Prevalence and demographic correlates of alcohol-related problems in Japanese employees.

To examine the relationship of basic sociodemographic characteristics to alcohol-related problem in Japanese employees, a questionnaire survey was conducted of a total of 2,581 employees of a computer factory in a suburb of Tokyo. The questionnaires included items on gender, age, marital status, social class (i.e., education, family income and occupation), alcohol consumption, and the Kurihama Alcoholism Screening Test (KAST). Data from 1098 male and 265 female current drinkers aged 20 years or older were analyzed; 15% and 6% of the male and female subjects, respectively, were classified as having alcohol-related problems on the basis of the KAST score (13% and 4% of the entire study population, respectively). Multiple logistic regression analysis indicated that alcohol-related problems were more prevalent in the less educated, managers and those who had a high alcohol consumption. The results suggested that education and occupation are important factors related to alcohol-related problems in Japanese employees.


Prevalence of infantile autism in four French regions.

A survey conducted in four French regions identified a sample of 154 autistic children born in the birth cohorts 1972 and 1976. Their mean ages were respectively 6.9 and 5.5 years when their handicaps were registered to local administrative services. The overall prevalence estimate is 4.9/10,000, with little difference between the two cohorts. The boy/girl sex ratio is 2.1:1, and more than two thirds are mentally retarded. The SES distribution does not deviate from census data. An elevated incidence of epilepsy is found (22%), with higher rates among the most retarded subjects and those with perinatal antecedents. Otherwise, relatively few autistic subjects were reported to have a clearcut medical disorder known for its association with autism.


Vertebral burst fractures: an experimental, morphologic, and radiographic study.

Spinal burst fractures are produced by rapid compressive loading, and may result in spinal cord injury from bone fragments forced from the vertebral body into the spinal canal. This fracture is one of the most difficult injuries of the spine to successfully treat, in part because the biomechanics of reduction and the exact mechanism by which the distraction forces are transmitted to the intracanal fragments of the burst fracture have not been adequately investigated. The authors developed a reproducible technique for creating these fractures in vitro. The fractures produced were identical to those observed in clinical practice, and were used for investigating the mechanics of this fracture and its reduction. This work describes the pathologic anatomy of the burst fracture both on the gross structure and also on microtome sections of the vertebrae, and examines the biomechanics of fracture reduction. The margins of the vertebral bone fragment, which was forced posteriorly into the spinal canal during fracture, were noted to extend far laterally beyond the pedicles. The authors also found extensive damage not only to the disc above the injured level, but also to that below, explaining the clinical observation that disc degeneration frequently occurs at both levels. Examination of anatomic data provided by microtome section supported the hypothesis that the fibers that actually reduce the intracanal fragment originate in the anulus of the superior vertebra in the midportion of the endplate and insert into the lateral margins of the intracanal fragment. Investigations using magnetic resonance imaging confirmed that these obliquely directed fibers account for the indirect reduction of the fragment. The authors' studies demonstrate that the posterior longitudinal ligament provides only a minor contribution in the reduction of the fracture in comparison to the attachments of the posterior portion of the anulus fibrosus. The forces required to reduce this fragment were studied. Distraction was found to be the predominant force required for indirect posterior reduction. This was confirmed by a series of tests using devices that provided segmental fixation. The application of uniform distraction forces was most effective in the posterior reduction of the intracanal fragment.


Fibrinolytic activity as a predictor of the outcome of prolapsed intervertebral lumbar disc surgery with reference to background variables: results of a prospective cohort study.

In a prospective study 122 patients with a slipped lumbar disc and no previous surgery were preoperatively examined for fibrinolytic activity. Surgical results for these patients were evaluated 12 months postoperatively by clinical overall assessment. In a multiple linear regression analysis fibrinolytic variables, euglobulin clot lysis time and plasminogen activator inhibitor 1, were shown to have predictive value regarding outcome of surgery; that is, normal fibrinolytic activity favors a satisfactory outcome and vice versa. Background variables and lipid profile were also recorded preoperatively. Body mass index, gamma-glutamyl transpeptidase, triglycerides and smoking were of statistical significance in relation to euglobulin clot lysis time and plasminogen activator inhibitor 1. Postoperative fibrinolytic re-examination of 20 patients seem to confirm that patients at risk of surgical failure have a prolonged depression of fibrinolytic activity.


Classification of nonspecific low back pain. I. Psychological involvement in low back pain. A clinical, descriptive approach.

An unselected sample of outpatient subjects (n = 330) with localized nonspecific low back pain (LBP) was studied. Investigation consisted of clinical assessment, physical examination, and psychiatric interview based on the DSM-III classification. A psychiatric disorder, according to the DSM-III criteria (axis I) was found in 41% of the subjects. Multiple correspondence analysis and cluster analysis were used to objectively identify clinical subtypes without preconceived theoretical models. Correspondence analyses suggested the existence of a 'psychological pain' syndrome consisting of several of the following symptoms: diffuse back pain, impossibility to assess intensity of pain on a pain scale, aggravation of pain by changing climate, by domestic activities or by psychological factors and dysesthesias in the back. Cluster analysis provided support for a four-group classification of low back pain, which may be interpreted through the relationships between psychological disturbances and the LBP clinical features. The results call for further investigation of the complex relationship between psychological disturbances and back pain. However, clinicians must be aware of the interest of a minimal psychiatric assessment in low back pain patients: psychiatric disorders frequently appear in these patients and an appropriate treatment of the psychiatric syndrome may reduce back pain.


Classification of nonspecific low back pain. II. Clinical diversity of organic forms.

A classification study was conducted in an unselected sample of outpatient subjects with localized nonspecific low back pain. The heterogeneity of a subgroup of patients without a psychiatric disorder according to the DSM-III classification (axis I), and whose low back pain may be labeled as 'purely organic' (see part 1 of the study in the companion paper), led to further evaluation of this group by correspondence and cluster analysis. A seven-cluster population structure emerged from the cluster analysis. Comprehensive description of these clusters suggests at least four well-differentiated clinical entities or 'syndromes.' Although no satisfactory correlation with pre-existing 'pathoanatomic' classification or hypotheses was found, this variable clinical presentation suggests different etiological or physiopathologic patterns for low back pain (and possibly more specific management of this condition). More comprehensive descriptions and evaluations of clinical symptoms and syndromes appear necessary in order to elaborate a clinical classification of LBP.


The evolution of compensated occupational spinal injuries. A three-year follow-up study.

This study was undertaken to follow up an incidence rate study of spinal injuries carried out from a cross-sectional random sample consisting of 2,342 workers who were compensated at least once in the year 1981 by the Quebec Worker's Compensation Board (QWCB) for an absence from work. These workers were followed for 3 years using the QWCB information system to record any recurrence of compensated absence from work. A total of 850 (36.3%) had at least one recurrence, and had longer episodes of absence than those without a recurrence (P less than 0.0001). Of these 850 workers, 824 (96.9%) had less than five recurrences and showed a systematic trend of gradual increasing duration of absence on each subsequent recurrence (P less than 0.05 in a repeated measures analysis of variance). A positive relationship was found between the duration of the initial episode of absence from work and the subsequent history of absence from work, both in terms of risk of recurrence (P less than 0.001) and of cumulated absence from work (P less than 0.0001), after controlling for age, sex, and site of symptoms. The computed instantaneous risk of entering a recurrence in a 31 year-old man experiencing lumbar symptoms, was 19.9% (95% confidence interval = 19.8-19.9) in the year following an initial episode of one day duration, and 26.7% (95% confidence interval = 24.3-29.3) after an initial episode of 6 months.


Self-reported low back symptoms in urban bus drivers exposed to whole-body vibration.

The prevalence of self-reported low back symptoms was investigated by a postal questionnaire in a group of 234 urban bus drivers exposed to whole-body vibration and postural stress and in a control group of 125 maintenance workers employed at the same bus municipal company. The average vertical whole-body vibration magnitude measured on the seat pan of the buses was 0.4 m/s2. After controlling for potential confounders, the prevalence odds ratios for the bus drivers compared to the controls significantly exceeded 1 for several types of low back symptoms (leg pain, acute low back pain, low back pain). The occurrence of low back symptoms increased with increasing whole-body vibration exposure expressed in terms of total (lifetime) vibration dose (years m2/s4), equivalent vibration magnitude (m/s2), and duration of exposure (years of service). The highest prevalence of disc protrusion was found among the bus drivers with more severe whole-body vibration exposure. Frequent awkward postures at work were also related to some types of low back symptoms. It is concluded that bus driving is associated with an increased risk for low back troubles. This excess risk may be due to both whole-body vibration exposure and prolonged sitting in a constrained posture. The findings of this study also indicated that among the bus drivers low back symptoms occurred at whole-body vibration exposure levels that were lower than the health-based exposure limits proposed by the International Standard ISO 2631/1.


The association of pain with physical activities in chronic low back pain.

Most patients with chronic low back pain associate strenuous physical activities with increased pain. This association can cause avoidance of those activities believed to cause intolerable discomfort. This study explored the relationship of performance of physical activities with self-reported pain measures in 40 consecutive patients with disabling low back pain (mean duration 17 months) during a functional restoration rehabilitation program (mean treatment period 7 weeks). Evaluations were performed at initial presentation and at program completion. Measures included quantification of performance on eight physical tests assessing flexibility, lifting capacity and endurance. Before physical testing patients were asked to complete a pain analog scale, a quantified pain drawing, and a rating of the pain anticipated to result from the performance of each physical test. Results showed that pain measures did not generally correlate with measured physical performance. At completion of treatment, significant improvement in performance on all physical tests was found, but these were not associated with consistent changes in pain measures. These results demonstrate that subjects with chronic low back pain can increase their physical performance abilities within their same pain experiences. Medical recommendations for subjects' involvement in physical activities should not be based solely on the reported association of pain with those activities.


Lifting capacity. Indices of subject effort.

