Precision Determination of the Neutral Weak Form Factor of ^{48}Ca

We report a precise measurement of the parity-violating (PV) asymmetry A_{PV} in the elastic scattering of longitudinally polarized electrons from ^{48}Ca. We measure A_{PV}=2668±106(stat)±40(syst) parts per billion, leading to an extraction of the neutral weak form factor F_{W}(q=0.8733  fm^{-1})=0.1304±0.0052(stat)±0.0020(syst) and the charge minus the weak form factor F_{ch}-F_{W}=0.0277±0.0055. The resulting neutron skin thickness R_{n}-R_{p}=0.121±0.026(exp)±0.024(model)  fm is relatively thin yet consistent with many model calculations. The combined CREX and PREX results will have implications for future energy density functional calculations and on the density dependence of the symmetry energy of nuclear matter.

Current practices in lipid emulsion utilization in the prevention and treatment of intestinal failure-associated liver disease: a survey of pediatric intestinal rehabilitation and transplant centers

BACKGROUND

Newer intravenous lipid emulsions (ILEs), such as fish oil-based intravenous lipid emulsions (FO-ILEs) and soybean oil, medium-chain triglycerides, olive oil, and fish oil-based intravenous lipid emulsions (SMOF-ILEs), provide alternatives to soybean oil-based intravenous lipid emulsions (SO-ILEs). We explored current ILE use practice patterns among intestinal rehabilitation and transplant centers.

METHODS

A survey was developed addressing ILE availability, ILE preference in clinical scenarios, and factors influencing ILE choice. This survey was reviewed locally and by the NASPGHAN Intestinal Rehabilitation Special Interest Group, the IRTA scientific committee, and the ASPEN pediatric intestinal failure section research committee. We recruited providers nationally and internationally from centers with and without intestinal transplant programs.

RESULTS

Of 34 complete responses included, 29 respondents were from the US. Center volume varied with 5 centers following <10 patients and 12 centers following >50. Sixteen centers performed intestinal transplants. All centers had access to SMOF-ILEs, 85% had access to FO-ILEs, and 91% had access to SO-ILEs. In new patients, 85% use SMOF-ILEs as the first choice ILE. In those with new intestinal failure-associated liver disease (IFALD), FO-ILE was preferred to SMOF-ILE (56% vs 38%). In those developing IFALD on SMOF-ILE, 65% switch to FO-ILE while 24% remain on SMOF-ILE. Half of respondents reported liver histology to be "Useful but not available" routinely.

CONCLUSIONS

Centers have routine access to alternative ILEs, and these are quickly replacing SO-ILEs in all circumstances. Future work should focus on how this shift in practice affects outcomes to provide decision support in specific clinical scenarios. This article is protected by copyright. All rights reserved.

New Measurements of the Beam-Normal Single Spin Asymmetry in Elastic Electron Scattering over a Range of Spin-0 Nuclei

We report precision determinations of the beam-normal single spin asymmetries (A_{n}) in the elastic scattering of 0.95 and 2.18 GeV electrons off ^{12}C, ^{40}Ca, ^{48}Ca, and ^{208}Pb at very forward angles where the most detailed theoretical calculations have been performed. The first measurements of A_{n} for ^{40}Ca and ^{48}Ca are found to be similar to that of ^{12}C, consistent with expectations and thus demonstrating the validity of theoretical calculations for nuclei with Z≤20. We also report A_{n} for ^{208}Pb at two new momentum transfers (Q^{2}) extending the previous measurement. Our new data confirm the surprising result previously reported, with all three data points showing significant disagreement with the results from the Z≤20 nuclei. These data confirm our basic understanding of the underlying dynamics that govern A_{n} for nuclei containing ≲50 nucleons, but point to the need for further investigation to understand the unusual A_{n} behavior discovered for scattering off ^{208}Pb.

Accurate Determination of the Neutron Skin Thickness of ^{208}Pb through Parity-Violation in Electron Scattering

We report a precision measurement of the parity-violating asymmetry A_{PV} in the elastic scattering of longitudinally polarized electrons from ^{208}Pb. We measure A_{PV}=550±16(stat)±8(syst) parts per billion, leading to an extraction of the neutral weak form factor F_{W}(Q^{2}=0.00616  GeV^{2})=0.368±0.013. Combined with our previous measurement, the extracted neutron skin thickness is R_{n}-R_{p}=0.283±0.071  fm. The result also yields the first significant direct measurement of the interior weak density of ^{208}Pb: ρ_{W}^{0}=-0.0796±0.0036(exp)±0.0013(theo)  fm^{-3} leading to the interior baryon density ρ_{b}^{0}=0.1480±0.0036(exp)±0.0013(theo)  fm^{-3}. The measurement accurately constrains the density dependence of the symmetry energy of nuclear matter near saturation density, with implications for the size and composition of neutron stars.

Megacystis Microcolon Intestinal Hypoperistalsis Syndrome: A Case Series With Long-term Follow-up and Prolonged Survival

OBJECTIVES

Describe clinical characteristics, management, and outcome in a cohort of megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) patients.

METHODS

We conducted a retrospective chart review of MMIHS patients followed at a large transplant and intestinal rehabilitation center over a period of 17 years.

RESULTS

We identified 25 patients with MMIHS (68% girls, 13 transplanted). One transplanted and 1 nontransplanted patient were lost to follow-up. We estimated 100, 100, and 86% for 5-, 10-, and 20-year survival, respectively, with only 1 death. Of the 22 patients alive at the time of study (11 transplanted, 11 nontransplanted), median age was 9.2 years (range 2.7-22.9 years). Longest posttransplant follow-up was 16 years. Seventeen patients had available prenatal imaging reports; all showed distended bladder. Eight had genetic testing (5, ACTG2; 2, MYH11; 1, MYL9). Almost all patients had normal growth with median weight z-score -0.77 (interquartile range -1.39 to 0.26), height z score -1.2 (-2.04 to -0.48) and body mass index z-score 0.23 (-0.37 to 0.93) with no statistical difference between transplanted and nontransplanted patients. All nontransplanted patients were on parenteral nutrition with minimal/no feeds, and all except 1 of the transplanted patients were on full enteral feeds. Recent average bilirubin, INR, albumin, and creatinine fell within the reference ranges.

CONCLUSIONS

This is the largest single-center case series with the longest duration of follow-up for MMIHS patients. In the current era of improved intestinal rehabilitation and transplantation, MMIHS patients have excellent outcomes in survival, growth, and liver function. This observation contradicts previous reports and should alter counselling and management decisions in these patients at diagnosis.

