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

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

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

PURPOSE

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

DESIGN AND METHODS

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

RESULTS

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

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

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

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

Caring for yourself during times of organizational change

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

Utilization of outpatient mental health services after inpatient alcoholism treatment

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Postpartum teaching priorities: the viewpoints of nurses and mothers

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

Identification of preferred topics and methods for postpartum teaching.

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Descriptive study.

SETTING

Tertiary care facility.

PATIENT(S)

Premenopausal females undergoing salpingectomy or salpingostomy for hydrosalpinges.

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

Development of single cell mouse embryos in vitro.

RESULT(S)

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

CONCLUSION(S)

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

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

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

Collaborative QI in community-based long term care

BACKGROUND

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

CURRENT STATUS

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

LESSONS LEARNED

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

SUMMARY AND CONCLUSIONS

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

Attributions about spouse abuse in cases of bidirectional battering

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

Aging of the human crystalline lens and anterior segment

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

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

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

Risk factors for AMA discharge from VA inpatient alcoholism treatment programs

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

The relationship between mortality and intensity of inpatient alcoholism treatment

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Age and ethnicity among hospitalized alcoholics: a nationwide study

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

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

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

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

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

Ethical dilemmas in driver reeducation

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

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

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

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

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

Potentiation by adrenaline of thrombin-induced elevation of pHi is not essential for synergistic activation of human platelets

Gel-filtrated human platelets were stimulated with thrombin in the absence and presence of adrenaline. Adrenaline markedly enhanced the thrombin-induced increase in cytoplasmic pH (pHi) in BCECF-loaded platelets. This rise in pHi was strongly inhibited by the Na+/H+ exchange blocker EIPA. The potentiation by adrenaline of thrombin-induced PLC activation measured as [32P]PA formation and final platelet responses was, however, not blocked by EIPA, even at low concentrations of thrombin. These results indicate that the enhancement by adrenaline of thrombin-induced cytoplasmic alkalinization may be a secondary effect which is not essential for the potentiation by adrenaline of platelet activation by thrombin.

Use of actin-bound adenosine 5'-diphosphate as a method to determine the specific 32P-radioactivity of the gamma-phosphoryl group of adenosine 5'-triphosphate in a highly compartmentalized cell, the platelet

Determination of the specific 32P-radioactivity of cytoplasmic ATP in 32P-Pi-labeled platelets is complicated by the presence of a large pool of metabolically inactive, granule-stored nucleotides. Moreover, our data show that the specific 32P-radioactivity of cytoplasmic ATP is severely underestimated when determined in platelets after the complete secretion of granule-stored nucleotides, possibly due to isotopic dilution with granule-stored phosphate. As F-actin-bound ADP is ethanol-insoluble, this pool can be readily separated from the other nucleotide pools in platelets. Here we show that the specific 32P-radioactivity of F-actin-bound ADP accurately reflects that of the gamma-phosphoryl group of cytoplasmic ATP. During uptake of 32P-Pi by human platelets the specific 32P-radioactivity of F-actin-bound ADP equals that of the monoester phosphates of phosphatidylinositol 4-phosphate and phosphatidylinositol 4,5-bisphosphate, which are in metabolic equilibrium with cytoplasmic ATP. Therefore, this method enables the determination of the specific 32P-radioactivity of the gamma-phosphoryl group of cytoplasmic ATP in platelets even under short-term labeling conditions.

Increasing patients' knowledge of radiation therapy

Scripts for a set of patient education programs were developed by a multidisciplinary team of health care professionals to provide information to cancer patients receiving a 4-7 week course of external beam radiation therapy. The programs were designed to be presented sequentially at three critical points during a course of treatment: Pretreatment, Treatment Week 2, and Final Treatment Week. A total of 72 patients, 24 per program, with cancers of the lung, breast, or prostate, were assessed for their level of knowledge after hearing the audiotape appropriate to their treatment phase (posttest). Half of the patients, on a random basis, were also assessed prior to hearing their tape (pretest). This split design allowed the differentiation of true learning effects from effects of multiple assessments. Knowledge test items were developed from learning objectives for each program. Posttest results indicate a very high level of patient learning for all three programs, significantly exceeding the target of 75% correct. For patients tested twice, posttest scores were significantly higher than pretest scores. No testing effects were found for the Pretreatment and Treatment Week 2 programs. Final Treatment Week subjects who were pretested scored slightly higher on the posttest than their controls who were not pretested; however, additional analysis demonstrated true learning effects for this group as well. The results indicate that the programs are effective for increasing patients' knowledge regarding their treatment program, its side effects, and strategies to manage those side effects. Further research and intervention programs are discussed.

