Project ASPIRE: A feasibility randomized controlled trial of a brief intervention for reducing risk of depression and alcohol-related harms among South African adolescents

OBJECTIVE

Brief interventions could reduce adolescents' risk of depression and alcohol-related harms, but evidence of their feasibility and acceptability for low-and middle-income countries is lacking. To address this gap, we conducted a feasibility trial of the ASPIRE intervention, a four-session multi-component counselling intervention for South African adolescents.

METHOD

We recruited 117 adolescents who met our inclusion criteria. Participants were randomly assigned to the ASPIRE intervention or a comparison condition. Outcomes were assessed at baseline, six-week, and three-month post-randomization time points. Primary outcomes were based on feasibility of study procedures and intervention delivery (assessed on seven predetermined progression criteria). Clinical outcomes (risk of depression and alcohol harms) were secondary.

RESULTS

Despite modifications to all study procedures arising from Covid-19 restrictions, five of the seven key progression criteria were fully met, including: feasibility of data collection and outcome measures, counsellor competencies, randomization and blinding, adverse advents, and acceptability of the intervention. The progression criterion for recruitment and intervention retention were not fully met.

CONCLUSION

Findings suggest that the ASPIRE intervention was generally feasible to deliver and acceptable to adolescents. However, modifications to the trial design and intervention delivery are needed to optimize the validity of a definitive randomized controlled trial of the ASPIRE intervention.

Fundamental dissipation due to bound fermions in the zero-temperature limit

The ground state of a fermionic condensate is well protected against perturbations in the presence of an isotropic gap. Regions of gap suppression, surfaces and vortex cores which host Andreev-bound states, seemingly lift that strict protection. Here we show that in superfluid 3He the role of bound states is more subtle: when a macroscopic object moves in the superfluid at velocities exceeding the Landau critical velocity, little to no bulk pair breaking takes place, while the damping observed originates from the bound states covering the moving object. We identify two separate timescales that govern the bound state dynamics, one of them much longer than theoretically anticipated, and show that the bound states do not interact with bulk excitations.

[Everything is on the map: Integrated Mental Health Atlases as support tools for service planning. SESPAS Report 2020]

OBJECTIVE

This article reviews the usability of the Integrated Atlases of Mental Health as a decision support tool for service planning following a health ecosystem research approach.

METHOD

This study describes the types of atlases and the procedure for their development. Atlases carried out in Spain are presented and their impact in mental health service planning is assessed. Atlases comprise information on the local characteristics of the health care system, geographical availability of resources collected with the DESDE-LTC instrument and their use. Atlases use geographic information systems and other visualisation tools. Atlases follow a bottom-up collaborative approach involving decision-makers from planning agencies for their development and external validation.

RESULTS

Since 2005, Integrated Atlases of Mental Health have been developed for nine regions in Spain comprising over 65% of the Spanish inhabitants. The impact on service planning has been unequal for the different regions. Catalonia, Biscay and Gipuzkoa, and Andalusia reach the highest impact. In these areas, health advisors have been actively involved in their co-design and implementation in service planning.

CONCLUSIONS

Atlases allow detecting care gaps and duplications in care provision; monitoring changes of the system over time, and carrying out national and international comparisons, efficiency modelling and benchmarking. The knowledge provided by atlases could be incorporated to decision support systems in order to support an efficient mental health service planning based on evidence-informed policy.

Operating Nanobeams in a Quantum Fluid

Microelectromechanical (MEMS) and nanoelectromechanical systems (NEMS) are ideal candidates for exploring quantum fluids, since they can be manufactured reproducibly, cover the frequency range from hundreds of kilohertz up to gigahertz and usually have very low power dissipation. Their small size offers the possibility of probing the superfluid on scales comparable to, and below, the coherence length. That said, there have been hitherto no successful measurements of NEMS resonators in the liquid phases of helium. Here we report the operation of doubly-clamped aluminium nanobeams in superfluid 4He at temperatures spanning the superfluid transition. The devices are shown to be very sensitive detectors of the superfluid density and the normal fluid damping. However, a further and very important outcome of this work is the knowledge that now we have demonstrated that these devices can be successfully operated in superfluid 4He, it is straightforward to apply them in superfluid 3He which can be routinely cooled to below 100 μK. This brings us into the regime where nanomechanical devices operating at a few MHz frequencies may enter their mechanical quantum ground state.

