Low frequency of HLA DRB1*03 - DQB1*02 and DQB1*0302 haplotypes in Romania is consistent with the country's low incidence of Type I diabetes

AIMS/HYPOTHESIS

Our study aimed to determine the association of HLA class II HLA-DQB1 alleles with Type I (insulin-dependent) diabetes mellitus and the frequencies of these alleles in the Romanian population, which has one of the lowest incidences of Type I diabetes in children aged 0-14 years in Europe at 3-4 cases per 100,000 person-years.

METHODS

We used the sequence specific primer-polymerase chain reaction (PCR-SSP) technique to type HLA-DQB1 alleles, the HLA-DRB1alleles DRB1*03 and one single nucleotide polymorphism (SNP) in the insulin gene (INS). We studied 204 Type I diabetic Romanian families, 196 of which were simplex with 70.3 % of subjects diagnosed under 14 years of age. Data was analysed using a modified version of the Transmission Disequilibrium Test, the Transmission Disequilibrium Test itself, and the affected family-based control method.

RESULTS

We found, as expected, the strong positive DQB1*02-DRB1*03 and DQB1*0302, and negative DQB1*0602, HLA class II allele associations with Type I diabetes in these Romanian families. However, using the affected family-based control method, we found relatively low population frequencies of DQB1*02-DRB1*03 and DQB1*0302 alleles in Romania (15.8%) compared with Sardinia (31.3%), a high incidence European region (35 cases per 100,000 person-years in children aged 0-14years). The INS locus had a strong effect in this data set with 80.5 % transmission of the susceptible INS allele from parents to affected siblings (relative risk = 4.1).

CONCLUSION/INTERPRETATION

Part of the explanation for the low incidence of Type I diabetes in Romania could be the lower frequency of the DRB1*03 DQB1*02 and DQBI*0302 susceptibility haplotypes in this country.

Effects and risk assessment of linear alkylbenzene sulfonates in agricultural soil. 4. The influence of salt speciation, soil type, and sewage sludge on toxicity using the collembolan Folsomia fimetaria and the earthworm Aporrectodea caliginosa as test organisms

Sewage sludge applied to agricultural soils often contains linear alkylbenzene sulfonates (LAS) in the range of 1 to 10 g/kg dry weight, and their toxicity to relevant soil organisms should, therefore, be assessed to ensure safe use of sewage sludge as a fertilizer. Studies of LAS toxicity to soil organisms are few, and to our knowledge, factors that may influence the toxicity in the field have not been studied in detail. In this paper, we report on the influence of speciation of LAS in the test solution added to soil (soluble Na-LAS vs poorly soluble Ca-LAS or Mg-LAS), the influence of soil type, and the modifying effects of sludge amendment on the toxicity of LAS. These issues were investigated using reproduction of Collembola and growth of juvenile earthworms as test parameters. Speciation of the LAS added to test soil did not have any influence on toxicity for any of the test species. Likewise, in three different agricultural soils (sand, loam, and clay), we found almost equal toxicities. The LAS added to test soil in a sludge-water suspension was equally toxic as when it was added in an aqueous solution. However, anaerobic incubation for 7 and 14 d of the LAS-sludge suspension (with no decay of LAS) caused the toxicity to increase almost threefold in both collembolan and earthworm. The relationships between soil constituents, bioavailability, and toxicity are also discussed.

The role of ITAM- and ITIM-coupled receptors in platelet activation by collagen

The major activation-inducing collagen receptor glycoprotein VI (GPVI) has been cloned within the last two years. It is a member of the Ig superfamily of proteins and is constitutively associated with the ITAM-bearing Fc receptor gamma-chain (FcR gamma-chain). GPVI signals through a pathway that involves several of the proteins used by Fc, B- and T-lymphocyte receptors and which takes place in glycolipid-enriched membrane domains in the plasma membrane known as GEMs. Responses to GPVI are regulated by PECAM-1 (CD31) and possibly other ITIM-bearing receptors. Despite a pivotal role for GPVI, there are important differences between signalling events to collagen and GPVI-specific ligands. This may reflect a role for co-receptors in the response to collagen.

