvae of the mosquito Culex pipiens quinquefasciatus. It was found that strain 1593 developed a level of toxicity 3000 times that of strain SSII-1. Although the toxic activity of B. sphaericus SSII-1 was relatively unchanged throughout growth, an increase in activity of strain 1593 occurred as the bacteria began to sporulate. Strain differences were examined by (i) growth cycle experiments, (ii) bioassays of the toxicity of oligosporogenous mutants, and (iii) manganese limitation experiments. The toxin of strain 1593 was shown to be more stable than that of strain SSII-1. Unlike the spores of strain SSII-1, the spores of B. sphaericus 1593 were found to be highly toxic. Thin sections of SSII-1 or 1593 cells did not reveal the presence of any inclusion body that might be related to toxicity.