Perspectives: the mental health care gap in intellectual disabilities in Spain: impact analysis and knowledge-to-action plan

BACKGROUND

Intellectual developmental disorder or Intellectual disability (ID) is a prevalent condition with a high impact along the life-span particularly when associated to other mental disorders (MD).

SPECIFIC AIM

To estimate the unmet needs and to design a knowledge to action plan to reduce the care gap in ID-MD in Spain.

METHOD

We followed a 5-step `maxi' impact assessment and a mixed qualitative/quantitative design including expert panels, secondary analysis of databases and a prospective survey in the 17 regions in Spain. Schizophrenia was used as comparator due to similar prevalence rates and burden.

RESULTS

Persons with ID-MD had ten times less outpatient contacts and hospital admissions than patients with schizophrenia. The outpatient case load was 2.31% in ID and 14.6% in schizophrenia. ID had the lowest hospitalization rate amongst all mental disorders but the highest length of stay. The expert panel estimated that half of persons with ID-MD are not adequately assessed and 95% do not receive the required care in Spain. Basic care needs include 6.5 beds and an ID-MD outpatient service per 1 million population. At least 134 specialized psychiatrists and psychologists and 277 beds are needed to reach the minimum standards in Spain.

CONCLUSION

This study quantifies the ID-MD care gap in Spain and the basic specialized services needed. In spite of the societal and health implications of ID-MD the knowledge-to-action plan had a modest impact limited at the regions where ID-MD programmes were already implemented.

IMPLICATIONS FOR HEALTH POLICY

Specific priority setting on ID-MH should be incorporated to mental health strategy at the Ministry of Health within a broader health and ID plan. National and regional policies should incorporate an integrative care approach through the life cycle. The development of excellence centers on ID-MD and a national observatory on this topic should be encouraged.

Image reconstructions with the rotating RF coil

Recent studies have shown that rotating a single RF transceive coil (RRFC) provides a uniform coverage of the object and brings a number of hardware advantages (i.e. requires only one RF channel, averts coil-coil coupling interactions and facilitates large-scale multi-nuclear imaging). Motion of the RF coil sensitivity profile however violates the standard Fourier Transform definition of a time-invariant signal, and the images reconstructed in this conventional manner can be degraded by ghosting artifacts. To overcome this problem, this paper presents Time Division Multiplexed-Sensitivity Encoding (TDM-SENSE), as a new image reconstruction scheme that exploits the rotation of the RF coil sensitivity profile to facilitate ghost-free image reconstructions and reductions in image acquisition time. A transceive RRFC system for head imaging at 2 Tesla was constructed and applied in a number of in vivo experiments. In this initial study, alias-free head images were obtained in half the usual scan time. It is hoped that new sequences and methods will be developed by taking advantage of coil motion.

Coding long-term care services—eDESDE-LTC

Introduction

Semantic variability is a barrier to effective networking of long-term care (LTC) services. The same name may be used for services providing different activities (i.e. day centres), and services with different names may have a similar pattern of care delivery. Furthermore, services are complex constructs which depend on local characteristics, vary over time and do not allow comparisons like with like. At present there is no standard coding system of LTC in Europe. This fact impedes cross-national comparisons, hampers European statistics on service availability, access and use, and slows down the development of international care planning strategies and patient mobility.

Description

The ‘Description and Evaluation of Services and Directories in Europe’ (DESDE) adapts to LTC the only currently available methodology for mapping, comparing and monitoring mental health and disability services (European Service Mapping Schedule—ESMS), which has already been applied in 16 countries in Europe. The system is based on descriptors called ‘Main Types of Care’ (MTC) including accessibility, information, self-help, outpatient and community care, day care and residential care. Services are arranged or organised in cluster combination of MTCs which emulate ‘bar codes’, identifying service characteristics according to MTCs. Thus, MTC availability and use can be compared across areas regardless of how services are named.

Conclusion

DESDE is a standard coding system of services for LTC which can be incorporated to electronic registers, databases and websites.

Comparative study of mental health services availability and use in Chile and Spain

Introduction

There is an enormous interest about improving international comparisons to provide relevant information for policy and planning in mental health. Most of the available information is provided at the macro-level (countries or regions). However, information gathered at the meso-level may diverge from data aggregated at higher territorial levels.

