Barriers and enablers in the implementation of a standardised process for nutrition care: findings from a multinational survey of dietetic professionals in 10 countries

BACKGROUND

To explore the barriers and enablers experienced by nutrition and dietetic professionals in the implementation of the standardised Nutrition Care Process (NCP) across 10 different countries. NCP related beliefs, motivations and values were investigated and compared.

METHODS

A validated online survey was disseminated to nutrition and dietetics professionals in 10 countries in the local language during 2017. Cross-sectional associations and differences between countries were explored for level of implementation, barriers/enablers and attitudes/motivation among the respondents.

RESULTS

Higher NCP implementation was associated with greater occurrence of enabling aspects, as well as fewer occurrences of barriers. The most common enabler was 'recommendation by the national dietetic association' (69%) and the most common barrier was 'lack of time' (39%). A longer experience of NCP use was associated with a more positive attitude towards all NCP aspects. Differences between countries were identified, regarding both the occurrence of barriers/enablers and attitudes/motivations.

CONCLUSIONS

Implementation efforts need to be tailored to country-specific contexts when implementing a new standard of care framework among nutrition and dietetic professionals. Additional research is needed to further assess the management and workplace strategies to support the development of nutrition and dietetics professionals in multidisciplinary healthcare organisations.

The process of seeking sex partners online and implications for STD/HIV prevention

Research has shown that online sex-seeking among men who have sex with men (MSM) is related to elevated risk for sexually transmitted diseases (STDs), including HIV infection; however, the process of seeking sex online is not well understood. It is important to understand the process of seeking sex partners in order to determine the best method for reaching MSM at high risk for infection. We report on baseline data from the Smart Sex Quest, an Internet-based STD prevention intervention targeting MSM (n = 1,776, 79% white, mean age = 33 years). Results indicate that older, white, college-educated men solicited sex partners on AOL, whereas Gay.com was a more frequent choice among younger men. Yahoo was named as a solicitation site more frequently by those with no college education, as were 'bareback' websites devoted to facilitating anal sex without the use of condoms. Following online solicitation, men tended to meet in public restrooms (86%), partners' homes (74%) and their own home (57%). Though results are limited by the self-selected nature of the sample, the data have important implications for online outreach, study recruitment and intervention.

Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: the smart sex quest project

There is an increasing interest in developing interventions for HIV and STD prevention that can be delivered on the Internet. However, we know little about what it takes to identify, recruit and retain participants in interventions so that we can test their efficacy and effectiveness. Objectives for this investigation were to evaluate rates of recruitment and retention in an Internet-based randomized controlled trial (RCT) to increase sexually transmitted disease (STD) prevention among men who have sex with men (MSM). The Smart Sex Quest study was a RCT conducted online. Eligible participants were MSM, at least 18 years old and US residents. After completing a baseline risk assessment, participants were exposed to tailored or control messages and asked to return to the site at three months for a follow-up interview. From January 2002 through June 2003, 3,625 persons logged on as potential study participants; of these, 563 were not eligible, while 1,286 left the site without filling out a baseline survey. Complete baseline data were available for 1,776 participants, all of whom were eligible to complete a follow-up. Complete follow-up data were available for 270 (15.2%) participants. While the Internet is a valuable tool for conducting research, conducting this longitudinal research online was severely affected by a loss to follow-up, and analyzing outcome data was hampered by significant differences between those who did and did not complete the study. Alternate ways to recruit for and evaluate online trials must be considered.

Use of the urinary trypsinogen-2 dip stick test in early diagnosis of pancreatitis after endoscopic retrograde cholangiopancreatography

BACKGROUND

This study aimed to prove that the urinary trypsinogen-2 dip stick test can be used for early diagnosis of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

For this prospective, blinded, pilot study, urine samples were collected before ERCP, 1 h after ERCP, and 4 h after ERCP. The urine dipstick test was used to detect trypsinogen-2 on the basis of immunochromatography. The dipstick results were compared with those of current methods used to diagnose post-ERCP pancreatitis. Once the patient disposition was finalized, pancreatic enzymes, clinical findings, and final diagnosis were obtained from the chart and compared with the urine trypsinogen-2 test findings. The sensitivity, specificity, and positive and negative predictive values were calculated.

