Acetazolamide and high altitude diseases. Acetazolamide is a useful prophylactic for acute mountain sickness causing marked reduction in headache, nausea, vomiting, weakness, etc. Improvements correlate with increased arterial oxygen concentrations, reduction in proteinuria and peripheral oedema and other objective measures of acute mountain sickness. Evidence that Acetazolamide is beneficial for pulmonary oedema or cerebral oedema is scanty because of the lower frequency of these severe forms of mountain sickness. Dexamethasone, used prophylactically, also reduces the symptoms of acute mountain sickness partly due to its euphoric effect. Use of Acetazolamide as a treatment for established acute mountain sickness has been investigated. Large doses of Acetazolamide increase arterial oxygen levels over a few hours and this leads to a reduction of symptoms but data is limited and faster acting carbonic anhydrides inhibitors such as Methazolamide may be preferable in an emergency situation. There is no comparison of the effectiveness of Acetazolamide with other drugs used for treating acute mountain sickness such as steroids and calcium channel blocking drugs. Also, there is no data on drug combinations which could have additive effects and thereby be more beneficial than individual drugs.


Prevention and treatment of high altitude pulmonary edema by a calcium channel blocker. High altitude pulmonary edema (HAPE) is characterized by marked pulmonary hypertension. Treatment of 6 subjects suffering from radiographically documented HAPE with the calcium channel blocker nifedipine, lowered pulmonary artery pressure and resulted in clinical improvement, better oxygenation, reduction of alveolar-arterial oxygen gradient and a progressive clearing of alveolar edema on chest x-ray. This amelioration occurred despite continued exercise at an altitude above 4000 m and without supplementary oxygen. Prophylactic application of nifedipine slow release preparation, 20 mg every 8 hours, prevented HAPE in 9 out of 10 subjects with a history of radiographically documented HAPE upon rapid ascent and subsequent stay to an altitude of 4559 m. Seven of 11 comparable subjects who received placebo developed pulmonary edema at 4559 m. As compared with the subjects who received placebo, those who received nifedipine had a significantly lower mean systolic pulmonary artery pressure, alveolar-arterial pressure gradient of oxygen and symptom score of acute mountain sickness at 4559 m. Thus nifedipine offers a potential emergency treatment of HAPE when descent or evacuation is impossible and oxygen is not available. Prophylactic administration of nifedipine prevents HAPE in susceptible subjects. High pulmonary artery pressure has an important role in the pathogenesis of HAPE.


The effect of vasodilators on pulmonary hemodynamics in high altitude pulmonary edema: a comparison. High altitude pulmonary edema is characterized hemodynamically by a markedly restricted pulmonary vascular bed. Pulmonary vascular resistance is six to eight times higher than control values at altitude, and mean pulmonary pressure is generally elevated two to four-fold over control values. We wished to compare the effect of various vasodilators on the hemodynamics of HAPE, both to gauge their potential effectiveness in treatment of HAPE, and also to gain clues as to the mechanism of the altered pulmonary circulation. In a series of field experiments using a total of 16 subjects with HAPE and 10 well controls, we measured pulmonary hemodynamics by non-invasive Doppler echocardiography. The per cent reduction in pulmonary vascular resistance and mean pulmonary artery pressure, respectively, were 46 and 33 for oxygen, 30 and 29 for nifedipine, 29 and 25 with hydralazine, 57 and 42 with phentolamine, and 72 and 52 when oxygen and phentolamine were combined. All the vasodilators improved gas exchange, suggesting a link between edema formation and pulmonary vasoconstriction. A number of vasodilators may be useful in the treatment of HAPE; the superiority of an alpha adrenergic blocker may implicate the sympathetic nervous system in the pathophysiology of high altitude pulmonary edema.


Treatment of high altitude diseases without drugs. Treatments other than descent and supplemental oxygen are discussed in this short review. Exercise gives rise to physiologic responses which may enhance acute mountain sickness (AMS), high altitude cerebral edema (HACE) and high altitude pulmonary edema (HAPE). Therefore, physical rest can be considered the principle treatment for moderate AMS and it should always accompany any treatment of severe high altitude illnesses as long as descent is not possible. Therapy with a portable fabric hyperbaric chamber has a beneficial short-term effect in subjects with AMS, HACE and HAPE. However, treatment modalities using this device which result in long-term beneficial effects need yet to be established. New technical solutions practicable under field conditions at extreme altitude are required for the removal of CO2 from the bag. Expiratory positive airway pressure (EPAP) improves arterial oxygen saturation by 10-20% in subjects with HAPE in trials of 10 min duration. Clinical studies examining longterm effects are necessary, before EPAP can be recommended as initial emergency treatment of HAPE.


The causes of death among trekkers in Nepal. A review of trekking deaths from 1984 to mid-1987 showed a death rate of 15/100,000 trekkers. Altitude sickness deaths accounted for 3/23 (13%) of these deaths. Recently, we followed up on our original study by compiling the number and causes of trekking deaths in Nepal from mid-1987 through 1991. The overall number of deaths was 40, out of 275,950 trekkers (death rate 14/100,000). Illness accounted for 14 deaths, trauma was the cause of 12 deaths, altitude sickness was the cause of 10 deaths, 3 people were found dead after being reported missing, and one person is still missing and presumed dead. Eight out of 10 altitude sickness deaths occurred in organized trekking groups, even though only 40% of trekkers trek in organized groups. Four people were reported to have died from heart attacks, and 3 people died from apparent diabetic ketoacidosis above 4000 meters in altitude. Trekking in Nepal is a relatively safe holiday that currently attracts more than 60,000 people each year. Monitoring the causes of death among trekkers can help generate advice that could make trekking even safer.


Detection of high-risk subjects for high altitude diseases. The variability in sensitivity to acute mountain sickness among individuals is a phenomenon well known to physicians and high altitude alpinists. The measurement of cardiac and respiratory responses to hypoxia (FIO2 = 0.115) at rest and during exercise (50% VO2max) allows the detection of those subjects who are more liable to suffer from high altitude diseases. In a retrospective study performed on 288 subjects evaluated with a hypoxic test during a Mountain medicine consultation, we found that the most clinically susceptible subjects had at least one abnormal response to the hypoxic tests, especially during exercise. The observation of one or several abnormal values in cardiac or respiratory responses to hypoxia leads us to advise a modification in the alpine or trekking objective, an increase in the acclimatization time and/or prevention by acetazolamide.


Pathophysiology and epidemiology of chronic mountain sickness. Chronic mountain sickness, which affects permanent residents of high altitudes, is the outcome of a progressive loss of ventilatory rate which naturally occurs with age and resulting in excessive hypoxemia and polycythemia. A theoretical model predicts the progressive failure of homeostatic control of the hemoglobin concentration when the values increase above those found at sea level. This is confirmed by lack of feedback mechanism between high altitude erythrocytosis and serum erythropoietin. The results of epidemiological studies are in agreement with the physiological findings. In a male population living at 4,300 m, an increase with age of the prevalences of excessive erythrocytosis (Hb > 213 g/l), blood oxygen saturation < 83%, headaches and a high score of symptoms of chronic mountain sickness has been found. The studies suggest the possibility that in addition to an accentuated hypoxemia, the excessive erythrocytosis may also result from an overreaction of the bone marrow to a fixed level of hypoxemia in ageing individuals.


Anaerobic performance at altitude.

Anaerobic performance at altitude. Anaerobic metabolism is usually evaluated by the determination of the anaerobic capacity and the maximal anaerobic mechanical external power (Wmax). Conflicting results are reported on anaerobic capacity evaluated by maximal oxygen deficit and debt, and maximal blood lactate concentration during acute or chronic hypoxia (acclimatized subjects). Data on muscle biopsies (lactate concentration, changes in ATP, phosphocreatine and glycogen stores, glycolytic enzyme activities) and the few studies on lactate flux give in most cases evidence of a non-alteration of the anaerobic capacity for altitudes up to 5,500 m. No differences are observed in Wmax measured at high altitudes up to 5,200 m during intense short-term exercises: (1) jumps on a force platform which is a good indicator of alactic Wmax, and (2) 7-10 s sprints (i.e. force-velocity test) which solicit alactic metabolism but also lactic pathway. For exercises of duration equal or more than 30 s (i.e. Wingate test), there are conflicting results because a lower participation of aerobic metabolism during this test at high altitude can interfere with anaerobic performance. In conclusion, we can admit that anaerobic performances are not altered by high altitudes up to 5,200 m if the length of exposure does not exceed 5 weeks. After this period, muscle mass begins to decrease.


Are Tibetans better adapted?

Are Tibetans better adapted? Evidence is reviewed from our recent (1987-1991) investigations which demonstrate better high-altitude adaptation among Tibetans than in acclimatized newcomers or other lifelong high-altitude residents. Characteristics of oxygen transport contributing to the Tibetans' remarkable exercise performance are described.


Muscle enzymatic composition and metabolic regulation in high altitude adapted natives. Quechuas and Sherpas have long attracted the interest of high altitude biology and medicine. From our current knowledge, it appears that three of their most impressive high altitude adaptations are (i) high efficiency performance even in hypobaric hypoxia, (ii) low maximum (aerobic and anaerobic) capacities, and (iii) high endurance (the latter being less well documented, but widely accepted). Muscle biopsy and enzyme activity measurements clarify the basis for at least some of these adaptations. Firstly, low activity levels of enzymes in oxidative metabolism (comparable to power athletes) predict low VO2max capacities, as previously observed. Secondly, anaerobic glycolytic capacities also are low (comparable to endurance athletes) which explains low anaerobic work capacities. Thirdly, the glycolytic pathway is seemingly organized for carbohydrate oxidation, not fermentation. Because glucose (glycogen) metabolism uses O2 efficiently, the endurance characteristic may arise from coupling carbohydrate-based adenosine triphosphate (ATP) synthesis with efficient pathways of ATP utilization (for high yield of muscle work/ATP).


