Regional anaesthesia quality indicators for adult patients undergoing non-cardiac surgery: a systematic review

Improvement in healthcare delivery depends on the ability to measure outcomes that can direct changes in the system. An overview of quality indicators within the field of regional anaesthesia is lacking. This systematic review aims to synthesise available quality indicators, as per the Donabedian framework, and provide a concise overview of evidence-based quality indicators within regional anaesthesia. A systematic literature search was conducted using the databases MEDLINE, Embase, CINAHL and Cochrane from 2003 to present, and a prespecified search of regional anaesthesia society websites and healthcare quality agencies. The quality indicators relevant to regional anaesthesia were subdivided into peri-operative structure, process and outcome indicators as per the Donabedian framework. The methodological quality of the indicators was determined as per the Oxford Centre for Evidence-Based Medicine's framework. Twenty manuscripts met our inclusion criteria and, in total, 68 unique quality indicators were identified. There were 4 (6%) structure, 12 (18%) process and 52 (76%) outcome indicators. Most of the indicators were related to the safety (57%) and effectiveness (19%) of regional anaesthesia and were general in nature (60%). In addition, most indicators (84%) were based on low levels of evidence. Our study is an important first step towards describing quality indicators for the provision of regional anaesthesia. Future research should focus on the development of structure and process quality indicators and improving the methodological quality and usability of these indicators.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

SWIFT: prospective 48-week study to evaluate efficacy and safety of switching to emtricitabine/tenofovir from lamivudine/abacavir in virologically suppressed HIV-1 infected patients on a boosted protease inhibitor containing antiretroviral regimen

BACKGROUND

In the United States, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a preferred nucleoside reverse transcriptase inhibitor (NRTI) backbone with lamivudine/abacavir (3TC/ABC) as a commonly used alternative. For patients infected with human immunodeficiency virus (HIV-1) virologically suppressed on a boosted protease inhibitor (PI) + 3TC/ABC regimen, the merits of switching to FTC/TDF as the NRTI backbone are unknown.

METHODS

SWIFT was a prospective, randomized, open-label 48-week study to evaluate efficacy and safety of switching to FTC/TDF. Subjects receiving 3TC/ABC + PI + ritonavir (RTV) with HIV-1 RNA < 200 c/mL ≥3 months were randomized to continue 3TC/ABC or switch to FTC/TDF. The primary endpoint was time to loss of virologic response (TLOVR) with noninferiority measured by delta of 12%. Virologic failure (VF) was defined as confirmed rebound or the last HIV-1 RNA measurement on study drug ≥200 c/mL.

RESULTS

In total, 311 subjects were treated in this study (155 to PI + RTV + FTC/TDF, 156 to PI + RTV + 3TC/ABC). Baseline characteristics were similar between the arms: 85% male, 28% black, median age, 46 years; and median CD4 532 cells/mm(3). By TLOVR through week 48, switching to FTC/TDF was noninferior compared to continued 3TC/ABC (86.4% vs 83.3%, treatment difference 3.0% (95% confidence interval, -5.1% to 11.2%). Fewer subjects on FTC/TDF experienced VF (3 vs 11; P = .034). FTC/TDF showed greater declines in fasting low-density lipoproteins (LDL), total cholesterol (TC), and triglycerides (TG) with significant declines in LDL and TC beginning at week 12 with no TC/HDL ratio change. Switching to FTC/TDF showed improved NCEP thresholds for TC and TG and improved 10-year Framingham TC calculated scores. Decreased estimated glomerular filtration rate [corrected] (eGFR) was observed in both arms with a larger decrease in the FTC/TDF arm.

CONCLUSIONS

Switching to FTC/TDF from 3TC/ABC maintained virologic suppression, had fewer VFs, improved lipid parameters and Framingham scores but decreased eGFR. CLINICALTRIALS.GOV IDENTIFIER: NCT00724711.

Mortality from asbestosis and mesothelioma in Britain by birth cohort

BACKGROUND

Analysis of occupational mortality in England and Wales during 1991-2000 showed no decline in work-attributable deaths from asbestosis.

AIMS

To explore why there was no decline in mortality from asbestosis despite stricter controls on asbestos exposure over recent decades.

METHODS

Using data from registers of all deaths in Great Britain with mention of mesothelioma or asbestosis on the death certificate, we plotted death rates by 5 year age group within 5 year birth cohorts for(a) mesothelioma and (b) asbestosis without mention of mesothelioma.

RESULTS

Analysis was based on a total of 33,751 deaths from mesothelioma and 5396 deaths from asbestosis. For both diseases, mortality showed a clear cohort effect; within birth cohorts, death rates increased progressively with age through to 85 years and older. However, highest mortality from mesothelioma was in men born during 1939-43, whereas, mortality from asbestosis peaked in men born during 1924-38.

CONCLUSIONS

Our findings suggest that mortality, in Britain, from asbestosis has been determined mainly by cumulative exposure to asbestos before 45 years of age and that the effect of such exposure continues through to old age. That mortality from asbestosis peaked in earlier birth cohorts than mortality from mesothelioma may reflect a difference in exposure-response relationships for the two diseases. The discrepancy could be explained if risk of asbestosis increased more steeply than that of mesothelioma at higher levels of exposure to asbestos and if the highest prevalence of heavy exposure occurred in earlier birth cohorts than the highest prevalence of less intense exposures.

