Implantable cardioverter defibrillators in Israel: utilization and implantation trends

BACKGROUND

Since its introduction, the implantable cardioverter defibrillator (ICD) has evolved to its present status as the dominant therapeutic modality for patients with life-threatening arrhythmias. Several randomized studies have shown the benefit of ICD implantation as the first choice of treatment for primary as well as secondary indications for ventricular arrhythmias. Therefore, it is expected that the use of ICDs will increase further. The main objectives of this study were to analyze the Israeli experience with ICD implantation from 1993 to 1999, to examine the diffusion of ICD therapy in Israel and the evolution of implantation patterns and indications.

METHODS

We conducted a retrospective review and analysis of an ICD registry for the period of January 1993-December 1999. Data collected included demographic, administrative, clinical and survival data.

RESULTS

A total of 732 new implantations were identified and reviewed. The mean length of follow up of all patients was 30.7+/-21.1 months. 86% of patients were males and the mean age at implantation was 62.6+/-12.4 years. 79% of patients had CAD and the mean EF of all patients was 29.2+/-11.2%. 135 patients (18.4%) died during follow-up. One, two and three-year survival rates were calculated and were 92.7%, 87.8% and 82.0% respectively. A steady increase in implantation rate and in implanting centers was observed over the years.

CONCLUSIONS

ICD therapy is relatively expensive; therefore a national registry which is continuously monitored may be the most expedient method to follow clinical and economic aspects of the utilization of this therapeutic modality.

Short term oral cefixime therapy for treatment of bacterial conjunctivitis

BACKGROUND

There have been few controlled studies evaluating treatment of bacterial conjunctivitis beyond the newborn period. Topical therapy of bacterial conjunctivitis achieves a clinical cure but does not prevent acute otitis media (AOM).

OBJECTIVES

The aim of this study was to compare systemic antibiotic therapy (cefixime) with topical therapy with polymyxin-bacitracin for treatment of acute bacterial conjunctivitis with regard to clinical and bacteriologic cure and prevention of AOM.

METHODS

This study was a randomized, double blind, placebo-controlled trial of polymyxin-bacitracin ointment and oral placebo vs. topical placebo and oral cefixime in children with presumed acute bacterial conjunctivitis. Topical therapy was administered for 7 days; oral therapy was administered for 3 days. Bacterial cultures were obtained at entry and on Day 3 of treatment. Children were examined on Days 3 and 10 or if they worsened within 15 days of entry.

RESULTS

Eighty children were enrolled in the study. Bacterial cultures of the conjunctiva were positive in 70% of children: Haemophilus influenzae (53.7%); Streptococcus pneumoniae (13.8%); H. influenzae and S. pneumoniae (1.2%); and Moraxella catarrhalis (1.3%). There were 7 (17.5%) bacteriologic failures among children receiving topical antibiotic and oral placebo and 15 (37.5%) bacteriologic failures among children receiving topical placebo and oral cefixime (P = 0.07 with Yates correction). There was no difference between study groups with regard to either clinical cure or the development of AOM. Nine children (11%), 5 who received active topical therapy and 4 who received active oral drug, developed AOM either during or within 15 days of study entry.

CONCLUSION

Cefixime was not more effective than topical polymyxin-bacitracin in either the eradication of conjunctival colonization with respiratory pathogens or the prevention of AOM in children with acute bacterial conjunctivitis.

[Costs and benefits of laparoscopic inguinal hernia repair--is there an economic justification?]

BACKGROUND

With the recent accelerated development of laparoscopic surgery, it has been applied in all fields of surgery. The main issue today is not the technical ability of performing laparoscopic procedures but rather their justification while considering the disease and cost-benefit aspects.

OBJECTIVES

The present study surveys the experience accumulated in recent years concerning the economical aspects of laparoscopic inguinal hernia repair. Issues like length of the surgical procedure, cost, typical complications and recuperation time are being addressed.

METHODS

We reviewed controlled clinical trials that compare laparoscopic and open repair of inguinal hernia. Trials that included at least 100 patients and were published in peer-reviewed journals since 1996 were included. Various operative techniques were compared using clinical and economical parameters.

RESULTS

Most studies examined the issues from an institutional or health care system viewpoint and not from a comprehensive societal perspective. Therefore, indirect costs were seldom included. Operative times were longer and direct costs were significantly higher in the laparoscopic approach as compared to conventional open surgery. However, recovery time and return to work were found to occur earlier in patients who underwent laparoscopic surgery.

CONCLUSIONS

A shorter recovery time and shorter off-work period after laparoscopic hernia repair could compensate for the increased hospital expenditures. However, this contribution has not yet been completely established and needs further validation by supplementary studies. Other aspects that will have to be evaluated include quality of life and patient satisfaction.

Newspaper advertising by health maintenance organizations during the reform of healthcare services in Israel

BACKGROUND

On 1 January 1995 a new mandatory National Health Insurance Law was enacted in Israel. The new law fostered competition among the four major Israeli healthcare providers (HMOs or sick funds) already operating in the market due to the possibility that an unlimited number of patients and the relative budget share would shift among the HMOs. This led them to launch advertising campaigns to attract new members.

OBJECTIVES

To examine newspaper advertising activities during the early stages of healthcare market reform in Israel.

METHODS

Advertising efforts were reviewed during a study period of 24 months (July 1994 to June 1996). Advertisements were analyzed in terms of marketing strategy, costs and quality of information.

RESULTS

During the study period 412 newspaper advertisements were collected. The total advertising costs by all HMOs was approximately US$4 million in 1996 prices. Differences were found in marketing strategy, relative advertising costs, contents and priorities among the HMOs.

CONCLUSIONS

The content of HMOs' newspaper advertising was consistent with their marketing strategy. The messages met the criteria of persuasive advertising in that they cultivated interest in the HMOs but did not provide meaningful information about them. Future developments in this area should include consensus guidelines for advertising activities of HMOs in Israel, instruction concerning the content of messages, and standardization of criteria to report on HMO performance.