Physical fitness of children resident at high altitude in Bolivia. In 7-15-yr-old children living in La Paz (Bolivia, altitude 3,700 m) (HA): 1) Maximal oxygen consumption (VO2max) varies from 35 to 45 ml.min-1.kg-1 and maximal heart rate from 188 to 194 beats.min-1. These values are lower than those of their counterparts at low altitude (LA) by 10-20% and 10-15 b.min-1, respectively. 2) The anaerobic metabolism is not affected by chronic hypoxia if the nutritional conditions and pubertal development of HA and LA boys are the same. When related to percent of VO2max, submaximal O2 debts are similar at HA and LA. After supramaximal exercise, maximal O2 debts (45.7 +/- 2.7 vs 45.9 +/- 3.8 ml.kg-1) and blood lactate concentrations (7.6 +/- 0.6 vs 6.5 +/- 0.6 mmol.l-1) are also the same at HA and LA. No differences are observed between the 2 altitudes in ventilatory (60 vs 56% VO2max) and lactate (60 vs 65% VO2max) thresholds. The altitude of La Paz does not alter the anaerobic performance of a force-velocity test (from 6 to 10 W.kg-1) between the ages of 7 to 15 years but reduces by 14-17% the mean anaerobic power developed during a 30-s Wingate test. This decrease could be linked to a lower participation of glycolysis and aerobic metabolism at HA during this test. 3) Poor socio-economic and nutritional conditions do not modify the aerobic performance of boys living in La Paz but lead to lower maximal anaerobic power (from -17% to -25%) when compared with HA boys from a high socio-economic background.(ABSTRACT TRUNCATED AT 250 WORDS)


Surveillance for equity in primary health care: policy implications from international experience. Experience around the world shows that health agencies can promote community-based surveillance for equity to focus low-cost interventions on priority needs. Social inequities which have seemed intractable can be resolved if care responds directly to demonstrated need. The concept of promoting equity as a basic principle of primary health care has an interesting psychological twist. The ethical imperative of equity can strengthen services when linked with the practical management tool of surveillance. Moral conviction in applying this social justice norm can facilitate action which is made efficient by the realism of statistically based methods of surveillance. If international agencies condition their aid on surveillance for equity their assistance will more likely go to those in greatest need. This is a more efficient and effective way of tracking their money than the previous tendency to set up vertical programmes which generally have poor sustainability. Surveillance helps mobilize political will and community participation by providing practical data for local, district and national decision-makers. The many field demonstrations of successful surveillance for equity tend to have been brushed off by development experts who say they are difficult to replicate nationally. The Model County Project in China shows how a systematic extension process can test procedures in experimental areas and adapt them for general implementation. Surveillance can help bureaucracies maintain capacity for flexible and prompt response as decentralization promotes decision-making by local units which are held responsible for meeting equity targets. Surveillance for equity provides a mechanism to ensure such accountability.


Effect of occupational and recreational activity on the risk of colorectal cancer among males: a case-control study. Epidemiological studies have consistently demonstrated that either occupational or recreational physical activity is protective against colon cancer. However, it is unclear whether recreational activity is similarly protective among those who engage in high or low occupational activity. We therefore compared 440 male cases of colorectal cancer with 1164 male hospital patients. Occupational activity was defined according to job title, while recreational activity was assessed by questionnaire for three different periods of life. Occupational activity was protective with respect to colorectal cancer irrespective of whether one engaged in recreational activity at any different period of life. In contrast, recreational activity, performed at 20-44 years of age appeared to decrease colon cancer risk by 10-25% irrespective of the intensity of job activity. The present results suggest that, although we observed a larger effect with occupational activity than with recreational activity, middle-aged men may reduce their risk of colorectal cancer if they exercise when they are not working. These findings need to be confirmed in other populations.


Occupational risk factors for acute leukaemia: a case-control study. A case-control study has been performed for occupational risk factors of acute leukaemia, based on 185 cases more than 30 years old and 513 matched controls. There was a significant excess of polyvalent farming and electronic engineers among professions of cases, and, in addition of metal workers when considering the professions pursued for more than 5 years. The corresponding exposures were analysed through a detailed questionnaire, and assessed by an industrial hygienist after blinding the case-control status. The odds ratios (OR) were computed after adjustment on matching variables and prior chemo- or radiotherapy treatment, and after stratification for the level and total duration of exposure. There was no excess of professional exposure to ionizing radiation among cases. A significant relationship was observed between acute leukaemia and high or medium exposure to benzene, as well as over 10 years high or medium exposure to exhaust gas. In addition a significant relationship was observed with exposure to pesticides--insecticides and/or weed killers--and to electric and magnetic fields (EMF). The relationship with pesticides was significant when considering high or medium exposure to weed killers and more than 10 years exposure to both subtypes of pesticides. The relationship with pesticides and EMF remained significant when confounding factors were taken into consideration and after adjustment on co-exposure to benzene. The cytological studies showed that acute leukaemias following exposure to benzene (high or medium) and to EMF were only of myelogenous subtypes, whereas those following exposure to pesticides were divided between lymphoblastic and myeloblastic subtypes. Cytogenetic studies failed to show increased frequency of chromosomal abnormalities, as described in acute leukaemias secondary to anti-cancer treatments. Our study adds credence to the hypothesis that pesticides and EMF are leukaemogenic agents, together with benzene.


A case-control study of coronary heart disease in Athens, Greece. A case-control study of coronary heart disease (CHD) was conducted in Athens, Greece. The case series consisted of 329 patients with electrocardiographically confirmed coronary infarct or a diagnostic coronary arteriogram, or both, who were admitted during a 16-month period to a major teaching hospital. Controls were 570 patients admitted to the same hospital just before or after the CHD cases for minor surgery; eye, ear, nose or minor urological problems; or chest problems definitely shown to be unrelated to CHD. All cases and controls were interviewed in the hospital wards and selected laboratory data were abstracted. The main analysis was done by modelling through multiple logistic regression, controlling for demographic variables as well as for the mutual confounding effects of the investigated risk factors. Obesity, hypertension, diabetes mellitus, elevated blood cholesterol and excessive coffee intake were significant (P < 0.02) independent risk factors with relative risk estimates in the 2- to 3-fold range. Non-significant positive associations were found with respect to tobacco smoking and modest coffee consumption, whereas non-significant negative associations were noted with respect to alcohol intake and regular exercise. A negative association with duration of afternoon siesta was of borderline statistical significance.


The Framingham Type A behaviour pattern and coronary heart disease in three countries: a cross-cultural comparison. The Framingham Type A behaviour pattern (TABP), a risk factor for cardiovascular disease mortality, was examined in a cross-cultural study involving three countries known to differ in cardiovascular disease mortality, namely Germany, Lithuania and Northern Ireland. The factorial structure of the Framingham TABP scale was strikingly similar in the three countries, with three factors (work pressure, hard driving, and impatience) identified; evidence for the cross-cultural validity of the scale. Scores on all three factors showed considerable variation between the three populations for both men (multivariate P < 0.0001) and women (multivariate P < 0.0001). Of particular note, on the two factors, hard driving and impatience, thought to be core pathogenic elements in the TABP complex, Lithuanian and Northern Irish males and females scored substantially higher than their German counterparts. These cross-cultural variations in levels of risk are discussed in the context of the different ischaemic heart disease mortality rates in the three countries.


Time trends in survival from myocardial infarction in Stockholm County 1976-1984. In Stockholm county, a rapid decline in mortality from acute myocardial infarction (AMI) was observed among middle-aged men in the early 1980s. In the present study survival among AMI patients from 1976 to 1984 was investigated in order to explore whether improvements in survival may have contributed to this decline. AMI patients aged 30-74 years (n = 16,108) were identified through a hospital discharge register. Deaths within one year of hospital admission were ascertained by means of linkage to the national cause of death register. Survival 1 year after hospital admission increased in both genders during the period 1981-1984, but among women there was no uniform trend over the whole study period. The estimated age-adjusted relative risk of death within one year after hospital admission for patients with a first infarction admitted to hospital in 1983-1984 as compared to in 1981-1982 was 0.88 for men and 0.79 for women. The causes of the observed increase in survival could not be determined from this study, but changes in medical intervention as well as diagnostic improvements may have been important. Improved survival may have contributed to about 30% of the decline in mortality from AMI among middle-aged men in Stockholm county during the early 1980s.


Reinterpreting the effects of maternal smoking on infant birthweight and perinatal mortality: a multivariate approach to birthweight standardization. Infants of women who smoke during pregnancy have lower birthweights and have been observed to have higher rates of perinatal mortality than infants of non-smokers. It is not clear whether this increased risk of mortality is due to an excess of small births among smokers or to an independent effect of smoking. Although infants of smokers have overall higher mortality rates than non-smokers, low birthweight (< 2500 g) infants of smokers have lower mortality rates than low birthweight infants of non-smokers. However, comparison of birthweight-specific mortality between two groups is problematic when there are differences in the birthweight distributions. Methods that have been developed to standardize for these differences by comparing mortality rates relative to their own mean do not allow for simultaneous control of confounding variables. Using data from over 13,000 births of women who participated in a prepaid health care plan we present a method to standardize for birthweight while adjusting for variables that may confound the relationship between maternal smoking and perinatal mortality. After controlling for race, maternal age, education, parity, and number of cigarettes smoked, we found that 85% of the increased mortality due to smoking was attributable to an excess of small births in the birthweight distribution of offspring of smoking mothers, while 15% was due to higher birthweight-specific mortality at almost all standardized birthweights. Contrary to previous reports, we found that low birthweight infants of smoking mothers are at higher risk of perinatal mortality if a population-specific standard for birthweight is used.