The use of physicochemical methods to detect organic food soils on stainless steel surfaces

Food processing surfaces fouled with organic material pose problems ranging from aesthetic appearance, equipment malfunction and product contamination. Despite the importance of organic soiling for subsequent product quality, little is known about the interaction between surfaces and organic soil components. A range of complex and defined food soils was applied to 304 stainless steel (SS) surfaces to determine the effect of type and concentration of soil on surface physicochemical parameters, viz surface hydrophobicity (DeltaG(iwi)), surface free energy (gamma(s)), Lifshitz van der Waals (gamma_LW(s)), Lewis acid base (gamma_AB(s)), electron acceptor (gamma_+(s) ) and electron donor (gamma_-(s) ) measurements. When compared to the control surface, changes in gamma_AB(s), gamma_+(s) and gamma_-(s) were indicative of surface soiling. However, soil composition and surface coverage were heterogeneous, resulting in complex data being generated from which trends could not be discerned. These results demonstrate that the retention of food soil produces changes in the physicochemical parameters of the surface that could be used to indicate the hygienic status of a surface.

The prevalence of transmitted antiretroviral drug resistance in treatment-naïve patients and factors influencing first-line treatment regimen selection

OBJECTIVES

To estimate the prevalence of transmitted antiretroviral (ARV) drug resistance, and to assess whether resistance testing influences first-line ARV regimen selection.

METHODS

Data on patients' characteristics were collected through questionnaires. ARV drug resistance was tested by genotypic methods and defined by Quest-Stanford classification rule. Physicians reported the intended and actual treatments and the factors considered in treatment selection.

RESULTS

Two hundred and twenty-eight patients were included. The prevalence of ARV drug resistance was 12.1%, with 9.8% for non-nucleoside reverse transcriptase inhibitors (NNRTIs), 4.5% for nucleoside reverse transcriptase inhibitors and 1.8% for protease inhibitors (PIs). Pill burdens, dosing frequency and physicians' experience with regimens were the major factors considered in treatment selection. The intended and actual treatment differed for 73 and 44% of the patients with and without ARV drug resistance, respectively [odds ratio (95% confidence interval, CI)=3.6 (1.5-9.0), P=0.006]. NNRTI-based regimens were intended for 10 patients with resistance to NNRTIs; these patients were prescribed PI-based regimens after genotypic testing.

CONCLUSIONS

Transmitted ARV drug resistance was detected in 12.1% of treatment-naïve patients, with resistance to NNRTIs the most common. Resistance-testing results played a partial role in first-line treatment selection. However, resistance to NNRTIs pre-empted NNRTI use.

Orthodontic treatment for deep bite and retroclined upper front teeth in children

BACKGROUND

Correction of the type of dental problem where the bite is deep and the upper front teeth are retroclined (Class II division 2 malocclusion) may be carried out using different types of orthodontic treatment. However, in severe cases, surgery to the jaws in combination with orthodontics may be required. In growing children, treatment may sometimes be carried out using special upper and lower dental braces (functional appliances) that can be removed from the mouth. In many cases this treatment does not involve taking out any permanent teeth. Often, however, further treatment is needed with fixed braces to get the best result. In other cases, treatment aims to move the upper first permanent molars backwards to provide space for the correction of the front teeth. This may be carried out by applying a force to the teeth and jaws from the back of the head using a head brace (headgear) and transmitting this force to a part of a fixed or removable dental brace. This treatment may or may not involve the removal of permanent teeth. In some cases, neither functional appliances nor headgear are required and treatment may be carried out without extraction of any permanent teeth. Instead of using a headgear, in certain cases, the back teeth are held back in other ways such as with an arch across or in contact with the front of the roof of the mouth which links two bands glued to the back teeth. Often in these cases, two permanent teeth are taken out from the middle of the upper arch (one on each side) to provide room to correct the upper front teeth. It is important for orthodontists to find out whether orthodontic treatment only, carried out without the removal of permanent teeth, in children with a Class II division 2 malocclusion produces a result which is any different from no orthodontic treatment or orthodontic treatment only involving extraction of permanent teeth.

OBJECTIVES

To establish whether orthodontic treatment, carried out without the removal of permanent teeth, in children with a Class II division 2 malocclusion, produces a result which is any different from no orthodontic treatment or orthodontic treatment involving removal of permanent teeth.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. The handsearching of the main international orthodontic journals was updated to April 2006. There were no restrictions with regard to publication status or language of publication. International researchers, likely to be involved in Class II division 2 clinical trials, were contacted to identify any unpublished or ongoing trials.

SELECTION CRITERIA

Trials were selected if they met the following criteria: randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of orthodontic treatments to correct deep bite and retroclined upper front teeth in children.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were to be conducted in duplicate and independently by two review authors. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated including both clinical and methodological factors.

MAIN RESULTS

No RCTs or CCTs were identified that assessed the treatment of Class II division 2 malocclusion in children.

AUTHORS' CONCLUSIONS

It is not possible to provide any evidence-based guidance to recommend or discourage any type of orthodontic treatment to correct Class II division 2 malocclusion in children.