The association between manual materials handling and occupational low back injuries has generated a wide variety of devices and protocols for testing lifting capacity. The validity of these tests depends critically on the subject's effort during the evaluation. This study compares the accuracy of several physiologic effort indices in identifying maximal and submaximal lifting efforts. Twenty-one men and twenty-three women free from back pain underwent isometric, isokinetic, and isoinertial tests of lifting capacity applying 50 and 100% efforts in random order. Effort indices included isokinetic force/distance curve variation, isoinertial peak force: weight ratios and peak force--weight differences, and heart rates and peak force variances for all three modes. Differences between 50 and 100% effort means were significant at P less than 0.01 for isokinetic force/distance curve variation, isoinertial peak force: weight ratios, and peak force--weight differences, and for heart rates in all three modes using analysis of variance. Differences were not significant (P greater than 0.05) for peak force variances in any mode using Wilcoxon Signed Rank Tests. According to a discriminant analysis model with optimal cutoff values, the only effort indices with better than 60% accuracy in identifying maximal and submaximal efforts were isokinetic force/distance curve variation (74%) and isoinertial peak force: weight ratios (69%), peak force--weight differences (62%) and heart rates (65%). For each index, subjects were divided into three groups according to whether their lifting outputs during 50% effort bouts were greater than, equal to, or less than one half their outputs in the 100% effort bouts.(ABSTRACT TRUNCATED AT 250 WORDS)


Computed tomographic follow-up study of forty-eight cases of nonoperatively treated lumbar intervertebral disc herniation.

The authors prospectively followed the natural evolution of lumbar disc herniation in 48 patients treated by conservative measures. The initial computed tomographic scan was obtained during the acute phase of the disc herniation and the second was performed 1-48 months after healing. The initial computed tomographic scan allowed classification of the herniations according to size: 13 were considered small, 20 medium and 15 large. Comparison with follow-up computed tomographic scans showed that 9 of the herniations decreased by at least 25%, 8 decreased between 50 and 75% and 31 decreased between 75 and 100%. In the later group, a few had disappeared even though the second computed tomographic scan was performed as early as the month immediately after successful treatment. The largest herniations were those which had the greatest tendency to decrease in size. It is postulated that this could be secondary to the herniation breaking through the outer fibers of the anulus and entering the epidural space.


Local electrophysiologic stimulation in experimental double level cauda equina compression.

Double level compression of nerve roots has been known to exist for a long time, but only in recent years the clinical significance of such conditions has been discussed. In the current study, nerve root function in double level compression was analyzed by measurements of tail muscle electromyogram, after stimulations of 1) the intermediate segment between the compression sites and 2) cranial to the two compression sites in a pig model. The electromyogram-amplitudes were more reduced after intermediate, than cranial stimulation. This difference was suggested to be based on an additional increasing threshold to elicit an action potential within the intermediate segment due to a nutritional deficit at this location. The results further stress the importance of local changes within the intermediate segment in double level nerve root compression.


The effect of lactate and pH on proteoglycan and protein synthesis rates in the intervertebral disc.

The intervertebral disc is the largest avascular tissue in the body. Its metabolism is mainly anaerobic, and thus lactate is produced at a significant rate. As a result the lactate concentrations in the center of the disc may be 8-10 times as high as in the plasma. The pH in the disc center is thus acidic. Because low values of pH are known to affect proteoglycan synthesis in other cartilages, the authors measured the effect of lactate levels and pH on 35S-sulphate and 3H-proline incorporation rates in the nucleus of bovine coccygeal discs and in human disc obtained during percutaneous nucleotomy. The maximum incorporation rate occurred at pH 7.2-pH 6.9. Here the rate was 40-50% greater than at pH 7.4. Below pH 6.8 the rate fell steeply, more so for sulphate than for proline. At pH 6.3 the sulphate incorporation rate was around 20 percent that at pH 7.4. The results indicate that proteoglycan synthesis rates in particular are sensitive to extracellular pH, and that the peak rate occurs around the level of pH seen in vivo. Factors that cause lactate levels to rise, such as a fall in O2 levels as the result of smoking or vibration (Holm and Nachemson, 1988) could lead to a fall in proteoglycan synthesis rates, ultimately leading to a fall in proteoglycan content and to disc degeneration.


The mechanism of initial flexion-distraction injury in the lumbar spine.

The threshold for flexion-distraction injuries was determined on lumbar functional spinal units exposed to a combined flexion-shear load in the sagittal plane. The specimens could resist a bending moment of 121 Nm and a shear force of 486 N at the first sign of a permanent deformation of the osteoligamentous components, which occurred at 78% of the assumed ultimate strength of each specimen. The flexion angulation was 16 degrees. The bone mineral content determined in adjacent vertebrae by means of dual photon absorptiometry was an accurate predictor of structural properties of the entire functional spinal unit even at the first sign of a substantial structural injury and not only at ultimate failure as previously demonstrated.


Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms.

The mortality and causes of death in 115 patients (80 women), born 1902-1937, with untreated scoliosis were compared to the expected according to official Swedish statistics. Subgrouping for cause and onset of scoliosis was done. Fifty-five patients had died; 21 of respiratory failure and 17 of cardiovascular diseases. The mortality was significantly (P less than 0.001) increased. The increased risk was apparent at 40-50 years of age. The mortality was significantly increased in infantile (P less than 0.001) and juvenile (P less than 0.01) scoliosis but not in adolescent scoliosis. The mortality was also increased in post-polio scoliosis, scoliosis combined with rickets and scoliosis of unknown etiology indicating an increased mortality in idiopathic scoliosis. Among the surviving patients anti-hypertensive treatment was frequent (23 of 50).


Prevalence of scoliosis in children with myelomeningocele in western Sweden.

In a cross-sectional study of the prevalence of scoliosis in patients with myelomeningocele, 131 patients 5-20 years of age were investigated with clinical examination and radiograms. Sixty-nine percent of the myelomeningocele patients had scoliosis, this prevalence being present already at a young age (6 years). The occurrence of scoliosis increased drastically at high levels of dysraphism, being 20% in patients with sacral myelomeningocele but 94% in patients with thoracic MMC level. Between ages 5 and 10, the mean scoliosis increased successively from 15 to 33 degrees. After this age there was no significant further increase. The ambulatory status of the patients was strongly correlated to the scoliosis incidence. Forty-nine percent of the patients had a uni- or bilateral hip dislocation. There was no correlation between the side of the scoliosis convexity and the side of hip dislocation.


Sitting balance in spinal deformity.

A computerized pressure plate system was used to analyze the sitting pressure distribution and balance of 100 subjects with both normal and abnormal spines. Normal subjects had a balanced sitting posture with the weight taken evenly on each ischial tuberosity. Patients with idiopathic scoliosis showed significant sitting imbalance especially in the presence of lumbar curves. Bracing improved the sitting balance and stability in most patients. Abnormal sitting patterns were seen with the spinal deformities of myelodysplasia or cerebral palsy. Some patients with severe scoliosis had very asymmetric patterns, which correlated with their loss of sitting stability. The kyphosis of myelodysplasia produced an abnormal tripod sitting pattern due to pelvic flexion and a hyperlordosis of cerebral palsy a pubic sitting pattern due to pelvic extension. The patients studied after spinal fusion also had poor sitting balance and occasionally persisting decubitus ulceration.


Delay in diagnosis of intradural spinal tumors.

Fifty-seven patients with primary intradural spinal tumors operated on in North Manchester and Salford between 1978 and 1988 were reviewed retrospectively. The commonest diagnoses were meningioma and nerve sheath cell tumors (neurilemmomas and neurofibromas). The median delay in diagnosis was 2.5 years (range 3 days to 24 years). Fifty-eight percent were initially referred to orthopaedic surgeons and 95% percent to specialties other than neurosurgery. The commonest presenting symptom was back pain, but later neurologic and urinary symptoms came to predominate. Eighty-eight percent are disease-free at a mean follow-up of 5.7 years. Symptoms were partially or completely relieved in the majority of patients. Delay in diagnosis of these tumors arises from failure to consider the diagnosis in patients with longstanding back pain or neurologic problems.


[Financial diversity for the delivery of health services].

Financial options for the National Health System in Mexico are discussed in this paper. In the first part the conceptual elements needed to support financing schemes are presented. The second part deals with financing models of the National Health System. Finally, a map of financing proposals are discussed with the aim of enriching the financial options of the health sector.


[Decentralization of the health sector in Mexico. Scope and limitations of local health systems].

This paper is a product of the reflection on the decentralization and sectorization experiences in Mexico since 1917 with particular emphasis on the 1980s. The historical analysis included the creation of an analytical model designed to identify the relationship between the distinct sanitary policies implemented in Mexico and the tendencies towards decentralization and integration. This analysis is combined with a critical review of the recent decentralization experiences undertaken in the states of Guerrero, Oaxaca and Nuevo León. While comparing Guerrero and Oaxaca, restitution and deconcentration under similar socio-economic conditions were discussed. The comparison between Guerrero and Nuevo Leon allowed the discussion of the benefits and limits of restitution under different socio-economic conditions. In addition, with this model the author discusses a few generalizations regarding the possible future of decentralization.


[Regionalization].

Health services regionalization is analyzed in its concept, components, characteristics and variations through literature review of experiences in different countries. It is concluded that regionalization means ordering or reordering resources and services within an area, provided that physical installations and personnel are already organized in order to assure health services at the highest quality. Those services must be economical, accesible and established in a comprehensive, coherent set with different levels of care in order to meet patients' needs. A regionalization model based on silos is presented, including functions, strategies and policies. Reasons to encourage the regionalization are also presented, such as the decrease in costs, increasing of program effectiveness and the potential development of the regionalized areas.


[Health technology in Mexico].

The features of the health technology cycle are presented, and the effects of the demographic, epidemiologic and economic transition on the health technology demand in Mexico are discussed. The main problems of science and technology in the context of a decreasing scientific and technological activity due to the economic crisis and the adjustment policies are also analyzed: administrative and planning problems, low impact of scientific production, limitations of the Mexican private sector, and the obstacles for technology assessment. Finally, this paper also discusses the main support strategies for science and technology implemented by the Mexican government during the 1980s and the challenges and opportunities that lie ahead.


[Advances and challenges in setting priorities in health].