Maternal smoking during pregnancy and delinquency of the offspring: an association without causation? The aim was to evaluate the association between maternal smoking in pregnancy and delinquency of the offspring in youth and early adulthood. The study population consisted of 5966 male members of the Northern Finland birth cohort of 1966, of whom 355 (6.0%) had committed a crime which led to a criminal record by early 1989, which was taken as an indicator of delinquency. Data collection was started during pregnancy and the development and health of the children was followed up continuously to the age of 14. The incidence of delinquency by the age of 22 was 4.6% among the sons of the mothers who did not smoke during pregnancy and 10.3% among those of the smokers. No clear dose-response gradient was observed, and those stopping smoking during the first trimester of the pregnancy had only a slightly smaller incidence of delinquency than those continuing smoking through pregnancy. The association of maternal smoking with delinquency was studied by controlling a number of social and demographic variables using an approach based on stratification by a confounder score. The adjusted incidence difference between smoking and non-smoking mothers was 4.1% (95% confidence interval [CI] : 2.5-5.8) and the ratio was 1.73 (95% CI : 1.41-2.12). A parallel analysis by logistic regression yielded an estimated odds ratio of 1.74 (95% CI : 1.37-2.11) for the same comparison. Even though the association between maternal smoking and delinquency of the offspring remained after adjustment for the available social and demographic factors, maternal smoking may be symptomatic of a certain lifestyle and norm-breaking behaviour which is likely to increase delinquency in the children rather than being an agent with a direct causal role. This is supported by the lack of any clear dose-response pattern and the minor importance of stopping smoking. Another possibility is that maternal smoking may cause some kind of brain damage which affects the behaviour of the child.


Occupational accidents and alcohol consumption in Spain. The real impact that alcohol consumption has on occupational accidents is unknown. We estimate the percentage of occupational accidents related to the regular consumption of alcohol in the population through the population attributable proportion (PAP). Spanish National Health Survey data were used to calculate the odds ratio (OR) and prevalence of alcohol consumption. The study restricted the selection of individuals by age and sex, using only interviews of men aged between 16 and 64 years. The results obtained show that approximately 17% of all occupational accidents can be attributable to alcohol consumption; 19% aged 16-24 years, 21% in those aged 25-44, and 9% in those aged 45-64. Although this methodology has some limitations, the advantages of this kind of study are important in public health because the magnitude of the problem, the potential impact of different strategies and the population groups most susceptible to intervention are addressed.


Control-informant agreement on exposure history in case-control studies of Alzheimer's disease. Data on control-informant agreement from four published case-control studies of Alzheimer's disease are compared, using both the kappa statistic and proportion of agreement for the presence and absence of exposures. Agreement was best for exposures involving lifestyle, medical interventions or disorders of more recent origin, and worst for exposures which involved judgements by the respondent. Agreement levels are similar across studies, and are commensurate with levels of specificity and sensitivity to be expected in this type of enquiry. We discuss the problems and implications associated with the interpretation of data from such studies of the elderly.


Diabetes diagnosed before the age of 2 years: mortality in a British cohort 8-17 years after onset. Childhood diabetes diagnosed before the age of 24 months presents specific management problems. We report here on the establishment (using the British Diabetic Association [BDA] Children's Register) and mortality of a cohort of children with diabetes diagnosed before age 24 months. Children registered during the period 1972-1981 were traced by contacting consultants or by using the National Health Service Central Registers (NHSCR) of the Office of Population Censuses and Surveys (OPCS). Standardized mortality ratios (SMR) were estimated using person-years of follow-up for each child and age-specific death rates for the England and Wales population for the years 1972-1989. Of 339 children notified during 1972-1981, 231 were traced through consultants and 99 of the remaining 108 through the NHSCR. Twenty were found to be ineligible. The cohort available for mortality analysis comprised 310 (97%) of 319 eligible children. Their age at the time the cohort was established was 8-18 years, and their duration of diabetes 8-17 years. The male:female ratio is 1.4:1. Of 310 children studied, seven have already died: SMR 5.4 (95% CI: 2.5-11.5). We have established a large, unique cohort of children with diabetes diagnosed before age 24 months and still living in the UK and Ireland. The natural history including mortality and occurrence of complications will be analysed prospectively in this cohort and compared to other cohorts of similar disease duration, but later age at onset.


Migraine and tension-type headache in a general population: psychosocial factors. In a cross-sectional study of headache disorders in a representative general population, the prevalence of migraine and tension-type headache was assessed in relation to various psychosocial factors. The random sample comprised 1000 25-64 year old men and women of whom 740 attended the investigation. The headache disorders were classified on the basis of a clinical interview, a physical and a neurological examination using the operational diagnostic criteria of the International Headache Society. None of the sociodemographic variables: marital status, cohabitation, educational level, occupational category or employment status were significantly associated with migraine or tension-type headache. In the univariate analyses tension-type headache was significantly associated with a high Neuroticism score on the Eysenck Personality Questionnaire whereas migraine was not. Variables on work conditions and psychosocial factors significantly associated with the headache disorders in univariate analyses were subjected to multivariate analysis. Migraine was significantly associated with exposure to chemicals and fumes at work in women and poor self-appraisal of health in men. In the univariate analyses tension-type headache was significantly related to a series of psychosocial variables. In the multivariate analyses it remained associated with a current feeling of fatigue in both sexes, time-pressure at work in women and exposure to fumes in men.


Effects of different designs and extension of a food frequency questionnaire on response rate, completeness of data and food frequency responses. The authors studied how the introduction of several modifications to a basic food frequency questionnaire can influence the results of dietary surveys. Modifications covered eight combinations based on three levels: increasing versus decreasing order of frequency categories; questionnaires without versus with questions about portion sizes, and questionnaires without versus with extra non-dietary questions. The sample included 6783 women between the ages of 40 and 70 years who took part in mammography screening. The women were randomly assigned to one of the eight study groups. All of the women in each group received one of the eight differently modified questionnaires. The forms extended in length by extra non-dietary questions and portion size categories resulted in a 20% higher total non-response compared to the shorter basic form. Partial non-response was significantly lower for all four questionnaire types that included portion sizes. When portion sizes were included in the questionnaire, the reported mean frequency of consumption was significantly reduced for fat (-10 times per month), milk (-6), bread (-5), vegetables (-2) and fish (-0.4). The decreasing order of responses to the frequency categories was associated with a statistically significant increase in the frequency responses for bread (2.6 times per month), vegetables (2) and fish (0.6). These data provide evidence that the design and extension of food frequency questionnaires influence the results of dietary studies.


Validity and reliability of a questionnaire on fecundability. The validity of a short questionnaire on fertility problems was tested on a group of 151 moderately educated women who had participated in a prospective study on early pregnancy failure some years before. Part of this group was approached by a personal interview, another part by telephone interviews and a third part was sent a questionnaire by mail. Reliability was tested on another population of 89 women with at least one child. The questionnaire was presented to these women twice with an interval of 3-5 weeks. The validity study showed no systematic errors for either of the approaches. Random errors were fairly large except for the personal interviews. The reliability showed great stability for the telephone interviews as well as for the mailed questionnaire. It is concluded that the questionnaire performs reasonably well, but on some items the draft questionnaire should be rephrased. The choice of a specific approach to the study population depends on the research question.


Excreta disposal behaviour and latrine ownership in relation to the risk of childhood diarrhoea in Sri Lanka. A case-control study of environmental and behavioural risk factors for childhood diarrhoea was conducted in Kurunegala district, Sri Lanka. From five hospitals, 2458 children aged less than 5 years and suffering from diarrhoea were recruited as clinic cases, and a further 4140 reporting with complaints other than diarrhoea were recruited as clinic controls. Community-based cross-sectional surveys were also conducted in three of the five areas served by these hospitals, and from these a further 1659 children were recruited as community controls. Children from households where excreta were reported to be disposed of in a latrine were less likely to have diarrhoea than children whose families improperly disposed of excreta. The results obtained from comparisons of cases with clinic controls (adjusted odds ratio [OR] 1.42, 95% confidence interval [CI] : 1.01-1.98), and of cases with community controls (OR 1.35, 95% CI : 0.85-2.13) were in agreement, suggesting that no important selection bias operated on this association. If the observed proportion (91%) of improper excreta disposal among the population could be reduced to 50%, 12% of childhood diarrhoea episodes would be prevented. Although latrine ownership may be a necessary condition for safe excreta disposal behaviour, diarrhoeal morbidity may only be reduced in Sri Lanka if behavioural changes take place concomitant with the construction of sanitation facilities.


Seroepidemiology and evaluation of passive surveillance during 1988-1989 measles outbreak in Taiwan. A seroepidemiological study was carried out to explore the risk factors of a measles outbreak that occurred among school children at a rural village (Li-Tse) in Taiwan. Among the 1166 participants, the percentage susceptible before the outbreak was 10.5% (122/1158) which was estimated as the sum of measles IgG-negative (29/1158) and IgM-positive (93/1166) individuals. Among 340 vaccinated children, 16 (4.7%) were measles IgM-positive and 10 (2.9%) were measles IgG-negative; therefore the vaccine failure rate was estimated to be 7.6% (26/340) and vaccine efficacy was 79.7% (95% confidence interval [CI] : 65.0-88.5). The most important risk factors for acquiring measles infection were the presence of other measles cases in the family (Odds Ratio [OR] = 32.5, P = 0.002) and the presence of more than two cases in a class (OR = 29.1, P = 0.003). The physician reporting rate was 6.1% (4/66), and the sensitivity of passive measles surveillance was only 4.3% (4/93) by active serosurvey. A concomitant rubella epidemic also amplified the inaccuracy of a passive reporting system based only on clinical diagnosis. Five children developed measles IgM but did not experience any symptoms, indicating that asymptomatic measles infection can occur. Our experience has highlighted three important areas for future measles elimination: (1) the need for serological evaluation of vaccinees, particularly those who were born during the introduction of mass immunization; (2) improvement in measles vaccine efficacy; and (3) further investigations on the role of asymptomatic transmission and susceptibles who remain after mass immunization.