Deficient and Null Variants of SERPINA1 Are Proteotoxic in a Caenorhabditis elegans Model of α1-Antitrypsin Deficiency

α1-antitrypsin deficiency (ATD) predisposes patients to both loss-of-function (emphysema) and gain-of-function (liver cirrhosis) phenotypes depending on the type of mutation. Although the Z mutation (ATZ) is the most prevalent cause of ATD, >120 mutant alleles have been identified. In general, these mutations are classified as deficient (<20% normal plasma levels) or null (<1% normal levels) alleles. The deficient alleles, like ATZ, misfold in the ER where they accumulate as toxic monomers, oligomers and aggregates. Thus, deficient alleles may predispose to both gain- and loss-of-function phenotypes. Null variants, if translated, typically yield truncated proteins that are efficiently degraded after being transiently retained in the ER. Clinically, null alleles are only associated with the loss-of-function phenotype. We recently developed a C. elegans model of ATD in order to further elucidate the mechanisms of proteotoxicity (gain-of-function phenotype) induced by the aggregation-prone deficient allele, ATZ. The goal of this study was to use this C. elegans model to determine whether different types of deficient and null alleles, which differentially affect polymerization and secretion rates, correlated to any extent with proteotoxicity. Animals expressing the deficient alleles, Mmalton, Siiyama and S (ATS), showed overall toxicity comparable to that observed in patients. Interestingly, Siiyama expressing animals had smaller intracellular inclusions than ATZ yet appeared to have a greater negative effect on animal fitness. Surprisingly, the null mutants, although efficiently degraded, showed a relatively mild gain-of-function proteotoxic phenotype. However, since null variant proteins are degraded differently and do not appear to accumulate, their mechanism of proteotoxicity is likely to be different to that of polymerizing, deficient mutants. Taken together, these studies showed that C. elegans is an inexpensive tool to assess the proteotoxicity of different AT variants using a transgenic approach.

Acute DSS colitis alters EphB6 receptor expression in neurons of the spinal dorsal horn

The ephrin family of receptors (Eph) and their ephrin ligands are involved in pain associated hyperalgesia, but the underlying mechanisms involved have not been fully elucidated. The EphB6 receptor is a distinctive member of the EphB subclass in that its kinase domain contains several alterations in the conserved amino acids and thus lacks catalytic activity. We sought to identify a role for EphB6 in inflammatory pain, with the murine dextran sulfate sodium (DSS) colitis model of inflammatory bowel disease (IBD). Colitis, induced with the administration of 4% (wt./vol.) DSS in the drinking water, significantly decreased EphB6 protein expression levels in neurons of the lower thoracic superficial layers of spinal dorsal horns, the location of neurons that receive the majority of nociceptive information from the colon, via the primary afferents. A shift towards increased EphB/ephrinB forward signaling, mediated by EphB6 down-regulation in neurons of the dorsal horn, may play a role in inflammatory pain caused by IBD.

Automated high-content live animal drug screening using C. elegans expressing the aggregation prone serpin α1-antitrypsin Z

The development of preclinical models amenable to live animal bioactive compound screening is an attractive approach to discovering effective pharmacological therapies for disorders caused by misfolded and aggregation-prone proteins. In general, however, live animal drug screening is labor and resource intensive, and has been hampered by the lack of robust assay designs and high throughput work-flows. Based on their small size, tissue transparency and ease of cultivation, the use of C. elegans should obviate many of the technical impediments associated with live animal drug screening. Moreover, their genetic tractability and accomplished record for providing insights into the molecular and cellular basis of human disease, should make C. elegans an ideal model system for in vivo drug discovery campaigns. The goal of this study was to determine whether C. elegans could be adapted to high-throughput and high-content drug screening strategies analogous to those developed for cell-based systems. Using transgenic animals expressing fluorescently-tagged proteins, we first developed a high-quality, high-throughput work-flow utilizing an automated fluorescence microscopy platform with integrated image acquisition and data analysis modules to qualitatively assess different biological processes including, growth, tissue development, cell viability and autophagy. We next adapted this technology to conduct a small molecule screen and identified compounds that altered the intracellular accumulation of the human aggregation prone mutant that causes liver disease in α1-antitrypsin deficiency. This study provides powerful validation for advancement in preclinical drug discovery campaigns by screening live C. elegans modeling α1-antitrypsin deficiency and other complex disease phenotypes on high-content imaging platforms.

Trinitrobenzenesulphonic acid colitis alters Na 1.8 channel expression in mouse dorsal root ganglia neurons

Visceral inflammation evokes hyperexcitability in nociceptive dorsal root ganglia (DRG) neurons and these changes are associated with increased voltage-gated sodium channel (Na(v)) 1.8 current density, but the molecular determinants of these changes are unclear. This study used Western blotting to measure changes in Na(v) 1.7, 1.8 and 1.9 protein expression during trinitrobenzenesulphonic acid (TNBS) colitis and quantitative polymerase chain reaction (PCR) to examine corresponding changes in mRNA. Colonic neurons were labelled with the retrograde tracer Fast Blue injected into the wall of the distal colon and quantitative PCR performed on laser-captured labelled colonic neurons from ganglia at T9-13 or unlabelled DRG neurons from the upper spinal cord. Immunohistochemistry and western blots were performed on whole DRG from the same sites. Fast Blue-labelled neurons demonstrated Na(v) 1.7, 1.8 and 1.9 immunoreactivity. On day 7 of colitis, which correlated with electrophysiological studies, there was a threefold increase in Na(v) 1.8 protein in ganglia from T9 to 13, but Na(v) 1.7 and 1.9 levels were unchanged. There was no corresponding change in the Na(v) 1.8 alpha-subunit mRNA levels. However, on days 2 and 4, Na(v) 1.8 mRNA was decreased 10-fold. Na(v) 1.8 protein and mRNA levels were unchanged in neurons isolated from ganglia in the upper spinal cord, where colonic neurons are not found. These findings suggest that the TNBS evoked increase in Na(v) 1.8 currents is associated with increased numbers of channels. The absence of corresponding changes in transcript suggests a translational or post-translational mechanism, but the 10-fold recovery of transcript preceding this time point also demonstrates a complex transcriptional regulation.

