Cultural sensitivity and day care workers. Examination of a worksite based cardiovascular disease prevention project

Reaching workers in small worksites presents economic and access barriers for occupational health nurses. Some barriers can be overcome through strategies based on cultural sensitivity. Day care centers employ young, low income, mostly minority women in settings with few workers onsite at any one center. These settings were used to develop a culturally sensitive approach tested through onsite cardiovascular screening, informal interviews, and discussion of behavior change for better health. The study examined both the impact of the Healthier People Health Risk Appraisal (HPHRA) as a culturally appropriate recruitment strategy to involve a group of child day care workers in a cardiovascular disease (CVD) screening and risk reduction program and the effect of that program on observable CVD measures. Faculty and students from an institution of higher education forged a trust relationship with day care providers at nine day care centers in a large metropolitan area. Cardiovascular health was the impetus for the project because minority populations in the southeastern United States have high heart attack and stroke mortality and morbidity rates. Participation rates in the project increased from 26% of the day care workers in the first year of the project to 73% when long term relationships were built on culturally appropriate strategies. The project's culturally sensitive educational intervention focused on individual risks and lifestyle. Statistical analysis of outcomes of the intervention and personal interviews demonstrated the improvement of cardiovascular status in the day care workers. This psychosocial approach can provide the foundation for culturally sensitive care in larger occupational and community settings.

Identification of the Ly49L protein: evidence for activating counterparts to inhibitory Ly49 proteins

Previous studies have indicated that NK cells from different strains of inbred mice may express distinct Ly49 repertoires. Screening of NK cells from the CBA/J mouse for inhibitory and activating Ly49s revealed a novel DAP12-associated receptor that was immunoprecipitated with the Ly49G-specific mAb 4D11. Degenerate primers were designed to amplify and clone Ly49 cDNAs from CBA/J NK cells. A novel activating Ly49 cDNA was identified, which bears strong homology to the partially sequenced Ly49l gene found in C57BL/6 mice. Transfection of Ly49l into a DAP12+ cell line and subsequent immunoprecipitation experiments showed that Ly49L is likely the activating Ly49 detected by the 4DD11 antibody in CBA/J NK cells. Antibody-mediated cross-linking of Ly49L induced DAP12 phosphorylation, providing evidence that Ly49L is a functional activating receptor. Comparison of the extracellular domains of Ly49 family members indicates that all known activating members have an inhibitory counterpart with a highly related extracellular region.

Bion and binocular vision

The author describes his contact with Bion over a twenty-year period, from Bion's supervision of his control case in London in 1960 to the period from 1968 to 1978 when they were both working in Los Angeles. He outlines Bion's views on the use of 'instinct' and intuition in patient observation, the depressive position in patient and analyst, and memory and desire as impediments to knowledge of 'ultimate reality'. Some case material is presented, illustrating how Bion's ideas, particularly concerning attacks on linking, informed the course of the treatment. The author then discusses Freud's, Klein's and Bion's approaches to the problem of resistance, Bion's expansion of some of Klein's ideas, his definitions of psychosis and his formulation concerning thoughts that develop before thinking. The author then argues how essential it is for the analyst to differentiate between primitive projections from the patient that are pre-verbal attempts to communicate a state of mind and those that are an expression of hostility or control. He then discusses the importance of understanding idealizing projections and differentiating these from a healthy positive transference. He concludes by characterising Bion's way of working in terms of his humility, his courage and, fundamentally, his use of his intuitive binocular mind.

Thalamic terminal fields of individual axons from the ventral part of the dentate nucleus of the cerebellum in Macaca mulatta

