Prevention of tuberculosis in children: missed opportunities. We conducted an eight-year prospective investigation in Tennessee of all cases of tuberculosis (TB) reported statewide in children younger than 15 years of age. Of the 109 verified childhood cases reported from 1981 to 1988, at least 23 (21%) were preventable. Eleven children developed the disease while they were under surveillance but were not receiving preventive therapy, nine cases resulted from failure of health care providers to conduct timely contact interviews/investigations, and three were due to other reasons. Improved surveillance, increased use of preventive therapy, and ensured compliance will contribute significantly to the elimination of tuberculosis in children at high risk of developing the disease.


Focal and diffuse benign hepatic disease: correlative imaging. With the large numbers of screening CT scans and ultrasounds performed in a busy radiologic practice, it is not uncommon to discover an unexpected focal or diffuse process in the liver. When there is no history of primary malignancy, many of these lesions are benign. We discuss the variety of benign focal and diffuse diseases that can be readily imaged within the liver using ultrasound, CT, and MR.


Female employee participation in a worksite mammography screening program. We conducted a survey of 1,184 women 35 years of age or older who were employees of a company in Los Angeles County, California, to determine why some women participated in a worksite mammography screening program whereas others did not. Of the 111 who accepted a mammogram, 90 responded to the survey; of the 1,073 who declined mammography, 620 responded. The women were predominantly white, were well educated, and had health insurance. Of the 111 women who received mammograms, one was diagnosed with carcinoma. Seventy-three percent of the respondents to the survey 40 years of age or older who declined mammograms had already fulfilled American Cancer Society (ACS) guidelines for mammography screening at the time of the program. Women who accepted a mammogram were more likely to have had at least one previous mammogram than were women who had not met ACS guidelines yet who declined screening. We conclude that many female employees who are white, are well educated, and have health insurance may not participate in a worksite mammography screening program because they have been screened elsewhere. Companies providing worksite mammography screening should target education to women who have not met ACS guidelines, especially those who have never had a mammogram.


Correlative imaging of malignant liver tumors. Radiologists play a vital role in the management of malignant liver disease, both by providing accurate data regarding extent and segmental localization of lesions as well as demonstrating their relationship to major vascular structures. The interrelationship between the major cross-sectional imaging modalities (ultrasound, CT, and MRI) must be understood in order to use each modality effectively and efficiently. Characteristic behavior of certain tumors (such as venous invasion by hepatomas) can help in recognition of tumor type and may have a major impact on decisions regarding resectability. Pitfalls in liver imaging (such as the presence of benign conditions that may mimic malignant lesions) must be well understood in order to avoid errors in diagnosis. Difficulties may arise in underdetection of tumors arising in chronically diseased livers and overstatement of the extent of tumors in livers with coexistent benign and malignant lesions. The appearances and behavior of primary and metastatic liver cancer is reviewed, emphasizing the features listed previously.


Narrowing the gap in health status of minority populations: a community-academic medical center partnership. A major challenge in the United States is to narrow the gap in the excess morbidity and mortality rates of minority populations. This article presents a synthesis of the 15-year results of a collaborative program between the Johns Hopkins Medical Institutions and an African-American community with the highest rates of premature disease and death in Maryland. The program began with an efficacious disease prevention clinical trial with patients and ended with effective population approaches. We transferred key components to community ownership and formally trained community health workers who provided health promotion counseling, monitoring, linkage, and referral services. Results indicated significant decreases in morbidity and mortality as a result of improved control of hypertension. This program has begun to decrease the health status gap in an African-American population and has demonstrated long-term sustainability. Current joint activities are directed at several major causes of excess morbidity and mortality, including smoking, obesity, hyperlipidemia, and hypertension, and at plans for programs to control diabetes, substance abuse, and breast and cervical cancer.


Spectral and color Doppler sonography.

Spectral and color Doppler sonography. Color Doppler sonography has become an integral part of modern hepatic sonography. Color Doppler can enhance the conspicuity of focal lesions and bile ducts in jaundiced patients by illuminating normal vessels with flow. Spectral and color Doppler may prove useful in limiting the sonographic differential diagnosis of focal liver lesions. Color flow sonography effectively evaluates pseudoaneurysms, A-V fistulae, collaterals, and flow reversal in portal hypertension, venous clot and tumor invasion, Budd-Chiari syndrome, hereditary hemorrhagic telangiectasis, and many other hepatic vascular lesions. We have found it invaluable in evaluating cirrhotic and liver transplant patients.


Trend analysis of social and economic indicators of mammography use in Hawaii. We examine the relationship between ethnicity and income as determinants of mammography use over a span of four years as a means of assessing community intervention impacts. The sample consisted of 1,447 women older than 34 years, living in Hawaii, who participated in the Behavioral Risk Factor Surveillance System (BRFSS). The percentage of women in the sample reporting a screening mammogram within the past two years was 31.4% in 1987, 54.1% in 1989, and 51.6% in 1990. Women of Hawaiian ancestry had the lowest percentage of mammogram use in the past two years (38.7%), while Japanese women had the highest percentage (49.8%). Results of logistic regression analysis indicate a significant increase in mammography use from 1987 to 1989 and no difference from 1989 to 1990. Findings also showed an association between age, income, and ethnicity with use in the past two years. Greater age, higher income, and Japanese origin, compared to Hawaiian, were all independently associated with increased odds of having had a mammogram in the past two years. We discuss results in terms of program evaluation and future research implications for community health surveys.


MR angiography of the liver.

MR angiography of the liver. Recently, several versatile techniques have been developed for performing magnetic resonance (MR) angiography in the body. Relative to MR angiography in the head and neck, these methods require more interactive involvement by a physician to derive their full benefit, but they show great promise in the clinical workup of several vascular problems relating to the liver. This article outlines practical clinical applications for MR angiography of the liver, based on the experience of the authors and others working in the field.


Noninvasive liver imaging: new techniques and practical strategies. The goals and expectations of liver imaging have expanded as the treatment options for a range of liver diseases have advanced. Unfortunately, no single modality can yet achieve all the goals that an ideal imaging modality should satisfy. Currently available liver imaging techniques should be considered complementary rather than competitive in their roles, and appropriate utilization of the expanding technical capabilities of cross-sectional imaging depends on many considerations, including patient factors, referring physician expectations and biases, experience and bias of the radiologist, and the availability of state-of-the-art technical capabilities for each modality. This article reviews the advantages, limitations, and roles of fast CT and fast MR liver imaging techniques as well as the complimentary role of ultrasound, and the future of new imaging considerations including the role of contrast agents.


Sensitivity and specificity of lump detection in breast models. Lump detection accuracy in models provides an index of ability to detect lumps in breast tissue. Recent research suggests poor lump detection accuracy in nontrained persons. Following individualized nurse-provided instruction in breast self-examination (BSE), 113 well-educated white women exhibited 89% mean lump detection sensitivity and 81% mean specificity (sensitivity = number of lumps correctly identified divided by actual lumps; specificity = percentage of exams completed without detection of false lumps). Problems with hands were potentially linked to poor specificity. Completeness of search was significantly associated with sensitivity. Lumps most unlikely to be detected were those in the fleshy upper outer quadrant of torso models. High accuracy levels here may be attributable to timing of assessments, homogeneous sample, models used, numbers/sizes of lumps, and long search times. BSE instruction should emphasize complete search, examination of outer quadrant of breasts, and assessment of hand problems.


Cross-sectional imaging of liver transplantation. Orthotopic liver transplantation is commonly performed at many institutions around the world. The care of these critically ill patients has heavily relied upon cross-sectional imaging. CT, MRI, and ultrasound help enormously in the preoperative assessment of these patients and in the postoperative management of the various complications. This article reviews the role of these cross-sectional modalities and their respective strengths and weaknesses in the adult transplant candidate and recipient.


Occurrence of the purine nucleotide cycle in rat pancreatic islets. The presence of the purine nucleotide cycle is investigated in rat pancreatic islets. Adenylosuccinase, adenylate deaminase, and adenylosuccinate synthetase activities are characterized in islet homogenates. In the assay of the latter enzyme, evidence is obtained for operation of the full cycle in islet extracts. The activities of the three enzymes are not vastly different in islet and brain. These findings are discussed in the light of the role currently ascribed to the purine nucleotide cycle in producing ammonia from amino acids, in adjusting the concentration of Krebs cycle intermediates, in regulating the relative concentrations of ATP, ADP, and AMP, and in controlling the activity of phosphofructokinase.


Glycoprotein metabolism in neuronal ceroid lipofuscinosis fibroblasts. Human skin fibroblast lines of the infantile form of neuronal ceroid lipofuscinosis and control lines were cultured in the presence of [3H]glucosamine plus [3H]mannose and [35S]methionine. The labeled glycoconjugates were compared by quantitative polyacrylamide gel electrophoresis in sodium dodecyl sulfate. The infantile form of the disease showed a 75% decrease of four glycoprotein components of M(r) 120-140 kDa. These components appeared to be N-linked glycoproteins as peptide-N4-(N-acetyl-beta-glucosaminyl) asparagine amidase (PNGase F) released 86-96% of the labeled carbohydrate from the labeled protein. These results suggest that the infantile form of this disease may be characterized by abnormalities in glycoconjugate metabolism leading to reduction of specific glycoproteins.


Lack of hormonal stimulation of pyridoxine metabolism in isolated rat hepatocytes. Isolated hepatocytes obtained from Sprague-Dawley rats (145-175 g) were incubated for 15 min at 30 degrees C in Krebs-Henseleit bicarbonate buffer, pH 7.4, containing 0.5 mM concentration of each of the 20 natural amino acids and either 4.5 or 23 microM [U-14C]pyridoxine. Pyridoxine, pyridoxal, pyridoxal phosphate, and pyridoxic acid separated by an anion-exchange chromatographic technique were quantified using a phosphate analyzer and a liquid scintillation counter. The conversion of [U-14C]pyridoxine to its metabolites was more than doubled by increasing the amount of pyridoxine (4.5 to 23 microM) in the incubation medium. Insulin (10 mU/ml), glucagon (1 nM), or epinephrine (10 microM) did not have any significant effect on the conversion of [14C]-pyridoxine to pyridoxal, pyridoxal phosphate, or pyridoxic acid. Our earlier observations of a large decrease in serum pyridoxal phosphate in the diabetic rat cannot be explained by any direct hormonal effects on pyridoxine metabolism.