The ‘Chesterfield stent’: an aid to the placement of midpalatal implants

A palatal endosseous implant is a valuable adjunct to orthodontic treatment. Its insertion is considerably simplified by the use of a stent that was designed in our department and that we describe here.

Complications Common to Ventricular Assist Device Support Are Rare with 90 Days of DeBakey VAD® Support in Calves

The DeBakey VAD is a miniaturized, electromagnetically driven axial flow pump intended for long-term ventricular assist. Safety and performance data from six calves implanted with the complete DeBakey VAD system are reported elsewhere; here we describe complications and necropsy findings for these same six animals, all of which survived 90 days. The study was conducted according to a uniform protocol, which included anticoagulation and antibiotic prophylaxis. Clinical complications tracked included bleeding, cardiovascular abnormalities (e.g., arrhythmias, tachycardia unrelated to pain, bradycardia), hemolysis, hepatic dysfunction, renal dysfunction, thromboembolism (neurologic or peripheral), or infection. Each adverse event was retrospectively categorized with regard to severity (mild, moderate, severe) and relationship to device. Clinical findings were confirmed by necropsy. There was no evidence of systemic infection, thromboembolism, hemolysis, or renal or hepatic dysfunction in these six animals during the study period. A single adverse event was noted in each of two of the calves. Both events were considered mild according to the predefined criteria. Bleeding related to the surgical implantation procedure and requiring reoperation occurred in one animal. The other animal had evidence of a superficial infection at the exit site of the cables on the left lateral thoracic wall; the infection did not extend into the thoracic cavity. Chronic, healed small renal infarct scars were present in several animals. Mild valvular endocardiosis was observed in two calves and mild fibroelastosis was present in the endocardium at the site of the inflow cannula in three calves; however, these lesions were not considered clinically significant. No other gross or histologic abnormalities were noted at necropsy. In conclusion, calves implanted with the complete DeBakey VAD for 90 days demonstrated few complications and had no significant necropsy findings. Complications common to ventricular assist device (VAD) support (i.e., hemolysis, infection, bleeding, thromboembolism) were rare during long-term support (90 days) with the DeBakey VAD.

Measles-mumps-rubella and other measles-containing vaccines do not increase the risk for inflammatory bowel disease: a case-control study from the Vaccine Safety Datalink project

CONTEXT

A link between measles virus-containing vaccines and inflammatory bowel disease (IBD) has been suggested by recent studies.

OBJECTIVE

To address whether receipt or timing of measles-containing vaccine (MCV) increases risk for IBD.

DESIGN

A case-control study.

SETTING

Four large health maintenance organizations (HMOs) that are part of the Centers for Disease Control and Prevention's Vaccine Safety Datalink project.

PATIENTS OR OTHER PARTICIPANTS

A total of 155 persons with codes from International Classification of Diseases, Ninth Revision specific for IBD, born between 1958 and 1989 and enrolled from birth to the onset of disease, were identified. Up to 5 controls were matched by sex, HMO, and birth year.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Risk for IBD, Crohn's disease, and ulcerative colitis.

RESULTS

Past vaccination was not associated with an increased risk for Crohn's disease (odds ratio [OR] for measles-mumps-rubella vaccine [MMR], 0.4; 95% confidence interval [CI], 0.08-2.0), ulcerative colitis (OR, 0.8; 95% CI, 0.18-3.56), or IBD (OR, 0.59; 95% CI, 0.21-1.68). Risk for IBD was not increased among children vaccinated who were younger than 12 months (OR for MMR, 0.61; 95% CI, 0.15-2.45) or aged 12 to 18 months (OR, 0.86; 95% CI, 0.28-2.59) relative to unvaccinated children. Children vaccinated with MMR who were older than 18 months were at significantly decreased risk for IBD (OR, 0.16; 95% CI, 0.04-0.68). Neither past vaccination nor age at vaccination with other MCV was associated with increased risk for Crohn's disease, ulcerative colitis, or IBD. Risk for Crohn's disease, ulcerative colitis, or IBD was not elevated in the time immediately following vaccination with either vaccine.

CONCLUSIONS

Vaccination with MMR or other MCV, or the timing of vaccination early in life, did not increase the risk for IBD.

Safety of oral versus intravenous hydration during induction therapy with intravenous foscarnet in AIDS patients with cytomegalovirus infections

We undertook a study to compare the safety of intravenous (i.v.) versus oral hydration to prevent nephrotoxicity associated with the use of foscarnet for induction therapy of cytomegalovirus (CMV) infection in HIV-infected persons. Patients, given foscarnet at a dose of 90 mg/kg every 12 h, were randomized to receive either i.v. or oral hydration. Thirty-seven patients were given i.v. hydration and 44 were given oral hydration. Median duration of therapy for both groups was 17 days. There was no difference between the 2 groups in either serious adverse events or rise of creatinine to > or = 2.0 mg/dl. However, serum creatinine, while generally remained within normal limits, increased more in patients who received oral hydration after 10 days of therapy (significant only by slope analysis, P < 0.05). Although i.v. hydration provided better protection against nephrotoxicity, oral hydration was relatively safe and convenient provided that creatinine clearance (CrCl) is monitored closely.

