Skeletal status of men with early and late ankylosing spondylitis

PURPOSE

To assess the influence of extent of disease on the skeletal status of men with ankylosing spondylitis (AS).

PATIENTS AND METHODS

Fourteen men with AS were studied at entry and again after 15 months. Bone mineral density (BMD) was assessed by single photon absorptiometry (SPA), dual energy x-ray absorptiometry (DXA), and quantitative computed tomography (QCT). Calciotropic hormones and bone turnover were also assessed, and biopsies of iliac crest and skin were taken after tetracycline double-labeling from 10 subjects. Clinical evaluation and Health Assessment Questionnaires were used to assess functional status.

RESULTS

Of the 14 participants, 7 had sacroiliitis alone without radiologic evidence of spinal involvement (early disease) and 7 had sacroiliitis with extensive vertebral calcifications and immobilization (late disease). QCT baseline lumbar spine BMD was very low in both groups compared with normative standards (Z score = -3.08 +/- 1.83, P < 0.0001) and did not change significantly over 15 months. This low BMD was more marked in late disease than in early disease subjects (P < 0.01). DXA BMD at the lumbar spine was lower than predicted in early disease subjects (Z score = -1.08 +/- 0.67, P = 0.005) but not in the late disease group. DXA BMD was also low at the all three hip sites (Z score = -0.96 +/- 0.86, P < 0.01). Significant differences between late disease group and normative values were apparent at all hip sites. Values in early disease subjects, however, did not differ from age-predicted norms. Bone mineral status did not change significantly over the 15-month period of observation. Circulating parathyroid hormone (PTH) and vitamin D metabolites were normal in both groups as were creatinine clearance and urinary excretion of calcium and hydroxyproline. Osteocalcin levels were normal in all but the two youngest subjects in the early disease group. Histomorphometry of the iliac crest showed no consistent change in bone turnover. Bone volume and trabecular width were low in many cases. Cancellous bone volume correlated with lumbar spine BMD by QCT (r = 0.69, P = 0.026) but not with DXA. Although beneficial changes occurred in exercise tolerance and pain over time, anthropometric measurements did not improve.

CONCLUSION

BMD is low in both the axial and peripheral skeleton in men with AS and is independent of spinal immobilization. Anterioposterior lumbar spine DXA in late AS is less useful than QCT in determining the degree of osteopenia in late AS. Bone mineral deficits in AS do not reflect measurable metabolic derangement or hypogonadism. Although bone histomorphometry suggests both trabecular thinning and loss of structural elements as mechanisms involved in low bone volume, the exact cause of osteopenia in AS remains to be determined.

Huge variation in Russian mortality rates 1984-94: artefact, alcohol, or what?

BACKGROUND

According to published data, between 1984 and 1994 mortality rates in Russia initially underwent a rapid decline followed by an even steeper increase. In 1994, male life expectancy at birth was 57.6 years, having fallen by 6.2 years since 1990. There has been concern that such striking fluctuations in mortality are an artefact, although, among other factors, alcohol consumption has been implicated.

METHODS

We analysed the age-specific and cause-specific patterns of mortality decrease and increase by use of data from a newly reconstructed mortality series for Russia so that we could examine the plausibility of various explanations for the mortality trends.

FINDINGS

All major causes of death, with the exception of neoplasms, showed declines in mortality between 1984 and 1987 and increases between 1987 and 1994. In relative terms, these tended to be largest for the age-group 40-50 years; surprisingly, they were of the same magnitude among women and men. The largest declines and subsequent increases in proportional terms were observed for alcohol-related deaths and accidents and violence. However, pronounced effects were also seen for deaths from infections, circulatory disease, and respiratory disease. No substantial variations were seen for neoplasms.

INTERPRETATION

The stability of mortality from neoplasms in contrast to other causes over the period 1984-94 largely precludes the possibility that the changes in life expectancy are mainly an artefact, particularly one due to underestimation of the population. Although factors such as nutrition and health services may be involved, the evidence is that substantial changes in alcohol consumption over the period could plausibly explain the main features of the mortality fluctuations observed. These results provide a major challenge to public health in Russia and to our understanding of the determinants of alcohol consumption and its role in explaining mortality patterns within and between many other countries.

Family practice residency behavioral science training: influence on graduate practice activity

BACKGROUND AND OBJECTIVES

The educational efficacy of family practice residency behavioral science training and how various educational approaches might influence graduate practice activity are poorly understood. In this study, we compare a traditional didactic and clinical block rotation approach to a problem-based learning (PBL) and clinical, experiential behavioral science curriculum.