Biosynthesis and characterization of (S)-and (R)-3-hydroxy-3-methylglutaryl coenzyme A. (S)-3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA), the physiologic substrate of HMG-CoA reductase and of HMG-CoA lyase, is available commercially only as (R,S)-HMG-CoA, a mixture of diastereomers. To provide (S)-HMG-CoA for our continuing investigation of HMG-CoA reductase, we used homogeneous, overexpressed Pseudomonas mevalonii HMG-CoA reductase (EC 1.1.1.88) and an NAD(+)-regenerating system to convert (R)-mevalonate to (S)-HMG-CoA with an overall yield in excess of 50%. We also used P. mevalonii HMG-CoA lyase (EC 4.1.3.4) to prepare (R)-HMG-CoA from (R,S)-HMG-CoA. Each diastereomer was then isolated by ion-exchange chromatography. Large-scale preparations provide for economical production of (S)-HMG-CoA, particularly when recovered coenzyme A is recycled. (S)-HMG-CoA was evaluated as a substrate, and (R)-HMG-CoA as an inhibitor, for the P. mevalonii enzymes HMG-CoA reductase and HMG-CoA lyase, and for Syrian hamster HMG-CoA reductase (EC 1.1.1.34). For both HMG-CoA reductases, (R)-HMG-CoA inhibited competitively with respect to (S)-HMG-CoA. The ratio Ki/Km was 0.7 +/- 0.1 and 0.6 +/- 0.2 for the bacterial and hamster enzymes, respectively. By contrast, (R)-HMG-CoA did not inhibit P. mevalonii HMG-CoA lyase.


Statistical analysis of the effect of cadmium and zinc on hamster teratogenesis. Maternal smoking is correlated with lower average birth weights and an increase in malformations in some studies. Increased maternal cadmium levels and reduction of zinc levels in certain tissues from fetuses of women who smoke suggest a biological association during pregnancy. Zinc has a protective effect on hamster teratogenesis caused by cadmium. To determine whether this protective effect is additive or synergistic (interactive), pregnant golden Syrian hamsters were injected (iv) on Day 8 of gestation with a test solution based on maternal body weight (0.5 ml per 100 g). Five doses were given: 2 mg/kg zinc chloride, 2 mg/kg cadmium chloride, 3 mg/kg cadmium chloride, 2 mg/kg zinc chloride plus 2 mg/kg cadmium chloride, and 2 mg/kg zinc chloride plus 3 mg/kg cadmium chloride. Fifty dams were randomly placed into one of the groups, for a total of 10 pregnant dams in each group. Twenty other dams were randomly placed into untreated or saline control groups. Fetuses were recovered on Day 15 and weighed, crown-rump length was measured, and fetuses were examined for viability and external malformations. Resorptions were noted. Statistical analyses included one- and two-way nested ANOVA, and logistic regression adjusted for litter effect. Zinc's protective effect on acute cadmium embryonic/fetal toxicity and teratogenicity was confirmed. The protective effect was of the same magnitude relative to the dose-dependent effect of the cadmium exposure, indicating that the effect was statistically additive and not synergistic. This suggests that the effect depends on competition of the two elements at some common binding site(s).


Effect of insulin on the proline transport activity in cultured fibroblasts from patients with Werner syndrome. The effect of insulin on the transport of proline has been studied in cultured fibroblasts from normal individuals, non-insulin-dependent diabetic patients, and patients with Werner syndrome. In fibroblasts from normal individuals and those with diabetes mellitus, incubation with 10(-7) M insulin resulted in more than a twofold increase in the transport rate after about 14 h incubation. In contrast, fibroblasts from patients with Werner syndrome had a markedly attenuated response to insulin, suggesting a defect in insulin action on the transport of this amino acid in Werner syndrome.


[The circadian evolution of the karyometric indices of the inner hair cells. A statistical analysis]. We have realized a statistic study about "Karyometric Index" in the hair cells of the Corti organ of the albino Wistar rat [correction of guinea pig] in thirty of these animals; after in vivo fixation. The Karyometric Index variations are a good indicator of the cellular basic functional activity. Therefore we tried to clarify if the their cells are or not resembling to other cellular types with the functional circadian circles as well as if they present it or not in their basic functionalism, as they are also included in the "Endocrine Difusse System" and the "Paraneuron" concepts.


[Paget's disease with temporal bone involvement, hypoacusis and vertigo. Apropos a case]. The Paget disease is a chronic osteodystrophy of unknown etiology, very frequent in 50 years of age and above. It's an anatomo-radiologic syndrome that sometimes, is accompanied by clinical symptoms. May be monostotic or polyostotic but never generalized. Occasionally it affects the temporal bone producing deafness, tinnitus and vertigo. We report a case with important temporal bone demineralization, deafness and vertigo.


[Laryngomalacia: a review of 42 cases].

[Laryngomalacia: a review of 42 cases]. In the period from 1981 to 1990, in the Children's Hospital from Sevilla were performed 220 direct laryngoscopies and bronchoscopies to newborns and infants that showed as a main finding: stridor voice change or aspiration syndromes. In the 30 percent the main cause was a congenital laryngeal anomalies. Laryngomalacia is the most common congenital laryngeal anomaly with 42 cases. For it frequency, the otolaryngologist should be familiar with the clinical findings, diagnosis and actual management.


[Incidence and causes of neonatal seizures in the last 10 years (1981-1990)]. We report the incidence of neonatal seizures in the last 10 years. Between 1981-1990, 28,925 infants were born in the Japanese Red Cross Medical Center. Very low-birth-weight infants (< 1,500 g) were excluded in this study. Seizures were identified in 67 infants (0.23%) during the first 7 days of life. Seizures occurred more frequently in low-birth-weight infants (1,500-2,499 g) than in normal-birth-weight infants (> 2,499 g). Fifty-one infants (0.19%) of 27,276 normal-birth-weight infants and 16 (0.97%) of 1,649 low-birth-weight infants developed seizures. The frequency of seizures was 0.25% during the first 5 years and 0.20% during the second 5 years. In low-birth-weight group, the frequency of seizures decreased form 1.49% to 0.48% during the 5-year periods, and seizures due to post asphyxial hypoxic-ischemic encephalopathy also decreased from 0.14% to 0.06%. The decreased incidence in neonatal seizures during the last 10 years was probably achieved by the progress in intervention of low-birth-weight infants in NICU and by the obstetrical prevention of intrapartum asphyxia.


[Pneumocephalus as a complication of mastoid surgery]. Non-traumatic otologic diseases are a rare cause of pneumocephalus. Among them, few reports have been described whereas it occurred following oto-surgery. We present a case report of pneumocephalus in a patient who presented with CSF-otorrhea, headache, disorientation, after recent mastoid radical surgery. The definite diagnosis was done by CT scan imaging. We realize a review of the literature about this subject, we describe the clinical and diagnostic features, its possible physiopathology, and its surgical management.


[Changes in CSF tryptophan metabolite levels in infantile spasms]. Cerebrospinal fluid (CSF) from 6 cases of asymptomatic infantile spasms (IS) (mean age, 6.1 months) was collected before and after treatment with adrenocorticotropic hormone (ACTH). The concentration of CSF tryptophan (TRP) metabolites was analyzed using HPLC and compared to the metabolite concentration in CSF from 10 age-matched controls (mean age, 6.7 months). Levels of CSF serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), and kynurenine (KYN) at pretreatment were significantly lower in IS patients compared to controls (p < 0.05). In contrast, the levels of CSF 3-hydroxykynurenine (3-OHKY) before ACTH treatment were significantly higher in IS patients than in controls (p < 0.05). After the treatment, significant increases in 5-HIAA and decreases in KYN and 3-OHKY levels (p < 0.05) were observed in CSF of infants whose seizures were eliminated by ACTH. These findings suggested that the presence of seizures in IS was associated with a significant decrease in serotonergic activity, or that the turnover in the direction of 3-OHKY was altered. The possibility that elimination of seizures by ACTH might be related to decreased production of kynurenine metabolites was discussed.


[Rhinoscleroma. A case report with nasal and laryngeal involvement]. We present a case of rhinoscleroma that were studied in a spanish patient. The location was nasal and extranasal, appearing in the larynx. The diagnosis was established by the morphological picture. A review is given of the geographical distribution of this disease and the principal diagnostic procedures are outlined with special emphasis ou the most reliable staining methods (PAS, Gram), immunofluorescence, immunoperoxydase reactions and electron microscopic study are discussed.


[The importance of laryngeal compartmentation in the limitation of tumor extension]. Histologic specimens from 75 patients with squamous cell carcinoma of the larynx treated exclusively by surgery were studied with special attention paid to the growth of the tumor in relation with the different laryngeal compartments. Some aspects traditionally admitted are discussed. The result show a not very close relation between the classic anatomic descriptions and the tumoral growing.


[The nasal location of calcinosis cutis. Apropos a case]. The metastatic calcifications, feasible in the renal chronic insufficiency, they are conditioned by tissular deposits of calcium. The metabolic and hormonal aetiology is inevitable. The known predilection for some tissues and organs in these calcic fixations, is gets to value the endonasal and cutaneous infrequent appearance, on this case.


[A study on functional plasticity of the brain in childhood. II. Speech development and intelligence after the damage of cerebral hemisphere under 1 year of age]. To investigate the functional plasticity of the brain in childhood, the speech development, the intelligence test and dichotic listening test were performed on 27 patients who had suffered from hemiplegia under 1 year of age. Among 13 patients with right hemiplegia, 7 to 24 years old, 11 patients showed a left ear dominance suggesting the lateralization of language in the right hemisphere. All 14 patients with left hemiplegia, 5 to 37 years old, showed a right ear dominance suggesting the lateralization of language in the left hemisphere. All 27 patients acquired speech function enough to converse with other people during daily life. There were no differences in speech development or intelligence scores between both groups of hemiplegia. Although there was no correlation between the speech development and the age of onset of hemiplegia, there was a correlation between the speech development and the intelligence score in both groups of hemiplegia.


