DSM-III mental disorders in general medical sector: a follow-up and incidence study over a two-year period. In three general medical settings (general practice, hospital medical wards and emergency rooms) about 20% of the adult attenders had a DSM-III mental disorder, mainly in the area of affective and anxious disorders. Some of these disorders were quite severe. Of those cases reassessed 1 year and 2 years after the first interview, less than a quarter reached a "no-diagnosis status". The chronicity of most cases dependent on the interplay not only of either relapse or duration of the main disorder but also of comorbidity and incidence of new disorders. A high incidence of more transient disorders in subjects who were well at first assessment was also found.


Psychosis in Asian immigrants from the Indian sub-continent: preliminary findings from a follow-up study including a survey of general practitioners. The paper presents preliminary findings from a follow-up study of 86 first-generation immigrants to the United Kingdom from the Indian sub-continent, and a matched indigenous English-born control group. All subjects had originally been seen at the Bethlem Royal and Maudsley Hospitals and had been diagnosed as suffering from a functional psychosis. Attempts to locate the patients 5-20 years later revealed that a significantly higher proportion of the immigrant group could not be traced to a general practitioner within the United Kingdom, or otherwise accounted for. Possible explanations for this finding are advanced; the fact itself has important implications for those concerned with the provision of care and services for mentally ill immigrants in this country.


Prodromal symptoms in manic depressive psychosis. Twenty patients suffering from manic depressive psychosis were interviewed about the prodromes to both manic and depressive episodes. These prodromal periods were compared with a recent control period during which the patient was in remission. It was possible for 85% of patients to identify a depressive prodrome and 75% a manic prodrome. Prodromal periods were characterised by a significant increase in the number and magnitude of symptoms compared with those present during remission. The mean duration of manic prodromes was slightly longer than that of depressive prodromes (28.9 days and 18.8 days respectively). The majority of patients could identify a time sequence to the retainment of insight during their prodromes and could also identify idiosyncratic symptoms.


Cross-national differences in the frequency and outcome of schizophrenia: a comparison of five hypotheses. Measures of morbid risk for schizophrenia derived from the WHO Determinants of Outcome of Severe Mental Disorders Study showed large correlations with the following: an occupational index, a measure of urbanicity, geographical and climatic variables, a dietary measure, and the infant mortality rate. The same variables were also correlated with a measure of outcome derived from the International Pilot Study of Schizophrenia. Nearly all of the correlations were significant. The postulated "explanatory" variables were themselves highly intercorrelated.


Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine. A nerve root impingement within a stenotic neuroforamen is a common sequela of cervical degenerative arthritis and herniated nucleus pulposus. Understanding of the effects of cervical position on foraminal size is important in the assessment of pathology and injury, for selection of a provocative maneuver to elicit symptoms and in selecting a position of immobilization for the management of nerve root impingement syndrome. This biomechanical study of human cadaver cervical spines reports the measured variations in the sizes of neuroforamina as a function of cervical positioning. Five fresh frozen adult human cadaver cervical spines (C2-T1) were tested with combinations of flexion-extension and rotational position. Ten pounds of axial load was applied to simulate a normal loading of a cervical spine. The foramina of C5, C6, and C7 were directly measured using a set of finely graded circular probes. Compared to the foraminal diameter at the neutral position, there were statistically significant reductions in the foramen diameter of 10% and 13%, at 20 degrees and 30 degrees of extension respectively (P < 0.01). Conversely, in flexion, there were statistically significant increase of 8% and 10% at 20 degrees and 30 degrees of flexion respectively (P < 0.01). Though there was a reduction in the foraminal size with ipsilateral 20 degrees rotation, and an increase with contralateral 20 degrees rotation, these changes were not significantly different from the mean of the control. Combinations of flexion or extension position with axial rotation did not significantly change the foraminal size compared to the respective sagittal position with no axial rotation.(ABSTRACT TRUNCATED AT 250 WORDS)


Repair of symptomatic pseudoarthrosis of anterior cervical fusion. Posterior versus anterior repair. Thirty-four patients with symptomatic pseudarthrosis of anterior cervical fusion were treated. There were 16 men and 18 women. Eighteen patients had pseudarthrosis at 1 level; 14 at 2 levels; and 2 at 3 levels, with C5-6 and C6-7 levels most commonly involved. Anterior repair of pseudarthrosis was done in 17 patients, which resulted in 76% radiologic fusion. Of 17 patients repaired posteriorly, 94% achieved radiologic fusion. Average follow-up was 60 months, with a minimum of 24 months. "Excellent" or "Good" results were achieved in 59% of anterior repair and 88% of posterior fusion group. This study demonstrates that posterior cervical fusion is the more effective method for repairing symptomatic pseudarthrosis of anterior cervical fusion.


Electromyographic detection of paraspinal muscle metastasis. Correlation with magnetic resonance imaging. Electromyographic (EMG) examination demonstrating marked segmental compromise of the posterior primary ramus distal to the spinal root with relative sparing of the anterior ramus may be the earliest objective evidence of paraspinal muscle metastasis. Antecedent studies are often initially normal, failing to disclose the underlying cause of back pain. Although paraspinal muscle metastasis has been histopathologically demonstrated at postmortem, attempts to image the suspected malignancy with computed tomography have been unsuccessful because the tumor in muscle remains isodense. This study reports the use of magnetic resonance imaging (MRI) to substantiate the existence of EMG-suspected paraspinal muscle metastasis. An EMG pattern of segmental posterior primary ramus denervation is not pathognomonic of metastasis. A confirmatory MRI, however, does permit earlier treatment with palliative radiation therapy.


Effects of distraction on physiologic integrity of the spinal cord, spinal cord blood flow, and clinical status. The authors determined the effects of distraction of the spine on physiologic integrity of the spinal cord using neurogenic motor evoked potentials (NMEPs), somatosensory evoked potentials (SEPs), spinal cord blood flow measurements, and clinical status in nine hogs. Spinal cord blood flow was measured after each level of distraction using the hydrogen washout technique. The results indicated that blood flow of at least 65% of baseline was required to maintain physiologic integrity of the spinal cord, and that a decrease of blood flow to 12% of baseline was associated with paraplegia. Neurogenic motor evoked potentials always correlated with the animal's postsurgical clinical status, whereas the SEP was falsely negative in one animal.


Choosing fusion levels in progressive thoracic idiopathic scoliosis. The selection of fusion levels in thoracic idiopathic scoliosis was subjected to multicenter retrospective review to test the validity of the classification system and recommendations of King et al. The 253 patients reviewed were treated by posterior fusion and Harrington instrumentation. Bending films were of little help in selecting fusion levels. Standing radiographs alone were usually adequate. King Type II curves may yield better lumbar correction if the lumbar curve is partially included in the fusion. Type IV curves may be safely fused one level proximal to the stable vertebrae.


Chiba Spinal System in the operative management of scoliosis. The Chiba Spinal System was developed for three-dimensional correction of scoliosis. The system consists of a 7-mm diameter smooth solid rod, closed and open hooks, and specially designed conical sleeves. The rod does not have ratchets or threads, thus minimizing stress concentrations. The closed and open hooks are attached to the rod using the conical sleeves. The sleeves have longitudinal slits permitting compression during insertion. The outrigger system with a torque wrench is used to correct the deformity in the frontal plane. When correcting lordosis with vertebral rotation, a sagittal correction device may be used. Fifty-two patients with idiopathic scoliosis were operated on with this system from 1986 through 1989. The average correction of the scoliosis was 58%. For the 21 patients with thoracic lordosis less than 0 degrees, the mean preoperative lordosis was -8 degrees, which was corrected to +7 degrees. The mean correction of the vertebral rotation was 24%. Two patients complained of paresthesia of the thoracic region after operation, but this disappeared within 2 weeks. In 32 patients with more than 2 years' follow-up, the mean loss of correction was 3 degrees. One case with instrumentation failure was noted.


The variability of response of scoliotic spines to segmental spinal instrumentation. Ninety-two patients (71 idiopathic, 15 neurogenic, 2 Marfan's syndrome, 1 Down's syndrome, 1 osteogenesis imperfecta, 1 Prader-Willi syndrome, 1 Klippel-Trenaunay-Weber syndrome), ages 9-49 years, had posterior spine fusion and stabilization with Luque L-rods and sublaminar segmental wires (SSI) for progressive scoliosis. There were no neurologic complications. The average preoperative major curve of 52 degrees (37-113 degrees) initially corrected to 30 degrees (6-94 degrees), and at last follow-up (range, 2-7 years), was 33 degrees (8-90 degrees). There was marked variability in curvature correction and maintenance of correction, with 14 patients progressively decreasing their curvatures postoperatively. Average preoperative Pedriolle vertebral rotation angle for all 92 patients was 16 degrees (4-26 degrees), which initially corrected to 14 degrees (0-24 degrees), and at last follow-up remained 14 degrees (0-23 degrees). Although SSI had little influence on rotation, 12 patients progressively decreased their rotational deformity after operation. Aside from the positive influence of curve flexibility on the degree of postoperative curve correction, the authors could not identify factors explaining how curvature and vertebral rotation responded so variably to SSI. The authors recommend continued use of SSI to stabilize curvatures in osteopenic patients (particularly those with neuromuscular disease), but rotational deformity will probably persist.


In vivo analysis of canine intervertebral and facet motion. Using an instrumented spatial linkage, a method for measuring intervertebral motion in vivo was developed and used on six dogs. The segmental motion was recorded as the animals were exercised in routine functions. The standing posture was found to be a repeatable position. During walking, the average excursion between opposing facets was 3.4 +/- 1.3 mm, as the L2-L3 motion segment moved into 2.3 degrees of kyphosis with respect to the standing position. This method has the ability of measuring facet motion (+/- 0.7 mm), vertebral body motion (+/- 0.5 mm), and vertebral body rotations (+/- 0.6 degrees) with suitable accuracy such that it is a useful tool in documenting the in vivo response of a motion segment to surgical procedures.


