Evaluation of the first strategic plan for Aboriginal health in south western Sydney, 1993-98

The 1993-98 Aboriginal Health Strategic Plan for South Western Sydney represented the first partnership of its kind between an Area Health Service, local Aboriginal Health Workers and the local Aboriginal Community Controlled Health Service in Australia. During 1998, an evaluation of the plan was undertaken as part of the preparation for the second Aboriginal Health Plan. Of the 45 strategies in the first plan, 38% had been fully implemented, 42% had been partly implemented, and 20% were not implemented at all. This paper discusses the importance of data collection and monitoring systems, the integration of Aboriginal health into mainstream services, the further development of Aboriginal health infrastructure, and continued leadership by senior managers.

Agreement in symptoms of anxiety and depression between patients and GPs: the influence of ethnicity

BACKGROUND

Few studies have focused specifically on the role of ethnicity in the identification and treatment of anxiety and depressive symptoms among patients consulting GPs.

METHODS

A survey was conducted of 4753 patients aged 18-90 years attending general practices in Sydney, Australia. Three methods of case detection were used: a GHQ-12 score (> or = 3), self-report symptoms (using a checklist) and GP detection of symptoms. Four regional groupings based on country of birth [other English speaking countries (ESB), European, Asian (predominantly south east Asian) and other non-English speaking (other NESB)] were compared with Australian (AB) patients.

RESULTS

Compared with AB patients, Asian patients had a lower mean GHQ-12 score (2.04 versus 2.54) and a lower rate of GP detection (10.4% versus 20.5%) but they recorded a similar rate of self-report symptoms (16.7% versus 20.1%). For Asian patients, 24.6% of all cases identified by self-report or by GP detection were identified by both methods, compared with 44% for AB patients. Similar patterns of treatment and referral were observed for detected cases. Compared with AB patients, Asian and other NESB patients were more likely to desire more time to discuss their problems with their GP (18.5% versus 42.0%, 37.3%) and receive an explanation of medications prescribed (18.9% versus 46%, 40.0%).

CONCLUSION

These results suggest that there are substantial variations in the rates of detection of anxiety and depressive symptoms in GP patients depending on the screening methods used and the broad ethnic background of patients. Such symptoms may be under-diagnosed in Asian patients in particular.

A normative reference database study for Pronosco X-posure System

Cortical width from radiographs has been used for more than 40 yr as a means of estimating bone strength. In the last 5-10 yr, increased availability of computers and the development of automated algorithms for image assessment have led to an increased interest in radiogrammetry. In this study, we examined a new radiogrammetry device, the Pronosco X-posure System, which estimates bone mineral density (BMD) from forearm/hand radiographs. We obtained hand and forearm radiographs and performed dual X-ray absorptiometry (DXA) at the wrist and hip on 832 women ages 20-79 at four clinical centers across the United States. We then used the X-posure System to estimate BMD (DXR-BMD). The goal of the study was to establish reference ranges for the method and to compare the measurement to DXA measurements of BMD at the wrist and hip. Using statistical models, we estimated that the peak value for DXR-BMD occurred at age 38 (mean = 0.598 g/cm2, standard deviation = 0.034 g/cm2). The correlation between DXR-BMD and DXA was 0.90 at the wrist and 0.61 at the hip. The relationship of DXR-BMD to reported history of fracture was of similar magnitude to that for DXA at the wrist and hip. The strong correlation of DXR-BMD from the X-posure System with DXA at the wrist from the Hologic machine suggests that the X-posure System may be an alternative to DXA at the wrist for the assessment of osteoporosis.

Infection of human cells by dengue virus is modulated by different cell types and viral strains

Although prior studies have investigated cellular infection by dengue virus (DV), many have used highly passaged strains. We have reassessed cellular infection by DV type 2 (DV2) using prototype and low-passage isolates representing genotypes from different geographic areas. We observed marked variation in the susceptibility to infection among cell types by different DV2 strains. HepG2 hepatoma cells were susceptible to infection by all DV2 strains assayed. Although the prototype strain generated higher titers of secreted virus than the low-passage isolates, this difference did not correspond to positive- or negative-strand viral RNA levels and thus may reflect variation in efficiency among DV2 isolates to translate viral proteins or package and/or secrete virus. In contrast, human foreskin fibroblasts were susceptible to the prototype and low-passage Thai isolates but not to five Nicaraguan strains tested, as reflected by the absence of accumulation of negative-strand viral RNA, viral antigen, and infectious virus. A similar pattern was observed with the antibody-dependent pathway of infection. U937 and THP-1 myeloid cells and peripheral blood monocytes were infected in the presence of enhancing antibodies by the prototype strain but not by low-passage Nicaraguan isolates. Again, the barrier appeared to be prior to negative-strand accumulation. Thus, depending on the cell type and viral isolate, blocks that limit the production of infectious virus in vitro may occur at distinct steps in the pathway of cellular infection.