RESULTS

The urine trypsinogen dip stick test was performed for 30 patients (15 men and 15 women). Post-ERCP pancreatitis was diagnosed in 5 of 29 patients by clinician assessment, serum pancreatic enzyme levels, or both. The amylase and lipase levels for post-ERCP patients with and without pancreatitis were 650 +/- 145 vs 134 +/- 26 (p = 0.023) and 1,658 +/- 594 vs 84 +/- 17 (p = 0.057), respectively. This statement proves that patients who developed post ERCP pancreatitis had significant elevation of amylase and lipase compared to patients who did not have pancreatitis. For the dip stick test, 6 of 28 patients had positive results in 1 h and 6 of 29 patients had positive results in 4 h. The sensitivity of the 1-h test was 1.0, and the specificity was 0.91. The positive predictive value (PPV) was 0.66, and the negative predictive value (NPV) was 1.0. The sensitivity of the 4-h test was 1.0, and the specificity was 0.96. The PPV was 0.8, and NPV value was 1.0.

CONCLUSION

The urinary trypsinogen-2 dip stick test is useful for early diagnosis of post-ERCP pancreatitis and allows the testing physicians to begin management early in its course.

The effects of triiodothyronine augmentation on antithrombin III levels in sepsis

Sepsis and multisystem organ failure are often associated with disseminated intravascular coagulation and consumption of coagulation inhibitors such as antithrombin III (ATIII). The "sick euthyroid syndrome" is also seen in association with significant illnesses and consists of decreased levels of circulating triiodothyronine (T3). We evaluated whether T3 supplementation would affect ATIII levels in septic rats. Thirty Sprague-Dawley rats were divided into three groups: sham laparotomy (S) plus saline, cecal ligation and puncture (CLP) plus saline, and CLP plus T3 (3 ng/hour) via an osmotic minipump. Twenty-four hours after laparotomy blood was drawn, and T3 and ATIII levels were then compared with baseline values. T3 supplementation partially negated the sepsis-induced decrease in circulating T3 levels. The levels are expressed as percentage change from the levels before surgery (S, -12.9 +/- 3.1; CLP, -60.0 +/- 5.3; CLP + T3, -34.9 +/- 4.3; mean +/- standard error; P < 0.05). T3 supplementation also statistically changed the percentage difference in ATIII levels toward the control (S, 9.6 +/- 2.8; CLP, -37.9 +/- 5.4; CLP + T3, -16.0 +/- 4.5; mean +/- standard error; P < 0.01). T3 supplementation reduced the sepsis-induced decrease in ATIII levels. Whether this was accomplished by decreased consumption or increased production of ATIII via the direct anabolic effect of T3 on acute-phase protein synthesis in the liver is unknown and warrants further investigation.

A new teaching model to prolong breastfeeding among Latinos

Latino women in Salt Lake City, Utah, have some of the lowest breastfeeding rates in the state. In an attempt to prolong breastfeeding duration in this population, the authors designed a new class to be taught by certified WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) personnel to pregnant Spanish-speaking participants. The class was designed after a literature review and onsite ethnographic research. The term la cuarentena del bebé was introduced to signify the recommended 40 days when mothers should exclusively breastfeed, avoiding bottles, pacifiers, and supplementation. As part of the teaching model, class participants prepare an infant-feeding plan. Preliminary interviews show that WIC participants and staff view the new approach as an improvement. A randomized controlled trial is under way to evaluate the effectiveness of the class.

