Molecular Detection of Tick-Borne Bacteria from Amblyomma (Acari: Ixodidae) Ticks Collected from Reptiles in South Africa

Reptiles are hosts for various tick species and tick-associated organisms, many of which are zoonotic. However, little is known about the presence and diversity of tick-borne bacteria infecting reptiles and their ticks in South Africa. Amblyomma ticks (n = 253) collected from reptiles were screened for the presence of Coxiella, Anaplasma, Rickettsia, and Borrelia species by amplification, sequencing and phylogenetic analysis of the 16S rRNA, 23S rRNA, gltA, OmpA, and Flagellin genes, respectively. This study recorded the presence of reptile associated Borrelia species and Coxiella-like endosymbiont in South Africa for the first time. Furthermore, a spotted fever group Rickettsia species was observed in 7 Amblyomma marmoreum and 14 Amblyomma sylvaticum from tortoises of genera Kinixys and Chersina. Francisella-like endosymbiont was observed from 2 Amblyomma latum collected from the Mozambique spitting cobra, Naja mossambica. Coxiella burnetii and Anaplasma spp., were not detected from the current samples. Although the direct evidence that reptiles can act as reservoir hosts remains to be determined, observations from this study provide indications that reptilian ticks may play a role in the transmission of pathogenic bacteria to homothermic animals. Furthermore, the absence of Anaplasma spp., and C. burnetii does not mean that these pathogens should be completely neglected.

Molecular screening of ticks of the genus Amblyomma (Acari: Ixodidae) infesting South African reptiles with comments on their potential to act as vectors for Hepatozoon fitzsimonsi (Dias, 1953) (Adeleorina: Hepatozoidae)

In South Africa, the role of reptilian ticks in the transmission of haemoparasites is lacking, in part, due to limited information on tick diversity and their associated haemoparasites. The aim of this research was to identify tick species parasitizing reptiles and to molecularly screen these ectoparasites for species of the blood apicomplexan genus Hepatozoon. Samples were collected from Ndumo Game Reserve, KwaZulu-Natal, and the Cape Columbine region, Western Cape. Reptiles collected included 2 snakes, 2 monitor lizards of a single species respectively, as well as 17 tortoises of four species. Ticks collected from these were morphologically identified as Amblyomma latum (n = 2) and Amblyomma marmoreum (n = 98), this identification was molecularly confirmed using 16S rRNA and CO1 genes. Screening for Hepatozoon was done by amplifying the 18S rRNA gene. A species of Hepatozoon, Hepatozoon fitzsimonsi, was identified from A. marmoreum ticks, with an overall prevalence of 10%. This Hepatozoon species, has been described parasitizing tortoises from southern Africa, and has been reported from ticks infesting tortoises from Kenya, East Africa. Even though ticks have been suggested to be the likely vector of this Hepatozoon species, with this supported by the findings of Hepatozoon-like developmental stages in ticks collected off of infected tortoises, a recent systematic revision placed this species in a newly erected genus Bartazoon, a genus vectorised by biting insects. The present study thus provides further support for ticks acting as the potential vectors of H. fitzsimonsi.

The neglected diversity: Description and molecular characterisation of Trypanosoma haploblephari Yeld and Smit, 2006 from endemic catsharks (Scyliorhinidae) in South Africa, the first trypanosome sequence data from sharks globally

With over 200 species of sharks reported from South African waters, the potential of discovering new blood parasites is very high. Unfortunately, this remains a poorly explored area of research, particularly in this biogeographical region. To date, only a single trypanosome species, Trypanosoma haploblephari Yeld and Smit, 2006, has been described from elasmobranchs off the coast of South Africa infecting the catsharks Haploblepharus pictus (Müller & Henle) and Haploblepharus edwardsii (Schinz). With only a single trypanosome species described and absence of molecular information, a study was conducted to provide further morphological and molecular information on T. haploblephari, a species considered not to demonstrate any pleomorphism. Thin blood smears were prepared, and blood was collected in molecular-grade ethanol from the caudal vein of two shark species, H. pictus and Poroderma pantherinum (Müller & Henle). Trypanosomes were morphologically described and molecularly characterised based on analysis of fragments of the 18S ribosomal gene. The presence of T. haploblephari in H. pictus was confirmed using the original description based on morphology, type host and locality, which allowed for the molecular characterisation of the species. In addition, this species was found parasitising P. pantherinum, its morphology considerably different in this host species as compared to that in the species of Haploblepharus, demonstrating that T. haploblephari may show extreme pleomorphism. This paper provides both morphological and molecular data for both morphotypes of T. haploblephari, with molecular comparisons to the only two other elasmobranch species of trypanosome for which sequence data is available. To elucidate the relationship of trypanosomes from aquatic hosts in general, more efforts need to be placed on elasmobranchs, as current phylogenetic studies are predominantly focused on trypanosomes infecting freshwater fishes.

•

First molecular characterization of trypanosomes in endemic sharks in South Africa.

•

Illustration of extreme morphological plasticity in trypanosomes.

•

Phylogenetic analysis of marine and freshwater fish trypanosomes.

Morphological and molecular characterization of an African freshwater fish trypanosome, including its development in a leech vector

Trypanosomes are ubiquitous blood parasites of fishes and at least 16 species were originally described infecting African freshwater fishes. This number was later reduced to six and in the late 1990s it was proposed that most records of freshwater fish trypanosomes across Africa are Trypanosoma mukasai Hoare, 1932. Recently, results from a molecular analysis of fish trypanosomes from the Okavango Delta, Botswana, reported the presence of at least two genotypic groups and concluded that the identification of T. mukasai remains problematic. The aims of the present study were thus to elucidate the life cycle of a freshwater fish trypanosome from southern Africa and to do a morphological and molecular characterization of this parasite from both the fish host and leech vector. To locate trypanosome stages, leeches were removed from fishes captured in the Phongolo River, South Africa, and fish blood films and leech squashes were Giemsa-stained and screened. To determine whether trypanosome stages in fishes and leeches were of the same genotype, DNA was extracted and fragments of the 18S rDNA gene were amplified and sequenced. Trypanosomes were detected in the fish families Cichlidae, Clariidae, Mochokidae and Schilbeidae. Sequence data showed that the trypanosome from one of the leeches, identified as Batracobdelloides tricarinata (Blanchard, 1897), was highly similar to those obtained from the plain squeaker, Synodontis zambezensis, with 0.7% difference recorded between them. From morphological and molecular data presented here, it is clear that the trypanosomes from Phongolo are closely related to those of the Okavango and should be considered as a single diverse species with genetic differentiation between 0.4-2.9%, under the 3-5% differences expected to be seen between true distinct species within the rRNA. Developmental stages of the trypanosome found in the leech B. tricarinata supports its status as the vector and the molecular evidence shows the relationship between the trypanosome in the fish and leech, but also illustrates the exceptional genetic and morphological diversity of a single species of trypanosome between host species. The work presented here provides us with clear information to take further steps in resolving the taxonomy and systematics of African freshwater fish trypanosomes.