The influence of lordosis on axial trunk torque and trunk muscle myoelectric activity. Force contributions from the facet complex and posterior ligaments during the generation of axial torque are a function of lordosis, and it has been speculated that these forces together with muscular contributions play a role in axial trunk twisting. This study investigated the electromyographic activity of the trunk musculature and torque-generating capacity of the lumbar spine under the conditions of normal lordosis, hyperlordosis, and hypolordosis. Eleven male subjects volunteered for this study. The subjects performed isometric twisting efforts and maximum dynamic twisting efforts at 30 degrees/sec. The myoelectric activity levels (normalized to maximal amplitude obtained from nontwist activities) were quite low despite maximal efforts to generate axial torque (for example: approximately 60% maximum voluntary contraction for latissimus dorsi and even lower for the abdominals). Furthermore, changes in lordosis did not produce any consistent changes in muscle activity, although a hyperlordotic spine produced significantly smaller axial torques, and a hypolordotic spine smaller still. Larger torques were measured during all three conditions of lordosis, as the subjects rotated toward an untwisted position, and lower torques as the subjects rotated away. The opposite trend was observed, however, in myoelectric activity of the agonistic side of latissimus dorsi, the thoracic level of erector spine, and the lumbar level of erector spinae, i.e., larger amplitudes were observed as the trunk was twisted away from the untwisted position. These data suggest that tissues other than muscle (i.e., passive tissue) contribute significantly to axial torque production and that the flexed and twisted spine is less able to resist applied axial torques, possibly increasing the risk of torsional injury.


Magnetic resonance signal patterns of lumbar discs in patients with low back pain. A prospective study with discographic correlation. This study presents a large prospective analysis of abnormal magnetic resonance signal patterns in 1,389 lumbar discs in 892 patients with chronic low back pain. Discographic correlations were available at 166 disc levels. Six different signal patterns were identified, and correlations with discograms would suggest that these patterns reflect the differing and progressive changes of lumbar disc degeneration that occur in vivo in patients with low back pain.


The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. The purpose of this study was to assess the natural history of sciatica due to lumbosacral nerve root compromise and to evaluate the pathomorphologic changes that accompany the natural resolution of the disease. One hundred sixty-five consecutive patients, 114 males and 51 females, with an average age of 41 years (range, 17-72) and an average duration of symptoms of 4.2 months (range, 1-72) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study. The cornerstone of treatment was the serial epidural administration of steroid and local anesthetic by the caudal route on an outpatient basis. Lumbar epidural injection or periradicular infiltration at the appropriate level, confirmed under image intensifier, was the next step before considering surgical decompression. An average of three injections (range, 0-8) was received by each patient. Patients underwent clinical examination and computed tomography. Twenty-three patients (14%) underwent surgical decompression. The remainder were clinically assessed at 1 year after presentation, and 111 were rescanned at the appropriate levels. All conservatively managed patients made a satisfactory clinical recovery: average reduction of pain on the visual analog scale was 94% (range, 45-100), and 64 (76%) of the 84 disc herniations and 7 (26%) of the 27 disc bulges showed partial or complete resolution (chi-square = 20.27, P = 0.0001). Thus a high proportion of patients with discogenic sciatica make a satisfactory recovery with aggressive conservative management, and this recovery is accompanied by resolution of disc herniations in a significant number. Only a small proportion of patients needed surgical decompression.


Stenosis of the lumbar spinal canal in vertebral ankylosing hyperostosis. Certain morphologic features frequently observed in radiography or computed tomography (CT) scan in patients with hyperostosis led us to study the association between a narrowed spinal canal and vertebral hyperostosis. Twenty-eight items were selected and studied by three different investigators (two rheumatologists and one radiologist) in radiographs and CT scans of 100 patients with acquired stenosis of the lumbar canal, with or without hyperostosis (46 and 54 cases, respectively). The most distinctive points that we suggest can be used as diagnostic criteria of the hyperostotic narrowed lumbar canal are anterior or posterior lateral marginal somatic osseous proliferations, proliferations of the nonarticular aspects of the posterior apophyses, and ossifications of the posterior articular capsule and of the ligaments (yellow ligament, posterior longitudinal ligament, and the supraspinal ligament). Four of these six criteria should be present to establish the diagnosis of hyperostotic lumbar stenosis. The appearance of lumbar hyperostosis on X-ray or CT scans differs from that of simple degenerative changes due to arthrosis, and the hyperostosis can be held responsible for dural compression.


Decoupling of bilateral paraspinal excitation in subjects with low back pain. This study compared bilateral paraspinal excitation in normal subjects and subjects with low back pain. Comparison was made between six control subjects and seven low back pain subjects who performed maximum-effort isometric trunk extension in minimum elapsed time at two trunk angles. Electromyographic signals were collected bilaterally from the paraspinal musculature. The time- and amplitude-normalized electromyographic data were analyzed using a repeatability criterion sensitive to temporal and amplitude differences. This analysis showed that low back pain subjects demonstrated temporal and amplitude decoupling of the paraspinal musculature bilaterally. Low back pain subjects also demonstrated clinically meaningful disruptions between paraspinal excitation and isometric trunk extension moment. This method may be useful in quantifying neuromotor control in low back pain for initial and follow-up clinical evaluation for static and dynamic functional tests.


Cost-effectiveness of a back school intervention for municipal employees. This study investigated the effect of a back school rehabilitation program on lost work time, lost time cost, medical cost, and number of injuries in municipal employees. Seventy back-injured workers who participated in a 6-week back school were compared on the dependent variables with 70 randomly selected back-injured city employees who had not participated in a back school. Back school participants demonstrated a significant decrease on all dependent variables. Back school participants had significantly fewer injuries in the 6-month postintervention period. No statistically significant differences were found between groups on the time and cost variables. Actual dollars saved in lost time and medical costs between groups was of practical value to the city. Study findings offer support for the back school as a cost-effective measure.


Intraoperative evoked EMG monitoring in an animal model. A new technique for evaluating pedicle screw placement. An electric drill was used to introduce holes in the L4 through L7 pedicles in pigs. Constant-voltage stimulating pulses (5.5 V, stimulus rate = 3/sec) were delivered through a ball-tipped probe used to palpate the walls of each pedicle, and observation was made of electromyogram (EMG) evoked from hind limb muscles. Screws were placed in each pedicle hole, and evaluated for absolute voltage necessary to evoke EMG (threshold). At the conclusion of each experiment, screw positions were ascertained by removal and dissection of the lumbosacral spine. Approximately 50% of screw placements resulted in defects of the pedicle. In each of these cases, 5.5 V stimuli delivered through the probe evoked EMG from muscles innervated by adjacent motor axons. Conversely, for those cases where the pedicle was intact, significantly higher voltages were needed to evoke EMG. The authors believe that this is a promising intraoperative technique to simply and reliably identify mispositioned screws, thereby minimizing neurologic complications.


Surgical pathology of the intervertebral disc. Is routine examination necessary? A retrospective review of 508 charts of patients undergoing laminectomy for all reasons was carried out with special attention to the preoperative diagnosis, postoperative diagnosis, pathologic diagnosis, and discharge diagnosis. The elimination of routine pathologic examination of surgical discectomy specimens would not have lowered the standard of care; the pathologist's report had no discernible influence on patient management. Unusual clinical features will continue to require careful examination of surgical specimens by the pathologist. Millions of healthcare dollars can be saved by eliminating this routine examination, which is based on outmoded routines. Hospital medical staffs who wish to change this practice must revise their hospital bylaws in keeping with the standards of the The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).


Restriction of indication for automated percutaneous lumbar discectomy based on computed tomographic discography. This report details the authors' early experience using the automated percutaneous lumbar discectomy (APLD) procedure, developed by Onik et al., in 97 patients with a disc protrusion. In the evaluation of a herniated disc, we used computed tomography (CT) discography. According to the distribution of the dye inside the disc, five different disc types can be differentiated. With a follow-up after 3-7 months, the short-term outcomes of the first 40 APLD-treated patients varied, depending on the shape of the protruded nuclear material. Patients with a broad dye base on CT discography had better short-term outcomes than patients with a narrow dye base. In the next 57 patients we treated with APLD, this tendency was confirmed. The success rate of a consecutive group of patients with a disc protrusion with a broad dye base, treated with APLD, was 80%. In comparison, the patients with a disc protrusion with a narrow dye base had an overall success rate of only 53%. The difference is statistically significant (P < 0.05). The message of this report is that APLD is a useful invasive treatment for patients with a disc protrusion. The outcome depends, however, on the shape of the protruded nuclear material as shown by CT discography, which makes this examination as a conditio sine qua non before treating patients with a disc protrusion with APLD.


Unilateral facet dislocation of the lumbosacral junction. Fracture-dislocation of the lumbosacral junction is an extremely rare injury. The authors are aware of only 24 reported cases. Only seven of these were unilateral facet dislocations. In this report, the authors review their experience with four cases of unilateral facet dislocations at the lumbosacral junction. In one of these cases, there was a pre-existing spondylolysis at L5, and the patient sustained a concomitant sacral fracture. From their review, the authors recommend the use of open reduction with internal fixation and lumbosacral fusion as the treatment of choice for this injury.


Case report. Pelvic rib/digit.

Case report. Pelvic rib/digit. In summary, a case of a pelvic rib/digit is presented. Although there is no surgical proof that the finding does indeed represent a sacral rib, its radiographic findings are characteristic enough to warrant this diagnosis. In some respects, the lesion is similar to other cases that have appeared in the literature, but it differs in that it has features of both a pelvic rib and pelvic digit, suggesting a spectrum of development of these anomalous bony structures.


Illness as a lifestyle. The role of somatization in medical practice. Persons with psychological problems who translate their distress into somatic symptoms (somatize) are frequent users of medical care. These patients often have underlying depression, anxiety, obsessive--compulsive symptoms, or personality disorders. Descriptions of the somatizing syndromes are provided in association with recommendations as how to recognize and manage the patient with somatization.


A taxonomy of chronic pain syndromes.