The advances and problems in the definition of explicit criteria to measure health needs are discussed. In part one the advantages and limitations of the retrospective and prospective approaches in the identification of health needs for a rational distribution of resources are described. In part two progress in the application of explicit criteria for the prioritization of diseases and interventions to control them are analyzed. Finally, the methodological, conceptual, and operative challenges confronted by this field are discussed.


[Coverage of health services].

In this paper the concepts and criteria related to health coverage are discussed in the context of the organization of national health systems. The main international agreements based on WHO/PAHO proposals are also described. The relationship between primary health care and health coverage is analyzed and the evolution of the programs for the extension of health coverage in Mexico are discussed, with emphasis on the problems of overlap and definition of the universe in the several institutions of the health sector. Finally, the author reviews the problems to measure coverage in order to guarantee social and operative efficiency of the Mexican health system.


[Towards a strategy of quality assurance. From concepts to action].

The purpose of this paper is to present the basic principles needed to implement a national strategy for quality assurance in medical care in Mexico. The first part is devoted to a review of the basic concepts of quality of care with the aim of analyzing the evolution of the discussion of the concept of "quality assurance". This review constitutes the reference frame of the description of the historical evolution of quality assurance in different parts of the world. Finally, the experiences regarding quality assurance in Mexico are discussed and several basic proposals for the design of a national quality assurance strategy are presented.


[Efficiency in the delivery of health care].

In this paper the role of efficiency in health care delivery is discussed. In the first part several definitions of efficiency are presented and the most common efficiency analysis are described. In the second part of the paper some experiences aimed at improving the efficiency of health care delivery in England, Latin America and Mexico are discussed. Finally, the author presents four proposals for the improvement of efficiency of health care delivery in Mexico: monetary reward associated to performance, alternative organization of health services, investment in management training for health manpower, and operational research in the health systems.


[Is survival enough? Challenges of the integration of health and well-being in the third world].

In this paper the paths taken by developing countries to improve the health and well-being of their populations in a context of diminishing resources is discussed. Emphasis is placed on Latin American countries and the objective is to clarify the changing nature of the relationship between health and social well-being in the 1970s and 1980s. In the second part of the paper three viable and different political scenarios to confront this problem are presented: 1) survival without well-being; 2) survival and eradication of extreme poverty, and 3) survival, eradication of extreme poverty, and selective reconversion of the poor.


[Co-responsibility and social participation].

Social participation in health is the main issue of this paper. In the first part the role of the state and the necessary elements to guarantee political stability are discussed. In the second part the various forms of social participation are described. Finally, two possible scenarios regarding participation of the society in health activities in Mexico are analyzed.


[Integration of the delivery of health services].

In Mexico the Constitution defines the right to health care as a social right and, as such, confers to the state the guiding role in the access of the population to health services. Unfortunately, this constitutional principle has not been fully met. One of the reasons for this is the fragmentation of public action in health and the continuous postponement of the integration of health services. In this paper the conceptual and practical limits of integration of health services are discussed, using as starting point a brief diagnosis of inequity and fragmentation of the health system in Mexico. The doctrinaire principles of integration are also described, as well as its practical advantages and disadvantages. Finally, a typology of forms of integration and previous integration experiences in Mexico are discussed. In the concluding remarks the integration prospects for Mexico are analyzed.


[Equity and health].

This paper discusses the right to health in Mexico. The authors present some ideas regarding equity and data which shows the existence of a deep inequity in the field of health in the country. The efforts of the social security agencies and of the Ministry of Health aimed at diminishing inequity in health are also described. The authors conclude that it is time to avoid retorical positions and attitudes of administrative solidarity and start to implement actions to improve the health conditions of those living in extreme poverty. These actions should include providing comprehensive health services to all the population, reinforcing specific preventive programs, improving certain basic health indicators and prompting intersectoral collaboration.


[Clinical significance of rheumatoid factor--its complement activating property and isotype].

We investigated the relationship between complement-activating properties of rheumatoid factors (RF) and their isotypes. Active and inactive RA patients without extra-articular symptoms (EAS) and those with EAS were studied. Patients with SLE, liver cirrhosis (LC) and normal volunteers were served as controls. Isotype of RF was measured by ELISA and complement activation (CA) of RF was measured by hemolytic assay. The CA values were significantly higher in RA patients with EAS than those in RA patients without EAS and with other diseases. The IgG and IgM-RF values were significantly higher in active RA without EAS than in inactive RA. Positive correlations between IgM-RF values and CA values were observed in RA with or without EAS, SLE and LC. The Sephadex G-200 gel filtration analysis of sera revealed CA in only 19S IgM fraction. Additionally, we purified 19S IgM-RF from sera of RA, SLE and LC patients by affinity chromatography, and found 19S IgM-RF had CA. These data suggest that serum IgM-RF may play a critical role in the pathogenesis of RA, especially in RA with EAS.


[Studies on criteria for clinicopathological diagnosis of allergic granulomatous angiitis (AGA)].

Comparative studies in the evaluation of criteria for clinicopathological diagnosis of AGA which was proposed by Japanese Health and Welfare Ministry (JHWM) in 1988 and American College of Rheumatology (ACR) in 1990 were conducted. Twenty seven Japanese patients with AGA and 231 Japanese controlled patients with polyarteritis nodosa (PAN) and Wegener's granulomatosis (WG) were used as material patients who had been provided a second questionnaire in 1984 sponsored by the JHWM. As a result, the JHWM criteria was 85.2% in sensitivity and 96.5% in specificity, which was superior to the ACR criteria being 74.1% in sensitivity and 93.9% in specificity. These results were due to the low sensitivity and low accuracy in paranasal sinus abnormality and pulmonary infiltrates which were included in the ACR criteria. Furthermore, the JHWM criteria could be diagnosed as AGA using not only the histopathological findings but by the clinical symptoms alone. The controlled patients who were overdiagnosed as AGA using ACR criteria were thought to be included as patients with WG. On the other hand, the controlled patients who were overdiagnosed as AGA using JHWM criteria were thought to be included as patients with overlap syndrome of AGA and PAN. Accuracy of polyneuropathy, muscle weakness, melena and pretibial edema were over 60%, indicating that these clinical symptoms were available for vasculitis symptoms of the JHWM criteria.


[Induction of interleukin-1 production in the cultured synovial cells from patients with rheumatoid arthritis].

Interleukin-1 (IL-1) is believed to be involved in articular destruction in rheumatoid arthritis. HLA-class II antigens are expressed on synovial cells of patients with RA. The relation between the production of IL-1 and expression of HLA-class II antigens was studied. Synovial cells of rheumatoid patients appeared to express HLA-DR and DQ antigens to a significantly greater extent than those of osteoarthritic patients. These cells produced IL-1 following interferon-gamma (IFN-gamma) stimulation and there was synergistic enhancement of production induced by IFN-gamma and monoclonal antibodies to HLA-DR or DQ antigens in combination. In the intracellular signal transduction mechanism for the production of IL-1 beta by these cells following IFN-gamma stimulation, protein kinase C and calmodulin may be involved as second messengers.


[A histological study on the synovial tissue of rat knee joints in the experimental beta 2-microglobulin derived amyloidosis].

In recent years, a clinical syndrome comprising carpal tunnel syndrome, destructive spondylarthropathy, and cystic bone lesions has been recognized in the long-term hemodialysis patients. It is well known that the amyloid deposits have been found in these affected tissues and also beta 2-microglobulin (beta 2-MG) has been identified as an amyloidgenic protein. But, those problems such as the mechanisms of amyloidgenesis from beta 2-MG in vivo and the subchondral bone cysts formation are not clarified yet. If it becomes clear, it will give us a very useful information of therapeutic and prophylactic considerations to the hemodialysis related arthropathy. Since the experimental amyloidosis derived from beta 2-MG has not been reported in the past, we intended to make the experimental amyloidosis derived from beta 2-MG in rats. We have used the Sprague-Dawley strain rats (4 weeks old) and performed the 3 different procedures as follows. Procedure 1: clip renal vessels to make the experimental renal failure. Procedure 2: induce arthritis by the type II collagen induced arthritis (CIA). Procedure 3: inject beta 2-MG (10 micrograms) into the knee joint once every week for 6 weeks. We combined the above-mentioned procedures to make 5 experimental groups as follows. Group A: Procedure 1 + Procedure 3. Group B: Procedure 1 + Procedure 2. Group C: Procedure 1 + Procedure 2 + Procedure 3. Group D: Procedure 2 + Procedure 3. Group E: No treatment. After 6 weeks, they were sacrificed. We took specimens from the synovium and bone in their knee joints. First, the light microscopic specimens are stained with the Congo-red stain. When we confirmed the positive green birefringence in polarized light, we have performed the immunohistochemical stain with the monoclonal anti-amyloid P-component antibody, the anti-beta 2-MG antibody and the anti-amyloid A protein for the immunohistochemical stain subsequently. Moreover, we have used the electron microscope to confirm the amyloidfibrils in cases that the Congo-red and immunohistochemical stain of the amyloid P-component are both positive. As a result, we could confirm the amyloid fibrils in the 60% of the group C only. In this group, the amyloid deposition is observed in the inflammatory proliferated synovium in the joint as well as the subchondral bone lesion where the synovial capsule attaches to the bone. In other groups, although a certain degree of inflammation or proliferation of synovium as well as erosive changes of the joint surface are found, no amyloid deposition is confirmed.(ABSTRACT TRUNCATED AT 400 WORDS)


[A case of the eosinophilia-myalgia syndrome].

The Eosinophilia-myalgia syndrome (EMS) is a recently described clinical entity consisting of severe myalgia and eosinophilia that has ascribed to the ingestion of the amino acid L-tryptophan. Over 1500 cases of EMS have been reported to the Centers for Disease Control of United States as of June 1990. We report a case of EMS associated with the ingestion of L-tryptophan. A 24-year-old woman was admitted to our hospital due to severe myalgia. She had swelling on extremities and eosinophilia (1880/mm3). Full thickness biopsy of affected portion showed inflammation of fascia with eosinophils and histiocytes, which were compatible with eosinophilic fasciitis. She had a history of ingestion of fitness protein tablets bought at Hawaii for 3 months from Sep. to Dec. 1989, which contained the amino acid L-tryptophan. On the basis of these findings, we diagnosed her as EMS. It is suggested that this case is rare and important in Japan.