Developmental changes in morphometry of the small intestine and jejunal sucrase activity during the first nine weeks of postnatal growth in pigs1

The objective of this study was to investigate the development of small intestinal size and digestive capacity of the jejunum in growing pigs. The weight, length, surface area, and mucosa weight of the small intestine were measured when pigs were 1, 3, 5, and 9 wk of age. Sucrase and alkaline phosphatase (ALP) activities of the jejunal brush-border membrane, prepared by differential centrifugation and Mg2+ precipitation, were determined at the respective postnatal stages. Body weights increased 7-fold from 2.7 kg at 1 wk to 23.32 kg at 9 wk postnatal. Body weight gains were greater (P < 0.05) from wk 3 to 5 than from wk 1 to 3. Weights of the small intestine and of the intestinal mucosa increased faster (P < 0.05) from 3 to 5 wk than from 1 to 3 wk; the slowest increase occurred from 5 to 9 wk. Weights of the duodenum, jejunum, and ileum, and mucosa from the respective sections increased (P < 0.05) as pigs grew from 3 to 9 wk. Mucosa weight relative to the weight of the section was greater (P < 0.05) for the duodenum and jejunum than for the ileum at 9 wk of age. Between the ages of 3 and 9 wk, the increase in mucosa weight was highest for the jejunum followed by the duodenum and the ileum. The increase was greatest for the duodenum followed by the jejunum and the ileum when mucosal weight was expressed per unit of appropriate intestinal section weight. There was a 55-fold increase in jejunal sucrase activity from 1 to 9 wk; the greatest rate of increase occurred between 5 and 9 wk. Total jejunal ALP activities in pigs at 9 wk was greater (P < 0.05) than at 5 wk, which in turn was greater than at 1 wk of age. In summary, increases in BW during the first 9 wk of postnatal growth in pigs are accompanied by significant developmental changes in digestive capacity including intestinal weights, length, and area as well as jejunal brush-border sucrase and ALP activities.

The relationship between attendance at religious services and cardiovascular inflammatory markers

OBJECTIVE

Previous studies have shown an association between attendance at religious services and health, particularly cardiovascular morbidity and mortality. Little research has focused on religious attendance and physiological markers of cardiovascular risk. The purpose of this study was to explore the relationship between religious attendance and inflammatory markers of cardiovascular risk.

METHOD

Nationally representative sample of non-institutionalized United States adults aged 40 and over derived from the National Health and Nutrition Examination Survey III 1988-1994 (n = 10,059). The main outcome measures were the inflammatory system markers C-reactive protein, fibrinogen, and white blood cell count.

RESULTS

40.8 percent of the population attended religious services 40 or more times in the previous year while 22.4 percent attended services less than 40 times and 36.8 percent attended no religious services at all. Non-attenders of religious services were more likely than attenders to have elevated white blood cell counts (p = .001), highly elevated C-reactive protein (p = .02), and elevated fibrinogen (p = .05). After adjusting for demographic variables, health status, and BMI, the association between religious attendance and cardiovascular markers remained. Once current smoking was added to the model the independent effect of religious attendance dropped below conventional confidence limits.

CONCLUSIONS

These findings suggest that people who have attended religious services in the previous year are less likely to have elevated levels of certain inflammatory markers, however, current smoking has significant shared variance with religious attendance.

COPD: management of acute exacerbations and chronic stable disease

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are treated with oxygen (in hypoxemic patients), inhaled beta2 agonists, inhaled anticholinergics, antibiotics and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators. Antibiotic therapy is directed at the most common pathogens, including Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Mild to moderate exacerbations of COPD are usually treated with older broad-spectrum antibiotics such as doxycycline, trimethoprim-sulfamethoxazole and amoxicillin-clavulanate potassium. Treatment with augmented penicillins, fluoroquinolones, third-generation cephalosporins or aminoglycosides may be considered in patients with more severe exacerbations. The management of chronic stable COPD always includes smoking cessation and oxygen therapy. Inhaled beta2 agonists, inhaled anticholinergics and systemic corticosteroids provide short-term benefits in patients with chronic stable disease. Inhaled corticosteroids decrease airway reactivity and reduce the use of health care services for management of respiratory symptoms. Preventing acute exacerbations helps to reduce long-term complications. Long-term oxygen therapy, regular monitoring of pulmonary function and referral for pulmonary rehabilitation are often indicated. Influenza and pneumococcal vaccines should be given. Patients who do not respond to standard therapies may benefit from surgery.

Gender differences in the EEG of abstinent cocaine abusers

Gender differences in the EEG were explored in cocaine-abusing individuals not seeking treatment. Twenty currently abstinent cocaine-abusing females aged 21-41 were studied. Their cocaine use history was matched to 20 currently abstinent cocaine-abusing males. Twelve female and 20 male non-drug-abusing individuals served as a control group. Resting eyes closed EEG was recorded from 8 leads. The males who used cocaine had elevated EEG beta (p<0.0125) and reduced alpha (p<0.0125) when compared to the cocaine-abusing females and control subjects. These findings suggest that the EEG of cocaine-abusing women may be more normal than that of cocaine-abusing men. Such gender-specific differences for cocaine-abusing populations may require gender-specific treatment to improve outcome.

Does hyperconcentration result in platelet activation? A flow-cytometric study of hyperconcentrated random donor platelets

BACKGROUND AND OBJECTIVES

Hyperconcentration of platelets may lead to platelet activation and loss of platelet function.

MATERIALS AND METHODS

Platelet activation following hyperconcentration was assessed using flow-cytometric detection of platelet P-selectin expression and platelet swirling.

RESULTS

Platelet hyperconcentration led to a minimal increase in P-selectin expression and no difference in platelet swirling.

CONCLUSION

Hyperconcentration was not associated with a clinically significant change in platelet activation and had no significant effect on platelet quality as detected by pH and platelet yield.

New classification and update on the quinolone antibiotics

The newer fluoroquinolones have broad-spectrum bactericidal activity, excellent oral bioavailability, good tissue penetration and favorable safety and tolerability profiles. A new four-generation classification of the quinolone drugs takes into account the expanded antimicrobial spectrum of the more recently introduced fluoroquinolones and their clinical indications. First-generation drugs (e.g., nalidixic acid) achieve minimal serum levels. Second-generation quinolones (e.g., ciprofloxacin) have increased gram-negative and systemic activity. Third-generation drugs (e.g., levofloxacin) have expanded activity against gram-positive bacteria and atypical pathogens. Fourth-generation quinolone drugs (currently only trovafloxacin) add significant activity against anaerobes. The quinolones can be differentiated within classes based on their pharmacokinetic properties. The new classification can help family physicians prescribe these drugs appropriately.

