Ethylmalonic and methylsuccinic aciduria in ethylmalonic encephalopathy arise from abnormal isoleucine metabolism

Ethylmalonic encephalopathy (EE), an organic aciduria of unknown etiology characterized by developmental delay, hypotonia, and vascular instability associated with lactic acidemia and urinary excretion of ethylmalonic acid (EMA) and methylsuccinic acid (MSA), has been described in 11 patients. To test the possibility that the underlying biochemical defect involves isoleucine catabolism, we determined the response to oral L-isoleucine (IIe) load (150 mg/kg) in a 5-year-old girl with EE and in three healthy, age- and sex-matched controls. Following IIe load in the patient, there was accumulation of 2-methylbutyrylglycine (2-MBG) and a delayed and lower peak urinary excretion of tiglylglycine (TGL), suggesting a partial defect in 2-methyl-branched chain acylcoenzyme A dehydrogenase (2M-BCAD). In vitro measurements 2M-BCAD activity in cultured skin fibroblasts from patients with EE have been reported to be normal. Our results show that isoleucine is a source for the elevated EMA and MSA in patients with EE, and suggest a functional, possibly secondary, deficiency of activity of 2M-BCAD in vivo.

Family process in health research: extending a family typology to a new cultural context

To describe family context in health research, the authors tested a typology of families developed in California with a sample of families in Quebec, Canada. Family scales from the California study were submitted to focus groups, translated, and standardized on a sample of 209 parents. A panel of experts then revised the scales to make them relevant to Quebec families and to health promotion. Data from the new and revised scales were collected on 509 Quebec couples (1,018 spouses) and were clustered separately by gender, using K means. The procedure classified all respondents into family types that paralleled the original typology. Discriminant analyses indicated that family profile variables significantly distinguished family types. Comparisons with family, stress, and health variables further differentiated among the types and expanded their meaning. The study demonstrates a method for redefining and extending family data in health research with different cultural groups.

Every nurse is a leader

Some nurses have the goal to lead others and to be in charge of patient groups and groups of staff. They want to make changes at the upper levels of the organization and see their actions affect large numbers of people. Many others, however, really desire to be a bed-side nurse giving excellent patient care. They want to enjoy the close relationship that can make an individual feel better about him or her self as a person and the satisfaction that they have made a difference in one person's life. However, whether the nurse leads through a management position or practices leadership techniques in bedside nursing, all nurses are leaders and need to demonstrate expertise in the use of leadership techniques.

Speech recognition performance of older children with cochlear implants

HYPOTHESIS

The primary purpose of this study was to determine if children, > or =5 years old, with onset of deafness before the acquisition of spoken language (i.e., prelingually deafened) derived more benefit from multichannel cochlear implants than from conventional hearing aids. It was hypothesized that children who used oral communication (speech plus listening) would demonstrate higher levels of performance after implantation than children who used total communication (English sign system plus speech and listening).

BACKGROUND

Previous research suggests that prelingually deafened children given implants at an older age derive limited benefit from these devices. Changes in candidacy criteria and advances in technology, however, may make cochlear implants a more viable treatment option for this group of patients.

METHODS

A repeated-measures design was to used to compare patients' preoperative performance with hearing aids to postoperative performance with the CLARION cochlear implant after 3 and 6 months of device use. Pre- and postoperative performance were analyzed separately for children who used oral and total communication.

RESULTS

Both groups of children (oral and total communication) demonstrated significant postoperative improvement on all outcome measures over time. Postoperative scores of the children who used oral communication were significantly higher than those of the children who used total communication on four of the five outcome measures.

CONCLUSIONS

Prelingually deafened children who do not receive cochlear implants until > or =5 years of age derive significant benefit from current implant devices compared with that obtained with conventional hearing aids. The greatest benefit is derived by children who use oral communication, with much more limited benefit demonstrated by children who use total communication.