A new verbal learning and memory test for English- and Spanish-speaking older people

Word-list verbal learning and memory tests with appropriate normative data can be highly sensitive to cognitive decline, but there are significant limitations of such tests available for use with older Hispanic and non-Hispanic people living in the US. The purpose of this study was to (1) create a new word-list learning and memory test in both English and Spanish and, (2) validate it with respect to sensitivity to cognitive impairment, and (3) develop statistical corrections for the effects of significant demographic variables, including ethnicity, language of administration, age, education, and gender. A community dwelling sample of 801 English- and Spanish-speaking older people was employed. Recall on learning trials and the delayed recall trial of the word-list learning test were strongly related to the Mini-Mental State Examination (MMSE). moderately related to age, and weakly related to gender and education. The relationship of word-list variables and the MMSE did not significantly differ across ethnicity/language groups. Regression coefficients for demographic variables were used in a statistical correction formula to adjust raw word-list scores, and then to develop specific percentile cut-off values.

Factors that influence the cost of caring for patients with severe psychotic illness: report from the UK 700 trial

BACKGROUND

Many factors influence the type and quantity of services received by patients and, thus, the total cost of care. Knowledge of these factors can aid budgetary and service-planning decisions.

AIMS

To investigate factors that influence the cost of caring for patients with severe psychotic illness.

METHOD

Univariate and multivariate analyses were used to examine associations between baseline characteristics and subsequent 2-year total direct costs in 667 patients from the UK 700 case management trial.

RESULTS

Significantly more money was spent on younger patients, those with longer duration of illness, those who had spent less time living independently and those who had spent longer in hospital for psychiatric reasons.

CONCLUSIONS

Total costs of caring for patients with severe psychotic illness appear to be influenced to a large extent by age, duration of illness and past levels of dependence on statutory services. The strength of these relationships is greater than the impact of illness severity.

Spinal anesthesia improves the early recovery profile of patients undergoing ambulatory knee arthroscopy

PURPOSE

We compared the recovery profiles, postoperative complications, perioperative OR utilization times, and times to discharge of patients undergoing ambulatory knee arthroscopy under spinal anesthesia (SA) or general anesthesia (GA).

METHODS

In this randomized, prospective study, 84 ASA I-II patients were randomized to receive either SA with 50 mg of 1% lidocaine, or a standardized GA. Postoperative pain, nausea and vomiting, sedation, OR utilization, postanesthesia care unit (PACU), and ambulatory surgical unit (ASU) recovery were compared.

RESULTS

Patients in the GA group had more pain in the PACU than the SA group (61% vs 15%, P <0.01), and a higher incidence of PACU analgesic use (59% vs 7.5%, P <0.01). Patients in the SA group were able to drink and eat sooner than the GA group (83 +/- 23 vs 95 +/- 22 min, P <0.05 and 88 +/- 27 vs 105 +/- 29 min, P <0.01, respectively). The times to sit, walk, and void were similar. The length of PACU and ASU stay between the GA and SA groups were similar (67 +/- 17 vs 60 +/- 19 min, P >0.05 and 122 +/- 27 vs 127.9 +/- 31 min, P >0.05, respectively). The incidence of backache was higher in the SA group (35 vs 13.6%, P <0.05) than the GA group. However, the incidence of sore throat was higher in the GA compared to the SA group (25% vs 2.5%, P <0.01).

CONCLUSIONS

SA with 50 mg of 1% lidocaine provides an improved recovery profile for ambulatory knee arthroscopy. Discharge times were similar, and with the exception of backache and sore throat, the incidence of complications was similar.