[Lobenzarit disodium (CCA)--induced diabetes insipidus in a patient with rheumatoid arthritis].

A 44-year-old female with 16-year history of rheumatoid arthritis visited Akiru Hospital with complaints of a thirst, a dry mouth and a general fatigue. One week prior to admission, the patient manifested excessive thirsty feeling, a body weight loss and a sleepless by the polyuria. She has been given 5-10 mg of prednisolone and 240 mg of lobenzarit disodium (CCA) in a day for 11 months. A hematologic examination showed no abnormality, and the examination of her serum showed the following values: BUN, 9.3 mg/dl; creatinine, 0.9 mg/dl; sodium, 139 mEq/l; chloride, 102 mEq/l; potassium, 3.9 mEq/l; osmolality, 290 mOsm/l. Plasma antidiuretic hormone (ADH) level increased slightly (6.0 pg/ml). Examination of her urine revealed specific gravity, 1.005; no trace of glucose, protein, blood and ketones; normal sediment; and osmolality, 209 mOsm/l. The patient was given exogenous ADH (10 units of vasopressin tannate in oil, intramuscularly) to obtain a diagnosis, and she was found to be unable to concentrate her urine more than 1.008 in the specific gravity. A water restriction, as a test for diabetes insipidus, also failed to concentrate her urine in the specific gravity and in the osmolality. Together with these findings, the patient was diagnosed to be a diabetes insipidus, and CCA was seemed to account for the disease. This unfavorable effect of CCA appeared to be reversible, since the patient recovered her urinary concentrating ability after the medication of CCA was discontinued.


[A case of Sweet's syndrome (acute febrile neutrophilic dermatosis) associated with mixed connective tissue disease].

Sweet's syndrome (acute febrile neutrophilic dermatosis) is an unusual condition characterized by fever, polymorphonuclear neutrophil leukocytosis of the blood, thick painful plaques on the face, neck and limbs, and a dense dermal infiltrate of mature neutrophils seen histologically. Recently, this disease has also been reported in association with various malignant neoplasms and chronic inflammatory disorders. In the literature, seven cases of Sweet's syndrome associated with collagen diseases have been reported, but no cases with mixed connective tissue disease (MCTD). The first case of Sweet's syndrome associated with MCTD was herein described and discussed. A 49-year-old man was admitted to our hospital with the complaints of high fever and painful erythema on his face, neck and limbs. Six months ago, MCTD was suspected, with the presence of limited cutaneous sclerosis of the hands, Raynaud's phenomenon, polyarthralgia, an elevation of CPK value and a positive anti-RNP antibody. Just before hospitalization, he suffered a prodromal infection of the upper respiratory tract for two weeks. He was diagnosed as Sweet's syndrome by the clinical and histological features. He began receiving corticosteroid therapy (prednisolone 60 mg/day), and within a week he showed dramatic improvement in the above symptoms.


[Improvement of pancytopenia and articular and by splenectomy in a patient with Felty's syndrome].

A forty seven year-old woman with a 18 years history of rheumatoid arthritis presented with recurrent infection and pancytopenia. A diagnosis of Felty's syndrome was made hand on clinical and laboratory findings. In spite of drug therapy using nonsteroidal anti-inflammatory drugs, D-penicillamine and corticosteroid, the hematological abnormalities and active joint symptoms continued. Recurrences of severe bacterial infection and the rupture of esophageal varices necessitated splenectomy. Soon after the operation, dramatic improvement of hematological abnormalities were observed. Furthermore, after 3 months postoperatively, marked decrease in rheumatoid activities and disappearance of subcutaneous nodules were noticed. Titer of rheumatoid factor also showed a significant reduction and became negative 6 months after the operation. Although the efficacy of splenectomy on hematological abnormalities in Felty's syndrome has been well documented, its effect on rheumatic disease has not been clarified. The case presented here might suggested that suppression of reticuloendothelial system may have therapeutic effects in rheumatoid arthritis. The possible mechanisms involved in these findings have been discussed.


Sphenoid sinus disease. Experience at King Edward VIII Hospital, Durban.

The increasing use of computed tomography (CT) to evaluate sinus disease in general, appears to have led to an increased pickup rate in isolated sphenoid sinus disease. It is probable that subtle disease of the sphenoid sinus was missed before the use of CT as a diagnostic tool. Six patients with sphenoid sinus disease and related pathological conditions seen during the past 2 years, are reviewed; these included 4 mucoceles, 1 case of aspergillosis and 1 of squamous cell carcinoma. Experience with sphenoid disease, with particular reference to the diagnosis, management and complications of this condition, is discussed.


Endoscopic transnasal dacryocystorhinostomy. Results in 21 patients.

The transnasal endoscopic approach to the nasolacrimal sac was successfully applied in 20 out of 23 operations. The patients were followed up for 4-26 months, the first 21 operations having been performed in August 1988. Twenty-one nasolacrimal sacs had primary endoscopic transnasal surgery and 2 had previous failed external operations. Five operations were revised of which 3 were still unsuccessful.


Massive gastro-intestinal haemorrhage due to vascular ectasia of the duodenum. A case report.

Vascular ectasia of the duodenum as an unusual source of upper gastro-intestinal bleeding in a patient with cirrhotic portal hypertension and oesophageal varices is reported. Morphological structure and situation of ectatic duodenal vessels indicate the possible coexistence of variceal distension and angiodysplasia.


Is tube cecostomy safe in the surgery of Hirschsprung's disease?

The use of concomitant tube cecostomy remains an option for decompression after distal large-bowel surgery but has been criticised because of a reported high complication rate. Two hundred and three patients who underwent a Soave endorectal pull-through procedure for Hirschsprung's disease (1974-1990) were evaluated. Operative technique included a modified sutured Soave endorectal pull-through procedure and a Stamm tube cecostomy utilising a large-lumen catheter. One hundred and twenty patients who had a modified two-stage procedure plus concomitant tube cecostomy were compared with 83 patients who underwent a three-stage procedure with colostomy cover. Early postoperative complications occurred in 8 patients (6.6%) in whom cecostomies were performed. A distal cuff abscess developed in 1 patient (0.8%), an anastomotic leak in 1 (0.8%) and 3 patients (2.5%) had colo-anal stenosis. The cecostomy tube dislodged in 2 patients and 1 required operative closure of a faecal fistula at the cecostomy site. Colonic venting was adequate and little nursing care was required. In 2 instances colonic distension developed after cecostomy clamping. Decompression was achieved by opening the cecostomy tube; this resulted in relief of symptoms and a good subsequent recovery. In contrast, there were 11 postoperative complications in the 83 patients undergoing a three-stage procedure (13.2%). In 2 patients (2.4%) an anastomotic leak occurred and 5 distal cuff abscesses (6%), 3 (3.6%) early strictures and 1 (1.2%) neorectal retraction developed. The use of a concomitant tube cecostomy with a two-stage Soave procedure is an effective and safe means of providing proximal colonic venting and did not add to mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)


Presentations to the Surgical Research Society of Southern Africa--the second 10 years (1982-1991).

Over the 10-year period 1982-1991, 594 papers were read at the annual meetings of the Surgical Research Society of Southern Africa. One hundred and thirty-five (23%) reported work performed on experimental animals with a trend to an increase from this base; 152 (26%) were presentations from surgeons-in-training, also with a trend to increase over the decade. The distribution by subspecialty was: upper gastro-intestinal tract 28%; hepatobiliary 12%; vascular 16%; immunology/transplantation 9%; further subspecialties 9%; and miscellaneous 26%. Major observations are that the number of papers has doubled since the first decade, probably due to establishment of the poster session, and that presentations by surgeons-in-training remain in the minority at the Society.


Routine peri-operative management of the diabetic patient.

Many aspects of peri-operative management of the diabetic patient remain controversial, although there are a variety of approaches towards management. These patients are at risk for certain complications related to the severity and chronicity of the disease. The surgeon and the anaesthetist must be conversant with the management of diabetes in elective and emergency situations. Reasonable metabolic control can be achieved within a few hours pre-operatively and clinical assessment can be performed on an out-patient basis. Anaesthetic management consists of assessment of the control of the disease followed by evaluation of diabetic complications and their severity. Different views are expressed regarding tight control of blood glucose level (4-8 mmol/l) versus moderate control (8-12 mmol/l) when managing diabetic patients. The importance of guarding against factors favouring metabolic decompensation in the peri-operative period, is stressed. Minor or major surgery has important implications regarding the management of diabetes. All patients scheduled for major surgery should be treated with intravenous insulin. Blood sugar should be monitored at regular intervals to protect the patient against hypoglycaemia. Emergency surgery is usually associated with an infectious process. Pronounced hyperglycaemia, dehydration and metabolic derangement may be present. The underlying pathology may aggravate the diabetic state and surgery may actually improve the patient's condition. It is unnecessary to postpone surgery to treat ketosis fully, because this may need 12-24 hours. Extreme insulin resistance and greater insulin requirements are present during cardiopulmonary bypass, hypothermia and rewarming. Beware of severe hypoglycaemia after cardiopulmonary bypass.


Diabetic complications with special anaesthetic risk.

Diabetes mellitus leads to acute and chronic complications. Acute complications include hypoglycaemia, diabetic keto-acidosis, hyperglycaemic hyperosmolar non-ketotic syndrome and lactic acidosis. Chronic complications are neuropathies, nephropathy, retinopathy, peripheral arterial disease, cerebrovascular disease, coronary artery disease, cardiomyopathy, hypertension, infection, delayed wound healing and stiff joint disease. End-organ pathology is in part responsible for the increased morbidity and mortality seen in diabetic patients in the peri-operative period. A thorough pre-operative search for end-organ pathology is essential to optimise patient management. Relevant diabetic complications and their anaesthetic risk are discussed.


Postoperative hypoxaemia--its causes and prevention.