Ontogenetic development of intestinal digestive functions in White Pekin ducks

The ontogenetic development of intestinal digestive functions for avian species other than the domesticated chicken are not well documented. Therefore, this study was conducted to resolve the developmental patterns of some intestinal digestive functions in White Pekin ducks. The ducks were killed and their intestines harvested when they were 1, 3, 5 and 7 wk old. Several small intestinal tissue characteristics, sucrase and alkaline phosphatase (ALP) activities of homogenates from the small intestine mucosa were measured, and the small intestinal L-threonine uptake capacities were estimated with brush border membrane vesicles prepared from the corresponding age groups. Between 1 wk (0.37 +/- 0.04 kg) and 7 wk (3.79 +/- 0.06), posthatch ducks exhibited relative body growth rates of 352, 77 and 28% from 1 to 3, 3 to 5 and 5 to 7 wk, respectively. Allometric changes in small intestine weight indicated that the small intestine grew in direct proportion to the duck's metabolic body weight. Total homogenate sucrase activity per unit body weight did not differ (P > 0.05) among the age groups studied. Total homogenate ALP activity per body weight was lower at 3 wk than at 1 wk (P < 0.05) but did not differ (P > 0.05) among 3, 5 and 7 wk-old ducks. The development pattern of L-threonine uptake capacities normalized to body weights paralleled the course of relative body growth rates.

Utility of flow cytometry in subtyping composite and sequential lymphoma

Composite lymphoma (CL) is defined as more than one distinct lymphoma variant occurring in the same anatomic site, and sequential lymphoma (SL) is defined as different lymphoma variants occurring at different sites or at different times in the same patient. The utility of flow cytometry immunophenotyping in evaluating CL and SL has only been investigated in a few single-case studies. To further define the utility of flow cytometry in evaluating these tumors, records were searched at two institutions. Cases representing high-grade progression of low-grade lymphoma were excluded. For each CL/SL, clinical data was obtained and morphology was evaluated in routinely processed H&E-stained tissue sections. Tumor components were subtyped using revised European-American classification (REAL) criteria. Follicle center components were graded using modified Rappaport criteria. Immunophenotype was determined using two-color flow cytometry and paraffin-section immunostains. Four cases were identified. Case 1, nodal follicle center, follicular, grade III plus marginal zone CL, showed two discrete populations of monoclonal B-cells that differed in their expression of CD10. Case 2, cutaneous lymphoplasmacytoid lymphoma followed by mesenteric non-Hodgkin's lymphoma (lymphoplasmacytoid plus follicle center, follicular, grade III) plus Hodgkin's disease CL, showed CD5-/CD10-/CD19+/kappa+ cells by flow cytometry in both tissue samples. The Hodgkin's disease component showed CD3-/CD15-/CD20-/CD30+ Reed-Sternberg cell variants in paraffin-section immunostains. Case 3 represented nodal follicle center lymphoma, follicular, grade I (CD3-/CD5-/CD10-/CD19+/kappa+) followed by cutaneous anaplastic large T-cell lymphoma (CD2+/CD4+/CD5+/CD19- cells with partial expression of CD3 and CD7). Case 4 represented cutaneous follicle center lymphoma, follicular, grade I (CD5-/CD10+/CD19+/CD23+/lambda+) followed by bone marrow B-cell small lymphocytic lymphoma (CD5+/CD10-/CD19+/CD23+/kappa+). Results show that flow cytometry is a potentially useful adjunct in characterizing CL and SL.

Neurovascular deficits in cocaine abusers

The nature of the neurological and cerebrovascular deficits in cocaine abusers and whether they persist in abstinence is unclear. Blood flow velocity of the anterior and middle cerebral arteries was measured by transcranial Doppler sonography in cocaine abusers (n = 50) and control subjects (n = 25). Blood flow velocity was measured within 3 days and again after about 28 days after being admitted to an inpatient research ward to determine whether blood flow velocity improved during monitored abstinence conditions. The mean, systolic, and diastolic velocities as well as the pulsatility index in middle and anterior cerebral arteries significantly differed between controls and cocaine abusers (p < .05). Cerebrovascular resistance is increased in cocaine abusers and the increase persists for over a month of abstinence. Further research is needed to determine whether cerebrovascular resistance can be improved by pharmacological manipulations and whether improved blood flow relates to improved treatment outcome.

Photodynamic alteration of the surface receptor expression pattern of murine splenic dendritic cells

The photosensitizer benzoporphyrin-derivative monoacid ring A (BPD-MA, verteporfin), in combination with visible light irradiation, a clinical procedure termed photodynamic therapy (PDT), has immunomodulatory activity in various mouse models. We studied the impact of BPD-MA and light upon DBA/2 mouse splenic dendritic cells (DC), a potent antigen-presenting cell (APC) type. DC treated with nanomolar amounts of BPD-MA and 690 nm wavelength light had a reduced capacity to stimulate the proliferation of alloreactive T cells. Treatment with BPD-MA and light reduced DC levels of major histocompatibility (MHC) Class I and II antigens, intercellular adhesion molecule-1 (ICAM-1, CD54), the costimulatory B7-1 (CD80) and B7-2 (CD86) molecules, leucocyte common antigen CD45, the apoptosis-regulating Fas (CD95) receptor and the integrin CD11c. In contrast, DC expression of leucocyte function-associated-1 (LFA-1, CD11a), Mac-1 (CD11b), integrin beta2 chain (CD18) and the DEC-205 receptor increased, while CD40 levels were relatively unchanged 24 h after the treatment. MHC Class I and ICAM-1 levels decreased to 40% of control levels within 2 h following the photodynamic treatment. In the absence of light, BPD-MA did not affect DC receptor levels. Changes in DC receptor levels produced by BPD-MA and red light were similar to those produced by ultraviolet B light irradiation. The photodynamic treatment of activated splenic B cells, a separate APC class, had little effect upon receptor expression, except that MHC Class II levels were moderately decreased 24 h later. Changes in DC receptor expression may contribute to the immunomodulatory action of PDT.

Cardiac tamponade and death from intrapericardial rupture [corrected] of sinus of Valsalva aneurysm

A 35-year-old woman presented with dyspnea and chest pain. She had a large aneurysm of the non-coronary sinus of Valsalva. Before her scheduled urgent surgery, the patient collapsed and died of cardiac tamponade secondary to intrapericardial rupture of the aneurysm. We would advocate urgent repair of this type of lesion to prevent such an outcome. We are aware of no other specific reports addressing extracardiac rupture of non-coronary cusp aneurysms [corrected].