Objectives

This study describes the comparison on availability and use of mental health services between Chile and Spain.

Methods

Availability and utilization of services for the adult population were assessed in two urban areas in Chile and in three (two urban and one rural) areas in the South of Spain by using the European Service Mapping Schedule (meso-level data).

Results

For the two countries, local data on availability differed from data provided at the national level. There were differences in use of residential and day care between the benchmark area in Spain and the areas explored in Chile. In Chile’s catchment areas there was no availability of non-acute hospital services, any work-related services for persons with mental disorders, or 24-h mobile or non-mobile emergency psychiatric care. The meso-level data indicated that delivery and use of care in Chile was more similar to the pattern found in the poorer area in Southern Spain than macro-level data would indicate.

Conclusions

The European Service Mapping Schedule was useful for describing mental health care outside of Europe and allowed for an international comparison between Chile and Spain. The meso-level description gathered in this study adds to the macro-level information on the mental health care system that has been provided in other reports.

Stages of homogeneous nucleation in solid isotopic helium mixtures

We have made pressure and NMR measurements during the evolution of phase separation in solid helium isotopic mixtures. Our observations indicate clearly all three stages of the homogeneous nucleation-growth process: (1) creation of nucleation sites; (2) growth of the new-phase component at these nucleation sites; and (3) coarsening: the dissolution of subcritical droplets with the consequent further late-stage growth of the supercritical droplets. The time exponent for the coarsening, a=1/3, is consistent with the conserved order parameter Lifshitz-Slezov evaporation-condensation mechanism.

A genome segment on mouse chromosome 12 determines maxillary growth

The primary and modifier genes that regulate normal maxillofacial development are unknown. Previous quantitative trait locus (QTL) analyses using the F2 progeny of 2 mouse strains, DBA/2J (short snout/wide face) and C57BL/6J (long snout/narrow face), revealed a significant logarithm-of-odds (LOD) score for snout length on mouse chromosome 12 at 44 centimorgan (cM). We further sought to validate this locus contributing to anterior-posterior dimensions of the upper mid-face at the D12Mit7 marker in a 44-centimorgan portion of chromosome 12. Congenic mice carrying introgressed DNA from DBA/2J on a C57BL/6J background were selected for submental vertex cephalometric imaging. Results confirmed QTLs, determining that short snout length (P < 0.05) and face width relative to snout length (P < 0.01) were present in the 44-cM region of chromosome 12. We conclude that one or more genes contributing to the shape of the maxillary complex are located near 44 cM of mouse chromosome 12.

Development and usefulness of an instrument for the standard description and comparison of services for disabilities (DESDE)

OBJECTIVE

Mental health research has made significant progress in international comparison and instrument development. This study reports the adaptation of the European Service Mapping Schedule (ESMS) to the assessment of services for persons with disabilities.

METHOD

Qualitative groups were used to develop the Description and Evaluation of Services for Disabilities in Europe (DESDE). The psychometric analysis of DESDE covered: feasibility, inter-rater reliability, descriptive validity and internal validity. A demonstration study was also carried out.

RESULTS

Compared to the original ESMS, a new main branch and several sub-branches were added. We identified 826 services for persons with disabilities, which provided 1284 main types of care. The feasibility and reliability was good for the majority of codes. Only 6% of services were not properly classified. The Boolean factor analysis supported the internal validity of DESDE.

CONCLUSION

DESDE is a useful and reliable instrument for the assessment of services for persons with disabilities.

Spinodal decomposition in solid isotopic helium mixtures

We report the first observations of spinodal decomposition in solid helium isotopic mixtures, using NMR measurements. The experiments were performed at a 3He concentration of 50% where the transition proceeds through the critical point. We used an initial pressure such that the system remained solid. Our observations indicate that the transition occurs by the mechanism of spinodal decomposition and we are able to study its evolution in real time.