[An analysis of the DNA content in a stage-T-1 epidermoid carcinoma of the vocal cord. The methodology and results]. DNA content of tumor cells determined by flow cytometry has been correlated to biologic behavior and to prognosis for many solid tumors, but insufficient data has been accumulated for squamous cell carcinoma of the larynx. In order to know the predictive value of this parameter in the prognosis of T-1 vocal cord squamous cell carcinoma, we have studied 27 patients submitted to cordectomy. The patients outcome was followed for a minimum of five years or until death, DNA content was determined by Hedley method in paraffin-embedded sections of formalin-fixed blocks in an EPICS Profile flow cytometer. 24 of these tumors were diploid (89%) and 3 aneuploid (11%). We didn't find statistical correlation between ploidy and survival, local failure or someone of the pathological parameters.


[A severe rhinological mycosis: mucormycosis. A report of 3 cases]. Mucormycosis is a fungal infection, the most frequent form begins in the nose and the paranasal sinus and can rich the brain. It is a fulminant and often fatal disease, not well known by many specialists. The authors present three cases with positive cultures, histology and postmortem studies, drawing attention to the importance of its prompt diagnosis and aggressive treatment.


[Supracricoid laryngectomies with cricohyoidopexy. A clinical study of 6 cases]. A prospective study was carried out in 6 patients with cancer of larynx operated between 1986 and 1988. Technical aspects for supracricoid partial laryngectomy with cricohyoidopexy are described. Indications, follow-up and complications are discussed.


[A clinical study on neuron-specific enolase activities in cerebrospinal fluid of neonates]. Activities of neuron-specific enolase (NSE) in the cerebrospinal fluid (CSF) were measured in 104 neonates (24 cases with CNS diseases and 80 cases without CNS diseases) aged from 0 to 27 days and 50 children without CNS diseases aged 3 months to 15 years. They were determined by using the radioimmunoassay of the Eiken Kit. The enzyme activity in neonates without CNS diseases was significantly higher than that in children. No significant correlation was found between the level of NSE activity and gestational age, birth weight or the days after birth. The mean level of NSE activity in the CSF of neonates with CNS diseases was significantly higher than that of neonates without CNS diseases. Those activities gradually decreased with the clinical course. It was considered that the appropriate cut-off level of NSE activities in CSF for anticipating CNS damage and neurological sequelae was 20.0 ng/ml.


[Correlation between morphological abnormalities of Chiari malformation and evoked potentials]. We studied correlation between morphological abnormalities of Chiari malformation and evoked potentials (short-latency somatosensory evoked potential [SSEP] and auditory brainstem response [ABR]). On SSEP the inter-peak latency prolongation of P3-N1 was revealed in 6 out of 8 cases with Chiari malformations. The feature of positive wave between P3 and N1 was divided into 2 groups. The tendency of the positivity between P3 and N1 was more marked in cases of prolonged P3-N1 latency and correlated with the medullary kink. On ABR the prolongation of III-V inter-peak latency was revealed in one side in 3 patients Chiari malformations with malformed pons and tegmentum.


[2 cases of facial osteosarcoma originating in the maxilla and mandible]. Two cases of facial osteosarcoma are presented. The principal aspects of each patient are related, exposing the fundamental clinical and radiographic features. The respective bibliography is revised, considering the experience of some authors.


[Maternal hyperthermia during pregnancy in severely multi-disabled children]. In a study of prenatal etiologic factors for 5,901 severely multi-disabled children (jushoji as called in Japan), 159 patients were found to have been exposed to maternal febrile illnesses in utero. Among them, 57 patients did not have any causative factors other than maternal febrile illness. In addition to severe brain dysfunction, nonspecific anomalies were found in 46.2% of 26 children exposed to maternal hyperthermia before 4 months of gestation. The recent findings of other investigators tend to support the concept of unusual hyperthermia being teratogenic in human. Our retrospective study suggested that maternal hyperthermia might induce severe brain damage of embryo, but no definite malformation complex could be determined.


[The study of mismatch negativity].

[The study of mismatch negativity]. We studied age related correlations of mismatch negativity (MMN) auditory event-related potentials (ERPs) using odd ball paradigm in 121 normal subjects (from 6 months to 43 years) and 33 mentally retarded subjects (from 2 to 18 years). The subject was instructed to read a book in order to ignore the stimulus during the experiment, or no specific task was imposed on young child. The MMN wave form was clearly obtained in normal 6 month old subjects. As the age advanced from 6-months, the latencies of MMN progressively shortened till about 7 years, when the latency reached adult level. One-third of mentally retarded patients had prolonged MMN than that normal age-matched subjects. Reliable recording of P300 requires subject's cooperation and attentiveness, which are difficult to achieve in young children or mentally retarded patients. MMN may be utilized in children to evaluate the development of the cognitive function.


[Neonatal tuberous sclerosis: report of a case studied by cranial MRI]. We reported longitudinal cranial MRI studies of a neonate with tuberous sclerosis who presented convulsive seizures on the first day after birth. Cortical tubers were not detected on MRI performed at the age of 1 month, but became evident at 18 months after birth. This finding might reflect the pathological difference between the amount of myelin around the cortical tuber and other white matter lesions, which increased with age. A heterotopic islet was shown as partially stratiform appearance on MRI. This result suggests that the structure of the heterotopic islet might be heterogeneous.


[A case of neonatal tuberous sclerosis with large calcified lesions in the brain parenchyma]. A patient was reported, who was diagnosed as having tuberous sclerosis in neonatal period. He began to have complex partial seizures at 3 weeks of age. At 27 days of age, brain CT revealed a large high density lesion from the left temporal cortex to the left posterior horn, in addition to periventricular nodules. These lesions were not enhanced after injection of contrast medium. Brain MRI demonstrated more nodular lesions, the intensity pattern of which was different form those in previously reported cases. Ictal EEG showed secondary generalization from left temporal focus, which was compatible with complex partial seizures. In English literature, neonatal cases of tuberous sclerosis with large parenchymal lesions on brain CT were reported by only a few authors, and only two cases of neonatal MRI findings were documented. The neonate with tuberous sclerosis should be carefully evaluated because of the atypical appearance of MRI in rare cases.


[Benign familial neonatal convulsions in a family with one member with infantile spasms]. A pedigree of benign familial neonatal convulsions (BFNC) was reported. Seven members of two generations experienced convulsions in the neonatal period and/or in early infancy. All of these members except one had a good prognosis. One member who had infantile spasms was uneventfully delivered at 37 weeks of gestation, with a birth weight of 2,562 g and, without trouble during pregnancy. At the age of 20 days, she began to have adversive seizures. Later, she developed complex partial seizures and infantile spasms at 1 month and 10 days of age. Interictal EEG showed hypsarrhythmia. Biochemical investigations and MRI of the head revealed no abnormality. Treatment with sodium valproate and carbamazepine succeeded in stopping the seizures and she had no seizures after 3 months. But her psychomotor development was moderately delayed at 8 months. No case with severe epilepsy such as infantile spasms has been reported in the previous literature on BFNC. From our experience, early treatment and careful follow-up are considered to be important for BFNC.


[A case of Fahr's disease accompanied with persistent vitreous artery]. Serial imaging studies in a 16-year-old female affected by Fahr's disease accompanied with persistent vitreous artery were performed. She suffered from chronic subdural hematoma, which was re-moved at the age of 5 months. Brain CT scan performed at the age of 4 revealed calcified lesions at the corticomedullary junctions in the frontal lobes of cerebrum. Yearly repeated CT scans revealed an increasing number of the calcified lesions, which were observed at the cortico-medullary junction of cerebrum, globus pallidus, thalami and dentate nuclei of the cerebellum. Calcifications have not increased in the last 4 years. Laboratory examinations of serum and urine failed to prove any abnormalities. She also had bilateral persistent vitreous arteries. The combination of these rare two diseases may have occurred coincidentally, but there is a possibility that the capillary dysfunction played a role in the pathogenesis of two diseases.


[The first case of infantile type neuronal ceroid-lipofuscinosis in Japan]. We reported the first case of typical infantile-type neuronal ceroid-lipofuscinosis (INCL) in Japan. The patient was a 1-year-old girl presenting with rapidly progressive psychomotor deterioration and blindness. Muscular hypotonia, microcephaly and myoclonic jerks became marked with the progression of her disease. Diminution in amplitude of EEG, VEP and ERG was prominent in the initial stage, but ABR was normal. MRI showed progressive brain atrophy. Electron microscopic examination of the biopsied skin revealed granular matrix, the specific inclusion bodies, in the epithelial cell of sweet glands. Many sea-blue histiocytes were demonstrated in her bone marrow samples. INCL is a common progressive encephalopathy in the Scandinavian countries, but a typical case had not yet been fully reported in Japan. This prompted us to report our case. Future reports are need for the study of INCL in Japan.


[Changes in nuclear DNA content in nasopharyngeal epithelium]. The nuclear DNA content was measured by flow cytometry (FCM) in 167 specimens with normal nasopharyngeal epithelium, paracarcinoma tissue and nasopharyngeal carcinoma (NPC). Thirty eight (38%) of 101 NPC, seven (58%) of 12 recurrent and six (30%) of 20 paracarcinoma tissues were nondiploid. There was no nondiploid at all in 20 specimens of normal nasopharyngeal epithelium. Two of six patients with VCA-IGA(+) were nondiploid. Cellular proliferation index (PI) of NPC was increased significantly as compared with that of the normal epithelium (P < 0.01). However there was no marked difference in PI. between NPC and paracarcinoma tissues. The rate of cervical metastasis in nondiploid NPC was significantly higher than that in diploid NPC (P < 0.025). But there was no correlation of DNA content between the stage of the tumor and the titer of VCA-IGA. These data show that FCM may prove useful in the diagnosis and predication of prognosis in NPC.