A taxonomy of chronic pain syndromes. This article has had as its purpose the delineation of the complexity of the production of pain on an organic basis as opposed to any psychological amplification. The issues addressed apply directly to the problem of spinal pain. Classical nociception arising in the structures of the spine thus would include the application of mechanical and chemical stimuli to muscles, ligaments, apophyseal joint capsules, bone, and other structures with adequate innervation, particularly the anterior dura and its extensions. Disease and injury productive of direct nociception are well understood sources of spinal pain. Less well understood, but of at least equal importance in the spinal pain problem, are the activities within the central nervous system that control the transfer of nociceptive information to the higher centers. These activities account for some of the variability known to occur in the experience of pain. Further, the fact that the nervous system changes its activities in response to chronic pain, particularly that arising from damaged neural elements, is of paramount importance in understanding how chronic pain syndromes differ so greatly from simple nociceptive events. Insidious deafferentation ongoing in spinal nerve roots subject to chronic compression and fibrosis offers a fertile field for research into the origin of permanent pain in patients in whom application of accepted therapies does not result in relief. All of this material must be considered by the clinician who is challenged with analyzing spinal pain problems in patients.


Chronic cervical pain: radiculopathy or brachialgia. Noninterventional treatment. Chronic cervical pain is not always attributable to radiculopathy. Pain may derive from peripheral myofascial syndromes and/or central inflammatory root irritation from degradation of discal proteoglycans. This concept is presented with its application in 30 patients with follow-up observations up to 30 months. Twelve of twenty-five achieving a pain level of 0 (out of a possible 10), ten of twenty-five had a pain level of 2, and three of twenty-five had a pain level of 4. Five cases were considered to be failures because of patient noncompliance. Treatment was multidisciplinary: aggressive physical medicine, behavioral medicine, vocational, and recreational rehabilitation with the goal of a return to socioeconomic productivity or previous lifestyle, secondary to which pain relief or control follows. Emphasis was placed on the restoration of musculoskeletal physiology to normal with behavioral modification, good body mechanics and the application of engineering/ergonomic principles at work or recreation.


Study of experimental cervical spondylotic myelopathy. Most cervical spondylotic myelopathy cases show insidious onset. Experimental cervical spondylotic myelopathy models were made using cats to analyze advancing patterns of myelopathy in the spinal cord and to identify the most responsible factor. Spinal cord compression was applied anteriorly using one screw through the C5 vertebral body or three screws through the C4, C5, and C6 vertebral bodies. Every few weeks, the screws were turned approximately 1 mm at a time up to approximately 50% of the spinal canal. At more than 6 months after final compression, limb function and evoked spinal cord potentials were evaluated. Thereafter, histologic examinations were performed. the single compression group showed normal limb function, but the multiple compression group showed sluggish gait. Histologically, mild neuronal decrease in the gray matter was noticeable in the single compression group. Conversely, the multiple compression group showed severe changes in the gray matter and significant changes in the posterior and anterior columns. There was a correlation between the evoked spinal cord potentials and histologic changes. It was clear that multiple compressions to the spinal cord caused more severe deterioration functionally and electrophysiologically as well as histologically than a single compression.


Preoperative and postoperative magnetic resonance image evaluations of the spinal cord in cervical myelopathy. To evaluate the morphologic changes of the spinal cord in patients with cervical myelopathy due to cervical spondylosis and ossification of the posterior longitudinal ligament, the authors measured the thickness and signal intensity of the cervical cord with magnetic resonance imaging in healthy adults and patients with cervical myelopathy, and compared these findings. In patients with cervical myelopathy, the preoperative and postoperative magnetic resonance imaging findings were compared with the severity of myelopathy and postoperative results. In healthy adults, the anteroposterior diameter of the cervical cord was 7.8 mm at the C3 level and decreased at lower levels. In the patients with cervical myelopathy, the preoperative spinal anteroposterior diameter was significantly reduced at various levels corresponding to the stenosis site within the vertebral canal. In the group with ossification of the posterior longitudinal ligament, the minimal anteroposterior diameter of the cervical cord tended to decrease with increasing severity of myelopathy. However no relationship was observed between the two parameters in the cervical spondylotic myelopathy group. In the group with ossification of the posterior longitudinal ligament, surgical results were good when the postoperative anteroposterior diameter was increased, whereas in the cervical spondylotic myelopathy group there was no relationship between the two parameters. In the patients with myelopathy, a high intensity area was observed in about 40% of all patients before operation and about 30% after operation. However, the presence or absence of a high intensity area did not correlate with the severity of myelopathy or with surgical results in the group with ossification of the posterior longitudinal ligament and the cervical spondylotic myelopathy groups.


Age and gender related normal motion of the cervical spine. The purpose of this study was to develop a clinical method for measuring three-dimensional motion of the cervical spine using the CA 6000 Spine Motion Analyzer (Orthopaedic Systems Inc., Hayward CA). Normal values for passive examinations of flexion-extension, lateral bending, rotation, rotation out of maximum flexion, and rotation out of maximum extension were obtained and analyzed for each gender in a group of 150 normal subjects. Gender classifications were further subdivided into age groups, with each decade containing asymptomatic volunteers. Values for each group were compared for differences with respect to age and gender differences. A detailed error analysis was also performed on the interobserver and intraobserver repeatability, differences between passive and active testing, and the use of different fixation devices. Significantly decreased motion differences were found between age groups within gender, and between gender groups in corresponding decades. Results of rotation out of maximum flexion suggest and support earlier conclusions that the rotation of the C1-C2 segment does not decrease with age, but rather increases slightly to perhaps compensate for the overall decreased motion in the lower segments.


Benign tumors of the cervical spine.

Benign tumors of the cervical spine. Benign tumors of the cervical spine are relatively infrequent but have a number of common characteristics that aid in the evaluation and treatment of these lesions. The tumors are most common in the first and second decades of life, presenting as pain, neck stiffness and torticollis. In approximately 70%, the lesions are visible on plain roentgenograms and the remainder are well visualized on bone scan and computed tomographic scan. The majority are present in the posterior elements and may be treated adequately with excisional biopsy by curettage. Stage 3 lesions are best treated by marginal excisional techniques and may require adjunctive techniques such as embolization or radiation therapy. The location of the lesion and extent of excision determine the necessity for fusion.


Metastatic malignancy of the cervical spine. A nonoperative history. Of 48 patients with spinal metastases treated at the Kenneth J. Norris Cancer Center at The University of Southern California Medical Center in Los Angeles, California between 1984 and 1987, 19 consecutive patients with cervical metastatic disease were identified and followed until death or remission. Prostate, breast, and lung neoplasms accounted for 57% of the cervical metastases. Associated nonspinal skeletal, extraskeletal, or multiple-level spinal metastases were seen in 95% of patients. Mean time from diagnosis of primary tumor to cervical metastasis was 29 months and mean survival after that was 14.7 months. Pain was the initial symptom in 89% of cases. No patient had neurologic deficit and three (16%) had slight radiographic collapse and deformity. Only one (5%) patient had documented instability. All patients had nonoperative treatment with radiotherapy, chemotherapy, or a combination. Irrespective, the pain recurred in all patients by 6 months. Nonoperative treatment may be appropriate in the absence of significant neurologic deficit or instability. The return of symptoms by 6 months warrants alternative modes of therapy.


The force exerted by the halo pin. A study comparing different halo systems. Seven different halo systems were evaluated biomechanically to compare the force exerted by the halo pin in each system. In three different experiments torque values of 2, 4, 6, 7, and 8 in lb were applied to the halo pin, and the force at the skull end of the halo pin was measured using a load cell. In the first experiment, the threads on the halo pin were dry, in the second experiment saline was applied to the threads on the pin, and in the third experiment cadaveric bone from the skull was interposed between the pin and the load cell. The results showed that for a given value of applied torque to the pin, the force exerted by the pin end varied widely according to the halo system and whether or not the pin was "lubricated."


Anterior cervical discectomy and fusion. A comparison of techniques in an animal model. An animal model for three-level anterior cervical discectomy and fusion was established in the goat. Twenty-one goats underwent surgery, with seven goats in each of three experimental groups. In Group I, all seven goats underwent three-level anterior cervical discectomy without fusion. In Group II, each of the seven goats had a three-level discectomy with autogenous bone performed according to the Smith-Robinson technique. In Group III, fresh-frozen allograft bone was used for each of the three-level discectomy and fusion. Each goat was then killed after 12 weeks. Analysis consisted of radiographic review, fluorochrome labeling, biomechanical rigidity and flexion and extension, axial compressive load, and torsion. Histologic analysis was also performed for evidence of fusion and vertebral body histomorphometric analysis. The analysis of results showed that radiographic union was judged to have occurred in 0 of 21 Group I disc spaces, 10 of 21 Group II disc spaces, and 8 of 21 Group III disc spaces. Histologic fusion was judged to have occurred in 0 of 21 Group I goats, 10 of 21 Group II goats, and 0 of 21 Group III goats. The histologic fusion rate was significantly higher in Group II than either Group I or Group III. Biomechanically, the spines that had autogenous bone grafting (Group II) were significantly stiffer in compressive axial load and in extension. Both Group II and Group III were stiffer in flexion than Group I. An evaluation of the peri-endplate vascularity showed that the vascularity measured 10.4% in Group I, 16.7% in Group II, and 8.5% in Group III.(ABSTRACT TRUNCATED AT 250 WORDS)


Modified Smith-Robinson procedure for anterior cervical discectomy and fusion. Fifty-one consecutive patients with cervical radiculopathy or spondylosis were treated with single or multilevel anterior discectomy and fusion using a modified Smith-Robinson procedure. There were 33 single-level fusions, 16 two-level fusions, and 2 three-level fusions. The three modifications included: 1) the endplates at the fusion level were completely removed with a high-speed bur to exposed bleeding cancellous bone in parallel planes; 2) the Caspar distractor (Aesculap, Burlingame, CA) was used to increase distraction and improve visualization; 3) the tricortical autologous iliac crest bone graft was placed in reverse position, that is, with the cortical cross-section facing posteriorly, creating a stabilizing strut in the middle column. With an average follow-up of 1 year, the fusion rate was 94% (67 of 71 levels). The single-level fusion rate was 97%, the two-level fusion rate was 94%, and the three-level fusion rate was 83%. Of the four nonunions, only two were symptomatic. Results by clinical examination revealed 36 (71%) excellent, 11 (21%) good, 3 (6%) satisfactory, and 1 (2%) poor outcomes. There were no significant disc collapses or extrusions. One patient had an increase in kyphotic deformity of > 5 degrees, none with > 10 degrees kyphosis. There were no wound infections or neurologic complications. The modified Smith-Robinson procedure for anterior cervical discectomy and fusion has led to the successful treatment of cervical radiculopathy and spondylosis with improved results and few complications.