Tuberculosis among institutionalized elderly in Alberta, Canada. Previous studies in the US have suggested that the risk of tuberculosis is increased among elderly residents of nursing homes. This registry-based study determined and compared the tuberculosis incidence rate for the elderly in nursing homes and community dwellings in Alberta, Canada, over the 5-year period 1979-1983. Rate ratios (RR) using the community elderly rate as baseline, were estimated for all notified cases and for culture positive cases only. Adjustment was made for the variables age, sex, and ethnicity. The nursing home elderly in Alberta did not have an increased risk of tuberculosis: adjusted RR = 1.09, 95% CI : 0.38-1.80.


Pleural plaques and exposure to asbestos: a mathematical model. The objective of this study was to find a model to describe the relationship between the occurrence of pleural plaques and exposure to asbestos. A simple model based on the cumulative exposure was postulated and empirically tested on shipyard workers occupationally exposed to asbestos. Exposure time was used to approximate the cumulative dose. It was found that the incidence of pleural plaques could be described as K(t-w)a where 't' is time since onset of exposure; 'K' is a constant that would depend on the level of asbestos exposure; 'w' is a latency period and was around 13 years; 'a' is a constant that was 0.4. In subgroups of the workers, i.e. plumbers, fitters and platers, 'a' was 0.4, 0.6 and 0.2 respectively.


A method to compare exposed populations in seroepidemiology. In seroepidemiology when a single sample is taken from exposed and non-exposed subjects, the results of serological tests are usually reduced to a dichotomy: normal (low or no antibodies) or elevated (high or antibodies found). The choice of the cutoff point between these values has been based on various vaguely defined methods and the results depend, at least partly, on the method chosen. An alternative method is introduced here which is not based on the absolute value of a serological test but on the rank order of the values of the test. In this ordered series the risk ratio (RR) and the upper and lower confidence limits (CL) are plotted for each exposed subject as the cutoff value is moved from the highest value to the lowest one. The method is applicable in quantitative immunoassays. If a priori defined RR and confidence limit or limits are reached at any point of the plot, the data support the original hypothesis. The advantage of this alternative method is that no single cutoff value is needed.


Incorporation of azaglutamine residues into peptides synthesised by the ultra-high load solid (gel)-phase technique. The solid (gel)-phase peptide synthesis of peptides, each containing an azaglutamine residue, has been examined. Procedures using various mono-, di- and tripeptide and carbazate fragments containing or relating to an azaglutamine (1) residue have been evaluated. N-Activation of the amino-terminus of a resin-bound peptide with bis-(2,4-dinitrophenyl)carbonate (2) yielded the terminal isocyanate species, which reacted with protected carbazates to give resin-bound protected peptides containing the aza-residue. By contrast, coupling of activated amino-acid derivates to the free amino-group of a resin-bound peptide with an aza-residue at the N-terminus was a slow and unsatisfactory process. It is concluded that the route yielding the best results involves the reaction of a protected amino-acyl carbazate to a resin-bound isocyanate-activated peptide.


Synthesis of specific peptide substrates for HIV-1 proteinase. Two small peptide substrates for HIV-1 proteinase were synthesised. The sequences chosen were basically from that of the gag-pol protein, which is the natural substrate for the proteinase. To protect these peptides from the attack of exopeptidases, the N- and C-termini were suitably protected, which also makes these substrates specific to HIV-proteinase and eliminates the requirement for highly purified enzyme.


Purification of synthetic peptides using reversible chromatographic probes based on the Fmoc molecule. A rapid, versatile, reversible procedure for purifying synthetic peptides has been developed based on the specific incorporation of 4-carboxylate Fmoc derivatives onto the terminal amino acid of peptidyl-resins. The acid stable 4-COR-Fmoc derivatives were synthesised with a variety of chemical groups thus altering the chromatographic properties of the "target" peptides and permitting their convenient purification, either by reversed-phase HPLC or ion exchange chromatography. The assembly of the peptides involved a capping step to prevent the formation of deletion forms. The 4-COR-Fmoc derivatives were incorporated either as preformed amino acid conjugates or as activated succinimidyl esters. After HF cleavage and purification the 4-COR-Fmoc probes were quantitatively removed with organic bases. The efficiency of the technique was demonstrated by the purification of small to large sized peptides, including a cyclic analogue.


Conformation of cyclosporin A in polar solvents. A major conformation of cyclosporin A in methanol and in aqueous methanol was revealed by some simple NMR experiments. Thus, a stepwise transition of cyclosporin A conformation from 100% CDCl3 to 100% CD3OD was followed by 1H NMR, which showed that the chloroform conformation of cyclosporin A was still the major one in methanol. Employing the same technique, it was also shown that the chloroform conformation of cyclosporin A was one of the major conformations in 50% aqueous methanol. This may be the first experimental determination of a major conformation of cyclosporin A in polar solvents.


Conformational studies on beta-bend containing a cis peptide unit. Conformational studies have been carried out on the X-cis-Pro tripeptide system (a system of three linked peptide units, in the trans-cis-trans configuration) using energy minimization techniques. For X, residues Gly, L-Ala, D-Ala and L-Pro have been used. The energy minima have been classified into different groups based upon the conformational similarity. There are 15, 20, 18 and 6 minima that are possible for the four cases respectively and these fall into 11 different groups. A study of these minima shows that, (i) some minima contain hydrogen bonds--either 4-->1 or 1-->2 type, (ii) the low energy minima qualify themselves as bend conformations, (iii) cis' and trans' conformations are possible for the prolyl residue as also the C gamma-endo and C gamma-exo puckerings, and (iv) for Pro-cis-Pro, cis' at the first prolyl residue is ruled out, due to the high energy. The available crystal structure data on proteins and peptides, containing cis-Pro segment have been examined with a view to find the minima that occur in solid state. The data from protein show that they fall under two groups. The conformation at X in X-cis-Pro is near extended when it is a non-glycyl residue. In both peptides and proteins there exists a preference for trans' conformation at prolyl residue over cis' when X is a non-glycyl residue. The minima obtained can be useful in modelling studies.


Conformational regions of Boc-Ala-Aib-Ala-OMe. Sampling with molecular dynamics simulations using time averaging of distance restraints. The method of time averaging of distance restraints in molecular dynamics simulations is applied to Boc-Ala-Aib-Ala-OMe in order to demonstrate the improved sampling properties of this method compared to conventional distance restraining. Two conformational regions, beta-turn type II and gamma-turn, are seen during MD runs at a simulation temperature of 500 K, while in simulations with conventional distance restraining, no conformational transitions could be observed for temperatures up to 1000 K.


Activation of carboxylic acids by pyrocarbonates. Synthesis of symmetric anhydrides and esters of N-protected amino acids using dialkyl pyrocarbonates as condensing reagents. Activation of carboxylic acids was achieved via dialkyl pyrocarbonates (ROCO)2O, R = C2H5, i-C3H7, sec-C4H9, tert.-C4H9) in aprotic solvents in the presence tertiary amines. A convenient procedure for the preparation of carboxylic acid anhydrides from carboxylic acids and di-tert.-butyl pyrocarbonate in the presence of pyridine is reported. Analogously, di-isopropyl- or diethyl pyrocarbonate may be used in the presence of N-methylmorpholine (triethylamine). With pyridine, di-isopropyl- or diethyl pyrocarbonate carboxylic acids form isopropyl- or ethyl esters, respectively. A wide variety of esters were prepared in good yields in a one-pot procedure from carboxylic acids, including N-protected amino acids, and alcohols or from phenols by means of di-tert.-butyl pyrocarbonate in the presence of pyridine (Boc2O-pyridine system). t-Butyl esters of carboxylic acids were obtained by the same procedure with 4-dimethylaminopyridine. In the absence of carboxylic acid, with 4-dimethylaminopyridine Boc2O and alcohols generate alkyl tert.-butyl carbonates.


Fatty acid and drug binding to a low-affinity component of human serum albumin, purified by affinity chromatography. Binding equilibria for decanoate to a defatted, commercially available human serum albumin preparation were investigated by dialysis exchange rate determinations. The binding isotherm could not be fitted by the general binding equation. It was necessary to assume that the preparation was a mixture of two albumin components about 40% of the albumin having high affinity and about 60% having low affinity. By affinity chromatography we succeeded in purifying the low-affinity component from the mixture. The high-affinity component, however, could not be isolated. We further analyzed the fatty acid and drug binding abilities of the low-affinity component. The fatty acids decanoate, laurate, myristate and palmitate were bound with higher affinity to the mixture than to the low-affinity component. Diazepam was bound with nearly the same affinity to the low-affinity component as to the albumin mixture, whereas warfarin was not bound at all to the low-affinity component.


A bifunctional heterodimeric insect neuropeptide analog. The synthesis and biological activity of a bifunctional, heterodimeric insect neuropeptide analog are described. The heterodimer is composed of the C-terminal pentapeptide active core regions of the leucokinin/achetakinin and pyrokinin neuropeptide families linked via their N-terminal amino groups with a succinyl diacid moiety. Members of the leucokinin/achetakinin family can induce fluid secretion in malpighian tubules of the house cricket, Acheta domesticus, whereas the pyrokinins demonstrate activity in a cricket oviduct myotropic bioassay. No cross-activity is observed for the two neuropeptide families in these bioassays. However, the heterodimer elicits responses in both Acheta bioassays. Such a bifunctional analog may in future serve as a template for the design of stable, bifunctional pest insect control agents of greater efficiency.


Antibacterial peptides designed as analogs or hybrids of cecropins and melittin. Eight new analogs of cecropin A, two new analogs of melittin and 30 hybrid peptides containing sequences from cecropins and melittin have been synthesized. The lengths of the peptides have varied from 37 residues (the length of cecropin A) to 18 residues. The peptides have been assayed for lysis of sheep red blood cells and for antibacterial activity against two Gram negative and three Gram positive bacteria. The best analogs of cecropin A maintained the anti-Escherichia coli activity of the parental peptide, and were not lytic for red blood cells. Melittin and its replacement analogs were all lytic for red blood cells, but an analog with transposed segments was not. Several of the hybrid peptides were found to be both non-hemolytic and highly active against all test bacteria. The data were used to define the structural requirements for antibacterial activity.