[Immunohistochemical distribution and fine localization of the gamma-aminobutyric acid in the organ of Corti of normal guinea pigs]. This paper presents the distribution and fine localization of the gamma-aminobutyric acid (GABA) in the Corti's organ of normal guinea pigs by using immunohistochemical technique (ABC-GDN method) and immunoelectron microscopy. GABA-IR was found in axons of efferent neurons in all turns of the cochlear spiral, but no positive endings may be found in the apical. The positive immunoreactive products were seen in the efferent components, including inner spiral bundle, tunnel spiral bundle, tunnel-crossing fibers, and large nerve endings on outer hair cell bases. Some of the GABA-IR negative outer hair cells could be seen between the positive endings. One GABA-IR positive nerve fiber could form synapse with six or seven outer hair cell bases. The GABA-IR positive efferent endings, negative efferent endings and negative afferent endings could be seen on the out hair cell bases with transmission electronic microscope. The GABA-IR positive efferent endings and negative afferent endings could form the neuraxon-neurodendron synapse on the inner hair cells bases. These morphological distribution suggests that the GABA may be one of the cochlear efferent neurotransmitter or modulator.


[Effects of furosemide on endocochlear potentials, auditory action potentials and summating potentials and the changes of inner ear pathology]. Guinea pigs were injected with furosemide 50 mg/kg (group A) and 25mg/kg (group B). Two minutes after injection, EP of group A decreased to -13.9mv while that of group B decreased to +65 mv. Also, AP of group A disappeared, and recovered at 8.5 mins. while AP amplitude of group B decreased to 78%. The SP value of group A changed from -14.5mv to +23.4mv 1 min after injection and returned to negative polarity in 12 min. Edema of stria vascularis was observed under light microscope. Transmission electron microscope showed edema between marginal cells and intermedia cells, cytoplasm of the marginal cell protruded to the cochlear duct, and cell membrane of outer hair cell folded. The finding of this study illustrates that furosemide inhibits the transportation of the active ions of cochlear duct tissue resulting in decrease of EP and alters the function of hair cells causing the change of AP amplitude. -SP depends on the ion transportation, the polarity can be inversed while large dosage of furosemide was used.


[Prevention of noise induced hearing loss in musicians of Chinese opera]. The incidence of hearing impairment in musicians of Chinese opera is higher than that in popular music and rock and roll music. The sound levels of different instruments used in Chinese opera measured acoustically showed drums, gongs and cymbols to be hazardous to the ear. The conventional measures of prevention, such as ear plugs are not acceptable by the musicians because of interference to the musician's hearing ability. A rearrangement of situations of the musicians was suggested by the authors. The percussive musicians should be situated one meter lower than other musicians. Animal (guinea pigs) experiments by study of AP in EcochG and ultrastructural observations of the cochlea have confirmed that our suggestion for prevention of noise induced hearing impairment to be efficient.


[Topographic mapping of the auditory evoked potentials. I. Auditory cortex response and middle latency response]. Color imaging of the human auditory cortex response and middle latency response of 21 otologically normal young adults was studied. All the waveforms, latencies, amplitudes and the location of FNa, FPa, FN1, FP2 were analysed. Considerable variations about the foci location in normal adults were found in this study.


[Determinations of nasal effective cross-sectional area in 1100 normal subjects]. Generally speaking, the NECA represents the narrowest site of the nasal airway and mirrors the site of the nasal valve in normal subjects. So the NECA is the basic element in producing and determining the NAR. A flow-pressure technique with software was developed to measure the NECA in 1100 normal subjects. The normal values values of NECA in children and adults were established to be 0.40 +/- 0.12cm2 and 0.52 +/- 0.17cm2 respectively. There was a significant positive correlation between the age increase and NECA augmentation in children (r = 0.649, P < 0.01), and NECA grew at a rate of 0.022 cm2 per year from 5 to 16 years of age, but revealed some peculiar characters in different phases of pediatric development. From 20 years of age the change of NECA began to take a stable course, but had a trend to crawl up with ageing. There were no significant differences of NECA between the male and female in different age groups. It was also noted that there was a negative linear relationship between ipsilateral NECA and NAR, and also so between the NECA of both sides combined and total NAR. From the findings above, we propose that NECA could be a quantitative and objective parameter for assessing the nasal airway impairment.


[Transnasal endoscopic surgery].

[Transnasal endoscopic surgery]. We have performed operations of transnasal endoscopic surgery successfully. This study was intended to analyze and discuss the method of operation on the ostium meatus unit, the removal of polyps in sphenoethmoidal recess or superior turbinate and our viewpoint of ethmoid sinus operation. We conclude that (1) the 70 degree nasal endoscope is the main instrument in endoscopy; (2) an endoscope and a head lamp should be used alternatively in order to proceed the operation quickly and smoothly; (3) the bone wall should not be broken rashly and a good drainage should be the main purpose in ethmoid sinus operation; (4) a bipolar electrical coagulator, a laser and other techniques should be used to make operative fields clear.


[Aorto-esophageal fistula caused by swallowed foreign body (report of 17 cases)]. Seventeen cases of aorto-esophageal fistula (AEF) induced by foreign bodies (Fb) were reported. Ingested fish and chicken bones were the most frequent offending agents (15 cases). The objects were lodged at the level of the aortic arch. It is those arrested in this region that may penetrate the esophageal wall and cause an AEF. The average latent period between the time of swallowing the FB and the signal of hemorrhage was about 8 days. A signal of hemorrhage preceding the exsanguinating episodes had been present in 14 cases. This can be taken as the indication for urgent operation. Early diagnosis of AEF can be made by the history alone, Esophagoscopy may invite a sudden death from massive hemorrhage once an AEF is already present. In a small number of cases, an aortic false aneurysm or an esophago-bronchial fistula can produce respiratory symptoms without hematemesis, Mediastinal widening on chest X-ray films usually suggests a false aneurysm but it must be differentiated from a mediastinal abscess or a tumor mass. Of these 17 patients, 11 were treated conservatively and all died. Six patients were treated surgically with 5 deaths and one surgical survivor. This case is believed to be the third reported surgical survival.


[Scanning electron microscopic observations on the middle ear mucosa of human fetuses]. The epithelial development of middle ear mucosa in nine human fetuses, ranging from the 12th week to full term, was observed by the scanning electron microscopy. The results showed that the ciliated cells were found in the tympanic cleft of the 12th week fetus. The ciliated cells were especially dense in a crescent region along the antero-inferior periphery of the inner surface of eardrum, and were distributed around the tympanic orifice predominantly, above and blow the promontory and the hypotympanum. The length of cilia and the population of the ciliated cells increased with the fetal age. At the 26th week, the ciliated cell population and the length of cilia were similar to those of the neonate. The goblet cells appeared at the 26th fetal week. The secretory phenomenon of the goblet cells was seen at the 34th fetal age. These findings indicated that the mucociliary transportation system has been developed well at the late period of fetal development.


[Techniques for isolating hair cells from guinea pig cochlea]. Isolated live hair cells are important models for studying the electrophysiology, pathology and pharmacology of the hair cell. Using mechanical isolation method after papain treatment 70 +/- 27 hair cells, including 0 to 4 inner hair cells, could be obtained from each cochlea of 4 guinea pigs. The criteria for a good viability of isolated cochlear hair cells were: 1. a smooth hair cell membrane; 2. hair cells not swollen; 3. the nucleus in the normal position; 4. the cytoplasm in a state of semitransparency with a halo at the periphery (birefringence) and 5. no Brownian movement of the organelles within the cytoplasm. With short-term culturing at room temperature, approximately 90% of the isolated hair cells retained a good viability at the end of two hours. Subsequently the hair cells gradually degenerated but still, at the end of five hours, about 40% of them appeared intact. The degeneration patterns have been carefully observed and described.


[Changes in vascular stria after blast traumatized guinea pigs by colloidal lanthanum tracing technique]. The exudation of endotheliocyte in the capillary vessels of vascular stria after blast traumatized guinea pigs was studied by colloidal lanthanum tracing technique. The high density lanthanum ion shown as a line--distribution can be found in the endothelial surfaces of vascular stria by using transmission electron microscopy, but nolanthanum granulars were seen in the cytoplasm of endotheliocyte, the base membrane, and the tissular interval of vascular stria. At six hours after exposure to impulse noise, the lanthanum ion can exudate to the base membrane of capillary vessels through the closed-linkup between two endotheliocytes. On twelve hours after exposure, the exudation of the vascular endothelial cell membrane was increased and the lanthanum ion of the high electronic density was precipitated to the inside of cytoplasm. This study suggested that the impulse noise may have a obvious early effect on the exudation of vascular stria and the colloidal lanthanum tracing technique is a better method in studying the cochlear microcirculation.


[Establishment of immunofluorescence for the testing serum antibodies against inner ear tissues and its clinical application]. A modified Sainte-Marie technique for processing the inner ear tissues of guinea pigs was described in this paper. The inner ears were fixed over night in 95% cold ethanol, decalcified 7-10 days in 10% EDTA-Na2 at 4 degrees C, and embedded in paraffin. The deparaffinized sections were exposed 15 min in 95% ethanol precooled to 4 degrees C to fix the serum antibodies of patients and labeled antibody respectively. The sections were counterstained with Evans-blue. This method is simple, rapid, and sensitive, and antigenicity. Also, the specificity was enhanced and the preservation of fluorescence was prolonged. By means of this method, antibodies against inner ear tissue were found in the serum of 18 out of 30 patients with Meniere's disease, sudden deafness or uncertain forms of progressive sensorineural hearing loss. The results suggest that autoimmune response may play an important role in some inner ear disease.