Identification of ICAM-1 polymorphism that is associated with protection from transplant associated vasculopathy after cardiac transplantation

Transplant associated coronary disease (TxCAD) is the main cause of late graft loss following cardiac transplantation. It is a multifactorial disease with immunologic and nonimmunologic components involved. This study was undertaken to analyze the gene polymorphism in adhesion molecules in donors and recipients and to investigate its potential association with the development of TxCAD. A total of 82 cardiac transplant patients, 96 donors and 101 UK controls, were genotyped retrospectively. Nine nucleotide polymorphisms in L-selectin, E-selectin, ICAM-1, and PECAM were analyzed using allele-specific PCR-SSP assay. Recipients were selected on the basis of the development of TxCAD: patients who had developed TxCAD within 2 years after transplantation, and patients who did not have TxCAD within 4.5-5 years after transplantation. All recipients received CyA and azathioprine as a primary immunosuppression. Associations were assessed by using Fisher's exact test. No association was found between E-selectin, L-selectin, and PECAM allele or genotype frequencies and TxCAD. However, the donors whose recipients did not develop TxCAD at first 2 years had a significant increase of ICAM-1 E-469 allele compared with donors, whose recipients developed TxCAD (63.8% vs 46.4%, p = 0.042) and to UK controls (63.8% vs 47%, p = 0.04). Moreover, we found that the decreased frequency of ICAM E469 allele was associated with the increased number of rejection episodes. The 469 E/K polymorphism is in exon 6 and results in a change from glutamic acid to lysine in Ig-like domain 5 of ICAM-1, which is thought to affect interactions with LFA-1 and adhesion of B-cells. Our data suggest the presence of allele E469 ICAM-1 in either donor or recipient is protective against allograft rejection in a transplant setting.

5-year qualitative results of isolated cryosurgical ablation for hepatic malignancy at Walter Reed Army Medical Center(1)

Cryosurgical ablation (CSA) is an established treatment for primary and metastatic liver malignancies. The study objective was to qualitatively define our patient CSA experience and compare it with the existing literature.A retrospective review was conducted of patients who underwent isolated CSA from September 1995 to April 2000. Data were collected on patient characteristics, tumor characteristics, sequential 12-hour laboratory data, transfusion requirements, and survival data. SPSS 9.0 (SPSS, Chicago, Illinois) was used for data analysis.Twenty-four patients (14 men, 10 women) were studied. Eighty-seven lesions (mean 3.8/patient) were treated. Six patients underwent treatment for primary liver tumors, whereas 16 were treated for metastatic disease. White blood cell count increased 1.7-fold, and platelet count decreased 2.0-fold. Aspartate aminotransferase and alanine aminotransferase increased significantly 42- and 29-fold, respectively. Seven out of 21 (33%) patients required blood transfusion. Our overall complication rate was 25%. Perioperative mortality was 0%. Kaplan-Meier survival analysis revealed an overall survival of 46% at a median follow-up of 33.7 +/- 6.8 months.CONCLUSIONS:Although isolated CSA of hepatic malignancies results in major and minor alterations in serologic parameters, they equate to little clinical significance. Blood product transfusions are necessary in 30% patients post-CSA. Significant perioperative complications occur in 25% of patients. Survival estimates suggest that nearly 50% of patients undergoing CSA can be expected to survive longer than 2 years post-CSA.

Intraoperative vs postoperative morphine improves analgesia without increasing PONV on emergence from ambulatory surgery

PURPOSE

To compare the timing of administration of morphine in patients undergoing painful ambulatory surgical procedures to determine whether there was a difference in postoperative nausea or vomiting (PONV), quality of analgesia, and recovery profile.

METHODS

In a double-blinded, placebo-controlled, prospective study, 70 ASA I-II patients were randomized to receive 0.1 mg x kg(-1) morphine intraoperatively (lop) (n=35), or postoperatively (Pop) (n=35). The severity of nausea and pain were measured using visual analog scales (VAS).