This study examined organization of the projection from the dentate nucleus of the cerebellum to the ventral lateral nucleus (VL) of the thalamus in Macaca mulatta. Small injections of biotinylated dextran amine were placed in the ventral parts of dentate nuclei. The distribution of all contralateral terminal fields in the thalamus was charted, and representative individual axons that terminated in the VL were traced in serial sections under the light microscope. These axons were reconstructed with all their branches and terminal fields in the thalamus. The geometry and size of the terminal fields as well as the number and distribution of boutons and neurons in them were analyzed. The terminal fields of all labeled axons were distributed widely over the VL either singly or in clusters. Two types of axons were found: simple axons formed only one terminal field and complex axons formed multiple terminal fields at a distance. Individual terminal fields were focal, had the form of flattened discs, and generated up to 200 boutons distributed between 10 and 29 nerve cell bodies. These findings suggest that a simple axon activates a small group of neurons at one site. The complex axons, in turn, influence similar size cell groups at different VL locations. The total number of boutons generated by a single complex axon was up to 300. Future studies should determine whether simple axons could be branches of complex axons that took off below the thalamus. The results reveal a complex organization of the input from the ventral dentate to the VL that only partially fits into the traditional concept of somatotopic organization of the nucleus.

Comparison of the healing rates and complications of three four-layer bandage regimens

This randomised controlled study compares the healing rates, complications and patient and staff acceptability of three four-layer bandage regimens for leg ulcers. A total of 149 patients were recruited into the study, of whom 50 received the original Charing Cross system (CX4L), 50 a modified Charing Cross system (Parema) and 49 a commercially available kit, Robinson Ultra Four (Robinson). No significant difference was found in the healing rates of the three systems. Overall 12 weeks' healing was 65%, while the 20-week healing rates for the individual systems were 87% (CX4L), 84% (Parema) and 83% (Robinson). Analysis of known risk factors for delayed healing showed that no bandaging system had an advantage over the others. Staff familiarity resulted in an initial preference for the CX4L but there was no bandage preference by the end of the study. The data suggest that none of the systems has an advantage over the others and that cost savings can be made by pursuing a competitive pricing policy.

Continuum approach to car-following models

A continuum version of the car-following Bando model is developed using a series expansion of the headway in terms of the density. This continuum model obeys the same stability criterion as its discrete counterpart. To compare both models we show that traveling wave solutions of the Bando model are very similar to those of the continuum model in the limit of small changes of headway. As the change of headway across the wave increases the solutions gradually diverge. Our transformation relating headway to density enables predictions of the global impact and characteristics of any car-following model using the analogous continuum model. In contrast, we show that the conventional continuum models which account for effects of pressure and dispersion predict behavior which is distinct from the global behavior of discrete models.

Hepatic manifestations of familial patent ductus venosus in adults

BACKGROUND

The ductus venosus connects the umbilical vein to the inferior vena cava during fetal life and subsequently closes rapidly after birth. It is known as patent ductus venosus when it remains patent in adulthood.

PATIENTS

A 43 year old man with a history of panhypopituitarism presented with recurrent bouts of pedal oedema associated with fatigue, hypoalbuminaemia, and elevated prothrombin time. An ultrasound examination of his abdomen with Doppler revealed notable attenuation of the main portal vein with diminished intrahepatic branches; a computed tomography scan with angiography revealed a large collateral vein within the liver consistent with a patent ductus venosus. Sequential liver biopsies showed a considerable reduction in the calibre and number of the portal veins. His younger brother, who was diagnosed with alcohol related cirrhosis, suffered from intermittent bouts of encephalopathy and was found to have the same vascular lesion. A third brother was found to have a patent ductus venosus as well as two large hepatic masses consistent with focal nodular hyperplasia.

CONCLUSION

The syndrome of familial patent ductus venosus has only previously been described in three infant brothers who presented with hepatic encephalopathy and fatty degeneration of the liver. This report documents three brothers with a patent ductus venosus presenting in adulthood with different manifestations of liver disease. The presence of the same vascular anomaly in three brothers is highly suggestive of a recessive genetic trait with an anatomical manifestation of patent ductus venosus.