Pathophysiologic and pharmacotherapy considerations in the management of the black hypertensive patient

The mortality and morbidity of hypertension-related diseases among blacks are much higher than in age- and sex-matched white counterparts. New data show that the incidence of renal damage may be 18 to 20 times greater in blacks than in whites. Some preliminary data also indicate that coronary heart disease is much more prevalent in blacks than previously suspected and that coronary heart disease mortality among blacks may indeed not be declining, as it is for white populations. Major contributors to these findings in blacks are an increased prevalence and severity of hypertension, a possibly increased susceptibility to end-organ damage, socioeconomic factors and beliefs that affect hypertension control, and very possibly some obsolete treatments that focus on blood pressure numbers and do not emphasize the black person and the associated risk factors. Diuretic therapy has long been the mainstay treatment for black hypertensives, but the effects of diuretics on lipid levels and left ventricular hypertrophy, among other factors, should be carefully assessed. A recent study of beta-blockers in blacks showed that metoprolol was effective and well tolerated. Consideration of epidemiologic, pathophysiologic, and pharmacotherapeutic features of hypertension in blacks may require traditional views of this disease and its treatment in this special population to be reevaluated.

Turnover of the phosphomonoester groups of polyphosphoinositol lipids in unstimulated human platelets

The metabolic activity of the polyphosphoinositol lipids in unstimulated human platelets was studied by short-term labelling with [32P]Pi, by replacement of [32P]Pi from pre-labelled platelets with unlabelled phosphate, and by depriving the cells of metabolic ATP. Under short-term labelling conditions, the 4- and 5-phosphate groups of phosphatidylinositol 4-phosphate (PtdIns4P) and phosphatidylinositol 4,5-bisphosphate [PtdIns(4,5)P2] had the same specific 32P radioactivity as the gamma-phosphate of metabolic ATP. The specific 32P radioactivity of the 1-phosphates of phosphatidylinositol, PtdIns4P and PtdIns(4,5)P2 was similar, but only 4-13% compared to that of the ATP-gamma-phosphate. When [32P]Pi pre-labelled platelets were incubated with up to 25 mM of unlabelled phosphate, the displacement of the 32P label from PtdIns4P, PtdIns(4,5)P2 and metabolic ATP followed similar kinetics. Inhibition of ATP regeneration in platelets pre-labelled with [32P]Pi resulted in a rapid fall in metabolic ATP with a much slower fall in [32P]PtdIns(4,5)P2, whereas [32P]PtdIns4P increased initially. However, ATP turnover was not abolished, as indicated by the marked (25% of the control) incorporation of extracellular [32P]Pi into PtdIns4P and PtdIns(4,5)P2 in metabolically inhibited platelets. This low phosphate turnover may explain the relative resistance of PtdIns4P and PtdIns(4,5)P2 to metabolic inhibition. We conclude that PtdIns4P and PtdIns(4,5)P2 are present as a single metabolic pool in human platelets. Turnover of the 4- and 5-phosphates of PtdIns4P and PtdIns(4,5)P2 in unstimulated platelets is as rapid as that of the gamma-phosphate of metabolic ATP, and accounts for about 7% of basal ATP consumption.

Stimulation of phosphate uptake in human platelets by thrombin and collagen. Changes in specific 32P labeling of metabolic ATP and polyphosphoinositides