Vascular endothelial growth factor gene therapy in ischaemic rat skin flaps

Gene therapy with the complementary DNA (cDNA) of the angiogenic cytokine vascular endothelial growth factor (VEGF) has emerged as a promising strategy in the treatment of myocardial and lower-limb ischaemia. The objective of this study was to determine whether these principles could be applied to a recognised model of skin-flap ischaemia. Plasmid vectors including the cDNA of green fluorescent protein (GFP) and one of three VEGF isoforms (A165, B167 or B186) were constructed, and their base sequences confirmed. GFP expression was used as a marker of successful in vitro transfection of human endothelial cells with each plasmid. The plasmids were then administered subcutaneously to rat abdominal skin flaps surgically rendered ischaemic, and the percentage of viable tissue was assessed at 1 week. Angiograms of the flaps and histological preparations of flap tissue were assessed for evidence of angiogenesis. The survival of flaps treated with VEGF A165 or B167 cDNA was significantly greater than that of controls (P < 0.05). The survival of flaps treated with VEGF B186 cDNA was greater than that of controls, but statistical significance was not reached. Angiograms and microvessel density counts failed to produce evidence of angiogenesis. With improved delivery strategies, VEGF may have a role in the management of surgical ischaemia.

Altered expression of the carboxylesterases ES-4 and ES-10 by peroxisome proliferator chemicals

The nonspecific carboxylesterases (EC.3.1.1.1) are a large group of enzymes that play important roles in the metabolism of foreign xenobiotics and endogenous lipids, including activators of the peroxisome proliferator-activated receptor alpha, a nuclear receptor that is the central mediator of peroxisome proliferator (PP) effects in the rodent liver. A number of reports have demonstrated that PP exposure leads to alterations in levels of carboxylesterases in the liver. In this study, we determined by Western blot analysis whether exposure to diverse PP results in alteration of expression of two highly expressed microsomal carboxylesterases. Chronic exposure to the PP WY-14,643 (WY) and gemfibrozil (GEM), but not di-n-butyl phthalate (DBP), led to decreases in ES-4 in male rat livers. ES-4 was increased in female rat livers treated with GEM. WY exposure led to decreases in ES-10 in male and female rat livers. ES-10 was increased in female rats treated with DBP. Compared with other end points that are altered within days after PP exposure, the downregulation of ES-4 and ES-10 by WY was considerably slower, occurring between 1 and 5 weeks of exposure. Decreased expression of ES-4 was observed at doses of WY or GEM as low as 10 or 8000 ppm, respectively, whereas decreased expression of ES-10 was more resistant to changes by any PP occurring only with WY at doses as low as 50 ppm. After chronic exposure to WY or diethylhexyl phthalate in wild-type mice, kidney, but not liver, expression of ES-4 and ES-10 was downregulated. These decreases in kidney ES expression were not observed in PPARalpha-null mice lacking a functional PPARalpha gene, demonstrating the importance of this transcription factor in these changes. These studies demonstrate that ES protein expression is under complex control by PP that is sex- and compound-dependent. These results lend support to the hypothesis that PP exposure leads to a reprogramming of expression of enzymes important in the metabolism of PPARalpha activators.

Hypertension outcomes in an urban nurse-managed center

PURPOSE

To assess the quality of hypertension (HTN) care in an urban nurse-managed center (NMC) by chart audits of insured and uninsured (N = 52) African Americans who were managed by nurse practitioners.

DATA SOURCES

A chart audit form was developed by the authors that merged Health Plan Employer Data and Information Set (HEDIS) criteria with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria.

CONCLUSIONS

There was near comparable hypertension control among the two groups. No difference was found in systolic blood pressure (BP) control; however, the uninsured group had a slightly greater average diastolic BP compared with the insured group. There was no significant difference in the number of HTN medications or the number of risk factors. A significant difference was found in the number of NP visits per year between the two groups; the uninsured group averaged 3.2 more visits per year.

IMPLICATIONS FOR PRACTICE

Nurse practitioners in this NMC were able to manage HTN in a high-risk population despite a lack of insurance coverage for anti-hypertensive prescriptions. The finding that the uninsured group had more clinic visits per year than the insured group is significant in that it increases the cost of providing care for these patients and the health care system. The patient cost in time, transportation and burden needs further assessment.

A review of therapeutic angiogenesis and consideration of its potential applications to plastic and reconstructive surgery

The use of exogenous agents to stimulate the growth of new blood vessels into ischaemic tissue is a potentially revolutionary therapy in a wide variety of clinical specialties. Therapeutic angiogenesis research has been mostly confined to ischaemia of the heart and the lower limb. There has been relatively little research into the potential applications of the technique to plastic, reconstructive and burns surgery. In this paper, relevant published work is reviewed and potential applications of therapeutic angiogenesis to our specialty are considered.