Is disease management relevant in Europe: some evidence from the United Kingdom

Actions or approaches by the pharmaceutical industry, going under the general label 'disease management', have become very popular in the USA. However, there appears to be uncertainty about what exactly 'disease management' is and about the extent to which it can be applied in Europe. A postal questionnaire on disease management was sent out to senior personnel in the UK NHS and pharmaceutical industry. The survey aimed to explore the meaning of the term 'disease management' and its relevance to the NHS, assessing how perspectives differed between the two groups of respondents. Views on the barriers to the increase of disease management within the NHS were also sought. Finally, respondents were asked to indicate any involvement in joint disease management ventures. Most respondents agreed that disease management included estimating the total cost of managing a disease (92%) and the devising of clinical guidelines (97%). When asked about the particular role a pharmaceutical company might play, the level of agreement dropped in both groups of respondents, but by a greater degree in the NHS group. In defining disease management for themselves, just 4% of respondents referred to a 'partnership' between the NHS and the pharmaceutical industry. It would seem that, for the majority of respondents, 'joint ventures' are a possible, but not a necessary, means of undertaking disease management. Almost 30% of NHS respondents and 55% of industry respondents indicated that their Authority or company had experience of a joint venture in disease management. The major perceived barrier to an increase in disease management was NHS suspicion of pharmaceutical companies (86% of all respondents), with the difficulty in drawing up contracts coming a close second (79%).

Benefits of using telemedicine and first results in Bosnia and Herzegovina

In October 1996 the Institute of Pathology with the Radiology and Ophthalmology Clinic of the university hospital of Sarajevo joined the experimental telemedicine project SHARED. Two months after the project began, dermatology, paediatrics and haematology were also included. During the first phase we had 40 teleconsultations that showed us the benefits of using telemedicine. Our opinions and the opinions of the pathologist in Milan were similar for most of the biopsies (78%). The total time required for the consultation for the first 40 cases was 372 min, or 9.3 min each, on average. The longest consultation time was 25 min. The largest number of images was 44 per case, the smallest four. Because of problems of infrastructure and lack of experts, telemedicine will be important to a small country like Bosnia and Herzegovina.

Alleged allergy to local anaesthetic drugs

OBJECTIVE

To identify the true nature of an acute reaction in 25 patients initially diagnosed as allergic to local anaesthetic drugs.

SETTING

University General and Dental Hospitals.

INTERVENTIONS

Detailed review of each patient's previous exposure to local anaesthetic drugs and of the history of the acute event was followed up with challenge testing by intradermal injection.

RESULTS

One patient was subsequently found to be genuinely allergic to a local anaesthetic drug of the amide type. A wide range of conditions had actually precipitated the other adverse reactions, but all could be classified under three major headings: an immunological condition to a different antigen; a manifestation of anxiety; or an iatrogenic problem.

CONCLUSION

Local anaesthetic allergy is rare, but does occur. All reactions to local anaesthetic drugs must be assessed carefully and specialist referral may be appropriate.

The prevalence of Tourette syndrome in a mainstream school population

The aim of this study was to ascertain accurately the prevalence of Tourette syndrome (TS) in a mainstream school population. All year 9 pupils (aged 13 to 14 years) in a mainstream secondary school were investigated using a two-stage procedure. Standardized questionnaires were completed by parents, teachers, and pupils. Class observations were also carried out to identify tics. Those pupils identified as having tics underwent a semistructured interview to determine whether they had TS according to DSM-III-R criteria. Data were available from at least one source (parent, teacher, or self-reports) on 166 of the 167 pupils in the year. Five subjects were identified as having TS according to DSM-III-R criteria, yielding a prevalence estimate of 299 per 10,000 pupils in this age group. The results of this study suggest that TS in the community as a whole is more common and milder than those prevalence estimates and descriptions of the disorder based on TS encountered in secondary or tertiary health-care service settings.

Mutagenesis of the aspartic acid ligands in human serum transferrin: lobe-lobe interaction and conformation as revealed by antibody, receptor-binding and iron-release studies

Recombinant non-glycosylated human serum transferrin and mutants in which the liganding aspartic acid (D) in one or both lobes was changed to a serine residue (S) were produced in a mammalian cell system and purified from the tissue culture media. Significant downfield shifts of 20, 30, and 45 nm in the absorption maxima were found for the D63S-hTF, D392S-hTF and the double mutant, D63S/D392S-hTF when compared to wild-type hTF. A monoclonal antibody to a sequential epitope in the C-lobe of hTF reported affinity differences between the apo- and iron-forms of each mutant and the control. Cell-binding studies performed under the same buffer conditions used for the antibody work clearly showed that the mutated lobe(s) had an open cleft. It is not clear whether the receptor itself may play a role in promoting the open conformation or whether the iron remains in the cleft.