Postoperative hypoxaemia presents with varying degrees of severity. Aetiology of the condition is diverse and may originate in the pre-, intra- or postoperative periods. However, induction of anaesthesia and the type of operation are important initiating factors over which there is little control. The impact of postoperative hypoxaemia, especially when detected early, can be alleviated. This article attempts to explain the pathophysiology and provide suggestions as to detection and management of postoperative hypoxaemia.


Pre-operative assessment and management of the patient with ischaemic coronary artery disease in non-cardiac surgery.

Peri-operative cardiac events are the leading cause of death following anaesthesia and surgery. We attempt to put into perspective the various methods of pre-operative assessment of patients at risk, and suggest a logical sequence for the use of potentially costly investigations such as 12-lead ECG, exercise stress ECG, ambulatory ECG monitoring, myocardial perfusion imaging, radionuclide ejection fraction, and coronary angiography. Important principles are given for the management of patients at risk of peri-operative cardiac incidents if the decision is made to proceed with non-cardiac surgery despite the potential risk or because of inoperable coronary disease.


The impact of chronic diseases of lifestyle and their major risk factors on mortality in South Africa.

The purpose of this study was to determine the impact of chronic diseases of lifestyle on the mortality pattern of South Africans and to estimate the number of South Africans affected by major risk factors for these diseases. The proportion of deaths due to chronic diseases of lifestyle was calculated from the deaths reported to the Central Statistical Services. This group of diseases was responsible for 24.5% of deaths of all South Africans and 28.5% of those aged 35-64 years whose deaths were reported in 1988. The major causes of death contributing to these figures were cerebrovascular diseases (7.2% of all deaths and 7.9% of deaths of persons aged 35-64 years) and ischaemic heart disease (8.7% of all deaths and 9.6% of deaths of persons aged 35-64 years). The age-standardised prevalence rates for the major risk factors reported in five cross-sectional studies in different areas and groups are compared. Estimates from the reported prevalence rates, based on the size of the South African population recorded in the 1985 census figures, were calculated for the major risk factors. Overall 4.88 million South Africans smoked, the largest group of smokers being black males (2.6 million). for hypertension 5.5 million South Africans had blood pressures above 140/90 mmHg; again the largest groups were blacks (3.0 million). For hypercholesterolaemia and raised low-density lipoprotein cholesterol levels, 4.8 million and 3.1 million South Africans respectively had an increased risk for ischaemic heart disease, blacks having the lowest levels.(ABSTRACT TRUNCATED AT 250 WORDS)


Dietary patterns and nutritional status in free-living older white men with established vascular disease.

Thirty-nine white men aged 51-84 years with established vascular disease were studied to investigate the effect of fish oil capsules on the regression of these lesions. This article deals with the baseline data of the study. The subjects completed a 7-day dietary record, weight and height were measured and a fasting blood sample was analysed for proteins, haematological values and certain vitamins. Dietary analysis indicated that the mean energy intake was 8,552 kJ (SD = 2,095). The energy distribution was 15.5% protein, 33.6% fat and 46.4% carbohydrate. In the light of the recommended dietary allowances the diet was lacking in zinc, vitamin B6 and folic acid, which suggests that the subjects might be deficient in these micronutrients. Although the diets were lacking in these nutrients, no clinical stigmata were observed. The subjects averaged a body mass index of 26.1 and could therefore be classified as overweight. The mean haematological values as well as the plasma vitamins were within the normal range. In conclusion it can be said that the men consumed a diet that was too high in fat and that the diet lacked certain micronutrients.


The level of mortality in South Africa in 1985--what does it tell us about health?

South African mortality data are inadequate for health planning. Estimates of mortality levels in blacks for 1985, derived using indirect demographic techniques, have provided an opportunity to analyse South African mortality in a health context. The infant mortality rate (IMR) for the population as a whole was 64/1,000 live births in 1985, which is high when compared with those of other countries. The IMR varied between population groups and was highest in blacks (males 73, females 68) and lowest in whites (males 11, females 7). Adult mortality rates, measured in terms of the chance of a 15-year-old dying before reaching the age of 60, ranged from 42.8% for black males and 29.4% for black females, to 21.8% and 11.5% for white males and females respectively. Life expectancy at birth of black males and females was 55 and 61 years respectively, while for white males and females it was 68 and 76 years respectively. Infectious diseases are a leading cause of death in blacks under 5 years of age, while trauma, poverty-related diseases and chronic diseases related to lifestyle all contribute to the high levels of adult mortality in this group. Prevention and health promotion strategies focusing on these as well as HIV/AIDS must be incorporated in a primary health care strategy to reduce premature mortality. Most importantly, it is crucial to improve the registration system that is vital to facilitate ongoing evaluation.


Beliefs about smoking and health and attitudes toward tobacco control measures.

The opinions of a representative sample of adult South Africans about the effects of smoking on health and their attitudes toward tobacco control measures were surveyed by means of an interviewer-administered questionnaire. Seventy-five per cent of the respondents were black and 55.3% were female. More than 50% of blacks and Asians (61.7% and 53.2%) were non-smokers, whereas 52.1% of 'coloureds' were current smokers and 23.8% of whites ex-smokers. The majority of smokers (68.5%) acknowledged the harmful effects of direct smoking and a larger percentage of non- and ex-smokers (79.7% and 77% respectively) shared this view. A similar trend was observed in beliefs about passive smoking. Seventy-five per cent of participants felt that tobacco sales to minors should be banned and 55.8% thought that taxes on tobacco products should be increased. There was substantial white opposition to measures that prohibit tobacco companies from sponsoring sporting events. Most respondents felt that tobacco advertising should be banned on television (59.7%), radio (60.1%), in newspapers (58.4%), on billboards (58.7%) and in cinemas (59.3%). The results indicate that in the main the public supports the introduction of the measures proposed in the draft Tobacco Products Control Act and even more extensive legislation to control tobacco consumption. This augurs well for future strategies aimed at tobacco control in South Africa.


Alcohol intake in relation to lipids, lipoproteins and blood pressure.

A cross-sectional population study of 655 men and 731 women was undertaken to evaluate the association between the level of alcohol intake, the level of high-density lipoprotein cholesterol (HDL-C) and its subfractions, and blood pressure in men and women in different age groups (20-44 and 45-64 years). Habitual alcohol intake was significantly related to higher levels of HDL-C in both men and women. In the case of men both HDL2-C and HDL3-C levels were raised, while in women this rise was restricted almost entirely to HDL2-C. Plasma apolipoprotein A-I and A-II levels were elevated in men who drank, but not in women. In both, triglyceride and blood pressure levels were raised with habitual alcohol intake, and the increases in HDL subfractions and blood pressure levels became more marked with increasing age in both men and women. Recent alcohol intake had less effect on all the variables except blood pressure. We conclude that both HDL3-C and HDL2-C contribute to the rise in HDL-C levels that accompanies alcohol use, notwithstanding differences in the responses of the sexes. A regular alcohol intake is more likely to be beneficial and some of the positive or protective aspects of alcohol consumption could be reduced by the adverse changes in triglycerides and blood pressure levels.


Risk factors and coronary heart disease in Durban blacks--the missing links.

Coronary heart disease (CHD) is still relatively uncommon in the black population of South Africa. We embarked on a study to determine the prevalence of risk factors leading to CHD in the black population of Durban. The study sample was selected from patients attending a dental clinic at a hospital. A total of 458 patients (age range 16-69 years) was studied. The prevalence of CHD was 2.4%. The percentage prevalences of selected risk factors were: hypertension (blood pressure > or = 140 mmHg systolic and/or > or = 90 mmHg diastolic) 28% (31.9% for males, 25.4% for females); protective levels of high-density lipoprotein/total cholesterol > or = 20%, 81.3%; diabetes mellitus 4.9% for males, 2.9% for females; smoking > or = 10 cigarettes per day 28.1% for males, 3.4% for females; obesity 3.7% for males 22.6% for females. We found the Minnesota Coding System for electrocardiographic changes of CHD and the Rose questionnaire to be unreliable for eliciting CHD in blacks. Hypercholesterolaemia is less common, and this may explain the low incidence of CHD in blacks. Epidemics of CHD as seen in Indian, coloured and white South Africans can still be prevented in the black population, but preventive measures must be instituted rapidly.


Hypertension in family practice. A study of knowledge, attitudes and practices.

A study was conducted in Cape Town during 1990 to investigate the knowledge, attitudes and practices of 90 family practitioners with regard to hypertension and its management. Hypertension was regarded as an important health problem by 59% while 5% thought that it was not important. Sixty-eight per cent of family practitioners estimated that less than 15% of their patients suffered from hypertension and 78% of family practitioners estimated that more than 70% of their hypertensive patients' blood pressures were controlled. Fifty-five per cent of family practitioners thought it acceptable for a lay person to measure blood pressure and 68% felt that the use of a hypertension register in the practice would assist in the management of hypertension. The information gathered will be of great value in planning intervention strategies and developing hypertension management aids that could assist the family practitioner.


Distribution of health personnel in the Republic of South Africa with special reference to medical practitioners.

Data from various sources indicate that there is no shortage of medical practitioners in the RSA. This was confirmed in a 1990 survey by the Department of National Health and Population Development. The perceived shortage is relative in nature and due to a geographical and functional maldistribution. The majority (77%) of medical practitioners reside in metropolitan areas in the RSA; the ratio of doctors to members of the population is 1:696. Only 23% of medical practitioners practise in non-metropolitan areas; the calculated ratio is 1:1 920. The overall ratio in the self-governing territories is 1:15 272 and compares unfavourably with the ratios in non-metropolitan magisterial districts in the RSA. The medical practitioner/population ratio varies fifty-fold between the metropolitan areas in the RSA and the essentially rural self-governing territory of Lebowa (1:30 449). The registered medical practitioner/population ratios for the various development regions vary from 1:672 to 1:7 642. Failure to address these imbalances will have serious implications for the future rendering of acceptable and equitable health care.


Can medical graduates afford to become state medical officers?