METHODS

Surveys of pre- and post-intervention cohorts were used to assess graduates' perceptions of their understanding of broad behavioral science concepts, their competence to manage specific behavioral conditions, and their behavioral science practice activity. The two cohorts were University of California, Irvine family practice residency program graduates from 1984-1988 (58) and residency graduates from 1993-1995 (27). American Board of Family Practice (ABFP) In-service Training Examination scores were also compared.

RESULTS

No significant differences were detected in self-perceived competence and ABFP examination performance. Residency graduates in the post-intervention cohort more often included depression, marital counseling, and eating disorders in their practice and reported more frequent practice activity for situational stress and sexual dysfunction. The post-intervention group reported less involvement with alcohol and substance abuse problems. This group also reported practice activity that exceeded perceived levels of competence for attention deficit disorder, learning disorders, and eating disorders.

CONCLUSIONS

Participants in a PBL-clinical experiential curriculum reported higher levels of practice activity for several common behavioral problems. It seems unlikely that these differences were due to curriculum changes. Further investigation of the influence of educational and other factors on residency graduate practice activity is needed.

Young adults' drug use: a 17-year longitudinal inquiry of antecedents

This longitudinal study examined the interrelation of personality and peer factors on young adults' drug use and also the influence of the interaction of personality and peer factors on drug use. The sample of 756 males and females were interviewed four times between the M ages of 6 and 22. Personality attributes in childhood were related to peer factors in early adolescence which, in turn, were related to personality traits in later adolescence. These traits were linked with selection of peers and, ultimately, drug use in young adulthood. Additionally, the adolescent and young adult domains had direct effects on young adults' drug use. Significant interactions indicated that a few protective childhood personality traits buffer the risk of deviant peers in adolescence on young adults' drug use. More earlier protective characteristics from one domain enhanced the effect of later protective traits from the other domain.

Adult acute leukaemia--a retrospective study of 66 consecutive patients

BACKGROUND

Advances in therapy and supportive care have improved the outlook for many patients with acute leukaemia, however elderly patients have increased treatment-related toxicity and shorter survival. Most clinical trials have selected patient populations with young median ages and it is therefore difficult to apply results to the general population where the majority of patients presenting with acute leukaemia are over 60 years. There is little information in the literature guiding appropriate treatment of these patients.

AIMS

To determine the relationship between age, treatment received, and outcome in patients presenting with acute leukaemia.

METHODS

A retrospective analysis was performed on all patients presenting to Prince Henry's Hospital and Monash Medical Centre with acute myeloid leukaemia (AML) or acute lymphocytic leukaemia (ALL) during a five year period.

RESULTS

Sixty-six patients (51-AML, 15-ALL) presented with acute leukaemia between March 1989 and April 1994. Median patient age was 63 years; 32% of patients received supportive therapy only; 86% of patients with ALL and 58% of patients with AML commencing remission-induction chemotherapy entered a complete remission. Median survival for patients receiving only supportive therapy was three months. Median survival in patients under 55 years was almost twice as long as patients over 55 years receiving similar treatment (AML-eight vs four months p = 0.023; ALL-3.5 vs seven months p = 0.029).

CONCLUSIONS

Median survival for acute leukaemia is inversely proportional to age. Applying results from selected series to elderly patients with acute leukaemia is inappropriate.

Cigarette smoking in young adults: childhood and adolescent personality, familial, and peer antecedents

Three models (independent, interdependent, and mediational) were hypothesized in this study, to examine the interrelation of personality, family, and peer determinants and their effects on tobacco use by young adults. Mothers were first interviewed about their children when they were between the ages of 1 and 10 years old. Three subsequent interviews were conducted with the children when they reached adolescence and young adulthood. Results show support for the mediational model. In accordance with family interactional framework conceptions, there was a sequence in patterning: from parenting during early adolescence; to personality and peer factors, extending to smoking in late adolescence; and culminating in smoking in adulthood. With a developmental approach, a number of psychosocial measures were related in both younger and older children. Nevertheless, some interesting developmental differences emerged. The findings suggest at least four possible targets for therapeutic or preventive intervention: the parent, the child, the adolescent, and the peer group.

Phagophobia: a form of psychogenic dysphagia. A new entity

There is a group of patients presenting with either acute or chronic dysphagia secondary to fear of swallowing. We have termed this entity phagophobia. It is characterized by various significant swallowing complaints in the face of normal findings on head and neck examination, oropharyngeal swallowing videofluoroscopy, and standard barium swallow study. Ten patients who received diagnoses of phagophobia after a full evaluation at our swallowing disorders center are presented. Each patient was then evaluated by a psychologist, and an attempt at therapy was undertaken. We discuss the specific clinical features, assessment, and treatment of this frequently misdiagnosed disorder.