Anterior decompression, structural bone grafting, and Caspar plate stabilization for unstable cervical spine fractures and/or dislocations. Fourteen patients who sustained acute cervical spine fractures and/or dislocations with associated posterior ligamentous disruption had anterior decompressions, structural bone grafting, and anterior Caspar plate stabilization. With an average 30-month follow-up, no patient has had loss of fixation. Despite criticism raised from biomechanical testing, the Caspar anterior plate system (Aesculape, Tuttlingen, Germany) may be added to structural bone grafting of unstable cervical fractures and/or dislocations, yielding an in vivo solid construct, which obviates the need for simultaneous posterior stabilization.


Spontaneous fracture of the odontoid process in rheumatoid arthritis. Six cases of spontaneous fracture of the odontoid process in rheumatoid arthritis are presented. Fifty-one patients with atlantoaxial subluxation in rheumatoid arthritis underwent surgery between 1981 and 1990. This included six patients (in 10%) who had subluxation accompanied by fracture of the odontoid without apparent trauma. The mean patient age was 58 years and all had a long history of rheumatoid arthritis. No trauma was considered to be the cause of the fracture. This is a fracture caused by erosion and osteoporosis of the odontoid process due to rheumatoid synovitis, aging and steroid therapy. In addition, another cause is a dynamic load produced from the instability accompanying atlantoaxial subluxation working on the odontoid in cervical extension. It is important remember that the odontoid process is susceptible to spontaneous fracture.


Treatment of lower cervical spinal injuries--C3 to C7. Injuries of the lower cervical spine are categorized according to the morbid anatomy of the lesion. Most often, such injuries are successfully treated by surgery through a posterior approach. After anatomic restoration, internal fixation with plates and screws provides for stability and arthrodesis. Of 221 cases of lower cervical spine injuries, posterior stabilization was accomplished in 89%. There was no secondary displacement in 85% of cases.


Management of fracture separations of the articular mass using posterior cervical plating. Fracture separations of the articular mass are a specific group of unilateral facet fractures that must be considered separately because of their unique two-level instability. This fracture pattern involves a longitudinal fracture of the lamina and a fracture of the pedicle on the same side of the spine at the same level. It is characterized roentgenographically by horizontalization of the lateral mass, with a mean translation of 4.6 mm and a mean angulation of 6.9 degrees. In this study the deformity most commonly occurs at the level below the fracture (19 patients) but also occurred at the level above (5 patients). There is a high incidence of neurologic involvement (14 of 24 patients), most often radicular in nature. This injury results in two level instability requiring a three-level, two-interspace stabilization. All twenty-four patients in this series underwent posterior cervical plating with either an asymmetric (8), symmetric (9) or porte manteau (7) construct. Statistically significantly better results (P < 0.05) were achieved with either a symmetric or porte manteau construct. Complications including neurologic deficit and loss of correction were more frequent in the asymmetric group.


[Regionalization in health: an instrument for jurisdictional planning]. This study carried out the regionalization of Sanitary Jurisdiction No. III seated in Cuautla, Morelos, consisting of 16 of a total of 33 municipalities in the state of Morelos. This regionalization was carried out through the delination of areas sharing similar socioeconomical and demographic characteristics (SED). Subsequently, the major health hazards and the intraregional distribution of human health resources (physicians and nurses) and infrastructure services (institutional health centers) were identified for each region. The aim of this work was to devise an instrument for a better understanding of and approach to health problems at a juridictional level and to pave the way for health planning that would be congruent with regional characteristics and needs. Health sector efforts would be directed towards the promotion of preventive health care with greater efficiency and equity. In order to regionalize the jurisdiction, 17 SED indicators were studied in each of the 16 municipalities. Analysis was performed using the Principal Components Method (MCP) and an epidemiologic score. As a result, the sanitary jurisdiction was divided into three regions: Region I, with the best SED conditions, Region II, with moderate SED conditions and Region III with the lowest SED conditions. The results of this study show that there is an inverse relationship between the intraregional distribution of health resources with respect to the delineated regions and the health resources with respect to the delineated regions and the health needs and problems found in each one. Region III showed the worst SED conditions and the highest incidence of disease. It proved to be the region which had the greatest lack of material and human health resources, the latter having the lowest technical training level in all of the jurisdiction. In contrast. Region I had the best SED conditions and the lowest incidence of disease. It also had the highest number of material and human health resources, the latter having a high level of preparation. This situation is opposite to the national health policies in regards to equity "...give more benefits to the more vulnerable groups..."


[The migration process as risk factor in chronic malnutrition of pre-school children from Jalisco]. The purpose of this study was to identify risk factors in the family's migratory profile of preschool children with chronic malnutrition. A comparative observational study was conducted, including 511 12 to 60 months old children from childcare centers in the Jalisco sugar cane area, from February to March 1988. We evaluated their nutritional status using anthropometric indicators and Waterlow's classification. Their migratory history included information on place of origin, migratory mobility, cause of immigration, sociodemographic characteristics of parents and history of siblings who died under five years. The prevalence of malnutrition was 79 percent per 100 preschool children (68.5% adapted, 21.5% acute chronic and 10.4% acute). Factors associated with chronic malnutrition (OR greater than 1 CI 95%) included: coming from a poverty stricken population and being permanent migrants. A significant difference (p less than 0.05) was found among children of parents who were jobless at the time of migration. These findings could be used to justify the implementation of nutritional epidemiologic surveillance and intervention programs.


[Pregnancy, labor, and puerperium: concepts and practices of midwives in the state of Morelos]. In Mexico a combined type of care for the health-sickness phenomenon exists, where three systems interact: domestic, academic and traditional medicine. In relation to reproductive health, in the state of Morelos approximately 50 per cent of women in rural areas receive attention from traditional birth attendants, who make up one of the principal resources of traditional medicine. The goal of this study was to gather knowledge about and describe the concepts, resources and practices used by traditional birth attendants in their care during pregnancy, birth and puerperium; and likewise to determine their socio-demographic characteristics, their geographic distribution, their number and the level of training which they possess. A census based on three sources was carried out in which information about seven basic variables was sought. This information was completed with structured interviews with key informants which allowed the definition of a profile of the different types of traditional birth attendants according to the population they care for and the resources they use. The most relevant results indicate that 630 traditional birth attendants are distributed throughout the 32 municipalities of the state, with an average age of 52 years and 50 per cent having attended training courses. 17.5 per cent fall within the category of traditional birth attendant, 50 per cent are trained empiricists and 11.6 per cent are non-trained empiricists. The 20 per cent did not fit this typology. The strong social and cultural identification that exists between traditional birth attendants and their patients indicates the need to incorporate this valuable resource in rural reproductive health programs.


[Common personality traits in obese individuals]. This study is part of an interdisciplinary investigation in which the obese patient is evaluated from different aspects. This paper deals with the psychometric evaluation of obese people to search for common personality traits in obese patients attending the Weight Control Program offered by the Nutrition Project of ENEP Iztacala. The results show that differences do exist between obese and non-obese people, especially on some scales of the Inventory of Temperamental Traits.


[Method for estimating the population risk attributable to a transfer station of municipal solid waste]. Due to the great volume of municipal solid waste that is produced daily in the Metropolitan Area of Mexico City a sound management has been an impossible task. This is why during the past few years solid waste transfer stations have been constructed in the City, allowing a more efficient solid waste collection. The attributable risk to the population's health for the operation of such stations needs to be assessed in order to have them working within the urbanized areas without posing a potential risk to the health of the inhabitants of the inhabitants of the surrounding areas.


[The supply of physicians in Mexico: excess and shortage]. The purpose of this paper is to find out whether a decrease in the number of medical undergraduates doing their social service has any influence on the quantity of medical services provided by health care institutions in Mexico. Spearman's Rank Test was used to correlate the number of medical undergraduates and the number of services. Data for analysis were taken from the statistical information bulletins of the Ministry of Health for the decade of the 1980's. The analysis found that there is a significant correlation between the number of medical undergraduate and the number of primary health care services provided, and that this correlation disappears in the cases of secondary and tertiary health care services. The results underscore the importance of reconsidering the adequate number of physicians required to satisfy the health care needs of the Mexican population.


[Risk of tuberculosis infection in the health jurisdictions of Jalisco, Mexico]. This paper reports an evaluation of the risk of tuberculosis infection in school children in the sanitary jurisdictions of Jalisco, Mexico. It also compares the official figures of incidence of smear-positive pulmonary tuberculosis with those estimated with this epidemiological indicator. The study included 6,469 first grade children, six to seven years old, from 95 state schools. We skin-tested 4,260 of them with 2 TU PPD. Sixty per cent of the children tested were vaccinated with BCG. This proportion varied between the jurisdictions: from 43 per cent in Tepatitlan to 70 per cent in Ameca. The rate of tuberculosis infection was 6.3 per cent, with differences between children with a BCG scar and those with no scar (7.4% and 4.4%, respectively). We also found differences in the annual risk of infection between the jurisdictions. The annual risk was 0 per cent in Lagos de Moreno and 1.60 per cent in Ameca. With the exception of two jurisdictions, the incidence of smear-positive pulmonary tuberculosis estimated with this indicator is several times higher than that officially reported.


