Adolescent alcohol use and the community health agenda: a study of leaders' perceptions in 28 small towns

The study assessed leaders' perceptions of adolescent alcohol use as a public health issue in 28 small communities in northern Minnesota, as part of formative evaluation for a community-based intervention to reduce adolescent alcohol access and consumption. One hundred and eighteen leaders from five key community sectors were interviewed about their perceptions of social, health and alcohol-related problems in their communities. Analyses indicated that school representatives and police chiefs perceived adolescent alcohol use and related problems to be serious; newspaper editors mentioned other social problems more often; and mayors and business representatives did not perceive adolescent alcohol problems to be as serious. In relation to efforts to affect local policy, the study suggested government and business sectors in these communities may need to be educated about the problem to build its importance on the community agenda of health issues. Thus community leaders in some sectors may comprise a key target audience for intervention.

Informed consent in research

The relationship between physician and patient, as generally delineated by the Hippocratic Oath and the American Medical Association's 1994 Principles of Medical Ethics, is one between a fiduciary and a principal. In such a relationship, the duties of loyalty and trust run from the fiduciary to the principal. The fiduciary (physician) is the person to whom the relevant interests of the principal (patient) are entrusted. It is the medical best interests of the patient, not the physician, that are in trust. The relationship, while usually gratifying and financially rewarding, is essentially one of professional altruism. Nevertheless, the satisfaction of this fiduciary obligation requires the performance of general duties at levels dictated by the nature and scope of medical intervention.

Three major issues in infection control

In considering the three major issues in infection control the author decided upon education and empowerment, community practices, and research availability and application as they span a range of infection control practices and healthcare settings. Education and empowerment of staff is needed to ensure safe practice. This requires collaboration between education providers and infection control personnel and should be available to all disciplines of staff. Infection control needs to be seamless across the primary and secondary care interface and must include infection prevention advice to the population in general. Evidence relating to infection control is either lacking or not achievable. When it is available, it is not always implemented because of lack of resources.

New techniques for biopsy and culture of human olfactory epithelial neurons

OBJECTIVE

To improve the success of culturing olfactory neurons from human nasal mucosa by investigating the intranasal distribution of the olfactory epithelium and devising new techniques for growing human olfactory epithelium in vitro.

DESIGN

Ninety-seven biopsy specimens were obtained from 33 individuals, aged 21 to 74 years, collected from 6 regions of the nasal cavity. Each biopsy specimen was bisected, and 1 piece was processed for immunohistochemistry or electron microscopy while the other piece was dissected further for explant culture. Four culture techniques were performed, including whole explants and explanted biopsy slices. Five days after plating, neuronal differentiation was induced by means of a medium that contained basic fibroblast growth factor. After another 5 days, cultures were processed for immunocytochemical analysis.

RESULTS

The probability of finding olfactory epithelium in a biopsy specimen ranged from 30% to 76%, depending on its location. The dorsoposterior regions of the nasal septum and the superior turbinate provided the highest probability, but, surprisingly, olfactory epithelium was also found anteriorly and ventrally on both septum and turbinates. A new method of culturing the olfactory epithelium was devised. This slice culture technique improved the success rate for generating olfactory neurons from 10% to 90%.

CONCLUSIONS

This study explains and overcomes most of the variability in the success in observing neurogenesis in cultures of adult human olfactory epithelium. The techniques presented here make the human olfactory epithelium a useful model for clinical research into certain olfactory dysfunctions and a model for the causes of neurodevelopmental and neurodegenerative diseases.