RESULTS

There was no difference between the groups in postoperative nausea scores or the incidence of PONV. Upon awakening, patients who received Pop morphine had higher pain VAS scores with movement (7.6 +/- 2 vs 5.4 +/- 3, P < 0.003) and at rest (6.9 +/- 3 vs 5.1 +/- 3, P < 0.013) than the lop morphine group. The total number of PCA attempts and analgesic requirements were similar. Patients who received Pop morphine were able to drink sooner than the lop group (90 +/- 34 vs 111 +/- 38 min, P < 0.05). All other recovery milestones were similar. Times to discharge from hospital were similar.

CONCLUSIONS

Administration of 0.1 mg x kg(-1) morphine iv intraoperatively improves postoperative analgesia upon emergence from painful ambulatory surgical procedures without increasing the incidence of PONV There was no increase in PONV when morphine was administered intraoperatively rather than postoperatively.

Genetic analysis of the Drosophila 63F early puff. Characterization of mutations in E63-1 and maggie, a putative Tom22

The 63F early puff in the larval salivary gland polytene chromosomes contains the divergently transcribed E63-1 and E63-2 ecdysone-inducible genes. E63-1 encodes a member of the EF-hand family of Ca(2+)-binding proteins, while E63-2 has no apparent open reading frame. To understand the functions of the E63 genes, we have determined the temporal and spatial patterns of E63-1 protein expression, as well as undertaken a genetic analysis of the 63F puff. We show that E63-1 is expressed in many embryonic and larval tissues, but the third-instar larval salivary gland is the only tissue where increases in protein levels correlate with increases in ecdysone titer. Furthermore, the subcellular distribution of E63-1 protein changes dynamically in the salivary glands at the onset of metamorphosis. E63-1 and E63-2 null mutations, however, have no effect on development or fertility. We have characterized 40 kb of the 63F region, defined as the interval between Ubi-p and E63-2, and have identified three lethal complementation groups that correspond to the dSc-2, ida, and mge genes. We show that mge mutations lead to first-instar larval lethality and that Mge protein is similar to the Tom22 mitochondrial import proteins of fungi, suggesting that it has a role in mitochondrial function.

Endophyte infection influences disappearance of perennial ryegrass seed

bare ground was compared with that of seed infected by the fungal endophyte Neotyphodium lolii in four field trials One trial included clover seed and two trials contained seed infected with two different endophytes Infection with either endophyte significantly reduced seed disappearance and increased survival of seed to germination Clover seed disappeared at a similar rate to endophytefree ryegrass seed Bird netting reduced seed disappearance of all treatments but in most cases not significantly so Feeding by black field cricket nymphs and adults small field cricket adults and black beetle adults on ungerminated and newly germinated endophyteinfected and endophytefree seed was tested in the laboratory It was concluded that none of these insects caused the differences in seed disappearance observed in the field

Mannose-binding lectin promoter and structural gene variants in sarcoidosis

BACKGROUND

Sarcoidosis is a chronic granulomatous disease of unknown aetiology. Studies have suggested that the causative agent may be an infectious micro-organism. The mannose binding lectin (MBL) is involved in innate immunity to a wide range of micro-organisms. Mutations in the promoter region and exon 1 of the MBL gene occur with high frequency and are associated with reduced serum levels of MBL and increased susceptibility to microbial diseases. This study investigated whether MBL variants predispose to sarcoidosis by increasing their susceptibility to micro-organisms.

METHODS

MBL gene promoter and exon 1 variants were detected by sequence specific primer polymerase chain reaction (SSP-PCR) in 167 UK Caucasian sarcoidosis patients and 164 control subjects. Severity of pulmonary disease outcome among patients was assessed by radiography after a minimum of 4 years from disease onset and classified as mild, moderate, and severe disease categories, accordingly.

RESULTS

MBL variant frequencies were similar in patients and controls studied. Among sarcoidosis patients, the frequencies of variants were similar regardless of severity of disease outcome. The average patient ages at time of diagnosis were similar for all MBL genotypes.

CONCLUSIONS

MBL gene variants do not appear to influence susceptibility to sarcoidosis, age of disease onset, or severity of disease.