Reimbursement policies, incentives and disincentives to perform laparoscopic surgery in Israel

The introduction of laparoscopic surgery was believed to bestow great advantages to patients and health services. Health services and societal costs may also be affected by changes in length of hospital stay, operating room costs and return to normal activity. The aim of this paper is to examine the influence of two different reimbursement methods (per diem and DRG) on the incentives and disincentives given to different role players in the Israeli health-care system regarding two common surgical procedures: appendectomy and inguinal hernia repair. Three different perspectives are discussed: society, the hospitals and the sick funds. From the hospital's perspective, laparoscopic surgery is usually more expensive compared to open procedures, mainly due to higher operating room costs. We suggest that as far as current reimbursement methods are preserved, hospitals have no economic incentive to adopt the laparoscopic technology as benefits occur only to society. In general, sick funds would encourage hospitals to perform laparoscopic appendectomy, where the payment is per diem and would be economically indifferent regarding laparoscopic inguinal hernia repair, where hospitals are compensated on a DRG basis. It has been suggested that economic advantages to society may arise from a faster return to work after laparoscopic appendectomy and laparoscopic inguinal hernia repair. In this case, new payment arrangements should be set to give proper incentives for the adoption of laparoscopic procedures.

Association between the serotonin 2A receptor gene and tardive dyskinesia in chronic schizophrenia

Tardive dyskinesia (TD) is a long-term adverse effect of antipsychotic drugs that are dopamine D2 receptor blockers.(1) Serotonin receptor antagonism has been proposed as a common mechanism contributing to the low extrapyramidal effects profile of atypical antipsychotic drugs.(2) We examined the association of three polymorphisms in the 5-HT2A receptor gene (HTR2A) with TD susceptibility--T102C(3) and his452tyr(4) in the coding region and A-1438G(5) in the promoter--in matched schizophrenia patients with (n = 59, SCZ-TD-Y) and without TD (n = 62, SCZ-TD-N) and normal control subjects (n = 96). The T102C and the A-1438G polymorphisms are in complete linkage disequilibrium but not his452tyr. There was a significant excess of 102C and -1438G alleles (62.7%) in the SCZ-TD-Y patients compared to SCZ-TD-N patients (41.1%) and controls (45.9%; chi(2) = 12.8, df = 2, P = 0.002; SCZ-TD-Y vs SCZ-TD-N, chi(2) = 11.4, df = 1, P = 0.0008, OR 2.41, 95% CI 1.43-3.99) and of 102CC and -1438GG genotypes (SCZ-TD-Y 42.4%, SCZ-TD-N, 16.1%, controls 20.8%, chi(2) = 13.3, df = 4, P = 0.01). The 102CC and the -1438GG genotypes were associated with significantly higher AIMS trunk dyskinesia scores (F = 3.9; df = 2, 116; P = 0.02) and more incapacitation (F = 5.0; df = 2, 115; P = 0.006). The his452tyr polymorphism showed no association with TD. These findings suggest that the 5-HT2A receptor gene is significantly associated with susceptibility to TD in patients with chronic schizophrenia. Previously reported association of the T102C and A-1438G polymorphisms with schizophrenia(6) may reflect association of a sub-group of patients with a susceptibility to abnormal involuntary movements related to antipsychotic drug exposure.

Nocturnal hallucinations in ultra-orthodox Jewish Israeli men

Hallucinations that occur predominantly at night are reported in 122 out of a sample of 302 ultra-orthodox Jewish Israeli men referred for psychiatric evaluation. Demographic data and the content of a semistructured interview in 302 ultra-orthodox Jewish young men seen over a 10-year period in Jerusalem were evaluated retrospectively by two researchers. Of the 302 subjects, 122 reported hallucinations predominantly at night, 23 reported hallucinations with no diurnal variation, and 157 did not report hallucinations. Most of those with nocturnal hallucinations were in their late teens, were seen only once or twice, were brought in order to receive an evaluation letter for the Army, and had a reported history of serious learning difficulties. The nocturnal hallucinatory experiences were predominantly visual, and the images were frightening figures from daily life or from folklore. Many of the subjects were withdrawn, monosyllabic, reluctant interviewees. Ultra-orthodox Jewish beliefs include a belief in demons, particularly of dead souls, who visit at night. This cultural group's value on study at Yeshivas away from home places significant pressure on teenage boys with mild or definite subnormality, possibly precipitating the phenomenon at this age in this sex. Although malingering had to be considered as a possible explanation in many cases owing to the circumstances of the evaluation, short-term and long-term follow-up on a limited sample allowed this explanation to be dismissed in a significant number of cases. We suggest therefore that nocturnal hallucinations are a culture-specific phenomenon.

Recidivism of child molesters: a study of victim relationship with the perpetrator

OBJECTIVE

To compare the rates among of recidivism or re-offense among convicted child molesters who offend against biological children, stepchildren, and relationships where the child is an extended family member, acquaintance or stranger to the victim.

METHOD

Four hundred male subjects 18 years of age or older and at least 5 years older than the victim at the time of the index offense, were convicted of a hands on sexual offense against one or more children under the age of 16. Subjects were grouped into five categories according to the type of relationship the perpetrator had with the victim. The subjects records of criminal arrests and convictions was obtained from the national Royal Canadian Mounted Police data. Subjects were then followed-up for a period of up to 15 years after conviction when they were at risk to re-offend in the community. Survival outcome data after the index sexual offense was collected for all new sexual, violent, and any criminal offenses.

RESULTS

A larger proportion of men ( 16.2%) who sexually offended against children who were acquaintances, were charged with a new sexual offense than men who sexually offended against biological (4.8%) or their stepchildren (5.1%). The percentage of men who were subsequently charged with any type of criminal offense and who offended against their biological children (19%) was smaller than men who offended against children where the relationship is an extended family member (40%), acquaintances (35.9%) or strangers (45.2%).

CONCLUSIONS

When comparing the different categories of relationship the victim had with the perpetrator, the category of stranger has been highlighted as a group with a higher risk for re-offense. Our results have shown that comparatively, the risk of acquaintance group is a significantly higher risk category than was previously thought. Although professionals are principally concerned with sexual recidivism, general criminality appears to present in relatively large proportions of all child molesters with the stranger group at the highest risk level. While no single factor will predict recidivism in itself, the importance of defining the relationship between the perpetrator and victim is evident from this study.

Hospitalization for primary varicella-zoster virus infection and its complications in patients from Southern Israel

BACKGROUND

We conducted this study to determine the impact of chickenpox on two different ethnic populations in southern Israel: Jews and Bedouins.

METHODS

Hospital records of 113 patients discharged from the Soroka Medical Center with the diagnosis of varicella during a 4.5-year period were reviewed.