Management of choledocholithiasis in the era of laparoscopic surgery

Laparoscopic biliary surgery is changing the management of choledocholithiasis. Between November 1989 and December 1998, 2834 cholecystectomies were performed at two institutions. Choledocholithiasis was suspected in 420 patients on the basis of elevated preoperative laboratory and ultrasound criteria [bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, serum glutamate pyruvate transaminase, and common bile duct (CBD) size]. One hundred seventeen patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP) because of persistent elevation in their enzymes beyond 24 to 48 hours or as an emergency. Laparoscopic intraoperative cholangiogram was attempted in 329 patients whose enzymes fell rapidly within the first 24 to 48 hours or had a failed ERCP. Eighty-one of the 329 were found to have stones. Seventy-three had laparoscopic attempt to clear the CBD, with success in 62 patients (85%). This included 41 transcystic duct and 21 direct CBD exploration. Eight patients had post-operative ERCP for retained stones. Six (0.25%) were in patients with normal preoperative enzymes. We conclude that choledocholithiasis can be suspected with preoperative laboratory and ultrasound criteria. By waiting 24 to 48 hours (except in an emergency), a good number of CBD stones will pass. With increases in laparoscopic experience, laparoscopic removal of CBD stones may replace preoperative ERCP. The small number of cases of retained or missed stones that occur with the use of selective cholangiography can be easily handled with postoperative ERCP.

HIV, hepatitis B, and hepatitis C in the Code One trauma population

The resuscitation of a trauma patient is a very hectic and seemingly chaotic situation. The nature of the situation increases the likelihood that a health care worker will receive an accidental needle stick while caring for the patient. There is also a common belief that there is a higher prevalence of communicable bloodborne diseases in the trauma population, and human immunodeficiency virus (HIV) causes the greatest amount of fear. This belief of higher prevalence communicable diseases in the trauma population is supported by the literature. We sent blood from our Code One (life-threatening) trauma population for analysis for HIV, hepatitis B surface antigen, and hepatitis C antibodies. We found that 0.52% of our trauma population had HIV. We also found that 1.5 per cent had hepatitis B surface antigen, and 13.8 per cent had hepatitis C antibodies. Our prevalence of HIV and hepatitis B is similar to that found in other studies of the trauma populations and higher than the general population. Our hepatitis C prevalence is surprising, considering the very low reported prevalence in the general population. Hepatitis C may be a more significant threat to the health of medical personnel than previously believed.

HIV prevention in U.S. Asian Pacific Islander communities: an innovative approach

Few HIV prevention efforts have focused on Asian Pacific Islander communities in the United States. Prevention messages developed for the general U.S. population have failed to reach many Asian Pacific Islanders. This article describes the development of an HIV prevention strategy for Asian Pacific Islanders through health care workers. This strategy was based on the ecological disease theory and action research methodology. The prevention program comprised four components: (1) a symposium for the health care workers, (2) a culturally sensitive and appropriate HIV-related video for the health care workers and their patients, (3) ongoing training of the health care providers, and (4) ongoing liaison and consultative services for the health care providers. The intervention is intended to encourage HIV risk-reduction behaviors among the patients, to encourage the HIV testing of those who may be at risk for HIV, and to facilitate access to services for those found to be infected.

Laparoscopic training in residency program

The use of laparoscopy in general surgery has provided surgeons with a new approach to multiple procedures. New techniques are being developed daily. Laparoscopic training for surgical residents must be incorporated into their curriculum. To decrease the risks of training residents on patients and to decrease operative time, a program of videoscopic "bench" training exercises, to improve eye-hand coordination, was instituted for junior residents. Between July and September 1995, nine surgical residents participated in this proficiency videoscopic study. At the end of the study, there was a statistically significant improvement in the residents performance by an average of 37% (P = 0.0109). This program proved to be both effective and economical. It can be reproduced and easily incorporated into any surgical residency program.