Dihydropteroate synthase of Mycobacterium leprae and dapsone resistance

Two Mycobacterium leprae genes, folP1 and folP2, encoding putative dihydropteroate synthases (DHPS), were studied for enzymatic activity and for the presence of mutations associated with dapsone resistance. Each gene was cloned and expressed in a folP knockout mutant of Escherichia coli (C600DeltafolP::Km(r)). Expression of M. leprae folP1 in C600DeltafolP::Km(r) conferred growth on a folate-deficient medium, and bacterial lysates exhibited DHPS activity. This recombinant displayed a 256-fold-greater sensitivity to dapsone (measured by the MIC) than wild-type E. coli C600, and 50-fold less dapsone was required to block (expressed as the 50% inhibitory concentration [IC(50)]) the DHPS activity of this recombinant. When the folP1 genes of several dapsone-resistant M. leprae clinical isolates were sequenced, two missense mutations were identified. One mutation occurred at codon 53, substituting an isoleucine for a threonine residue (T53I) in the DHPS-1, and a second mutation occurred in codon 55, substituting an arginine for a proline residue (P55R). Transformation of the C600DeltafolP::Km(r) knockout with plasmids carrying either the T53I or the P55R mutant allele did not substantially alter the DHPS activity compared to levels produced by recombinants containing wild-type M. leprae folP1. However, both mutations increased dapsone resistance, with P55R having the greatest affect on dapsone resistance by increasing the MIC 64-fold and the IC(50) 68-fold. These results prove that the folP1 of M. leprae encodes a functional DHPS and that mutations within this gene are associated with the development of dapsone resistance in clinical isolates of M. leprae. Transformants created with M. leprae folP2 did not confer growth on the C600DeltafolP::Km(r) knockout strain, and DNA sequences of folP2 from dapsone-susceptible and -resistant M. leprae strains were identical, indicating that this gene does not encode a functional DHPS and is not involved in dapsone resistance in M. leprae.

Modulation of Dengue virus infection in human cells by alpha, beta, and gamma interferons

A role for interferon (IFN) in modulating infection by dengue virus (DV) has been suggested by studies in DV-infected patients and IFN receptor-deficient mice. To address how IFN modulates DV type 2 infection, we have assayed IFN-alpha, -beta, and -gamma for the ability to enhance or diminish antibody-independent and antibody-dependent cell infection using a competitive, asymmetric reverse transcriptase-mediated PCR (RT-PCR) assay that quantitates positive and negative strands of viral RNA, a flow cytometric assay that measures viral antigen, and a plaque assay that analyzes virion production. Our data suggest that IFN-alpha and -beta protect cells against DV infection in vitro. Treatment of hepatoma cells with IFN-alpha or -beta decreases viral RNA levels greater than 1, 000-fold, the percentage of cells infected 90 to 95%, and the amount of infectious virus secreted 150- to 100,000-fold. These results have been reproduced with several cell types and viral strains, including low-passage isolates. In contrast, IFN-gamma has a more variable effect depending on the cell type and pathway of infection. Quantitative RT-PCR experiments indicate that IFN inhibits DV infection by preventing the accumulation of negative-strand viral RNA.

Reliability and validity of the CANDID--a needs assessment instrument for adults with learning disabilities and mental health problems

BACKGROUND

People with learning disabilities and mental health problems have complex needs. Care should be provided according to need.

AIM

To develop a standardised needs-assessment instrument for adults with learning disabilities and mental health problems.

METHOD

The Camberwell Assessment of Need for Adults with Developmental and Intellectual Disabilities (CANDID) was developed by modifying the Camberwell Assessment of Need (CAN). Concurrent validity was tested using the Global Assessment of Functioning (GAF) and the Disability Assessment Schedule (DAS). Test-retest and interrater reliability were investigated using 40 adults with learning disabilities and mental health problems.

RESULTS

CANDID scores were significantly correlated with both DAS (P < 0.05) and GAF scores (P < 0.01). Correlation coefficients for interrater reliability were 0.93 (user), 0.90 (career), and 0.97 (staff ratings); for test-retest reliability they were 0.71, 0.69 and 0.86 respectively. Mean interview duration was less than 30 minutes.

CONCLUSIONS

The CANDID is a brief, valid and reliable needs assessment instrument for adults with learning disabilities and mental health problems.