No more problems in Coltheart's neighborhood: resolving neighborhood conflicts in the lexical decision task

In the area of visual word recognition, there is considerable disagreement as to whether neighborhood effects for words in the lexical decision task are facilitatory or inhibitory: While they seem to be mostly facilitatory in English, they tend to be absent or inhibitory in French or Spanish. The present study investigated the possibility that the facilitatory neighborhood effect obtained in English is due to the fact that most neighbors in English are body neighbors (i.e. they share the same orthographic rime). Our results showed that when words were matched for orthographic neighborhood (N), the effects of body neighbors (BN) were facilitatory (i.e. shorter reaction times for words with many body neighbors than for words with few body neighbors). In contrast, when words are matched for BN, the effects of N are unreliable with a tendency towards inhibition. In conclusion, it appears that research conducted in English has always found neighborhood effects to be facilitatory because of the dominant role of body neighbors in English. In contrast, neighborhood effects in French and Spanish may have been more ambiguous because these languages either do not confound N and BN, or they do not require a greater sensitivity to the body/rime unit.

Outbreak of Shigella sonnei in a clinical microbiology laboratory

Laboratory technologists (22%) developed infections with Shigella sonnei. The isolates had the same antibiogram and pulse-field gel electrophoresis pattern as an unknown isolate handled by a laboratory student. Covering faucet handles with paper towels during hand washing in the laboratory was protective. No further cases occurred after the laboratory was cleaned with a phenolic agent and a handle-free faucet was installed.

[Macroenzymes: an interesting laboratory finding, without clinical relevance]

Macroenzymes are complexes of serum enzymes with proteins which have a higher molecular weight and longer plasma half-life than the normal enzyme. The presence of macroenzymes is suggested by finding increased serum enzyme activity, not associated with symptoms. Thus, macroenzymes can cause diagnostic errors and the performance of unnecessary tests or invasive procedures. We describe 2 patients with highly elevated serum levels of lactate dehydrogenase (LDH) and creatine kinase (CK) due to formation of complexes with immunoglobulin G. 1 patient had LDH of 4500 u/L but was otherwise normal and in the second CK was elevated with no evidence of ischemic heart disease. Awareness of the phenomenon of macroenzymes may save the patient long and sometimes invasive investigation.

Increased toxicity of high-dose furosemide versus low-dose dopamine in the treatment of refractory congestive heart failure

OBJECTIVE

To evaluate the safety and efficacy of low-dose dopamine, high-dose furosemide, and their combination in the treatment of refractory congestive heart failure.

METHODS

Twenty consecutive patients with refractory congestive heart failure were randomized to receive intravenous low-dose (4 micrograms/kg/min) dopamine combined with low-dose (80 mg/day) oral furosemide (group A; n = 7), intravenous low-dose dopamine with medium-dose furosemide (5 mg/kg/day through continuous intravenous administration; group B; n = 7), or high-dose furosemide (10 mg/kg/day through continuous intravenous administration; group C; n = 6).

RESULTS

The three groups showed similar improvement in signs and symptoms of congestive heart failure, urinary output (2506 +/- 671 ml/24 hr, mean +/- SD) and weight loss (3.3 +/- 2.3 kg) after 72 hours of therapy. Mean arterial blood pressure (MAP) decreased by 14% +/- 8% and 15% +/- 6% in groups B and C, respectively, but increased by 4% +/- 15% in group A (p = 0.017). Renal function deteriorated significantly in groups B and C: creatinine clearance decreased by 41% +/- 23% and 42% +/- 23%, respectively, but increased by 14% +/- 35% in group A (p = 0.0074). MAP decrease was positively correlated with the decrease in creatinine clearance (r = 0.7; p = 0.0007). Patients in group B and C had more hypokalemia than group A. Two patients in group C sustained acute oliguric renal failure and one patient in group B died suddenly while sustaining severe hypokalemia.

CONCLUSION

Combined low-dose intravenous dopamine and oral furosemide have similar efficacy but induce less renal impairment and hypokalemia than higher doses of intravenous furosemide taken either alone or with low-dose dopamine. The renal impairment induced by intravenous furosemide is probably related to its hypotensive effect in patients with refractory congestive heart failure.