Effect of exercise intensity on bone density, strength, and calcium turnover in older women

PURPOSE

This study examined the effects of 24 wk of high intensity strength training or low intensity walking on lumbar bone mineral density (BMD), muscular strength, and calcium turnover in Australian women either taking hormone replacement therapy (HRT) or not taking HRT.

METHODS

A subject pool of 64 women between 45-65 yr and randomly allocated into weights (N = 21), walking (N = 20), weightsHRT (N = 14), and walkingHRT (N = 9) groups completed this study. All subjects trained twice weekly in either a 50-min walking or weight-training program (60-90% IRM). Measurements included maximal isometric knee strength, IRM bench press, IRM squat, isokinetic back strength, lumbar (L2-L4) BMD, serum osteocalcin, and urinary deoxypyridinoline crosslinks (Dpd).

RESULTS

No significant group differences in BMD were evident at the completion of training. However, a significant (P < 0.05) within group change was apparent for the walking group since BMD decreased 1.3% below baseline testing. Osteocalcin levels increased significantly (P < 0.05) in the walking (22%) group. Maximal bench press and squat strength improved significantly (P < 0.05) in the weights (25.8% and 37.7%) and weightsHRT (25.4% and 35.7%) groups. The weights group also increased significantly (P < 0.05) in isokinetic back strength (22.2%).

CONCLUSION

It was concluded that short-term high intensity resistance training provides an effective means for increasing muscular strength in women between 45 and 65 yr. The training effects on lumbar BMD were not apparent in the present study.

Epidemiologic typing of Salmonella enterica serotype enteritidis in a Canada-wide outbreak of gastroenteritis due to contaminated cheese

A major Canada-wide outbreak of gastroenteritis due to Salmonella enterica serotype Enteritidis phage type (PT) 8 occurred in 1998, and this was traced to contaminated cheese in a commercial lunch pack product. Phage typing and pulsed-field gel electrophoresis linked the clinical and cheese isolates of serotype Enteritidis but failed to differentiate outbreak from nonoutbreak PT 8 strains. Further differentiation was made by biotyping based on melibiose fermentation.

Monitoring Piscirickettsia salmonis by denaturant gel electrophoresis and competitive PCR

Reported strains of Piscirickettsia salmonis, a pathogen of salmonid fishes, were analyzed by amplifying part of the internal transcribed spacer (ITS) of the ribosomal RNA (rRNA) operon followed by denaturing gradient gel electrophoresis (DGGE) of the amplicons. All amplified fragments differing in sequence were distinguished by migration during DGGE. A simpler format, constant denaturant gel electrophoresis (CDGE), allowed the same diagnostic distinctions among strains. Sampling during 1997 and 1998 of salmonids from 5 different sites on and near Chiloé Island in southern Chile displaying piscirickettsiosis revealed only P. salmonis resembling LF-89, the type strain first isolated in 1989. These observations are encouraging for control strategies, which might otherwise be compromised by unpredictable shifts of P. salmonis types in salmon farms. A competitive PCR assay offered insight about the power of PCR for quantification and about specific tissue invasiveness by this intracellular pathogen. This approach revealed that the PCR could amplify approximately 1 to 10 P. salmonis genome equivalents against a background of > 99.9% salmonid DNA. It also raised the possibility that the salmonid brain is an important site for P. salmonis survival, with its bacterial load in 1 individual having been about 100 times the loads observed in liver and kidney. Pathogen detection by competitive PCR in a surface seawater sample from a netpen in use indicated a density of about 3000 to 4000 P. salmonis cells (or their DNA remnants) 1(-1). Such quantitative estimates should aid decisions about disease prevention and management as, for example, choice of netpen sites following fallow periods and certification of ova, which are known conduits of infection.