Effect of resuscitation solutions on the immune status of dogs in hemorrhagic shock

The purpose of this study is to examine the effects of three different types of fluid resuscitation on the immune system of dogs in hemorrhagic shock. Using a modified Wigger shock model, 18 conditioned male dogs were bled to mean arterial blood pressure of 60 mm Hg for 90 minutes and placed into three groups based on the resuscitative method. Group I: Crystalloid Resuscitation; Group II: Autotransfusion; Group III: Banked Blood. Laboratory methods for immune status evaluation included total lymphocyte count, T4/T8 ratio, total serum immunoglobulins, and immunoglobulin electrophoresis. These values were obtained pre-hemorrhagic shock, just before resuscitation, and subsequently on days 1, 4, and 7. Humoral immunity, represented by total serum immunoglobulin levels (IgA, IgG, IgM), was higher in Groups II and III when compared with group I on all post-resuscitation days. IgA and IgM levels were higher in Group III compared with Groups I and II. IgG level was higher in Group II compared with Groups I and III. Cellular immunity was also affected by transfusion. Total lymphocyte count was increased in Group II on Day 1; however, the three groups were similar with respect to this variable on subsequent days. The absolute T4 helper cell level in Group II was similar to Groups I and III until Day 7, at which time the level became higher in Group II.(ABSTRACT TRUNCATED AT 250 WORDS)

Handpiece asepsis: a survey of the attitudes of dental practitioners

The methods of handpiece asepsis employed by general dental practitioners (GDPs) in England and the problems considered to be associated with handpiece sterilisation were investigated by means of a postal questionnaire distributed to a random sample of 500 GDPs during July 1993. A total of 267 replies were received (53.4% response). The results indicated that at the time of the survey, autoclavable handpieces were possessed by 90.6% of the respondents (n = 242), with 45.9% (n = 111) of these respondents indicating that they autoclaved their handpieces routinely after every patient. Reasons given by respondents for not autoclaving handpieces routinely included insufficient handpieces, fear of handpiece damage, cost, and the consideration that sterilisation was not necessary. Handpiece asepsis procedures had been upgraded by 89% (n = 237) of respondents in the 5 years preceding the survey. Media coverage was found to have exerted influence on the respondent dentists' behaviour, with the overall incidence of routine handpiece autoclaving increasing by 20.6% after media coverage of the subject.

Setting standards for a school nursing service

School nurses in Airedale have developed a set of standards and procedures for their service using British Standard BS 5750* as a framework. Liz Lloyd et al describe this innovative approach to achieving an effective, client-responsive quality management system.

Effect of social networks on cancer-screening behavior of older Mexican-American women

BACKGROUND

Previous studies have determined that Hispanic women and, in particular, Mexican-American women have the lowest rates of cancer screening of any race and ethnic group in the United States. In the development of cancer control strategies for this population, little attention has been given to factors that encourage Mexican-American women to seek cancer preventive care. Recent studies suggest that social networks can have a positive influence on cancer-screening participation.

PURPOSE

We determined the extent to which differences in social networks account for variations in breast and cervical cancer-screening practices among low-income Mexican-American women.

METHODS

The data analyzed in this study were obtained from a baseline survey of knowledge, attitudes, and cancer-screening practices conducted prior to implementation of community interventions designed to improve Pap smear and mammography screening in low-income Mexican-American women 40 years old and older living along the U.S.-Mexican border in El Paso County, Texas. A random selection of 1300 households served as a sampling frame to identify Mexican-American women 40 years old and older for personal interviews. Of the 549 households identified as having at least one eligible female, 450 women completed the personal interviews that provided the data for this study. Personal interviews solicited information on age, income, marital status, place of birth, education, health insurance coverage, Pap smear- and mammogram-screening practices, and six questions relating to social network. A social network score was assigned to each woman by summation of the following six variables: number of confidants, number of close friends, number of close relatives, frequency of contact with these close friends or relatives per month, church membership, and church attendance. Women were grouped into three linear strata of social network (low, medium, high) based on tertiles of the scores. Cancer-screening history was also ascertained during the interview.

