Thoracic spine trauma.

Thoracic spine trauma. Thoracic spine fractures are most commonly flexion injuries resulting from vehicular accidents or falls. The initial evaluation of any multiple trauma victim should include AP and cross-table lateral radiographs of the thoracic spine. Conventional and computed axial tomography can add additional information regarding posterior element integrity and spinal canal encroachment. MRI can also be useful in that it directly images the effects of fractures on the spinal cord.


MR imaging of skeletal metastases from medulloblastoma. The findings of MR imaging in 3 patients with bone metastases from medulloblastoma are reported. The first patient showed focal lesions of low signal intensity on T1-weighted spin echo images at a time when bone scintigraphy was negative for metastases. This patient later developed extensive osteosclerotic lesions visible on plain films. The bone marrow of the second patient showed diffuse low signal intensity on T1-weighted images. After chemotherapy the signal intensity of the bone marrow increased which correlated with a return of normal hematopoietic tissue. A response to chemotherapy was also found on MR imaging and repeat bone marrow biopsies in a third patient. A consistent finding was a low signal intensity on pre-gadolinium images, but the pattern (focal or diffuse abnormal signal intensity) was different in each patient. To our knowledge, this is the first report on MR imaging findings in bone metastases from medulloblastoma.


Alcoholism-associated spinal and femoral bone loss in abstinent male alcoholics, as measured by dual X-ray absorptiometry. Although alcoholism is a known risk factor for osteoporosis, there are few published reports on alcoholism-associated bone loss. To study alcoholism-associated bone loss, this study used a dual X-ray absorptiometry (DXA) densitometer to measure lumbar and femoral bone mineral density (BMD) in a previously little-studied population: 32 relatively healthy, nonhospitalized, Caucasian, alcoholic men with a period of abstinence longer than that previously studied (median abstinence 4.0 months, range 3 days-36 months). DXA is a new, highly precise densitometric method with many advantages over the methods used in previous studies. The subjects had statistically significant bone loss at three sites: lumbar spine, femoral neck, and Ward's triangle (multiple correction adjusted two-tailed P < 0.008). Compared to the mean BMD of sex-, age-, and race-matched norms, the subjects' average femoral neck, Ward's triangle, and lumbar BMDs were, respectively, 0.56, 0.69, and 0.57 standard deviations (SDs) below the normative values.


The hallux sesamoids revisited.

The hallux sesamoids revisited. The hallux sesamoids are vulnerable to significant injury and weight-bearing stress in both the athlete and the nonathlete. Unfortunately, they are often dismissed as inconsequential accessory bones. The historical significance, embryology, anatomy, and physiology of the sesamoids and the salient features of both traumatic and nontraumatic pathologic conditions affecting these structures are presented. Because the sesamoids can be responsible for prolonged disabling foot pain and discomfort, it is important for both clinician and radiologist to pay attention to these bones and recognize the early signs of abnormality.


Computed tomography appearance of bone metastases of leiomyosarcoma. Bone lesions in leiomyosarcoma are uncommon. When encountered, they are usually a late manifestation of disease seen in the setting of widespread systemic metastases. We present five cases of metastatic leiomyosarcoma, including one in which a bone lesion predated detection of a primary gastric leiomyosarcoma and one in which bone metastases signaled disease recurrence. Computed tomography in 14 of 16 osseous leiomyosarcomas demonstrated a lytic, non-expansile pattern.


Shoulder impingement syndrome: impingement view and arthrography study based on 100 cases. A prospective evaluation combining the shoulder impingement view and arthrography was made in patients presenting with chronic shoulder pain. Five hundred and twenty-three patients with chronic shoulder pain were X-rayed using conventional views and impingement views. One hundred of these patients (mean age 62 years) had subacromial bony spurs on the impingement view; these underwent arthrography. They were divided into two groups according to the degree of spur formation--whether or not the size of the spur exceeded one half of the acromial width as measured from the outer margin to the acromioclavicular joint. Of the 100 subacromial spurs demonstrated on the impingement view, only 18 were visible on the conventional view as assessed by an independent radiologist. Arthrography showed 35 cases of rotator cuff tear. The size of the bony spur was strongly associated with the incidence of rotator cuff tear (P < 0.02).


Magnetic resonance imaging of Achilles tendon xanthomas in familial hypercholesterolemia. The demonstration of tendon xanthomas is helpful in diagnosing heterozygous familial hypercholesterolemia, but in many patients lipid may accumulate without clinical abnormality being present. We investigated the possibility of detecting the lipid element with magnetic resonance (MR) imaging in seven patients with familial hypercholesterolemia and six controls. Although the mean relative signal intensities measured on long TR/TE spin echo sequences of the tendon were significantly higher in patients than in controls, the lack of such elevation does not rule out the presence of such lesions. In vitro measurements indicated that the signal intensity of triglycerides was quenched by cholesterolesters. The anatomic findings of MR imaging were compared with those of ultrasonography (US), showing excellent correlation in measurements between MR images and US [r(S) = 0.95 and 0.97 respectively]. MR imaging and US provide equal information on the anatomy of the Achilles tendon; as an abnormally increased signal intensity within the xanthoma on MRI was found in only a minority of our patients, the value of MRI in the demonstration of Achilles tendon xanthomas is limited when using conventional T1 and T2 spin echo sequences.


MRI evaluation of amyloid myopathy.

MRI evaluation of amyloid myopathy. Amyloid myopathy is a rare complication of primary amyloidosis. The magnetic resonance imaging (MRI) features of two patients with amyloid myopathy were studied. Slight prolongation of muscle T1 and T2 relaxation times was evident but the striking abnormality was marked reticulation of the subcutaneous fat. The clinical findings of indurated extremities far exceeds the minimal signal intensity alteration seen in the muscles. The MR appearance of amyloid myopathy differs from that of other neuromuscular conditions in the minimal changes found in muscle, but the striking abnormality seen in subcutaneous fat makes it distinct from many neuromuscular conditions.


Case report 736: Retained surgical sponge (gossypiboma) with a foreign body reaction and remote and organizing hematoma. This 50-year-old woman presented with progressive pain in the left thigh. Radiographs showed a 9 x 6 cm soft-tissue mass located at the lateral border of the left femur. Magnetic resonance (MR) examination showed an eccentric, nonhomogeneous, soft-tissue mass abutting the femur. The preoperative differential diagnosis was schwannoma, low-grade neurogenic tumor, large periosteal ganglion, or fibroma. At operation, the cut surface of the specimen had features of an organizing hematoma with recent remote hemorrhage and areas of fibrosis. Histopathological examination confirmed the presence of polarizable foreign body material in a background of foreign body reaction. The specimen represented a retained surgical sponge which had been present since the patient's surgery for a comminuted fracture 35 years earlier. Gossypiboma, or cotton balloma, is a term used to describe a mass within the body composed of cotton matrix. Radiopaque markers are now present on surgical sponges, and their appearances have been well documented. The gossypiboma, however, may still present a diagnostic problem if the marker is distorted by folding, twisting, or disintegration over a period of time. Without the radiopaque markers, retained sponges are difficult, if not impossible, to diagnose, as was the situation in this case.


Case report 754: Xanthoma of the Achilles tendon. The MRI features of bilateral xanthoma of the achilles tendon in type II hyperlipoproteinemia are reported. MRI has proved to be the best imaging modality available in assessing enlargement of the Achilles tendon. It demonstrates the heterogeneous signal on both T1- and T2-weighted images where the xanthomatous deposits are relatively higher in signal intensity than the tendon itself. MRI also has a potential value in the clinical assessment and therapeutic response of the xanthoma after operative intervention.


Case report 756: Chronic multifocal osteomyelitis. We report the case of a young boy referred to our Department of Nuclear Medicine under the suspicion of a malignant tumor. The leading clinical symptoms were pain in the joints and loss of weight and vitality. Radiographic findings were suggestive of osteogenic sarcoma, but bone scans showed multiple increased tracer depositions along the cortex of femur and tibia, and in the lower and upper jaw. The enrichment pattern was not typical for metastases, but more probably demonstrated the multiple foci of osteomyelitis. This assumption was confirmed by the histological findings, which were diagnosed as primary chronic osteomyelitis. This rare pediatric bone disorder has been described by Giedion et al. The etiology of the disease is unknown, and therapy is discussed controversely in literature.


Case report 757: Giant cell tumor of rib. A case of the rare occurrence of conventional GCT in a rib is presented. Due to its radiological aggressivity, the possibility of a MGCT was entertained clinically, and preoperative chemotherapy and radiation therapy were given. The literature on giant cell tumors of the ribs is reviewed, and their distinction from primary MGCT and other giant-cell-containing lesions is discussed.


Contemporary health care and the colonial and neo-colonial experience: the case of the Dominican Republic. This article traces the development of health care policies in the Dominican Republic from their colonial and neo-colonial roots to contemporary times. The Dominican case exemplifies the unique historical processes by which its health policies were created and maintained, and simultaneously, reflects the political and historical forces that shape the Caribbean as a whole.


Transformations in maternity services in Jamaica. Analysis of the current organization and delivery of maternity care in Jamaica profits not only from an assessment of recent health issues but from consideration of the development of maternity services over the past century. Historical analysis indicates that a critical element in public health policy has been the effort to encourage use of biomedical obstetrical care and to eliminate the lay midwife. However, while women increasingly patronize hospitals, the delivery of services has deteriorated, resulting in widespread client dissatisfaction. Economic contingencies have contributed to the decline in maternity services, but health personnel manifest the ideology prevalent throughout the colonial era equating social irresponsibility with health complications. The cultural construction of illegitimacy and maternity is shown to be a dimension of class relations having an impact on health policy throughout Jamaica's history.