An overview of the Dactylosomatidae (Apicomplexa: Adeleorina: Dactylosomatidae), with the description of Dactylosoma kermiti n. sp. parasitising Ptychadena anchietae and Sclerophrys gutturalis from South Africa

Haemogregarine (Apicomplexa: Adeleorina) blood parasites are commonly reported from anuran hosts. Dactylosomatidae (Jakowska and Nigrelli, 1955) is a group of haemogregarines comprising Dactylosoma Labbé, 1894 and Babesiosoma Jakowska and Nigrelli, 1956. Currently Dactylosoma and Babesiosoma contain five recognised species each. In the current study, a total of 643 anurans, comprising 38 species, 20 genera, and 13 families were collected from South Africa (n = 618) and Belgium (n = 25), and their blood screened for the presence of dactylosomatid parasites. Three anuran species were found infected namely, Ptychadena anchietae (Bocage, 1868) and Sclerophrys gutturalis (Power, 1927) from South Africa, and Pelophylax lessonae (Camerano, 1882) from Belgium. Based on morphological characteristics, morphometrics and molecular results a new dactylosomatid, Dactylosoma kermiti n. sp. is described form Pty. anchietae and Scl. gutturalis. The species of Dactylosoma isolated from Pel. lessonae could not, based on morphological or molecular analysis, be identified to species level. Phylogenetic analysis shows species of Dactylosoma infecting anurans as a monophyletic group separate from the other haemogregarine groups. Additionally, the mosquitoes Uranotaenia (Pseudoficalbia) mashonaensis Theobald, 1901 and U. (Pfc.) montana Ingram and De Meillon, 1927 were observed feeding on Scl. gutturalis in situ and possible dividing stages of this new parasite were observed in the mosquitoes. This study is the first to describe a dactylosomatid parasite based on morphological and molecular data from Africa as well as observe potential stages in possible dipteran vectors.

The distribution and host-association of a haemoparasite of damselfishes (Pomacentridae) from the eastern Caribbean based on a combination of morphology and 18S rDNA sequences

Coral reefs harbor the greatest biodiversity per unit area of any ecosystem on earth. While parasites constitute the majority of this biodiversity, they remain poorly studied due to the cryptic nature of many parasites and the lack of appropriate training among coral reef ecologists. Damselfishes (Pomacentridae) are among the most abundant and diverse fishes on coral reefs. In a recent study of blood parasites of Caribbean reef fishes, the first ever apicomplexan blood parasites discovered in damselfishes were reported for members of the genus Stegastes. While these blood parasites were characterized as “Haemohormidium-like”, they appear to be distinct from any other known apicomplexan. In this study, we examined host associations, geographic distributions, and provide further insights on the phylogenetic affiliation of this parasite. A combination of morphological characteristics and 18S rDNA sequences suggest that this parasite may be the same species at multiple sites and occurs from the southern to the northern extreme of the eastern Caribbean, although it appears rare in the north. At present it appears to be limited to members of the genus Stegastes and infects all life history stages. It is most common in benthophagous species that occur in high population densities and appears basal to a major monophyletic clade containing species of coccidia, distinct from the Piroplasmida, the order to which Haemohormidium spp. have been assigned. These findings suggest a possible fecal-oral mode of transmission.

•

A new species of Haemorhormidium-like apicomplexan blood parasite has recently been discovered in Caribbean damselfishes.

•

Morphological and molecular data indicate that it is widespread in the eastern Caribbean.

•

This parasite is limited to damselfish species of the genus Stegastes and infects juveniles and adults.

•

It is most common in benthophagous species that occur in high population densities.

•

This parasite resembles coccidia but 18S rDNA show it to be distinct from known genera, as well as genera of piroplasms.

Occurrence of Hepatozoon canis (Adeleorina: Hepatozoidae) and Anaplasma spp. (Rickettsiales: Anaplasmataceae) in black-backed jackals (Canis mesomelas) in South Africa

Background

Domestic dogs are not native to sub-Saharan Africa, which may account for their susceptibility to Babesia rossi, of which endemic black-backed jackals (Canis mesomelas) are natural reservoirs. There is virtually no information on the occurrence of potentially pathogenic haemogregarines (e.g. Hepatozoon canis) or even rickettsial bacteria (e.g. Ehrlichia spp. and Anaplasma spp.) in indigenous canids in sub-Saharan Africa. Such organisms could pose a risk to domestic dogs, as well as to populations of endangered indigenous canid species.

Results

Genomic DNA extracted from blood samples taken from 126 free-ranging and 16 captive black-backed jackals was subjected to reverse line blot (RLB) hybridization assay; 82 (57.8%) specimens reacted only with the Ehrlichia/Anaplasma genera-specific probe. Full-length bacterial 16S rRNA gene of five of these specimens was cloned and the recombinants sequenced. The ten 16S rDNA sequences obtained were most closely related, with approximately 99% identity, to Anaplasma sp. South African Dog, various uncultured Anaplasma spp., as well as various Anaplasma phagocytophilum genotypes. Ninety-one specimens were screened for haemogregarines through PCR amplification using the 18S rRNA gene; 20 (21.9%) specimens reacted positively, of which 14 (15.4%) were confirmed positive for Hepatozoon genotypes from within H. canis. Two (2.2%) specimens were found positive for two different Hepatozoon genotypes.

Conclusions

Sequence analyses confirmed the presence of 16S rDNA sequences closely related to A. phagocytophilum and Anaplasma sp. South African Dog as well as two H. canis genotypes in both free-ranging and captive black-backed jackals. Distinguishing between closely related lineages may provide insight into differences in pathogenicity and virulence of various Anaplasma and H. canis genotypes. By building up a more comprehensive understanding of the range and diversity of the bacteria and eukaryotic organisms (piroplasms and haemogregarines) in the blood of indigenous canids, we may gain insight to such infections in these often-endangered species and the potential for horizontal transmission to and from domestic dogs via ticks where favourable conditions exist.

Developing an Apicomplexan DNA Barcoding System to Detect Blood Parasites of Small Coral Reef Fishes

Apicomplexan parasites are obligate parasites of many species of vertebrates. To date, there is very limited understanding of these parasites in the most-diverse group of vertebrates, actinopterygian fishes. While DNA barcoding targeting the eukaryotic 18S small subunit rRNA gene sequence has been useful in identifying apicomplexans in tetrapods, identification of apicomplexans infecting fishes has relied solely on morphological identification by microscopy. In this study, a DNA barcoding method was developed that targets the 18S rRNA gene primers for identifying apicomplexans parasitizing certain actinopterygian fishes. A lead primer set was selected showing no cross-reactivity to the overwhelming abundant host DNA and successfully confirmed 37 of the 41 (90.2%) microscopically verified parasitized fish blood samples analyzed in this study. Furthermore, this DNA barcoding method identified 4 additional samples that screened negative for parasitemia, suggesting this molecular method may provide improved sensitivity over morphological characterization by microscopy. In addition, this PCR screening method for fish apicomplexans, using Whatman FTA preserved DNA, was tested in efforts leading to a more simplified field collection, transport, and sample storage method as well as a streamlining sample processing important for DNA barcoding of large sample sets.

Ultrastructural Comparison of Hepatozoon ixoxo and Hepatozoon theileri (Adeleorina: Hepatozoidae), Parasitising South African Anurans

To date, only two haemogregarine parasite species have been described from South African anurans: Hepatozoon ixoxo, infecting toads of the genus Sclerophrys (syn. Amietophrynus); and Hepatozoon theileri, parasitising the common river frog, Amietia quecketti. Both species have been characterised using limited morphology, and molecular data from PCR amplified fragments of the 18S rRNA gene. However, no ultrastructural work has been performed thus far. The aim of this study was to add descriptive information on the two species by studying their ultrastructural morphology. Mature gamont stages, common in the peripheral blood of infected frogs, were examined by transmission electron microscopy. Results indicate that H. ixoxo and H. theileri share typical apicomplexan characteristics, but differ markedly in their external cellular structure. Hepatozoon ixoxo is an encapsulated parasite presenting a prominent cap at the truncate pole, and shows no visible modifications to the host cell membrane. In comparison, H. theileri does not present a capsule or cap, and produces marked morphological changes to its host cell. Scanning electron microscopy was performed to further examine the cytopathological effects of H. theileri, and results revealed small, knob-like protrusions on the erythrocyte surface, as well as notable distortion of the overall shape of the host cell.