[Intraoperative monitoring auditory function during surgery of internal auditory canal and C-P angle]. Intraoperative measurement of electrocochleography, auditory brainstem responses and eighth nerve action potentials are utilized to assess the functional integrity of the cochlea and cochlear nerve. All such assessments have only one purpose: for warning the surgeon the possibility of damage the auditory system or its surrounding structure. Eighteen patients with various otoneurological diseases undergoing surgery had intraoperative monitoring of such evoked electrophysiological responses. Hearing was preserved in sixteen patients. However, the CM/N1 in ECochG still keep for a few minutes even after transection of the cochlear nerve and there is another disadvantage of need for signal averaging in BAER. Recording of the response of the the auditory nerve directly from the eighth nerve provides the surgeon with immediate information when an insult has been made to the cochlear and eighth nerve. Therefore, combination of these three measurements are recommended depending on the situation.


[Revision stapedectomy].

[Revision stapedectomy]. Early and delayed complications in the inner or middle ear may follow stapedectomy and require revision surgery. The records of 72 patients who had undergone revision stapedectomy were analyzed to determine: 1. the causes of failure. 2. how to revise the conditions due to the failure following previous operation. 3. hearing results. These 72 revision operations consisted of 66 case of conductive deafness and 6 sensorineural loss. The commonest cause of failure was dysfunction of prosthesis (23.6 per cent), followed by otosclerotic regrowth (22.2 per cent), incus dislocation (13.9 per cent), reparative granuloma (12.5 per cent), incus necrosis (11.1 per cent), and fibrous adhesions (9.7 per cent). A review of these cases demonstrates that the results of revision stapedectomy are different from those for primary stapedectomy. The revision operations resulted in post-operative air-born gaps of 15 dB or less in 39.4 per cent of cases. Primary stapedectomy resulted in successful closure of the air-bone gap to 15 dB or less in 97.2 per cent of cases. 'Dead ears' were encountered in 9.1 per cent as against 2.1 per cent in the primary cases. Thus the surgeon should be aware of the problems and risks involved in revision stapedectomy.


[The reconstruction of upper alimentary tract after resection of hypopharyngeal and cervical esophageal cancer]. The most difficult problem during surgical treatment in the hypopharyngeal and cervical esophageal cancer is the reconstruction of upper alimentary tract after resection of the lesions. From April 1984 to October 1990, 52 patients of hypopharyngeal and cervical esophageal cancer were treated by surgery (39 men and 13 women). The age ranged 43-73 years. All of the cases were squamous cell carcinoma except one adenocarcinoma. The pectoralis major myocutaneous flap (PMF) was used in 32 patients, total gastric transposition (GT) in 15 patients, free jejunal interposition (FJI) in 3 patients and free forearm flap (FFF) in 2 patients. Results showed that satisfactory and lasting deglutatory function was achieved in 48 of 52 patients (92.3%). One and three-year survival rates were 86.2% and 65% respectively. These data showed that reconstructive method described above are effective and reliable.


[Comparison of diagnostic value between the parameters of auditory brain stem response in 48 patients with retrocochlear lesions]. This study was done for comparing the diagnosing value between some parameters of the time and frequency domain analysis of ABR in 48 patients with retro-cochlear lesions which were identified by CT and/or surgical, pathological examination. In conclusions, it revealed that the abnormalities of wave I-VIPL and delta V value could be the most sensitive and reliable index; the changes of AR spectrum and III-V/I-IIIIPL ratio could be the assist one. Combined with the ILD and difference between bilateral I-VIPL, must be useful for determining the location of retro-cochlear lesions.


[Vascular relationships of the trigeminal root with trigeminal neuralgia]. The vascular relationships of 79 trigeminal nerves exposed surgically for treatment of trigeminal neuralgia were studied. 87 etiologic vessels (vein in 28, artery in 59) were found and the most common arterial and venous etiologic vessel was the superior cerebellar artery (33/59) and petrous vein (16/28) respectively. The result provided some clinic data for microvascular decompression in treatment of idiopathic trigeminal neuralgia.


[Traumatic orbital wall fracture].

[Traumatic orbital wall fracture]. Thirteen patients with orbital wall fracture by trauma were reported. Among them, 6 cases were inferior-wall type, another 6 cases were interioinferior-wall type, and 1 case with interior-wall type. The clinical manifestation was mainly enophthalmos. All of patients were treated with plastic operation through nasal sinuses and fixed with national osseous cement. 11 cases were cured, 1 case was improved, 1 case had no change.


[Diagnostic value of stroboscopy in early glottic carcinoma]. Stroboscopic evaluation was conducted on 34 cases with glottic T1 carcinomas, and the relationship was studied between the area, thickness and volume of the lesion and the amplitude as well as mucosal wave of vibration. In all cases the mucosal wave of the lesion (WAVL) was abolished. The amplitude of the lesion (AMPL) was decreased in 17 and abolished in another 17 cases. There were significant relationship between the area of the lesion and the mucosal wave of the entire vocal fold (WAVE), the thickness of the lesion and AMPL, and the volume of the lesion and WAVE, AMPL, and the amplitude of the entire vocal fold (AMPE). The present paper suggested that if WAVL is reserved, the lesion is not invasive carcinoma, nor is it if any one of AMPE, AMPL, WAVE or WAVL is normal (except for lesions confined to the cartigenous vocal fold).


The measurement of patient satisfaction. Many applied health service researchers launch into patient satisfaction surveys without realizing the complexity of the task. This paper identifies the difficulties involved in executing patient satisfaction surveys. The recent revival of interest in 'satisfaction' and disagreements over the meaningfulness of a unitary concept itself are outlined, and the various perspectives and definitions of the components of satisfaction are explored. The difficulties of developing a comprehensive conceptual model are considered, and the issues involved in designing patient satisfaction surveys--and the disasters that occur when these issues are ignored--are then set out. The potential cost-effectiveness of qualitative techniques is discussed, and the paper concludes by discussing how health care management systems could more effectively absorb the findings of patient satisfaction surveys.


Discounting in health care decision-making: time for a change? Economic appraisal is increasingly being used to inform health care decision-making. To allow comparison, costs and benefits spread over time are weighted according to when they are experienced. The further in the future, the less heavily they are weighted or the more they are discounted. Traditional economic appraisal techniques are based on the view that social decisions should reflect private preferences. The practice of discounting future streams of costs and benefits is principally justified by the fact that individuals have a positive time preference, preferring consumption sooner rather than later. Discounting weights public decision-making in favour of interventions resulting in short-term benefits and against longer-term benefits. This discriminates against preventive and other public health programmes. This paper provides a critique of the foundations of discounting. It is argued that health policy should have a longer time horizon, reflecting social values rather than individual preferences. Factors which make discounting the future rational from the individual's point of view are shown to be irrelevant to a societal perspective. Although uncertainty about the effectiveness of interventions and technological change are good reasons for weighting some future benefits less highly, the routine use of a single discount rate for economic evaluations of health programmes is not justified.


A comparison of prospective and retrospective diary methods of assessing alcohol use among university undergraduates. The objective of this study is to compare data about the quantity of alcohol consumed by university undergraduates using a prospective diary with those data collected using a retrospective diary. Five hundred and ninety-eight subjects were randomly selected and divided into two groups matched for age, sex, year of study and subject group; one group received a prospective and one a retrospective questionnaire-301 students received prospective and 297 retrospective questionnaires. Sixty-eight per cent responded to the prospective and 75 per cent to the retrospective survey. There was no significant difference in the median alcohol consumption detected for men or women in this study (p = 0.13; p = 0.47). However, the prospective diary recorded a greater proportion of heavy drinkers, this difference being significant for men and women (p less than 0.05). The quantitative results of the retrospective diary are similar to those obtained by a similar method in a previous survey. The conclusion is that a prospective diary detects a greater proportion of heavy drinkers than a retrospective diary. The prospective survey may be the most appropriate method for assessing alcohol use in certain situations.


Quality of hospital service: a study comparing 'Asian' and 'non-Asian' patients in Middlesbrough. To compare 'Asian' and 'non-Asian' patients' experience of and satisfaction with non-clinical aspects of their hospital care, and to evaluate the effect of subsequent provision of 'Asian' food, we undertook interview surveys of recently discharged adult patients in Middlesbrough. Fifty-two 'Asians' and 52 'non-Asians' matched for sex, age, specialty of admission and hospital reported similar experiences in regard to the amount of information received, the presence of medical students during examination, and satisfaction with privacy and visiting arrangements. The main differences between the groups related to the receipt of written information in the patients' first language, 'Asian' patients' inability to communicate because of lack of English and their dissatisfaction with existing interpreting arrangements, 'Asian' women's attitudes to examination by male doctors, and provision of and satisfaction with hospital food. For example, 47 (90 per cent) 'Asians' and 14 (27 per cent) 'non-Asians' required a special diet but 19 per cent and 86 per cent, respectively, received it; and 'Asians' were less satisfied with the food overall. Despite being disadvantaged 'Asian' patients seldom complained. Following the provision of 'Asian' food, 'Asian' patients reported satisfaction levels comparable with those of 'non-Asians'. Equitable health care provision for ethnic minorities requires a level of service comparable with that enjoyed by the majority community. Written information in minority languages, professional interpreters, examination of female patients by women doctors and culturally suitable food were confirmed as priority needs. Staff training and community education may ensure successful implementation of policy on health care of ethnic minorities. Finally, the quality of non-clinical care in hospital needs to be raised for all groups of patients.


A geostatistical approach to the analysis of pattern in rare disease. The incidences of human disease vary from place to place, and some show distinct patterns. Patterns in rare diseases, such as childhood cancer, are not readily discernible, however, and this makes it difficult to relate their distribution to factors in the environment in seeking possible causes of the disease. Provided cases are geographically indexed, data on a disease can be analysed geostatistically. Variograms can be computed to determine the strength and spatial scale of any pattern, and to summarize the variation, and then the risk of developing the disease can be estimated by kriging. This has been done for the incidence rates of childhood cancer from 1980 to 1984 in the West Midlands Health Authority Region of England. A novel modification was made to compute the variogram of the risk from that of the frequencies, taking into account the binomial nature of the data. The incidence of the disease appears patchy. The results show that this patchiness is spatially correlated and not purely random. The risk appears greatest in the rural south west of the Region and in some of the suburbs around the conurbation. This approach using geostatistics seems very promising and will be developed further as more data for this and other diseases become available.