Radiation hybrids for mapping and cloning DNA sequences of distal 16p. Three hundred fifteen radiation hybrids (RH) were isolated using a monochromosomal cell hybrid containing chromosome 16 only. A panel of 18 RH, which showed breakpoints among four markers (3.15, 26.6, 3'HVR, and 5'HVR) mapping in the distal portion of 16p, were selected and characterized for the retention of nine additional DNA sequences already localized in this region, and for one centromeric sequence. One or more breakpoints were identified in nine of the 12 intervals defined by the 13 single-copy sequences used. This panel of RH represents a tool for the construction of a detailed physical map of the distal part of 16p and for cloning sequences located in the proximity of disease genes. Three inter-Alu DNA sequences, amplified from one of these RH containing the autosomal dominant polycystic kidney disease (PKD1) gene, were cloned and mapped in the panel. Sequencing of the ends of one of three clones showed a (CAAA)n repeat, which revealed a two-allele polymorphism.


[Problems identified by geriatric evaluation at a nursing home]. A geriatric evaluation was carried out in a group of 37 elderly nursing home residents. A complete history and physical examination was performed in all the patients. We identified 185 new medical problems in the patients, 40.7 per cent of whom were rehabilitation candidates. A functional status evaluation on daily activities showed dependency in 56.8 per cent of the patients while in daily instrumental activities 51.3 to 81 per cent of the patients required assistance. A mental status evaluation showed abnormalities in 46.8 per cent of the patients. This analysis shows the need of implementing this particular form of evaluation of elderly patient in our community and nursing homes.


Gene targeting using a mouse HPRT minigene/HPRT-deficient embryonic stem cell system: inactivation of the mouse ERCC-1 gene. A convenient system for gene targeting that uses hypoxanthine phosphoribosyltransferase (HPRT) minigenes as the selectable marker in HPRT-deficient mouse embryonic stem (ES) cells is described. Improvements to the expression of HPRT minigenes in ES cells were achieved by promoter substitution and the provision of a strong translational initiation signal. The use of minigenes in the positive-negative selection strategy for gene targeting was evaluated and the smaller minigenes were found to be as effective as a more conventional marker--the herpes simplex virus thymidine kinase gene. Minigenes were used to target the DNA repair gene ERCC-1 in ES cells. A new HPRT-deficient ES cell line was developed that contributes with high frequency to the germ line of chimeric animals. The ability to select for and against HPRT minigene expression in the new HPRT-deficient ES cell line will make this system useful for a range of gene-targeting applications.


[Self-medication in a urban population of Cuernavaca, Morelos]. This work contains the results of a study on the prevalence of family drug consumption. In our country, self medication should be considered a public health problem due to the population's lack of medical education. Nevertheless, this problem has not been properly studied. For this reason, we completed an exploratory study in an urban population of Cuernavaca, Morelos, México. Its purpose was to gather information about the situation of drug consumption and self medication. A survey was given to 373 domestic groups from the Carolina neighborhood in Cuernavaca. These groups were selected through systematic and probabilistic sampling. A total of 1,537 individuals of all ages were surveyed with an average of four participants per domestic group. Thirty one per cent of those surveyed had consumed drugs during the two weeks prior to the survey. Of these consumers, 53.3 per cent did it through self medication, and 64.9 per cent of them were females. If classified by age group, the highest consumer rate, 7.6 per cent, belonged to the users between 25 to 44 years. If the classification is done by sex and age, women between 25 to 44 years consumed more antibiotics and analgesics which were obtained over the counter. Among the surveyed population, the consumption of medicines was done primarily through self medication, mostly administered by women, and most frequently consumed by infants under one year of age. This phenomenon occurred regardless of the availability and accessibility of public and private health services. The data collected do make us identify women as a fundamental element in the consumption of drugs and self medication.(ABSTRACT TRUNCATED AT 250 WORDS)


Molecular cloning of a gene involved in methotrexate uptake by DNA-mediated gene transfer. A methotrexate-resistant Chinese hamster ovary cell line deficient in methotrexate uptake has been complemented to methotrexate sensitivity by transfection with DNA isolated from a wild-type Chinese hamster ovary genomic cosmid library. Primary and secondary transfectants, which contain a limited number of cosmid sequences, have been shown to regain methotrexate sensitivity and to take up methotrexate. Furthermore, the DNA from three cosmid clones, isolated from a primary methotrexate-sensitive transfectant, after transfection rescued the methotrexate-resistant phenotype at a high frequency. Restriction endonuclease analysis of the DNA of these cosmid clones indicated that they overlapped extensively and shared two regions of Chinese hamster ovary DNA of 6.6 kb and 20.6 kb. These observations indicate that a gene involved in methotrexate uptake is contained in its entirety within one of these regions. This is the first report of the functional molecular cloning of a gene involved in methotrexate uptake. A general strategy is also described for screening large cosmid libraries from primary transfectants.


[Education needs for the development of binational programs of health care]. The purpose of this article is to describe a research project carried out in Virginia, Maryland, Delaware and Pennsylvania. The main objective was to find out the continuing education needs of the staff implementing Primary Health Care (phc) programs developed with Mexican migrant workers. The methodology was based on applied research techniques. It was divided into two stages. The first stage was an interview which was applied to the coordinators of three programs: medical care, health education and sexually transmitted diseases. The second part of the methodology was to design a continuing education course with the input of the first stage. The course was implemented in the School of Public Health of Mexico in 1990. It had three main components: sociology and health in Mexico; health programmes in Mexico, and traditional medicine. The course also included a set of visits to clinics, hospitals and curanderos. The course has generated a group of scholars who are planning projects in this field to define the health needs of the migrant Mexican population in that area and the impact in Mexico. The course is also part of the regular Continuing Education Programme of the School of Public Health of Mexico now.


A gene that partially complements xeroderma pigmentosum group A cells maps to human chromosome 8. A gene that partially complements sensitivity of xeroderma pigmentosum cells of group A to UV irradiation has been mapped to human chromosome 8. Isolation of this gene has previously been described. A cDNA clone pEMKR that represents part of this gene was used for mapping. Based upon the nucleotide sequence of pEMKR, a set of oligonucleotide primers were designed for PCR amplification of DNAs from hybrid cell lines. A panel of rodent-human hybrid cell lines representing the total human genome was screened by PCR and Southern blot analysis for chromosomal assignment of this gene. PCR amplification and hybridization occurred only in the case of human and hybrid cell lines that contained human chromosome 8. The pEMKR thus represents a different gene than a DNA repair gene XPAC that has been mapped to human chromosome 9.


New chromosomal mapping assignments for argininosuccinate synthetase pseudogene 1, interferon-beta 3 gene, and the diazepam binding inhibitor gene. Argininosuccinate synthetase pseudogene 1 (ASSP1), interferon-beta 3 (IFNB3) gene, and diazepam binding inhibitor (DBI) gene have previously been mapped to human chromosome 2. Their nucleotide sequences, recorded in the GENBANK data base, were used to generate DNA primers to amplify specific sequences using the polymerase chain reaction (PCR). These primers failed to amplify DNA sequences when used to analyze microcell hybrid clones containing human chromosome 2. In order to map these genes, a panel of somatic cell hybrids was analyzed by PCR with these primer sets. The results of these experiments place ASSP1 sequences on human chromosome 6, IFNB3 on human chromosome 8, and DBI on human chromosome 6.


[Incisional, stab and gunshot wounds of the abdomen and thorax]. The authors give an account of the incidence and prognosis of the mentioned injuries treated during the past five years (1987-1991) at the surgical department of a district hospital in the centre of Prague. During the past two years a marked increase of these injuries was recorder. A total of 10 persons with abdominal injuries had ambulatory treatment and nine patients with injuries of the chest. During the same period 24 patients with abdominal injuries and 6 patients with chest injuries were hospitalized as well as four patients with combined abdominal and chest injuries. Nineteen ambulatory patients and 34 hospitalized patients during the five-year period are an ever increasing group of casualties who suffered injuries usually when drunk or due to violence.


[Extensive corium grafts].

[Extensive corium grafts]. Even in our times of revolutionary advances in the technology and operative techniques in plastic surgery, the corium is a material with multiple applications and can be found in the patient at varying thickness. The aim of the article is to show that its indication to reinforce flaccid musculature or to cover muscular defects of the abdominal wall is fully justified even in a time of routine use of plastic nets.


[Is cooling harmful to wounds?].

[Is cooling harmful to wounds?]. An adequate blood supply and stable temperature of the wound are very important for the healing process. During healing of a wound we can observe in the surrounding area two of rises temperature. The first rise is produced by the inflammation in the close vicinity of the wound and its peak is approximately on the 5th-10th day after treatment. The second peak can be found locally after 10 days. It is due to new formation of capillaries and thus a more ample blood supply of the wound and an increased tissue metabolism in the area surrounding the wound. Algidity affects healing in an adverse manner. The author mentions the results of some experiments which provide evidence of the favourable effect of stable temperature on wound healing. This can be achieved by adequate dressing technique and a correct procedure when changing dressings. Wounds must not remain undressed for prolonged periods to avoid drying up and cooling.


[Complications of mediastinoscopy examinations]. In 1970-1990 in the Institute of Lung Diseases in Prague a total of 180 mediastinoscopies were performed. In the submitted paper the authors discuss 169 of these examinations. In this group 20 examinations were associated with a peroperative or postoperative complications, i.e. a total of 12% of the examinations. However, only in three patients, i.e. cca 1.8% from the total number serious complications were involved which were unequivocally specific for mediastinoscopy. In two instances massive haemorrhage occurred from lacerated mediastinal vessels associated with superior vena cava syndrome and in one case pneumothorax developed. All these complications were controlled by surgical intervention made in time. The most frequent complication after mediastinoscopic examination was retention of a serohaematoma in the wound--this was recorded 11 times. The cause of its development is the method of preparation and anatomical conditions in the pre- and paratracheal space. The percentage of this complication can be reduced by using active drainage of the mediastinum.


[Evaluation of chemical necrectomy of burns using benzoic acid]. The author tries to define indication for chemical necretomy. He also discussed views regarding the toxicity of benzoic acid and thus attempts to express its use quantitatively.