A new lizard malaria parasite Plasmodium intabazwe n. sp. (Apicomplexa: Haemospororida: Plasmodiidae) in the Afromontane Pseudocordylus melanotus (Sauria: Cordylidae) with a review of African saurian malaria parasites

Background

Saurian malaria parasites are diverse apicomplexan blood parasites including the family Plasmodiidae Mesnil, 1903, and have been studied since the early 1900s. Currently, at least 27 species of Plasmodium are recorded in African lizards, and to date only two species, Plasmodium zonuriae (Pienaar, 1962) and Plasmodium cordyli Telford, 1987, have been reported from the African endemic family Cordylidae. This paper presents a description of a new malaria parasite in a cordylid lizard and provides a phylogenetic hypothesis for saurian Plasmodium species from South Africa. Furthermore, it provides a tabular review of the Plasmodium species that to date have been formally described infecting species of African lizards.

Methods

Blood samples were collected from 77 specimens of Pseudocordylus melanotus (A. Smith, 1838) from Platberg reserve in the Eastern Free State, and two specimens of Cordylus vittifer (Reichenow, 1887) from the Roodewalshoek conservancy in Mpumalanga (South Africa). Blood smears were Giemsa-stained, screened for haematozoa, specifically saurian malaria parasites, parasite stages were photographed and measured. A small volume was also preserved for TEM studies. Plasmodium and Haemoproteus primer sets, with a nested-polymerase chain reaction (PCR) protocol, were employed to target a fragment of the cytochrome-b (cyt-b) gene region. Resulting sequences of the saurian Plasmodium species’ isolates were compared with each other and to other known Plasmodium spp. sequences in the GenBank database.

Results

The presence of P. zonuriae in both specimens of the type lizard host C. vittifer was confirmed using morphological characteristics, which subsequently allowed for the species’ molecular characterisation. Of the 77 P. melanotus, 44 were parasitised by a Plasmodium species, which when compared morphologically to other African saurian Plasmodium spp. and molecularly to P. zonuriae, supported its description as a new species Plasmodium intabazwe n. sp.

Conclusions

This is the first morphological and molecular account of Plasmodium species within the African endemic family Cordylidae from South Africa. The study highlights the need for molecular analysis of other cordylid Plasmodium species within Africa. Future studies should also include elucidating of the life-cycles of these species, thus promoting the use of both morphological and molecular characteristics in species descriptions of saurian malaria parasites.

Redescription, molecular characterisation and taxonomic re-evaluation of a unique African monitor lizard haemogregarine Karyolysus paradoxa (Dias, 1954) n. comb. (Karyolysidae)

Background

Within the African monitor lizard family Varanidae, two haemogregarine genera have been reported. These comprise five species of Hepatozoon Miller, 1908 and a species of Haemogregarina Danilewsky, 1885. Even though other haemogregarine genera such as Hemolivia Petit, Landau, Baccam & Lainson, 1990 and Karyolysus Labbé, 1894 have been reported parasitising other lizard families, these have not been found infecting the Varanidae. The genus Karyolysus has to date been formally described and named only from lizards of the family Lacertidae and to the authors’ knowledge, this includes only nine species. Molecular characterisation using fragments of the 18S gene has only recently been completed for but two of these species. To date, three Hepatozoon species are known from southern African varanids, one of these Hepatozoon paradoxa (Dias, 1954) shares morphological characteristics alike to species of the family Karyolysidae. Thus, this study aimed to morphologically redescribe and characterise H. paradoxa molecularly, so as to determine its taxonomic placement.

Methods

Specimens of Varanus albigularis albigularis Daudin, 1802 (Rock monitor) and Varanus niloticus (Linnaeus in Hasselquist, 1762) (Nile monitor) were collected from the Ndumo Game Reserve, South Africa. Upon capture animals were examined for haematophagous arthropods. Blood was collected, thin blood smears prepared, stained with Giemsa, screened and micrographs of parasites captured. Haemogregarine morphometric data were compared with the data for named haemogregarines of African varanids. Primer set HepF300 and HepR900 was employed to target a fragment of the 18S rRNA gene and resulting sequences compared with other known haemogregarine sequences selected from the GenBank database.

Results

Hepatozoon paradoxa was identified infecting two out of eight (25 %) V. a. albigularis and a single (100 %) V. niloticus examined. Phylogenetic analyses revealed that H. paradoxa clustered with the ‘Karyolysus’ clade, and not with those of reptilian Hepatozoon spp.

Conclusions

In addition to this being the first morphological and molecular characterisation of a haemogregarine within the African Varanidae, it is the first report of a species of Karyolysus infecting the monitor lizard family. Furthermore, this constitutes now only the third described and named Karyolysus species for which there is a nucleotide sequence available.

Hepatozoon species (Adeleorina: Hepatozoidae) of African bufonids, with morphological description and molecular diagnosis of Hepatozoon ixoxo sp. nov. parasitising three Amietophrynus species (Anura: Bufonidae)

Background

Haemogregarines comprise a large group of apicomplexan blood parasites. In 1996 all anuran haemogregarines still in the genus Haemogregarina Danilewsky, 1885 were reassigned to the genus Hepatozoon Miller, 1908. Most (11/15, 73%) African anuran Hepatozoon species have been recorded from the family Bufonidae, however, all these are recorded from only two host species, Amietophrynus mauritanicus (Schlegel, 1841) and Amietophrynus regularis (Reuss, 1833) from Northern and central Africa. To the authors’ knowledge the only description of an anuran haemogregarine from South Africa is Hepatozoon theileri (Laveran, 1905), parasitising Amietia quecketti (Boulenger, 1895).

Methods

Thin blood smears for morphometrics and whole blood for molecular work, were collected from 32 Amietophrynus garmani (Meek, 1897), 12 Amietophrynus gutturalis (Power, 1927), and nine Amietophrynus maculatus (Hallowell, 1854), in Ndumo Game Reserve and Kwa Nyamazane Conservancy, KwaZulu-Natal, South Africa. Smears were Giemsa-stained, screened for haemogregarines, parasite stages measured, compared to each other and to other described African bufonid haemogregarines. Parasite 18S rDNA was amplified using two apicomplexan-specific primer sets, HepF300/HepR900 and 4558/2733. Resulting sequences of the haemogregarine isolates from the three Amietophrynus species were compared with each other and to comparative haemogregarine sequences selected from GenBank.

Results

Morphological characteristics of parasite stages, in particular characteristically capped mature gamont stages, and molecular findings, supported all three haemogregarine isolates from all three Amietophrynus species to be the same, a species of Hepatozoon, and furthermore different morphologically from other previously recorded bufonid Hepatozoon species. The haemogregarine fell within a clade comprising other anuran Hepatozoon species and furthermore, within a monophyletic sub-clade along with H. theileri and are described as Hepatozoon ixoxo sp. nov.

Conclusions

This is the first morphological and molecular account of Hepatozoon species within the family Bufonidae from South Africa, a study hoped to encourage the redescription and molecular analysis of those Hepatozoon species described in the past from Amietophrynus species, as well as to promote the use of both morphological and molecular characteristics in Hepatozoon species descriptions. This will aid in comprehensive Hepatozoon descriptions, which along with the use of phylogenetic analysis will give a better indication of these parasites possible vectors and life cycle dynamics.