RESULTS

The 2-year prevalence of Pap smear and mammography use increased with social network. For each gain in social network level (low, medium, high), adjusted for sociodemographic factors, the odds ratio for Pap smear use was 1.33 (95% confidence interval = 1.02-1.73); it was 1.40 (95% confidence interval = 1.02-1.93) for mammogram use. Of the six social network components, the number of close friends was the most important predictor of mammography (P = .002) and Pap smear (P = .025) screening.

CONCLUSION

Social networks appear to be an important determinant of cancer-screening behavior among low-income, older Mexican-American women.

The role of endoscopic retrograde cholangio-pancreaticrogram in laparoscopic cholecystectomy

Four hundred and fifty-nine patients were studied to evaluate the role of diagnostic and therapeutic endoscopic retrograde cholangio-pancreaticrogram (ERCP) in their management before laparoscopic cholecystectomy (LC) when choledocholithiasis is suspected. Using bilirubin, liver function tests (LFTs) (alkaline phosphatase, SGOT, SGPT) and findings on ultrasound of a dilated common bile duct (CBD), 37 patients (8.1%) were suspected of having concomitant common bile duct stones preoperatively. These patients were subjected to the following diagnostic and therapeutic procedures: 25 ERCPs, 20 laparoscopic cholangiograms, and three extracorporeal shock wave lithotripsies. Preoperative ERCP was done on 19 patients, intraoperative ERCP-sphincterotomy was done on one patient, and postoperative ERCP-sphincterotomy was done on five patients. Fifteen laparoscopic cholangiograms were done as primary tests and five after preoperative ERCP. Sixteen patients (3.5%) had stones in their CBD. Four patients had their laparoscopic cholecystectomy cancelled, and one patient had laparoscopic common duct exploration that was converted to an open procedure. Three groups were identified: group I, patients with a high index of suspicion, included elevated bilirubin with elevation of all three LFTs, or normal bilirubin with elevation of all three LFTs with or without dilated CBD. Seventy-five per cent of this group had CBD stones. Group II, patients with a low index of suspicion, included normal bilirubin and normal CBD by ultrasound with elevation of the alkaline phosphatase alone or elevation of two of the three LFTs. Six per cent of this group had CBD stones. Group III, patients with no index of suspicion, were patients with normal preoperative laboratory test results and CBD. Two patients (0.47%) in this group had elevated LFTs postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic cholecystectomy: morbidity and mortality in a community teaching institution

From November 1989 to December 1990, 474 elective laparoscopic cholecystectomies were performed. This study analyzes the first year's experience with regard to complications, postoperative response in terms of pain and nausea, and time back to activity and work. There were 369 females and 105 males in the group. The average age was 51.5 years. Of these, 394 were discharged within 23 h and 80 required admission postoperatively. Of the group requiring hospitalization, there were 10 (2.1%) major complications, 37 (7.8%) minor complications, 14 (3.0%) aborted laparoscopic cholecystectomies, and 19 (4.0%) others. Major complications occurred early in the surgeon's experience, all but two within the surgeons' first 25 cases. Patients in the short stay group were followed-up with a phone questionnaire. In this group, most patients experienced minimal abdominal pain following surgery, with an average score of 2.4 (SD = 1.38) on a scale of 1 (absent) to 5 (extreme). At home, 48.6% of patients experienced some form of postoperative discomfort. Of these, 38.2% experienced abdominal pain, 18.7% shoulder pain, and 32.7% nausea. The average postoperative time to resume normal daily activity was 7.9 days (SD = 8.2) and to return to work was 11.6 days (SD = 9.9).