[Amyloidosis associated with rheumatoid arthritis after total joint replacement]. Rheumatoid arthritis patients who had secondary amyloidosis have been studied retrospectively. There were eight patients out of 105 rheumatoid arthritis patients who had total joint replacement surgery from 1979 to 1990 in our institute. The grade of inflammation, renal and hepatic function have been compared with the RA patients without amyloidosis pre- and post- operatively. All of eight patients was female, and their average age at the diagnosis of amyloidosis was 57.8 year-old (range 4-76 year-old). The average preoperative period was 14.4 years (range 4-27 years), and the secondary amyloidosis had been diagnosed at the time of 3.8 years (range 1-9 years) after operation. The major clinical features leading to the diagnosis were gastrointestinal disturbance in six cases and renal dysfunction in two cases. The data of the renal function of amyloidosis patients showed slightly lower than that of the RA patients without amyloidosis, and showed significantly decrease postoperatively. The white blood cell (WBC) count was higher at the time of operation in the amyloidosis patients and showed continuous increase postoperatively. Lansbury index, alpha 2-globulin and WBC count did not improve in the amyloidosis patients during three years after operation. On the contrary, the patients without amyloidosis improved in these clinical data during the same period. Three amyloidosis patients died of renal failure and one died of bronchopneumonia. The average survival period was 1.8 years (range 1-5 years) after diagnosis of amyloidosis, and was 6.3 years (range 2-10 years) after operation in these four patients.(ABSTRACT TRUNCATED AT 250 WORDS)


[Reassessment of measurement of anti double-stranded DNA antibodies by Farr's assay using double-stranded DNA from E. coli and application of DNA binding Activities in high salt solution]. Farr's assay using double-stranded (ds) DNA from E. coli is a most sensitive and specific method for the detection of anti ds-DNA antibodies in patients with systemic lupus erythematosus (SLE). Because of the lack of sufficient DNA antigens, however, final antibody titers were hardly determined when the sera contained antibodies titered more than 100U/ml (or more than 60 per cent by DNA binding activities). In such sera DNA binding activities were measured by using ds-DNA tracer adjusted final concentration of NaCl to 125 mM. Higher binding activities measured by high-salt tracer are obtained significantly in SLE patients groups with nephrotic syndrome, proteinuria, cast, renal failure, diffuse proliferative nephritis, low serum complement levels, anemia and/or low IgG/IgA levels compared with the patients who lacked these clinical findings. In contrast the patients with digital rash or cramp showed significantly lower high-salt binding activities. The patients with pleuropericarditis tended to have lower bindings. The non-lupus patients including MCTD also had lower levels. These clinical characteristics could not be evaluated by standard Farr's assay. High-salt bindings suggest the presence of high avidity antibodies and also partly may mean the high levels of low avidity antibodies. The application of high-salt binding activities, thus, is a useful tool for the evaluation of clinical characteristics of SLE patients who had high levels of anti ds-DNA antibodies by standard Farr's assay.


[Clinical characteristics and prognosis of secondary amyloidosis in patients with rheumatoid arthritis--renal involvement and therapy]. Secondary amyloidosis is an important complication that may have a strong influence on the prognosis of patients with rheumatoid arthritis (RA). We studied 21 RA patients with secondary amyloidosis. The two major initial signs were gastrointestinal symptoms and renal involvement. When 15 of the 21 patients were diagnosed as having secondary amyloidosis, they displayed renal involvement including proteinuria, hematuria and hypercreatininemia. The 15 patients with amyloidosis were either subjected to dialysis or died within 35 months on the average. The causes of death in 13 patients were cardiac failure, gastrointestinal bleeding and infection, which were strongly implicated with renal failure. Dialysis was applied to seven patients. Three of them were maintained with chronic dialysis. We discussed the induction-time and the method of dialysis in patients with amyloidosis secondary to RA.


[Clinical usefulness of the measurement of type-II procollagen carboxypeptide (C-II propeptide, pColl-II-C) in synovial fluid as a marker of collagen metabolism in cartilage]. Type-II procollagen-C-peptide (pColl-II-C) in synovial fluids was studied in 319 patients with osteoarthritis (OA; 151), rheumatoid arthritis (RA; 141), traumatic arthritis (TA; 27) and 15 healthy volunteers using the newly developed ELISA kit. The mean levels of pColl-II-C in synovial fluids of healthy controls, OA, TA, and RA were 0.3 +/- 0.1 ng/ml, 5.9 +/- 0.3 ng/ml, 6.8 +/- 1.4 ng/ml and 1.1 +/- 0.1 ng/ml, respectively. pColl-II-C levels in synovial fluids of OA and TA were significantly higher compared to those of healthy controls and RA. It was also demonstrated that pColl-II-C levels could reflect the quantitative and qualitative change of cartilage metabolism. Therefore, the quantification of this molecule in synovial fluid could be beneficial to know the synthetic activity of type II collagen of chondrocytes, since pColl-II-C is a part of the precursor molecule of type II collagen.


[A case of adult onset hypophosphatemic vitamin D resistant osteomalacia]. A case of adult onset hypophosphatemic vitamin D resistant osteomalacia is described. A 40-year-old female who complained of thorax and lumbar pain and gait disturbance was admitted to our hospital on 7 November, 1988. The patient had hypophosphatemia with normal plasma calcium, parathyroid hormone and 25-hydroxy vitamin D3 concentrations, but had decreased tubular reabsorption of phosphate and decreased plasma 1, 25-dihydroxy vitamin D3 concentrations. The iliac crest bone biopsy showed osteomalacic changes. The 99mTc-MDP bone scintigram showed evidence of increased bone turnover with raised plasma alkaline phosphatase concentrations. After treatment with oral 1 alpha-hydroxy vitamin D3 (3-6 micrograms/day) and intravenous or oral phosphate supplement (0.47-1.74g/day), the subjective and clinical findings improved.


[A case of late-onset SLE complicated with EDTA-dependent pseudothrombocytopenia]. A 57-year-old man was admitted to our clinic with complaints of proximal myalgia in extremities. He was diagnosed as late-onset SLE based on the findings of pleuritis, pericarditis, arthritis and antibodies to DNA and cardiolipin. Aggregation of the platelets and the decreased counts of platelets were observed when EDTA was used as anticoagulant for the blood tests. However, the platelet aggregation was not noted with normal counts of platelets when Heparin-Theophylline was used as anticoagulant. From this observation, EDTA-dependent pseudothrombocytopenia was diagnosed and IgM class of EDTA-dependent anti-platelet antibody was detected by means of flow cytometry. Administration of prednisolone at 40mg/day reduced the symptoms and EDTA-dependent pseudothrombocytopenia, and EDTA-dependent anti-platelet antibody disappeared. His clinical course suggested that EDTA-dependent pseudothrombocytopenia was closely associated with the disease activity of SLE.


[Gold-induced severe cholestatic jaundice in rheumatoid arthritis patient and effect of repeated steroid pulse therapy]. A 32-year-old female with early stage of rheumatoid arthritis (RA) developed anorexia, pruritus, dark urine, pale stool and jaundice 3 weeks after initiation of chrysotherapy. She was administered a total of 35mg of gold sodium thiomalate (GST) intramuscularly and auranofin 6mg per day orally. Liver function tests and biopsy specimens showed severe cholestatic jaundice. Prednisolone 30mg per day and plasma exchange were started. No response however was obtained and the total bilirubin level gradually increased. Steroid pulse therapy, 1000mg methylprednisolone for successive 3 days as one therapy unit, was repeated 4 times. Liver functions were then gradually improved. Gold induced hepatotoxicity is a rare complication. We concluded that the hepatotoxicity in this case was caused by allergic reaction against GST and repeated steroid pulse therapy was very effective to these conditions.


[A case of rheumatoid arthritis complicated with pseudotumor around odontoid process successfully treated by methotrexate]. A 69-year-old-female with a history of rheumatoid arthritis since 1975 had suffered from dysesthesia of extremities since October 1989. Radiating pain and weakness occurred when she tried to stand up on Dec. 25 in 1989. She was admitted to our hospital in October 1990. Physical examination showed emaciation, hypesthesia of extremities, hypesthesia over the right chest and back, impaired vibration and position sense, and hyperreflexia. Laboratory findings revealed that the erythrocyte sedimentation rate was elevated to 46mm/hr, rheumatoid factor (RF) to 83.1IU/ml and CRP to 3.7mg/dl. Her blood sugar was high and she was diagnosed as having diabetes mellitus. Cervical X ray film showed atlanto-axial subluxation. A pseudotumor around the odontoid process bulging into the spinal canal and compression of the upper cervical cord was observed by MRI. In spite of administration of bucillamine (100mg/day), the size of pseudotumor did not change. Methotrexate (MTX) at a dose of 5mg/week was started in February 1991 and the pseudotumor decreased in size with a concurrent reduction of ESR, RF and CRP. However, the high intensity lesion by T2 weighed image did not change and dysesthesia persisted. The pseudotumor was thought to be due to pannus and it was revealed that MTX was effective for reduction. The persistent dysesthesia was probably due to the degeneration of the upper cervical cord, although diabetic neuropathy may also have played a role.


[An autopsied case of progressive systemic sclerosis with anti Wa antibody who showed a rapid progression]. An anti Wa antibody was reported as a new t-RNA related protein antibody in 1986. This autoantibody is now considered specific for the diagnosis of progressive systemic sclerosis (PSS). Up to date only 5 cases with anti Wa antibody have been identified. We report here an autopsied case of PSS with this antibody. A 53 years old female was admitted to our hospital because of dry cough and dyspnea in Sep 1987. There were fine crackles and chest X ray revealed interstitial pneumonia. The progressive respiratory failure was treated by steroid pulse therapy effectively. Sclerotic skin changes of hand began to appear in Sep 1988 and rapidly progressed to arms, chest and forehead by Dec 1988. A skin biopsy confirmed PSS changes. An anti Wa antibody was detected by double immunodiffusion and the protein antigen was associated with t-RNA when immunoprecipitation was conducted. She died of heart failure in July 1989. An autopsy revealed the diffuse fibrotic change of the heart and the lung. Cases with anti Wa antibody were shortly reviewed from the literature.