Redescription and molecular diagnosis of Hepatozoon theileri (Laveran, 1905) (Apicomplexa: Adeleorina: Hepatozoidae), infecting Amietia quecketti (Anura: Pyxicephalidae)

Blood smears prepared from the peripheral blood of 20 wild caught Amietia quecketti (Boulenger) from the North-West University Botanical Gardens, North West Province, South Africa, were examined for the presence of haemogregarines. A haemogregarine species comparative in morphology, host and geographical locality to that of Haemogregarina theileri Laveran, 1905 was detected. The original description of H. theileri was based solely on frog peripheral blood gamont stages. Later, further parasite stages, including trophozoites and merogonic liver stages, were recorded in a related Amietia sp. from equatorial Africa. This species was originally classified as a member of the genus Haemogregarina Danilewsky, 1885, but due to the close life cycle and morphological resemblance to those of Hepatozoon species, H. theileri was later transferred from Haemogregarina to Hepatozoon Miller, 1908. In the present study, meront and merozoite stages not described before, along with previously observed trophozoite, immature and mature gamont stages, are described from the peripheral blood of hosts. In addition, comparative phylogenetic analysis of the partial 18S rDNA sequence of Hepatozoon theileri to those of other haemogregarine species, including those of species of Hepatozoon and a Haemogregarina, support the taxonomic transfer of H. theileri to Hepatozoon, nesting H. theileri within a clade comprising species parasitising other amphibians. This is the first molecular and phylogenetic analysis of an African anuran species of Hepatozoon.

Reassignment of the land tortoise haemogregarine Haemogregarina fitzsimonsi Dias 1953 (Adeleorina: Haemogregarinidae) to the genus Hepatozoon Miller 1908 (Adeleorina: Hepatozoidae) based on parasite morphology, life cycle and phylogenetic analysis of 18S rDNA sequence fragments

SUMMARY Research was undertaken to clarify the true taxonomic position of the terrestrial tortoise apicomplexan, Haemogregarina fitzsimonsi (Dias, 1953). Thin blood films were screened from 275 wild and captive South African tortoises of 6 genera and 10 species between 2009-2011. Apicomplexan parasites within films were identified, with a focus on H. fitzsimonsi. Ticks from wild tortoises, especially Amblyomma sylvaticum and Amblyomma marmoreum were also screened, and sporogonic stages were identified on dissection of adult ticks of both species taken from H. fitzsimonsi infected and apparently non-infected tortoises. Parasite DNA was extracted from fixed, Giemsa-stained tortoise blood films and from both fresh and fixed ticks, and PCR was undertaken with two primer sets, HEMO1/HEMO2, and HepF300/HepR900, to amplify parasite 18S rDNA. Results indicated that apicomplexan DNA extracted from tortoise blood films and both species of tick had been amplified by one or both primer sets. Haemogregarina  fitzsimonsi 18S rDNA sequences from tortoise blood aligned with those of species of Hepatozoon, rather than those of species of Haemogregarina or Hemolivia. It is recommended therefore that this haemogregarine be re-assigned to the genus Hepatozoon, making Hepatozoon fitzsimonsi (Dias, 1953) the only Hepatozoon known currently from any terrestrial chelonian. Ticks are its likely vectors.

Hemoproteids (Apicomplexa: Haemoproteidae) from South African tortoises (Cryptodira: Testudinidae)

Terrestrial tortoises, Chersina angulata (Schweigger, 1812), Kinixys belliana belliana Gray, 1831, K. lobatsiana Power, 1927, K. natalensis Hewitt, 1935, and Stigmochelys pardalis (Bell, 1828), both wild (n  =  84) and captive (n  =  70), were examined for hematozoans from the provinces of Gauteng, Kwazulu-Natal, North West, and Western Cape, South Africa. In Giemsa-stained blood films, 2 species of hemoproteids were identified, 1 previously described, that is, Haemoproteus testudinalis ( Laveran, 1905 ) Wenyon, 1915, the other unknown. Haemoproteus testudinalis occurred in 2/27 wild K. lobatsiana and 1/41 S. pardalis and 2/2 captive K. lobatsiana from the North West and Gauteng, respectively, whereas Haemoproteus sp. A was recorded in 1 of 3 captive K. natalensis from Kwazulu-Natal. Haemoproteus testudinalis had pale blue-stained, often vacuolated, halteridial macrogametocytes, pale pink-stained microhalterdial to halteridial microgametocytes, and dark, scattered, often bacillus-like hemozoin granules. Haemoproteus natalensis n. sp. had ameboid growth stages, blue-stained halteridial to circumnuclear macrogametocytes, purple-stained circumnuclear microgametocytes, and brownish, often clustered, pigment granules. It is recommended that Haemoproteus balazuci Dias, 1953, become a junior synonym of H. testudinalis.

Long-term Adjustment After Surviving Open Heart Surgery: The Effect of Using Prayer for Coping Replicated in a Prospective Design

PURPOSE

despite the growing evidence for effects of religious factors on cardiac health in general populations, findings are not always consistent in sicker and older populations. We previously demonstrated that short-term negative outcomes (depression and anxiety) among older adults following open heart surgery are partially alleviated when patients employ prayer as part of their coping strategy. The present study examines multifaceted effects of religious factors on long-term postoperative adjustment, extending our previous findings concerning prayer and coping with cardiac disease.

DESIGN AND METHODS

analyses capitalized on a preoperative survey and medical variables from the Society of Thoracic Surgeons' National Database of patients undergoing open heart surgery. The current participants completed a mailed survey 30 months after surgery. Two hierarchical regressions were performed to evaluate the extent to which religious factors predicted depression and anxiety, after controlling for key demographics, medical indices, and mental health.

RESULTS

predicting lower levels of depression at the follow-up were preoperative use of prayer for coping, optimism, and hope. Predicting lower levels of anxiety at the follow-up were subjective religiousness, marital status, and hope. Predicting poorer adjustment were reverence in religious contexts, preoperative mental health symptoms, and medical comorbidity. Including optimism and hope in the model did not eliminate effects of religious factors. Several other religious factors had no long-term influences. MPLICATIONS: the influence of religious factors on the long-term postoperative adjustment is independent and complex, with mediating factors yet to be determined. Future research should investigate mechanisms underlying religion-health relations.

A redescription of Haemogregarina fitzsimonsi Dias, 1953 and some comments on Haemogregarina parvula Dias, 1953 (Adeleorina: Haemogregarinidae) from southern African tortoises (Cryptodira: Testudinidae), with new host data and distribution records

Blood films were examined from 154 wild and captive tortoises from four provinces of South Africa, including Gauteng, Kwazulu-Natal, North West and Western Cape. The five species ofchelonians studied were Chersina angulata (Schweigger), Kinixys belliana belliana (Gray), K. lobatsiana Power, K. natalensis Hewitt, and Stigmochelys pardalis (Bell). Two species of haemogregarines, previously reported from Mozambique, were identified in blood films, namely Haemogregarina fitzsimonsi Dias, 1953 and Haemogregarina parvula Dias, 1953. Additional stages of development (trophozoites and probable meronts, merozoites and immature gamonts) in blood preparations from South Africa warranted the redescription of H. fitzsimonsi. A variety of hosts and broad host distribution range were observed for this haemogregarine, with all five species of tortoises parasitized, wild and captive, from all four provinces, in all seasons. In contrast, only two individuals of K. b. belliana and one S. pardalis, all three captive in Kwazulu-Natal, contained H. parvula with encapsulated stages resembling those of Hemolivia mauritanica (Sergent et Sergent, 1904). For H. fitzsimonsi, parasite prevalences, but not parasitaemias, were significantly higher in captive than wild S. pardalis; captive female S. pardalis also showed a significantly greater prevalence of infection than males, but younger, lighter hosts were not significantly more heavily parasitized than older, heavier individuals. The ticks, Amblyomma marmoreum Koch, 1844 and A. sylvaticum (De Geer, 1778), found attached to some tortoises, may prove to be definitive hosts for the two species of haemogregarines observed.