Social factors mediating social class differences in blood pressure in a Jamaican community. Research on the factors mediating social class differences in blood pressure was carried out in a Jamaican community. It was found in a previous report that higher social class is related to lower blood pressure for females, while for males higher social class is related to higher blood pressure. These differences are examined in greater detail here, especially in terms of the historical context of the specific community studied, which is on the fringe of the Kingston urban area, and in terms of the continuing importance of a social class system established under colonial rule. In the current study it is shown that social class differences in blood pressure for males are mediated by perceptions of social support. Social class differences in blood pressure for females are mediated by perceptions of economic stress. It is suggested that specific patterns of the growth of the city, and the historically-based social class system, have resulted in the juxtaposition of lower and middle class Jamaicans within this community, who in turn are influenced by different factors affecting blood pressure.


West Indian gender relations, family planning programs and fertility decline. Nearly all West Indian islands initiated marked fertility declines sometime between 1960 and 1970. Family planning programs have not played an important role in these declines. Neither have other variables that conventional social theory tells us should promote reduced family sizes, like education and rising standards of living. The historical experience of Barbados and Antigua, which reached replacement-level fertility in the 1980s, suggests that West Indian fertility declines reflect structural changes in national economies that created job opportunities for women. Family planning programs need to be evaluated with reference to the distinctive health and human rights goals other than fertility transition that they can effectively reach.


The effect of parental age, birth order and other variables on early childhood mortality: a Caribbean example. The 4275 births to women of native ancestry that took place on the island of St Barthélemy, French West Indies between 1878 and 1970 were analyzed according to the sex of the child, the year of birth, maternal age, maternal parity, paternal age and the number of children the father already had to determine the effects of these variables on rates of perinatal death, death before age 1 and death before age 5. The year of birth, the number of children the father already had, and maternal parity influenced death before age 1 and death before age 5. The sex of the child also influenced the probability of dying in the first year of life but not the first 5 yr of life when the other variables were controlled. Perinatal deaths were influenced only by the sex of the child, but even this effect disappeared when the other variables were controlled.


Family planning in St Vincent, West Indies: a population history perspective. St Vincent's population history, first as a slave society, then, after Emancipation, as a migration-oriented society, has strongly influenced cultural attitudes towards sexuality and fertility. In contemporary St Vincent, sexual activity and procreative ability are highly valued and linked to social status for both men and women. This paper assesses historical and contemporary factors influencing population dynamics in St Vincent, West Indies, and Vincentians' reactions to programs developed to curb population growth. The efforts of private and government programs to introduce family planning and change pronatalist attitudes are evaluated for their cultural appropriateness. Shifting migration patterns and modernization are also affecting gender roles, the social and economic value of children, and the acceptability of contraception to contribute to recent fertility declines.


Social inequities in cardiovascular disease risk factors in East and West Germany. Social class related differences in prevalence of cardiovascular disease risk factors in Germany were investigated with special emphasis on comparisons between East and West Germany and on time trends. Databases for West Germany are the first and second National Health Survey (survey 1: N = 4794, survey 2: N = 5315), carried out in the framework of the German Cardiovascular Prevention Study, and for East Germany the first GDR-MONICA project (N = 6125). Different social class indices were applied to evaluate social inequities for hypertension, hypercholesterolemia, cigarette smoking, obesity and predicted cardiovascular disease mortality. As a main result, it was found that very similar patterns in the relation between social class characteristics and cardiovascular disease risk factor prevalence occurred for both parts of Germany. Social class gradients were strongest for obesity and weakest for hypercholesterolemia. Analysis of time trends for the period from 1984 to 1988 (for West Germany only) revealed an increase in social inequalities for hypertension in males and cigarette smoking in females. These findings point to the need to focus more on social disadvantaged segments in the population when community based health promotion and disease prevention programs are brought into action.


An occupational health programme for adults and children in the carpet weaving industry, Mirzapur, India: a case study in the informal sector. The Indo-Dutch Environmental and Sanitary Engineering Project under Ganga action Plan in Kanpur and Mirzapur is being executed within the framework of Indo-Dutch bilateral development cooperation. The project aims to integrate technological, social and health related improvements. It is expected that the development approach and methodology can be replicated in other urban settlements in India. The project is being supplemented by a training and institutional strengthening programme, which will facilitate the transfer of new technologies and improvements in operation and maintenance of these new technologies. One of the project's goals is to improve living conditions in the targeted areas by installing drinking water and drainage systems. A socio-economic unit (SEU) in the project supports these technical interventions by encouraging the community to participate in project activities. The Occupational Health Programme in Mirzapur was conceived by the SEU to improve the health and living conditions of child and adult weavers. At the start of the programme, 200 weavers and 60 non-weaver workers from Mirzapur city, matched for age and socio-economic status, were interviewed and underwent a physical examination. The mean age of the weavers is 27 years, reflecting the relatively large percentage of child labour (13.5%). Illiteracy among them is 73%, whereas 14% have had only a primary education. 64.5% of the carpet weavers are Muslims and 35.6% are Hindus. 61% own a loom or work in a family owned loom shed. 95% of the weavers have a monthly income of less than 600 Rs. Complaints of a persistent cough and cough with expectoration, backache, the common cold and joint pains occurred more often in the weaver population than in the comparison group and have been identified as 'occupational hazards'. An intervention programme has been implemented based on the results of the occupational health survey. These interventions include awareness camps, installment of plexiglass tiles for light improvement in the loom sheds, training of community health volunteers and house-to-house health education. Another essential part of the programme is the provision of functional literacy classes for child and adult labourers in the carpet weaving industry. Occupational health as an entry point proved to be a successful approach in this segment of the informal sector, where child labour plays an important role.


The costs of diabetes and its complications. Diabetes mellitus is a disease with major long-term implications, not only for the health and well-being of affected individuals, but also for costs to the National Health Service. Treatment of the disease and its complications takes up 4-5% of total health care expenditure in the U.K. These costs are dominated by in-patient care for the complications arising from diabetes. This paper presents a review of studies which have been carried out on the costs of diabetes and its complications. For such a chronic and potentially disabling disease with numerous complications it is surprising that costs have not been more extensively researched. A large amount of data are available about the implications of diabetes in terms of incidence and prevalence, but few costs have been collected, particularly indirect and marginal costs. Both insulin dependent (IDDM) and non-insulin dependent (NIDDM) diabetic patients exhibit similar complications so that the cost of treatment may be comparable, but further studies are needed to establish this. In addition, few studies have included diabetes as a secondary diagnosis. The studies which are available have tended to focus on direct costs, for example, the costs of hospital care, consultations and drugs, because they are the easiest to measure. Fewer studies have included indirect costs, such as the effect of time lost from work, early retirement and premature death, because of the difficulties in assigning monetary values to these factors. The most important contributors to the costs of diabetes are those of treating complications such as eye and limb disease, heart disease, neuropathy and nephropathy.(ABSTRACT TRUNCATED AT 250 WORDS)


Depression and self-esteem: rapid screening for depression in black, low literacy, hospitalized tuberculosis patients. One hundred black hospitalized tuberculosis (TB) patients (75 males and 25 females) were interviewed to ascertain levels of depression and self-esteem. The standard of literacy for 65% of the sample was such that they were unable to complete a self-report inventory. Reliability (internal consistency) was good for the 21-item Beck Depression Inventory (BDI: r = 0.79), the 13-item shortened BDI (ABDI: r = 0.76) and the Rosenberg Self-Esteem scale (RSE: r = 0.78). There was a significant positive relationship between the BDI and the ABDI (r = 0.92, P = 0.0001). The recommended ABDI cut-off scores established no depression for 32 patients, mild depression for 22 patients, moderate depression for 38 patients and severe depression for 8 patients. There were significant negative relationships between the BDI and the RSE (r = -0.54, P = 0.0001), and between the ABDI and the RSE (r = -0.56, P = 0.0001). Self-esteem scores dropped in accordance with category of depression, revealing that low self-esteem is a characteristic feature of depression. It was concluded that the ABDI was a reliable, rapid, initial screening device for depression in black persons with low literacy levels.


Contributions of the proximate determinants to fertility change in Senegal. The 1978 World Fertility Survey (WFS) and the 1986 Demographic and Health Survey (DHS) data are used to examine the relative contributions of three proximate determinants (nuptiality or marriage, contraception and post-partum infecundability) to fertility change in Senegal. The aim is to identify the important variables that is amenable for policy towards fertility reduction. Analysis shows that there are increases in the absolute measures of all three determinants. The magnitude of change is greatest in contraceptive use, moderate in marriage but least in duration of breast-feeding. However, the index of contraceptive use exerts the least impact on fertility reduction while that of post-partum infecundability makes the strongest impact on fertility. The impact of the nuptiality index on fertility change lies in-between contraception and breast-feeding.


Going to extremes: the cultural context of stress, illness and coping in Antarctica. The question of whether the concept of adaptation remains useful in medical anthropology is examined in the context of the human experience in Antarctica. This experience is characterized by prolonged isolation, confinement, and exposure to extreme environmental conditions. Men and women who winter-over at scientific research stations often exhibit a complex of psychophysiological symptoms in response to these stressors. However, this experience also appears to provide long-term health benefits. It is argued that the psychological symptoms are themselves part of the process of coping and do not necessarily represent an inability to adapt to the extreme environment. Coping is viewed as a process of negotiation leading to a compromise between individual and group needs. The cultural systems of Antarctic research stations are both a product of this negotiation and a set of normative and pragmatic rules regulating this process. Further, this process fosters the acquisition of new strategies or resources for coping with subsequent stressful experiences.