RESULTS

Mean age was 9.2 years and the average hospital stay was 5.4 days. Bacterial skin or soft tissue infections were the most common complications (30%), followed by pneumonia (17%) and central nervous system complications (11.5%). There were no fatal cases throughout the study period. The calculated hospitalization rate for varicella was one in every 319 cases. Major differences between Jews and Bedouins included an older mean age of Bedouin patients (13.9 years versus 4.5 years); higher hospitalization rate (relative risk [R.R.]: 2.8, 95% confidence interval: 1.9-4.2), and higher risk for complicated varicella (R.R.: 2.1, 95% confidence interval: 1.3-3.4).

CONCLUSION

Hospitalization of patients with varicella in southern Israel is common and varicella infection in Bedouins is associated with greater morbidity compared with that in Jews in southern Israel.

A survey of the teaching of undergraduate psychiatry in Israel

BACKGROUND

The 1960-70s saw significant advances in the teaching of psychiatry in medical schools. Subsequently there have been developments in the structure of health care and in the methods and goals of medical education.

METHOD

All four departments of undergraduate teaching of psychiatry in Israel and single departments in Greece, UK and US were asked to respond to a questionnaire about the structure and content of their teaching program.

RESULTS

The amount and content of preclinical and clinical teaching have not changed over the last two decades. There has not been a significant "move into the community" and the nucleus of the program, particularly in Israel, is still in-patient psychiatry. None of the departments approached are evaluating clinical skills using performance-based techniques.

CONCLUSIONS

The increased awareness of the need for physicians to have knowledge and skills in psychiatry has not lead to an increase in the teaching of psychiatry to medical students. Further, the content of teaching carried out in most of the centers studied does not meet the needs of physicians, particularly those in primary care, who have to identify and manage a wide range of psychopathology.

Different preferences for oils with similar fatty acid profiles

While preference for fat can be influenced by concentration and physical form, the influence of fatty acid composition on relative preference for oils has not been systematically investigated. Therefore, the purpose of the present investigation was to assess the relative preference for oils rich in oleic (Extra Light Olive Oil and Extra Virgin Olive Oil) and linoleic (Safflower Oil) acid. Male Fischer rats (n = 10) were used to determine preference in a two-choice testing procedure in which three pairs of oils were each tested twice. Preference testing occurred at dark onset at which time the rodent diet and water were removed and each rat was allowed 2-h access to his assigned pair of oils. There was a main effect of oil type (p<0.01), but no significant effect of oil pairing and no interaction between oil pairing and oil type. Rats preferred the Extra Light Olive Oil to the Extra Virgin Olive Oil (p<0.05). This is the first report of preference testing in which two oils with similar fatty acid profiles were included. The present data indicate that the fats with similar fatty acid profiles were not equally preferred, suggesting that a property other than the fatty acid composition of the oils accounts for the demonstrated preference.

Involving family members in cancer care: focus group considerations of patients and oncological providers

Family members are an integral part of a patient's cancer care from the moment the diagnosis is delivered to the conclusion of treatment. Family members bring with them a range of emotional reactions, interpersonal dynamics and expectations for the care the patient receives. This study is part of a multi-institutional project to continue to improve the process of cancer care. In this study, 19 focus groups (11 patient and 8 provider) were conducted concerning issues related to doctor-patient communication in eight cancer centers in the United States. The content of the conversations was analyzed and thematic categories emerged that highlight the various strengths and difficulties associated with family involvement. The focus groups' comments support the need for explicit conversations between professional caregivers, patients and their loved ones, in order to negotiate the expectations and needs of each team member. Implications for clinical practice and strategies for working with family members are offered.

Cryptosporidial infections after solid organ transplantation in children

The diagnosis and treatment of moderate-to-severe diarrhea in solid organ transplant recipients is often a challenge because of the variety of infectious and non-infectious causes. The morbidity associated with this clinical condition is of particular significance in the pediatric population where malnutrition may lead to poor growth and development. Rarely, Cryptosporidium has been identified as the cause of clinically significant diarrhea in pediatric solid organ transplant patients. A retrospective review identified cases of cryptosporidiosis among the 1160 non-renal, abdominal organ transplant recipients cared for at the Children's Hospital of Pittsburgh between 1981 and June 1998. Four cases of clinically significant diarrhea were identified in three liver transplant recipients and one small bowel transplant recipient. Endoscopy and biopsy with histologic confirmation diagnosed three cases; ova and parasitic examination of stool specimens identified the fourth case. Therapy varied among the patients depending on when they had been diagnosed as, over the years, different and newer agents have been indicated for the treatment of cryptosporidiosis. All four patients resolved their infections. Hence, endoscopy and biopsy is recommended for pediatric transplant patients who present with chronic diarrhea of unknown etiology. The patients who may be at a higher risk for cryptosporidial infections include those with an increased immunosuppressive state (i.e. pre-existing immunodeficiency, malignancy, re-transplantation, and those receiving higher doses of immunosuppressive therapy). While cryptosporidiosis is a non-lethal complication, it allows the clinician to gain further insight into the degree of immunosuppression of their patient.

Atypical Chryseobacterium meningosepticum and meningitis and sepsis in newborns and the immunocompromised, Taiwan

From 1996 to 1999, 17 culture-documented systemic infections due to novel, atypical strains of Chryseobacterium meningosepticum occurred in two newborns and 15 immunocompromised patients in a medical center in Taiwan. All clinical isolates, which were initially misidentified as Aeromonas salmonicida by an automated bacterial identification system, were resistant to a number of antimicrobial agents. The isolates were characterized as atypical strains of C. meningosepticum by complete biochemical investigation, 16S rRNA gene sequence analysis, cellular fatty acid analysis, and random amplified polymorphic DNA fingerprinting (RAPD). This is the first report of a cluster of atypically variant strains of C. meningosepticum, which may be an emerging pathogen in newborns and the immunocompromised.

Interference of antibody production to hepatitis B surface antigen in a combination hepatitis A/hepatitis B vaccine

A randomized trial comparing 3 manufacturing consistency lots of a combination hepatitis A/hepatitis B vaccine to each other and to hepatitis A vaccine and hepatitis B vaccine given separately and concurrently was done to evaluate safety, tolerability, and immunogenicity. Healthy volunteers >/=11 years of age were divided into 4 groups. Each of 3 groups received a separate consistency lot of the combination vaccine, and 1 group received separate but concurrent injections of hepatitis A and hepatitis B vaccines. Injections were given at weeks 0 and 24. The combination vaccine was generally well tolerated. The hepatitis A portion of the combination vaccine produced clinically acceptable high seropositivity rates 4 and 52 weeks after the first injection. The hepatitis B portion of the vaccine did not produce clinically acceptable seropositivity rates 4 weeks after the second injection. Lack of antibody production may be attributed, at least in part, to immunologic interference.