Aging of the optics of the human eye: lens refraction models and principal plane locations

Biometric data describing the geometry and spacings of emmetropic human eyes were combined with lens shape and placement within the globe to generate paraxial models of image formation as a function of age. Three different representations of the shape of the internal refractive index gradient of the lens were evaluated--a Gullstrand-type model consisting of cortical and nuclear regions with different refractive indices, a power series model, and a linear-gradient model. All three refractive models satisfy the requirements for focus for all the data sets, indicating that lenticular refractive index gradient shape is essentially underdetermined in the paraxial limit. Lens refractive power decreases by almost 2 D during a 50-year period, and the concomitant decrease in system refractive power is due almost entirely to this effect. The reduction in spacing between the lens principal planes is a function of this, as is their anterior movement with age, and suggests that the compensatory processes maintaining far focus at the expense of near are not exactly balanced. Despite these changes in the lens contribution and their effect on the location of the system principal planes, which also move anteriorly, the spacing between the system principal planes remains constant. However, the trend toward reduced overall system power with age indicates the primary role of the lens in mediating image formation onto the retina over time.

Aging of the human lens: changes in lens shape at zero-diopter accommodation

Scheimpflug photographs of the zero-diopter-accommodated anterior segments of 100 human subjects, aged 18 to 70 yr and evenly spaced over this range, were digitized and analyzed to characterize lens and lens nucleus shape as a function of age by the Hough transform and other image analysis methods. Anterior and posterior lens surface curves exhibit a decrease in radius of curvature with increasing age, in qualitative but not quantitative agreement with the earlier observations of Brown [Exp. Eye Res. 19, 175 (1974)]. In contrast, the shape of the lens nuclear boundaries changes little with age. Overall lens volume at zero diopters increases with age, but the volume of the lens nucleus remains unchanged. The lens center of mass moves anteriorly with increasing age, as does the central clear region of the lens. Although these data sets were found to be more variable than those of Brown, the complementary variability of other factors, such as anterior chamber depth, for each subject leads to a very high statistical correlation between lens shape and lens location relative to the cornea. This supports the finding of previous work that image formation on the retina for a given individual results from the multifactorial balancing of related factors.

Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood

OBJECTIVE

To explore several key aspects of the diagnosis and assessment for posttraumatic stress disorder (PTSD) in infants and young children.

METHOD

Fifteen traumatized, clinic-referred children, and a comparison sample of 12 at-risk children, all younger than 48 months of age, were assessed with a standardized procedure and a semistructured diagnostic interview. The assessments were videotaped and reviewed by two blind raters for scoring DSM-IV PTSD criteria and an alternative set of PTSD criteria for young children. Raters were debriefed and consensus ratings were used to make best-estimate diagnoses.

RESULTS

The investigation of procedural validity showed that 12% of the diagnostic criteria present in these children could be detected by a clinician through direct observation or interaction with the children. The remainder of criteria were apparent only through caregiver report. Problematic aspects of parental reporting were most evident for the avoidance/numbing of responsiveness criteria. The traumatized subjects showed significantly more alternative criteria of PTSD than DSM-IV criteria of PTSD. The main sources of rater disagreement are described.

CONCLUSIONS

Additional sources of information would complement the multidimensional assessment of PTSD in young children. The set of alternative criteria appears to show greater criterion validity than the DSM-IV criteria.

Complementary alternative medicine in health and mental health: implications for social work practice

This article describes the increasing use of complementary alternative medicine (CAM) in this country and its implications for social work practice, education, research and policy in the health care field. Descriptive examples of CAM treatment modalities are provided along with their underlying rationale, common uses and available empirical support. It is concluded that patients will be better served by social workers who have knowledge of CAM treatment modalities. Furthermore, the need for further research on the efficacy of many CAM treatments and the certification of CAM treatment providers is discussed.

Caring for yourself during times of organizational change

Mergers, acquisitions, and other organizational changes in the health care system pose many challenges and stresses for nursing leaders. Although considerable effort is expended helping staff adjust to change, nurse managers and executives often neglect their own vulnerability to occupational stress. The personal and organizational costs of managerial burnout are high, sometimes resulting in physical illness, mental exhaustion, and decreased productivity. This article emphasizes the importance of prevention through the recognition of potential or actual signs of organizational stress. Handy tips are provided on effective ways to cope with the stress of organizational change.

Utilization of outpatient mental health services after inpatient alcoholism treatment

It is generally agreed that use of aftercare services following discharge from alcoholism treatment is optimum for patients to achieve long-term recovery. However, the quantity and duration of utilization of such services in non-experimental settings are generally unknown. Using secondary data sources, we studied 5,635 alcoholics completing formal extended inpatient treatment and 1,860 alcoholics discharged from brief inpatient hospitalizations in Department of Veterans Affairs medical centers. Weekly use of outpatient mental health services (OPMH) prior to hospital admission was equally low for both patient groups (approximately 2-3% of patients) until four weeks prior to admission, at which time OPMH use increased, particularly for the extended treatment group. In the four weeks after discharge, use of OPMH services was substantially higher for patients with extended treatment compared to those with brief hospitalizations (40% vs. 18%), with 22% of patients completing treatment utilizing such services in the first week after discharge. Utilization steadily decreased until only 8% and 4% of both groups, respectively, were using OPMH services at the end of six months after discharge. Study results suggest the need to examine barriers to outpatient mental health utilization after discharge as well as interventions to increase compliance with long-term aftercare.

Alcoholism treatment, severity of alcohol-related medical complications, and health services utilization

In efforts to contain costs and efficiently allocate resources, evaluation studies in alcoholism have increasingly assessed the effect of treatment on the use of health services through comparisons of treated and untreated alcoholics. The success of this approach requires that evaluators identify and adjust for differences between these two groups, thereby decreasing the likelihood that health utilization outcomes are attributed to the effects of treatment when in fact they may be related more to unidentified group differences. Using a sample of 63,873 hospitalized alcoholics, this study focused on one critical group difference, the severity of alcohol-related medical complications. Comparisons between treated alcoholics who either completed alcoholism treatment or detoxification only and untreated alcoholics with either primary medical/surgical or psychiatric diagnoses demonstrated the following: (a) untreated alcoholics with medical/surgical diagnoses were more likely to have severe alcohol-related medical complications than the other groups; (b) a positive linear relationship between health services utilization in the previous year and the severity of medical complications existed for all groups, except untreated alcoholics with psychiatric diagnoses; and (c) untreated alcoholics with psychiatric diagnoses with the most severe complications used fewer health services than any of the other three groups. Differences between treated and untreated alcoholics in both severity of medical complications and previous health utilization patterns demonstrate the need to identify and adjust for these factors in evaluation studies that examine the outcomes of alcoholism treatment.

Access barriers and the use of prenatal care by low-income, inner-city women

An important public health agenda in the United States is improving access to prenatal care, particularly for low-income women. The study discussed in this article was designed to determine which social, environmental, and psychological barriers are most likely to interfere with the early and regular use of prenatal health services. Low-income adult women hospitalized on the postpartum unit of a large urban medical center were interviewed about the barriers they experienced gaining access to prenatal care. Access barriers involving family and friends significantly increased the odds of receiving inadequate care, particularly not wanting anyone to know about the pregnancy and not having help getting to clinic appointments. Other important barriers included those related to the health care system and intrapersonal issues. Social workers are in an ideal position to help women eliminate barriers to access to prenatal care through clinical expertise in assessment, advocacy, outreach, and case management.

Functional impairment and co-occurring psychiatric disorders in medically hospitalized men

BACKGROUND

Although previous research has described a high prevalence of psychiatric comorbidity among general medical and surgical patients, prevalence estimates based on diagnostic criteria and the assessment of health care outcomes including functional status has not been conducted for a broad range of psychiatric disorders.