1,1,1-trichloro-2,2-bis (p-chlorophenyl)-ethane (DDT) and reduced bone mineral density

The organochlorine pesticide 1,1,1-trichloro-2,2-bis (p-chlorophenyl)-ethane (DDT), is a well-known and widely dispersed "environmental estrogen" (World Health Organization Criteria no. 9; Geneva, Switzerland [1979]). Kelce et al. (Nature, 1995; 375:581-85) recently identified the DDT metabolite, 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE), has also recently been identified as a potent androgen receptor antagonist. The authors examined the relationship between serum levels of DDE and bone mineral density in 68 sedentary women who reported adequate dietary intake of calcium. Reduced bone mineral density was correlated significantly with age (r = -.36, p = .004), as well as with increases in the log of DDE levels in serum (r = -.27, p = .03). The authors also used multiple-regression analysis to examine the influence of other predictor variables on the relationship between log DDE and bone mineral density. The strongest model (p = .002) included log DDE (p = .018), age (p = .002), and years on hormone replacement therapy (p = .10) as predictor variables, and this model afforded prediction of 21% of bone mineral density variation. These results suggest that past community exposures to DDT may be associated with reduced bone mineral density in women.

Autoreactive B cells escape clonal deletion by expressing multiple antigen receptors

IgH and L chain transgenes encoding a phosphocholine (PC)-specific Ig receptor were introduced into recombinase-activating gene (Rag-2-/-) knockout mice. The PC-specific B cells that developed behaved like known autoreactive lymphocytes. They were 1) developmentally arrested in the bone marrow, 2) unable to secrete Ab, 3) able to escape clonal deletion and develop into B1 B cells in the peritoneal cavity, and 4) rescued by overexpression of bcl-2. A second IgL chain was genetically introduced into Rag-2-/- knockout mice expressing the autoreactive PC-specific Ig receptor. These dual L chain-expressing mice had B cells in peripheral lymphoid organs that coexpressed both anti-PC Ab as well as Ab employing the second available L chain that does not generate an autoreactive PC-specific receptor. Coexpression of the additional Ig molecules rescued the autoreactive anti-PC B cells and relieved the functional anergy of the anti-PC-specific B cells, as demonstrated by detection of circulating autoreactive anti-PC-Abs. We call this novel mechanism by which autoreactive B cells can persist by compromising allelic exclusion receptor dilution. Rescue of autoreactive PC-specific B cells would be beneficial to the host because these Abs are vital for protection against pathogens such as Streptococcus pneumoniae.

Prompt Optical Observations of Gamma-Ray Bursts

The Robotic Optical Transient Search Experiment (ROTSE) seeks to measure simultaneous and early afterglow optical emission from gamma-ray bursts (GRBs). A search for optical counterparts to six GRBs with localization errors of 1 deg2 or better produced no detections. The earliest limiting sensitivity is mROTSE>13.1 at 10.85 s (5 s exposure) after the gamma-ray rise, and the best limit is mROTSE>16.0 at 62 minutes (897 s exposure). These are the most stringent limits obtained for the GRB optical counterpart brightness in the first hour after the burst. Consideration of the gamma-ray fluence and peak flux for these bursts and for GRB 990123 indicates that there is not a strong positive correlation between optical flux and gamma-ray emission.

The multigenerational treatment setting for the chemically dependent adolescent; impact on cost, quality and treatment outcomes

The treatment outcome from homogeneous age group substance abuse treatment centers, whose clientele consist of adolescent chemical dependents, has never clearly been demonstrated to be superior to heterogeneous age group treatment. An analysis of research in several disciplines concerning outcome studies related to adolescent chemical dependency and mental health treatment, demonstrates that heterogeneous (multigenerational) treatment settings may be superior to homogeneous age group treatment. Other adolescent issues in the family and society that directly affect treatment philosophies in centers directed toward youth are compared to the treatment philosophies of adult centers. It is suggested that multigenerational treatment facilities cost less, require less staff, are better received by the client, and produce higher abstinence rates than adolescent-specific centers.