Health status in 52 long-term survivors of pediatric brain tumors

The percentage of children who survive childhood brain tumors is increasing. A number have neurological and other sequelae which impact on the quality of their survival. We reviewed long-term survivors using a standardized health status instrument. The mothers of 52 survivors of brain tumors were surveyed. Eight different aspects (attributes) of health status were scored. The first 6 of these attributes were scored in a health status index (HSI) developed at McMaster University. Subgroup analysis was performed. Limitation in the quality of life was found in one of the 8 attributes in all but 2 of the subjects. The health status index (HSI) score using the first 6 attributes of this survey had a median of 0.73 (range 0.16-1.00). This score is lower than that found in previously surveyed survivors of leukemia or other childhood cancers. Examination of age at diagnosis, extent of surgery, sex and therapeutic modalities used showed no correlation with HSI score. Those with supratentorial astrocytomas had a lower HSI score (0.65) than those with infratentorial astrocytomas (0.85) (p = 0.05). Children with craniopharyngiomas had a poor score (0.64). This survey shows that the survivors of brain tumors have an appreciable burden of morbidity. Most have deficits in health status that affect many areas of their lives. Apart from site of the primary tumor, there was little correlation between subgroups studied and health status. The health status of children who survive brain tumors is lower than that of survivors of other childhood malignancies.

Orbital and globe rotation: the role of the periorbita

We hypothesize that excyclorotation of the globe and extraocular muscle cone associated with external orbital rotation around each orbital axis in craniofacial conditions could be at least partially corrected by leaving the anterior periorbita (periosteum lining the orbit) attached to the surgically rotated portion of the orbit. This hypothesis was tested by comparing the degree of rotation of the globe in response to internal rotation of the anterior orbit, leaving the periorbita attached to the rotated portion of the orbit on one (study) side, and stripping the periorbita on the opposite (control) side, in nine fresh cadavers. There was a highly significant difference (P < 0.0001) between the study and control sides. The possible extrapolations of this finding to the clinical situation are discussed.

Health status in 52 long-term survivors of pediatric brain tumors

The percentage of children who survive childhood brain tumors is increasing. A number have neurological and other sequelae which impact on the quality of their survival. We reviewed long-term survivors using a standardized health status instrument. The mothers of 52 survivors of brain tumors were surveyed. Eight different aspects (attributes) of health status were scored. The first 6 of these attributes were scored in a health status index (HSI) developed at McMaster University. Subgroup analysis was performed. Limitation in the quality of life was found in one of the 8 attributes in all but 2 of the subjects. The health status index (HSI) score using the first 6 attributes of this survey had a median of 0.73 (range 0.16-1.00). This score is lower than that found in previously surveyed survivors of leukemia or other childhood cancers. Examination of age at diagnosis, extent of surgery, sex and therapeutic modalities used showed no correlation with HSI score. Those with supratentorial astrocytomas had a lower HSI score (0.65) than those with infratentorial astrocytomas (0.85) (p = 0.05). Children with craniopharyngiomas had a poor score (0.64). This survey shows that the survivors of brain tumors have an appreciable burden of morbidity. Most have deficits in health status that affect many areas of their lives. Apart from site of the primary tumor, there was little correlation between subgroups studied and health status. The health status of children who survive brain tumors is lower than that of survivors of other childhood malignancies.

Design of a 2 T multipole wiggler insertion device for the SRS

Two new identical insertion devices have been designed for the Daresbury SRS. They are 2 T permanent-magnet multipole wigglers that will provide high flux in the X-ray region. This paper describes the magnetic and mechanical design of the arrays of steel pole pieces and permanent-magnet blocks. Also given is the engineering design of the support structure that will cope with the very large forces present while maintaining high levels of precision in gap setting and parallelism. The engineering design has been fully assessed using finite-element techniques to predict the deflections of critical parts of the structure. These two devices are due to be installed into the SRS by the end of 1998.

Protocol for accurate assessment of ABPI in patients with leg ulcers

Ankle brachial pressure index (ABPI) calculations are performed by nurses in the assessment of patients with leg ulceration. The measurement of pressure in one arm alone can result in inaccuracy which may be clinically significant. Two vascular nurse technologists performed ABPI measurements on 250 patients with 487 lower limbs. Community nurses replicated the study on 71 patients, assessing 123 lower limbs. The study shows that 22% of patients in the vascular laboratory and 20% in the community had a difference in brachial pressures of > or = 15 mmHg, indicating the presence of arch vessel or upper limb arterial disease. Furthermore, 6% of patients in the laboratory and 2% in the community demonstrated that the difference in brachial pressures affected the ABPI calculation around the value of 0.8, thus potentially influencing their clinical management. ABPI measurements should be performed, taking both brachial pressures for optimum results.