Low fractional calcium absorption increases the risk for hip fracture in women with low calcium intake. Study of Osteoporotic Fractures Research Group

BACKGROUND

Decreased ability to absorb calcium with age limits adaptation to low calcium intake and is thought to lead to secondary hyperparathyroidism and increased risk for hip and other fractures. However, the associations between fractional calcium absorption, dietary calcium intake, and risk for fracture have never been studied.

OBJECTIVE

To determine whether low fractional calcium absorption in women with low calcium intake increases the risk for subsequent hip and other nonspine fractures.

DESIGN

Prospective cohort study.

SETTING

Four clinical centers in Baltimore County, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania.

PARTICIPANTS

5452 nonblack women 69 years of age or older participating in the fourth examination of the Study of Osteoporotic Fractures.

MEASUREMENTS

Fractional calcium absorption was measured by using a 3-hour single isotope (45Ca) technique. Incident fractures were identified prospectively and were confirmed by radiographic report.

RESULTS

During an average of 4.8 years, 729 women (13%) experienced at least one nonspine fracture; 153 of these women had hip fractures. After adjustment for age, women with lower fractional calcium absorption were at increased risk for hip fracture (relative risk per 1-SD [7.7%] decrease in fractional calcium absorption, 1.24 [95% CI, 1.05 to 1.48]). Women with low fractional calcium absorption and low calcium intake were at greatest risk for subsequent hip fracture; among women whose dietary calcium intake was less than 400 mg/d, those who had fractional calcium absorption at or below the median value of 32.3% had a 2.5-fold (CI, 1.29-fold to 4.69-fold) increase in risk for hip fracture compared with those who had greater absorption efficiency. Fractional calcium absorption was not related to risk for other nonspine fractures (relative risk per 1-SD [7.7%] decrease in fractional calcium absorption, 1.05 [CI, 0.96 to 1.14]).

CONCLUSIONS

In elderly women, low fractional calcium absorption in the setting of low calcium intake increases the risk for hip fracture. Our findings support the hypothesis of type II osteoporosis, which postulates that decreased calcium absorption is an important risk factor for hip fracture in older persons.

Rapid subtyping of dengue virus serotypes 1 and 4 by restriction site-specific PCR

We previously reported a simple subtyping method, restriction site-specific PCR (RSS-PCR), for dengue virus serotypes 2 and 3; here we describe its application for subtyping dengue virus serotypes 1 and 4. Three major RSS-PCR types were observed for dengue virus serotype 1 and two types were observed for dengue virus serotype 4, in agreement with previous strain classifications based on sequence analysis. Because of its simplicity, this method is amenable to rapid subtyping and application to epidemiological studies of dengue in countries where dengue is endemic.

Prevalence, detection and management of anxiety and depressive symptoms in unemployed patients attending general practitioners

INTRODUCTION

This study examined the detection and management of anxiety and depressive symptoms among unemployed patients attending general practitioners (GPs).

METHOD

A cross-sectional study was undertaken of anxiety and depressive symptoms in general practice using measures completed by patients and GPs. Eligible patients were adults aged 18 to 64 years either working (n = 2273) or unemployed (n = 392).

RESULTS

Eighty per cent of patients were attending their regular GP at the time of the study. Unemployed patients were found to have a higher mean general health questionnaire (GHQ-12) score than employed patients (3.8 compared with 2.4, p < 0.001); were more likely to report symptoms of anxiety and depression which required medical treatment during the previous 4weeks (30.9% compared with 14.6%, p < 0.001); and were more likely to have been treated for anxiety and depression by the GP (27.8% compared with 15.7%, p < 0.001). Among patients who the GPs reported treating for anxiety and depression, unemployed patients were 3.3 times (95% CI: 2.0-5.4) more likely to be prescribed medication than employed patients when severity was controlled but were no more likely to be referred to other health services. Unemployed patients identified increased use of services and were less satisfied with the care that they had received.

CONCLUSIONS

Unemployed patients attending GPs have an increased risk of anxiety and depressive symptoms. Increased prescription of medication as opposed to referral suggests that GPs may treat their unemployed patients differently to employed patients. GPs need to be aware of the higher risk and severity of anxiety and depressive symptoms among unemployed patients and their desire to be more actively involved in their treatment. General practice is an important setting for addressing the health needs of unemployed people.