Differences in prevalence of and risk factors for subclinical vascular disease among black and white participants in the Cardiovascular Health Study

A composite measure of subclinical vascular disease has been developed in the Cardiovascular Health Study (CHS). In previous reports, we measured the prevalence of subclinical disease among the original 5201 participants in the CHS, the relationship of risk factors to subclinical disease, and the association of subclinical disease to clinical coronary heart disease. In 1992 to 1993 (year 4 of the study), a larger cohort of 424 black women and 248 black men was added to the study. In this study, we have compared the prevalence of subclinical disease among blacks and whites in the CHS and the association with cardiovascular risk factors. The prevalence of subclinical disease for all participants (aged > or =65 years) was 41.3% for white women, 39.7% for black women, 41.9% for white men, and 43.7% for black men. The prevalence increased with age. The risk factor associations for subclinical disease were similar among blacks and whites. In multivariate analysis, age, systolic blood pressure, LDL cholesterol, smoking, and family history of myocardial infarction were independently associated with subclinical disease among both black and white women, while for white men, systolic blood pressure, use of antihypertensive medication, smoking, body mass index, and diastolic blood pressure (inverse) were related to subclinical disease. In black men, blood triglyceride level, use of antihypertensive medications, and family history of myocardial infarction (inverse) were associated with subclinical disease.

Disturbances of the stress response: the role of the HPA axis during alcohol withdrawal and abstinence

Interactions among the brain, the pituitary gland, and the adrenal glands (i.e., the hypothalamic-pituitary-adrenal [HPA] axis) help regulate the body's response to stress. The adrenal hormone cortisol plays a key role in stress reduction through its effects on multiple body systems. Excessive cortisol activity during both chronic alcohol administration and withdrawal may underlie some of the clinical complications of alcoholism, including increased risk of infectious diseases; bone, muscle, and reproductive system changes; altered energy metabolism; and disorders of mood and intellect. Despite excessive cortisol levels during intoxication and withdrawal, however, the HPA axis becomes less responsive to stress during abstinence, potentially resulting in an impaired capacity to cope with relapse-inducing stressors.

Potencies of agonists acting at tachykinin receptors in the oestrogen-primed rat uterus: effects of peptidase inhibitors

The uterotonic potencies of the naturally occurring mammalian tachykinins and the synthetic subtype-selective agonist analogues of these agents [Lys5,MeLeu9,Nlel0]neurokinin A-(4-10) and [Nle10]neurokinin A-(4-10) (tachykinin NK2 receptor-selective), [Sar9,Met(O2)11]substance P (tachykinin NK1 receptor-selective) and senktide (tachykinin NK3 receptor-selective) were determined using preparations from oestradiol-treated rats. The endopeptidase 24.11 inhibitor, N-[N-[1-(S)-carboxyl-3-phenylpropyl]-(S)-phenyl-alanyl-(S)-isoserine+ ++ (SCH 39370), potentiated responses to neurokinin A, neurokinin B and substance P, but not to [Lys5,MeLeu9,Nle10)]neurokinin A-(4-10) or senktide. [Nle10]neurokinin A-(4-10) effects were potentiated by SCH 39370 with amastatin and those to [Sar9,Met(O2)11]substance P were potentiated by SCH 39370 and captopril in combination. In the presence of optimal concentrations of peptidase inhibitors the relative order of agonist potency was: neurokinin A > substance P > neurokinin B for the naturally occurring mammalian tachykinins and [Lys5,MeLeu9,Nle10]neurokinin A-(4-10) > [Nle10]neurokinin A-(4-10) > [Sar9,Met(O2)11]substance P > senktide for the synthetic tachykinin analogues. Thus, while a tachykinin NK2 receptor predominates in the oestrogen-primed uterus, a tachykinin NK1 receptor may also be present. The non-peptide tachykinin NK3 receptor antagonist, SR 142801, did not antagonise the effects of senktide suggesting that tachykinin NK3 receptors do not mediate its relatively minor effect on the uterus of the oestrogen-primed rat.

Bismuth subsalicylate instead of metronidazole with lansoprazole and clarithromycin for Helicobacter pylori infection: a randomized trial

OBJECTIVE

We evaluated the efficacy of lansoprazole, clarithromycin, and metronidazole (LCM) administered twice daily for 7 days. Because there is growing concern about the development of metronidazole-resistant H. pylori (HP) strains, we also tested a novel regimen consisting of lansoprazole, clarithromycin, and bismuth subsalicylate (LCB).

METHODS

Patients with active HP infection and peptic ulcer, a history of peptic ulcer, or nonulcer dyspepsia were randomized to either lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and metronidazole 500 mg b.i.d. or lansoprazole 30 mg b.i.d., clarithromycin 500 mg b.i.d., and bismuth subsalicylate 524 mg b.i.d. (LCB) for 7 days. Compliance and side effects were recorded by using a diary.