Loss of ATM function enhances recombinant adeno-associated virus transduction and integration through pathways similar to UV irradiation

Ataxia telangiectasia is caused by a genetic defect in the ATM gene that results in altered cellular sensitivity to DNA-damaging agents such as gamma-irradiation. ATM deficiency is associated with an increased incidence of neurological disorders, immune deficiency, and cancer. In this report we demonstrate that recombinant adeno-associated virus (rAAV) gene transfer in ATM-deficient fibroblasts is significantly enhanced over normal fibroblast cell lines. This enhancement of rAAV transduction in AT cells is correlated with an increased abundance of circular form rAAV genomes, as well as a higher number of integrated head-to-tail concatamer proviral genomes. Studies evaluating AAV trafficking using Cy3-labeled virus suggest that a nuclear mechanism is responsible for increased rAAV transduction in AT cells, because binding, endocytosis, and nuclear trafficking of virus are unaffected by the AT phenotype. Additionally, the profile of rAAV transduction after UV irradiation is significantly blunted in AT cells, suggesting that the level of DNA repair enzymes normally associated with UV augmentation of viral transduction may already be maximally elevated. These results further expand our understanding of genes involved in rAAV transduction.

Safety of revaccination with pneumococcal polysaccharide vaccine

CONTEXT

Revaccination of healthy adults with pneumococcal polysaccharide vaccine (PPV) within several years of first vaccination has been associated with a higher than expected frequency and severity of local injection site reactions. The risk of adverse events associated with revaccination of elderly and chronically ill persons 5 or more years after first vaccination, as is currently recommended, has not been well defined.

OBJECTIVE

To determine whether revaccination with PPV at least 5 years after first vaccination is associated with more frequent or more serious adverse events than those following first vaccination.

DESIGN

Comparative intervention study conducted between April 1996 and August 1997.

PARTICIPANTS

Persons aged 50 to 74 years either who had never been vaccinated with PPV (n = 901) or who had been vaccinated once at least 5 years prior to enrollment (n = 513).

INTERVENTION

PPV vaccination.

MAIN OUTCOME MEASURES

Postvaccination local injection site reactions and prevaccination concentrations of type-specific antibodies.

RESULTS

Those who were revaccinated were more likely than those who received their first vaccinations to report a local injection site reaction of at least 10.2 cm (4 in) in diameter within 2 days of vaccination: 11% (55/513) vs 3% (29/901) (relative risk [RR], 3.3; 95% confidence interval [CI], 2.1-5.1). These reactions resolved by a median of 3 days following vaccination. The highest rate was among revaccinated patients who were immunocompetent and did not have chronic illness: 15% (33/228) compared with 3% (10/337) among comparable patients receiving their first vaccinations (RR, 4.9; 95% CI, 2.4-9.7). The risk of these local reactions was significantly correlated with prevaccination geometric mean antibody concentrations.

CONCLUSIONS

Physicians and patients should be aware that self-limited local injection site reactions occur more frequently following revaccination compared with first vaccination; however, this risk does not represent a contraindication to revaccination with PPV for recommended groups.

Alterations in acid-base balance and serum electrolyte concentrations in cattle: 632 cases (1984-1994)

OBJECTIVE

To determine typical alterations in acid-base balance and serum electrolyte concentrations in cattle grouped on the basis of age, breed type, hydration status, clinical signs, and underlying disease.

DESIGN

Retrospective study.

ANIMALS

632 cattle.

PROCEDURE

Information on blood pH, PVO2, PVCO2, HCO3-concentration, and base excess (BE) as well as serum or plasma sodium, potassium, chloride, and total carbon dioxide concentrations was obtained. Values for calves (ie, cattle < 1 month old) were compared with values for cattle > or = 1 month old. Within each age-group, values were compared for cattle grouped on the basis of breed type, previous treatment, and hydration status. Proportions of cattle with various disorders for which values were within, greater than, or less than reference ranges were determined.

RESULTS

BE, pH, and HCO3- concentration were significantly higher and PVCO2 and sodium, potassium, and chloride concentrations were significantly lower among cattle > or = 1 month old than calves. Base excess and HCO3- concentration were significantly lower among dairy than beef calves. Sodium and potassium concentrations were significantly lower among dairy than beef cattle > or = 1 month old. A higher proportion of cattle that did not survive had a high anion gap than cattle that did survive. Sodium, potassium, and chloride concentrations were significantly lower among dehydrated cattle than cattle that were not dehydrated.

CLINICAL IMPLICATIONS

Because certain alterations were consistently found in some groups of cattle, it may be possible to make reasonable predictions of alterations in acid-base balance and serum electrolyte concentrations when laboratory evaluations are not available.