Pituitary adenylate cyclase activating polypeptide (PACAP) with 27 residues. Conformation determined by 1H NMR and CD spectroscopies and distance geometry in 25% methanol solution. The conformation of pituitary adenylate cyclase activating polypeptide with 27 residues (PACAP27) has been determined by two-dimensional NMR and CD spectroscopies and distance geometry in 25% methanol. Residues 9-20 and 22-25 have well-defined conformations but other residues do not show ordered conformations. The conformation of residues 9-20 is composed of three distinct regions of beta turn-like conformation (residues 9-12), alpha helix (residues 12-14) and the looser helical conformation (residues 15-20), while residues 22-24 form alpha helix. PACAP27 has a 2 helices separated by a disordered region similar to a VIP analog reported by Fry et al. but is distinct from the VIP analog in the position of the first helix, which is shifted by 2 residues toward the C-terminus, and in the form of the second helix [Fry, D.C., Madison, V.S., Bolin, D.R., Greeley, D.N., Toome, V. and Wegrzynski, B.B. (1989) Biochemistry 28, 2399-2409].


Spectroscopic studies on proteinase K and subtilisin DY. Relation to X-ray models. Circular dichroic spectroscopy has been used to study the effect of pH, guanidinium hydrochloride concentration and temperature on the conformation of the fungal subtilisin-like proteinase K and the bacterial DY. The ellipticity of the bands in the far ultraviolet region remains almost unchanged in the pH range 3.0-11.0 (PMS-proteinase K) and 5.0-10.0 (PMS-subtilisin DY). The same ranges of pH stability were determined from the pH dependence of the near ultraviolet dichroic spectra. Hence the changes in the tertiary and secondary structure occur in parallel. Proteinase K is considerably more stable at acidic and somewhat more stable at alkaline pH than subtilisin DY. At neutral pH proteinase K is more resistant to denaturation by guanidinium hydrochloride than is subtilisin DY. The midpoints of the denaturation curves were 6.2 M and 3.2 M guanidinium, respectively. The thermal unfolding of proteinase K occurred at a higher temperature than for subtilisin DY, the transition midpoints being 65 degrees and 48 degrees, respectively. Thus proteinase K is overall a much more robust molecule than subtilisin DY, showing greater resistance to all three forms of denaturation. The differences in the stability of the two proteinases can be partly explained by differences in their calcium binding sites.


Enclaves and excursions.

Enclaves and excursions. This paper describes and names as 'enclaves' and 'excursions' two deteriorations of the psychoanalytic situation, which occur when an analyst exceeds the limited, partial acting out inevitable in clinical work. Under pressure from his patient an analyst may unwittingly turn the analysis into a refuge from disturbance, i.e. an enclave. If he succumbs to pressures to move away from, instead of towards, knowing what is psychically urgent, an analyst may turn the analysis into a series of flights, i.e. an excursion. Unrecognized, these deformations interfere with or even halt the therapeutic process, which requires that the analyst find a way of working which accommodates both the patient's communication of, and need for, a refuge or flight with the analyst, while at the same time analysing it.


The dialectically constituted/decentred subject of psychoanalysis. II. The contributions of Klein and Winnicott. The present paper focuses on the contributions of Klein and Winnicott to a psychoanalytic conception of the dialectically constituted and decentred subject. Klein's idea of 'positions' represents a conception of the subject constituted in the creative and negating dialectical interplay of fundamentally different modes of attributing meaning to experience. The Kleinian subject is decentred in psychological space and in psychoanalytic time. The concept of projective identification provides the elements of a theory of the creation of the subject in the context of a psychological-interpersonal dialectic. The subject for Winnicott is not coincident with the individual psyche: 'There is no such thing as an infant [apart from the mother]'. Winnicott's notion of the creation of the subject in the psychological space between mother and infant involves a conception of the on-going constitution of the subject in the simultaneity of forms of dialectical tension between at-one-ment and separateness, internality and externality, I and me, I and Thou.


The psychoanalytic setting as the instrument of the container function. Different settings reveal the operation of different psychical mechanisms; for this reason I try in this paper to take a fresh look at the psychoanalytic setting which underlies the specificity of what we psychoanalysts call psychoanalysis and helps to distinguish it from other forms of therapy--in particular, psychotherapy. In my view, the analyst's creative container function is expressed particularly through the setting. This setting is not an inert vessel, a mere juxtaposition of rules, but an active container which interacts dynamically with the process. Observance of the conditions of the psychoanalytic setting seems to me important if what comes to life is intended to be a psychoanalytic process; the analysand's (or analysand-to-be's) pressures on the analyst to abandon aspects of the setting can then sometimes be interpreted as unconscious attacks on the creative container function of the analyst and on that of the patient himself. A number of clinical examples are given, showing that, like 'Donkey Skin', the analysand may sometimes demand not only pieces of gold from psychoanalysis but also, unconsciously, its skin.


The Eros of dreaming.

The Eros of dreaming. This paper examines the aspects of dreaming derived from the principle of Eros, the life instinct as described by Freud in Beyond the Pleasure Principle. The life instinct is interpreted in information-processing terms, as the inverse of entropy. The paper emphasizes the role of condensation as a mechanism that binds together the representations of present and past events in the imagery of the dream. This distinguishes it from displacement, which appears to be a mechanism whose function is solely defensive. The role of the dream in finding a common ground between current and past experience (Galton's method of comparison by superimposition) is discussed in detail. It is suggested that condensation is a primitive cognitive mechanism at work in many kinds of mental activity. The implications of this idea for psychoanalysis and for the creative process in general are explored in brief.


The analyst's transference imagery.

The analyst's transference imagery. The countertransference is a concept whose meaning has changed considerably. Freud and his followers regarded it as a negative reaction in the treatment which the analyst had to master. Since 1950 and Paula Heimann's pioneering paper, the countertransference has been understood and used more positively and has come to be seen as an essential tool for achieving completeness in the work of analysis. In line with this approach, this paper describes a countertransference reaction which has proved to be useful. It concerns the appearance of images of houses in the analyst. These houses correspond to important experiences revived by the analysand's material. The emotional content of these images links up with an identical content in the patient. An interpretation based on this experience has an enhanced therapeutic strength and effect. The paper concludes with a case study and a theoretical discussion of the phenomenon.


A fantasy penis: its development, multiple meanings and resolution. A 30-year-old single woman came to analysis because of anxiety, guilt and a sense of being bad. After two years of analysis that focused primarily on her relationship with her family members, an unconscious fantasy of having a penis was uncovered. The origin of the fantasy was traced to the narcissistic crisis and the birth of her brother, and as an attempt to regain the loss of mother's love. However, other meanings were added during subsequent developmental stages; namely, the fantasy penis was an umbilical cord that connected her with her mother, it bestowed power and licence to do whatever one wants and was a shield against father's subtle breach of the oedipal fantasies. The resolution of the fantasy passed through a stage of losing the penis and ending up with 'nothing' before a vagina could be experienced as a natural way to be.


Turning points and change in psychoanalysis. The turning point is defined as the sudden change of quality that plays the part of a forerunner or prerequisite to the slow structural change in psychoanalytic treatment. Turning points have two common elements, confrontation and surprise, that lead to the centre of the turning point experience -- the feeling of having an inner life--which leads up to the interpretive working through process that corresponds to structural change. To restore or create the feeling of having an inner life runs parallel to restoring the psychoanalytic process from acting-out temptations. Harold Stewart's agents of change are discussed as having the characteristics of turning points and clinical vignettes are described to show the main points. Finally, the countertransference aspect of allowing turning points to happen is discussed.


The psychoanalytic experience and psychic change. In an effort to examine psychic change and the factors promoting this therapeutic growth on the psychoanalytic situation, the analytic material from three sequential stressful periods in an analysis is compared. The patient, an 8-year-old child, was particularly vulnerable to conflicts surrounding separation and abandonment and there were three long summer vacations in the course of his treatment. Reflections of his psychic growth are first underscored and clarified, and then elements of the psycho-analytic experience that prompted this change and growth are delineated and discussed. An integration of the insight oriented aspects and the interactional components of the psycho-analytic experience is suggested.


Some technical and theoretical considerations regarding the missed session. Although Freud (1913b) originally proposed the 'principle of leasing a definite hour', there are many proponents of a more 'lenient' fee policy. The author critically examines some of the arguments put forward by the latter writers and argues that the missed session risks degrading into a 'missing' session if a financial marker does not remain in the patient's vacated place. The conflict mobilized in both partners to the therapeutic relationship by the missed session is best left open for analytic exploration rather than solved by a 'rational' and 'flexible' fee arrangement. The author suggests ways of theorizing, and eventually interpreting, the 'breach' in the relationship in terms of the absent, decentred subject, the Desire of the Other, the inherent contingency of our most primitive identifications, and the ineluctable violence and alienation of human interdependency. The 'rule of indenture' is seen in closer affinity to these basic contradictions than the more gracious 'gentlemen's agreement'.


About interpretation of self-envy.

About interpretation of self-envy. I present clinical material from two patients in order to describe self-envy interpretation in borderline structures, where negative therapeutic reaction type of mechanisms are usually present, and where massive and intrusive projective identifications are continuously used with the main unconscious purpose of establishing a perverse collusion with the analyst. In these cases there is also a need for splitting and projection of sadistic superego components, in order to provide a corporeity to the persecutor by placing it outside. Self-envy interpretation may help the analyst to deal with the transferential pressure exercised by these patients, and as a consequence improving the 'working space' and providing a better analytical objectivity.


The transference: distortion or plausible conjecture? The paper begins with a description of two conceptions of the transference found in the literature: transference as distortion and transference as plausible conjecture based on the signals received by the analysand from the analyst. The plausibility of the transference phenomenon in the Freudian conception of the transference is then reviewed. The author continues by considering the analyst's function as bait and how it is related to the stripping down of reality practised by the analyst. A brief clinical vignette is given to illustrate these propositions. To conclude, there is a discussion of the paradox of the reality sense, the transference and interpretation, based on the ideas of Matte-Blanco, mental functioning being considered in terms of bi-logic.