[A systemic lupus erythematosus patient with multiple aseptic bone necroses, thrombosis of superior mesenteric artery and anti-phospholipid antibody]. A 38 year old woman with systemic lupus erythematosus (SLE) was admitted because of epigastralgia and fever. The diagnosis of SLE was made 22 years ago based on Raynaud's phenomenon, butterfly rash, hair loss, photosensitivity and positive antinuclear antibody. She had episodes of consciousness disturbance, transient visual disturbance of the left eye, and a necrosis of the left big toe. She underwent artificial arthroplasty of bilateral femoral heads 11 years ago, when multiple aseptic necroses of thirteen bones were found, and when anti-cardiolipin (CL) antibody was found to be positive. An echogram of abdomen suggested an obstruction of superior mesenteric artery (SMA) when she was admitted. Selective angiography revealed a complete obstruction of SMA and splenic artery, and incomplete obstruction of celiac artery. Conservative treatment with urokinase infusion and prednisolone 50 mg/day was not effective, and small intestine and right colon were resected on the 23rd hospital day. The pathological examination showed thrombosis of SMA. There was no evidence of arteritis or atherosclerosis. Anti-CL antibody and lupus anticoagulant were positive on admission, but the level of both anti-DNA antibody and complement was normal. Therefore, it was suggested that the thrombosis was related with anti-phospholipid antibody. The characteristic clinical feature were multiple aseptic bone necroses and thromboses of several arteries. We discussed the relationship of thrombosis and the etiology of multiple bone necrosis in this case with anti-phospholipid antibody.


[Tubulo-interstitial nephritis (TIN) with no glomerular lesions, distal renal tubular acidosis and asteatosis cutis in a patient with systemic lupus erythematosus (SLE): a case report]. We report a 28-year-old woman with systemic lupus erythematosus (SLE) who showed tubulo-interstitial nephritis (TIN) without any glomerular changes. In 1990, she was admitted to our hospital, complaining of anorexia, vomiting and persistent high fever. Laboratory findings showed proteinuria, pancytopenia, hypocomplementemia and positive for antinuclear antibody, anti-DNA antibody, anti-Sm antibody, anti-SSA antibody and anti-SSB antibody. We made a diagnosis of SLE. Furthermore, distal renal tubular acidosis and asteatosis cutis were revealed. The diagnosis of Sjögren's syndrome was not made. We treated with high-dose prednisolone (60mg/day) and achieved improvement of symptoms and laboratory data. Open renal biopsy showed TIN without any glomerular changes. Predominant TIN is very rare in SLE. We discussed its pathogenesis and relation to the renal lesions of Sjögren's syndrome.


[A case of rheumatoid arthritis associated with progressive systemic sclerosis and primary biliary cirrhosis in the presence of various autoantibodies]. The patient (a 49 year-old, female) had been diagnosed in Apr. 1987 as having rheumatoid arthritis (RA) following the history as chronic non-A, non-B hepatitis for 4 years. Progressive systemic sclerosis (PSS) and primary biliary cirrhosis (PBC) were also defined on 1989 in the same patient mainly due to proximal scleroderma and histological findings of liver biopsy. On the other hand, the coexistence of rheumatoid factor, anti-Scl-70 antibody, anti-mitochondrial antibody (anti-MC, anti-MD and an unidentified fraction) and anti-centromere antibody have been observed with marked polyclonal hypergammopathy in her sera since July 1990. Her disease activity has been controlled well with the administration of D-penicillamine and ursodeoxycholic acid during recent clinical course. Few cases of RA associated with PSS and PBC, showing various autoantibodies as a disease marker in sera, have been reported. In order to evaluate the mechanisms of autoimmune disease especially chain reaction of autoimmunity, it should be important to accumulate the reports concerning such cases.


[Hemostasis screening in the emergency laboratory]. While automation of laboratories is of great value for analysts, as it makes technical work easier, and for clinicians, as the results are available in a shorter time, the requests increase strikingly bringing about higher costs. The emergency laboratory is an example of what happens in the general laboratory. In order to make an estimate of this subject, the haemostasis screening was chosen since it is a recently automated technique in that laboratory, attention being paid to the aim and indication of the screening and its economical burden. A study of the haemostasis screening performed during July 1990 was carried out of considering the 24 hours per day work. The requests were classified, in accordance with their indication, as diagnostic, pre-surgical, therapeutic or unknown; the justification and purpose of those requests was also examined. The total number of studies performed in that month was 1,273, with a daily mean of 41, as opposed to 2,095 performed in the haemostasis laboratory in the same period. According to the American Medical Association criteria only 48% of the requests could be warranted, and abnormal findings appeared in only 10% of them. The cost per isolated parameter is low, but it increases greatly when compared with the benefit that it reports to the patient because, as those biological tests indirectly measure the concentration of clotting factors, they are subjected to error when performed by non-specialized personnel; on the other hand, the most valuable information for detecting haemorrhagic troubles comes from the patient's history. The economical burden in the month studied amounted to 985,879 PTA; one year later, the same laboratory, in the same month, had a 50% increase of studies.


[Antithrombin III: its prognostic value in acute pancreatitis]. Antithrombin III (AT-III) activity was studied in relation to the seriousness of a series of patients with acute pancreatitis (AP). The aim of this study was to determine whether AT-III can be a prognostic factor for early detection of negative evolution on these patients. AT-III was determined on days 1, 3, 5, 7, 10, 15 and 21 after admission and weekly until discharge in 28 consecutive patients with AP, admitted in our hospital during a period of six months. The patients were 13 males and 15 females, with a mean age of 57 years (range 32 to 82). Fifteen AP were serious and 13 were not. AT-III levels under 80% of activity were found up to the 10th day in serious AP, turning back to normality from this day. In nonserious AP, AT-III remained within normal levels. This different evolution between both kinds of AP was statistically significant (p less than 0.05) during the first seven days, and became more evident in patients with fatal evolution (p less than 0.001). After grouping the lower levels of AT-III observed during the first 48 hours with those detected at the end of the first week, and introducing a cut off value of AT-III under 70% of activity, serious and nonserious AP presented predictive indexes of 67 and 70% respectively. Every deceased patients had, at admission and at the end of the first week, average levels of AT-III under 70%. We conclude that determination of AT-III levels is a good prognostic factor to differentiate between serious and nonserious AP, especially during the first week of illness.


[Progression to AIDS among HIV-seropositive hemophiliacs]. To assess the incidence of AIDS, along with its origin and mortality rate, in a group of sero-positive haemophiliacs with long follow-up. The progression into AIDS in 94 HIV-seropositive haemophiliacs (88 with haemophilia A and 6 with haemophilia B) followed since 1986 has been analyzed. The mean age was 19 years and 64% of the patients had severe haemophilia. All of them had been previously treated with non virus-inactivated factor concentrates. Was detected HIV antigen in 13 of them and 32 were treated with zidovudine. Actuarial analysis started from seroconversion date or from the first positive result and the average observation time was 90 months (5-97). Sixteen patients developed AIDS, resulting in an eight-years accumulative actuarial indice of about 24%. AIDS incidence was lower (p less than 0.0001) in haemophilia A (21%) than in haemophilia B (67%). The eight-years progression rate to AIDS showed a significant dependence on patient age, it being higher in patients aged greater than 30 (77%) than in those aged 15-30 (30%) and less than 15 (9%). Patients who presented CD4+ counts lower than 0.5 x 10(9)/L or CD4/CD8 ratios lower than 0.5 at the beginning of the observation period had a greater 8-year AIDS incidence (63% and 57% respectively) than the remaining patients (16% and 12%). At AIDS diagnosis, all patients had CD4+ lymphocyte counts lower than 0.2 x 10(9)/L, two had detectable HIV antigenaemia and six had been previously treated with zidovudine. The cause of AIDS was an opportunistic infection in all the cases namely, P. carinii pneumonia and candidiasis, but no secondary neoplasia was registered. Nineteen patients died during the follow-up, 12 because of AIDS and 7 because of other reasons unrelated to HIV-infection. Our results suggest that 25% of the haemophiliacs will develop AIDS eight years after seroconversion, and a decreasing incidence is not observed. Lower progression rate to AIDS in children than in adults is confirmed.


[Utility of the examination of plasma-cell morphology in the study of multiple myeloma]. To assess the classification of Greipp et al in a group of multiple myeloma (MM) patients, in an attempt to correlate the morphological patterns with the clinico-biological features of the disease. Bone marrow aspirates from 135 patients with multiple myeloma were examined by two different observers. Full accordance existed in 122 cases (90%). The four morphological MM subgroup distribution was: mature, 38%; intermediate, 30%; immature, 18%, and plasmoblastic, 14%. The analysis of the M component types with regard to morphology showed increased IgA cases within the intermediate (40%) and immature (48%) MM (p = 0.01), and Bence-Jones cases within the plasmoblastic MM (32%). On the contrary, no differences were found with regard to the clinical stage, although none of the plasmoblastic MM was in stage I. The incidence of renal insufficiency and of high bone-marrow infiltration progressively increased from mature to plasmoblastic MM, the difference between the extreme morphological groups being significant. The incidence of hypercalcaemia and lower paraprotein rates was higher in plasmoblastic myeloma, with significant difference with respect to mature myeloma (p = 0.05). The median survival was longer in intermediate (27.8 months) and mature (22.5 months) myelomas than in plasmoblastic (17.9 months) and immature (13.6 months) myelomas. After grouping the mature forms (intermediate plus mature) and the immature ones (plasmoblastic plus immature) the survival differences approached statistical significance (p = 0.07). This study suggests that the morphological examination of plasma cells should be included in the prognostic criteria of multiple myeloma.