Over the past 7 years, the cost of tuition and residence fees at the University of Cape Town Medical School has risen by 21.75% each year. This is considerably higher than the increase in the consumer price index over the same period and students are increasingly having to resort to loans to finance their education. The starting salary of a medical officer in the state services has, however, only risen by 9.73% each year over the same period. If these trends continue, the likelihood of young medical doctors employed in such posts being able to repay their loans is bleak and the services will experience increasing difficulty in filling posts, particularly in the peri-urban and rural areas. An innovative manner of financing medical education is needed. This could include allowing education costs to be tax-deductible after graduation, or providing incentives, rather than using coercion, to encourage young doctors to settle in less popular locations.


The incidence of surgical glove perforation during obstetric and gynaecological surgical procedures.

The increasing prevalence of diseases such as AIDS and hepatitis B makes safe surgical techniques more important than ever before. Intact surgical gloves act as a barrier against these infections and a study was therefore done to determine the incidence of surgical glove perforation during obstetric and gynaecological surgical procedures. Surgical gloves were collected and tested for perforations following 353 consecutive obstetric and gynaecological operations. Forty pairs of new unused surgical gloves were tested for perforations in the same way. Whereas none of the 40 control pairs of gloves was found to be perforated, 22%-24% of used gloves were perforated. The experience of the surgeon had no influence on the incidence of glove perforation (P = 0.997; chi 2-test). Left-hand gloves were more frequently perforated than right-hand gloves, but this difference was not statistically significant (P = 0.075: chi 2-test). These findings must be a source of concern to all those practising obstetrics and gynaecology and measures are therefore suggested to decrease the risk of HIV or hepatitis B transmission during operations.


Road traffic collisions involving children as pedestrians. Provisional results of a hospital-based study.

In December 1990 a study was undertaken at Red Cross Children's Hospital to examine the circumstances surrounding pedestrian injuries in children under the age of 13. The provisional results, based on the first 154 parental interviews, are reported here. There is a strong correlation between pedestrian injury and children playing or running errands in residential areas during day-light hours, particularly in the late afternoon. Lack of adult supervision may be an important factor. The relevance of these findings to future road safety strategies is discussed.


Financial compensation following road traffic injury: who is footing the bill?

A study was undertaken at Red Cross Children's Hospital to assess how aware parents were of motor vehicle accident (MVA) claim procedures on behalf of their children. Of 160 questionnaires sent out to the parents of road traffic injury (RTI) victims, 100 were answered. Sixty-six per cent of parents who responded had an income below R500 per month. The identity of the motorist responsible for injuring the child was known to only 26 parents. Third party damages were claimed by only 32 parents or guardians; the remaining 68 failed to do so principally through lack of awareness. The implications of these findings for both RTI victims and the hospitals where they are treated are discussed here.


Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results.

From 1960 10 1984, 2,501 women underwent diagnostic laparoscopy (index laparoscopy) because of a clinical suspicion of acute pelvic inflammatory disease (PID). Of these women, 1,844 had abnormal laparoscopic findings (patients) and 657 had normal findings (control subjects). The reproductive events after index laparoscopy of 1,732 patients and 601 control subjects were followed. The patients and control subjects were followed for a total of 13,400 and 3,958 woman-years, respectively. During the follow-up period, 1,309 (75.6%) of the patients and 451 (75.0%) of the control subjects attempted to conceive. Of these women, 209 (16.0%) of the patients and 12 (2.7%) of the control subjects failed to conceive. A total of 141 (10.8%) of the patients and 0 (0%) of the control subjects had confirmed tubal factor infertility, 21 (1.6%) of the patients and 3 (0.7%) control subjects had other causes of infertility, and 47 (3.6%) patients and 9 (2.0%) control subjects did not have a complete infertility evaluation. Additional information on tubal morphology (hysterosalpingography, laparoscopy, or laparotomy) in women from couples for whom evaluation was incomplete indicated that 165 (12.2%) patients and 4 (0.9%) of the control subjects had abnormal tubal function or morphology after index laparoscopy. Tubal factor infertility after PID was associated with number and severity of PID episodes. The ectopic pregnancy rate for first pregnancy after index laparoscopy was 9.1% among the patients and 1.4% among control subjects.


Comparison of polymerase chain reaction, monoclonal antibody based enzyme immunoassay, and cell culture for detection of Chlamydia trachomatis in genital specimens.

An enzyme immunoassay (EIA; AntigEnz Chlamydia; Northumbria Biologicals, Northumberland, United Kingdom) and a polymerase chain reaction (PCR) assay (Genemed Biotechnologies, San Francisco, CA) were evaluated for the detection of Chlamydia trachomatis in urogenital specimens. Of 324 specimens, 23 were positive by cycloheximide-treated McCoy's cell culture method. Of 23 culture-positive specimens, 20 and 22 were found to be positive by EIA and PCR, respectively. Among 301 culture-negative samples, 4 were found to be positive by both PCR and EIA, 2 were PCR-positive and EIA-negative, and 3 PCR-negative and culture-negative specimens were found to be positive by EIA. In comparing nonculture methods with cell culture technique, combined sensitivities of 87.0% (90.9% in men and 83.3% in women) and 95.6% (90.9% in men and 100% in women), and specificities of 97.7% (99.4% in men and 95.7% in women) and 98.0% (99.4% in men and 96.5% in women) are achieved by EIA and PCR, respectively. The PCR proved to be the more sensitive of these two nonculture methods, and it can be used for the rapid diagnosis of C. trachomatis urogenital infection.


Mucopurulent cervicitis as a predictor of chlamydial infection and adverse pregnancy outcome. The Investigators of the Johns Hopkins Study of Cervicitis and Adverse Pregnancy Outcome.

The role of mucopurulent cervicitis in identifying pregnant women with Chlamydia trachomatis infection and poor pregnancy outcome was examined at the Johns Hopkins Hospital Obstetric Clinic in Baltimore, Maryland. The women studied were at high risk for chlamydial infection (14%), low birthweight (12%), and preterm delivery (13%). Yellow endocervical discharge on a cotton swab had a sensitivity of 23.9%, specificity of 89.4%, and positive predictive value of 28.6% for predicting chlamydial infection. The presence of greater than or equal to 30 polymorphonuclear cells per 1000 x field had a sensitivity of 25.0%, specificity of 87.6% and positive predictive value of 24.3%. Women with cervicitis defined by greater than or equal to 30 polymorphonuclear cells per 1000 x field were twice as likely to deliver a low-birthweight infant. Adjustment for potential confounding variables did not explain this association. The poor sensitivity, specificity, and positive predictive value of mucopurulent cervicitis suggests that this parameter is not a useful screening tool for chlamydial infection in pregnant women. However, mucopurulent cervicitis may be an indicator of increased risk for poor pregnancy outcome.


The emergence of penicillinase-producing Neisseria gonorrhoeae strains carrying the 4.9 kb (Toronto) plasmid in Denmark and of a novel large plasmid in two nonpenicillinase-producing Neisseria gonorrhoeae strains.

This study comprised plasmid analysis and antimicrobial susceptibility testing of 712 out of a total of 730 penicillinase-producing Neisseria gonorrhoeae (PPNG) and 744 random non-PPNG strains isolated in Denmark between 1985 and 1990. The rate of patients with PPNG infections rose from 1% to 2% during 1985-1987 to 6.9% in 1989, and then decreased to 4.8% in 1990. A decrease in cases of gonorrhea from 9,798 to 1,990 was seen during the same period. Strains harboring the 4.9 kb (Toronto) plasmid first appeared in 1987; in 1988-1990, 65% to 78% of strains from patients with PPNG infections acquired in Denmark contained this plasmid. The majority of these strains seemed to belong to a single clone. Tetracycline-resistant PPNG strains (MIC greater than 32 mg/L) first appeared in Denmark in 1989, and tetracycline-resistant non-PPNG strains carrying a 40 kb plasmid (tetM?) first appeared in 1990. A novel 41-42 kb plasmid appeared in one strain in 1987 and another in 1988. The minimum inhibitory concentration (MIC) of tetracycline for these two strains was 4 mg/l. The significance of this plasmid is yet unknown.


Temporal trends in gonococcal antibiotic resistance in Baltimore.

Each month from August 1986 through July 1990, clinical and laboratory data were evaluated for the first 25 urethral isolates of Neisseria gonorrhoeae from men attending a Baltimore sexually transmitted disease (STD) clinic as part of an effort to understand factors that contribute to changes in gonococcal antimicrobial susceptibility. During the 48-month study period, 1193 gonococcal isolates were evaluated; the proportion of penicillinase-producing N. gonorrhoeae (PPNG) isolates steadily increased, the prevalence of tetracycline-resistant N. gonorrhoeae (TRNG) remained relatively stable, and chromosomally mediated penicillin resistance increased steadily during the first 5 6-month intervals, then decreased, only to increase again during the final 2 6-month intervals. Changes in antibiotic treatment regimens for gonorrhea were associated with changes in the prevalence of chromosomally mediated penicillin resistance. In a supplementary study to characterize patterns of antibiotic use among men and women attending the STD clinics, 9% of patients reported antibiotic use in the 2 weeks prior to clinic visit. Antibiotics were taken prior to clinic attendance by 65% of patients reporting antibiotic use, because of concerns regarding possible STD or STD exposure. These patients were significantly less likely to be culture positive for N. gonorrhoeae when compared with patients who did not report antibiotic use. Temporal trends in N. gonorrhoeae antibiotic resistance appear to be influenced by many factors, including treatment regimens and self medication.


Effectiveness of latex condoms as a barrier to human immunodeficiency virus-sized particles under conditions of simulated use.

Condoms were tested in an in vitro system simulating key physical conditions that can influence viral particle leakage through condoms during actual coitus. The system quantitatively addresses pressure, pH, temperature, surfactant properties, and anatomical geometry. A suspension of fluorescence-labeled, 110-nm polystyrene microspheres models free human immunodeficiency virus (HIV) in semen, and condom leakage is detected spectrofluorometrically. Leakage of HIV-sized particles through latex condoms was detectable (P less than 0.03) for as many as 29 of the 89 condoms tested. Worst-case condom barrier effectiveness (fluid transfer prevention), however, is shown to be at least 10(4) times better than not using a condom at all, suggesting that condom use substantially reduces but does not eliminate the risk of HIV transmission.