Adolescence and borderline pathology: characteristics of the relevant psychoanalytic process. This paper results from a research project on the specific characteristics of borderline adolescents and their analysability. An in-depth understanding of the adolescent process is considered essential because it is superimposed on the specific pathology of the borderline subject. Our cases agree in almost all respects with symptomatologies described in the international literature, although pronounced differences emerge in regard to serious acting out and behavioural disturbances. Separation processes, particularly from the mother, are very important in both cases presented. In the authors' view, this research shows that borderline adolescents constitute a definite clinical reality and that strict psychoanalytic technique can be used successfully with them.


Psychic changes in the paternal image.

Psychic changes in the paternal image. My main objective in this article is to show the changes which take place in the inner world of a young patient after his father's suicide, and the identifications he goes through. I hope the clinical material presented succeeds in doing so. We can also see the solid primary identifications which made it possible for this patient to get better and achieve a cure. It was not my aim to embark on a theoretical discussion of primary and secondary identification, an extremely complex subject in the writings of Freud.


Carboplatin combined with carmustine and etoposide in the treatment of glioblastoma. The aim of this study was to verify the tolerability and efficacy of therapeutic chemotherapy protocols, employing different combinations of cisplatin, carboplatin, etoposide and carmustine in primary glioblastoma patients. The purpose was focused on 2 end points: the response index to treatment, the TTP (tumor progression) and the ST (survival time). Eighty-four out of a group of 99 consecutive glioblastoma patients, entered this study. Patients were divided into 4 disparate treatment groups: (A) BCNU alone; (B) CDDP + VP-16; (C) CBDCA + BCNU; (D) CBDCA + BCNU + VP-16. The effectiveness and the TTP of the protocols differed, but differences were not statistically significant. Data concerning platinum treatment compare favorably with the best literature results. At 18 months more than half the carboplatin-treated patients are alive. Moreover these patients had a significantly longer ST than those treated with BCNU. We conclude that platinum-based chemotherapy has a beneficial effect on glial tumors.


EEG changes induced by carbamazepine therapy at rest and during mental processes. The effects of carbamazepine (CBZ) on EEG background activity have been studied, at rest and during mental processes, in 18 epileptic patients suffering from focal epilepsy and starting antiepileptic treatment for the first time. The EEGs were recorded before and after CBZ therapy, at rest with eyes closed (EC), during blocking reaction (BR), fixation (FIX) and mental arithmetic (MA) tasks, and then evaluated by spectral analysis. All data underwent statistical evaluation utilizing the ANOVA and correlation coefficient. The following parameters were evaluated: mean absolute and relative power and mean frequency. The results have shown that CBZ induced a significant increase of slow activity at rest with EC, which was represented by delta potentials, and was correlated with CBZ plasma levels. In evaluating the different cortical activation patterns, a decrease of the alpha reactivity was noted during BR and FIX, while a significant increase of beta activity was observed during the performance of all tasks. The relationship between the increased beta power, possibly reflecting an increase of cognitive activity for processing information, and the lack of a significant decrease of alpha activity are discussed.


Single-blind, placebo-controlled multicenter trial of vigabatrin in the treatment of epilepsy. The Italian Study Group on Vigabatrin. A single-blind, placebo-controlled multicenter trial of vigabatrin was carried out in 101 epileptic patients (mostly with partial seizures) refractory to conventional therapy. The study design included four consecutive periods: (i) an observation phase (run-in), (ii) a placebo period, (iii) fixed-dosage add-on vigabatrin (2 g/day) and (iv) dose titration (up to a maximum of 4 g/day) to optimize clinical response. Each period lasted 8 weeks, except for the titration phase, which could be extended to 16 weeks. 90 patients completed the trial. Eleven dropped out, one patient developing absence status and 4 cases showing an increased seizure frequency. In the patients completing the trial, the median number of seizures/month decreased from 16 (inter-quartile range 8-34) during placebo to 5 (2-10) during the last 8 weeks on vigabatrin (p < 0.0001). Both partial and generalized tonic clonic (mostly secondary) seizures were significantly reduced. A greater than 50% reduction in seizure frequency (compared to placebo) was observed in 60 patients. Sedation and weight gain were the most frequently reported adverse events.


Neurological examination in patients recovering from general anesthesia. We performed serial neurological evaluations on 86 patients who underwent surgery for herniated lumbar disk during the first 3 hours after the end of anesthesia (isoflurane-N20-02 for 25 patients, halothane-N20-02 for 38, fentanyl-droperidol-N20-02 for 23). At time 0, the idiomuscular response to percussion of the extensor carpi muscle was present in every patient, while tendon reflexes were always absent. Hyperreflexia was as frequent as shivering, but it took place earlier; we could determine no correlation between these two phenomena. There was no correlation between shivering and rectal temperature of the patients. Although almost all the patients were cooperative and could correctly calculate 100-7, the post-hyperventilation-apnea test was positive in 35 patients at time 120 minutes: this suggests that many patients considered "awake" still exhibit neurological abnormalities, such as inadequate respiratory drive.


Phenobarbital in the prophylaxis of late posttraumatic seizures. 390 patients with severe head injuries were treated with phenobarbital (PB) orally for a period of 12 months in order to determine whether this drug could reduce the incidence of posttraumatic epilepsy (PTE). An intramuscular PB dose of 2.5-3 mg/kg body weight per day was administered within 24 hours after the trauma; after 5 days, or longer if the coma persisted, the drug was administered orally. Maintenance dosage adjustments, when necessary, were based on serial plasma concentrations of the drug, sustained at between 5 and 30 micrograms/ml. 293 patients completed the study. 66% of these presented one risk factor, while 34% presented two or more. 6 patients (2.04%) had at least one seizure during the twelve months. Plasma drug levels at the time of the seizure, with one exception of 15 micrograms/ml, ranged from 20 to 28 micrograms/ml. The results of the study indicate that PB administered during the first twelve months after the trauma, even at relatively low doses, can have a prophylactic effect on PTE.


Acute monophasic focal demyelinating diseases of the central nervous system: longitudinal clinico-neuroradiological study of two patients. We report the clinical features and laboratory-instrumental findings in two patients with acute monophasic demyelinating disease with focal clinical expression: one case of incomplete cervical transverse myelitis and one of focal supratentorial encephalitis. We describe the clinical course and evolution of the neuroradiological findings (CT and MRI) and discuss their pathological meaning and diagnostic value.


Ossification of the posterior longitudinal ligament (OPLL) in the cervical spine. Clinical, neuroradiological and neurophysiological study on 9 cases. Ossification of the posterior longitudinal ligament (OPLL) in the cervical spine is considered to be uncommon in western countries, although widely known and studied in Japan. We report on 9 cases of OPLL cervical myelopathy investigated by x-ray films and cervical CT and by somatosensory evoked potentials. The patients reported spastic tetraparesis, sensory disorders of the limbs and, in one case, sphincter incontinence. Neuroradiological examinations showed that the posterior columns of the spinal cord were more affected than the roots. Our data suggest that OPLL is more frequent in the West than has so far been reported and that combined radiological and neurophysiological investigation ensures correct diagnosis and accurate assessment of the cord impairment.


Hemichorea due to a cavernous angioma of the caudate. Case report of an aged patient. A 75 year old man presented left hemichorea due to a cavernous angioma of the head of the contralateral caudate. Cavernous angiomas of the basal ganglia are an infrequent cause of hemichorea especially in older subjects but should be considered in the differential diagnosis.


Biopsy diagnosis of a case of adult onset orthochromatic leukodystrophy. Clinical and brain biopsy findings. We report the intra vitam histopathological findings on the brain of a female patient presenting an adult form of orthochromatic leukodystrophy. At 38 years of age the patient began to show progressive dementia and a pseudobulbar syndrome. The pedigree revealed an autosomal dominant pattern of inheritance. The CT scan showed a wide hypodensity of the anterior white matter. Biochemical investigations showed only a slight elevation of serum VLCFA and no alteration of urinary enzymatic activities. Cortical and subcortical biopsy specimens from the right frontal lobe showed: neuronal loss in the gray matter, accumulation of autofluorescent material within residual neurons and sudanophilic material within macrophages and astrocytes, sparing of axons. Electron microscopy showed lamination and fragmentation of the myelin and the presence of electrondense bodies and vesicular material into oligodendrocytes and astrocytes. We discuss the differential diagnosis of OLD forms with adult onset, namely between Löwenberg-Hill disease and the pure form of OLD with pigmented glial cells.


Associated polyneuropathy and demyelinating disease. Case report. We report a case in which an acute Guillain-Barré-like syndrome was quickly followed by a central demyelinating disease, documented by the clinical findings as well as by magnetic resonance imaging (MRI), electrophysiological and cerebrospinal fluid examinations. The close follow-on of the clinical signs seems to exclude a simple coincidence of two separate diseases and it may constitute further evidence for a possible etiological link between central and peripheral myelin damage. We discuss the possibility of a common pathogenic factor underlying central and peripheral demyelination.


Smoking attitudes amongst nursing tutors and their students. We have compared the smoking habits, and attitudes towards the habit, in 51 nurse tutors and 649 of their students. There were similar proportions of never-smokers, but rather more ex-smokers among the tutors. Only nine (17.6%) of the smoking and ex-smoking tutors admitted to having started smoking before the age of 18, compared with 75.5% of the students. Seven tutors and a similar proportion of students believed that smoking was not very harmful. Social behaviour differed between the two groups, the students tending to smoke in pubs and the tutors at home and over coffee. Reasons for having stopped also differed; in tutors cost was cited most often, whereas in students smell on clothes and future health damage ranked most highly. Cost, future health damage and smell were given as the main reasons for wanting to stop by smokers in both groups. We suggest that slightly different anti-smoking strategies might be required in students and tutors.