Male and female morbidity in general practice: the nature of sex differences. Outcomes from large scale health surveys suggest women's morbidity and medical care utilization to be higher than men's. Survey findings have often been questioned on methodological grounds, a main criticism being the subjective nature of the data on which the alleged sex differences are based. Moreover, health differences vary with the type of illness (behavior) that is assessed. Instead of asking subjects about their illness experiences, we performed analyses on data derived from a continuous registration of morbidity as presented in four general practices in the Netherlands. Information was obtained on physician diagnoses of 4723 male and 4963 female patients of all ages enlisted in the four practices from 1984 to 1988. To gain insight in the nature of sex differences, four diagnostic categories were distinguished (sex specific conditions, trauma, symptoms without disease, and prevention and diagnostics). Data on mean number of diagnoses, sex ratio's and proportions of overall morbidity are presented for separate age-groups. In addition, the contribution of each diagnostic category to overall female excess morbidity was computed, for age-groups. Results show that over 40% of the significantly higher overall female morbidity is accounted for by gynaecological and obstetrical diagnoses, and more than a quarter could be explained by prevention and diagnostics. In contrast with the often alleged female excess of 'vague' or psychosomatic symptoms, these accounted for less than 20% of the overall sex difference.


Adolescence and health inequalities: extensions to Macintyre and West. The paper investigates class based health inequalities in mid to late adolescence. Health status is assessed by means of three subjective self-report measures; evaluation of general health, psychological well-being and disability/long-standing illness. Using six measures of social class (three occupationally and three non-occupationally based) which derive from parental characteristics, no evidence for consistent class based differentials in health amongst adolescents is found. However, it is not concluded that class based health inequalities are absent at this stage of the life cycle. Instead, it is argued that the above measures of social class differentiate between young people on the basis of the socio-economic status of their parents. As such they fail to allow for the possibility that variations in the current social position of young people themselves may have important consequences for their health. Current social position is assessed in terms of economic activity status, occupation and educational attainment. Using these measures, class based health inequalities are indeed found. Extending the analysis further, the relationship between social class of origin, current social circumstances and self-assessed health status is investigated by considering inter-generational occupational mobility. Again, evidence for class based health inequalities is found.


Health and nutrition effects of cash crop production in developing countries: a comparative analysis. The paper presents results of a comparative analysis of the health and nutritional effects of cash crop production in 6 countries--The Gambia, Guatemala, Kenya, Malawi, the Philippines, and Rwanda. The 6 country case studies were conducted during the same time period and used a similar, although not identical, research protocol. Participation in cash crop schemes resulted in increases in household income. Short-term increases in household income did not result in a decrease in the incidence of illness in preschool-aged children nor in the total time that preschoolers were ill. Increases in household income did result in increases in the preschooler's energy consumption; however, the income/calorie consumption links, although significant, were weak. The household income gains did not have an immediate or large impact on preschooler nutritional status. While, in the longer term, increases in income may bring about improvements in preschooler health, in the short term, it appears that increases in income must be accompanied by improvements in the health environment in order to have a significant effect in reducing preschooler morbidity and improving child nutritional status.


Psychometric investigation of a belief system: caregiving to the chronically ill parent. This research draws on psychometric theory to assess open-ended items and develop reliable measures for investigation of caregiver ideology. Coding criteria used in a qualitative investigation of caregivers' beliefs about filial obligation and parental dependency were transformed into closed-end items and fielded with a large sample. Factor analysis confirmed the dimensions derived from the qualitative inquiry, but also showed that variability on the filial obligation dimension was greater than anticipated. Assessing familial caregivers' beliefs about filial obligation and parental dependency is useful, for these beliefs predict aspects of caregiver satisfaction and burden. Thus, beliefs about one's commitment to render care are not simply a norm divorced from behavior, but rather a cultural model with motivational force.


On the seclusion of psychiatric patients. The seclusion of psychiatric patients is viewed by some as a violation of basic human rights, by others as a necessity for the control of violence, and by still others as a therapeutic modality. The purpose of this paper is to synthesize the findings from the limited and descriptive research on this controversial practice. The major conclusions suggested by the findings are: (1) The reason cited for seclusion is more often agitation than violence, raising questions as to its necessity. The lack of relationship between the reason for seclusion and its duration indicates loose and arbitrary criteria and raises the question of bias. (2) The tendency to seclude on admission suggests failure to follow the legal stipulation that less restrictive measures be employed first. (3) Psychotic, involuntary and younger patients are at higher risk for seclusion than other patients. (4) Incidence and duration of seclusion differ widely across institutions indicating unnecessary and excessive use in some units. Differences may be better explained by hospital factors such as location, staff attitudes and treatment philosophy than by patient characteristics. (5) Systematic studies of the effectiveness of seclusion are lacking, as is research on events transpiring during seclusion. (6) Attitudes of patients and staff toward seclusion differ greatly. Patients' attitudes are generally negative, whereas staff members believe seclusion benefits patients and preserves the unit's smooth functioning. Changes in procedures are suggested to reduce the frequency of seclusion, and to make seclusion more rational, effective and humane. Research and clinical implications are discussed.


A shamanic etiology of affliction from western Nepal. As a central feature of every ceremony, Nepali shamans (jhãkris) publicly recite lengthy oral texts, whose meticulous memorization constitutes the core of shamanic training. These texts include passages that explain the origins of diseases and afflictions, and provide elaborate instructions for their alleviation. Through a discursive analysis of key passages, I demonstrate that shamans possess a coherent etiology of affliction. These concepts are articulated as integrated parts of the treatments that shamans perform. Rather than attributing all afflictions to ambiguous other worldly causes, these shamanic etiologies identify precise sources and effects that cover a spectrum ranging from the purely physical to the purely metaphysical, intersecting the natural and supernatural worlds. Patients and the public are repeatedly instructed in this unambiguous system of affliction in every diagnostic and healing session, since these ceremonies always incorporate recitations of the relevant texts. Accessible to non-specialists, the system conveyed by these recitations acts to validate shamanic intervention as a significant and intelligible activity. Using their oral texts, shamans effectively reproduce worlds that require shamanic interventions.


Alcohol consumption among male reindeer herders of Lappish and Finnish origin. Ethnic differences in alcohol intake among male reindeer herders were studied, since historical evidence suggests that Lapps drink more than Finns and since the considerable freedom of the herding occupation may imply a high risk for alcohol problems. In 1988, 2001 men answered a mail questionnaire including questions on alcohol intake over the past 12 months. The mean alcohol intake was 22.3 g/day among the Lapps and 13.2g/day among the Finns (P less than 0.001). The percentage of heavy drinkers (20 g or more daily) was 33.9 among the Lapps and 19.1 among the Finns. The mean frequency of getting drunk was 35 occasions/year among both Lapps and Finns. An analysis of variance showed that alcohol intake was significantly related to age, marital status, region and being of Lappish origin, but not to being a full-time reindeer herder. A significant interaction between region and marital status was also detected. The Lappish reindeer herders drink more than their Finnish counterparts. The ethnic difference is not, however, very large when compared with the stereotypic view of the drunken Lapp.


Ethics are local: engaging cross-cultural variation in the ethics for clinical research. Relatively little consideration has heretofore been given to the interaction between Western clinical research ethics and non-Western ethical expectations. How should any conflict that might arise when a biomedical investigator and a research subject come from different cultural settings and have different ethical expectations be addressed? Which ethics should govern such trans-cultural clinical research? The answers to these questions are of increasing importance because many countries of the developing world are presently sites of field testing of biomedical agents sponsored and administered by countries of the developed world, especially in the context of the AIDS pandemic. Drawing mainly on examples from Asian medical systems and settings, I elucidate four possible ethical models to guide the conduct of transcultural biomedical research. Two assume that research ethics are culturally relative and two assume that a unified, universalistic conceptualization of research ethics is possible. All four, however, are problematic and are to a large extent deficient. The cause of the deficiencies of these models lies, I argue, in the way that ethics are ordinarily conceived. The proper approach to ethical conflict recognizes that culture shapes (1) the content of ethical precepts, (2) the form of ethical precepts, and (3) the way ethical conflict is handled. Medical ethics may be viewed in cross-cultural perspective as a form of 'local knowledge', and any differences in such knowledge between cultures--since such differences will not conveniently disappear--must be engaged and negotiated.


Culture, meaning and disability: injury prevention campaigns and the production of stigma. The potential production of stigma through health promotion campaigns is a problem that has not received attention in the current literature on the sociology of health promotion. Cultural production studies can shed light onto the ways in which injury prevention campaigns, and public health campaigns more generally, may call for life-saving interventions at the social expense of people with disabilities or other stigmatized conditions. Questioned here are not only the presumed benefits of health promotion campaigns, but also our conventional understandings of 'health' and 'disability'. This paper examines the way in which cultural production studies can contribute to a theory of the production of stigma by public health professionals. One view of cultural production views culture as a reflection of economic relationships between the dominant and the dominated. A second approach emphasizes the 'reception' of cultural works, or how audiences experience culture. Third, cultural production is sometimes analyzed in terms of texts, or the content of cultural artifacts. Insight into the dilemmas of health promotion can be provided by analyzing health promotion strategies in terms of their production, reception, and content as cultural works. Focusing on the case study of injury control and disability rights, health promotion campaigns are seen as potentially contributing to the production of stigma for people who already possess the attributes targeted for prevention. This analysis moves toward a broader theoretical foundation with which to grasp the unintended, even harmful consequences of prevention strategies, and the shared and oppositional interests of people with stigmatized conditions, targeted audiences of prevention, and public health advocates.


The relationship between consumption and worker productivity: nutrition and economic approaches. That better fed, healthier individuals work harder may seem intuitively appealing but there is surprisingly little rigorous evidence to support the hypothesis. There are numerous problems in establishing a causal link between production and consumption due to difficulties in measuring the productivity of workers, misinterpretation of simple correlations between production and consumption, and jointly determined production and consumption variables. The extent to which research findings can be generalized to larger populations often is jeopardized by sample attrition and sample selection. It is the purpose of this article to explain how these empirical and experimental difficulties arise, their implications for research results, how they may be overcome, and to access what is known about the consumption-production relationship. The field of nutrition contributes understanding of the biological relationship between energy intake and energy expenditure, necessary measurement skills, and clinical evidence supporting the consumption-production hypothesis. Economists contribute understanding of the larger social context in which the biological relationship takes place and empirical techniques necessary to overcome measurement and data problems.