A rural advantage? Urban-rural health differences in northern England. Rural health inequalities have been relatively neglected in recent years. The data assembled for a large study of health and deprivation in the Northern Region of England have been reanalysed to examine three questions. How wide are rural health inequalities compared with those in urban areas? Is health intrinsically better in rural areas, given comparable deprivation or affluence? Is the association between health and wealth weaker in rural than in urban areas? It is shown that, although health inequalities are wider in urban areas, this corresponds to wider socio-economic divisions: at equivalent levels of wealth, health measures are similar. This relationship breaks down, however, when the most remote rural areas are compared with matching localities in conurbations, for in this case rural areas have a clear advantage. We go on to show that the apparent weakness of the association between health and wealth in rural areas is largely an artefact; the association becomes stronger when the units of population (electoral wards) are enlarged to resemble more closely those in urban contexts. The comparability of rural and urban forms of deprivation is discussed in the light of these results.


General practitioners, skin lesions and the new contract. We reviewed all skin lesions received in our laboratory from general practitioners (GPs) during a three-month period before the introduction of the new contract for GPs and during the same period a year later. For comparison we also reviewed skin lesions received from the general and plastic surgeons. Particular attention was paid to the completeness of excision. There was a significant increase in the number of skin lesions removed in general practice after the introduction of the new contract. Both benign and malignant lesions were more likely to be incompletely excised by GPs compared with surgeons. The GPs first noted to carry out minor surgery after the new contract came into force were less likely to have completely excised lesions than their more experienced colleagues. We suggest the future monitoring of lesions removed in general practice, possibly by the formation of a joint audit group.


Boneline: evaluation of an initiative to improve communication between specialists and general practitioners. In response to a previous study of GPs' and consultants' satisfaction with orthopaedic outpatient referrals, orthopaedic surgeons at Doncaster Royal Infirmary made themselves available for telephone consultations with general practitioners (GPs) at advertised times. This service, called 'Boneline', was used infrequently, though the GPs who did use it found it valuable, and reported that a number of referrals had been avoided by speaking to the consultant. There was, however, no significant change in the rate at which requests for out-patient appointments were received during the six months of Boneline's operation. Opportunities for improving telephone communication between GPs and consultants are discussed.


Towards the audit of geriatric day hospitals: a pilot project in west Surrey/north east Hampshire. Following the recommendation of a report on the performance of two geriatric day hospitals (GDHs) in West Surrey and North East Hampshire District Health Authority in 1988, a pilot study was set up to assess the efficacy of a proposed form of audit involving multidisciplinary teams. An outcome measure which consisted of four different scales was developed and agreed upon by the multi-professional team. These scales were used to work out a composite index (Patient Achievement Inventory-PAI). In addition, a new data form was designed for collection of patient data. To carry out this prospective clinical audit, targets were agreed for each patient, and progress was measured against them. Sixty-one (61) patients were studied (30 and 31 per respective hospital). Data form completion was 90 per cent and 81 per cent respectively. The PAI index proved to be reliable (kappa index of agreement = 0.72), and useful as an outcome measure. However, because the PAI index is made up of ordinal scales, it can only be used to measure change within individuals, not between them. The outcome measures, data forms and the continuous audit of these two GDHs proved to be meaningful and acceptable in practice.


Restoration of maxillary anterior teeth using porcelain jacket crowns and porcelain veneers. Combining different types of restorations when restoring maxillary anterior teeth poses a difficult esthetic problem. This article describes a method of restoring maxillary anterior teeth using a combination of porcelain jacket crowns and indirect porcelain laminate veneers.


Pharmacokinetics of astemizole in children. Astemizole is often administered to children in the treatment of rhinoconjunctivitis and urticaria with good efficacy and few side effects. Both astemizole and its major metabolite desmethylastemizole (DMA) are clinically effective without annoying side effects such as sedation. The pharmacokinetics in adults is well known. In three different studies we have investigated the pharmacokinetical properties of the drug in children. Study I (absorption): Thirty-eight children 8-16 years old (mean 12.6 years) and weighing 25-80 kg (mean 45 kg), with rhinoconjunctivitis due to birch pollinosis, were pretreated with either astemizole 5 mg daily or placebo for two weeks. Then, all children were treated with astemizole in doses increasing every week, i.e. 5, 10, 20 and 40 mg per day. There was a good correlation between the given dose per kg body weight and the plasma concentration of astemizole plus hydroxylated metabolites, indicating that astemizole is completely absorbed. Study II (time to reach steady state): A group of 21 children 7-18 years old (mean 13.9 years), plus 2 younger children, 2 and 5 years old, with allergy against birch- or grass pollen were treated with astemizole 10 mg daily for 12 weeks. Astemizole had reached steady-state plasma levels when the first sample was taken after 1 week, DMA reached steady state within 4 weeks. Study III (elimination half-life [t1/2 beta]): In 10 of the children from study II, t1/2 beta for astemizole plus DMA could be calculated (two samples) and was 10.8 days.(ABSTRACT TRUNCATED AT 250 WORDS)


Financial considerations regarding acquisition of the Siemens Cerec computer reconstruction system. There has been much interest in the in-office fabrication of ceramic posterior restorations using computer-aided design and computer-aided manufacture (CAD-CAM) units. One concern that practitioners have concerning the use of one of these systems is the initial expense of the CAD-CAM unit for the office. This article deals with the financial implications involved when considering the purchase or lease of a CEREC (CAD-CAM) unit.


Clinical experience with non-sedating antihistamines in paediatric allergic rhinitis. This paper reviews all clinical studies involving the use of astemizole in children. The indications of seasonal allergic rhinitis, perennial rhinitis and various allergic disorders were considered in a total of 21 studies (1,008 patients). Reference compounds were placebo and other antihistamines, such as chlorpheniramine and terfenadine. Astemizole and other antihistamines were effective in the treatment of these disorders with a more favourable result for those treated with astemizole. Astemizole appeared very satisfactory as regards laboratory data and absence of side effects.


Epidemiology of allergic diseases in children. The one-year-prevalence rate of bronchial asthma in children varies from 1-3%, when investigated in general practice, to 5-7% in population studies. The prevalence rate is highest in young boys. Eighty percent of the asthmatic children are allergic, house-dust-mite allergy being the most common allergy. The one-year-prevalence rate of rhinitis is 5-10% in general practice, and 10-12% in population studies. Again, the prevalence rate is highest in young boys. About 90% of children with rhinitis symptoms are allergic, with pollen allergy as the most common allergy. Risk factors for developing allergic diseases are many. The predisposition is probably the most prevailing risk factor. Period of birth, sex, race, diet, the presence of other allergic diseases, tobacco smoking, pollution, and allergens in the environment, all these factors alone or in combination almost double the risk. There is no doubt that both asthma and hay-fever prevalences have steadily increased within the last 50 years. Also, admissions to hospitals for childhood asthma have continued to increase, while the mortality of asthma in children has not risen statistically. This increase is in contrast to the effective medication available for both asthma and allergic rhinitis, and to the number of preventive factors known to us today. The time has come to try to change it at all costs. The outcome of allergic rhinitis and asthma shows that only 10% are cured, 50% ameliorate, 30% remain unchanged, and 10% deteriorate. Factors determining the outcome are age, immunotherapy, sex, mother's age at childbirth, infections, other allergic diseases, and signs and symptoms of food allergy.(ABSTRACT TRUNCATED AT 250 WORDS)


Changes in lip contour following treatment of maxillary protrusion with esthetic orthodontic appliances. With the advent of acid etching techniques and the elimination of unesthetic band materials, direct bonding of orthodontic attachments kindled a desire for cosmetic appliances such as labial ceramic brackets and lingual orthodontics. Owing to the esthetic nature of our combination upper-lingual lower-ceramic orthodontic approach, adults who would have normally avoided orthodontic treatment are now seeking treatment. This study evaluated the cephalometric changes in the soft tissue lip profile following treatment of Class II Division 1 malocclusion with upper first bicuspid extractions with our esthetic orthodontic appliance approach. Serial lateral cephalograms (pretreatment and posttreatment) of 16 adult patients with a mean age of 22.1 +/- 3.2 years were studied. The mean upper incisor retraction, upper lip retraction, upper lip lengthening, and lower lip retraction were 5.75 +/- 1.91 mm, 2.8 +/- 1.4 mm, 1.5 +/- 0.6 mm, and 1.4 +/- 0.6 mm, respectively. All these changes were statistically significant (p < 0.01). The nasolabial angle increase of 10.8 +/- 3.0 degrees was also statistically significant (p < 0.01). The upper lip retraction to upper incisor retraction was 1:2.1, while the upper lip lengthening to upper incisor retraction was 1:3.8. The correlation coefficients (r) were 0.91 (p < 0.01) and 0.57 (p < 0.01), respectively. This study shows that significant esthetic changes in lip profile are possible with this cosmetic orthodontic appliance approach. The treatment results in this study appear comparable to those published with labial metal brackets. With very few exceptions, patients were able to adapt within 2 weeks, with almost no trauma to the tongue.


Bond strength of fiber-reinforced composite resin restorations. Severe tooth wear is common in older dentate individuals, with one treatment option being composite resin restorations reinforced with a suitable matrix. This study evaluated the use of high modulus polyethylene (Celanese) fibers as a reinforcing matrix for composite resin. Human mandibular incisor teeth were sectioned to simulate severe tooth wear. Sectioned surfaces were measured, the teeth paired and assigned to control or test sample groups, and further assigned to be tested with a labial or lingual shearing force. A phosphorylated dentin bonding adhesive was applied to the abraded dentin surface. Labial and lingual intra-enamel bevel preparations were cut on each specimen. A piece of Celanese fabric was bonded onto the acid-etched labial and lingual bevels of the test specimens using an enamel bonding agent. Class IV composite resin restorations were then placed onto the test and control specimens. Following water storage, the specimens were subjected to shearing forces. Bond strengths for test specimens were significantly greater (p < 0.03) than the controls. Specimens with a labially applied force also had significantly higher bond strengths (p < 0.001). SEM analysis revealed adhesive bond failures over dentin surfaces, with cohesive bond failures within the composite resin. Celanese fibers maintained the restorations on the teeth, although adhesive failures were seen between the fibers and enamel bonding agent.