Depression in Latina mothers of children with mental retardation: a neglected concern

Depression among 148 Latina women who have children with mental retardation was examined. Results showed that their depressive symptomatology was elevated, with almost half reporting negative experiences in excess of a commonly used cut-off for the Center for Epidemiologic Studies Scale (CES-D). Depression scores related to variables pertaining to the child, mother's health and level of acculturation, and aspects of stress and coping. When mothers were categorized in three groups by CES-D scores, discriminant analysis correctly classified 84% of the low and high group mothers. High CES-D membership was predicted by mothers' reporting more family problems, worse health, fewer interactions with English-speaking persons in their daily lives, and more negative feelings about parenting their child with mental retardation.

Bone histomorphometry in adults with type IA osteogenesis imperfecta

A histologic and histomorphometric analysis was performed on undecalcified bone from 8 adult patients, ages 34 to 64 years, with Type IA osteogenesis imperfecta. Complete histomorphometric data, including static and dynamic parameters of bone remodeling, could be generated on 6 patients, and partial data were obtained from the other 2 patients. Findings in some patients of reduced eroded surfaces and reduced osteoid surfaces suggested low bone turnover. Other findings included normal or slightly reduced labeled surfaces, slightly reduced bone formation rate, decreased cortical thickness, and decreased bone volume. Histologic examination results showed lamellar bone with mature cortical Haversian systems. Trabeculae showed qualitatively normal connectedness despite low trabecular volume. The finding of normal or reduced bone turnover in adults with Type IA osteogenesis imperfecta has not been reported. Earlier histomorphometric studies, performed without correlation with a specific age or phenotype, indicated high bone turnover. The present study suggests that future research should correlate histopathologic changes with specific phenotypes. The finding of normal or slightly reduced bone turnover in Type IA osteogenesis imperfecta may have important therapeutic implications for this phenotype.

Localization of endogenous furin in cultured cell lines

Furin is a dibasic endopeptidase responsible for the proteolytic maturation of many precursor proteins in the secretory and endocytic pathways of mammalian cells. The levels of furin expression in most cells are very low, and this has hampered attempts to identify the intracellular compartments in which endogenous furin is localized. We have used a specific antibody reagent to a sequence in the carboxy terminus of furin to perform immunofluorescent staining of mammalian cell lines. This antibody was sensitive enough to detect staining for furin in various cell lines. For the most part, furin staining was confined to a juxtanuclear structure characteristic of the Golgi complex. Analyses by video microscopy and confocal microscopy showed that the distribution of furin was distinct from that of mannosidase II, a marker of the Golgi stack, and most closely resembled that of TGN38, a marker of the trans-Golgi network. Therefore, our results suggest that endogenous furin is predominantly localized to the area of the Golgi complex, most likely within the trans-Golgi network.

Prevention of infection in a patient with chronic idiopathic neutropenia undergoing coronary bypass surgery with peri-operative G-CSF

The prevention of postoperative infection complications in a patient with chronic idiopathic neutropenia treated with granulocyte colony stimulating factor (G-CSF) is reported. A 48-year-old woman who presented with chronic idiopathic neutropenia causing life-long recurrent infections, and postoperative suppurative wound infections, presented for elective coronary artery surgery. The patient was successfully treated with G-CSF, resulting in a significantly higher neutrophil count and no infection complications in the peri-operative period. Peri-operative G-CSF therapy in patients with chronic idiopathic neutropenia is effective in increasing the total neutrophil count, and decreasing infection complications.

Inflammatory myopathy causing pharyngeal dysphagia: a new entity

Seven patients presented to our swallowing center with solid food dysphagia. The age range at presentation was 69 to 90 years. All patients had normal findings on neurologic evaluation, and in those patients undergoing electromyography and nerve conduction studies, results of all such tests were also normal. Pooling of saliva in the pharyngeal recesses was noted on fiberoptic laryngoscopy in most cases. The swallowing videofluoroscopy findings were strikingly similar. All patients had a prominent cricopharyngeus muscle, and some had a prominence in a more proximal portion of the inferior constrictor muscle. All patients had decreased epiglottic tilt and moderate or severe residue in the pharyngeal recesses. Three patients underwent pharyngoesophageal sphincter myotomy. Biopsies of the omohyoid and cricopharyngeus muscles showed inflammatory myopathy with no evidence of inclusion bodies. This is a distinct clinical entity defined by isolated pharyngeal dysphagia in elderly patients with a unique videofluoroscopic appearance and pharyngeal myopathy.