RESULTS

"Per protocol" eradication with LCM was achieved in 41 of 47 (87%). By using "intention to treat" analysis, LCM eradicated HP infection in 43 of 53 patients (81%). By using "per protocol" analysis, LCB eradicated HP infection in 40 of 47 patients (85%). On an "intention to treat" basis, LCB led to HP eradication in 42 of 52 (81%). The most common significant side effects observed with LCM were altered taste (39%) and abdominal pain (19%). With LCB, the most common significant side effects were altered taste (23%) and dark stools (23%).

CONCLUSIONS

LCB for 7 days was as effective in eradicating HP infection as a 7-day course of LCM. Further studies evaluating the role of bismuth compounds in proton-pump inhibitor based triple therapy are warranted. Such therapy may have particular importance in areas where high metronidazole resistance is a concern.

No evidence for a schizophrenia susceptibility gene in the vicinity of IL2RB on chromosome 22

Pulver et al. [1994a] reported modest linkage evidence for a dominantly (D) inherited "schizophrenia gene" in the vicinity of IL2RB on chromosome 22q12, and Coon et al. [1994] adduced moderate evidence under a recessive (R) model. We report here a replication study to test the hypothesis that one of these two models (or a third, intermediate (I) model) adequately describes the co-segregation of schizophrenia and chromosome 22q12 markers in an independent sample of 23 multiplex families. Altogether nine transmission models were evaluated. The models differed depending on whether the 15 family members with a diagnosis of schizophrenia spectrum disorders were considered unaffected (a "narrow" (N) definition), affected (a "wide" (W) definition), or declared "unknown" (U). The entire region between D22S268 and D22S307 is excluded (i.e., lod <-2) for models RN, RW, RU, and IW. Lod scores for the remaining models are uniformly negative; albeit, equivocal with respect to the dominant hypothesis over a small region between D22S268 and IL2RB. Nonparametric analysis under both diagnostic criteria also failed to yield any evidence for a susceptibility locus in this region of chromosome 22.

Developing a strategy for managing behavioral health care within the context of primary care

Although most patients with psychological disorders are diagnosed and treated within the primary care setting, there are few guidelines to help primary care physicians and managed care plan administrators construct programs of behavioral health care that are compatible with the primary care environment. We report the findings from a review of the literature from 1970 to 1996 on factors that predict the use of mental health and substance abuse services with specific reference to primary care. We use a heuristic framework of service use that includes the characteristics of patients, primary care physicians, practice settings, and managed care plans. Recognizing that the factors associated with the use of services center on the primary care practice, we argue that programs of behavioral health care will work best when they are decentralized to account for variations among primary care patients, physicians, and practices; when they are integrated clinically, financially, and administratively within the primary care setting; and when primary care physicians are active leaders in the design and implementation of these services, for clinical and financial reasons.

No association between polymorphisms in the human dopamine D3 and D4 receptors genes and alcoholism

The human dopamine D2 receptor gene (DRD2) has received considerable attention for the past several years as a potential candidate that may affect susceptibility to alcoholism. The association studies that compared the frequencies of alleles of DRD2 gene between alcoholics and control groups have produced equivocal results. Dopamine D3 and D4 receptor genes (DRD3 and DRD4) are in the same class as DRD2 but with different pharmacological properties. We have used relative risk and haplotype relative risk approaches to test associations between alleles of DRD3 and DRD4 genes and alcoholism. For relative risk studies 162 probands from multiple incidence alcoholic families have been compared to 89 psychiatrically normal controls. Haplotype relative risk approaches have used 29 alcoholic probands in which both parents were available for genotyping. The Bal I restriction enzyme site in DRD3 and tandem repeat (VNTR) in DRD4 genes polymorphisms were used to genotype the above samples. The results of relative risk approaches for both DRD3 and DRD4 genes were negative for comparisons of alcoholics and subtypes of alcoholics with normal controls. Haplotype relative risk approaches also were negative for both genes. These results suggest that any role played by these receptors may account for only part of the variation in susceptibility to alcoholism.