Simplified occlusal anatomy for posterior composites. Direct posterior composites have had problems in the past and thus have not had wide acceptance. The newest generation materials overcome many of their previous shortcomings. Finishing with proper anatomy has been difficult and time-consuming. An alternative to overfilling and then grinding in the anatomy is proposed. Using a prefilled tip allows small increments of composite to be placed without flowing and sagging. Each cusp is individually shaped and initially cured for 10 seconds. Every attempt is made not to overfill the preparation to avoid unnecessary grinding. The anatomy shapes up almost automatically, similar to P.K. Thomas waxing. With only minor adjustments and polishing with a polishing paste, time spent finishing is reduced. Natural looking, functional, and beautiful occlusal anatomy is now possible with this simple technique.


[Ventricular tachycardia: the role of adrenergic stimulation in the prognosis of fatal arrhythmia]. A new method for appraising the individual efficacy of an antiarrhythmic agent is described. It is based on paired administration of isoprenaline and testing antiarrhythmics for maximum activity. The possibility of provoking ventricular tachycardia by isoprenaline made it possible to identify a contingent of patients with "catecholamine-sensitive" or "variable" tachycardia. The prognosis of "catecholamine-sensitive" ventricular tachycardia proved to be the worst in groups of patients with ischemic heart disease attended by postinfarction cardiosclerosis and in patients with arrhythmogenic dysplasia of the right ventricle.


[Surgical treatment of left-atrial myxoma]. The authors had 29 patients with myxomas of the left atrium under observation and treated them by operation. Three patients died after the operation. Examination of 22 patients in postoperative periods of 8 months to 15 years did not reveal recurrent tumors of the heart. The extremely rare development of tumors of the heart and the absence of specific clinical manifestations make it difficult to establish the diagnosis in time. The relatively high postoperative mortality (12%) is due, first of all, to establishment of the diagnosis during the operation as a consequence of which an emergency operation on an open heart cannot be conducted. Operative treatment is indicated for all patients with a recognized tumor of the heart.


[Surgical correction of double aortic arch in infants]. The article generalizes the experience in the surgical correction of a rare anomaly of the aortic arch--a vascular ring in the form of a double arch of the aorta in 2 babies. In a 9-month-old baby with Fallot's tetralogy the double aortic arch was found during an operation. The child died after the operation (division of the left arch of the aorta distal to the left subclavian artery in a left descending aorta and formation of a subclavian-pulmonary anastomosis). In the other 3-month-old patient with a marked picture of tracheo-esophageal compression tracheobronchoscopy and esophagography showed a double aortic arch with predominance of the right arch, right descending aorta, and a wide patent ductus arteriosus. The operation involved division of the ductus arteriosus and the hypoplastic left aortic arch between the left common carotid and left subclavian arteries. A prolonged period of regression of the symptomatology of tracheoesophageal compression was noted in the postoperative period. Early recognition of this anomaly of the aortic arch and active surgical tactics facilitate improvement of the results.


[10-year experience with correction of supraventricular tachycardia]. The results of a 10-year experience in surgical treatment of supraventricular tachyarrhythmias in 258 patients are analysed. Invasive and noninvasive methods of electrophysiological studies with the predominant use of Soviet-produced apparatuses were employed in establishing the diagnosis. Surgery of arrhythmias included catheter destruction, cryosurgery on a working heart, but the prevailing methods were various types of destruction of anomalous conducting paths under conditions of extracorporeal circulation. The authors suggest a method for dosed electrocoagulation of paranodal tissues in atrioventricular nodal tachycardias. The results of the operation were positive in over 90% of cases. Three fatal outcomes in operations with extracorporeal circulation occurred during the first years of accumulation of experience in the method. It is concluded that the operation is highly effective in severe tachyarrhythmias.


[Additional myocardial protection by normothermic cardioplegic reperfusion]. Three series of experiments were conducted on a model of an isolated working rat heart to study the efficacy of variants of cardioplegic myocardial protection in exposure to 30-minute total ischemia at 37 degrees C: (1) preischemic administration of potassium solution (K(+)-30 mM, Mg(2+)-1.6 mM, osmolarity 330 MOSM/1); ischemia, unmodified reperfusion; (2) preischemic administration of this solution, ischemia, postischemic administration of this solution for 5 minutes (normothermic cardioplegic reperfusion), putting in a working regimen; (3) the regimen of the experiments is the same as in series 2, but normothermic cardioplegic reperfusion was carried out with a modified potassium-magnesium solution (K(+)-15 mM, Mg(2+)-15 mM, osmolarity 360 MOSM/1). The values of functional restoration, rate and total discharge of the enzyme LDH into the perfusate were compared. Restoration of functional values (aortic pressure, aortic output, cardiac index) according to the experimental series: 3 greater than 2 greater than 1. LDH discharge into the perfusate: 3 less than 2 less than 1. The results of the study provide evidence that reperfusion damage may be lessened by normothermic cardioplegic reperfusion; the highest effect was produced by a solution with specially selected properties: electrolyte composition and high osmolarity.


[Separation and shunting of intramyocardial segments of the coronary arteries in their proximal affection by the arteriosclerotic process]. Operations for the formation of an aortocoronary shunt were performed on 395 patients in the period between October 1983 and January 1991. The anomalous position of one or more segments was found in 70 patients. The autologous vein was used as a graft in 65.7% of these patients and the internal thoracic artery in 34.3% of cases. The anterior interventricular branch (AIVB) was situated in the myocardium in 58.6% of cases and the circumflex branch (CB) in 31.4% of cases, in 8.6% of cases the segments of some arteries were situated anomalously. The AIVB was separated beginning from its segment distal in relation to its intramyocardial segment in the region of its subepicardial passage, after which an incision was made in the myocardium overlying the intramyocardial segment. The anomalously situated segments of the other coronary arteries were separated by the same techniques. In one case the AIVB was lying in the cavity, in another, it was stretched under the endocardium. After shunting these arteries were transposed to the surface of the left ventricle which allowed the ventriculotomy incision under them to be sutured. There were no complications linked with separation and shunting of intramyocardial segments of the coronary arteries. These segments of the coronary arteries have a larger lumen and are very rarely involved in an atherosclerotic process. Proceeding from the aforesaid, intramyocardial segments of coronary arteries whose proximal parts are affected by atherosclerosis must be separated and shunted.


[Complex evaluation of external respiratory function in patients with cancer of the lung]. Principles of complex appraisal of the function of external respiration were worked out on the basis of analysis of the mechanics of respiration with the use of body plethysmography and invasive examination of pulmonary circulatory dynamics and gas transport. The suggested method allows practicable appraisal of the mechanisms of oxygen transport disorders and identification of the leading link in the development of alveolo-respiratory failure.


[Echocardiographic diagnosis of the origin of the aorta and pulmonary artery from the right heart ventricle]. The origin of the aorta and pulmonary artery from the right ventricle is a congenital heart disease whose anatomical and echocardiographic criteria are the object of wide current discussion. The classification of the disease has been developed at the Bakulev Institute of Cardiovascular Surgery, USSR AMS. It is based on identification of the anatomical differences in the types of origin of the aorta and pulmonary artery from the right ventricle (RV OAPA). The present research was devoted to the study of the possibilities of echocardiography in the differential diagnosis of the types of the anomaly in the RV OAPA complex and the possibilities of noninvasive differential diagnosis of RV OAPA and adjacent anomalies of the conotruncus. The results of the study allow the conclusion that location of intracardiac structures with purposeful use of ultrasonic projections provides the possibility of making the differential diagnosis of the types of the anomaly in the RV OAPA complex and that the obtained echocardiographic criteria may serve for establishing the differential diagnosis of RV OAPA and other congenital anomalies of the conotruncus.


Outcome measures for primary health care: what are the research priorities? A Delphi technique was used to ask general practitioners for their opinions as to which clinical problems and types of measure they thought most appropriate for the development of outcome measures for use in primary health care. The study comprised two rounds of postal questionnaires, targeted at general practitioners in academic departments throughout the United Kingdom and at trainers in the northern region, with the second questionnaire feeding back opinions from the first. Ninety eight participants suggested one or more areas in which outcome measures could be developed, giving a total of 451 suggestions. Consensus produced in the second round indicated that three clinical conditions were preferred for the development of outcome measures: asthma, diabetes and hypertension. Six categories of outcome measures were developed from the responses given in the first round--level of function, level of clinical control, incidence of complications, iatrogenic problems, patient understanding of a condition, and quality of life. Participants gave these measures different levels of importance according to the clinical problem in question. This Delphi study of doctors' opinions is a first step in the development process of appropriate, practicable measures of outcome for use in primary care and has achieved a degree of consensus among general practitioners.


Problems of drug abuse, HIV and AIDS: the burden of care in one general practice. Responsibility for many of the problems of intravenous drug abuse and human immunodeficiency virus (HIV) infection lies with community care agencies, such as general practitioners, community psychiatric and district nurses and drug agencies. It is in general practice that this burden is most clearly observed, given that general practitioners are in charge of the day-to-day care of patients. In an attempt to quantify this workload in an inner city practice with 11,200 patients, data were gathered from several sources relating to drug use and HIV infection. The study identified 432 patients who had consulted with problems of drug abuse and/or HIV infection over the period 1981-90. Among this group of patients 161 (37%) were HIV antibody positive. Among 191 drug abusers who were still registered with the practice in 1990 dihydrocodeine was the most commonly prescribed substitute treatment (130 patients) and only nine patients were prescribed methadone. Forty seven per cent of drug users continued to inject drugs occasionally. However, analysis of urine samples revealed that there was a shift away from injecting mainly heroin to multiple drug use, including benzodiazepines, usually originating from prescribed sources. Drug abusers who were HIV positive consulted their general practitioner significantly more often over one year than those who were not (mean 24.9 versus 15.8 consultations, P < 0.01). However, there was no significant difference between these two groups in terms of days spent in hospital. A total of 61 patients were referred to a community psychiatric nurse over an eight month period.(ABSTRACT TRUNCATED AT 250 WORDS)


[Tracheal prosthesis].