Family practice night-call frequency: 1981-1997

BACKGROUND AND OBJECTIVES

Night call has both service and educational value. This study examined trends in night-call frequency from 1981-1997. Our hypothesis was that night-call frequency is decreasing in family practice residency programs.

METHODS

We reviewed the Directory of Family Practice Residency Programs from 1981, 1989, and 1997 and entered into a database information about call frequency from all of the programs in each year. In-house night-call frequency and frequency of home call requiring other trips to the hospital were combined to determine total calls per year.

RESULTS

The mean number of total calls for PGY-1 residents was 190, 124, and 104 for each cohort year, respectively (1981, 1989, 1997). PGY-2 total calls were 160, 96, and 74. PGY-3 total calls were 151, 73, and 57. For all years of residency, total calls in 1997 were fewer than for 1981 and 1989.

CONCLUSIONS

Family practice residents have less night call now than in 1981 or 1989. The educational consequences of decreasing night call should be evaluated.

Electronic medical records for prenatal patients: challenges and solutions

A longstanding impediment to successful medical computing is resistance on the part of physicians. Interaction with many medical computing systems is difficult, requiring the physician to spend valuable time and energy trying to figure out how to get the machine to do what needs to be done. In developing encounter forms for use in prenatal medical records, we confronted the challenges involved in designing a computing system that provides an intuitive and physician-friendly method of recording clinical data. In trying to meet those challenges, we also learned about how to evaluate a medical computing system for flexibility and ease of use.

Alignment correction algorithm for transformation of stereotactic anterior commissure/posterior commissure-based coordinates into frame coordinates for image-guided functional neurosurgery

OBJECTIVE

The goal was to describe an alignment correction algorithm for the transformation of stereotactic atlas-derived anterior commissure/posterior commissure-based coordinates into frame coordinates for image-guided functional stereotactic neurosurgery.

TECHNIQUE

The algorithm was developed for the calculation of targets that are referenced to the intercommissural line. It corrects for deviations of the axis of the intercommissural line in relation to the stereotactic frame (x, y, and z coordinates). The algorithm is easily implemented on a personal computer with a spreadsheet program. The calculation is fast and effective.

CONCLUSION

The procedure is universally applicable for functional stereotactic neurosurgery, and it can be used with different stereotactic frames, different imaging techniques, and different workstations.

Cocaine dependence. A clinical syndrome requiring neuroprotection

Cocaine use has increased the frequency of medical complications among younger individuals. Neurological and neurovascular complications include strokes, seizures, transient ischemic attacks, and headaches. Subclinical deficits in cerebral perfusion and EEG have been noted in this population. Although these subclinical deficits may be an indication of increased risk of medical complications, the prophalactic treatment of cocaine abusers with neuroprotective agents has not yet been advocated. Blood flow of the anterior and medial cerebral arteries was measured by transcranial Doppler sonography in cocaine abusers (n = 70) and control subjects (n = 20) to determine whether cocaine abusers might have reduced cerebral blood flow in large cerebral arteries. Blood flow was measured within three days of and again about 28 days after admission of subjects to an inpatient research ward to determine whether blood flow improved with monitored abstinence. The mean, systolic, and diastolic velocities as well as the Pulsatility Index (PI) in both arteries differed between the control and cocaine abusers (p < 0.05). After about a month of abstinence, blood flow for the cocaine-dependent subjects increased. These preliminary findings suggest that blood flow is reduced in cocaine abusers and that there is a slight improvement with abstinence. Further research is needed to determine whether blood flow in abstinent cocaine abusers can be increased by pharmacological manipulations.

Subclinical neurological and neurovascular deficits in cocaine dependence. Gender and psychosocial considerations

Neurological and neurovascular deficits were reported in cocaine abusers. In order to examine the contribution of cocaine use severity as well as other psychosocial factors to these deficits, we examined the following measures in a sample of cocaine abusers (n = 70): blood flow (transcranial Doppler sonography), and psychosocial measures (the Norbeck Social Support Questionnaire, the Symptom Check List 90R, the Beck Hopelessness Scale, and the Ellison Wellness Scale). Blood flow in the anterior and medial cerebral arteries was lower in the cocaine abusers than in the control subjects. Both cocaine use and psychosocial measures significantly predicted decreases in blood flow.

Certification of death by family physicians

Death certificates are important because morbidity and mortality statistics often come from death-certification data. These statistics are vital in developing approaches to disease treatment and strategies for increasing longevity. It is often the primary care physician who is responsible for completing the death certificate, for explaining the cause of death to the family and, if appropriate, for referring some cases to the medical examiner. The primary care physician should have an explicit understanding of how to determine the cause and manner of death and should use succinct, clear language in completing the death certificate. When doubt exists or an external cause of death is a possibility, the coroner or the medical examiner is the appropriate public health official to contact.

Inhibition of contact hypersensitivity with different analogs of benzoporphyrin derivative

Four structural analogs of benzoporphyrin derivative (BPD), a potent anti-tumor photosensitizer, were evaluated for their capacity to influence the immunologically-mediated contact hypersensitivity (CHS) response against the hapten 2,4-dinitrofluorobenzene (DNFB). Immunocompetent hairless strain mice received BPD monoacid ring A (BPD-MA, verteporfin) and returned to normal housing conditions or treated with 690 nm red light (transcutaneous photodynamic therapy, PDT). Unexpectedly, we found that mice given BPD-MA exhibited significantly reduced CHS ear swelling responses to DNFB upon antigenic challenge, whether or not they had been treated with PDT. A significant reduction in the CHS response to DNFB was observed when BPD-MA or PDT was given 48 or 24 h prior to, on the same day, or 24 or 72 h after DNFB sensitization. However, the magnitude of the CHS response was unaffected if these treatments were given 96 h after DNFB sensitization, 24 h before challenge with DNFB. Significantly reduced CHS responses also occurred in Balb/c mice given BPD-MA with or without PDT. Mice given BPD-MA but retained in total darkness throughout the experimental period generated full-fledged ear swelling responses to DNFB indicating that CHS suppression with BPD-MA was light dependent. BPD monoacid ring B (BPD-MB) strongly reduced the CHS response of Balb/c mice kept under ambient light while BPD diacid ring A (BPD-DA) and BPD diacid ring B (BPD-DB) also lowered the CHS response but were less effective than the monoacid forms. Other photosensitizers including Photofrin, tin etiopurpurin, and zinc phthalocyanine did not alter the CHS response of Balb/c mice maintained under ambient light. The ability of different BPD analogs to inhibit the CHS response in mice held under ambient light conditions appears related to the potent photosensitizing activity of these compounds.