On the edge: ward-rounds in a South African psychiatric emergency department. Psychiatry, like other institutions in South Africa, is affected by issues of race. An examination of ward-rounds in a South African psychiatric emergency department, however, revealed that as important to an understanding of this unit is the recognition of the place of psychiatry in biomedicine. A key feature affecting staff in the unit was the fact of psychiatry's marginality relative to general medicine. Race was seldom and obliquely discussed, but played an important contributory role. Work towards the transformation of psychiatric care in a democratic South Africa must consider the institutional level as well as the more obvious question of racial inequality.


Exploratory analysis of children's nutrition programs in Canada. This survey examined the processes by which programs feeding hungry children in Canada are initiated, implemented and sustained. The responses of 32 operators of these programs were obtained by semi-structured telephone interviews and were analysed using qualitative research methods. Concerned citizens within the community and teachers were the major proponents for programs; their primary indicators of need were children's hunger-related behaviours. Programs generally provided the breakfast or lunch meal, were overseen by a board, and were operated by a mix of paid and volunteer staff. A lack of resources, problems with parents and the community, and managerial stresses were the main perceived barriers to program continuance. Programs run by communities generally had more need for resources, expressed lower confidence in their sustainability, and were less likely to cooperate with other groups than school-run programs. While some programs deliberately tried to avoid stigmatization, program operators did hold some prejudicial views about the communities they served and few programs could be considered empowering to users.


Is users' knowledge about contraceptives adequate? A case study of Finnish IUD users. Intrauterine contraceptive devices (IUDs) are popular: in Finland, in 1987, about 25% of women of childbearing age used them. We studied Finnish women's knowledge about contraindications for and side-effects of IUD use, with emphasis on current users. In December 1987-January 1988, a postal questionnaire was sent to a random sample of 1000 women of childbearing age, in Uusimaa province, which includes the capital, Helsinki. After three reminders, the response rate was 84%. We compared the answers of current and past users and nonusers of IUDs, and analyzed the associations between IUD use, education, age, and knowledge about side-effects. In contrast to the recommendations for use and information to be given to the contraceptive users, a substantial proportion of current IUD users assumed there are few limitations for IUD use. Some side-effects possibly leading to severe consequences were not considered to be connected with IUD use, not even by users. Although risk of infection was a quite well known fact, infertility was seldom associated with IUD use, and 22% of current IUD users did not associate ectopic pregnancy with IUDs. The results thus suggest that contraceptive counseling is not fully adequate and should receive more attention.


Accounting for differences. Dutch training nurses and their views on migrant women. Fifteen extended essays about working experiences with migrants, written by district nurses, were analyzed as part of a larger research project on the perception of child rearing practices in and family relations in migrant households. The nurses have all been working in child health centers and intended to improve their expertise in the position of migrant women and the background of child rearing practices in migrant households by means of a graduate project during their training as a district nurse or senior staff member. I was especially interested to learn how the huge amount of literature about the different cultural background of Turkish and Moroccan migrants was used by the nurses to elaborate ideas about the specific problems of migrant mothers and the possibilities of professional support in child rearing affairs. The analysis of the essays revealed that in most essays the concepts of 'ignorance', 'unequal gender relations' and 'isolation' are central in the construction of the category of Turkish and Moroccan mothers as a specific risk or problem group; and that 'cultural differences', 'transiency' and 'deficiency' play an important part in the nurses' 'explanatory model' of the risks and problems in these households. It is argued, that the meaning and interrelationship of the nurses' definitions and explanations of characteristics and problems in migrant households should be understood in the context of (1) the orientalist literature about the population of 'eastern' countries which is recommended in the professional trainings, (2) former and current perceptions of class differences in child rearing practices by professionals and (3) traditional ideas about the position and responsibilities of mothers which dominate in youth health care in the Netherlands.(ABSTRACT TRUNCATED AT 250 WORDS)


Exploration of doctor and patient agendas in general practice consultations. A method for the interactional analysis of doctor/patient consultations is described and applied to six naturally occurring general practice interviews by three raters. The method is reliable given sufficient training and satisfies the stringent criteria for any method of analysis for medical interviews proposed by Wasserman and Inui [1: Wasserman R.C. and Inui R.S. Med. Care 21, 279, 1983].


Influence of bed supply and health care organization on regional and local patterns of diabetes related hospitalization. This paper undertakes both a macro- and micro-scale analysis of the influences exerted by the health care system on patterns of hospitalization. The health disorder of diabetes mellitus is used as the case study and the analyses are based on New Zealand data sets. The article first examines the extent to which both the supply and organization of primary and secondary health care affect rates of hospitalization. The macro-scale analysis investigates the applicability of Roemer's Law to regional variations in diabetes hospitalization. The organizational control of hospital utilization via doctor gatekeeping functions and interaction between health services are then examined at the local level. This analysis assumes a population based approach using the Canterbury Register of Insulin-treated diabetic persons as the study population. Diabetes discharge rates were found to be most highly correlated with hospital bed supply in 5 of the 8 years studied (1979-1986). Stepwise regression analysis indicated area rates of diabetes hospitalization were significantly influenced by resource factors even after controlling for differences in the socio-demographic characteristics of the area populations. This confirmed the presence of Roemer's Law at the aggregate level with rates of diabetes hospitalization appearing to have more to do with the availability of medical resources than to population needs. At the local level, hospital admission patterns were found to vary by general practitioner age, practice type found to vary by general practitioner age, practice type and diabetic caseload. Overall, insulin-treated diabetic patients most likely to be hospitalized were those in the care of young doctors new to general practice, and those who attended doctors who had small diabetic caseloads. Solo practitioners had the lowest rates of patient hospitalization. There were marked disparities in patient access to specialist diabetes education and clinical outpatient services by patient age, duration of diabetes and attendance on primary care. Overall, no significant differences were found in the propensity for hospitalization between users and non-users of these specialist services. This does not imply however, service ineffectiveness but rather is indicative of the complexity of the local diabetes care organization and the differing needs of the insulin-treated diabetic population within the community as a whole.


Church-based obstetric care in a Yoruba community, Nigeria. The analysis of data from available delivery registers in a Yoruba community, Nigeria suggests that about a half of recorded births between 1983 and 1990 were delivered in 'faith clinics' and not in a maternity centre. This paper reports on the mode of operation of these faith clinics in the town. It was observed that the faith clinics were under the control of mission-trained midwives all of whom claimed divine call as the reason for taking up the job. The midwives also listed prayer, fasting and guidance from the Holy Spirit as their main tools of trade. They offered no medicine to their clients and would not recommend any other treatment for them. Pregnant women that come for prenatal care are required to attend weekly prayer meetings for expectant mothers, take weekly baths in a particular river and maintain inward and outward cleanliness in their behaviour. The reasons for the relative success of these midwives in the town are discussed using a combination of economic, symbolic interactionist and pragmatic approaches. Recommendations on how best to tap their resourcefulness for a more effective health services delivery in the area include making them educators on and communicators of modern preventive health.


Marital status and infant health outcomes. Out-of-wedlock status has long been recognized as a demographic risk factor associated with infant mortality and low birthweight. However, the relationship between marital status and birth outcomes varies by maternal race and age. The negative impact of unmarried status is greatest for white women aged 20 and over. High infant mortality rates for married teen mothers challenge the assumption that marriage necessarily provides a protective environment for childbearing. Maternal and child health research and policy have been hindered by a deviance model of out-of-wedlock fertility, which is both biased and outdated. Inconsistencies in the effect of marital status indicate variations in both economic and social resources. Purely behavioral explanations for escalated risks to unmarried mothers are not justified by research findings. Alternative interpretations suggest the need for greater societal involvement in maternal health care created in part by changes in family structure.


Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery. Despite dramatic increases in use of hospital emergency rooms (ERs) since the 1950s, an estimated 85% of ER visits are made for non-life-threatening reasons. Using a modified version of the Andersen and Newman model of health care utilization, this paper reviews the research literature on ER use to examine what is known about factors that influence three stages of the help-seeking process: (1) problem recognition; (2) the decision to seek help; (3) the decision to use the ER. While predisposing factors other than race are not generally significant, enabling factors such as income, insurance coverage, having a usual source of care, and geographic proximity affect use of the ER, both alone and in interaction with race and other factors. The most common reason for non-urgent ER use was 'other care not available'. In addition to the absence of primary care, non-urgent use of the ER is linked to need factors arising from socioeconomic stress, psychiatric co-morbidities, and a lack of social support. Recommendations for future studies include examining prospectively all 3 stages of decision-making leading to ER use, and considering interactive effects among predictors. Implications for service delivery are discussed, including the need to re-structure health care delivery systems to provide greater access to primary care and provide more attention to psychosocial aspects of patient care in clinical settings.


Fertility differentials among the Ijo in southern Nigeria: does urban residence make a difference? The paper tests some of the conflicting hypotheses regarding the effects of urban living and education on fertility by examining the fertility levels of women migrants--some educated, others not--to various urban centers in one Nigerian ethnic group. Of particular interest are the conditions under which the urban residents live and the concept of 'urban' is examined in this West African context. Research methodology consisted of a two-pronged approach and combined an intensive ethnographic study of the families in the rural home community and in one urban center with a demographic survey administered to a larger sample of the rural residents and urban migrants. Analysis indicates that the effect of education on fertility is more powerful than urban or rural residence. The importance of utilizing culturally appropriate categories in demographic research is discussed.