Admissibility and per se exclusion of hypnotically elicited recall in American courts of law

State v. Mack (1980) ruled that hypnotically elicited testimony is per se excluded from Minnesota law courts; this court also ruled that police could employ hypnosis in an attempt to construct an independently corroborated case. In recent years, there have been moves to rescind this exclusion; this raises a question of the probative value of such additional information when it is uncorroborated. This situation is compared with that of the polygraph as an index of deception: Like hypnosis, it is excluded per se in most American jurisdictions. Some legal decisions in Wisconsin are used to illustrate one alternative to the per se exclusion approach. Admissibility of scientific evidence in American courts of law has been based on a criterion of "general acceptability within the relevant scientific community," as first elucidated in Frye v. United States (1923). Recently, the U.S. Supreme Court overturned the Frye decision in Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993), by making general acceptability but one of several admissibility criteria. Three Daubert-based decisions, one involving hypnosis and all concerned with "recovered repressed memories," indicate some problems in law posed by Daubert.

Control of varicella-zoster infection on renal and other specialist units

The introduction of chickenpox onto our renal unit recently raised several issues surrounding the management of patient and staff contracts. This paper describes the action taken and makes various recommendations for future management of similar cases. Guidelines are proposed for the management of patients and staff as well as the role of the infection control team in handling a chickenpox problem. Future developments, including the use of VZ vaccine for patient and staff, are also discussed.

Treatment of uveitis by oral administration of retinal antigens: results of a phase I/II randomized masked trial

PURPOSE

To evaluate the effect and safety of the oral administration of retinal antigens as a treatment of ocular inflammation.

METHODS

In a phase I/II randomized masked trial, patients with endogenous uveitis who were dependent on immunosuppressive agents were randomly assigned to receive either retinal S antigen alone (10 patients), retinal S antigen and a mixture of soluble retinal antigens (10 patients), a mixture of soluble retinal antigens alone (10 patients), or placebo (15 patients). An attempt was then made to taper patients completely off their standard immunosuppressive therapy over an 8 week period. The primary study endpoint was time to ocular inflammatory attack. The secondary study endpoint was the ability to taper patients completely off their immunosuppressive or cytotoxic medication within 8 weeks.

RESULTS

Time to development of the main study endpoint was not statistically significantly different for any of the four treatment groups. However, the group receiving the purified S antigen alone appeared to be tapered off their immunosuppressive medication more successfully compared with patients given placebo (P = .08), whereas all the other groups appeared to do worse than did those receiving placebo. No toxic effects attributable to any treatment were observed.

CONCLUSIONS

This phase I/II study is the first to test the use of orally administered S antigen in the treatment of uveitis. Although not statistically significant, patients given S antigen were more likely to be tapered off their chronically administered systemic immunosuppressive therapy than were the other groups tested.

Highly elevated lactate dehydrogenase level in a healthy individual: a case of macro-LDH

Macroenzymes are complexes of serum enzymes with a plasmatic protein. They have a higher molecular weight and a more prolonged serum half-life than those of unbound enzymes. Although macroenzymes may be found in the serum of post-myocardial infarction patients, they are not usually associated with any specific disease. Their presence, however, can cause an elevation in the serum levels of an enzyme, possibly leading to errors in diagnosis. We report a patient with extremely elevated serum levels of lactate dehydrogenase (LDH) due to the formation of complexes with immunoglobulin G. She had undergone a myriad of clinical examinations until the macroenzyme responsible for this finding was detected. We also review the literature on the clinical significance of macro-LDH. We propose that awareness of this rare and probably benign phenomenon can spare the patient from the distress of exhaustive investigations.