Differential satiating effects of fats in the small intestine of obesity-resistant and obesity-prone rats

The effects of duodenal infusions of fats on sham feeding was measured in two strains of rats that differ in their susceptibility to fat-induced obesity. Osborne-Mendel rats are prone to developing obesity on a high-fat diet and preferentially choose fats over carbohydrates in macronutrient selection paradigms. In contrast, S 5B/PL rats are resistant to developing obesity when eating a high-fat diet, and preferentially choose carbohydrates in macronutrient selection paradigms. To test the hypothesis that differences in the satiating potency of fats in the small intestine contributed to these differences between the two strains, we measured the effects of duodenal infusions of Intralipid and sodium linoleate on sham-feeding intakes. The results were consistent with the hypothesis. Duodenal infusions of either of these fats decreased intake significantly more in S5B/PL rats than in Osborne-Mendel rats. Both rat strains sham fed similar amounts when intestinally infused with 0.15 M NaCl. These results suggest that differences in responses to intestinal satiating mechanisms may contribute to the differences in susceptibility to fat-induced obesity in these rat strains.

Safety and immunogenicity of a new formulation of an inactivated hepatitis A vaccine

The safety and immunogenicity of a new formulation of the inactivated hepatitis A vaccine, Avaxim, was evaluated in 189 children, aged 18 months to 15 years in a monocentric, open trial. Two vaccinations were given six months apart. Enrollment was balanced within three age groups: 18 months to 3 years, 4-8 years and 9-15 years. Antibody titers were measured blindly by an independent laboratory using a modified radioimmunoassay. Two weeks after the first dose, seroconversion was achieved by 94.6, 94.3 and 96.4% of initially HAV-seronegative subjects (antibody titre <20 mIU/ml) in each age group (youngest to oldest, respectively), with corresponding geometric mean titre concentrations (GMC) of 72.2, 54.3 and 47.1 mIU/ml. Just before the booster dose, the seroconversion rate was 100% in all groups, and the corresponding GMC values were 163, 169 and 111 mIU/ml. All groups included, a 22.6-fold rise in GMC from prebooster levels was observed four weeks after the booster dose. An explanatory analysis suggested a tendency for higher antibody levels in younger children at all vaccination time points. Local reactions were noted in 18.2% of the vaccinees after the first dose and in 8.5% after the booster dose. The rates of systemic reactions were 23.8% after the first dose and 11.4% after the booster dose. Overall, this trial demonstrated the good safety and immunogenicity profile of this vaccine in children aged 18 months to 15 years of age.

A survey of state insurance mandates covering alcohol and other drug treatment

This article reports the results of a survey of health insurance mandate legislation for alcohol and other drug treatment in the 50 states through spring 1991. A total of 23 states (including the District of Columbia) requires insurance carriers to provide coverage for alcohol and other drug treatment. This paper compares the provisions in these states at the present time and contrasts these provisions with those in effect in 1981. The paper concludes with a discussion of the policy objectives states pursue through enactment of such legislation and the outcomes brought about by the mandates.

Bacteriologic efficacy of a three-day intramuscular ceftriaxone regimen in nonresponsive acute otitis media

OBJECTIVE

To determine the bacteriologic efficacy of ceftriaxone in nonresponsive acute otitis media in children.

METHODS

In a prospective study 92 patients ages 3 to 36 months (median, 11 months) with culture-proved nonresponsive acute otitis media were studied from January, 1995, through August, 1997. The patients were treated with intramuscular ceftriaxone (50 mg/kg/l/day) for 3 days. Middle ear fluid was aspirated for culture by tympanocentesis on day of enrollment (Day 1); a second tap was performed on Days 4 to 10. Additional middle ear fluid cultures were obtained if clinical relapse occurred. Bacteriologic failure was defined by positive culture on Days 4 to 10. Patients were followed until Day 17+/-2. Susceptibility was measured by E test.

RESULTS

The main drugs administered before enrollment were amoxicillin (38%), amoxicillinclavulanate (25%) and cefaclor (20%). Organisms recovered (n=105) were: Haemophilus influenzae, 54; Streptococcus pneumoniae, 47; Moraxella catarrhalis, 2; and Streptococcus pyogenes, 2. Thirty-four (72%) of the 47 S. pneumoniae isolates were intermediately resistant to penicillin (MIC 0.1 to 1.0 microg/ml), but all were susceptible to ceftriaxone (MIC < 0.5 microg/ml). Bacteriologic eradication was achieved in 100 of 105 (95%) cases: 54 of 54 (10O%) H. influenzae, 43 of 47 (92%) S. pneumoniae, 1 of 2 (50%) M. catarrhalis and 2 of 2 (100%) S. pyogenes. Bacteriologic success (with no relapse) occurred in 13 of 13 (100%) penicillin-susceptible S. pneumoniae vs. 28 of 34 (82%) S. pneumoniae intermediately resistant to penicillin (4 cases of bacteriologic failure and 2 cases of relapse).

CONCLUSION

A 3-day intramuscular ceftriaxone regimen is efficacious for the treatment of nonresponsive acute otitis media. The optimal duration of treatment in cases of nonresponsive acute otitis media and whether ceftriaxone is efficacious for the treatment of nonresponsive otitis media caused by S. pneumoniae highly resistant to penicillin is yet to be determined.

Dynamics of pneumococcal nasopharyngeal colonization during the first days of antibiotic treatment in pediatric patients

BACKGROUND

Nasopharyngeal (NP) carriage of antibiotic-resistant Streptococcus pneumoniae was shown to be associated with recent antibiotic treatment. To date no studies have evaluated early dynamics of pneumococcal NP carriage during antibiotic treatment.

OBJECTIVES

To observe changes in NP pneumococcal carriage within 3 to 4 days after initiation of antibiotic treatment in acute otitis media (AOM).

METHODS

Patients ages 3 to 36 months with AOM treated with various antibiotics were prospectively followed. Nasopharyngeal culture for S. pneumoniae was obtained before (Day 1) and 72 to 96 h after initiation of treatment (Days 4 to 5). Antibiogram and serotyping were performed in all isolates as was also the MIC of penicillin. The disappearance and persistence of the initial isolates as well as the appearance of isolates with new serotype or with new antibiotic susceptibility patterns were investigated.