METHODS

A random sample of male medical and surgical admissions to 3 Department of Veterans Affairs Medical Centers was enrolled in the study. Subjects were administered a computerized structured psychiatric diagnostic interview and completed a multidimensional measure of health-related functioning, the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Of 1007 medical and surgical inpatients, almost half (46.6%) met lifetime criteria for at least 1 Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition disorder, most commonly for alcohol abuse or dependence (32.5%), posttraumatic stress disorder (10.0%), and major depression or dysthymia (9.0%). Almost one fifth reported recent symptoms, most frequently for major depression or dysthymia (7.0%). Co-occurring psychiatric disorders were associated with substantial and significant (P<.001) impairment on all dimensions of functioning, with the greatest decrements observed in physical and emotional role functioning. Anxiety and mood disorders were associated with the most and somewhat similar reductions in functioning.

CONCLUSIONS

The prevalence of co-occurring psychiatric disorders was substantial but consistent with other studies of populations receiving health services. Given the observed additional burden of psychiatric disorders on functioning in medically hospitalized patients, the study indicates the importance of identification and treatment of co-occurring psychiatric disorders in this high-risk and clinically challenging group of patients.

Methods to obtain quantitative parametric descriptions of the optical surfaces of the human crystalline lens from Scheimpflug slit-lamp images. I. Image processing methods

Of the methods developed (e.g., phakometry, magnetic resonance imaging, etc.) for noninvasive measurement of the geometry of the anterior segment of the human eye, Scheimpflug photography offers the best resolution and the highest precision. The primary obstacle encountered with this or any other image-based method has been in obtaining quantitative measurements directly from the images. Image enhancement (gray-scale gradient analysis) and pattern recognition methods (Hough transform and recursive least-squares algorithms) are developed so that parametric representations of lens surfaces and zone boundaries can be obtained directly from the images. Methods to correct for nonlinear Scheimpflug camera reproduction ratios and provide error estimates for geometrical parameters are also developed and will be presented separately. Combined, these techniques yield representations of lens geometry having sufficient precision, to which paraxial ray tracing can be applied to determine lens optical properties by using well-posed optical models with one unknown.

Postpartum teaching priorities: the viewpoints of nurses and mothers

OBJECTIVE

To compare mothers' and nurses' perceptions of postpartum learning needs and effective teaching modalities.

DESIGN

Cross-sectional research design. Mothers were given a questionnaire during their postpartum stay to rate how important it was for them to learn about 44 maternal-infant topics before discharge. Nurses rated similar items on the basis of their perception of what is most important for mothers to learn during their postpartum stay.

SETTING

Postpartum units in six hospitals that are part of a large midwestern health care system.

PARTICIPANTS

English-speaking women who delivered either vaginally or by cesarean section without complications and the nurses on their postpartum units.

MAIN OUTCOME MEASURES

Identification of preferred topics and methods for postpartum teaching.

RESULTS

Mothers and nurses agreed that topics related to immediate physical health needs were most important. Unmarried mothers considered topics related to personal care and mobility as particularly important. First-time mothers rated more topics as important than did experienced mothers. Individual teaching was rated most effective by both groups. Classroom teaching and the use of audiovisual media were considered less effective.

CONCLUSIONS

This study supports postpartum education that focuses on the physical needs of mothers and infants, as well as individual teaching models. The special learning needs of new mothers, including those who are not married, must be considered.

Relationship between inpatient alcoholism treatment and longitudinal changes in health care utilization

OBJECTIVE

The purpose of the study was to evaluate changes in health care utilization associated with inpatient alcoholism treatment in alcoholics of low socioeconomic status with different histories of treatment relapse.

METHOD

The sample consisted of more than 85,000 male alcoholics using inpatient care in Department of Veterans Affairs medical centers in fiscal year 1987. Five treatment groups were identified to represent a continuum of length and intensity of alcoholism treatment, including formal inpatient alcoholism treatment, short detoxification and hospitalizations for primary diagnoses other than alcoholism. All inpatient and outpatient health services for 3 years before and 3 years after the index hospitalization were examined for differential changes in utilization associated with the five treatment groups after controlling for patient predisposing, enabling and need characteristics.

RESULTS

Both total inpatient days and outpatient visits increased significantly for all treatment groups, with the greatest increases occurring in the group completing inpatient alcoholism treatment (both p < .0001). However, use of inpatient medical care decreased and substance abuse inpatient care increased significantly for most groups, with the largest increases in substance abuse care found for the completed treatment group.

CONCLUSIONS

In a hospital system that does not deny care on the basis of ability to pay, certain groups of chronic alcoholics who cannot sustain prolonged remission will continue to be heavy utilizers of services. Alcoholism treatment may be associated with higher short-term costs but it remains to be seen whether provision of more focused treatment services is able to achieve longer term better outcomes and, ultimately, lower costs.

Accommodation and presbyopia in the human eye. Changes in the anterior segment and crystalline lens with focus

PURPOSE

To characterize changes in the sagittal dimensions of the human crystalline lens and anterior segment as a function of accommodation, to determine the potential age dependence of these changes, and to evaluate these changes in relation to the development of presbyopia.

METHODS

Scheimpflug slit-lamp photography, as well as a variety of standard ophthalmologic methods, was used to collect information about lens and anterior segment sagital dimensions in a population of 82 adults with refractive error < or = magnitude of 2.0 diopters and at least 0.25 diopter of accommodation for subjects 18 to 70 years of age. Data were analyzed statistically for dependence on accommodation, age, and age dependence of accommodative rate.

RESULTS

The rate of change per diopter of accommodation for each measured variable within the lens is independent of age for the entire adult age range. With increasing accommodation, the lens becomes thicker and the anterior chamber shallower along the polar axis. This increase in sagittal lens thickness is entirely because of an increase in the thickness of the lens nucleus. Because the anterior and posterior halves of the nucleus increase in thickness at approximately the same rate with accommodation, the increase in lens thickness results from equal changes in the lengths of the anterior and posterior portions.

CONCLUSIONS

Because changes along the sagittal axis of the anterior segment with accommodation are independent of age, any explanation of presbyopia that relies on simple changes in the rates of lens thickening and anterior chamber shallowing with age does not hold. In light of other age-related changes in the anterior segment and lens (e.g., increased sharpness of lens curvature, increased lens sagittal thickness, decreased anterior chamber depth), it appears that compensatory mechanisms to preserve far vision with age also preserve the rate of change per diopter of sagittal spacings.

Hydrosalpinx fluid has embryotoxic effects on murine embryogenesis: a case for prophylactic salpingectomy

OBJECTIVE

To ascertain if hydrosalpinges are associated with reduced pregnancy rates and increased pregnancy loss after IVF-ET. Increased volume and leakage of hydrosalpinx fluid may exert negative effects on follicular development and embryo quality and/or render the uterine environment hostile to embryogenesis. We undertook this study to examine the effect of hydrosalpinx fluid on murine embryogenesis in vitro.

DESIGN

Descriptive study.

SETTING

Tertiary care facility.

PATIENT(S)

Premenopausal females undergoing salpingectomy or salpingostomy for hydrosalpinges.

INTERVENTION(S)

Collection of discarded hydrosalpinx fluid and development of a dose response curve for the effect of hydrosalpinx fluid on murine embryogenesis.

MAIN OUTCOME MEASURE(S)

Development of single cell mouse embryos in vitro.

RESULT(S)

All samples of tubal fluid obtained from hydrosalpinges demonstrated a significant embryo toxic effect at either the 100% or 10% concentration. Hydrosalpinx fluid demonstrated pH values (8.45 to 8.65) significantly higher than the physiologic range. Correction of pH to that of media did not affect cavitation rate.