The Read Clinical Classification.

The Read Clinical Classification. After a short historical introduction, the article explains the roles of the NHS Centre for Coding and Classification, Computer Aided Medical Systems Ltd and the Scottish Clinical Coding Centre. The structure of the Read Clinical Classification (the Read Codes) is then described, its relationships to the other widely used classifications, and the potential which the codes have for use as the standard for the coding of clinical data.


Immunisation and health advice for travellers: the role of the general practitioner. More and more travellers go to ever more widespread destinations. Diverse sources of advice exist on the protection of travellers against medical hazards encountered abroad. This study attempts to show that the General Practitioner (GP) is the best person to give pre-travel health advice on immunisation and malaria prophylaxis. A postal questionnaire was sent to all 681 GPs in the Greater Glasgow area, to assess their views on the provision of health advice for travellers; in addition we asked whether they knew about the free access to a computerised database on travel health advice (Travax) provided by the Communicable Diseases (Scotland) Unit, and what their view was of the usefulness of this service. The overwhelming majority (87%) of responding GPs felt that pre-travel health advice was best provided in the primary care setting. This group of GPs appear enthusiastic about providing health advice for travellers, in accord with the apparent preference of travellers themselves, and 85% indicated that they would find the travel health advice service a useful aid.


The dependent elderly: a comparative survey of institutional care in Fife. Dependency levels were assessed in 441 elderly people in long term geriatric hospital care, 488 living in private nursing homes and 637 in the local authority residential homes in Fife. Results indicated that the most dependent were in hospital care, the most able in residential homes with private nursing homes accommodating elderly people with intermediate dependency levels. While each care setting cares for severely dependent elderly people, up to 29% of those in residential homes, 24% of those in nursing homes and 6% of hospital residents were considered by care staff to be fully independent. The implications of this in relation to the future provision and pattern of long term care for the frail elderly in Fife are considerable.


Clinical Directorates: a panacea for clinicians involved in management? A clinical Directorate is a managerial subunit led by a Clinical Director who is accountable for the Directorate's functioning and who exerts budgetary control over staff, equipment and supplies. The composition of Directorates and their possible structures are discussed, and requirements, conflicts of interest, and potential benefits are reviewed in the light of current experience.


Urinary incontinence: a survey of knowledge, working practice and training needs of nursing staff in Fife. Urinary incontinence results in substantial morbidity within society and presents a serious public health problem. Improvements in the well being of incontinence sufferers can be achieved by appropriately trained nursing staff. As part of the development of a strategy to tackle the problem of incontinence in Fife, a survey of nursing staff working in the Board's three health care units was carried out. Response rates between 64% and 100% were achieved among the different units. The results of the survey have revealed a number of deficiencies in current nursing practice, with a substantial proportion of nursing staff indicating a desire for more training in aspects of the management of incontinence. Health visitors in particular reported a significant lack of training in the area of childhood enuresis.


The chief scientist reports... Consultant out-patient services: provision at health centres in Scotland. Hospital based consultant (out-patient) services are most likely to be found in the community at health centres. By 1991 some 45% of the Scottish population had access to services provided at these health centres. The clinical specialties most commonly provided were psychiatry, obstetrics, paediatrics and gynaecology, and they accounted for some 10% or more of all attendances. Regular consultant visits in these and other specialties were more common at the larger health centres and at those further distant from alternative provision.


PRAD1 (cyclin D1): a parathyroid neoplasia gene on 11q13. Hyperparathyroidism is a central component of multiple endocrine neoplasia type 1 (MEN 1), and both sporadic and familial forms of parathyroid disease may share certain pathogenetic features. We recently identified a gene that is clonally rearranged with the PTH locus in a subset of sporadic parathyroid adenomas. This candidate oncogene, PRAD1 (previously D11S287), appears to contribute to parathyroid tumorigenesis in a fashion analogous to activation of C-MYC or BCL-2 by rearrangement with tissue-specific enhancers of the immunoglobulin genes in B-lymphoid neoplasia. The PRAD1 gene maps to 11q13 and has been linked to the BCL-1 breakpoint locus, although not to the most tightly linked MEN 1 markers, by pulsed field gel electrophoresis. PRAD1 may, in fact, be the long-sought BCL-1 lymphoma oncogene. PRAD1 encodes a novel type of cyclin protein and thus may normally function in controlling the cell cycle, perhaps through direct interaction with cdc2 or a related kinase. PRAD1's possible primary, or more likely secondary, involvement in the pathogenesis of MEN 1-related tumors is unknown and under investigation.


Should patients with medullary thyroid carcinoma undergo extensive lymph node (re)operation to improve long-term survival? To investigate the role of primary and/or secondary modified radical neck dissection (MRND) in patients with medullary thyroid carcinoma (MTC), follow-up data on 43 patients operated on between 1972 and 1983 were analyzed retrospectively; patients included 16 with sporadic MTC (group 1) and 27 with multiple endocrine neoplasia type 2 (group 2). Primary surgical therapy consisted of (near-) total thyroidectomy and limited lymph node dissection; one patient in group 1 and two in group 2 underwent primary MRND. Positive nodes were found in nine patients of group 1 and in 12 of group 2. Calcitonin (CT) was raised postoperatively in 11 group 1 patients, who all died (four after additional MRND). Postoperative CT was normal in the four survivors of group 1. In group 2, post-operative CT was raised in 15 patients, including those who had MRND and in four apparently node-negative patients. Three of them underwent additional MRND, which was successful in one case. One patient in this group died of the disease; two patients developed elevated CT levels during follow-up, whereas in one, CT normalized spontaneously. In conclusion, the role of extensive lymph node surgery in patients with more than limited lymph node involvement or elevated postoperative CT levels remains to be established.


Role of insulin-like growth factor-I in the autocrine regulation of cell growth in TT human medullary thyroid carcinoma cells. Since the TT human medullary thyroid carcinoma cell line required fewer exogenous growth factors (serum), we investigated whether this line has an autocrine mechanism by examining the effects of antibodies directed toward insulin-like growth factor I (IGF-I) and its receptor on TT cell growth in serum-free conditions. Treating cells with anti-IGF-I antibody for four days reduced the cell number by more than 50% compared with a nonimmune IgG control. Furthermore, a monoclonal antibody to the IGF-I receptor suppressed DNA synthesis when determined by a [3H]thymidine incorporation assay. Exogenous IGF-I (20 ng/mL) stimulated [3H]thymidine incorporation in serum-free medium; approximately 70% of the IGF-I-induced stimulation was blocked by the presence of the receptor antibody. Treating TT cells with IGF-I for 48 hours increased the cell population in the S phase by 62% when analyzed by flow cytometry. These data suggest that TT cells might respond to endogenously produced IGF-I and therefore provide an in vitro model for autocrine regulation of human tumor cell growth by IGF-I.


PDN-21 (katacalcin) and chromogranin A: tumor markers for medullary thyroid carcinoma. The malignant C-cell releases several markers of potential clinical significance into the circulation. To determine the usefulness of these markers for management of medullary thyroid carcinoma (MTC), it is necessary to compare the usefulness of these markers with calcitonin (CT), the classical tumor marker for MTC. Measurement of serum concentrations of the peptide PDN-21 (katacalcin), a carboxyterminal cleavage product of procalcitonin, showed a high correlation with serum CT levels (r = 0.99, P < 0.01, n = 65 patients with MTC). The presence of equimolar concentrations of CT and PDN-21 (CT/PDN-21 molar ratio = 0.95 +/- 0.33) indicates the peptide is cosecreted with CT. Stimulation of CT release by intravenous pentagastrin was associated with a parallel increase of PDN-21, providing further evidence of cosecretion of these two peptides. Finally, measurement of either PDN-21 or CT in selective venous catheterization specimens was useful for localization of MTC. Chromogranin A (CgA) levels were also measured in patients with MTC. Circulating levels were elevated in most patients with advanced disease. There was a moderate correlation between CgA and CT serum levels (r = 0.87, P < 0.01, n = 61 patients with MTC). Pentagastrin did not stimulate CgA, and the long half-life of CgA in the circulation did not make it possible to use this peptide for tumor localization by selective venous catheterization. We conclude that measurement of PDN-21 provides an independent assay system for diagnosis, localization, and postoperative management of MTC, whereas CgA measurement is not useful in early diagnosis of MTC and is of limited value for localization or management of progressive disease.


Biologic and cytogenetic characterization of three human medullary thyroid carcinomas in culture. Neuroendocrine features and cytogenetic abnormalities of one continuous cell line (MTC-SK) and two long-term cultures (GER, STAH) derived from three sporadic cases of human medullary thyroid carcinomas (MTCs) were studied. Specific neuroendocrine markers (NSE, chromogranins, calcitonin, calcitonin gene-related peptide) were identified by electron microscopy and immunocytochemistry. In situ hybridochemistry and Northern blot analysis confirmed endocrine activity. Cytogenetic studies of the cell line MTC-SK revealed three consistent marker chromosomes, t(3;10), 11p+, and 22p+. Cells of long-term cultures GER and STAH exhibited a consistent translocation t(2;18), a trisomy 7, and two consistent marker chromosomes der3 and 5p+, respectively. Recently, we have isolated 12 stable clones of this MTC-SK cell line, which showed two different growth patterns. Quantitative measurement of mitotic activity flow cytometry and semiquantitative analysis of AgNOR-, Ki67-, and Cyclin/PCNA-(immuno)reactivity showed different DNA composition and duplication rates, indicating at least two subpopulations. Some of our clones developed a new consistent marker (i.e., an unbalanced translocation between mar11p+ and 1q). However, no correlations between chromosome findings, growth rate, and neuroendocrine markers were observed.