RESULTS

A total of 120 patients were studied: 106 received beta-lactam antibiotics and 14 received azithromycin. Among the initial 76 pneumococcal isolates 63, 37 and 13% were resistant to > or =1, > or =2 and > or =3 antibiotic drugs. After 3 to 4 days of treatment with various beta-lactam drugs, 45, 63 and 100% of isolates with MIC values of <0.1 microg/ml, 0.125 to 0.25 microg/ml and 0.38 to 1.0 microg/ml, respectively, persisted in the NP (P = 0.038). There was a difference between the various beta-lactam drugs in their effect on NP colonization: a drug with lower MIC values (cefuroxime-axetil) had a better eradication rate of penicillin-susceptible organisms than a less active one (cefaclor), but neither significantly reduced carriage of penicillin nonsusceptible isolates. Azithromycin eliminated carriage of macrolide-susceptible organisms but increased the carriage of macrolide-resistant ones. In 19 of 120 (16%) patients a new S. pneumoniae isolate was recovered 3 to 4 days after initiation of treatment. Of those 16 (84%) were resistant to the drug the patient was receiving.

CONCLUSION

A rapid selection of nonsusceptible NP pneumococcal isolates during antibiotic treatment for AOM is common. This phenomenon may contribute to the spread of resistant pneumococci.

Early eradication of pathogens from middle ear fluid during antibiotic treatment of acute otitis media is associated with improved clinical outcome

OBJECTIVE

To determine the relation between early bacteriologic eradication and clinical outcome of acute otitis media (AOM) in infants and young children treated with various antibiotics.

STUDY DESIGN

The study group consisted of patients ages 3 to 24 months seen at the Pediatric Emergency Room with: (1) symptoms and physical findings consistent with AOM of < or = 7 days duration; (2) no spontaneous perforation or tympanostomy tubes; (3) positive initial middle ear fluid culture; and (4) a follow-up to at least Day 10+/-2 of the study with a second culture performed 72 to 96 h after initiation of antibiotic treatment. Any patient with a positive middle ear fluid culture 72 to 96 h after initiation of antibiotic treatment was considered to have bacteriologic failure. Otologic evaluation was done by an otolaryngologist unaware of the culture results and of the study drug allocation. A clinical score based on body temperature, report of irritability and ear tugging observed by the parents and the appearance and redness of the ear drum as observed by the otolaryngologist was also used for clinical evaluation.

RESULTS

The study group consisted of 123 patients, of whom 57 (46%) had positive middle ear fluid 72 to 96 h after initiation of antibiotic treatment. Clinical failure was observed in 21 of 57 (37%) patients in whom bacteriologic eradication did not occur vs. only 2 of 66 (3%) patients with bacteriologic eradication after 3 to 4 days of treatment (P < 0.001). Clinical score for both moderate and severe disease decreased significantly faster in those with bacteriologic eradication than in those in whom middle ear fluid was still culture-positive 72 to 96 h after initiation of treatment.

CONCLUSION

Clinical failures in our population were associated with inability to eradicate the causative organisms of AOM from the middle ear fluid within 3 to 4 days after initiation of antibiotic therapy. Most patients (including those without bacteriologic eradication) improved after 3 to 4 days of treatment, but patients with sterile middle ear fluid felt better after 3 to 4 days of treatment than patients in whom middle ear fluid was still culture-positive.

The relationship between apolipoprotein E, dementia, and vascular illness

The purpose of this study was to concurrently assess the relationship of Apolipoprotein E (APOE) with both dementias and vascular illnesses in the very old. Nine hundred and fifty nine subjects (mean age 85 years) in a long-term care facility were genotyped and cognitively tested with the Mini Mental State Exam. All subjects were studied for the relationship of APOE with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. Four hundred fifty individuals met criteria for inclusion into one of the following groups: Alzheimer's disease (n = 318), vascular dementia (n = 49), or not demented controls (n = 83) and were investigated for the relationship between APOE and these diagnostic categories. APOE epsilon4 was not associated with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. The APOE epsilon3 allele was more common in men with atherosclerotic heart disease. In contrast, the APOE epsilon4 allele was more common in patients with Alzheimer's disease (22%) and vascular dementia (26%) than in not demented controls (7%). APOE epsilon4 is associated with dementias in the very old, whereas its relationship with either peripheral or central nervous system vascular disease without dementia is not as robust.

The treatment of social phobia: a critical assessment

This article critically reviews the effects of psychological treatment (exposure, cognitive restructuring, social skills training) and pharmacological treatment (MAOIs, reversible MAOIs, anxiolytics and SSRIs) of social phobia. Only controlled studies have been included, and their outcomes were assessed for improvement in anxiety and avoidance, social functioning and clinical status. Both psychological and pharmacological treatments resulted in a significant and meaningful reduction in anxiety and, in most cases, a weakening of the tendency to avoid. Although useful, the effects were not of such a magnitude as to result in remission. Reduction in anxiety was long-lasting in patients treated by psychological methods. The lessening of anxiety did not necessarily lead to meaningfully improved social functioning. The combination of psychological and pharmacological treatments was disappointing, and did not exceed the effects of psychological treatments alone. However, the most promising medications were not tested. Subtype of social phobia and additional diagnoses did not determine the response to treatment.

Internal jugular vein thrombosis in a child due to a 'pencil point injury' of the palate

Penetrating trauma of the soft and hard palate are common in children and have been termed 'pencil point injuries.' Although such injuries are usually minor, the English literature has reported over 25 cases complicated by thrombosis of the internal carotid artery. We describe an unusual case of a 6 year old girl who presented with fever, cervical swelling and torticollis, following a pencil point injury. Physical examination and CT scan confirmed the diagnosis of internal jugular vein thrombosis (IJVT). The management of pencil point injuries and IJVT in children is reviewed and the possible mechanisms of IJVT in the case described here, are discussed.

Resistance pattern of middle ear fluid isolates in acute otitis media recently treated with antibiotics

BACKGROUND

Little information is available about the effect of antibiotic treatment on the prevalence and MIC of the subsequently isolated pathogens in cases of acute otitis media (AOM) failing a course of antibiotic therapy. This information is important, particularly regarding the effectiveness of the oral antibiotics used in children failing initial therapy.

PATIENTS AND METHODS

One hundred eighty-one children with culture-positive AOM were prospectively studied between October, 1995, and July, 1996. Sixty-three (35%) patients received various antibiotics for variable periods during the 14 days preceding enrollment.