Epidemiology of congenital cytomegalovirus infection: maternal risk factors and molecular analysis of cytomegalovirus strains

To determine factors that influence the occurrence of congenital cytomegalovirus (CMV) infection, the authors surveyed prospectively 8,254 infants born in eastern Iowa between October 1989 and June 1994. The authors conducted a case-control study to identify maternal risk factors, matching each CMV-infected infant with three uninfected infants according to hospital and date of birth. CMV strains were compared by using the polymerase chain reaction (PCR) to identify common sources of infection. Of the 7,229 infants cultured successfully for CMV, 35 (0.48%) were congenitally infected. Mothers of CMV-infected infants were more likely to be single (odds ratio (OR) = 3.05, p = 0.016), to work in sales (OR = 4.93, p = 0.008), or to be students (OR = 5.01, p = 0.017). Conversely, women who worked in health-care professions were less likely to have a congenitally infected infant (OR = 0.14, p = 0.049). PCR analysis indicated 27 distinct strains of CMV, but two groups of infants (two infants per group) excreted strains with indistinguishable molecular patterns. One of these pairs of infants had older siblings who attended the same child-care center during their mothers' pregnancies. The authors concluded that demographic and occupational factors influenced the risk of giving birth to an infant with congenital CMV infection. Many distinct CMV strains were identified, suggesting that major point source outbreaks had not occurred. Nonetheless, point source acquisition of CMV from child-care environments did account for some cases of congenital CMV infection in eastern Iowa.

Cytomegalovirus infection in newborns and their family members: polymerase chain reaction analysis of isolates

Polymerase chain reaction (PCR) analysis with primers for the pp65, a-sequence, glycoprotein B, and major immediate early genes of human cytomegalovirus (CMV) was used to study five congenitally-infected infants and their CMV-infected family members. Family members excreting CMV included three mothers and two siblings. The PCR results indicated that the CMV strain excreted by each infant was indistinguishable from that excreted by the corresponding family member. By contrast, the molecular profiles of the CMV strains were distinct between families, indicating that the PCR algorithm described in this study is a useful method for analyzing CMV strains.

Parent and sibling influences on adolescent alcohol use and misuse: evidence from a U.S. adoption cohort

OBJECTIVE

Although adolescent alcohol use has been consistently associated with parental drinking behavior, sibling drinking behavior and family functioning, the extent to which these associations owe to genetic or shared environmental influences has not been previously investigated. Using an adoption study design, we sought to determine whether the familial correlates of adolescent alcohol involvement were due to common genetic or common environmental effects.

METHOD

The sample consisted of 653 adopted families ascertained through adoption agencies in four U.S. states. Each family consisted of a target adopted adolescent, an adoptive mother and an adoptive father. In addition, 68 birth adolescents (i.e., biological offspring of the adoptive parents) and 187 second adopted adolescents from these families participated in the study. All participants completed a mail survey that included assessment of drinking behavior and family functioning.

RESULTS

The relationship between parental problem drinking and adolescent alcohol involvement was moderate and significant among birth offspring (corrected multiple correlation, Rc = .30), but small and non-significant among adoptive offspring (Rc = .00). The relationship between adolescent alcohol involvement and family functioning was substantial for birth offspring (Rc = .39), but only modest for adoptive offspring (Rc = .16). The nonbiological sibling correlation for involvement with alcohol was significant (r = .24) and moderated by sibling pair demographic similarity, such that same-sex, similar-age siblings were substantially more similar (r = .45) than opposite-sex, dissimilar-aged siblings (r = .01).

CONCLUSIONS

These findings suggest that adolescent alcohol use is affected minimally by the environmental consequences of parent problem drinking and family functioning, but substantially by sibling environmental effects.

Chronic sulfasalazine therapy in the treatment of delayed pressure urticaria and angioedema

BACKGROUND

Delayed pressure urticaria/angioedema can be profoundly disabling with painful and prolonged swelling of feet and hands as well as systemic symptoms of malaise and flu-like illness. Occupations requiring prolonged standing and forceful use of hands may be seriously compromised by this condition. The severe forms of the disease are usually unresponsive to antihistamines and nonsteroidal anti-inflammatory drugs, and patients frequently require corticosteroids for control of symptoms.

OBJECTIVE

It was the purpose of this report to evaluate the clinical utility of sulfasalazine for two patients with refractory delayed pressure urticaria.

METHODS

Sulfasalazine, starting at 500 mg/day (with weekly incremental dosing to a total of 4 g), was administered to two patients with disabling pressure urticaria and angioedema (symptomatic daily with normal activities) who had failed all other reported therapeutic options except corticosteroids.

RESULTS

Patient A required daily prednisone in excess of 30 mg (for more than 6 months) to control his painful angioedema sufficiently in order to continue working as a colorectal surgeon. Patient B also experienced daily symptoms for more than 1 year. Both patients tolerated sulfasalazine to a dose of 4 g/day without adverse reactions and achieved complete resolution of symptoms. Patient A continued to be well controlled 1 year after starting but must maintain a dose of 2 g or greater per day. Patient B reported excellent control 6 months after starting but was subsequently lost to follow-up.

CONCLUSION

Sulfasalazine, in doses used for inflammatory bowel disease, appears to be an effective alternative therapy for delayed pressure urticaria and angioedema in patients poorly controlled by traditional treatment and may act as a corticosteroid-sparing agent.

Clinical implementation of a rapid, automated assay for assessing fetal lung maturity

We retrospectively determined cutoff levels and implemented the use of the TDxFLx assay in assessing the likelihood or absence of respiratory distress syndrome or fetal lung maturity (FLM) in a high-risk obstetric setting when compared to the lecithin/sphingomyelin (L/S) ratio and disaturated lecithin (DSL) measurements. Using a mature TDxFLx cutoff value of > or = 50 mg/g and an immature cutoff value of < 20 mg/g, 88% of L/S ratio and DSL measurements could be eliminated without compromise to the patient. The > or = 50 mg/g TDxFLx cutoff value resulted in a sensitivity of 100% and specificity of 88%. We also recommend the use of the TDxFLx assay as a screening test in diabetic pregnancies. More timely patient care occurred when the rapid TDxFLx assay was implemented by the laboratory and used by clinicians.