[Initial dosage of vancomycin in neutropenic hematologic patients]. To evaluate the percentage of neutropenic patients who reach the therapeutic threshold when vancomycin is given at standard initial doses of 500 mg/6 hr, and to assess the creatinine clearance and body vancomycin clearance in such patients. The study was performed on 37 haematological patients with normal renal function. They received intravenous vancomycin at an initial 500 mg/6 hr doses. The plasma concentration of the drug was assessed 48-72 hr later, pharmacokinetic parameters being calculated. Creatinine clearance was estimated by two different methods. The concentration attained was beyond the therapeutic threshold in 100% of the patients. The correlations between vancomycin and creatinine clearance were r = 0.42 and r = 0.47 when the Cockroft-Gault's and the Jellife's methods, respectively, were used. Administration of vancomycin at initial doses of 500 mg/6 hr renders a very high percentage of patients with plasma concentration of the drug beyond the therapeutic margin. 1) The poor correlation between creatinine and vancomycin clearance in the patients with normal renal function does not allow using nomograms based on such values for estimation of the initial doses. 2) The estimation of initial doses based on the patient's weight (20-25 mg/kg) may render a higher percentage of patients with therapeutic concentrations from the beginning of treatment. The maintenance doses can be adjusted at 48-72 hr, after measuring the plasma concentrations. 3) Therefore, it seems advisable to perform further clinical assays on different groups in order to verify an increase of the drug's efficacy with no higher toxicity when the initial vancomycin doses is adjusted according to the patient's weight, as recommended here.


[Superoxide dismutase (SOD) and aging].

[Superoxide dismutase (SOD) and aging]. The rates of SOD in the Spanish population have been studied in an attempt to correlate them with aging. The study was comprised of 94 healthy blood donors with ages between 58 and 65 years. The findings were compared with those of 2,297 healthy normal subjects previously reported. The method of Miami and Yoshikawa was judged the technique of choice for a population study. The SOD levels found were 4.04 +/- 0.83 U/mL. Individuals from rural areas had values of 3.09 +/- 1.31 (p = 0.01), whereas subjects from urban environment showed values of 4.20 +/- 0.97 (p: ns). These figures, in the Spanish population as a whole, were 4.16 +/- 0.89, 3.81 +/- 0.9 and 4.22 +/- 0.97, respectively. The SOD rates in blood donors aged 58-65 years from the rural environment are significantly lower than those os their urban counterparts. The levels in this age-group are significantly lower than those of the general population. These findings suggest that increased SOD activity in the urban areas could result from a better protective mechanism with regard to higher concentrations of superoxide radicals which other would achieve toxic effects.


[Severe hemolytic anemia caused by anti-AB in renal transplantation with minor ABO incompatibility]. A 54 year-old woman subjected to renal transplant with minor ABO incompatibility developed clinically severe anti-AB haemolytic anaemia. On the 13th day after transplantation the patient had: haemoglobin, 7.5 g/dL, unconjugated bilirubin, 393 mumol/L (23 mg/dL), and undetectable haptoglobin levels. Positive direct antihuman globulin test was found, and an IgG antibody capable of binding complement and with anti-AB specificity was found upon studying the eluate. Immunosuppressive therapy improved the clinical picture, although antibodies could still be detected one month later. Clinically significant immune haemolysis after renal transplantation appears in about 10-15% of those cases having antibodies against the host's antigens. The peak red-cell destruction is seen one to two weeks after grafting, and haemolytic signs may last for about three weeks. Although self-limited, this condition may achieve high severity. The duration and severity of haemolysis depend upon the density of antigen sites on the surface of the host's red-cells, his secretor trait, the presence or absence of complement activation and the immunosuppressive therapy including cyclosporin. Several cases of anti-A and anti-B specificity have been reported, but anti-AB specificity had not been previously found; this fact is probably related to the scarce interest paid to its search thus far.


[Kikuchi-Fujimoto necrotizing lymphadenitis associated with brucellosis]. A 22 year-old woman was referred to the hospital for treatment after being diagnosed of Hodgkin's disease, established by lymph node biopsy. She complained of fever and sweats, and no lymph node enlargement or visceromegaly could be appreciated. Kikuchi's necrotising lymphadenitis was diagnosed after reviewing the lymph node specimen. The microbiological and serologic tests performed showed the existence of brucellosis. The clinical symptoms easily disappeared after treatment with streptomycin and doxycycline and she has been well, with no other symptoms or lymph node enlargement, after one year of follow-up. Kikuchi's disease is usually associated with different infections, although it had never been reported in association with brucellosis. This picture can easily be mistaken as malignant lymphoma or Hodgkin's disease.


Professional and family collaboration in case management: a hospital-based replication of a community-based study. This paper presents the results of research on a program that trains family members to serve as case managers for their elderly relatives. The effectiveness of the training program was evaluated using a randomized experimental design. Data were collected in an urban hospital setting about two groups of elderly patients: those with dementia and those needing hemodialysis. Family members of both types of patients were assigned randomly to an experimental group, which received systematic training in performing case management activities, or to a control group, which received only the services ordinarily provided by the hospital social work department. Post-test comparisons revealed that the experimental group family members performed significantly more case management tasks on behalf of their elderly relatives than did family members in the control group. Although trained family members assumed more responsibility for case management, there was no increase in the level of their subjective or objective caregiving burden. Implications for social work practice are presented.


Improving access to health care: case management for vulnerable children. Health care providers are being confronted by a change in childhood morbidity from primarily physical problems to complex problems rooted in the social, family, and environmental conditions that accompany persistent urban poverty. The clustering of multiple problems in one family necessitates redefining preventive and treatment strategies. Yet the lack of coordination among federal, state and local service programs often exacerbates the vulnerability of these beleaguered children and families. Therapeutic case management is a powerful service coordination strategy for increasing access and improving the health of vulnerable children. An ongoing evaluation of one case management model at the Center for the Vulnerable Child at Children's Hospital in Oakland, California is described in this article. Process evaluation data show this model to be effective in improving comprehensiveness and continuity of care among participating families.


Reducing older patients' reliance on the emergency department. Older adults tend to avoid mental health services and rely on hospital emergency departments for medicalization of these conditions. An intervention was designed for use in emergency departments to refer older adult patients with mental and social health problems to appropriate services within the hospital and community. Most of the patients in the study used the services to which they were referred; further, the intervention was found to decrease repeat utilization of the emergency department. Social work practice and policy implications of the findings are also discussed.


Hospitals and school districts: creating a partnership for child protection services. This article reports the initiation of a joint hospital-school district child protection committee in an urban setting of socio-economic blight. The committee provided a structure for consultation about troubling, complex situations of school children at high risk for physical and sexual abuse and medical neglect.


Patient psychoeducation: the therapeutic use of knowledge for the mentally ill. Psychoeducation has been used successfully with families of patients with psychiatric illness for over the past two decades. Modifying this model for use with mentally ill patients has demonstrated to both patients and staff the positive impact that knowledge can have on patients' functioning and attitudes. The model described has three objectives: (1) to impart information about psychiatric illness, medication and treatment regimens as a way of increasing patients' understanding, (2) to provide a forum which facilitates the integration of this information through group discussions with other patients and (3) to teach and model some specific management skills for patients as they deal with their illnesses.


Treating women incest survivors: a bridge between "cumulative trauma" and "post-traumatic stress". While the concept of traumatic stress plays an intrinsic part in the diagnosis and treatment of adult incest survivors, the developmental framework within which the victimization has occurred may be overlooked. This paper presents a treatment model that integrates theories of post-traumatic stress and early environmental trauma. A profile of women incest survivors is given and an overview of treatment strategies utilizing the above theories is discussed.


Working with denial: a critical aspect in AIDS risk intervention. Denial as a defense against anxiety can block the effectiveness of education and confrontation in work with clients manifesting AIDS risk behavior. The mechanism of denial is explored with reference to its role in supporting sexual acting out of unconscious conflicts. Clinical illustrations demonstrate the importance of work with denial as a prestage to effective AIDS risk intervention. Work with heterosexual and homosexual men and women is cited.


Obstacles to effective case management with AIDS patients: the clinician's perspective. A social work clinician filled the role of case manager with multiple functions of discharge planner, client advocate, counsellor and educator in her work with a young male AIDS patient and his family. Material from this case is used to illustrate seven problem areas identified as obstacles to effective case management: (1) The stigma of AIDS and homosexuality (2) Lack of adequate family support (3) Impact of AIDS dementia (4) Ethical dilemmas in discharge planning (5) Conflicts in the advocacy process (6) Lack of adequate resources and (7) Countertransference issues. Clinical observations are integrated with the existing social work literature which focuses on providing services to AIDS patients.


Latinos and HIV disease: issues, practice and policy implications. This paper examines critical issues faced by Latino PWAs and offers suggestions for meeting the needs for community support and care of Latino PWAs and their families. As HIV disease is shifting increasingly to minority communities, social workers need to consider new approaches to developing community care. Drawing on the strengths and informal support networks of the Latino community, the authors suggest ways in which these strengths can form the basis of service strategies that will effectively meet the needs of Latino PWAs.


Development of an instrument to measure volunteer's motivation in working with people with AIDS. A scale, "Attitude Towards Volunteer Motivation," was developed to measure motivation of volunteers who work with people with AIDS (PWAs). Fifty five questions were initially determined to have content validity. They were then administered to a random sample of youth services volunteers (n = 150) and members of an AIDS volunteer organization (n = 247). Results of factor analysis produced five subscales. Reliability of the constructed scale was established. It was correlated with a theoretically related scale to establish construct validity. Results of this initial research are promising and suggest further testing of the instrument.


Hospital boarder babies and their families: an exploratory study. Data were abstracted from the medical and social work charts of 20 newborns who were classified as boarder babies and their mothers (N = 18) to identify bio-psycho-social factors associated with boarding. The findings show that the mothers whose newborns remained in the hospital as boarders were usually drug users, had other children in out-of-home placement, and over half are periodically homeless. Most of these mothers also lacked informal social support. The major health problems of infants were prematurity and associated infections. The total number of infant boarding days was 195 for a total of $117,000 in unreimbursed costs to the hospital. Practice and program implications and directions for future research are discussed.