RESULTS

A total of 94 Streptococcus pneumoniae (Pnc) and 113 Haemophilus influenzae (Hi) were isolated. Thirty-eight Pnc and 35 Hi were isolated in the 63 patients with recently treated AOM. Pnc as a single isolate was more prevalent in patients recently treated with antibiotics (27 of 63, 43%) than among those not recently treated (32 of 118, 27%, P = 0.047). The MIC50 values of penicillin, cefaclor and cefuroxime axetil for Pnc were significantly higher in the pneumococci isolated from patients recently treated than among those isolated from patients not recently treated with antibiotics (0.38, 3 and 0.75 microg/ml vs. 0.094, 0.38 and 0.12 microg/ml, respectively). Seventy-nine percent of Pnc isolates in the recently treated group had MIC for penicillin of >0.1 microg/ml vs. only 47% in those not recently treated (P < 0.05). The respective figures for MIC >0.5 microg/ml of cefaclor were 79% vs. 41% for the recently treated and not recently treated groups (P < 0.001); cefuroxime MIC >0.5 microg/ml was found in 61 and 25%, respectively (P = 0.001).

CONCLUSIONS

Pneumococcus is more prevalent in AOM after a recent antibiotic treatment, and the MIC of the commonly used beta-lactam drugs for Pnc is considerably higher in this setting. In view of our data, the use of oral cephalosporins like cefaclor or cefuroxime as second line drugs in the treatment of unresponsive AOM, particularly in regions where resistant PNC is prevalent, should be reconsidered.

High prevalence of "Simkania Z," a novel Chlamydia-like bacterium, in infants with acute bronchiolitis

The newly described microorganism "Simkania Z" ("Z"), an obligate intracellular, penicillin-resistant microorganism most closely related to the chlamydiae, has been associated with adult community-acquired pneumonia. The possible involvement of "Z" in bronchiolitis in infants was examined in a prospective study of 239 infants with bronchiolitis and 78 controls. Other potential etiologic agents sought were respiratory syncytial virus (RSV), adenovirus, and cytomegalovirus. Evidence for the presence of "Z" in nasopharyngeal wash specimens (polymerase chain reaction and/or culture) was found in 25% of infants with bronchiolitis, while controls were all negative (P < .001). A serum IgA response to "Z" infection was detected by immunoperoxidase assay in 15% of infants with bronchiolitis versus 1.3% of controls (P < .001). Clinical findings were not different for infants with bronchiolitis associated with RSV alone, "Z" alone, or RSV and "Z" together. The high prevalence of "Z" in infants with bronchiolitis, often accompanied by an immune response, suggests a possible etiologic role of this agent in the disease.

Prospective study to determine clinical relevance of detection of pneumococcal DNA in sera of children by PCR

We undertook a prospective study to evaluate the accuracy of PCR of serum (aimed at the pneumococcal pneumolysin gene) at detecting pneumococcal infections in infants and children. The assay was positive for all blood and cerebrospinal fluid culture-positive samples and for 38 and 44% of patients with lobar pneumonia and acute otitis media, respectively. It was positive for 17% of healthy controls. There was a marked effect of age on the rate of positivity among healthy controls, with the highest rate (33%) being in 2-year-old children, the age group with the highest rate of nasopharyngeal (NP) carriage; the lowest rate was found among infants <2 months of age (13%) and adults ages 18 to 50 years (0%), age groups with the lowest NP pneumococcal carriage rates. Carriers of pneumococci in the nasopharynges had a higher rate of positivity than noncarriers of pneumococci in the nasopharynges for all groups. Our results suggest that although PCR of serum is a sensitive test for the detection of Streptococcus pneumoniae in sterile fluids, its high rate of positivity for healthy controls, related to NP pneumococcal carriage, might exclude it from being useful in detecting deep-seated pneumococcal infections.

Comparison of psychosocial adaptation of advanced stage Hodgkin's disease and acute leukemia survivors. Cancer and Leukemia Group B

BACKGROUND

The purpose of this study was to compare the long-term psychosocial adaptation of Hodgkin's disease and adult acute leukemia survivors.

PATIENTS AND METHODS

Two hundred seventy-three Hodgkin's disease (HD) and 206 adult acute leukemia (AL) survivors were interviewed by telephone concerning their psychosocial adjustment and problems they attributed to having been treated for cancer, using identical research procedures and a common set of instruments. The following measures were used: Psychosocial Adjustment to Illness Scale (PAIS); Brief Symptom Inventory (BSI); current Conditioned Nausea and Vomiting triggered by treatment-related stimuli (CNVI); Indices of Employment, Insurance and Sexual Problems Attributed to Cancer; Negative Socioeconomic Impact of Cancer Index (NSI). All participants had been treated on one of nine Hodgkin's disease or 13 acute leukemia Cancer and Leukemia Group B (CALGB) clinical trials from 1966-1988, and had been off treatment for one year or more (mean years: HD = 5.9; AL = 5.6).

RESULTS

HD survivors' risk of having a high distress score on the BSI was almost twice that found for AL survivors (odds ratio = 1.90), with 21% of HD vs. 14% of AL survivors (P < 0.05) having scores that were 1.5 standard deviations above the norm, suggestive of a possible psychiatric disorder. HD survivors reported greater fatigue (POMS Fatigue, P = 0.01; Vigor Subscales, P = 0.001), greater conditioned nausea (CNVI, P < 0.05), greater impact of cancer on their family life (PAIS Domestic Environment, P = 0.004) and poorer sexual functioning (PAIS Sexual Relationships, P = 0.0001), than AL survivors.

CONCLUSIONS

Treatment-related issues may have placed HD survivors at a greater risk for problems in long-term adaptation than AL survivors.

Positive blood cultures for coagulase-negative staphylococci in neonates: does highly selective vancomycin usage affect outcome?

The implication of highly-selective vancomycin usage on the outcome for infants with positive blood cultures for coagulase-negative staphylococci (CONS) was assessed retrospectively. The analysis was performed on partly prospective collected data from infants under 3 months of age with a least one CONS-positive blood culture in the neonatal intensive care unit at the Soroka University Medical Center between 1990 and 1996. During the study period, 239 episodes of CONS-positive blood cultures were identified from among 64,226 live births (3.7 per 1,000). Vancomycin was administered in 22 (9%) episodes, in all cases only after identification of the bacteria. The remaining 217 episodes were managed either without antibiotics or with continuation or initiation of empiric antibiotic therapy (usually ceftazidime +/- ampicillin) for suspected sepsis. Severity of the initial illness, subsequent morbidity and mortality were low regardless of the treatment administered. Only a single case of a blood-borne vancomycin resistant gram-positive organism was observed during the study period. The approach to CONS-positive blood cultures in neonates used here was associated with low morbidity and mortality. These findings support a policy of highly selective vancomycin usage in an era of emerging vancomycin resistance.