Allelic loss in locally metastatic, multisampled prostate cancer

In order to determine whether retention or loss of potential tumor suppressor loci that map to 8p, 10q, or 16q reflect genetic relationships among prostatic intraepithelial neoplasias (PINs), multicentric primary prostatic cancers, and regional lymph node metastases or are associated with the metastatic phenotype, we analyzed 19 cases of locally metastatic prostate carcinoma (stage D1) utilizing polymerase chain reaction techniques. In each case, tissue samples from metastatic tumor, the (dominant) primary tumor, and nonneoplastic prostatic tissue were examined. In selected cases, allelic loss in additional tumor foci, separate from the dominant tumor nodule, and areas of PIN were examined. Allelic loss of sequences on 8p, 10q, and 16q were observed in 20-29% of PINs, 18-42% of primary tumors, and 8-25% of metastatic tumors. Discrepancies in sequence dosage between histological components were most pronounced for 8p sequences, especially between the dominant tumor nodule and metastatic deposits in cases in which > or = 3 separate tumor foci/gland were identified. These results suggest that putative premalignant lesions, moderately or poorly differentiated, geographically separate primary tumor foci, and metastases within morphologically "complex" prostates (those with > or = 3 foci/gland) are likely to be more discordant for sequence dosage at 8p than those within "simpler" glands (< 3 foci/gland). Also, our results suggest that lymph node metastases may be genetically related to either the dominant or additional primary tumor foci in more complex prostates and that accumulation of genetic aberration may differ in primary and metastatic lesions.

A bullous skin disease patient with autoantibodies against separate epitopes in 1 mol/L sodium chloride split skin

BACKGROUND

We describe a patient with a subepidermal bullous skin disease associated with autoantibodies recognizing separate epitopes in 1 mol/L sodium chloride (NaCl) split skin.

OBSERVATIONS

Direct immunofluorescence microscopy showed deposits of immunoglobulins and C3 in a continuous pattern in the patient's epidermal basement membrane zone. Direct immunoelectron microscopy demonstrated thick deposits of IgG overlying the lamina lucida and the lamina densa in a unique pattern. The patient had circulating IgG anti-basement membrane zone antibodies that bound both sides of 1 mol/L NaCl split skin, exhibited at least a fourfold-higher titer against the dermal side of this test substrate, and bound basal keratinocyte hemidesmosomes as well as focal sites along the superior portion of the lamina densa on indirect immunoelectron microscopy. Affinity purification of anti-basement membrane zone antibodies against epidermal or dermal strips of 1 mol/L NaCl split skin yielded IgG that only bound the side of split skin from which it was eluted. The patient's serum contained IgG that immunoprecipitated and immunoblotted the 230- and 170-kd bullous pemphigoid antigens. Affinity purification of patient antibody against bullous pemphigoid antigen immobilized on nitrocellulose paper yielded IgG that bound only the epidermal side of 1 mol/L NaCl split skin. The patient showed no evidence of reactivity against type VII collagen by direct immunoelectron microscopy, indirect immunoelectron microscopy, or immunoblot.

CONCLUSIONS

This patient's bullous skin disease is associated with IgG anti-basement membrane zone antibodies with two specificities: one recognizing the bullous pemphigoid antigen in the epidermal side of 1 mol/L NaCl split skin, and another binding a distinct, yet presently unidentified, epitope in the superior aspect of the lamina densa.

The beta globin gene cluster of the prosimian primate Galago crassicaudatus: nucleotide sequence determination of the 41-kb cluster and comparative sequence analyses

The nucleotide sequence of the beta globin gene cluster of the prosimian Galago crassicaudatus has been determined. A total sequence spanning 41,101 bp contains and links together previously published sequences of the five galago beta-like globin genes (5'-epsilon-gamma-psi eta-delta-beta-3'). A computer-aided search for middle interspersed repetitive sequences identified 10 LINE (L1) elements, including a 5' truncated repeat that is orthologous to the full-length L1 element found in the human epsilon-gamma intergenic region. SINE elements that were identified included one Alu type I repeat, four Alu type II repeats, and two methionine tRNA-derived Monomer (type III) elements. Alu type II and Monomer sequences are unique to the galago genome. Structural analyses of the cluster sequence reveals that it is relatively A+T rich (about 62%) and regions with high G+C content are associated primarily with globin coding regions. Comparative analyses with the beta globin cluster sequences of human, rabbit, and mouse reveal extensive sequence homologies in their genic regions, but only human, galago, and rabbit sequences share extensive intergenic sequence homologies. Divergence analyses of aligned intergenic and flanking sequences from orthologous human, galago, and rabbit sequences show a gradation in the rate of nucleotide sequence evolution along the cluster where sequences 5' of the epsilon globin gene region show the least sequence divergence and sequences just 5' of the beta globin gene region show the greatest sequence divergence.