Evaluation of an enzyme immunoassay and a modified coagglutination assay for typing gonococcal isolates with monoclonal antibodies.

In order to resolve methodologic and interpretation problems associated with the serotyping of Neisseria gonorrhoeae isolates with monoclonal antibodies specific for Protein I (PI) by coagglutination (the standard method; CoA1), two methods were compared with CoA1: an enzyme immunoassay (EIA) and a modified coagglutination assay (CoA2), in which methylene blue was added to the monoclonal antibody reagents. When the EIA was compared with the CoA1 method, 92.7% of the WI isolates were typed identically and 89% of the WII/III isolates were typed identically. When the CoA2 was compared with the CoA1 method, 92.7% of WI isolates were typed into similar serovars, in comparison to only 80.5% of the WII/III isolates. With the EIA method, only 21 of 328 isolates (6.4%) were retested because duplicate results were inconsistent, in comparison to 72 isolates (22%) with the CoA1 method and 120 isolates (36.6%) with the CoA2 method. In most cases result inconsistencies between duplicate tests were due to differences in reading weakly positive coagglutination reactions with single reagents (which on duplicate testing might be negative), the most notable being PIA reagent 4A12(b) and PIB reagents 1F5(b) and 2G2(g). The EIA method was the most reproducible method, and provides some degree of automation when serotyping large numbers of isolates.


Condoms for men, not women. Results of brief promotion programs.

Three different brief intervention programs to promote condom use were tested among patients in inner-city sexually transmitted disease (STD) clinics. The first, "Condom Skills," focused on teaching mechanical aspects of how to use a condom. The second, "Social Influences," emphasized how to negotiate condom use with one's sexual partner. The third, "Distribution," provided patients with an unlimited number of free condoms, retrievable at local community businesses. Of the 903 subjects whose medical records were reviewed after exposure to the intervention programs, evidence of continued unsafe sexual behavior, documented by subsequent treatment for a new STD, was found for 12.6% of the women and 19.9% of the men. When compared with male control subjects, male study patients had fewer documented subsequent STD reinfections. The relative risk (RR) and 95% confidence interval (CI) values were 0.48 and 0.28, 0.81 for the condom skills group; 0.65 and 0.40, 1.04 for the social influences group; and 0.85 and 0.56, 1.29 for the distribution group. There was no decrease in the incidence of STDs among female patients compared with control subjects; indeed, there was a trend toward increased risk of STDs among women exposed to the Social Influences intervention program. This study demonstrates that brief condom promotion programs can be effective for male STD patients, and that caution must be exercised in promoting condoms to women with a high risk of acquiring STDs. Further research on programs promoting safer sex among these women is needed.


Sentinel surveillance of human immunodeficiency virus infection in sexually transmitted disease clinics in the United States.

From April 1988 through December 1989, sera obtained for syphilis testing from consecutive patients attending 98 sexually transmitted disease (STD) clinics in 37 metropolitan areas were tested for antibodies to human immunodeficiency virus (HIV) in an unlinked (blinded) survey. HIV seroprevalence in STD clinics ranged from 0 to 38.5% (median, 2.3%), with the highest rates found in the Mid-Atlantic states, Florida, and Puerto Rico. The highest median rates were found in men who have sex with men (36.1%) and heterosexual intravenous (IV) drug users (4.1%). For heterosexual persons who do not report IV drug use, median rates were highest in the 35- to 39-year-old age group for men (6.4%) and the 30- to 34-year-old age group for women (0.9%). Among persons who do not report risk behaviors for HIV infection, men had substantially higher median rates of HIV infection than women (P less than 0.001, Wilcoxon Signed Rank test), and rates were positively correlated with HIV infection rates in IV drug users in the same clinic (Pearson correlation coefficient [r] = 0.8; P less than 0.001). Among heterosexual STD clinic patients who do not report IV drug use, the median HIV infection rate for blacks (1.8%) was at least 2 times higher than the median infection rates for hispanics (0.9%) and whites (0.7%). The results of this study show that HIV infection in STD clinic patients varies by geographic area, sex, race and ethnic group, and risk behavior.(ABSTRACT TRUNCATED AT 250 WORDS)


Underdiagnosis of Chlamydia trachomatis infection. Diagnostic limitations in patients with low-level infection.

To determine limitations in commonly used methods for detection of Chlamydia trachomatis, 601 genitourinary specimens from patients in a sexually transmitted disease clinic were examined with quantitative cultures and by 2 different direct antigen tests, immunofluorescence (Micro Trak; Syva Company, Palo Alto, CA) and enzyme immunoassay (Chlamydiazyme; Abbott Laboratories, North Chicago, IL). Genital specimens were held no longer than 5 hours (at 4 degrees C) prior to inoculation for culture; 28% (168/601) were positive. To evaluate the effect of storage on culture efficacy, duplicate specimens were also stored at -70 degrees C and brought out subsequently for culture a second time. Only 32% (8/25) of specimens cultured within 5 hours and having less than 10 inclusions were positive on reculture, compared with 98% (49/50) positive for specimens with greater than or equal to 10 inclusions initially (P less than 0.001). Sensitivities of the two antigen tests were similar and taken together diminished significantly (P less than 0.001) as the number of organisms (inclusion forming units) in corresponding cultures decreased: 82% (51/62) sensitivity in cultures with greater than 100 inclusions; 50% (22/44) with 10-100 inclusions; and only 11% (6/53) with less than 10. Lack of urethral discharge in men with C. trachomatis infection (free of Neisseria gonorrhoeae) was associated with low numbers of inclusions (less than 10) and antigen tests failed in 68% (15/22) of these patients.


High-risk behaviors for transmission of syphilis and human immunodeficiency virus among crack cocaine-using women. A case study from the Midwest.

This study examines the drug use patterns, sexual practices, condom use, knowledge and attitudes toward sexually transmitted diseases (STD)s and AIDS, and seroprevalence of human immunodeficiency virus (HIV) and syphilis among women who use crack in Dayton, Ohio. In 1990, two indigenous outreach workers recruited 150 participants who were not in drug treatment programs, who were 18 years of age or older, and had used crack in the previous 3 months. Structured interviews revealed that 90% of the sample were black, 78% used crack "daily," 93% had multiple sexual partners, and 49% had 10 or more male sexual partners in the last 3 months. A majority (67%) of the women felt they were in need of drug treatment. No reactive syphilis serologies were detected in 138 serum samples; 2 women (1.4%) were HIV seropositive. This case study provides insight into the high-risk sexual behaviors of crack users in a medium-sized, midwestern city. The study demonstrates the value of indigenous outreach prevention and STD screening initiatives in reaching this segment of our society, which has a high risk of acquiring STDs.


Multiple partners and partner choice as risk factors for sexually transmitted disease among female college students.

Multiple sexual partners and partner choice are believed to increase the risk of sexually transmitted disease (STD), but these behaviors had not previously been assessed outside of clinical populations. In this study, a cross-sectional survey among single, white, female students in their senior year of college was conducted to measure the association between behavioral risk factors and the acquisition of self-reported STDs during college. The usable response rate was 47.2% (n = 467). The combined prevalence of chlamydial infection, gonorrhea, genital herpes, human papillomavirus (HPV) infection, syphilis, and trichomoniasis during a 3.5-year period was 11.7%. There was a strong association between number of sexual partners and having an STD: those women with 5 or more sexual partners were 8 times more likely to report having an STD than those with only 1 partner, even after adjusting for age at first intercourse (odds ratio = 8.1; 95% confidence interval = 1.99, 32.64). The prevalence of a history of STDs increased with more causal partner choice and earlier age at first intercourse, but neither factor was independently associated with a history of STDs. Of the respondents, 23% always used condoms. Future research should focus on identifying ways of effectively changing high-risk sexual behavior.


The sexually transmitted diseases laboratory in a framework of population-based diagnostics.

Laboratory support for the diagnosis and treatment of sexually transmitted diseases has traditionally been within a patient-based diagnostic paradigm. Tests and interpretative criteria developed within this paradigm may not be appropriate for laboratories supporting population-based STD control programs. As STD control strategies expand to population-based levels, the present patient-based laboratory models will have to be modified to meet these increased demands.


Fulminant endocarditis due to infection with penicillinase-producing Neisseria gonorrhoeae.

Endocarditis is a rare but potentially lethal manifestation of gonococcal infection. We report the case of a patient with fulminant endocarditis secondary to infection with penicillinase-producing Neisseria gonorrhoeae (PPNG). The patient had rapid deterioration from extensive destruction of the aortic valve with abscess and fistula formation. Lifesaving emergency surgery was performed. To our knowledge this is the first reported case of gonococcal endocarditis secondary to infection with a penicillinase-producing organism.


Treatment of chancroid with a single dose of spectinomycin.

Fifty patients with lesions characteristic of chancroid were enrolled in an open-label prospective study to examine the efficacy of a single 2-gm dose of spectinomycin for treatment of chancroid. Only those patients (41 men; aged 18 to 49 years) with positive culture results for Haemophilus ducreyi were included in the analysis. Patients each received a single 2-gm dose of spectinomycin intramuscularly. The recovery process began on the third day of follow-up, as evidenced by the occurrence of epithelialization and a decrease in inflammation. By the seventh day after treatment, only one patient had ulcers; 40 patients experienced eradication of all ulcers (P less than 0.0001). The condition of nodes affected by infection also indicated efficacy of treatment (P less than 0.01); only one patient still had a swollen node by the fourteenth day after treatment. Of the 41 patients, 37 (90%) had negative culture results for H. ducreyi on the third day after treatment. Only 4 patients (10%) required a second dose of spectinomycin on the seventh day to affect a cure. Treatment with spectinomycin resulted in a 98% cure rate 14 days after treatment. The minimum inhibitory concentration (MIC) of spectinomycin was 1 microgram/mL to 3 micrograms/mL in the 15 strains studied. The drug was well tolerated and no adverse reactions were reported. It is concluded that a single 2-gm dose of spectinomycin is a safe and effective alternative drug for treatment of chancroid.