Microelectrode-guided posteroventral pallidotomy for treatment of Parkinson's disease: postoperative magnetic resonance imaging analysis

The authors report the postoperative magnetic resonance (MR) imaging findings in 36 patients with advanced Parkinson's disease who underwent unilateral microelectrode-guided posteroventral pallidotomy. The lesions were placed within 1 mm of the ventral border of the globus pallidus internus (GPi) to include pallidothalamic outflow pathways. Sequential MR studies were obtained within 1 to 3 days postoperatively and at 6-month follow-up examination. Thirty-four (94%) of the 36 patients enjoyed sustained moderate or marked improvement of their parkinsonian symptoms 6 months postoperatively. Transient side effects occurred in five patients (14%), but there were no persistent complications. The pallidal radiofrequency lesions were prolate spheroid shaped and were composed of three concentric zones in the early postoperative studies. The mean volume of the middle zone, corresponding to the area of hemorrhagic coagulation necrosis, was 44.4 +/- 17.6 mm3; the mean lesion volume as defined by the outer zone, corresponding to perilesional edema, was 262.2 +/- 111.6 mm3. Additional edema spreading to the internal capsule was noted in 32 of 34 cases and to the optic tract in 11 of 34 cases. In two patients small ischemic infarctions involving the corona radiata were found, and in one a venous infarction was detected. Ischemic infarction resulted in mild transient Broca's aphasia in one patient, but there was no detectable neurological deficit in the other two. The mean volume of late-phase (6 months) lesions was 22 +/- 28.8 mm3. In three patients no lesion was identified despite sustained clinical improvement. The lesion was located in the posteroventral GPi in all cases except in one patient in whom it was confined to the GP externus (GPe). This 49-year-old woman did not experience sustained benefit. The authors found no consistent correlations between lesion size and location and clinical outcome as measured by a global outcome score, the Unified Parkinson's Disease Rating Scale motor, activities of daily living, and bradykinesia "off" scores or rating of dyskinesias. Lesioning of pallidal and subpallidal pathways may contribute to the sustained clinical benefit in this series. Magnetic resonance imaging analysis showed that intraoperative microelectrode recording facilitated accurate placement of the lesion in this critical area.

"Wineglass" confabulations among brain-damaged alcoholics on the Wechsler Memory Scale-Revised visual reproduction subtest

Confabulation is a clinically well-documented accompaniment of selective types of memory impairment, especially in brain-damaged alcoholics. This study reports specific occurrences of visual confabulation consisting of spontaneous alterations of Card D of the Visual Reproduction subtest of the Wechsler Memory Scale-Revised. The resemblance of a wineglass was fashioned by a 90-degree rotation into a "bowl and stem", observed in six of 30 brain-damaged alcoholics. There were no such instances in 132 other patients, including alcoholic controls, those with Parkinson's Disease, temporal lobe epileptics (pre- or post-surgery), and those with neurotoxic exposure. When asked, the subjects who identified the figure as a wineglass or similar drinking instrument reported that they had drawn it as originally shown to them. "Wineglass" confabulators had shorter periods of abstinence, longer drinking histories and lower intellectual functioning than their brain-damaged peers or an alcoholic control group. These findings lend support for the association of alcohol-related confabulation with visual, as well as previously-documented verbal material among brain-damaged alcoholics.

Community-acquired pneumonia in adults: initial antibiotic therapy

Community-acquired pneumonia is a common infection encountered in clinical practice and is the leading cause of death due to infectious disease in the United States. To choose initial antimicrobial therapy appropriately, physicians must keep informed of recent developments in the epidemiology and clinical manifestations of atypical pathogens, antibiotic resistance and new antibiotics. Differentiating between "typical" and "atypical" pneumonia based on the initial clinical presentation is difficult. Primary treatment for community-acquired pneumonia in young adults without comorbidities is erythromycin. Older adults or those with comorbidities should be treated with erythromycin plus trimethoprim-sulfamethoxazole, a second- or third-generation cephalosporin, or a new macrolide. Empiric therapy for moderately or severely III hospitalized patients usually begins with erythromycin plus a second- or third-generation cephalosporin. Physicians should use initial antibiotic therapy for coverage of both typical and atypical pathogens.

CD4 and CD8 antigen coexpression: a flow cytometric study of peripheral blood, bone marrow, body fluid, and solid lymphoreticular specimens

OBJECTIVE

CD4 and CD8 antigen coexpression occurs not only on blastic T-cell malignancies, but also on a small subset of mature lymphocytes. The aim of this study was to determine the prevalence of this population of cells and to identify features that can be used to differentiate them from T lymphoblasts.

DESIGN

All specimens submitted to the clinical flow cytometry laboratory from August 1, 1994, through July 31, 1995, were analyzed for CD4 and CD8 coexpression.

MAIN OUTCOME MEASURE

Percentage of lymphocytes coexpressing the CD4 and CD8 antigens.

RESULTS

Four percent (22/526) of all specimens contained a population of CD4/CD8 coexpressing cells. Five cases represented CD4 and CD8 antigen expression on neoplastic cells. In 17 cases, the CD4/CD8 coexpressing cells appeared to represent a population of mature lymphocytes with a normal phenotype. The immature cells of T-cell acute lymphocytic leukemia and lymphoblastic lymphoma represented a dominant uniform population of cells demonstrating strong staining with both the CD4 and CD8 antigens. Cases containing a mature population of CD4/CD8 coexpressing cells were characterized by fewer coexpressing cells and variable expression of CD8. There were cases where distinction of this population of mature CD4/CD8 coexpressing lymphoid cells from a blastic malignancy was not possible using immunophenotyping alone.

CONCLUSION

Correlation of clinical, morphologic, and immunophenotypic data is recommended to prevent the misdiagnosis of subtle involvement by a blastic T-cell malignancy.