CONCLUSION(S)

There is a well-defined and significant toxic effect of hydrosalpinx fluid. Procedures such as salpingectomy or proximal tubal occlusion to circumvent the passage of hydrosalpinx fluid into the uterine cavity may have beneficial effects on the developmental environment for embryos in vivo.

Screening for social and environmental problems in a VA primary care setting

Social workers are in an ideal position to identify and treat social and environmental problems early in the continuum of care. Information on these problems will facilitate informed decision making on the development and reallocation of resources to better meet patients needs. This study assessed the social and environmental problems of 132 patients seen in a primary care clinic at a university-affiliated Veterans Affairs (VA) medical center. The most prevalent social problems were financial difficulties, personal stress, family problems, legal concerns, and employment concerns. When asked, nearly one-third of all respondents requested social work services or information about services related to their problems. The findings suggest a clear need for social work interventions in VA primary care clinics that focus on both psychosocial problems.

Collaborative QI in community-based long term care

BACKGROUND

In a statewide demonstration project funded by The Robert Wood Johnson Foundation, the state of Indiana, vendors, clients and Indiana University researchers began working together in 1992 to use quality improvement (QI) techniques to improve the delivery of community-based long term care services. QI STRATEGIES: These collaborators, working with state Area Agencies on Aging (AAAs) case managers, are implementing two strategies--Normative Treatment Planning (NTP), which standardizes the clinical assessment of client needs and the prescription of services by case managers, and the Client Feedback System (CFS), a systematic method for obtaining feedback from long term care clients on the quality of in-home services.

CURRENT STATUS

This community-based long term care project has been implemented in AAAs throughout the state of Indiana. In January 1995 the state's 16 AAAs were randomly assigned to four experimental or control groups to assess the project's effectiveness. In the interim, clients are surveyed by telephone every six months to evaluate their satisfaction with services and clinical needs.

LESSONS LEARNED

The experience suggests several lessons: (1) build on existing and successful activities; (2) involve a wide range of participants, not just innovators; (3) obtain buy-in from trade and professional associations that represent program participants; (4) turn national attention given to the program into an asset; (5) conduct separate data collection to evaluate an intervention's success; (6) visit the field often; (7) pay as much attention to program implementation as to development; and (8) provide ongoing, informal educational opportunities for the field.

SUMMARY AND CONCLUSIONS

This project has resulted in significant movement toward a shared quality improvement vocabulary, information system, and a shared vision of high-quality home care.

Attributions about spouse abuse in cases of bidirectional battering

A particularly misunderstood type of domestic violence is the type of incident where both partners are violent, for example, where one partner is violent and the other is violent in self-defense. The present study examined third-party attributions about such battering. Subjects read a fictitious newspaper report of a domestic battering incident and then filled out rating scales about the participants and the event. The scenario described either an "asymmetric battering" incident where one party instigated the violence and was much more violent than the other, or an incident which was more of a mutual fight (symmetric battering). Both scenarios ended with one person seriously injuring the other. Each scenario had two versions, in which either the husband or the wife instigated the violence. Results showed that the person who had instigated the violence was judged more harshly and was given more responsibility for their actions in both the symmetric and asymmetric battering conditions. The less violent partner in the asymmetric conditions was judged to have more right to use force. In the symmetric battering, both parties were assigned blame.

Aging of the human crystalline lens and anterior segment

Changes in the unaccommodated human crystalline lens were characterized as a function of subject age for 100 normal emmetropes over the age range 18-70 yr by Scheimpflug slit-lamp photography. With increasing age, the lens becomes thicker sagittally, but since the distance from the cornea to the posterior lens surface remains unchanged, this indicates that the center of lens mass moves anteriorly and the anterior chamber becomes shallower. Sagittal nuclear thickness is independent of age, but both anterior and posterior cortical thicknesses increase with age, shifting the location of the nucleus and the central sulcus in the anterior direction. The amount of light scattered by the lens at high angles, as represented by normalized and integrated lens densities from the digitized images, increases with increasing age in an exponential fashion. Similar relationships to age are observed for the major anterior zone of discontinuity (maximum density) and the central sulcus (minimum density). The relationships of these results to accommodation and presbyopia are discussed.

The zones of discontinuity in the human lens: development and distribution with age

Statistical analysis of Scheimpflug images from the crystalline lenses of 100 emmetropic human subjects ranging in age from 18 to 70 yr confirms that specific zones of discontinuity are a function of lens development and growth. At and beyond the age of 40 yr, as many as four sharply demarcated and complementary zones are seen within the anterior and posterior lens cortex. The locations of the inner edges of the anterior cortical zones of discontinuity were characterized relative to the central sulcus of the lens. Consecutively from the central sulcus, the distances were 1.094, 1.415, 1.695, and 1.994 (+/- 0.11 mm). Since nuclear thickness in the adult lens is age-independent and the rate of cortical growth has been characterized, the location of the inner margins of the zones are indicative of the age at which they originated; these ages were 4 (+/- 1 yr), 9 (+/- 2 yr), 19 (+/- 4yr), and 46 (+/- 10 yr). All of the zones become broader along the outer margin and more dense upon aging, with specific zones appearing to merge in older presbyopic lenses. While lens fetal nuclear transparency decreases with age, it does not feature zones of discontinuity; instead, symmetrically amorphous regions appear centrally in the anterior and posterior nucleus. This demonstration of the onset of specific zones of discontinuity in emmetropic individuals, at defined periods of lens growth that are synchronous the production of successively more complex lens sutures, strongly suggests a causal relationship between lens sutures and the zones of discontinuity.

Risk factors for AMA discharge from VA inpatient alcoholism treatment programs

This study was designed to identify those risk factors associated with discharge from inpatient alcoholism treatment against medical advice (AMA) and the underlying reasons for these discharges. Data on the characteristics of patients and their index hospitalization were obtained from the systematic review of medical records for 186 alcoholics who were discharged AMA and 201 alcoholics who completed treatment. Comorbid medical diagnosis reduced the risk of AMA discharge by one quarter, whereas court referral to treatment reduced the risk by one half. A college education, vocational or other training, being employed, and having a history of previous AMA discharges significantly increased the risk. The most common reasons for AMA discharge, as perceived by treatment providers, were psychosocial problems, difficulties in the treatment program, and lack of interest in treatment. The clinical implications of these findings for the inpatient treatment of alcoholics are discussed.

The relationship between mortality and intensity of inpatient alcoholism treatment

OBJECTIVES

Previous studies have examined mortality in alcoholics receiving extended inpatient alcoholism treatment, but few have investigated less intense treatment. This study examined mortality within 3 years after discharge from varying intensities of inpatient alcoholism treatment.

METHODS

Using the computerized database of the Department of Veterans Affairs, we identified men participating in varying intensities of inpatient alcoholism treatment and followed them for 3 years after discharge. Adjusted mortality rates were computed and survival analysis was performed to assess the risk of death, adjusting for factors that may be related to mortality.

RESULTS

The death rate was lower for men who completed extended formal inpatient treatment than for those who began, but did not complete, inpatient treatment or those who underwent short detoxification. Differences among the treatment groups remained after age, race, marital status, and disease severity were controlled.

CONCLUSIONS

These results suggest that extended formal inpatient alcoholism treatment is associated with a lower risk of death than less intense forms of inpatient treatment.