[Tracheal prosthesis]. A prosthesis of the authors' design with various connective elements of knitted Lavsan fabric was tested in experiments on 43 mongrel dogs. Clinical, radiological, radiospirographic, and morphological studies showed that the optimal prosthesis is that in which the connective elements are made of knitted Lavsan fabrics with an average stitch size of 20-23. Granulation tissue grows through the prosthesis which is fastened well to the connective-tissue cuff forming around it. The trachea replaced by the prosthesis ensures adequate gas exchange and lung functioning, causes no essential disorders of pulmonary volumes, ventilation and perfusion of the right and left lungs.


Social indicators of health needs for general practice: a simpler approach. The ability of different measures of socioeconomic position to predict distress in a sample of general practice attenders has been examined. Perceived distress was measured using the Nottingham health profile. The measures of socioeconomic position included: social class, Jarman scores of patients' areas of residence, whether or not patients owned their own home, whether or not patients owned a car, whether or not they had been unemployed during the previous year and whether or not they had had further education. Social class data were only available for 84% of the 1075 respondents completing the Nottingham health profile. Those respondents for whom social class data were not available were significantly more likely to score positively on the social isolation, sleep and physical mobility dimensions of the Nottingham health profile. Not owning one's own home emerged as the measure of socioeconomic status that best predicted distress. The other measures of socioeconomic status that were significantly predictive of distress were not having had further education and having been unemployed during the last year. Different measures of socioeconomic position significantly predicted positive scores on different dimension of the Nottingham health profile. Although the Jarman score significantly predicted a positive score on the sleep dimension, it did not predict distress well when compared with the direct measures of disadvantage. There are simple, more direct measures of socioeconomic position than social class that could be collected routinely by practices which would form a better basis for the evaluation of services required to target those needs created by persisting social inequalities in health.(ABSTRACT TRUNCATED AT 250 WORDS)


Evaluation of urine sampling technique: bacterial contamination of samples from women students. A urine specimen is traditionally sampled using the clean-catch midstream technique, but this technique is poorly documented. The aim of this study was to evaluate the bacterial content of urine samples taken using individual steps of the clean-catch midstream technique, or combinations of steps. One hundred and ten women students provided a total of 864 early morning urine samples, using a different sampling technique each morning. Holding the labia apart during sampling more than halved the percentage of samples containing 10(5) colony-forming units per ml or more, and increased the percentage of uncontaminated samples, compared with passing urine without employing any of the precautions. Cleaning the perineum or using the midstream technique resulted in percentages no different from urination without employing any precautions. It is therefore recommended that women should be instructed to carry out the simplest effective urine sampling technique: holding the labia apart.


[Triple-valve prosthesis (old problems, new prospects)]. The article analyses 30 operations for prosthetics of the mitral, aortic, and tricuspid valves in patients with trivalve rheumatic heart disease. Twenty-nine patients had a marked organic tricuspid valvular disease. Various models of prostheses (ball, semispherical, biological, disk) were used for replacement of the valves. Techniques which allowed the subvalvular structures of the tricuspid valve to be preserved partly or completely were applied in 18 patients. The hospital mortality was 16.7%, long-term mortality 4%. Improvement by two functional classes and more occurred in 86% of patients. It is concluded that surgeons are no longer compelled to resort to prosthetics of the tricuspid valve, which has now become an alternative operation, particularly in the category of extremely grave patients with organic affection of 3 valves when the prognosis of the result is needed in view of the patient's severe condition. The techniques for preserving the valvular apparatus provides optimum conditions for functioning of the right ventricle in replacement of the tricuspid valve.


Acute herpes zoster and postherpetic neuralgia: effects of acyclovir and outcome of treatment with amitriptyline. This retrospective study was designed to assess the effects of acyclovir treatment of acute herpes zoster on subsequent postherpetic neuralgia, and to examine the effects of amitriptyline in the treatment of postherpetic neuralgia. Eighty seven patients with postherpetic neuralgia of three or more months' duration were studied: 24 of them had had their herpes zoster treated with oral acyclovir. At first presentation, only 25% of the 24 patients who had had their herpes zoster treated with acyclovir selected the word group containing burning on the McGill pain questionnaire compared with 76% of the 63 patients who had not received acyclovir. A higher proportion of patients who had had acyclovir than had not selected the word group which contains the word aching (63% versus 49%). Acyclovir thus appears to change the nature of postherpetic neuralgia. Postherpetic neuralgia was treated with amitriptyline, alone or in combination with distigmine and/or sodium valproate. There was a strong correlation between pain relief and the interval between the occurrence of herpes zoster and the initiation of treatment with amitriptyline--early treatment is almost twice as likely to be successful as late. Since conventional analgesics and sympatholytic drugs are of no benefit in the treatment of established postherpetic neuralgia, the sequelae of herpes zoster must, therefore, be recognized and treated with amitriptyline as soon as possible.


Determinants of outcome in smoking cessation. A large amount of research has been conducted into the factors which influence outcome in attempts to stop smoking. This article reviews the literature in two main areas: first, the effects of patient characteristics on outcome, and secondly, the effectiveness of various primary care interventions. The practical implications of this research for primary care interventions to help people stop smoking are explored.


Intermittent self catheterization for patients with urinary incontinence or difficulty emptying the bladder. Urinary incontinence, difficulty voiding and recurrent urinary tract infections are common in general practice. In patients with multiple sclerosis, spina bifida, intervertebral disc lesions, spinal injuries or tumours, the symptoms may be associated with a high residual volume of urine owing to a neuropathic bladder. Similar complaints may occur in elderly people or in women with gynaecological problems owing to atonic urinary retention. Provided that a significant residual volume of urine is found on abdominal examination, ultrasound, x-ray or catheterization, both groups of patients may be helped by intermittent self catheterization. Intermittent self catheterization is a safe and simple technique. By catheterizing themselves between four and six times daily patients can gain control over their bladders. Abandoning indwelling catheters or bulky external appliances does much for a patient's morale and self esteem. In addition, since the bladder is being drained effectively, urinary tract infections cease to be a problem and the kidneys are safeguarded. Severe disability is not a contraindication since patients in wheelchairs have mastered the technique despite paraplegia, an anaesthetic perineum, spinal deformity, intention tremor, mental handicap, old age or blindness. Patients should be referred to urologists for a trial of intermittent self catheterization. If unsuccessful or unacceptable it can be abandoned with no long term consequences. If it is effective the benefits may be considerable.


Provision of, and patient satisfaction with, primary care services in a relatively affluent area and a relatively deprived area of Glasgow. This paper presents the results of a survey of the structure of general practice in two contrasting areas within Greater Glasgow health board: the south west area had a more deprived social profile at the 1981 census and higher than average all cause and selected major cause standardized mortality ratios than the health board as a whole while the north west area had a more affluent social profile at the 1981 census and lower than average all cause and selected major cause standardized mortality ratios. The general practice survey data gathered in 1989 were supplemented with data from a survey of residents of the localities in three age cohorts carried out in 1987-88, which provided information on use of services, as well as perceived accessibility of and satisfaction with them. Despite the more deprived social and mortality profile of the south west area, and greater use of services, few systematic differences in the structure of general practices were found in the two areas. These findings support other studies which suggest that the stereotype of poorly resourced, low quality primary care in inner city areas may apply in London, but not elsewhere. Respondents in both areas were equally satisfied with services and found them accessible.


Changes resulting from increasing appointment length: practical and theoretical issues. The experience of one urban teaching practice in changing its appointment length from 7.5 to 10.0 minutes is described. Observed benefits to patients attending routine surgeries included an increased consultation time (mean 8.6 minutes before, 9.1 minutes after) and reduced waiting time (mean 19.1 minutes compared with 14.6 minutes). Overall, workload was unchanged but improving the 'fit' between supply and demand was associated with loss of flexibility--a greater number of extra patients required to be seen, apparently because fewer appointments were available at the start of each day. Waiting and consultation times in teaching surgeries and trainee surgeries (booked throughout at 10.0 minute intervals) were unchanged in response to the new arrangements. The changes introduced were well received by medical and reception staff although their response was not formally measured. Planning the organization of an appointment system requires several distinct decisions to be made. The preferred or actual average length of consultations has to be decided and booking arrangements designed to enable this to take place without the doctors persistently running over time. The number of appointments per week required to meet anticipated demand has to be calculated on the basis of list size and expected annual consultation rate. However, an exact fit between supply and demand will lead to congestion of the system and it appears that flexibility in the form of an overprovision of appointments to projected demand of about 120% should be built in. Sufficient vacant slots must be provided at the start of each day to allow sufficient flexibility to avoid excessive numbers of patients having to be accommodated.(ABSTRACT TRUNCATED AT 250 WORDS)


General practice based diabetes surveillance: the views of patients. Forty three patients with non-insulin dependent diabetes registered at two suburban practices were interviewed at least one year after the introduction of an organized general practice based system of diabetic surveillance and the results compared with data gathered from interviews administered before the introduction of the system. Structured data from the two interviews were compared in relation to the importance which patients attached to diabetes and its medical review, patients' preference for place of future review and the health professionals from whom they wished to receive diabetes care. Patients' ratings of the performance of health professionals on various aspects of care were compared with the ratings given before the introduction of the new service. At the follow-up interviews the reasons behind patients' responses to the structured questions were explored using a qualitative method. The introduction of a general practice based diabetes service was marked by an improvement in attendance for diabetes monitoring (56% before introduction, 98% in the year following introduction). This was associated with an increase in the importance which patients attached to diabetes and its medical review. After experience of diabetes care in general practice, patients remained enthusiastic about general practice involvement and confident in their general practitioners' knowledge about diabetes management. In spite of an improvement in the patients' ratings of hospital doctors' communication skills, they continued to rate general practitioners significantly more highly in these skills (P < 0.01) and in terms of convenience and accessibility (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)