Water sanitation practices on the Texas-Mexico border: implications for physicians on both sides. With the epidemic of cholera in South and Central America and reports of cholera in the Northern Hemisphere in Mexico, increasing concern focuses on sanitation problems along the border between the United States and Mexico. It is feared that binationally shared water supplies are threatened or contaminated by sewage and other wastes. Although much anecdotal information exists, surprisingly few hard data are available in the United States (or in Mexico, for that matter) regarding water quality on the Mexican side of the border. This shortage of data is felt most acutely in the semiarid portions of the border, where water is extraordinarily scarce. In 1987, researchers at the University of Texas School of Public Health (UTSPH) began gathering data on the availability, accessibility, and bacteriologic and chemical safety of raw and finished drinking water in Mexico at its border with Texas. In view of their timely significance, we wish to share pertinent data. This particular study was carried out in Ciudad Juarez, a city of more than 1 million people, situated just across the Rio Grande from the Texas city of El Paso. The investigation was conducted at the invitation and with the assistance of municipal authorities of Cd. Juarez. As far as we know, this was the first time the water in Cd. Juarez had been tested for indicator fecal bacteria and other selected contaminants.


Effect of aeromedical aircraft on care of trauma patients: evaluation using the Revised Trauma Score. Rotor wing aircraft used in transport of the trauma victim have not been subject to objective means of evaluating their contribution to patient care. A retrospective evaluation of a Bell 206 L-1 and an Aerospatiale 365 N-1 using the Revised Trauma Score Triage (RTS) as an indicator of status in 98 patients transported from the scene of injury was conducted. Ground (GT), flight (FT), and total mission (TMT) times, as well as initial RTS, final RTS, and the difference between them (DRTS) were determined for all patients. Statistical analysis was done using two-way ANOVA. GT, FT, and TMT were significantly lower in patients transported by the 365 N-1. In more severely injured patients (RTS < or = 10), DRTS and final RTS were significantly higher in the 365 N-1; FT was significantly less. The contributions of various aeromedical aircraft to the care of the trauma victim may be assessed using objective indices of patient status.


Gunshot wounds of the female breast: a risk for intra-abdominal injury. We report the results of a clinical study of female patients sustaining gunshot wounds to a breast. Thirteen homicides were reviewed by the Fulton County Medical Examiner. A prospective series of patients treated by the Grady Memorial Hospital Trauma Service included eight additional cases. Ten (48%) of the combined series of 21 patients had significant intra-abdominal injury; of these, five (24%) had injuries confined to the abdomen as a result of a missile striking a breast. A wound pattern consisting of a superior breast entrance wound, an inferior breast exit wound, and an inframammary thoracoabdominal reentry wound was noted in five patients, four of whom had intra-abdominal injuries and three only intra-abdominal injuries. Careful examination for this wound pattern should alert the clinician to the possibility of intra-abdominal injury. One should anticipate a 50% incidence of intra-abdominal injury in female patients sustaining gunshot wounds to a breast.


Clindamycin vaginal cream versus oral metronidazole in the treatment of bacterial vaginosis: a prospective double-blind clinical trial. Bacterial vaginosis is common among patients seen by gynecologists. Several types of therapy have been proposed. The purpose of this prospective, randomized, double-blind clinical trial was to examine the efficacy of clindamycin vaginal cream for the treatment of bacterial vaginosis. Sixty patients with symptoms of bacterial vaginosis were randomized into the study, and 46 completed the protocol. Twenty-three patients received 2% clindamycin vaginal cream (5 g applied intravaginally at bedtime for 7 days), with placebo oral tablets twice daily for 7 days. The other 23 patients received oral metronidazole tablets (500 mg twice a day for 7 days) and placebo vaginal cream (5 g intravaginally for 7 days). The cure rates for the two regimens were comparable. Twenty-two (97%) of the patients treated with clindamycin vaginal cream had improvement or cure at the first follow-up visit versus 19 (83%) of those taking metronidazole. There was no statistically significant difference between the two results. Side effects for both regimens were comparable. We conclude that 2% clindamycin vaginal cream offers similar efficacy and safety to standard oral metronidazole therapy for bacterial vaginosis.


Wedge resection for bronchogenic carcinoma in high-risk patients. At the Veterans Administration Medical Center in Washington, DC, 73 patients with bronchogenic carcinoma had pulmonary wedge resection from February 1967 to March 1988, with a 1.4% perioperative mortality and a 4.1% morbidity. Mean age of the patients was 63 years. Patients were considered poor risk with a mean Goldman index of 9 +/- 4 (class II), mean ASA physical status classification II, mean 1-second forced expiratory volume (FEV1) of 1.25 liters (42% predicted), ratio of FEV1 to forced vital capacity 30% predicted, and maximum voluntary ventilation 24% predicted. Staging of the bronchogenic carcinomas indicated 68% stage I, 15% stage II, and 17% stage III, and histology showed 41% epidermoid, 40% adenocarcinoma, 12% bronchoalveolar, 3% large cell, and 4% small cell type. For the 72 patients eligible for follow-up, data were available on 62 for a period ranging from 4 months to 15 years. Survival was 94% at 1 year, 55% at 3 years, 29% at 5 years, 5% at 10 years, and 2% at 15 years. Within 5 years, 21% of the patients had died of causes other than bronchogenic carcinoma. The rate of recurrence was 16%. Analysis by each stage of lung cancer showed local recurrence in 4% of patients with stage I disease, in 9% of those with stage II disease, and in 59% of those with stage III disease. We conclude that wedge resection provided acceptable surgical treatment in a group of high-risk surgical patients.


Hereditary angioedema.

Hereditary angioedema. Hereditary angioedema is a rare disease resulting from a lack of functional C1 esterase inhibitor (C1 INH). Several genetic defects can cause decreased production of the protein or the synthesis of a biologically inactive form. A similar, acquired condition is occasionally seen, associated with malignancies or as an autoimmune process. Disease severity varies greatly among affected individuals. Most patients have cutaneous, laryngeal, or gastrointestinal edema, often in combinations. The symptoms may appear spontaneously or result from a stimulus, usually trauma. When clinical suspicion exists, measurement of the C4 level screens for the disease. An assay showing low serum C1 INH function confirms the diagnosis. When disease severity warrants, symptoms can be controlled with anabolic steroids or antifibrinolytics. Doses should be increased before symptom-provoking events. Emergencies are treated with plasma infusions, fluids, and pain control. Where available, C1 INH concentrate is the treatment of choice. Therapy can usually be monitored by control of symptoms. With appropriate therapy, most cases remain well controlled.


Hypercholesterolemia: case finding in family practice. The recommendations of the expert panel of the National Cholesterol Education Program (NCEP) have been endorsed by national medical organizations as standards for the detection and treatment of hypercholesterolemia, yet information on how these recommendations are being followed in primary care settings is limited. This study was done to determine how family physicians in four primary care clinics associated with a teaching hospital in a large southern city follow the NCEP guidelines. Of the total patient sample (N = 817), about 60% had at least one total serum cholesterol measurement. Patients in the younger age groups were less likely to have a cholesterol determination than older patients. Of those in the "self-pay" category only 33% had a cholesterol determination. Variability by clinic and provider type was also noted, with physician assistants showing the highest compliance with screening guidelines (75%), whereas only 43% of patients seen by family practice residents had a cholesterol measurement. Of patients who should have had a lipoprotein analysis, based on total serum cholesterol and risk factors, only 23% actually had a lipid profile. Our study and other similar ones point out that case finding varies considerably and that efforts to improve case finding need to continue.


Reduction of caregiver stress by respite care: a pilot study. The purpose of this study was to determine whether providing respite care to persons with Alzheimer's disease and other dementias decreased stress and mood disturbances in caregivers. Caregivers of persons receiving respite care (n = 7), and not receiving respite care (n = 8) were tested at entry into the study and at 5 weeks and 10 weeks, using the Profile of Mood States and the Relative's Stress Scale. Using repeated measures analysis of variance, a downward trend for study subjects and an upward trend for controls was found for Relative's Stress Scores. Similar trends were found on the Personal Distress Subscale of the Relative's Stress Scale. No difference occurred in rates of institutionalization between those receiving and not receiving day care. Our study suggests that respite care for demented persons living at home significantly reduces the stress among caregivers.


Physicians' negative perception of sclerotherapy for venous disorders: review of a 7-year experience with modern sclerotherapy. Sclerotherapy is the injection of a sclerosing substance directly into a varicosity or telangiectasia to cause damage, fibrosis, and eventual obliteration of the vessel. Although sclerotherapy has been shown to be effective with a low incidence of side effects, many physicians in the United States are unaware of the technique or view it in a negative way. To better define the extent of physician unfamiliarity or prejudice toward sclerotherapy, we surveyed a local medical community of gynecologists by anonymous written questionnaire. The results indicated that 82% of the responding physicians believed that their knowledge of sclerotherapy was insufficient to advise their patients, leaving patients to learn about sclerotherapy from mass media sources. Sclerotherapy was perceived as only slightly effective therapy for varicose veins and was thought to have a relatively high incidence of side effects. With recent improvements in the technique, our collaborative experience with 3000 patients receiving 50,000 injections over the past 5 years has shown that sclerotherapy is a safe procedure achieving outstanding cosmetic results with concomitant symptomatic relief of painful varicosities and telangiectases. Sclerotherapy, as practiced today, offers an effective, simple, and less costly alternative to surgical stripping for most varicose and telangiectatic veins. The survey data demonstrate the need to educate the American medical community about the technique and merits of modern sclerotherapy so that patients may be properly guided by their physicians to the best sources of care for their aching and unsightly leg veins.