Intra-operative radiation therapy in pediatric neuroblastoma

External beam irradiation (EBRT) has been shown to improve response rates and event-free survival in children with neuroblastoma and regional lymph node metastases. Irradiation during surgical exposure (intra-operative radiotherapy, IORT) with displacement of adjacent radiosensitive organs out of the treatment field allows for more precise delineation of the target volume and significantly reduces the amount of normal tissue exposed to irradiation. We have incorporated IORT into the treatment regimen of 24 children with neuroblastoma between the years of 1983-1991. IORT was directed to any residual tumor or the tumor bed; the median dose of radiation was 1,000 cGY, equivalent to 3,000 cGY of conventional EBRT. There were 11 males and 13 females. Two patients had stage II, 12 patients had stage III, and 10 patients had stage IV disease. Ten children received IORT for suspected recurrent or persistent neuroblastoma. Twelve patients were disease-free survivors following IORT with a median follow-up of 54 months. For those patients with stage III disease, seven children were disease-free survivors, while only three of 10 patients with stage IV disease survived (median follow-up 30 months). Disease-free Survival (DFS) correlated with the achievement of local tumor control in children with both stage III and IV neuroblastoma. There was limited morbidity and no episodes of obstructive uropathy were encountered. We conclude that IORT appears to be well tolerated and may have therapeutic benefit for a select group of patients with neuroblastoma. IORT merits future exploration by prospective study.

Unusual pathogen in a man with HIV infection

A 41-year-old man who had tested positive for HIV infection presented with cough, yellow sputum, fever, and chills of 10 days' duration. He was short of breath at rest and had a poor appetite. He did not have chest pain, bloody sputum, or weight loss.

Chemoradiotherapy for organ preservation in oral and pharyngeal carcinoma

OBJECTIVES

To use concurrent chemoradiotherapy as primary treatment for resectable head and neck squamous cell carcinoma to (1) demonstrate the feasibility of an organ preservation approach for nonlaryngeal sites; (2) evaluate the toxic reactions and response to a new combination of two platinum compounds; and (3) monitor the effect of therapy on oral and pharyngeal function.

DESIGN

Case series, a prospective single-armed trial.

SETTING

Tertiary referral center.

PATIENTS

Twenty-two patients with head and neck squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx for whom surgery would significantly compromise function were entered in this trial.

INTERVENTION

Standard fractionation external-beam radiation therapy (2 Gy/Fx; total, 70 Gy) was given during a 9-week period, including a 2-week break after 40 Gy, concurrently with eight weekly doses of carboplatin and three doses of cisplatin (100 mg/m2) at 3-week intervals. A biopsy was performed 12 weeks after the completion of chemoradiotherapy to assess clinical response. All patients presenting with nodes greater than 3 cm had planned neck dissection.

MAIN OUTCOME MEASURES

Tumor response, toxic reactions, survival, and oral and pharyngeal function.

RESULTS

Overall complete response was 86%. Estimated overall 2-year survival was 64%, and disease-specific survival was 71% (median follow-up time, 25 months). Five patients have died of disease and two of unrelated causes. Treatment was completed by all, with toxic reactions including myelosuppression, mucositis, and dysphagia. Half of the patients required gastrostomy.

CONCLUSIONS

Concurrent chemoradiotherapy using two platinum analogues was tolerated with good local control and survival. Notable dysphagia was common. This study provides pilot data for randomized clinical trials to confirm the usefulness of chemoradiotherapy for nonlaryngeal organ preservation.

Cavity wound management in the community

Health care professionals in all specialties strive for high standards of care for their patients. This is particularly relevant in the area of wound management as major advances have been achieved over the past decade. However, there are many areas where improvements can still be achieved. This article highlights the area of cavity wound management in the community.