MHC-extended haplotypes in families of patients with Graves' disease

MHC-extended haplotypes were investigated in multiplex families of patients with hyperthyroid GD. Using a combination of both phenotypic (serology and protein electrophoresis) and genotypic (DNA-RFLP) markers, 159 MHC-extended haplotypes extending from HLA-A across the MHC class III (C2, Bf, C4A, and C4B) toward the HLA-DR/DQ complex were deduced from 217 (51 and 166 affected and unaffected) members of 21 families of patients with GD. Thyroid autoantibodies were measured and found positive in 27.1% of 166 clinically euthyroid unaffected members. Extended haplotypes were classified into four categories--affected (n = 40), Aff/Ab + ve (shared haplotype between affected and Ab + ve members, n = 31), Ab + ve (n = 29), and Ab - ve (n = 59)--based on the presence and absence of these haplotypes in 51 affected members with GD and 45 and 121 unaffected members who were respectively positive and negative for thyroid autoantibodies. Five recombinations were detected: three were found between HLA-A and B and two between HLA-B and the MHC class III. No recombination was found between or within the MHC class III and class II complex. Though the HLA-DR17 (DR beta 17(1) and DR beta 17(2)) allele was found to be significantly increased in both the affected and the Aff/Ab + ve when compared with the Ab - ve haplotypes (p < 0.042 and p < 0.018), the frequency of the HLA-B8, 2.7-kb SstI-4.5-kb TaqI/C2 Bf*S, 6.4-kb TaqI/C4A*Q0C4B*1, HLA-DR beta 17(1)/DQ alpha 2-DQ beta 2a extended haplotype was found to be significantly increased only in the affected haplotype (p < 0.05). These results suggest that while HLA-DR17 is a susceptibility allele shared between GD and individuals with positive thyroid autoantibodies, the HLA-B8, 2.7-kb SstI-4.5-kb TaqI/5'-3'C2 Bf*S, 6.4-kb TaqI/C4A*Q0B*1, DR beta 17(1)/DQ alpha 2-DQ beta 2a is a disease susceptibility-extended haplotype for Graves' disease.

Oxygenation of cardioplegic solutions: a note of caution

The merits of oxygenated crystalloid cardioplegic solutions have been well established in experimental animals. The positive effects of oxygenation of Plasmalyte B (Sabax Ltd) and St. Thomas Hospital solution (Plegisol) were achieved by gassing with 95% O2/5% CO2 and 100% O2, respectively. In view of the marked pH differences induced by these gas mixtures, we evaluated the effect of mode of oxygenation on myocardial recovery during reperfusion after hypothermic cardioplegic arrest. Oxygenation with 100% O2 of Plasmalyte B containing high K+ levels caused marked deterioration in myocardial recovery, whereas the mode of oxygenation did not affect recovery after arrest with St. Thomas Hospital solution. Because the major differences between these solutions reside in their respective K+, Mg2+, and HCO3- contents, the effects of variations in the levels of these ions were investigated. The results showed that oxygenation with 100% O2 was deleterious only in the presence of high K+ (29 mmol/L), low Mg2+ (3 mmol/L), and high NaHCO3 (28 mmol/L) levels. The marked decline in mechanical recovery during reperfusion was associated with significant changes in myocardial adenosine triphosphate and intracellular Ca2+ levels. Although an explanation for these findings is not readily available, it is suggested that complex ionic interactions and possibly oxygen free radical generation may lead to intracellular Ca2+ overload, depression in mitochondrial adenosine triphosphate generation, and, hence, deterioration in mechanical recovery.