Apnea after immunization of preterm infants

OBJECTIVE

To determine the frequency of adverse reactions, particularly the occurrence of apnea, among preterm infants after immunization with diphtheria and tetanus toxoids and whole cell pertussis vaccine adsorbed (DTP) and Haemophilus influenzae type b conjugate (HibC) vaccine in the neonatal intensive care unit.

STUDY DESIGN

After the occurrence of apnea in two preterm infants following immunization with DTP and HibC, a prospective surveillance of 97 preterm infants younger than 37 weeks of gestation who were immunized with DTP (94 also received HibC at the same time) in the neonatal intensive care unit was performed to assess the frequency of adverse reactions and in particular, the occurrence of apnea. For each infant, data were recorded for a 3-day period before and after receipt of the immunization.

RESULTS

The majority of preterm infants tolerated immunizations with DTP and HibC without ill effects. However, 12 (12%) infants experienced a recurrence of apnea, and 11 (11%) had at least a 50% increase in the number of apneic and bradycardic episodes in the 72 hours after immunization. This occurred primarily among smaller preterm infants who were immunized at a lower weight (p = 0.01), had experienced more severe apnea of prematurity (p = 0.01), and had chronic lung disease (p = 0.03).

CONCLUSION

The temporal association observed between immunization of preterm infants and a transient increase or recurrence of apnea after vaccination merits further study. Cardiorespiratory monitoring of these infants after immunization may be advisable.

A nurse-managed smoking cessation program for hospitalized smokers

OBJECTIVES

This study evaluated a nurse-managed smoking cessation program for smokers hospitalized for a variety of conditions.

METHODS

Hospitalized patients who smoked prior to hospitalization and who were motivated to quit (n = 660) were randomized to intervention or usual-care groups and followed for the next year. The intervention included a meeting with the nurse-case manager; the use of a videotape, workbook, relaxation audiotape, and nicotine replacement therapy; and nurse-initiated phone contacts after discharge.

RESULTS

The 12-month confirmed cessation rates were 21% and 31% for, respectively, the usual-care and intervention groups (odds ratio = 1.7; 95% confidence interval = 1.1, 2.3).

CONCLUSIONS

A nurse-managed smoking cessation intervention can significantly increase cessation rates for hospitalized patients.

Transgenic model for the discovery of novel human secretory non-pancreatic phospholipase A2 inhibitors

Transgenic mice were created which overexpress human secretory non-pancreatic phospholipase A2 (sPLA2) pansomatically as a potential disease and drug-testing model. The mice were produced using a DNA construct in which the inducible mouse metallothionein gene promoter drives expression of a human sPLA2 minigene. High levels of sPLA2 were detected in several tissues by immunofluorescence localization. Expression in the testes caused hypospermia and male infertility. Circulating catalytically active sPLA2 could be induced to levels observed in patients undergoing a systemic inflammatory response but had no detectable effect on the mice. Therefore, these results suggest that sPLA2 hyperphospholipasemia alone may have only limited pathophysiological consequences. We further show that 3-[3-acetamide-1-benzyl-2-ethylindolyl-5-oxy]propane phosphonic acid LY311727), a potent new inhibitor of phospholipase A2 catalysis developed by our group, dramatically suppresses the circulating enzyme activity in these animals whereas 3-[3-acetamide-1-benzyl-2-propylindolyl-5-oxy]propane phosphonic acid (LY314024), a substantially less potent LY311727 analog, is without effect. These later results thus motivate the further development of this compound as a potential new therapeutic agent and valuable research tool.

A starch-hemoglobin resuscitative compound

A resuscitative compound in freeze-dried form has been synthesized between a modified starch and a tetremerically stabilized hemoglobin. In order to complex the hemoglobin, the starch has been prepared in mono-, di-, tri-, and tetra-aldehyde moieties. The hemoglobin was stabilized with low molecular weight diacids. Electrophoretic densitometric patterns indicate compound formation. The resulting polymers were characterized with respect to oxygen transport (biotonometry), Hill constant and P50. The in vivo evaluation indicates that these compounds are effective in exchange-transfusion experiments with rats to a level of about 85% replacement of whole blood. The final product is a cost-effective acellular resuscitative compound which can be stored in freeze-dried form at room temperature for extended periods of time. This artificial blood substitute can be reconstituted upon the addition of water.