IMS, ISBA cooperation yields new laws on advance directives

Iowans have greater control over their medical care, thanks to the cooperative efforts of the Iowa State Bar Association and the Iowa Medical Society.

Lipase and pancreatic amylase activities in tissues and in patients with hyperamylasemia

Lipase, pancreatic amylase, and total amylase activities were measured in nondiseased and diseased human pancreatic tissues and in six different locations of the human digestive system. In addition, it was determined whether serum lipase and pancreatic amylase tests could replace the total amylase test to improved diagnostic efficiency in the evaluation of acute pancreatitis in hyperamylasemia patients. Nondiseased pancreatic tissue contained 4.5 times more lipase activity than total amylase activity. Diseased pancreatic tissue contained less activity for both lipase and total amylase compared to normal tissue. The total amylase activity of the pancreas was comprised solely of pancreatic amylase. Tissue obtained from six different anatomic locations in the digestive system contained 35 to 45 times less lipase and total amylase activity compared to the pancreas. Total amylase activity of the digestive system tissues were comprised of 25% pancreatic and 75% salivary isoamylases. Lipase, pancreatic amylase, and total amylase levels also were determined in serial serum samples from 17 consecutive hyperamylasemia patients admitted with possible acute pancreatitis. The serum lipase level remained higher than normal longer than either the total amylase and pancreatic amylase levels. In patients with hyperamylasemia of pancreatic origin, a poor correlation was observed at admission between serum pancreatic amylase and serum lipase. Not all patients with elevated lipase had an elevated pancreatic amylase level and vice versa. However, in every patient pancreatic disease would have been detected by the elevation of either lipase or pancreatic amylase levels. Diagnostic efficiency for pancreatic disease using serum pancreatic amylase, lipase, and total amylase tests was 94.1%, 76.5%, and 64.7%, respectively. These data suggest that lipase and pancreatic amylase tests are specific for the pancreas and might be considered replacements for total amylase as the stat or routine laboratory test for the diagnosis of pancreatic tissue injury.

An unusual vertical root fracture

A case of an unusual fracture in the mesial root of a lower first molar tooth is described. The possible causes of vertical root fractures are discussed.

Idiopathic thrombocytopenic purpura presenting with infraorbital nerve paraesthesia

A case of severe chronic idiopathic thrombocytopenic purpura is reported which presented with infra-orbital paraesthesia and haemorrhagic bullae of the oral mucosa.

Primate evolution at the DNA level and a classification of hominoids

The genetic distances among primate lineages estimated from orthologous noncoding nucleotide sequences of beta-type globin loci and their flanking and intergenic DNA agree closely with the distances (delta T50H values) estimated by cross hybridization of total genomic single-copy DNAs. These DNA distances and the maximum parsimony tree constructed for the nucleotide sequence orthologues depict a branching pattern of primate lineages that is essentially congruent with the picture from phylogenetic analyses of morphological characters. The molecular evidence, however, resolves ambiguities in the morphological picture and provides an objective view of the cladistic position of humans among the primates. The molecular data group humans with chimpanzees in subtribe Hominina, with gorillas in tribe Hominini, orangutans in subfamily Homininae, gibbons in family Hominidae, Old World monkeys in infraorder Catarrhini, New World monkeys in semisuborder Anthropoidea, tarsiers in suborder Haplorhini, and strepsirhines (lemuriforms and lorisiforms) in order Primates. A seeming incongruency between organismal and molecular levels of evolution, namely that morphological evolution appears to have speeded up in higher primates, especially in the lineage to humans, while molecular evolution has slowed down, may have the trivial explanation that relatively small genetic changes may sometimes result in marked phenotypic changes.

Assessment of renal function by inulin clearance: comparison with creatinine clearance as determined by enzymatic methods

We compared creatinine clearances determined by enzymatic (Kodak Ektachem 700 single-slide, Boehringer Mannheim creatinine PAP) and nonenzymatic (Jaffé, HPLC) methods with glomerular filtration rate measured by inulin clearance in patients with varying degrees of renal function. The Kodak enzymatic assay gave values for creatinine 2 to 3 mg/L higher than the other methods. This resulted in significantly lower creatinine clearances than inulin clearances and creatinine clearances determined by the other methods. However, correlations between all methods for serum and urinary creatinine values and clearances were good. To avoid between assay (enzymatic vs nonenzymatic) discrepancies, manufacturers should agree to an acceptable standard of calibration under the usual conditions used with patients.

Assessment of renal function by inulin clearance: comparison with creatinine clearance as determined by enzymatic methods

We compared creatinine clearances determined by enzymatic (Kodak Ektachem 700 single-slide, Boehringer Mannheim creatinine PAP) and nonenzymatic (Jaffé, HPLC) methods with glomerular filtration rate measured by inulin clearance in patients with varying degrees of renal function. The Kodak enzymatic assay gave values for creatinine 2 to 3 mg/L higher than the other methods. This resulted in significantly lower creatinine clearances than inulin clearances and creatinine clearances determined by the other methods. However, correlations between all methods for serum and urinary creatinine values and clearances were good. To avoid between assay (enzymatic vs nonenzymatic) discrepancies, manufacturers should agree to an acceptable standard of calibration under the usual conditions used with patients.