Pro-haemorrhagic effects of calcium antagonists: a comparison of isradipine and atenolol on ex vivo platelet function in hypertensive subjects

It has been suggested that long term treatment with calcium antagonist drugs might inhibit platelet function and lead to an anti-atheromatous effect. However recent data have also suggested that such an effect might increase mortality due to an increased incidence of gastrointestinal bleeding. We identified 43 subjects from general practice with uncomplicated mild to moderate hypertension to compare the effects of the calcium antagonist isradipine with that of the beta-blocker atenolol on platelet function, plasma beta-thromboglobulin levels, fibrinolysis, and serum lipids in a randomised double-blind parallel group study. After careful evaluation to exclude concomitant aspirin use, only 24 subjects were eligible to enter the study. While isradipine and atenolol produced comparable and clinically significant falls in blood pressure (167 +/- 2/102 +/- 1 to 153 +/- 3/91 +/- 2 mm Hg, and 165 +/- 2/101 +/- 1 to 156 +/- 4/91 +/- 2 mm Hg, respectively), neither drug produced a detectable effect on ex vivo platelet aggregation, platelet retention, or thromboxane generation with adrenaline, collagen, adenosine-di-phosphate, or platelet activating factor. However a decrease in plasma beta-thromboglobulin levels was observed which reached statistical significance (P < 0.05) after 12 weeks treatment in the isradipine but not the atenolol group. A 39% reduction with isradipine compared with 34% following atenolol treatment. Euglobulin clot lysis time was not altered by either drug. Serum cholesterol concentrations were also unaltered by drug treatment. Therapeutic doses of the calcium antagonist isradipine may produce a minor indirect effect on platelet function after several weeks of treatment. However, this is of doubtful clinical importance and may simply reflect an effect of lowered blood pressure on platelet function.

Phenytoin-oxacillin interactions in normal and uremic sera

Displacement of phenytoin (90% bound to albumin) by other strongly albumin-bound drugs such as salicylate and valproic acid may result in an increase in pharmacologically active free concentrations. The antibiotic oxacillin is also strongly bound to albumin and is often administered to patients receiving phenytoin. Oxacillin at a concentration of 15 micrograms/ml caused no significant displacement of phenytoin in a serum pool prepared from patients receiving phenytoin. However, a significant increase in the free phenytoin concentration was seen at an oxacillin concentration of 50 micrograms/ml. We also prepared a serum pool from uremic patients and another from patients with hypoalbuminemia and supplemented both of them with phenytoin. Significant increases in the free phenytoin concentration occurred with both 15- and 50-microgram/ml concentrations of oxacillin. In one hypoalbuminemic patient receiving both phenytoin and intravenous high-dose oxacillin, the free phenytoin fraction was 22.5% before oxacillin therapy, 24.1% 12 hours after first dose of oxacillin, and 27.2% after 60 hours, indicating the possibility of in vivo displacement of phenytoin by oxacillin. We conclude that the phenytoin-oxacillin interaction is not significant at lower dosages of oxacillin usually prescribed for oral therapy. However, the interaction may be significant at high concentrations of oxacillin, especially in patients with hypoalbuminemia or uremia.