The uptake of [32P]phosphate by human, gel-filtered blood platelets and its incorporation into cytoplasmic ATP and polyphosphoinositides was studied. In unstimulated platelets, uptake was Na+o-dependent and saturable at approximately 20 nmol/min/10(11) cells with a half-maximal rate at 0.5 mM extracellular phosphate. Upon stimulation with thrombin or collagen, net influx of [32P]Pi was accelerated 5- to 10-fold. With thrombin, [32P]Pi efflux was also increased. After the first 2 min, efflux exceeded influx, resulting in the net release of [32P]Pi from the platelets. Since the stimulus-induced burst in [32P]Pi uptake paralleled the secretory responses, it might be an integral part of stimulus-response coupling in platelets. The stimulus-induced burst in net [32P]Pi uptake led to an enhanced labeling of metabolic ATP, which was already detectable at 5 s after stimulation with thrombin. Concomitantly, the incorporation of [32P]Pi into phosphatidylinositol 4-phosphate and phosphatidylinositol 4,5-bisphosphate was accelerated. The thrombin-induced increase in specific 32P radioactivity of cytoplasmic ATP fully accounted for the simultaneous increase in specific 32P radioactivity of these phosphoinositides. In studying the extent of 32P labeling of phosphorylated compounds in response to a cellular stimulus, it is therefore essential to measure the effect of the stimulus on the specific radioactivity of cytoplasmic ATP.

Predictive value of minor anomalies. I. Association with major malformations

We examined 4305 white newborn infants for 114 minor physical features and major malformations to evaluate the hypothesis that the presence of three or more minor anomalies is highly predictive of a major malformation. We confirmed that the infant with three or more minor anomalies is at increased risk for a major malformation. However, this risk (19.6%) was much lower than the risk of 90% popularized by Smith and based on the study of Marden et al. (J Pediatr 1964;64:357). Analysis of the findings in the two studies showed that the lower predictive value was probably related to differences in study design. Nevertheless, some minor anomalies remain essential to the early recognition of several serious malformation syndromes.

Mucocutaneous pigmented spots and oral myxomas: the oral manifestations of the complex of myxomas, spotty pigmentation, and endocrine overactivity

The complex of myxomas, spotty pigmentation, and endocrine overactivity is a recently recognized syndrome, transmitted as an autosomal dominant trait. The most serious component of the disorder is cardiac myxoma, which has caused the death of one fourth of the affected patients and serious disability in an equal number. It is, therefore, important to recognize patients at risk from the syndrome and, in particular, to test them for cardiac myxoma. Fortunately, in many patients the myxoma complex has a clearly visible marker: mucocutaneous pigmentation. Among 58 patients with the syndrome, spotty facial pigmentation was present in 36 (62%), and 29 (50%) of these also had pigmented spots on their lips. This type and distribution of pigmentation should be a clue to the possible presence of the complex of myxomas, spotty pigmentation, and endocrine overactivity, and patients thus affected should be referred for further investigation. Oral cavity myxoma(s) occurred in four patients with the syndrome.

Antihypertensive drug compliance in black males

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Prediction of sustained antihypertensive efficacy of chronic captopril therapy: relationships to immediate blood pressure response and control plasma renin activity

The blood pressure (BP) lowering effect of the orally active angiotensin converting enzyme inhibitor, captopril (SQ14225), was studied in 59 hypertensive patients maintained on a constant sodium intake. Within 2 hours of the first dose of captopril BP fell from 171/107 to a maximum low of 142/92 mm Hg (p less than 0.001), and after 4 to 8 days to treatment BP averaged 145/94 mm Hg (p less than 0.001). The magnitude of BP drop induced by captopril was significantly correlated to baseline plasma renin activity (PRA) both during the acute phase (r = -0.38, p less than 0.01) and after the 4 to 8-day interval (r = -0.33, p less than 0.01). Because of considerable scatter in individual data, renin profiling was not precisely predictive of the immediate or delayed BP response of separate patients. However, the BP levels achieved following the initial dose of captopril were closely correlated to BP measured after 4 to 8 days of therapy, and appeared to have greater predictive value than control PRA of the long-term efficacy of chronic captopril therapy despite marked BP changes occurring in some patients during the intermediate period. Because of these intermediate BP changes, addition of a diuretic to enhance antihypertensive effectiveness of angiotensin blockade should be restrained for several days after initiation of captopril therapy.

An aid to computerization of Heyman's afterloading system

The authors describe a new type of dummy implant for use in the Heyman afterloading system. Inactive dummies with the same dimensions as the radioactive sources are loaded into the capsules before obtaining the orthogonal radiographs. The actual sources are not inserted until computer verification of satisfactory dose distribution has been obtained.