Diabetic nephropathy: an observational study on patients attending a joint diabetes renal clinic

Diabetic nephropathy is a major cause of renal failure, accounting for 20% of patients starting dialysis. In clinical trials, effective blood-pressure control, especially by angiotensin-converting-enzyme inhibitors (ACEIs), retards the rate of progression of renal failure substantially. We examined these effects in clinical practice by surveying patients at a joint diabetes renal clinic at Glasgow Royal Infirmary from 1989 to 1995. We examined the relationship between progression of diabetic nephropathy, mean arterial pressure (MAP), and the use of ACEIs. The average MAP of the whole group of patients fell by 7%, the urine albumin:creatinine ratio fell by 29%, and the rate of progression as measured by the slope of reciprocal of serum creatinine with time (l/mumol/day) was slowed, from -4.59 to -2.76. This is equal to delaying the necessity for dialysis by about 2 years. The joint clinic met its aim and was cost-effective.

Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence

OBJECTIVE

To determine whether newly developed anticipatory guidance materials designed to teach the use of time-outs and the importance of reductions in childhood television viewing would be recalled by parents and if their use would result in changes in self-reported parental behavior.

SUBJECTS AND SETTING

A total of 559 parents of children aged 14 months to 6 years recruited at the time of routine child health maintenance visits at 2 managed care pediatric departments in eastern Massachusetts.

METHODS

In-person parent interviews were conducted in the waiting room prior to office visits, with follow-up telephone calls 2 to 3 weeks after the visit. Two groups of families were enrolled: a control group who received usual anticipatory guidance and an intervention group who received written materials. Intervention group providers were trained to include study topics during the office visit and to introduce the written materials.

RESULTS

Provider training and the provision of written materials increased the parents' specific recall of anticipatory guidance of at least 2 to 3 weeks following the office visit. This effect was specific to the areas of intervention and did not carry over to other commonly used topics of anticipatory guidance. Among parents who had never used a time-out prior to the office visit, there was a significant increase in the use of time-outs. Parents who received anticipatory guidance regarding the link between exposure to television violence and subsequent violence in children were somewhat more likely to report reductions in weekend television viewing than were parents in the control group, although this change was not statistically significant.

CONCLUSIONS

Certain parenting behaviors have been associated with subsequent violence. Brief, inexpensive anticipatory guidance in relevant areas, provided in the context of routine health supervision visits, appears to result in favorable short-term changes in parenting practices.

Water: where from, and for whom?

When the agricultural sector takes measures to diminish water losses, access to water for domestic purposes may be greatly reduced and community health may be adversely affected.

Establishing a community network for recruitment of African Americans into a clinical trial. The African-American antiplatelet stroke Prevention Study (AAASPS) experience

A major aspect of a clinical trial is the ability to successfully recruit patients. There is a paucity of information concerning the nuances of recruiting study patients, especially those from minority communities. As minorities generally have been underrepresented in the health-care system, they may be less likely to participate in clinical trials or other studies. Thus, a strategy is needed to overcome this potential shortfall. One of our solutions has been the development of a community network to help disseminate information about our program. We believe that a key aspect has been the involvement of community members during pre-trial planning, community awareness programs, and our Community Advisory Panel. We also believe that it may be a major error to bring a health-care initiative unannounced into a targeted community without extensive pre-program planning in cooperation with that community. As our community awareness scheme suggests (Figure), there are many possible avenues to heighten awareness about a health-care program. While the church remains an important institution for religious and cultural activities in the African-American community, we have found that the news, television, and radio media also can be a powerful source for spreading awareness. Thus, we recommend creating awareness about an initiative through a "grassroots" approach of church and community organizations, along with a global approach through news, television, and radio media. As part of the awareness promotion campaign, it must be emphasized that the study is safe and provides benefits to enrollees. The success of health programs is largely dependent on community acceptance, which must be established in the pre-program planning stages of the initiative. This concept of obtaining community approval and acceptance prior to program initiation is not a new one, nor does it exclusively apply to the African-American community. Community leaders and members need to have a vested interest in such a program and a sense of empowerment. Through this type of communication, patient enrollment and community satisfaction can be substantial. Such success can serve as a springboard for other targeted health-care studies or programs in high-risk communities.