Comparison of quantitative HCV RNA assays in chronic hepatitis C

We compared the relative sensitivities of first-and-second generation branched nucleotide assays (Quantiplex HCV RNA 1.0 and 2.0, respectively, Chiron, Emeryville, Calif) for the detection of hepatitis C virus (HCV) RNA to that of a commercially available quantitative reverse transcriptase polymerase chain reaction (RT-PCR) method (Monitor, Roche Molecular Systems, Nutley, NJ) in 53 patients with chronic hepatitis C. The sensitivities of the second-generation branched DNA (bDNA) and RT-PCR assays were similar (91% and 92%, respectively), and both were significantly more sensitive (P < .001) than the first-generation method. Moreover, both assays detected HCV RNA in all 11 patients with type 2a, 2b, or 3a genotypes vs 45% with the HCV RNA 1.0 bDNA assay. We examined 174 serum samples by the bDNA 2.0 and RT-PCR assays. Major quantification differences were noted on a given specimen with the RT-PCR method reporting values an average 41-fold lower (range, 0-703-fold) than those obtained with the bDNA assay. We conclude that both methods can be used to detect HCV RNA in patients who are infected with the genotypes that are most commonly encountered in the United States. The HCV RNA 2.0 bDNA assay may offer advantages when attempting to quantify high-level viremia.

Prevalence of herpesviridae and hepatitis B virus DNA in the liver of patients with non-A, non-B fulminant hepatic failure

Members of the herpes virus family and hepatitis B virus (HBV) have been implicated as etiologic agents in non-A, non-B (NANB) fulminant hepatic failure (FHF), but the frequency of infection with these agents has not been established using appropriate controls. To examine this issue, we studied 50 NANB FHF patients and 104 liver transplant recipients from North America and Europe. Hepatic DNA was analyzed by polymerase chain reaction (PCR) for evidence of Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus I (HSV I) and II (HSV II), varicella-zoster virus (VZV), and human herpes virus-6 (HHV-6) nucleic acid sequences. The prevalence of HBV was assessed in North American subjects only. HSV I, HSV II, VZV, and HHV-6 viral sequences were not observed in any samples. Three of 50 FHF (6%) and 14 of 104 control patients (13%) were positive for CMV DNA. Two of 50 FHF (4%) and 10 of 104 control patients (10%) had EBV DNA, and HBV DNA was observed in 3 of 10 North American FHF patients (30%) and 3 of 59 controls (5%) without serum markers for HBV infection. The finding of HBV DNA in the liver of seronegative controls from North America but not Europe suggests that occult hepatitis B sequences in patients with NANB FHF may simply reflect geographic differences. The majority of cryptogenic FHF cases cannot be attributed to infection with herpes viruses or HBV.

Neuronal diversity in the subiculum: correlations with the effects of somatostatin on intrinsic properties and on GABA-mediated IPSPs in vitro

1. We used intracellular current-clamp techniques to record from 33 ventral subicular neurons in slices or rat hippocampal formation. Presumed pyramidal neurons were characterized by their responses to depolarizing current pulses as either intrinsically burst firing (IB) or regular spiking (RS). Within the subiculum, IB cells were encountered most frequently in the deep cell layer, whereas RS cells were encountered most frequently in the superficial cell layer. IB cells had more depolarized resting potentials, lower input resistances, and more sag in their voltage responses to hyperpolarizing current pulses. 2. Somatostatin (5 microM) applied in the bathing medium caused a hyperpolarization and reduction in input resistance. These effects were of greater magnitude in IB cells. Somatostatin had no effect on sag in either cell type. These effects of somatostatin were unchanged in the presence of gamma-aminobutyric acid (GABA) receptor antagonists. 3. In a series of experiments conducted in RS cells only, somatostatin reduced the amplitude of the late but not the early component of evoked biphasic inhibitory postsynaptic potentials (IPSPs). 4. A second series of experiments was conducted in RS and IB cells. Somatostatin reduced the amplitude of pharmacologically isolated GABAA IPSPS in both cell types. In IB cells but not RS cells there was a correlation between this effect and the somatostatin-induced hyperpolarization. Somatostatin also reduced the amplitude of isolated GABAB IPSPS in both cell types, but more so in IB cells. 5. Somatostatin had no effect on the reversal potential of either IPSP in either cell type and no effect on the GABAA-mediated conductance in either cell type. In contrast, the GABAB-mediated conductance was reduced, especially in IB cells. 6. The effects of somatostatin on GABAA IPSPS are principally a result of membrane shunting and reductions in ionic driving force, but these mechanisms do not account for the reduction in GABAB IPSPS. 7. We suggest that the combined effects of somatostatin are likely to alter the balance between fast and slow inhibition and to do so more in IB cells than in RS cells.