Monoclonal antibody LR-1 recognizes murine heat-stable antigen, a marker of antigen-presenting cells and developing hematopoietic cells

The rat monoclonal antibody LR-1 was initially described to be reactive with an antigen present on murine splenic B lymphocytes. However, flow-cytometric analyses of cells obtained from thymus, bone marrow, spleen, and lymph nodes showed that LR-1 stained approximately 95, 95, 60-70 and 20% of cells present within these tissues in normal DBA/2 mice. The marker recognized by LR-1 was present on peripheral erythrocytes and splenic dendritic cells, and activation with lipopolysaccharide A further increased expression of this antigen by splenic B cells. This particular tissue and cellular distribution was similar to that delineated with monoclonal antibodies reactive with heat-stable antigen (HSA). Duallabelling studies were conducted to compare the reactivity patterns of LR-1 and the HSA-reactive monoclonal antibody J11d and indicated that both antibodies recognized splenocytes bearing B cell (IgM) or erythroid (TER-119, CD71) but not T cell (CD4, CD8) markers. Splenocytes exposed to phosphoinostol-specific phospholipase C showed marked reduction in LR-1 binding, indicating that this antibody recognized a glycosylphosphatidylinositol-anchored cell surface protein, consistent with the known structure of HSA. Mixing of LR-1 with the HSA-specific antibodies J11d or M1/69 provided flow-cytometric profiles indistinguishable from those obtained with either antibody alone. However, LR-1 inhibited M1/69 binding to splenocytes by 83%, while J11d reduced M1/69 binding to these cells by only 18%. This finding suggested that LR-1 and M1/69 recognize identical splenic HSA epitopes, while LR-1 and J11d bind distinct antigenic determinants of spleen HSA. Western blot analysis of splenocyte, thymocyte, bone marrow cell and erythrocyte detergent extracts revealed that LR-1 reacted with glycoforms of HSA of known molecular weights (30-55 kD). Thus, LR-1 recognizes HSA, the murine analogue of human CD24, and will be a useful reagent with which to investigate the role of HSA in the immune response and hematopoiesis.

CD20 (pan-B cell antigen) expression on bone marrow-derived T cells

Antibodies directed against CD20 (L26, Leu 16, and B1) are frequently used to determine the presence of B lymphocytes. However, recent publications describe the unexpected presence of CD20-positive T cells in the peripheral blood of normal subjects and occasional T-cell neoplasms that express CD20. To determine the presence of CD20-positive T cells in bone marrow, flow cytometric analysis was performed on 34 aspirate specimens (14 normal, 5 acute lymphoblastic lymphoma [ALL], 5 acute myelogenous leukemia [AML], 4 HIV positive, 2 myelodysplastic/myeloproliferative, 2 chronic myelogenous leukemia [CML], 1 chronic lymphocytic lymphoma [CLL], 1 multiple myeloma). A small population of cells coexpressing CD3 (Leu 4) and CD20dim (Leu 16) was identified in 94% of the specimens, representing 0% to 11% (mean 1.77%) of marrow mononuclear cells and 0% to 22.2% (mean 6.54%) of marrow lymphoid cells. There was no correlation between the percentage of CD20-positive T cells and the CD4:CD8 ratio, patient age, gender, or diagnosis. CD20dim positive cells included immature B cells and CD20-positive T cells. Although evaluation of CD20 expression is useful in delineating B-cell processes, caution should be exercised in interpreting its expression on bone marrow T-lymphoid cells. CD20 expression on T cells may be seen in either normal, reactive, or neoplastic processes.

Effectiveness of erythromycin in the treatment of acute bronchitis

BACKGROUND

Clinical trials have not shown a consistent benefit of treating bronchitis with antibiotics. Many physicians, however, treat acute bronchitis with antibiotics because of the possibility of Mycoplasma pneumoniae or other pathogens. The objectives of this study were to determine the effectiveness of erythromycin treatment in patients with acute bronchitis and to determine whether a newly developed rapid M pneumoniae antibody test is useful in predicting which patients will respond to therapy.

METHODS

We conducted a randomized, double-blind, placebo-controlled clinical trial at three primary care centers in North Carolina. A convenience sample of 140 patients presenting with acute bronchitis were tested for M pneumoniae, 91 of whom were treated with either erythromycin 250 mg four times daily for 10 days or an identical-appearing placebo.

RESULTS

Patients treated with erythromycin missed an average of only 0.81 +/- 1.1 days of work compared with 2.16 +/- 3.2 days for placebo-treated patients (P < .02). There were no significant differences in cough, use of cough medicine, general feeling of well-being, or chest congestion between the erythromycin and placebo groups. Twenty-five percent of the patients tested positive for M pneumoniae. There were no differences in response to erythromycin based on whether the patient had a positive test for M pneumoniae.

CONCLUSIONS

Erythromycin is effective in significantly reducing lost time from work, but it is not effective in reducing cough or other symptoms in patients with acute bronchitis, regardless of the outcome of the M pneumoniae antibody test.

Fine-needle biopsy of pediatric lesions: a three-year study in an outpatient biopsy clinic

Diagnostic Cytology Laboratory, Inc., has an outpatient Fine Needle Biopsy Clinic, which evaluated 7,487 fine-needle biopsies (FNB) from January 1989 to February 1992. Two hundred eighty-eight (3.8%) of these specimens were collected from patients 19 years old or younger and this represents the largest study of this population in the scientific literature. The majority of these specimens were obtained from palpable masses in the head and neck region [lymph nodes (58.3%), thyroid (7.6%), and salivary gland (5.2%)] while a smaller number were collected from miscellaneous soft tissue (18.8%) and breast masses (10.1%). Thirteen (4.5%) (from 12 patients) were diagnosed as malignant by FNB and 275 (95.5%) (264 patients) were benign by FNB. This benign:malignant ratio (22:1) is significantly higher than has been reported from tertiary care institutions and is a reflection of the difference of this outpatient population. Two hundred nine of 276 patients (75.7%) had adequate follow-up, including 137 (49.6%) patients followed by observation, 48 (17.4%) patients followed by surgical biopsy, and 24 (8.7%) patients followed by some other modality: imaging studies, flow cytometry, or treatment. There was a single false positive diagnosis (a pilomatrixoma) and one (1) false negative interpretation (a cystic acinic cell carcinoma) resulting in a diagnostic sensitivity of 92.3% and a specificity of 99.6%. The positive predictive value was 92.3%, the negative predictive value was 99.6%, and the test efficiency was 99.3%. The utility, cost-effectiveness and uniqueness of the clinic population is discussed.

Common questions patients ask during pregnancy

When women become pregnant, they expect their family physicians to answer many questions about potential risks during the pregnancy and possible effects on the developing fetus. Many of these questions concern over-the-counter medications, common household exposures and daily activities, which often are not well discussed in obstetric texts. In general, women can be reassured that allergy medications and most common food additives, such as caffeine and aspartame, are safe to use during pregnancy. Most cosmetics and hair care products, including permanent wave solutions, are safe in limited exposures. Patients should be counseled to avoid exposure to insecticides and to continue good safety habits, such as wearing seat belts. Discussion of specific risks may prevent unnecessary anxiety and needless changes in work and home environment and lifestyle for pregnant women.