Split-dose metronidazole or single-dose tinidazole for the treatment of vaginal trichomoniasis.

In a double-blind, randomized, controlled trial, efficacy and safety of a single-day split dose of 1.6 g of metronidazole were compared with a single 2-g dose of tinidazole in the treatment of vaginal trichomoniasis. Women with symptomatic vaginal trichomoniasis were randomly assigned to one of the two treatment groups. There were 67 women in the group treated with the single-day split dose and 65 in group treated with the single dose. There was no significant difference between the two groups in terms of clinical characteristics (age, weight, and length of follow-up period). The cure rates, using trypticase yeast extract iron serum (TYI) medium to confirm microbiologic cure, were 98.5% and 100% for the groups treated with a single-day split dose and with a single dose, respectively. The side effects were minimal and did not warrant any treatment. The differences in the results were not statistically significant. We recommend that the single-day split dose of 1.6 g of metronidazole regimen be given as an alternative drug for vaginal trichomoniasis. Its advantages include being highly effective, significantly less expensive, and with minimal side effects.


Patterns of antibiotic susceptibility of gonococci isolated in Hong Kong, 1987-1990.

Among the 14,528 strains of Neisseria gonorrhoeae isolated from the Government Social Hygiene Sexually Transmitted Disease (STD) Clinics in Hong Kong between 1987 and 1990, there has been a trend toward a decrease in the percentage of penicillin resistant strains in both penicillinase-producing and nonpenicillinase producing N. gonorrhoeae (PPNG and non-PPNG) and an increase in moderate resistant strains, whereas the proportion of sensitive strains has remained stable, except for a small increase in 1990. Presently, PPNG still accounts for 31% of all isolates. In early 1991, 100 consecutive isolates were tested for minimum inhibitory concentrations (MIC) against 6 commonly used antibiotics. Although ofloxacin has been used as the first-line treatment for gonorrhea for the last 5 years, there is still no sign of in vitro resistance. Two isolates with high-level tetracycline resistance (MIC greater than 16 mg/l) were detected that have not been seen before. Sensitivity to spectinomycin, cefuroxime, and ceftriaxone has also been maintained, and these drugs can probably be recommended as alternative treatments in noncompliant cases. Analysis of location of contact shows an increasing proportion of cases of gonorrhea from overseas, particularly from parts of China. Comparison with the limited information published in the region shows that the population sampled can be very heterogeneous. With the continued flux of international travel, one should be extremely careful when trying to get an accurate assessment of epidemiologic data.


Prevalence of sexually transmitted disease infection in women alleging rape.

During a 2-year period ending in October, 1989, 110 women who claimed to have been raped were treated at the sexually transmitted disease clinic at Birmingham General Hospital. A total of 22 sexually transmitted infections were found in 14 (13%) women, of which Chlamydia trachomatis (in 8%) and Trichomonas vaginalis (in 6%) were the most frequently found pathogens. In none of these patients was it possible to determine whether infection resulted from rape or from voluntary intercourse with another person. The high prevalence of infection found in this study and in previous studies indicates that all women alleging rape should be investigated at a sexually transmitted disease clinic.


Toward an understanding of dynamic variables in ergonomics.

Although researchers have shown that dynamic activity may greatly increase the predicted loading experienced by a joint, most ergonomic assessments in the workplace have focused on the postures of the workers and the loads imposed on a joint due to these postures, ignoring the influence of dynamic motion on joint loading. Current technologic advancements now allow the performance of dynamic ergonomic assessments that were impossible a few years ago. This chapter reviews the recent efforts to understand how occupational settings influence the joint motions and subsequent risk of suffering an injury or illness, including the effect of trunk motion on the reaction of joint-supporting structures and the subsequent loading of the spine and wrist. The back appears to be sensitive to the velocity component of motion, and the wrist to acceleration.


A functional job analysis technique.

An analytical approach is presented for evaluating functional job demands and for facilitating a team problem-solving process that should find cost-effective resolutions for designs that do not meet ergonomic guidelines. Information is included on ways to collect information about the job elements and demands, how to relate the demands to population work capacities, how to predict fatiguing tasks, and how to facilitate a problem-solving session within the plant or business. A case study is used to illustrate the process from the initial review of jobs in a plant to the generation of a list of possible actions and their expected benefits.


Epidemiology of low-back pain in industry.

Low-back pain and back injuries are of such a complex nature that any one criterion cannot be applied by itself to give a valid assessment of the risk associated with manual materials-handling jobs. There is no question that low-back pain is an extremely significant cause of disability and has a major socioeconomic impact, but many different personal and job factors are associated with the incidence and prevalence of these complaints. There is a need for ongoing systematic investigations of the multiple risk factors that may be causally related to low-back pain and may possibly be amendable to preventive interventions. Knowledge of workplace and individual risk factors is far from complete. Prospective studies are needed so that factors contributing to the development of low-back pain can be separated from factors resulting from low-back pain. It is difficult to relate low-back pain to the workplace because it occurs quite often in workers employed in sedentary occupations. However, incidence, severity, and disability are all related to the physical demands of the job. In this regard, jobs involving lifting, lowering, pushing, pulling, carrying, and holding; body movements such as frequent bending, twisting, and sudden movements; and working in bent-over postures appear to have a significant potential for producing low-back pain. A combination of lifting, bending, and twisting appears to be most hazardous. It is concluded that lifting heavy loads contributes to increased frequency and severity rates for low-back pain. This is true regardless of whether the lifting is performed over a short period or throughout the day and whether it is performed a few times per day of repetitively. If, however, such lifting is performed repetitively, the medical hazard extends beyond low-back problems to other musculoskeletal strain and sprain injuries and to fatigue-related injuries, particularly for weaker workers. In this latter regard, gender, age, anthropometry, and previous history of back pain are known to modify these risks for populations of workers. The inherent variability between workers and within any worker over time precludes the use of such factors to assign risk to any particular individual.


Occupational biomechanics and low-back pain.

The basic principles of biomechanics are introduced and explained as they relate to the field of ergonomics, especially regarding the lumbar spine. The discussion is organized into the following sections: biomechanics--an overview, spinal structures and loading, biomechanical basis for low-back pain, compressive strength of the lumbar spinal column, biomechanical models, intra-abdominal pressure, lifting technique, and practical applications. The conclusion lists nine guidelines for understanding the internal stresses placed on the lower back by lifting and thereby for avoiding low-back injuries in the workplace.


Carpal tunnel syndrome.

Despite numerous publications in the literature, there is still a significant deficit of knowledge regarding carpal tunnel syndrome and its relationship to work. This chapter reviews a variety of observations from these studies. Epidemiologic studies have been mostly cross-sectional surveys using clinical criteria (symptoms and physical findings) as a basis for case definition, but these exposure assessments cannot discriminate between work-related and non-work-related cases of carpal tunnel syndrome. These studies do reveal a fairly consistent pattern of observations regarding the spectrum and relative frequency of upper extremity morbidity among jobs believed to be hazardous. Carpal tunnel syndrome, however, is but one of these disorders and is not the most common one. Historical perspectives, anatomic pathology, pathophysiology, theories of pathogenesis, epidemiologic observations, associations with exposure, and current issues are discussed.


Prevention strategies and the low back in industry.

Several different approaches have been tried in industry to prevent low-back injuries. The scientific literature shows that only job-specific strength testing and ergonomic job design are partially effective in preventing low-back injuries. Job-specific strength testing is supported as a means of identifying high-risk workers who need to perform manual materials handling. However, this approach should be carefully validated for its effectiveness before it is used as a form of selection procedure. At present, ergonomic job design offers the most potential for preventing disabling low-back injuries and other musculoskeletal injuries. Quantitative and objective methods (such as NIOSH guidelines, biomechanical models, energy expenditure, and strength data) are available to analyze a given job and to determine the relative risk of an injury.


Diagnoses and treatment options in occupational low-back pain.

Job modification is often effective for prevention of LBP, but employee selection is generally risky, unreliable, and (increasingly) illegal. For acute care, excellent results are obtained with a simple, well-organized protocol. A trial of additional interventions is usually not productive. In rehabilitation, the challenge is to choose interventions at the most cost-effective time and identify local programs which have proven effectiveness. Case-closure issues such as medical end-result, impairment rating, and permanent job restrictions continue to be poorly supported by scientific literature. They are often best resolved by consensus of the patient, physician, and employer. We look forward to more reliable predictors of long-term outcome. An old adage says, "If there are dozens of treatments for a disease, probably none of them is effective." In recent years we have advanced from dozens of equally acceptable treatments to a few well-documented ones, as outlined in the Quebec study. Such an approach is very effective in changing the course of back pain. However, there are still many unproven treatments in common use. Perhaps some will prove useful. In adding interventions to a simple, effective protocol, one must be aware of the true risks and benefits.


[Phakomatosis: anatomo-clinical expressions of urological interest].

Up to date etiopathogenetic knowledge of phakomatoses allows a more rational classification as compared to the known ones, based on anatomopathological and/or clinical features. Some genes have been identified, which are correlated with neurofibromatoses, tuberous sclerosis and other conditions, through general biologic mechanisms (derivatives of the embryonic neural crest; nerve growth factor and its receptor; oncogenes and antioncogenes, etc.). A prenatal predictive value from those genetic connections can also ensue. The new diagnostics, both by imaging and by laboratory techniques, may affect the therapeutic choices, as for as urological involvement is concerned.


Function, structure, and responses of components of the muscle-tendon unit.

A "muscle-tendon unit" is a composite structure that includes muscle, tendon, myotendon junctions, tendon sheaths, and tendon-bone junctions. Each component is unique in its structure, function, response to strain, and associated clinical disorders (usually called "tendinitis"). Tendinitis implies localized tenderness in the distribution of a muscle-tendon unit to palpation, passive stretching, or active contraction. A variety of distinct clinical entities associated with the various components of the muscle-tendon unit are usually grouped together under the term "tendinitis," although each has unique characteristics and etiologic factors. Most have short latencies and favorable prognoses with appropriate clinical management, and most also bear some direct relationship to biomechanical factors, such as compression or strain, as well as to work organizational factors, particularly unaccustomed work.