Responding to sexual discrimination: the effects of societal versus self-blame

Although self-blame has been considered to be a useful coping tool for victims, its benefits within the context of group discrimination are equivocal. The present research hypothesized that women encouraged to engage in self-blame for sex discrimination would be more likely to endorse accepting the situation or to endorse the use of individual, normative actions. In contrast, women encouraged to engage in societal blame for sex discrimination would be more likely to participate in nonnormative actions aimed at enhancing the status of women as a group. Female students in Canada were subjected to a situation of discrimination and were encouraged to blame either themselves or society. They were then given the opportunity to respond to the discrimination by endorsing various actions. A profile analysis of the endorsed actions indicated that the women encouraged to blame themselves were most likely to endorse accepting the situation, whereas the women encouraged to blame society endorsed nonnormative individual confrontation.

Tissue viability. Pressure sore prevention: scoring pressure sore risk in the community

To help combat the risk of patients developing pressure sores while being nursed at home, a new risk calculator has been researched and designed by the wound care specialist and members of the Walsall District Nursing Research Group. This article traces the development of the score and highlights its advantages for assessing the risk of pressure sores in the community.

The effects of soft tissue coverage on bone graft resorption in the craniofacial region

Experiments were performed to study the amount of resorption of endochondral bone grafts in pockets covered by muscle tissue compared to pockets covered by subcutaneous tissue in immature rabbits at 16 weeks post-grafting. In the first group the grafts were used as onlays on the buccal surfaces of the mandible with cover by masseter on one side of the face and subcutaneous tissues on the other. The second experiment was similar but the grafts were fixed semi-rigidly with wiring. In the third the grafts were used as onlays on the cranium with muscle or subcutaneous tissue coverage. The fourth group of bone grafts were implanted into muscle and subcutaneous tissue pockets in the abdominal wall. Bone graft resorption was significantly greater when covered by muscle than by subcutaneous tissue. This effect is probably mediated by movement imparted to the graft by adjacent active muscle, and over-rides any benefits of increased vascularising potential muscle may have. Semi-rigid fixation offered no protection against this effect.

Leech therapy and bleeding wound techniques to relieve venous congestion

Temporary restoration of capillary skin blood flow can be established by using leeches or by the creation of a dermal wound and the promotion of continued bleeding from the wound site in a flap with venous occlusion. An increasing restoration of capillary flow occurred with initial application of the leech and tended to exceed other techniques of restoring flow. However, all techniques of exsanguination, including leech therapy, restored very low perfusion over a two-hour course of therapy for a volume of tissue simulating a distal finger replant. The temporary increase in flap perfusion with a single leech application was greatest during the feeding activity of the leech and tapered off after the leech was satiated, to approximate flows achieved with local heparin injection and a punch wound.

Management of plexiform neurofibroma of the larynx

We report the ninth case of plexiform neurofibroma of the larynx, which occurred in a 2-year-old with multiple café au lait spots and obstructive sleep apnea. In discussing this clinical problem, we have attempted to make the following points. A patient's having more than six café au lait spots of greater than 1.5-cm diameter is diagnostic of von Recklinghausen's disease. It is much more difficult to completely excise plexiform neurofibroma than nonplexiform neurofibroma. The association of juvenile xanthogranuloma with von Recklinghausen's disease may be a risk factor for the later development of leukemia.

Venous distribution of superficial cervical region in rhesus (Macaca mulatta) monkey

The superficial veins of the cervical region in over 50 Macaca mulatta monkeys were studied. We found, in addition to the external jugular vein, another major vein, which we have termed jugular accessory. It is comparable in size and runs ventral to the external jugular vein. It commenced at the angle of the mouth, ran in a groove on the dorsal aspect of the submandibular gland, and descended on the surface of the sternocleidomastoid muscle where it was connected to the external jugular vein by a short transverse twig. It then descended toward the clavicle, crossed it ventrally, and immediately joined the cephalic vein. The resultant common vein pierced the thoracic wall between the clavicle and first rib and joined the external jugular and axillary veins, producing the subclavian vein. It was the jugular accessory and the external jugular, being connected as described, that formed an "H"-shaped system.