The relationship between dynamic, isokinetic and isometric strength and bone mineral density in a population of 45 to 65 year old women

This study investigated the relationship between age, lumbar spine bone mineral density (LS BMD) and muscular strength of peri and postmenopausal women between 45 and 65 years either taking or not taking hormone replacement therapy (HRT). Ninety six women were tested for LS BMD (L2-L4), one repetition maximum (1RM) bench press and squat, maximal voluntary isometric contraction (MVC) of the knee extensors and peak torque of back extensor muscles at a speed of 30 degrees s(-1). Bone and strength data were analysed to evaluate the relationships in incrementing five year age groups and based on groups either taking or not taking HRT. ANOVA revealed significant differences in LS BMD between the 45-49 and 55-59 (F[3,92]=2.6411, p<0.05; -8%) age groups amounting to an annual bone loss of 0.8% for this Australian based population. Non significant LS BMD results were evident after controlling for the influence of age and menopausal status on the groups either taking or not taking HRT. Significant differences between the 45-49 and 60-64 (F[3,92]=2.7463, p<0.05) age groups for 1RM bench press and the 45-49 and 60-64, 50-54 and 60-64, and, 55-59 and 60-64 (F[3,92]=4.2816, p<0.05) age groups for 1RM squat amounting to an 18.8% and 37.5% loss of dynamic upper and lower body strength, respectively. Group correlation coefficients ranged between (r=-0.20 and -0.34, p<0.05) for LS BMD, strength and age. The conclusions demonstrate a concomitant decline in maximal muscle strength and bone density between women 45 and 65 years irrespective of HRT. These results also demonstrate a 50% greater decline in lower body strength compared to upper body strength between women 45 and 65 years.

Rapid development of tolerance to dipyridamole-associated headaches

AIMS

In the Second European Stroke Prevention Study headaches associated with dipyridamole frequently (8% of patients taking dipyridamole or dipyridamole plus acetylsalicylic acid (ASA) vs 2% of patients taking ASA or placebo) led to discontinuation of therapy. We have now used data from a recent trial comparing the bioequivalence of two formulations of the fixed combination of 200 mg dipyridamole in an extended release formulation and 25 mg ASA to explore predicting factors for headaches associated with this drug combination.

METHODS

The bioequivalence trial employed a two-way crossover, randomised, open design. Trial medication was given for two periods of five days separated by a 72 h washout period. Statistical methods were employed to explore the prevalence, the time course, and the relation to individual pharmacokinetic parameters of treatment associated headaches.

RESULTS

Headache episodes, being mostly mild and transient, rapidly declined from 67% of the volunteers on the first day of treatment to 3% on the final days of treatment (days 4-5 of the second period). During the first days the prevalence of the headaches peaked 2-3 h after the morning administration, which coincided with the peak of the plasma concentrations of dipyridamole. The occurrence of headaches was not related to interindividual differences of the pharmacokinetic parameters.

CONCLUSIONS

The rapid decrease in the incidence of headaches over time implies that most patients quickly develop tolerance to dipyridamole-associated headaches. Appropriate information given to the patient when prescribing and dispensing dipyridamole/ASA may reduce early withdrawals from treatment and increase compliance.

A qualitative analysis of parental decision making for childhood immunisation

OBJECTIVE

Achieving high rates of childhood immunisation is an important public health aim. Currently, however, immunisation uptake in Australia is disappointing. This qualitative study investigated the factors that influence parental decision making for childhood immunisation, and whether parents' experiences were better conceptualised in terms of static subjective expected utility models or in terms of a more dynamic process.

METHOD

Semi-structured in-depth interviews were conducted with 20 predominantly middle-class mothers--17 immunizers and three non-immunizers, in Melbourne, Victoria, in 1997. The data were then examined using thematic analysis.

RESULTS

The results suggested that for these participants the decision regarding childhood immunization was better conceptualized as a dynamic process. The decision required initial consideration, implementation then maintenance.

CONCLUSION

If a better understanding of immunization decision making is to be achieved, future studies must look beyond static frameworks.

IMPLICATION

Clearer insight into the dynamic nature of immunization decision making should assist in the identification of more effective methods of promoting childhood immunization to groups at risk of non-compliance.