Pharmacologic treatment strategies for the depressed, poorly responsive patient. Treatment-resistant depression implies a failure of response to an ample dose of antidepressant medicine, prescribed over a sufficient length of time. Assessing drug levels in the blood is often helpful in confirming the adequacy of antidepressant dosages. Augmentation of the pharmaceutical activity can be achieved by coadministration of lithium, triiodothyronine, and/or stimulants. Neuroleptics are also prescribed with the antidepressant when psychotic features accompany depression. Such enhancements to drug efficacy are usually an advantage over beginning a new medication because of shorter response time. When a decision is made to change the antidepressant, a structurally different option is more likely to induce a remission than a medication of similar configuration. Electroconvulsive therapy is the most powerful treatment choice for depressed patients, especially when suicidal or psychotic features are present.


Hypercalcemia due to hard water used for home hemodialysis. We have described two patients from the same rural community in Georgia who had hypercalcemia during home hemodialysis. In the first patient the diagnosis was not considered until after the patient complained of the poor taste of her home tap water and of the white residue it left on her cooking utensils; other causes of hypercalcemia had been ruled out. The diagnosis was confirmed when samples of tap water that had passed through the in-line deionizer showed low to high calcium concentrations. Calcium concentrations were high after the deionizer filters had been in place for some time but within the acceptable guidelines for the type of filters used. The second patient, seen shortly after the first, had also received dialysis with hard water and also had hypercalcemia despite the use of an in-line deionizer. These cases suggest that dialysis-induced hypercalcemia can occur during home hemodialysis despite seemingly adequate pretreatment of the water source.


Invasive pituitary adenoma coexisting with infiltrating temporal lobe glioma. We have reported the case of a young man who had the uncommon coexistence of two relatively common intracranial tumors--a pituitary adenoma and a temporal lobe glioma. The pituitary adenoma invaded nerve bundles in the left cavernous sinus, but did not extend into the left temporal lobe, where an anatomically separate oligoastrocytoma was diagnosed at autopsy. Preoperative magnetic resonance imaging may assist in the diagnosis of this and similar uncommon conditions.


Disseminated infection due to Mycobacterium chelonei. We have presented a case of M chelonei subsp abscessus in an immunocompromised patient. The patient was given antimicrobial therapy, to which the organism appeared sensitive for 4 weeks, but he died because of other medical problems. Repeated negative blood cultures for mycobacteria after the initiation of therapy and a careful postmortem examination suggested that the antimicrobial therapy was effective.


Double Meckel's diverticulum.

Double Meckel's diverticulum. We have reported a case of double Meckel's diverticulum associated with volvulus of the small bowel. On extensive review of the literature, we found no other report of such a variant of Meckel's diverticulum.


Recurrent meningitis associated with intragastric migration of a ventriculoperitoneal shunt catheter in a patient with normal-pressure hydrocephalus. A 68-year-old man had ventriculoperitoneal shunt placement for normal-pressure hydrocephalus. Three and a half years later, he had repeated episodes of seizures and ophthalmoplegia. He eventually died of recurrent acute bacterial meningitis. At autopsy the distal segment of the shunt catheter was found inside the stomach, a condition believed to be responsible for the repeated attacks of bacterial meningitis.


Hereditary angioedema associated with pancreatitis. A 44-year-old woman with C1q esterase inhibitor deficiency was seen in consultation for recurrent right upper quadrant abdominal discomfort, nausea, and vomiting. Each of these episodes was accompanied by concomitant peripheral edema. Initial diagnostic efforts were fruitless. In time, intermittent elevations in amylase and lipase developed, and a diagnosis of relapsing pancreatitis was made. We contend that the patient's recurrent acute pancreatitis is associated with her hereditary angioedema. Possible pathogenesis could involve intermittent intrapancreatic edema with partial ductal obstruction or loss of inhibition on the kallikrein-kinin system.


Deceptive liver histology delays diagnosis of cardiac ascites. Cardiac ascites is a rare condition. Diagnosis is aided by liver histology, which characteristically shows diffuse hepatic congestion affecting the centrilobular region. In our case of refractory ascites due to constrictive pericarditis, diagnosis was delayed because centribular hepatic congestion was absent histologically. Contrary to numerous published reports, diffuse hepatic congestion is not uniformly present in cardiac ascites. Constrictive pericarditis is curable and should be considered in all cases of unexplained ascites, regardless of atypical hepatic histology.


Appearance of adherent cells suppressive to erythropoiesis during an early stage of Plasmodium berghei infection in mice. We examined the effect of adherent cells from bone marrow or spleen of mice infected with Plasmodium berghei on dyserythropoiesis. Significant reduction in number of erythroid progenitors (erythroid colony-forming units: CFU-E and erythroid burst-forming units: BFU-E) was observed in bone marrow as early as 1 day after P. berghei infection. When adherent cells were removed from bone marrow or spleen cells of infected mice, the number of CFU-E and BFU-E was clearly increased. Furthermore, addition of adherent cells from infected mice to nonadherent cells from normal mice inhibited erythroid colony formation significantly in a dose-dependent manner. These results suggest that the adherent cells obtained from bone marrow or spleen of mice in the early stage of P. berghei-infection have a suppressive effect on erythropoiesis.


Human behavior in relation to selection of malaria treatment. People in rural areas usually help themselves when malaria attacks by using a drug preparation under the name of "ya-chud" bought from the grocery in the village. The objective of this study was to determine the behavior towards malarial treatment of local inhabitants in two malarious areas in eastern Thailand. Groups of 271 and 131 local inhabitants in villages in Pong Nam Ron and Bo Thong Districts, respectively, aged more than 15 years were interviewed regarding health behavior in seeking care when they became ill with malaria. Forty-two percent of the population at Pong Nam Ron and fifteen percent at Bo Thong went to drug-stores or groceries when they developed minor illness, while 85.2% of the subjects interviewed at Bo Thong went to the local health center. However, when they became severely ill, treatment-seeking patterns were similar in the two study areas. Ninety-four percent of the subjects interviewed at Bo Thong and eighty-seven percent at Pong Nam Ron gave a history of having used ya-chud in the past. On average, a set of ya-chud for malaria infection consists of 3-5 drugs: antimalarial drugs together with others such as analgesic-antipyretics, steroids, anti-histamines, vitamins and antimicrobial agents (tetracycline). The price of one ya-chud varied from 3-9 baht. Such improperly use of antimalarial drugs in malarious areas can result in treatment failure and cause the development of drug resistance, which is a problem in the malaria control program in Thailand.


Anti-tuberculosis programs in Thailand: a cost analysis. The standard regimen, a combination of isoniazid and thiacetazone, which has been used for treatment of tuberculosis (TB) in Thailand for the past 20 years is inexpensive, but possesses a high degree of toxicity and requires 18-24 months of continuous treatment, resulting in poor compliance and a low success rate of treatment. The more efficacious short-course chemotherapy introduced into the National Tuberculosis Program in 1985 is limited by the high costs of drugs. However, the cost of providing care is not limited only to drug costs but also includes other services costs. The present study was undertaken to compare the total provider costs of 3 short-course regimens with that of the standard program in the treatment of newly diagnosed pulmonary TB. Data were collected at 4 zonal TB centers through out Thailand in 1987-1988. Analysis showed that the 3 short-course regimens had lower costs than the standard regimen from the provider perspective. Among these 3 regimens that of isoniazid, rifampicin and pyrazinamide for 2 months, followed by isoniazid and rifampicin twice a week for 4 months had the lowest costs (Baht 1,499). Despite the lowest drug cost (B 431) of the standard regimen, the total provider costs were the highest (B 2,541) due to the highest routine service cost of B 2,066. Thus to determine the cost of a disease requires consideration of both drug costs and also other cost components.


Effect of health education on community participation in control of dengue hemorrhagic fever in an urban area of Thailand. Dengue hemorrhagic fever (DHF), a disease transmitted by Aedes mosquitos, remains a serious public health problem in Thailand. This paper describes the effect of health education efforts on a community-based DHF vector control program in the municipality of Mae Sot District, Tak Province, northern Thailand, from 1988 through 1990. In 1988, public health education on DHF and larval control through mass media, lectures and discussions reduced the Aedes Breteau index from 241 in March to 126 in June 1988. In 1989 and 1990, twice a year house-to-house visits by trained health workers were added to the health education campaigns. Aedes larval indices were decreased far more in the epidemic year of 1990 than in 1989. During this 3-year period, water-storage containers for drinking, washing, bathing and ant-traps were the primary sources of larval habitats, accounting for about 90% of the total breeding places. Reduction of Aedes larvae in these sources was due to various larval control measures. By August 1990 water containers for non-drinking purposes were the remaining important breeding places. The introduction of larvivorous fish may be an effective method of larval control for these containers. Most houses were supplied by public piped water system; however, a shortage of piped water for a period of time resulted in a significant increase in the number of water containers. An adequate water supply to the community should be provided continuously to prevent creation of new breeding places. Modifying behavioral practices to reduce domestic man-made water containers should be encouraged.


A survey of knowledge, attitude and practice of the prevention of dengue hemorrhagic fever in an urban community of Thailand. To evaluate the effect of a health education program on the prevention and control of dengue hemorrhagic fever (DHF) in the municipality of Mae Sot, Tak Province, a survey of adult residents, mainly housewives, was conducted in late April 1990 to assess their knowledge of DHF and practice of preventive methods. A total of 417 respondents from 417 households selected by a systematic-cluster sampling method were interviewed. More than 90% of them knew that the disease is transmitted by Aedes mosquitos and indicated water jars and water retention in the houses as the common breeding places. However, the other two common breeding places, ant-traps and cement baths, were less frequently mentioned. This finding was consistent with the greater proportion of respondents who reported no larval control methods for these two kinds of containers than for the others. Covering water containers was the most common practice to prevent mosquito breeding in drinking-water containers whereas addition of abate (temephos sand granules) or changing stored water frequently was commonly used for non-drinking water storage. Larval control for ant-traps was mainly accomplished by the addition of chemicals, including abate, salt, oil or detergent. Health education efforts in this area could induce the majority of respondents to accept themselves as responsible for the Aedes control program. Health education by health personnel played an important role in disseminating DHF information and prevention methods. Radio and television were the main effective mass media for public health education on DHF in this area.