C4A gene deletion: association with Graves' disease

The association of HLA class I and class II antigens, particularly HLA-B8,DR3, with a variety of autoimmune diseases has been well documented. The C4A*Q0 (non-expressed C4A) allele which is in linkage disequilibrium with HLA-B8,DR3 has also been reported to be associated with systemic lupus erythematosus, insulin-dependent diabetes mellitus and Graves' disease. However, the number of studies has been limited by the requirement of family data for the assignment of the C4A*Q0 allele based on C4 protein typing. Recently, with the availability of a C4 cDNA probe, a C4A gene deletion associated with HLA-B8,DR3 has been reported in normal individuals. We have tried to resolve the problem of assigning the C4A*Q0 allele by using both phenotypic and genotypic approaches and have determined the significance of the C4A*Q0 allele in 80 unrelated patients with Graves' disease and in 50 normal control subjects. Our results demonstrate a strong association of the C4A*Q0 allele with Graves' disease (56 versus 26%; P less than 0.002, relative risk = 3.7) and in particular in association with HLA-B8 and/or DR3 (92 versus 70.6%; P less than 0.04) when compared with normal controls. All the C4A*Q0 alleles that were associated with HLA-B8 and/or DR3 were due to a C4A gene deletion. Of the C4A*Q0 alleles, in Graves' disease, 94% (compared with 82% in the control group) could be detected by C4 DNA analysis using either TaqI or EcoRI restriction endonucleases. It is suggested that a combination of C4 protein typing with C4 DNA analysis is the best approach for the determination of the C4A*Q0 allele in unrelated individuals without access to family data.

The use of ketoconazole in prophylaxis of Candida sepsis

Candida sepsis has become an increasing problem in ICU patients with up to 50 per cent mortality rate. Ketoconazole, an oral antifungal agent, was used prophylactically in guinea pigs to see if this would prevent Candida sepsis. Absorption of ketoconazole has been stated to increase in an acid environment. Thirty-six guinea pigs were divided into three equal groups: group I received 1 cc normal saline, p.o.; group II received 10 mg/kg ketoconazole dissolved in 1 ml Maalox (Rorer Consumer; Fort Washington, PA); group III received 10 mg/kg ketoconazole in 1 ml in HCl, all given daily. Each animal received 10(8) colony forming units intravenously. The viability of the innoculum was confirmed by culture both pre- and postinjection. Each animal was observed daily for weight and ocular and skin lesions. Half of the animals were sacrificed on day seven and the remaining were sacrificed on day 14. Cultures, complete blood count (CBC), ketoconazole levels, and specimen histology were obtained. There was no difference between groups as to weight, leukocyte counts, skin or ocular lesions, or ketoconazole levels. Histologic analysis and quantitative cultures revealed little Candida invasion. In conclusion, Candida sepsis cannot be induced in healthy guinea pigs. The blood levels of ketoconazole were not affected by pH.

Suicide in Texas: a cohort analysis of trends in suicide rates, 1945-1980

Recent clusters of teenage suicides in Texas suburban communities have focused national attention on the rise in teenage suicidal behavior. This study sought to clarify the teenage suicide phenomenon by using a cohort method of data analysis. Beginning with suicide rates for white males aged 15-19 in 1945, suicide rates were calculated and plotted for each 5-year age cohort entering the late teenage years, when suicide risk factors dramatically increase. Our analysis of these cohort patterns confirmed the ever-rising risk factor associated with the ages of 15-19. This trend is consistent with many studies suggesting that teenage suicide is a function of socioeconomic and psychological factors operating across community and national boundaries. In addition, our study revealed that as white males 15-19 years of age in 1945 aged, their suicide rates also increased, confirming earlier findings that the suicide risk factor increases with age. In fact, Texas data for 1980 revealed that older persons, not teenagers, had the highest suicide rates-a finding that confirms other studies' results. Finally, Texas cohort patterns for suicide revealed the recent curvilinearity tendencies of older adult male suicide rates. By 1980 Texas data revealed a bimodal distribution of high suicide risk, with white males in their late 20s and ages 55 and over having the highest rates.

Bilateral transection of ureters secondary to gunshot wound to abdomen

An unusual case in which a complete bilateral ureteral transection due to a single low velocity gunshot wound occurred. This case illustrates that in gunshot wounds to the abdomen involving the retroperitoneum, ureteral inspection is imperative especially in view of the fact that preliminary diagnostic workup during trauma resuscitation may be inadequate.