Re-entrant activity in a presubiculum-subiculum circuit generates epileptiform activity in vitro

The retrohippocampal cortices form the transition between neocortex and the hippocampus. Area CA3 of the hippocampus and the entorhinal cortex (EC) of the retrohippocampal region are established as brain regions that generate epileptiform activity. Interictal activity generated in EC consists of a primary population burst followed by multiple afterdischarges. The presubiculum is similar to EC in its six-layered structure, but lacks a columnar circuitry that the EC possesses. Isolated presubicular tissue cannot generate afterdischarges and isolated subicular tissue generates no spontaneous activity under some conditions. We report epileptiform activity in combined presubiculum-subiculum slices that consists of synchronous population bursts and multiple afterdischarges. Intracellular and field potential recordings reveal two re-entrant paths for interaction of presubicular and subicular neurons. We demonstrate a deep presubicular input to subiculum and separate return paths from subicular bursting neurons onto deep and superficial layer pre-/parasubicular neurons. Recordings from subicular cell apical dendrites showed repetitive burst firing during sustained depolarizing current injection. We conclude that re-entrant activity in a presubiculum-subiculum circuit generates epileptiform activity in both regions. Presubicular inputs to subiculum depolarize apical dendrites which can then burst repetitively. These bursts are transmitted back to the presubiculum. We suggest that iterations on this circuit act to prolong the dendritic depolarization of subicular bursting neurons and to entrain the activity across subicular cells resulting in multiple afterdischarges.

Application of molecular typing techniques in the 1998 dengue epidemic in Nicaragua

This report presents the results of applying the reverse transcriptase-polymerase chain reaction (RT-PCR) to the analysis of clinical specimens during the 1998 dengue epidemic in Nicaragua. The RT-PCR was validated through comparison with viral isolation, resulting in a sensitivity of 100% and a specificity of 90%. In-country application of the RT-PCR permitted the rapid identification of dengue-3 virus as the cause of the epidemic at the beginning of 1998 and the detection of the reintroduction of dengue-2 virus in the middle of the year. Nineteen isolates of dengue-3 and one of dengue-2 were characterized using the restriction site-specific (RSS)-PCR technique. This showed that the dengue-3 strain belonged to the "Sri Lanka" subtype and that the dengue-2 strain belonged to the "Jamaica" subtype, both of which have been associated with hemorrhagic dengue in the Americas. The application of these simple PCR-based strain typing methods in a country endemic for dengue virus infections can help to characterize the transmission dynamics of this important emerging infectious disease problem and provide this information to local health authorities in a timely manner so that appropriate control measures can be implemented.

A role for Gbx2 in repression of Otx2 and positioning the mid/hindbrain organizer

The mid/hindbrain (MHB) junction can act as an organizer to direct the development of the midbrain and anterior hindbrain. In mice, Otx2 is expressed in the forebrain and midbrain and Gbx2 is expressed in the anterior hindbrain, with a shared border at the level of the MHB organizer. Here we show that, in Gbx2-/- mutants, the earliest phenotype is a posterior expansion of the Otx2 domain during early somite stages. Furthermore, organizer genes are expressed at the shifted Otx2 border, but not in a normal spatial relationship. To test whether Gbx2 is sufficient to position the MHB organizer, we transiently expressed Gbx2 in the caudal Otx2 domain and found that the Otx2 caudal border was indeed shifted rostrally and a normal appearing organizer formed at this new Otx2 border. Transgenic embryos then showed an expanded hindbrain and a reduced midbrain at embryonic day 9.5-10. We propose that formation of a normal MHB organizer depends on a sharp Otx2 caudal border and that Gbx2 is required to position and sharpen this border.

Widespread atypical cutaneous Leishmaniasis caused by Leishmania (L.) Chagasi in Nicaragua

Leishmania chagasi, the causative agent of visceral leishmaniasis (VL) in the Americas, has recently been associated with atypical cutaneous leishmaniasis (ACL) in Central America; however, little comprehensive information about this disease is available. Clinical, epidemiologic, and parasitologic characteristics of 252 ACL cases and 44 VL cases in Nicaragua were analyzed. Visceral leishmaniasis is primarily associated with malnourished children less than five years of age, whereas ACL is found predominantly in children greater than five years of age and young adults. Genetically similar parasites are associated with both disease manifestations. The sand fly Lutzomyia evansi, in addition to Lu. longipalpis, may be involved in transmission of L. chagasi to humans. Our results indicate that ACL is more prevalent than previously thought, affecting up to 10% of a local population. The fact that the same parasite appears to cause both ACL and the potentially fatal visceral disease suggests that the host immune response is critical in determining the outcome of L. chagasi infection. The public health implications of the wide-spread presence of L. chagasi are discussed.