Comparison of the efficacy and metabolic effects of nicardipine and hydrochlorothiazide in hypertensive black men and women

A double-blind, randomised, parallel study compared the BP and metabolic responses in black hypertensive patients following monotherapy with nicardipine or hydrochlorothiazide (HCTZ). Following a single-blind placebo wash-out period of 1-4 weeks, the study drug, nicardipine 20-40 mg three times daily or HCTZ 25-100 mg four times daily, was administered in a double-blind fashion for 12 weeks. Doses were titrated to control sitting DBP (< or = 90 mmHg). Both drugs were effective in reducing sitting SBP and DBP as compared with baseline values (nicardipine: 152.5 +/- 1.6/102.0 +/- 0.6, HCTZ: 152.5 +/- 1.5/101.4 +/- 0.5 mmHg). DBP responses (reduction from baseline; nicardipine: -10.9, HCTZ: -12.7 mmHg), and the percentage of patients achieving a response < or = 90 mmHg (nicardipine: 54%, HCTZ: 63%) to the two drugs were similar. Although SBPs at baseline and endpoint (137.3 +/- 1.6 on nicardipine and 132.1 +/- 1.4 mmHg on HCTZ), and the percentage of patients achieving a response < or = 140 mmHg (nicardipine: 70%, HCTZ: 79%), were comparable between the two treatments, the SBP reduction with HCTZ was statistically greater (P = 0.026). A comparison of the metabolic responses in the two treatment groups showed significant differences. Nicardipine caused no significant changes in blood chemistry, whereas HCTZ caused statistically significant decreases (P < 0.001) in sodium and potassium and increases (P < or = 0.01) in glucose, BUN, creatinine, uric acid, cholesterol and LDL compared with baseline. In 12.7% of the patients in the HCTZ group, serum potassium dropped to levels < 3.5 meq/l, which occurred in only 1.4% of the patients who used nicardipine.(ABSTRACT TRUNCATED AT 250 WORDS)

Age and ethnicity among hospitalized alcoholics: a nationwide study

Little is known about the broad-scale demographic characteristics of low income or indigent alcoholics in public hospital systems. The purpose of the study was to examine issues relative to age, race/ethnicity, and marital status for a large group (n = 62,829) of alcoholic men receiving inpatient care in Department of Veterans Affairs (VA) medical centers nationally. Subjects were VA inpatients completing alcoholism treatment (n = 27,562), in brief alcohol detoxification or short intervention (n = 9,322), or hospitalized for primary diagnoses other than alcoholism but with a secondary diagnosis of alcohol dependence syndrome (n = 25,945). Minority alcoholics were significantly younger than Caucasian alcoholics. Hispanic and African-American men, as well as older alcoholics, were significantly less likely to complete treatment or attend detoxification and more likely to be hospitalized for other primary diagnoses. Native Americans, however, were most likely to complete alcoholism treatment. Results suggest that members of some minority groups and elderly alcoholics seek inpatient care for diagnoses other than alcoholism and that, as a result, such individuals may need targeted interventions to encourage them to seek alcohol-specific care.

Age-related psychiatric comorbidities and level of functioning in alcoholic veterans seeking outpatient treatment

The relationship of age and of level of adaptive functioning to comorbidity of mental disorders among alcoholics was studied in a survey of all alcoholics seeking outpatient mental health treatment in the Veterans Affairs mental health care system during a one-month period in 1986 (N = 22,463). More than half of the alcoholic outpatients had one or more comorbid psychiatric diagnoses. Rates for comorbid substance abuse disorders, posttraumatic stress disorder, schizophrenia, and personality disorders peaked in younger alcoholics and then decreased with age. Age-related increases were observed for major depression, anxiety disorders, and organic brain syndrome or dementia. DSM-III axis V ratings of poor to grossly impaired functioning were consistent across age groups. More than half of alcoholics with a comorbid psychiatric disorder were rated as severely impaired, compared with less than a third of those with no comorbid mental disorder.

Acquisition of the curves of the human crystalline lens from slit lamp images: an application of the Hough transform

To accurately model lens-based functions such as accommodation and image formation on the retina, it is essential to know anterior chamber depth, anterior segment length, lens thickness, and, most importantly, lens curvature both on the surfaces and internally. With the exception of lens curvatures, all these data can be obtained with a high degree of precision by one or more techniques (i.e., A-scan ultrasonography and pachymetry). Lens curvatures can be collected by Scheimpflug slit lamp photography, but the curvature data must be extracted from these images, a problem complicated by both linear and nonlinear image distortion. Previous approaches have involved significant magnification of the image combined with major subjective input and judgment. We present here a computer-based application of the Hough technique for measurement of curvature of lens surfaces observed in Scheimpflug slit lamp photography and related evaluation of (and solutions for) the associated image distortion. Minimal user input is required for successful application of this method, but the time required to obtain a fit for each surface is >1 min. Results obtained by this technique on test images compare favorably with those obtained by independent methods.

Ethical dilemmas in driver reeducation

This article illustrates ethical dilemmas faced by therapists who provide driver reeducation. The dilemmas discussed are (a) accepting a wide range of referral sources and client disabilities versus the inability to know enough to anticipate all driver performance errors, (b) the client's safety versus the client's right to independence, (c) financial constraints versus advantages of technology, and (d) the reporting of poor driving risk versus client confidentiality. A method for determining one's pattern of resolving ethical dilemmas is discussed.

In vitro studies on the mechanism of action of hepsulfam in chronic myelogenous leukemia patients

In the present study we have characterized the cytotoxicity and DNA damage induced by hepsulfam and busulfan in cells isolated from both chronic myelogenous leukemia (CML) patients and normal donors. hepsulfam inhibited colony-forming units-granulocyte, macrophage to a greater extent than busulfan in peripheral blood cells (PBCs) isolated from CML patients. Normal PBCs were equally sensitive to both agents and were more sensitive than the cells isolated from CML patients. Hepsulfam induced DNA interstrand cross-links in PBCs and bone marrow from both CML and normal volunteers, whereas busulfan produced few or no DNA interstrand cross-links. In addition, hepsulfam induced higher levels of DNA interstrand cross-linking than busulfam in three samples isolated from CML patients in blast crisis. Busulfan did however cause a small number of DNA strand breaks to be formed in human cells. Both agents produced similar levels of DNA-protein cross-links in PBCs from CML patients. These results suggest that the mechanism of DNA reactivity of hepsulfam and busulfan differ and that hepsulfam may prove useful in the treatment of CML.

In vivo suppression of erythropoiesis by tumor necrosis factor-alpha (TNF-alpha): reversal with exogenous erythropoietin (EPO)

Tumor necrosis factor-alpha (TNF-alpha) selectively kills tumor cells in vitro and in vivo and is being tested as a cancer therapeutic agent. We have shown that TNF-alpha significantly suppresses late-stage erythropoiesis, leading to anemia in chronically treated mice. These erythropoietic effects could limit the clinical use of TNF-alpha. Therefore, we have examined whether erythropoietin (EPO) could be used to prevent TNF-alpha-induced erythroid suppression. Normal mice were treated with a single dose of recombinant murine TNF-alpha (10(5) U/mouse, i.p.) with and without various concentrations of recombinant human EPO. After 3 days, effects on late-stage erythropoiesis were measured by determining the number of mature erythroid colony-forming cells (CFU-E) in the spleen and bone marrow. Simultaneous treatment with EPO abrogated the suppressive effect of TNF-alpha in a dose-dependent manner. EPO treatment also prevented the decrease in peripheral blood-hematocrit that was observed with chronic (5 x 10(4) U/mouse/day for 5 days) administration of TNF-alpha. TNF-alpha-induced hemorrhagic necrosis of tumors and stimulation of macrophage (CFU-M) progenitors were unaffected by EPO treatment. These results demonstrate that simultaneous injection of EPO can abrogate the TNF-alpha-induced suppressive effects on erythropoiesis.