Effect of volume on spinal anesthesia level with hyperbaric tetracaine. The purpose of this prospective, randomized, double-blind study was to determine if the volume of a fixed milligram dose of hyperbaric tetracaine hydrochloride injected into the subarachnoid space affected the average maximal dermatomal spread of sensory anesthesia, determined by pinprick testing. One hundred two adults received spinal hyperbaric tetracaine in a volume of 2 mL, 3 mL, or 4 mL with the dose based on the patient's height. The addition of 0.2 mg of epinephrine to the anesthetic solution was allowed at the discretion of the attending anesthesiologist. A two-way analysis of variance (ANOVA) demonstrated that neither the dose selected nor the use of epinephrine affected anesthetic spread. ANOVA showed that anesthetic volume insignificantly affects the spread of sensory anesthesia. A Tukey HSD multiple comparisons test demonstrated a mean difference greater than 1 sensory dermatome between volumes of 2 mL and 4 mL, which was clinically detectable but statistically insignificant. Increasing the volume of hyperbaric spinal tetracaine solutions to improve anesthetic spread is unjustified.


Invasive hemodynamic monitoring during cardiopulmonary resuscitation in a community hospital emergency department. Monitoring the effects of resuscitation efforts in a community emergency department are limited primarily to noninvasive techniques. Coronary perfusion pressure (CCP) has been used as a predictor for successful resuscitation. The authors investigated the feasibility of measuring the CPP in a community emergency department and incorporating the CPP into decisions for managing the resuscitation effort. During a 7-month period, the authors prospectively studied 77 nontraumatic, normothermic adults in cardiopulmonary arrest who were treated in the emergency department. Fifty-one patients underwent invasive monitoring and 26 patients entered a control (noninvasive monitoring) group. Successful CPP monitoring was accomplished in 84% of the patients; the average time to obtain an initial CPP was 12.1 +/- 7.3 minutes. Twenty patients had a return of spontaneous circulation, but no patient survived to hospital discharge. There was no significant difference in return of spontaneous circulation between patients in the invasively monitored and the noninvasively monitored group. Coronary perfusion pressure monitoring had a positive influence on the management of three patients. This study showed that CPP monitoring is feasible in a community hospital, but further studies are needed to better define the effects of CPP in resuscitation effort outcome.


Irritable bowel syndrome.

Irritable bowel syndrome. The irritable bowel syndrome is a common disorder of gastrointestinal motility. Abdominal pain, bloating, and inconsistent bowel habits are the hallmark symptoms of irritable bowel syndrome. Fever, weight loss, and gastrointestinal bleeding often indicate more serious pathologic gastrointestinal conditions, such as inflammatory bowel disease or infectious enteritis. Because irritable bowel syndrome is so prevalent in our society, the primary care physician should be able to readily recognize the clinical features of this disorder in order to spare patients expensive, unnecessary diagnostic and therapeutic interventions. In this review, the authors discuss the clinical and psychological features of irritable bowel syndrome and offer a useful approach to the diagnosis and treatment of this disorder.


The family physician's contribution to the care of patients in the final stages of HIV infection. This article concludes the monthly series developed from the AOA Task Force on AIDS Writers' Workshop, held August 16 to 18, 1991, in New York. The workshop was sponsored by an education grant from Burroughs Wellcome. This series has provided brief clinical updates and perspectives on the human immunodeficiency virus (HIV). Readers may request tear sheets from the AOA editorial offices.


Scurvy in a nonalcoholic person in the United States. Scurvy is rarely diagnosed in our society today. The authors describe the case of a 31-year-old man with weakness, gingival pain, and a rash over the lower extremities. He had a history of poor nutritional intake, no alcohol consumption, and a 13 pack-year history of cigarette smoking. Laboratory studies revealed an extremely deficient serum ascorbic acid level. Treatment was begun with oral ascorbic acid tablets and, within 3 days after discharge, all clinical symptoms of scurvy had resolved. Scurvy is an easily treated disease and should be considered when there is an appropriate history and classic clinical findings. Because vitamin C deficiency can be seen in many chronic disease states, it is important to recognize some of the early features and clinical manifestations of such nutritional deficiencies.


Chest pain secondary to membranous subaortic stenosis in a young woman. Left ventricular outflow obstruction can be divided into three distinct categories: valvular aortic stenosis, the most common form; supravalvular aortic stenosis, which is often seen in early childhood; and subvalvular stenosis, which can be further subdivided into muscular, tunnel, and fibromembranous subtypes. All may be found in a patient seen with symptoms of angina, syncope, or heart failure as a precursor to sudden death. Prompt clinical recognition is essential as is a high degree of suspicion when these signs are associated with a systolic ejection murmur on clinical examination. Echocardiography and a meticulous Doppler examination are very useful in the diagnosis of these disorders as well as in further distinguishing among the different subtypes. The authors describe the case of a 40-year-old woman with chest pain refractory to medical therapy and a long systolic ejection murmur.


Historical overview of the development of family-centered, community-based, coordinated care in Michigan. Caring for children with special health care needs (SHCN) is a challenge that has been faced with commitment and concern in this country. However, by the late 1970s, it was clear to some that an analysis of the efficacy of the existing structure of care was long overdue. As scrutiny of the current processes began to unfold, new and improved ideas were emerging throughout the United States. A continuous theme through that process was the need and desire to create care systems that were family-centered, aimed at coordinating care, and were close to the child and family's community. These activities provided a conceptual background from which Michigan began to redesign existing programs and develop new initiatives. Simultaneously, Michigan's experiences were influencing national efforts to create family-centered, community-based, coordinated care structures for children with SHCN. This article highlights key national efforts and individuals who influenced program development for children with SHCN in Michigan. In addition, specific family-centered efforts that occurred in the state since the early 1980s, and that continue to date, are described.


Building community-based service systems for children with special needs: the Michigan Locally Based Services program. The philosophy of the Michigan Department of Public Health, Division of Children's Special Health Care Services (DCSHCS) program holds that children with special health care needs have a right to every opportunity for self-support and self-fulfillment. To assist families, the program historically has provided support with medical care and treatment payments. Likewise, local health departments have shared in the process of supporting families of children with special health care needs. A growing awareness that these families experience a variety of other needs not directly attended to by these mechanisms led the Division to respond further to those needs. The response was aimed toward increasing the capacity to locate clients and provide family assessments, and, where necessary, case management services at the local community level. The implementation, on-going program development, stabilization, and future trends of the Locally Based Services program are described from the varying perspectives of the state and a local health department.


Parent/professional partnerships in caring for children with special health care needs. In order for children with special health care needs to be adequately cared for, a variety of integrated, coordinated services are needed to support the children and their families. To facilitate optimal coordination of care for these children, it is imperative that the professionals who serve them engage in a partnership of care with parents or other family members. To that end, the Division of Children's Special Health Care Services (DCSHCS), Michigan Department of Public Health has carried out a variety of efforts to foster such partnerships. This article describes the efforts that have been carried out over the last few years in Michigan to develop parent/professional partnerships. It is not intended to be a scholarly review of the literature, but rather an explanation of strategies that have been used successfully to develop this important interface. Particular emphasis is given to describing the establishment of partnerships between parents of children with special health care needs and nurses and physicians. It is hoped that the sharing of such information will assist others who are just beginning such efforts.


Parent-to-parent support: a critical component of health care services for families. Families of children with chronic medical conditions or disabilities face many unique difficulties. It is often necessary for them to assimilate technical medical information and participate in important decisions regarding their children's care before they have had time to adjust to their children's condition. Health care providers are not always available to help parents learn how to function in their dramatically changed roles. To adjust to their new parenting roles and work through feelings of confusion, denial, anxiety, guilt, anger, and depression, parents of children with special health care needs need opportunities to fully vent feelings, and to experience the grieving processes in their own way and at their own pace, in a nonthreatening, nonjudgmental environment. An informal support network is a powerful tool for accomplishing these tasks, for teaching day-to-day coping skills, and for supporting the establishment of new value systems that incorporate families' unique needs. The literature on family support documents ways in which parents of children with special health care needs are particularly qualified to help each other. This article briefly describes the philosophy of parent-to-parent support, its unique contributions in the health care setting, and the ways that health care providers can assist in creating an environment in which parents and professionals can work together more effectively.


Rabies surveillance in the United States during 1991. In 1991, 49 states, the District of Columbia, and Puerto Rico reported 6,972 cases of rabies in nonhuman animals and 3 cases in human beings to the Centers for Disease Control. Ninety-one percent (6,354 cases) were wild animals, whereas 8.9% (618 cases) were domestic species. The total number of reported cases of rabies increased 42.9% over that of 1990 (4,881 cases), with most of the increase resulting from continued spread of the epizootic of rabies in raccoons in the mid-Atlantic and northeastern states. Large increases in cases of rabies in animals were reported from Connecticut (200 cases in 1991, compared with 3 in 1990, an increase of 6,567%), Delaware (197 cases in 1991, compared with 44 in 1990, an increase of 348%), New York (1,303 cases in 1991, compared with 242 in 1990, an increase of 326%), and New Jersey (994 cases in 1991, compared with 469 in 1990, an increase of 112%). Other noteworthy increases were reported by Wyoming (96.4%), Texas (69.7%), California (41.3%), Oklahoma (33.1%), Minnesota (31.4%), Georgia (26.7%), and Maryland (23.7%). Hawaii reported 1 imported case of rabies in a bat. Only 16 states reported decreases in rabies in animals in 1991, compared with 30 in 1990. Pennsylvania and Iowa reported decreases of 40.6% and 27.4%, respectively. Rhode Island was the only state that did not report a case of rabies in 1991.


Effect of tiletamine/zolazepam sedation on intradermal allergy testing in atopic dogs. Seven atopic dogs underwent intradermal allergy testing with 46 inhalant antigens before and after administration of a tiletamine/zolazepam solution (4 mg/kg of body weight, IV). This anesthetic protocol had no significant effect on the intradermal response caused by histamine, whole flea extract, or various inhalant allergens. Short-acting chemical restraint induced by the drug combination facilitated the intradermal testing procedure.