NAGLU mutations underlying Sanfilippo syndrome type B

Sanfilippo syndrome type B (mucopolysaccharidosis III B) is a rare autosomal recessive disease caused by deficiency of alpha-N-acetylglucosaminidase, one of the enzymes required for the lysosomal degradation of heparan sulfate. The gene for this enzyme, NAGLU, recently was isolated, and several mutations were characterized. We have identified, in amplified exons from nine fibroblast cell lines derived from Sanfilippo syndrome type B patients, 10 additional mutations: Y92H, P115S, Y140C, E153K, R203X, 650insC, 901delAA, P358L, A664V, and L682R. Four of these mutations were found in homozygosity, and only two were seen in more than one cell line. Thus, Sanfilippo syndrome type B shows extensive molecular heterogeneity. Stable transfection of Chinese hamster ovary cells, by cDNA mutagenized to correspond to the NAGLU missense mutations, did not yield active enzyme, demonstrating the deleterious nature of the mutations. Nine of the 10 amino acid substitutions identified to date are clustered near the amino or the carboxyl end of alpha-N-acetylglucosaminidase, suggesting a role for these regions in the transport or function of the enzyme.

Serum neuroleptic levels during reduced dose fluphenazine decanoate maintenance therapy

Forty-one remitted and chronically psychotic schizophrenic out-patients completed a two-year clinical trial during which they were assigned, on the basis of their clinically determined maintenance dosages, to one of two reduced, fixed-dose fluphenazine decanoate (FD) regimens: 35 mg/4 wks (19 patients) or 10 mg/4 wks (22 patients). Eighty-one percent of chronically psychotic patients, who represented 74% of the high dose group, relapsed, in comparison with only 38% of remitted patients (p < .001), who represented 86% of the low dose group. During this study serum neuroleptic levels were assessed, using the radioreceptor assay, before the administration of each FD injection and whenever a patient relapsed. Overall, 334 serum neuroleptic activity measurements were performed. Serum neuroleptic levels were detectable in all patients and were higher, although not significantly, in the 35 mg/4 wks group. The dichotomous clinical outcome of chronically psychotic and remitted patients occurred within the framework of essentially similar serum neuroleptic levels. These findings suggest that: 1) serum neuroleptic levels can be monitored during low dose FD treatment, 2) the poor maintenance therapy outcome of chronically psychotic patients cannot be accounted for by inadequate neuroleptic bioavailability, 3) a majority of remitted FD maintained patients retain their clinical response at serum neuroleptic levels lower than those initially attained at steady state.

Bacteriologic response to oral cephalosporins: are established susceptibility breakpoints appropriate in the case of acute otitis media?

Bacteriologic response to cefuroxime axetil and cefaclor administered for 10 days was evaluated in acute otitis media (AOM) in patients aged 6-36 months. Middle ear fluid culture was obtained by tympanocentesis before treatment, on day 4 or 5 after initiation of treatment, and if clinical relapse occurred before day 17. Bacteriologic failure was observed in 32% of patients receiving cefaclor versus 15% of patients receiving cefuroxime axetil (P = .009). Failure rates increased with increasing MIC: For Streptococcus pneumoniae, 0.5 microg/mL (established as cutoff value for cefuroxime by the National Committee for Clinical Laboratory Standards [NCCLS]) discriminated between success and failure. For Haemophilus influenzae, high failure rates were observed for cefaclor, even with low MICs (< or = 1.0 microg/mL), and with both drugs they tended to increase with increasing MIC, even for values below the cutoff suggested by the NCCLS (8.0 and 4.0 microg/mL for cefaclor and cefuroxime, respectively). Thus, for AOM caused by H. influenzae, lower susceptibility cutoff levels for MICs should be established.

Psychogenic cough tic: a case report

A case of psychogenic cough tic is presented to demonstrate the problems and complications that can arise from misdiagnosis of this dramatic and disabling disorder. It can be confused with TS and may be treated more aggressively than is beneficial. A single case with a recurrent course is described with the hypothesis of a possible autoimmune contribution. The combination of organic precipitants and emotional maintaining factors suggests that psychogenic cough tic is a condition that lies between somatization and transient tic disorder.

A prospective study of neonatal sepsis and meningitis in southern Israel

OBJECTIVE

To study the epidemiology of neonatal sepsis and meningitis in the Negev area of southern Israel.

DESIGN

A prospective 8-year study conducted at the neonatal intensive care unit and pediatric wards of the Soroka University Medical Center.

RESULTS

Two hundred twenty-nine cases of hospital and community-acquired neonatal sepsis occurred during the study period. Thirty-two patients (14%) were meningitis. During this period 70,709 births (59% Jews and 41% Bedouins) were recorded; thus the rates of neonatal sepsis and meningitis were 3.2 and 0.5/1000 live births, respectively. One hundred seventeen (4/1000 live births) cases were recorded in Bedouins and 112 (2.6/1000 live births) in Jewish neonates (P < 0.001). Twenty-six percent of all sepsis cases occurred within < 24 h from birth, 25% from Days 2 to 7 of life and 49% between Days 8 and 28. A total of 251 organisms that were considered true pathogens were isolated. Fifty-seven of all isolates were Gram-negative organisms (mainly Klebsiella pneumoniae (20%) and Escherichia coli (16%)). Gram-positive organisms were isolated in 41% of cases. Although E. coli was the most frequently recovered Gram-negative pathogen in community-acquired late onset sepsis, Klebsiella and Enterobacter spp. represented the most commonly isolated Gram-negative organisms in nosocomial late onset sepsis. All Staphylococcus aureus isolates recovered in late onset sepsis were nosocomial. The incidence of Streptococcus agalactiae was 3 times higher in early onset sepsis than in late onset sepsis. All cases of Streptococcus pneumoniae sepsis occurred in Bedouins.

CONCLUSIONS

Neonatal sepsis and meningitis rates in southern Israel are similar to those reported in Western Europe and the United States. The incidence of neonatal sepsis is significantly higher for Bedouins than for Jewish neonates. The distribution of the main pathogens is different in southern Israel and although Gram-negative enteric organisms are predominant, S. agalactiae plays a relatively minor role in the etiology of sepsis during the first month of life. In southern Israel the etiology of community-acquired late onset sepsis is different from that of nosocomial late onset sepsis.