Mutations in the gene encoding 11-cis retinol dehydrogenase cause delayed dark adaptation and fundus albipunctatus

The metabolic pathways that produce 11-cis retinal are important for vision because this retinoid is the chromophore residing in rhodopsin and the cone opsins. The all-trans retinal that is generated after cone and rod photopigments absorb photons of light is recycled back to 11-cis retinal by the retinal pigment epithelium and Müller cells of the retina. Several of the enzymes involved have recently been purified and molecularly cloned; here we focus on 11-cis retinol dehydrogenase (encoded by the gene RDH5; chromosome 12q13-14; ref. 4), the first cloned enzyme in this pathway. This microsomal enzyme is abundant in the retinal pigment epithelium, where it has been proposed to catalyse the conversion of 11-cis retinol to 11-cis retinal. We evaluated patients with hereditary retinal diseases featuring subretinal spots (retinitis punctata albescens and fundus albipunctatus) and patients with typical dominant or recessive retinitis pigmentosa for mutations in RDH5. Mutations were found only in two unrelated patients, both with fundus albipunctatus; they segregated with disease in the respective families. Recombinant mutant 11-cis retinol dehydrogenases had reduced activity compared with recombinant enzyme with wild-type sequence. Our results suggest that mutant alleles in RDH5 are a cause of fundus albipunctatus, a rare form of stationary night blindness characterized by a delay in the regeneration of cone and rod photopigments.

PCR detection and identification of Leishmania parasites in clinical specimens in Ecuador: a comparison with classical diagnostic methods

A simplified polymerase chain reaction (PCR)-based assay was used for detection and typing of Leishmania parasites in clinical specimens from patients suspected of cutaneous leishmaniasis. Using cultures as the reference standard, our PCR detection method was more sensitive (92%) than classical diagnostic techniques, including microscopy (42% sensitivity), histologic staining (33%), and IgG enzyme-linked immunosorbent (20%). The PCR assay was also 100% specific. Parasites in both lesion biopsies and isolates cultured from lesion aspirates were identified as Leishmania braziliensis by PCR. In this study, we have demonstrated the suitability of simplified PCR assays for the simultaneous diagnosis and typing of parasites causing cutaneous leishmaniasis in a developing country where leishmaniasis is endemic.

Rapid subtyping of dengue viruses by restriction site-specific (RSS)-PCR

Dengue is a major public health problem worldwide. It is caused by four dengue virus serotypes, each further divided into distinct genetic subtypes. Strain typing is important for understanding the epidemiology and viral factors associated with disease transmission. However, most of the existing subtyping methods are expensive and technically unwieldy for timely, practical applications in developing countries. Here we describe a simple, rapid, PCR-based subtyping method, restriction site-specific (RSS)-PCR, which we used to analyze dengue virus serotypes 2 and 3. For each serotype, four primers targeted to sequences spanning polymorphic endonuclease restriction sites in the envelope gene were used to reverse transcribe and amplify viral RNA. These RT-PCR products generated distinct electrophoretic band patterns for different strains. Analysis of 73 dengue-2 strains and 54 dengue-3 strains representing a broad geographic distribution over several decades revealed that the RSS-PCR fingerprints reproducibly fell into 7 and 3 groups, respectively. These groups correlated well with previous phylogenetic classifications. This one-step assay should be widely accessible and allow more detailed epidemiologic investigations in dengue-endemic countries. This novel PCR approach to subtyping organisms based on restriction site polymorphisms should be applicable to other pathogens.

Drosophila engrailed can substitute for mouse Engrailed1 function in mid-hindbrain, but not limb development

The Engrailed-1 gene, En1, a murine homologue of the Drosophila homeobox gene engrailed (en), is required for midbrain and cerebellum development and dorsal/ventral patterning of the limbs. In Drosophila, en is involved in regulating a number of key patterning processes including segmentation of the epidermis. An important question is whether, during evolution, the biochemical properties of En proteins have been conserved, revealing a common underlying molecular mechanism to their diverse developmental activities. To address this question, we have replaced the coding sequences of En1 with Drosophila en. Mice expressing Drosophila en in place of En1 have a near complete rescue of the lethal En1 mutant brain defect and most skeletal abnormalities. In contrast, expression of Drosophila en in the embryonic limbs of En1 mutants does not lead to repression of Wnt7a in the embryonic ventral ectoderm or full rescue of the embryonic dorsal/ventral patterning defects. Furthermore, neither En2 nor en rescue the postnatal limb abnormalities that develop in rare En1 null mutants that survive. These studies demonstrate that the biochemical activity utilized in mouse to mediate brain development has been retained by Engrailed proteins across the phyla, and indicate that during evolution vertebrate En proteins have acquired two unique functions during embryonic and postnatal limb development and that only En1 can function postnatally.