Recombinant leukocyte A interferon therapy for advanced hairy cell leukemia. Therapeutic and immunologic results

Hairy cell leukemia is a lymphoproliferative disorder characterized clinically by cytopenias. Standard therapy following variable periods of disease stability consists of splenectomy that often restores normal hematologic parameters for periods ranging from weeks to years. Fifteen patients (five without prior splenectomy or chemotherapy) were treated with 3 X 10(6) units per day of recombinant leukocyte A interferon and 14 of 15 patients completed eight weeks of therapy and were evaluated for response. There was one complete and 12 partial responses for an overall response rate of 93 percent. All of these patients' conditions have remained in complete or partial remissions and they continue to receive interferon with a median follow-up of six months. Coincident with the normalization of peripheral blood counts was a return of natural killer activity and normalization of immunologic surface markers as determined by monoclonal antibodies. This study confirms and extends earlier observations with natural alpha-interferon and indicates that recombinant leukocyte A interferon in low daily doses is also very effective treatment for hairy cell leukemia. In fact, it may be the best single modality of therapy for inducing both hematologic and immunologic recovery of these patients and deserves consideration as initial therapy.

Contrasting effects of unmodified and time-release forms of niacin on lipoproteins in hyperlipidemic subjects: clues to mechanism of action of niacin

To minimize the cutaneous flushing symptoms associated with niacin use, a time-release capsule form of niacin has been formulated. Thus study compares the effects of time-release niacin with those of unmodified niacin on lipoprotein lipids, including HDL2 and HDL3, apoproteins A-I and A-II, clinical chemistries, symptomatic side effects, and adherence to the medication regimen. Seventy-one primarily hypercholesterolemic subjects were randomized to either unmodified niacin or time-release niacin ad took medication for a six-month period. The two groups were closely matched on anthropomorphic and lipid variables. Adherence to the therapeutic regimen at a dose of 1.5 g/d in the first month of treatment was similar in the two groups. Thereafter, at a dose of 3.0 g/d, adherence was in excess of 90% among subjects taking unmodified niacin but only 64% among those taking time-release niacin, chiefly because of aggravated gastrointestinal symptoms; cutaneous flushing side effects, however, were slightly less common with time-release niacin. At these levels of adherence, LDL cholesterol (C) was reduced 21% by unmodified niacin and 13% by the time release form. Plasma total triglyceride was reduced more with unmodified niacin (27%) than with time-release niacin (8% maximum), and HDL-C and HDL2-C were increased significantly with unmodified niacin (26% and 36%) and were not significantly changed by time-release niacin. Increased to a similar degree on both regimens were HDL3-C (approximately 35%) and apoA-I (approximately 12%). ApoA-II was not affected by either drug regimen.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of poor risk acute leukemia with sequential high-dose ARA-C and asparaginase

Resistance of leukemia cells to cytosine arabinoside (ARA-C) may be due to any one or combination of biochemical processes, which in certain instances may be substantially reversed by an appropriate increase in ARA-C dosage. Based on these and other laboratory observations indicating pharmacologic synergy between sequential high-dose ARA-C and asparaginase (HiDAC----ASNase), a therapeutic program was developed for the treatment of patients with acute nonlymphocytic leukemia (ANLL) refractory to conventional doses of ARA-C, as well as patients with high risk ANLL and advanced acute lymphocytic leukemia (ALL). Treatment consisted of 3-hr intravenous infusions of 3 g/sq m of ARA-C given at 12-hr intervals for 4 doses, followed by 6,000 IU/sq m ASNase given i.m. at hour 42. The same schedule was repeated on day 8. In 32 induction attempts, only 4 patients proved to be truly refractory, i.e., failed to achieve substantial leukemia cell cytoreduction. Complete remissions were achieved with HiDAC---- ASNase in 9 of 13 patients with refractory ANLL, 6 of 9 patients with antecedent hematologic disorders, and 3 of 10 patients with advanced ALL. These include 9 of 14 patients who had either failed induction or who had relapsed on active ARA-C therapy and 6 of 8 patients who had had no prior exposure to ARA-C. The median duration of unmaintained remission in ANLL was 5 mo. In a patient with central nervous system (CNS) leukemia, there was clearance of cerebral spinal fluid (CSF) blasts without intrathecal therapy, suggesting a role for HiDAC in CNS prophylaxis. In general, toxicity was tolerable and reversible. These data suggest that HiDAC----ASNase is an exceptionally effective and well tolerated regimen in leukemic patients with antecedent hematologic disorders and in those refractory to conventional doses of ARA-C.

Maxillo-facial and palatal reconstructions with the deltopectoral flap

A flexible method for reconstruction of the defects resulting from radical orbito-maxillary resections is described with 7 illustrative case reports, using the deltopectoral flap.