The immunogenetics of autoimmune diabetes and autoimmune thyroid disease

Although medical genetics is a well-developed area of interest, relatively little is known about the diseases caused by the combination of many genes. These multiinfluenced diseases include the autoimmune endocrine diseases. Recent advances in the techniques for whole-genome screening have shown a variety of loci that are linked to the development of insulin-dependent diabetes mellitus, and similar data are likely to be soon generated in autoimmune thyroid disease. Here, the authors survey the current state of genetic knowledge in these two areas and describe the investigative and analytical techniques that are now available. (Trends Endocrinol Metab 1997;8:63-70). (c) 1997, Elsevier Science Inc.

Single-and dual-energy CT with monochromatic synchrotron x-rays

We explored the potential for clinical research of computed tomography (CT) with monochromatic x-rays using the preclinical multiple energy computed tomography (MECT) system at the National Synchrotron Light Source. MECT has a fixed, horizontal fan beam with a subject apparatus rotating about a vertical axis; it will be used for imaging the human head and neck. Two CdWO4-photodiode array detectors with different spatial resolutions were used. A 10.5 cm diameter acrylic phantom was imaged with MECT at 43 keV and with a conventional CT (CCT) at 80 kVp: spatial resolution approximately equal to 6.5 line pairs (lp)/cm for both; slice height, 2.6 mm for MECT against 3.0 mm for CCT; surface dose, 3.1 cGy for MECT against 2.0 cGy for CCT. The resultant image noise was 1.5 HU for MECT against 3 HU for CCT. Computer simulations of the same images with more precisely matched spatial resolution, slice height and dose indicated an image-noise ratio of 1.4:1.0 for CCT against MECT. A 13.5 cm diameter acrylic phantom imaged with MECT at approximately 0.1 keV above the iodine K edge and with CCT showed, for a 240 micrograms I ml-1 solution, an image contrast of 26 HU for MECT and 13 and 9 HU for the 80 and 100 kVp CCT, respectively. The corresponding numbers from computer simulation of the same images were 26, 12, and 9 HU, respectively. MECT's potential for use in clinical research is discussed.

Quality management for health care in the Middle East and north Africa: professional cooperation as part of the peace process

BACKGROUND

In 1993, as the peace process opened up new possibilities for professional cooperation, the Quality Management (QM) Program for Health Care Organizations in the Middle East and North Africa was born of a shared perception that there is a high-priority need to improve the quality of health care and to cope with increasing costs and financial pressures. To date 22 health care organizations--including hospitals, primary care centers, health maintenance organizations, and ministries of health--are members of the QM Program and are actively implementing QM projects.

DEVELOPMENT OF THE PROGRAM

The QM Program began with an introductory conference, followed by an intensive training course. During the current phase of the program (1996-1999), a variety of facilitation activities--including training visits to the region by international experts, consultation support to member organizations by volunteer mentors in the United States, professional-exchange seminars, and site visits--are being conducted at the regional and national levels. Since the training course, the QM Program member organizations have implemented more than 40 model QM projects to improve both clinical and nonclinical processes. Projects consistent with national and organizational priorities were selected, with an emphasis on fast-paced improvements that reduce costs and enhance patient satisfaction.

FUTURE PLANS

The regional QM Program is envisioned to grow in size and strength through a four-year building process. By the year 2000, a cadre of local leaders should be prepared to carry the program forward into the new millennium.

Reduction of nasopharyngeal carriage of pneumococci during the second year of life by a heptavalent conjugate pneumococcal vaccine

Children 12-18 months old were randomized to receive one dose of a conjugate heptavalent pneumococcal vaccine, two doses of the same vaccine, or one dose of a 23-valent native polysaccharide vaccine. Before immunization, pneumococci included in the conjugate vaccine were isolated from 24% of the children, and an antibiotic-resistant pneumococcus was isolated from 22% of the children. The vaccines had no effect on carriage of non-vaccine-type pneumococci. In contrast, there was a significant reduction in carriage of vaccine-type pneumococci 3 months after one dose and 1 month after a second dose of conjugate vaccine (from 25% to 9% and 7%, respectively; P < .001). No effect was seen after vaccination with the nonconjugate vaccine. One year after immunization, carriage of antibiotic-resistant vaccine-type pneumococci in children receiving conjugate vaccine was lower than that in children receiving the nonconjugate vaccine (4% vs. 14%, P = .042). Conjugate pneumococcal vaccines may reduce spread of pneumococci in the community.

Next-generation informatics. A new picture of quality medicine

It's up to the physician executive to make an informed choice when selecting a "next-generation" information system. Look for systems that truly integrate (not merely interface) managed care components, clinical capabilities, and other features in a model that mimics the workflow of an actual practice. Take the time to learn about the technology. Consider how a vendor's product will work at every point within your organization. Seven critical features that physician executives should consider in their decision-making are described.

The controls of fat intake

OBJECTIVE

To present evidence on the control of the size of fatty meals in the context of the result of interactions of orosensory positive-feedback and postingestive negative-feedback mechanisms activated by fat stimuli in rodent models of feeding and of obesity.

METHOD

We examined the effects of orosensory stimuli and postingestive stimuli in Sprague-Dawley rats, and in the genetically obese Zucker (fa/fa) rat. We used the sham feeding rat preparation to isolate the orosensory stimulating and postingestive satiating properties of oils. The negative-feedback satiating properties of fats were elicited by intestinal infusions of fats. The Zucker rat is an animal model of obesity with abnormal control of meal size and increased intake of fats. Using this model we further examined the interaction of orosensory and postingestive stimuli in the control of meal size.

RESULTS

The orosensory properties of fats are sufficient to drive sham feeding and are not dependent on the postabsorptive metabolic consequences of oils in normal and Zucker rats. The satiating action of fats must act at preabsorptive sites because reduction of intake occurs before absorption of fat. The satiating potency of fats is dependent upon their specific chemical conformation and is mediated by endogenous cholecystokinin and afferent fibers of the abdominal vagus. We have found that oils produce significantly more orosensory positive feedback in obese Zucker rats than in lean rats in experimental tests of preference. This is probably the major abnormal mechanism responsible for the increased preference for fats that is characteristic of obese rats because we have not identified any significant decrease in the postingestive satiating potency of fats in obese Zucker rats.

CONCLUSIONS

Fat intake is controlled by both orosensory and postingestive stimuli in normal and genetically obese rodents. In the Zucker rat the investigation of this model of genetic obesity has produced data that is congruent with the preference for high fat foods in obese people and suggests further experiments directed toward a deeper understanding of the controls of fat intake and how they are disordered.