Intestinal parasitic infections in Likupang, North Sulawesi, Indonesia. A parasitological survey was conducted on the inhabitants of 6 villages of Likupang, Minahasa Peninsula, North Sulawesi, Indonesia, in August 1991. A total of 419 fecal samples were examined by using direct smear, flotation, formalin ether concentration, Harada-Mori culture and agar-plate culture techniques. Five nematode and 7 protozoan parasites were detected, while trematode and cestode infection was not observed. Soil-transmitted nematode infections were predominant. Among the younger inhabitants aged less than 15, positive rates of Ascaris, Trichuris and hookworm infections were almost same, namely 45.7, 45.3 and 47.7%, respectively. Among the elder people aged 15 or more, positive rate of hookworm infection (89.4%) was much higher than Ascaris and Trichuris infections (19.3 and 26.1%, respectively). Village to village differences in parasite prevalence, probably due to socio-economic and sanitary-environmental differences were observed. Both Necator americanus and Ancylostoma duodenale were detected. The agar-plate culture was proved to be an efficient method for detection of hookworm as well as Strongyloides stercoralis.


The effect of repeated chemotherapy on the prevalence and intensity of Ascaris lumbricoides and Trichuris trichiura infection. The prevalence and intensity of intestinal nematode infections were assessed during 3 anthelminthic interventions in an urban community in Malaysia. The prevalence levels of Ascaris lumbricoides at Interventions 1, 2 and 3 were 30.6%, 18.9% and 15.5%, respectively and the mean intensities were 1.9, 0.75 and 0.81 worms per person. For Trichuris trichiura, the prevalence levels at Interventions 1, 2 and 3 were 46.9%, 21.6% and 15.7%, respectively. The mean intensities for T. trichiura at Interventions 1, 2 and 3 were 3.30, 0.92 and 0.07 worms per person. No gender-related prevalence and intensity were observed for the two geohelminths in this community. Prevalences and intensity had convex age profiles. Although repeated chemotherapeutic intervention reduced both prevalence and intensity levels, intensity was a more sensitive indicator than prevalence. The results indicate that age-targetting treatment at school children of 7-12 years of age would be an appropriate strategy for this community.


Nutritional intervention in acute diarrhea: is a lactose-free formula essential? A prospective study was done to determine the incidence of disaccharide intolerance among 3-36 month-old patients with acute watery diarrhea who were on breast feeding and/or lactose-containing formula. The effect of feeding intervention on the outcome was investigated. Significant disaccharide intolerance was defined as one with (1) biochemical derangements: stool pH < 6.0 (Riedel de Haen pH paper) and reducing substances > or = 0.5 mg% (Clinitest) on two consecutive determinations and (2) clinical evidence: high purging rate (> 10 gm/kg/hour) and reappearance of dehydration and/or weight loss while on a lactose containing milk. Seven of 92 patients (7.8%) had biochemical evidence of disaccharide malabsorption on admission. Subsequent monitoring of the study population showed absence of disaccharide intolerance. Despite a lactose containing formula, a significant (p < 0.05) reduction in stool output from the first to the second day (145.85 +/- 130.26 vs 115.43 +/- 95.65 g/kg admission weight) was noted. Likewise, weight gain from admission to discharge (4.56 +/- 3.44%) was observed. The mean total duration of illness (4.75 +/- 2.84 days) was well within the usual course of five to seven days. This study supports the current recommendation of continued breast feeding and/or use of lactose containing formula during acute watery diarrhea.


Risk factors for hepatitis B carrier status among blood donors of the National Blood Center, Thai Red Cross Society. A study of risk factors for hepatitis B carriers among voluntary blood donors of the National Blood Center, Thai Red Cross Society was carried out in a case-control study design during January 1989 to June 1990. Cases were 876 blood donors whose blood identified HBsAg at time of recruitment and continued positive for more than 6 months. Controls were 1,750 blood donors whose blood was free from HBsAg who came for blood donation at the same period as the cases. The ratio of cases:controls = 1:2. Self-administered questionnaires were constructed and pretested before using both cases and controls. The study revealed that the risk factors for hepatitis B among voluntary blood donors were age of less than 30 years old; low socioeconomic status (family income of less than 8,000 Baht/month); single status, especially males; male occupations of students, monks, nongovernment workers compared with government officials; female occupations of laborers, students, nongovernment workers and government officials compared with housewives. Sharing of nail clippers, used blades and tooth brushes among family members are proved to be risk factors, especially among males. In addition, sharing of used blades in barber shops proved to be a risk among males while sharing of nail clippers in beauty salons, history of ear-piercing at department stores or history of caesarean section among females could not be shown to be risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)


Parasitological and histopathological studies on rhesus monkeys infected with Chinese mainland strain of Schistosoma japonicum. Fifteen rhesus monkeys were infected by cutaneous exposure each with 200 or 300 cercariae of Schistosoma japonicum. The dynamic distribution of schistosomula in the skin showed that 77-90% of them were found in the connective tissue, while 10-23% migrated in the hair follicles and sebaceous glands at different time intervals after cercarial penetration. Dead schistosomula recovered from the skin varied from 8.7% to 28.7%. The average rate of adult worm recovery was 74.4% and 61.3% in the 6th and 15th weeks of infection, thereafter the rate decreased to 32.3% and 9.0% in the 19th and 42nd weeks, respectively. The mean length of mature pair-worms was 13.2 +/- 2.3 mm in male and 18.0 +/- 1.9 mm in female 6 weeks of worm age. Afterwards the body length of females and their sexual gland diminished markedly. The mean prepatent period was 35.0 +/- 0.6 days. The average size of mature eggs in the feces was 86.6 +/- 5.4 x 64.3 +/- 3.6 microns, and the peak of eggs passage in the feces occurred between 7th and 15th weeks after infection, later on the number of eggs markedly decreased. Skin reaction to the primary infection was slight. The pathological changes observed in liver were chiefly cellular infiltration of portal spaces and the lesions produced by egg granulomas. The mean volume of single-egg granulomas of the productive stage in liver was 22.7 +/- 10.5 mm3 x 10(-3). The most intensive damages in the gastro-intestinal tract were observed in the large intestine.(ABSTRACT TRUNCATED AT 250 WORDS)


Sensitivity of different isolates of Schistosoma japonicum from China to praziquantel. Groups of C57BL inbred mice infected with each of the 4 different isolates, (Anhui, Hubei, Sichuan and Yunnan) of Schistosoma japonicum from the mainland of China were treated with praziquantel (PZQ) and the parasiticidal effects were compared. Worm reduction rate was recorded to assess systematically the sensitivity of 4 different isolates to PZQ in the mouse. Three dosage-levels of PZQ, ie 150, 230 and 310 mg/kg body weight in single doses were used. The worm development rates of control groups infected with schistosomes from Anhui, Hubei, Sichuan and Yunnan were 75.5, 81.8, 81.5, and 83.0%, respectively. At the dosage-level of 150 mg/kg, the worm reduction rates for the 4 different isolates were 36.0, 33.9, 25.5 and 35.6%, respectively. At the dosage-level of 230 mg/kg, the rates were 47.1, 46.0, 38.1 and 47.7%, while at the dosage-level of 310 mg/kg, they were 59.3, 58.6, 50.8 and 61.7%, respectively. The results indicated that the worm reduction rate of the Sichuan isolate was lower than that of the other three isolates, however, the differences were not statistically significant, suggesting that schistosomes of Anhui, Hubei, Sichuan and Yunnan isolates bear resemblance in drug response.


Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: basic hematological values of thalassemia traits. The present study was conducted in the Outpatient Department (OPD) of Yangon Children's Hospital (YCH) during June to November 1990 to determine the hematological data of 133 Myanmar patients with thalassemia trait who were the parents of patients with known beta-thalassemia major or hemoglobin E (Hb E)/beta-thalassemia. The mean values of hemoglobin (Hb) concentration, packed cell volume (PCV), mean cell hemoglobin (MCH) and mean cell volume (MCV) were significantly lower than normal controls but the mean cell hemoglobin concentration (MCHC) was the same as controls. Increased osmotic resistance tested in 0.36% buffered saline was detected in 81-97% of cases depending on the cut-off point. High levels of Hb A2 (> 3.5%) were found in 93% of cases whereas Hb F was increased (> 0.8%) only in 23% of cases. Although the mean red cell count (RBC) was significantly higher than normal, only 79% of thalassemia traits were detected if the RBC count of > 5.0 x 10(12)/1 was taken as the discrimination limit. Other discrimination functions such as MCH/RBC, MCV/RBC, (MCV)2 x MCH x 0.01 and MCV-(RBC/10(12)/1)-(5 x Hb) - 3.4 or - 8.4 were tested for their utility in diagnosing thalassemia traits. All of them were found not to be superior to each of the simple tests (MCV, MCH, Hb A2 or osmotic fragility) in diagnosing thalassemia traits. The one tube osmotic fragility test is a the suitable test to be used in future thalassemia screening programs in Myanmar.


Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: knowledge, attitudes and practice in relation to thalassemia. A maternal knowledge, attitudes and practice (KAP) study concerning the nature and prevention of thalassemia was carried out at the Yangon Children's Hospital in Myanmar. The KAP information was collected using a pretested schedule. Only 18 to 28% of the mothers knew at least one of the statements: thalassemia is a genetic disorder; both parents of thalassemic children carry abnormal genes; there is a 25% chance of recurrence in each subsequent pregnancy. Eighty-two per cent of the respondents decided not to have a further pregnancy for fear of recurrence and of these 62% were currently practising contraception. Oral contraception was the most commonly used method (56%). The median scores as well as the percent responses in favor of the three attitude scales relating to limiting thalassemic children, prenatal diagnosis and termination of pregnancy were high. Although there is a need to increase the community awareness of thalassemia in Myanmar, there is a possibility that prenatal diagnosis and pregnancy termination will be accepted for the prevention of thalassemia.


Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: cost analysis of the day-care-room services for thalassemia. A cost analysis study for the fiscal year 1989-1990 was conducted in the day care room (DCR) for thalassemia patients at the Yangon Children's Hospital in Myanmar to provide a basis for future cost-effectiveness, cost-benefit and efficiency analyses. Two types of costs, hospital costs and costs borne by the patients' families were studied by reviewing hospital records and by interviewing family members of patients. Of the total cost of DCR services for thalassemia 74 to 75% was contributed by material costs most of which were for imported items. The cost of each transfusion visit and the annual cost per patient were Kyats 166.5 to 173.3 and Kyats 1,108.6 to 1,208.7, respectively. The median cost (range) per treatment visit and the averaged annual median cost (range) borne by the patients' families were Kyats 21 (0-302) and Kyats 107 (0-1,509), respectively.


Are the endemic motor neuron diseases of Guam really disappearing? Death certificates were reviewed to observe trends in the number of persons on Guam reported to have chronic degenerative motor neuron diseases (amyotrophic lateral sclerosis, parkinsonism-dementia or Parkinson's disease) at the time of death. Additional data, including age and race of the deceased and the name of the certifying physician were also collected. The number of persons having been diagnosed with amyotrophic lateral sclerosis is apparently decreasing while their mean age is increasing suggesting that the etiologic agents or factors causing this disease are less prevalent on Guam today than they have been in the past. Trends with regard to parkinsonism-dementia and Parkinson's disease are less clear.


Ivermectin and diethylcarbamazine trials in leaf monkeys (Presbytis cristatus) infected with Wuchereria kalimantani. Clinical trials of Ivermectin in single oral doses of 200, 400, and 1,000 mg/kg body weight or in multiple doses of 200 mg/kg body weight for 5 consecutive days were performed in leaf monkeys (Presbytis cristatus) infected with Wuchereria kalimantani. Optimal microfilaricidal effect occurred at 200 mg/kg body weight. The drug was less effective than diethylcarbamazine in this animal model for human filariasis but had no adverse effects.


Etiology of acute severe lower respiratory tract infection in hospital-based patients. Acute respiratory infections are common childhood illnesses. Most are mild and self-limiting. Five percent are lower respiratory tract diseases and are potentially serious. A prospective study was conducted to ascertain the etiology of community-acquired severe lower respiratory tract infections (LRTI) in hospital based patients. Mycoplasma was the most frequently identified agent (33%). This was followed by viruses (28%) and bacteria (15%). Twenty-four percent of children had no identified causative agent.


Immunological activities of monoclonal IgG1 antibody against Trypanosoma gambiense. The present paper deals with the immune reaction between a monoclonal IgG1 antibody and Trypanosoma gambiense. The aggregation of trypanosomes, immune adherence to macrophages and protection against infection are associated with the antibody. IgG1-mediated clumping of trypanosomes is readily dissociated by the addition of complement. Dissociation of the clumped trypanosomes in the equivalence area released approximately fifty percent of previously bound surface antigens. These antigens were capable of binding again to new IgG1 antibody. Complement deposition rendered bivalent IgG1 antibody in the immune complex functionally univalent. Such an event in the presence of complement is of great advantage to the infected host in killing pathogens in vivo, as it allows more antibodies to attach to surface antigens and subsequently to initiate complement activity.


Course of antibody production by the DIG-ELISA method in neonatally infected and juvenile infected rats after primary infection with Breinlia booliati (Filarioidea: Onchocercidae). The course of antibody production in Wistar neonatal and juvenile rats after primary infection with Breinlia booliati was studied by the DIG-ELISA technique using filter papers impregnated with capillary blood drawn from the infected rat tails at 7, 14, 28, 60 and 90 days post infection. Sera of neonatally infected rats did not react with adult worm antigen until day 7 and the titers of antibody remained at very low levels for the next 7 days. There was little tendency to eliminate the filarial larvae during this time. The antibody levels then rose rapidly throughout the next fortnight and increased to a maximum at day 60 after which the titer leveled out at a constant high value until early patency at day 90. On the other hand, antibodies could be detected in sera of juvenile infected rats as early as day 7 and the levels of antibody rose markedly to a maximum at day 28. During the period from day 60 to day 90 at early patency, the antibodies declined gradually to lower levels. The humoral immune responses of 42 neonatally infected rats and 53 juvenile infected rats of 3 strains (Lewis, Wistar and Sprague Dawley) were tested against soluble B. booliati antigens from both female (1:50) and male (1:10) worm extracts by the DIG-ELISA method. Antibodies were detected in sera from all the microfilaremic and amicrofilaremic rats belonging to neonatally and juvenile infected groups. Sera of clean neonatal rats did not give a positive reaction zone.


Microbial flora in gut of Culex quinquefasciatus breeding in cess pits. The number and types of microorganisms in the gut of Culex quinquefasciatus larvae varied considerably from one site of collection to another. Larval gut, in general, contained enormous number of bacteria, a few fungi and negligible number of actinomycetes which belonged to 15 bacterial, 6 fungal and 4 actinomycete genera, respectively. Bacillus sp., Staphylococcus sp. and Pseudomonas sp. among bacteria, Aspergillus among fungi and Streptomyces sp. among actinomycetes were frequently encountered. Escherichia, Proteus, Aspergillus and Streptomyces were the most abundant genera. Isolates of Bacillus, Pseudomonas, Shigella and Staphylococcus caused 100% mortality during the early instar of larval development. None of the fungal isolates effected 100% mortality while Nocardiopsis sp. among actinomycetes gave 100% mortality. One of the Escherichia isolate suppressed the adult emergence completely while 27 others, belonging to most of the genera found, suppressed significantly. Isolates of Aspergillus, Alternaria and Streptomyces inhibited the emergence of adults completely.


Malacological survey in the Sirikit reservoir, the largest earthfilled dam in Thailand. Ten species of freshwater molluscs were found in a malacological survey in the Sirikit reservoir in 1985. Among these species, Tricula aperta or Neotricula aperta, intermediate host of human schistosomes, Bithynia (Digoniostoma) siamensis goniomphalos and B. (D.) funiculata, the first intermediate host of Opisthorchis viverrini were not found. It is revealed that most of the habitats in the Sirikit reservoir are not suitable for the survival and colonization of molluscs. Thus few species of edible molluscs in small numbers were found, except for Limnoperna siamensis, which were found in large numbers in the reservoir. Although it is not a medically important species, their attaching in large colonies may reduce the volume of water flowing into the power tunnels and obstruct small pipe lines in the dam area. So it is recommended to further study the life cycle of L. siamensis and to determine suitable molluscicides or biological agents to be used in controlling them.


Changes in the prevalence of symptoms of depression and depression across Greece. This paper reports on the regional prevalence of symptoms of depression and clinical depression (current major depressive episodes) in Greece in the years 1978 and 1984. Prevalence rates were estimated from two extensive, nationwide cross-sectional home surveys on psychosocial issues and health, carried out in four geographical areas: the Greater Athens area, the Greater Thessaloniki area, the rest of the urban areas and rural areas. The methodology used, the sampling procedure and the screening instrument (The Center for Epidemiologic Studies-Depression Scale) were the same in both surveys. Within the 6-year period a substantial increase in the prevalence of symptoms of depression in all geographic areas was observed, with the Athenian respondents expressing a higher number of symptoms of depression than their counterparts from the other areas. The prevalence of current major depressive episodes, according to specific criteria matched with criteria from the DSM III R, was increased in 1984 in Athens and in the rural areas only. We suggest that economic instability between 1978 and 1984 probably contributed to the changes in the rates of depressive disorders.


Pathways into sheltered employment.

Pathways into sheltered employment. Work ranks high in the rehabilitation of the mentally ill. Currently sheltered employment is often the only alternative to unemployment. We present a sample of 121 patients working at various facilities for vocational rehabilitation. All of these patients are chronically mentally ill, 77% of them suffering from schizophrenic disorders. With respect to their vocational backgrounds, they represent four groups that had come to the sheltered workplace by various means. One group of young patients had never had gainful employment, a second group had found jobs on the open labour market after onset of their illness, and a third group had been employed both before and after the onset of mental illness. The largest group, however, comprised those patients who had dropped out of normal working life immediately on onset of their illness to work in sheltered employment. The rate of isolation from working life was found to be influenced neither by professional qualification nor by the extent of vocational integration prior to the onset of mental illness. We discuss the consequences of the subjective experience of patients and the opportunities and problems presented in practice by vocational rehabilitation of the chronically mentally ill. A 5-year prospective study on the course of vocational rehabilitation is being designed by our group to provide further information on this subject.


Psychiatric diagnostic profiles in hospitalized adolescent and adult Navajo Indians. Diagnostic profiles of 400 adolescent and 1159 adult Navajo Indians consecutively admitted to a psychiatric unit between 1980 and 1989 are presented in this paper. The major discharge diagnoses for adolescents were as follows: adjustment reaction, mixed, and depression, not otherwise specified (NOS), with females accounting for two-thirds of either diagnosis; schizophrenia, with males accounting for 68% of all diagnoses, and personality disorder, NOS, with no gender differences. The four major discharge diagnoses for adults were schizophrenia and depression, NOS, in which there were no gender differences; alcohol withdrawal, syndrome, in which males accounted for 76% of those discharged; and adjustment reaction, mixed, in which females constituted 60% of those discharged. Over the 10-year period, there was a decrease in adult and an increase in adolescent admissions. During the last 2 years (1988 and 1989) adolescents accounted for almost 30% of all admissions compared with 14% during the first 2 years (1981 and 1982).