Practice variations between family physicians and obstetricians in the management of low-risk pregnancies

BACKGROUND

Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians.

METHODS

A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865.

RESULTS

During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians.

CONCLUSIONS

Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.

Combination antidepressant therapy in primary care

Increasing clinical experience with the selective serotonin reuptake inhibitors and tricyclic antidepressants make combination antidepressant therapy at times a reasonable alternative to single-agent therapy in primary care patients with depression. This article describes three cases that illustrate possible rationales for combination antidepressant therapy: reduced side effects, synergistic treatment effects, reduced treatment response time, prescriber familiarity, and clinical experience. The combination of selective serotonin reuptake inhibitors and tricyclic antidepressants may be useful in treating patients who experience intolerable side effects or who are resistant to therapy with a single antidepressant. Further research should be done to define the role of combination antidepressant therapy in the treatment of primary care patients with depression.

Religious affiliation and obstetric outcome

The purpose of this study was to explore the relationship between religious affiliation and obstetric outcome. We reviewed 1,919 records of patients whose infants were born at a university medical center. Data obtained from maternal and newborn records included demographic information, prenatal history, labor and delivery records, and religious affiliation. Maternal complications and neonatal intensive care unit (NICU) admissions were lowest for mainline Christians (11%, 11%), intermediate for evangelical Christians (17%, 12%), and highest for patients with no religious preferences (21%, 18%). After controlling for possible confounders, the association of religious affiliation and lower NICU admission rates remained. Mainline Christians had a lower frequency of maternal complications. Patients with a religious affiliation had better obstetric outcome than those without. Most of the association seems to be due to a lower risk social profile, but a small positive influence of religion persisted.

Carotidynia

Carotidynia has an extensive differential diagnosis, including such conditions as pharyngitis, otitis, bruxism, temporomandibular joint syndrome, neuralgia, myalgia and temporal arteritis. Carotidynia may be divided into three distinct classifications: migrainous, nonmigrainous (or classic) and arteriosclerotic. Successful treatment depends on correct classification of the disorder. Ergotamine, propranolol and tricyclic antidepressants have been effective treatments in patients with migrainous carotidynia, and steroids and nonsteroidal anti-inflammatory drugs have proved effective for the classic type of carotidynia. Further investigation is required before it can be determined if treatment for the arteriosclerotic type should be medical or surgical.

Beliefs and attitudes of hospital inpatients about faith healing and prayer

BACKGROUND

Physicians rarely question patients about their religious beliefs. This lack of inquiry may be contrary to patients' wishes and detrimental to patient care. This study examines whether patients want physicians to discuss religious beliefs with them.

METHODS

Two hundred three family practice adult inpatients at two hospitals were interviewed regarding their views on the relationship between religion and health.

RESULTS

Many patients expressed positive attitudes toward physician involvement in spiritual issues. Seventy-seven percent said physicians should consider patients' spiritual needs, 37% wanted their physicians to discuss religious beliefs with them more frequently, and 48% wanted their physicians to pray with them. However, 68% said their physician had never discussed religious beliefs with them.

CONCLUSIONS

This study supports the hypothesis that although many patients desire more frequent and more in-depth discussions about religious issues with their physicians, physicians generally do not discuss these issues with their patients.

Socioeconomic factors and the odds of vaginal birth after cesarean delivery

OBJECTIVE

To determine the independent effect of socioeconomic, organizational, and professional liability factors on the odds of vaginal birth after cesarean delivery (VBAC) while controlling for important clinical factors.

DESIGN

A retrospective study of 1989 New York State vital statistics data, supplemented with additional information on county- and hospital-specific variables. Using multiple logistic regression analysis, odds ratios (ORs) and 95% confidence intervals (CIs) were derived for 15 independent variables.

SETTING

Births occurring in 104 New York State hospitals.

DATA SET

A total of 13,944 births occurring to New York State residents with a history of cesarean delivery of which 3068 (22%) were vaginal deliveries.

RESULTS

The odds of VBAC increased with maternal education. The ORs were 1.15 (95% CI, 0.99 to 1.34) for 12 years of education; 1.36 (95% CI, 1.16 to 1.60) for 13 to 15 years; 1.59 (95% CI, 1.32 to 1.93) for 16 years, and 2.00 (95% CI, 1.64 to 2.45) for 17 years or more. The ORs also increased with the level of care provided by the hospital; they were 1.55 (95% CI, 1.34 to 1.81) and 1.30 (95% CI, 1.18 to 1.44) for hospitals with intensive and intermediate neonatal care facilities, respectively. The ORs were 1.15 (95% CI, 1.02 to 1.30) for health maintenance organization participants and 0.77 (95% CI, 0.63 to 0.94) for women giving birth in government hospitals. The ORs of VBAC for African-American and Hispanic mothers were 0.80 (95% CI, 0.70 to 0.93) and 0.61 (95% CI, 0.51 to 0.73), respectively. The ORs for a $5000 increase in physician's yearly malpractice premium and the hospital's paid loss due to malpractice claim settlements were 0.98 (95% CI, 0.97 to 0.99) and 1.01 (95% CI, 0.99 to 1.03), respectively.

CONCLUSIONS

In addition to clinical factors, a mother's level of education and ethnicity and specific characteristics of the hospital in which she delivers affect the odds of a vaginal delivery after a previous cesarean delivery. From our analysis, we cannot conclude that professional liability factors affected VBAC rates.

Diagnosis of illness presentation in the elderly

In the standard medical model of diagnosis, there is a 1:1 correspondence between clinical symptoms and signs and a pathological disease process. However, it is believed that this model does not accurately define many illness presentations in elderly patients. The frequency with which the medical model is diagnostically accurate, and the other models that might more effectively diagnose geriatric illness, are unknown. This study was designed to ascertain the frequency with which the medical model of diagnosis pertains in a clinical population of older adults and to develop and validate alternative models for diagnosis of illness presentation in this population. Using a retrospective chart review (n = 86) and a prospective validation in a second sample (n = 56) of geriatric assessment clinic patients, it was found that the medical model of illness fit less than half of the patients. To describe the illness presentations of the remaining patients, four new diagnostic models of illness presentation were identified which incorporate comorbidity, functional, and psychosocial factors. Use of these new models along with the medical model of illness diagnosis may assist in more accurate and complete diagnosis in elderly patients and enhance teaching of effective diagnosis in geriatric medicine.