Family medicine in a culturally diverse world: a solution-oriented approach to common cross-cultural problems in medical encounters

BACKGROUND

Using cultural sensitivity in the training of family practice residents generally results in positive consequences for patient care. However, certain potential problems associated with cross-cultural educational efforts deserve examination, including patient stereotyping, assumptive bias, and the confounding of ethnicity with class and socioeconomic status. Even awareness of these pitfalls may not guarantee physician avoidance of other barriers to effective patient care, such as communication difficulties, diagnostic inaccuracies, and unintentional patient exploitation. Despite these complications, future family physicians must continue to participate in educational activities that increase sensitivity toward and understanding of patients of different ethnicities. This article discusses certain features characteristic of the ways in which cultural variables operate in the doctor-patient encounter and identifies specific ways in which residents can successfully elicit and use cultural knowledge to enhance patient care.

Effects of parent drug use and personality on toddler adjustment

The interrelation between parental drug use and parental personality and the effects on 18-month-old children's adjustment were examined. Data on the parents were available at four points in time: Time 1 at mean age 6.1 years, Time 2 at mean age 13.7 years, Time 3 at mean age 16.4 years, and at Time 4 at mean age 22.2 years. Data on their toddlers at 18 months of age were also available. Structured interviews were used to assess personality and drug use and the toddlers' adjustment. Time 3 parental personality traits were related to Time 4 personality traits, which in turn were related to toddler adjustment. The influence of parental alcohol involvement (Time 3) on toddler adjustment was mediated by parental personality (Times 3 and 4) and parental alcohol problems (Time 4). Interactive effects demonstrated that protective parental personality traits (nondrug conducive) enhanced the effects of low parental drug use, resulting in the highest amounts of toddler adjustment. There are significant pathways between parental personality and drug use and toddler adjustment. Parental protective factors enhance the effect of parental low drug use on toddler adjustment.

Gaseous dynamics of the rabbit maxillary sinus

To better understand the mechanisms underlying maxillary sinus function, the gas composition of the sinus antrum in spontaneously breathing and tracheotomized rabbits (n = 17) was compared. The gas composition of samples (n = 117) obtained from rabbit maxillary sinuses was determined by gas chromatography. Results demonstrated significant differences (P < .005) in sinus gas composition between nasal breathing and tracheotomized animals for oxygen (02) and carbon dioxide (CO2). In tracheotomized animals O2 levels decreased while CO2 levels increased markedly to suprasystemic levels. This unexpected finding may be due to reduced sinus blood flow and the effects of nasal versus tracheal respiration. We conclude that the gaseous dynamics and perhaps the function of the maxillary sinus vary under different respiratory conditions. A better understanding of these processes may lead to earlier diagnosis and the development of improved treatments for sinus disease.

CSF inositol does not predict antidepressant response to inositol. Short communication

CSF inositol was reported to be reduced in depression and inositol has been reported to be effective in treatment of depression. We studied CSF inositol in 18 drug-free depressed patients and 36 normal controls; the depressed patients then participated in an open trial of 18 gm daily inositol treatment for 4 weeks. There was no difference in pre-treatment CSF inositol between depressed patients and controls. CSF inositol levels did not predict response on the Hamilton Depression Scale to 4 weeks of inositol treatment.

Longitudinally predicting late adolescent and young adult drug use: childhood and adolescent precursors

OBJECTIVE

To examine the childhood and adolescent personality determinants of young adult drug use.

METHOD

Data were obtained on children when they were approximately 5.5 (time 1; T1), 14 (T2), 16 (T3), and 22 (T4) years of age. T2-T4 interviews of subjects and their mothers assessed child personality and behavior. At T1, 976 mothers were interviewed. The analysis was based on 734 subjects.

RESULTS

Specific childhood and adolescent personality traits are related to stage of drug use in young adulthood. Regressions showed that (1) traits at T2 and T3 mediated the effect of traits at earlier ages on T4 drug use and (2) stage of drug use was stable from T3 to T4 despite controlling for personality. Significant interaction revealed two buffers weakening the effect of T3 drug use on T4 drug use. Many more T1-T3 personality traits, particularly low aggression, enhanced the effect of low T3 use on T4 use.

CONCLUSIONS

Earlier findings that childhood personality is related to adolescent personality and then to drug use were extended to young adulthood. This mediational model indicates the stability of personality across development. Despite this stability, other results suggest ways to modify drug use.