Mapping the lipid-exposed surfaces of membrane proteins

Phospholamban forms a stable complex of five long transmembrane helices. We show that the relative rotational orientation of the helices in the pentameric complex can be distinguished by S-H to S-D exchange of cysteine sulphydryl groups located in the transmembrane segment of the protein and exposed to the lipid environment. Of the three cysteine residues in phospholamban, two residues (Cys 36 and Cys 46) are oriented towards the helix interface and protected from exchange, while the third cysteine (Cys 41) is oriented towards the lipid interface and undergoes exchange with water diffused into the bilayer. Distinguishing the external and internal faces of a membrane protein by sulphydryl exchange provides a general approach for determining the three-dimensional fold of membrane proteins and enhances model building efforts to generate high-resolution structures.

Long-term sun exposure alters the collagen of the papillary dermis. Comparison of sun-protected and photoaged skin by northern analysis, immunohistochemical staining, and confocal laser scanning microscopy

BACKGROUND

Long-term solar irradiation produces both morphologic and functional changes in affected skin. Because collagen is the major structural component of skin, any alteration in its production or degradation could have profound effects on cutaneous functional integrity.

OBJECTIVE

Our purpose was to investigate alterations in the production and morphology of collagen fibers brought about by long-term sun exposure.

METHODS

We compared collagen and collagenase gene expression and collagen immunohistochemical staining and used confocal laser scanning microscopy for morphologic examination of dermal collagen fibers in photodamaged compared with sun-protected skin from the same persons.

RESULTS

Despite a large increase in elastin messenger RNA in sun-damaged skin, collagen and collagenase gene expression remained essentially unchanged. However, striking alterations in the papillary dermis of photoaged skin were found, which revealed large, abnormally clumped elastic fibers and deformed collagen fibers of various diameters, replacing the normal architecture of the papillary dermis.

CONCLUSION

Our data provide evidence for normal collagen gene expression in sun-damaged skin and suggest that degradation and remodeling of collagen take place in the papillary dermis accompanied by deposition of other matrix components, predominantly abnormal elastic fibers.

Social physique anxiety, body esteem, and social anxiety in bodybuilders and self-reported anabolic steroid users

Social physique anxiety, upper body esteem, social anxiety, and body dissatisfaction were examined among self-reported anabolic steroid (AS)-using bodybuilders, non-using bodybuilders, athletically active exercisers, and non-exercising individuals. Results indicate that: (a) the AS-using bodybuilder group had significantly lower levels of social physique anxiety than non-user groups, (b) AS-using bodybuilders have significantly higher upper body strength ratings than do non-users (non-using bodybuilders, athletically active exercisers, and non-exercisers), and (c) no differences among groups on a measure of social anxiety. Implications for further research and intervention are discussed in terms of the differences between anabolic steroids and other substances of abuse.

A comparison of filtered leukocyte-reduced and cytomegalovirus (CMV) seronegative blood products for the prevention of transfusion-associated CMV infection after marrow transplant

We performed a prospective, randomized trial in CMV seronegative marrow recipients to determine if filtered blood products were as effective as CMV-seronegative blood products for the prevention of transfusion-transmitted CMV infection after marrow transplant. Before transplant, 502 patients were randomized to receive either filtered or seronegative blood products. Patients were monitored for the development of CMV infection and tissue-documented CMV disease between days 21 and 100 after transplant. Infections occurring after day 21 from transplant were considered related to the transfusion of study blood products and, thus, were considered evaluable infections for the purpose of this trial. In the primary analysis of evaluable infections, there were no significant differences between the probability of CMV infection (1.3% v 2.4%, P = 1.00) or disease (0% v 2.4%, P = 1.00) between the seronegative and filtered arms, respectively, or probability of survival (P = .6). In a secondary analysis of all infections occurring from day 0 to 100 post-transplant, although the infection rates were similar, the probability of CMV disease in the filtered arm was greater (2.4% v 0% in the seronegative arm, P = .03). However, the disease rate was still within the prestudy clinically defined acceptable rate of < or = 5%. We conclude that filtration is an effective alternative to the use of seronegative blood products for prevention of transfusion-associated CMV infection in marrow transplant patients.