Group therapy in a general practice setting for frequent attenders: a controlled study of mothers with pre-school children

The frequent attendance of women suffering from anxiety and depression is a common problem in general practice and the problems are often externalized through the women's children. A small controlled study was carried out in a general practice surgery to see whether demand for medical attention by mothers of pre-school children would decrease after they attended a discussion group. Twenty women who fulfilled the study criteria of more than double the national average consultation rate for their age group and of having at least one pre-school child, were sequentially allocated to a treatment or control group. The group therapy was held over two terms of 10 sessions, each of 90 minutes, and was led by a psychologist and a general practitioner. Consultation rates (including surgery visits, house calls and prescription requests) were recorded for five consecutive six-month periods before and after the intervention. At follow-up six months after the end of the treatment a significant reduction in consultation rate had been achieved and maintained by the treated group compared with the controls (P<0.01). This study shows the value of attending to the cause of frequent consultation as well as to the complaints presented.

Relaxation and imagery in the treatment of breast cancer

OBJECTIVE

To see whether stress could be alleviated in patients being treated for early breast cancer.

DESIGN

Controlled randomised trial lasting six weeks.

SETTING

Outpatient radiotherapy department in a teaching hospital.

PATIENTS

One hundred fifty four women with breast cancer stage I or II after first session of six week course of radiotherapy, of whom 15 dropped out before end of study.

INTERVENTION

Patients saw one of two researchers once a week for six weeks. Controls were encouraged to talk about themselves; relaxation group was taught concentration on individual muscle groups; relaxation and imagery group was also taught to imagine peaceful scene of own choice to enhance relaxation. Relaxation and relaxation plus imagery groups were given tape recording repeating instructions and told to practise at least 15 minutes a day.

END POINT

Improvement of mood and of depression and anxiety on self rating scales.

MEASUREMENTS AND MAIN RESULTS

Initial scores for profile of mood states and Leeds general scales for depression and anxiety were the same in all groups. At six weeks total mood disturbance score was significantly less in the intervention groups, women in the combined intervention group being more relaxed than those receiving relaxation training only; mood in the control group was worse. Women aged 55 and over benefited most. There was no difference in Leeds scores among the groups.

CONCLUSIONS

Patients with early breast cancer benefit from relaxation training.

Hereditary xanthinuria in 2 Pakistani sisters: asymptomatic in one with beta-thalassemia but causing xanthine stone, obstructive uropathy and hypertension in the other

We describe a 3-year-old Pakistani girl who presented with recurrent urinary infections. She had a nonfunctioning hydronephrotic right kidney and hypertension. At operation a calculus was impacted in the right ureter with dilatation of the pelviocaliceal system. Nephrectomy was performed. Histology revealed end stage pyelonephritis. The calculus consisted of pure xanthine. Further investigations demonstrated low serum uric acid and absent urinary uric acid with increased excretion of xanthine. Eight months after nephrectomy blood pressure had decreased to normal. Her 5-year-old sister, who has beta-thalassemia, also has a low serum uric acid concentration and xanthinuria. The treatment of choice is to increase fluid intake so that the urine xanthine concentration remains below the level at which xanthine crystallizes. This may require adjustment of the urine pH.

Foetal heart rate and maternal emotional state

Forty-five pregnant women rated themselves for hostility, depression and anxiety. Maternal and foetal heart rates were recorded while they listened to a tape through headphones. The foetuses of anxious mothers showed pronounced responses to certain taped stimuli but this effect was not found for mothers with high hostility or depression scores.

Ill health and use of medical care. Community-based assessment of morbidity in children

The purpose of this study was to assess the relationship between morbidity and ambulatory care utilization in a randomly selected sample of children with stable patterns of use of services in a prepaid multispecialty group practice. The unique features of the approach were a focus on long-term relationships (over 8 years) and on assessment of health status by a combination of parent reports, child reports, teacher reports, and physical examination. Domains of health status that were assessed included types and frequencies of health conditions and disability associated with them, functional status (physical health, mental health, social health, general well-being), school absence, vision and hearing screening, and physical abnormalities. Children with persistently high levels of use of services in a 6-year period (1974-79) were more likely to have health problems of all types, both concurrent and in a subsequent 2-year period (1980-81) than children with lower levels of use. As these findings were in agreement with those obtained in a study where morbidity was determined by diagnoses recorded in medical records, it is likely that the measures could be more generally useful to assess child health status in the community. Moreover, they distinguish groups of children who differ in their pattern of use of services and hence may be useful in the planning and budgeting of services for child populations.

Utilization and morbidity: random or tandem?

Earlier studies have shown that one in eight children persist in being high users of health care services over long periods of time and, conversely, about the same proportion of children are consistently low users. As these studies failed to discover reasons for these persistent deviations from average, this study explored three possible explanations: persistent morbidity, mental health problem, and familial patterns of use. Although all three phenomena were associated with both persistence of high utilization of services as well as an overall large number of visits, the number of types of morbidity was the most significant correlate of high use. Children who were constantly low users of services were much more likely to have only a few types of morbidity whereas children who were constantly high users were much more likely to experience a wide variety of types of problems. These findings suggest that an understanding of the demand for health services requires an understanding of the interrelationships of illnesses within individuals rather than a focus on particular illnesses or particular types of illnesses.