Monoamine oxidases and alcoholism. I. Studies in unrelated alcoholics and normal controls

Low platelet MAO activity has been associated with alcoholism. In order to evaluate the role of MAO genes in susceptibility to alcoholism, we have taken a biochemical and molecular genetic approach. The sample consisted of 133 alcoholic probands who were classified by subtypes of alcoholism and 92 normal controls. For those subjects typed for platelet MAO activity, alcoholics (N = 74) were found not to differ from the non-alcoholics controls (N = 34). Neither was there a significant difference between type I and type II alcoholics or between either subtype and normal controls. However, we do find significant differences between male and female alcoholics, but not between male and female controls. The allele frequency distribution for the MAO-A and MAO-B dinucleotide repeats is different between the alcoholic sample (N = 133) and the normal control sample (N = 92). In a two-way analysis of variance of MAO-B activity as a function of the allelic variation of each marker locus and diagnosis, there is no evidence for mean differences in activity levels for the different alleles. Our findings do not rule out a role for the MAO-B gene in controlling the enzyme activity because the dinucleotide repeats are located in introns.

Dependent care, caregiver burden, hardiness, and self-care agency of caregivers

This is a partial replication of a descriptive correlation study that examined the relationship between dependent care, caregiver burden, health-related hardiness, and self-care agency of caregivers. Data from this replication were compared with those of the previously reported study. Data were collected from a home health agency and a radiation-oncology unit. A moderate significant negative correlation was found between objective burden and dependent care. Moderate significant positive correlations were found between self-care agency scores and the commitment/challenge and control subscales of health-related hardiness scores. The major difference between this study and the previous one was in the level of subjective burden. Even though caregivers reported greater levels of subjective burden, the correlation with self-care agency and hardiness was nonexistent. The small subsample of male caregivers (n = 14) prevented a statistical comparison with the previous data; however, in the pooled sample previous findings were supported.

Cataracts after bone marrow transplantation: long-term follow-up of adults treated with fractionated total body irradiation

PURPOSE

To determine the risk of, and risk factors for, developing cataracts after bone marrow transplantation.

METHODS AND MATERIALS

Four hundred and ninety-two adults who underwent bone marrow transplantation in Seattle were followed for 2 to 18 (median, 6) years. Before transplantation, patients received a preparative regimen of chemotherapy plus total body irradiation (TBI) (n = 407) or chemotherapy alone, without TBI (n = 85). TBI was administered in a single dose of 10 Gy (n = 74) or in fractionated doses totaling 12-15.75 Gy (n = 333). The risk of cataracts was determined for groups of patients with respect to the type of preparative regimen received and other pretransplant and posttransplant variables.

RESULTS

One hundred and fifty-nine patients (32%) developed cataracts between 0.5 to 11 (median, 2.3) years after transplantation. The probability of cataracts at 11 years after transplantation was 85%, 50%, 34%, and 19% for patients receiving 10 Gy of single-dose TBI, > 12 Gy fractionated TBI, 12 Gy fractionated TBI, and no TBI, respectively (p < 0.0001). Among those developing cataracts, the severity was greater in patients after single-dose TBI (59% probability of surgical extraction) than after > 12 Gy fractionated TBI, 12 Gy fractionated TBI, or no TBI (33%, 22% and 23%, respectively). Patients given corticosteroids after transplant had a higher probability of cataracts (45%) than those without steroids (38%) (p < 0.0001). In a proportional hazards regression model, the variables that were correlated with an increased probability of cataracts were single-dose TBI (relative risk (RR) = 2.46) and steroid therapy (RR = 2.34), while a decreased probability of cataracts was correlated with a nonTBI preparative regimen (RR = 0.41). The yearly hazard of developing cataracts in recipients of single-dose TBI was highest during the third year after transplantation, while in recipients of fractionated TBI, the hazard was distributed among years one through seven. The probability of cataracts in all groups reached a plateau at 7 years after transplantation, after which the development of cataracts was extremely unlikely.

CONCLUSION

TBI is the major risk factor for developing cataracts after BMT. Single-dose TBI results in the highest risk of cataracts. However, the risk of cataracts in recipients of fractionated-TBI is significantly higher than in patients who receive no TBI. In addition to TBI, steroid therapy is an independent risk factor for cataracts after BMT.

An empirically derived typology of families: I. Relationships with adult health

In this report we describe the development and partial validation of an empirically derived typology of families based on 11 family variable composites derived from the California Family Health Project. Our goal was to use the typology to condense and integrate the findings from previous analyses of a large group of family variables and to account for differences in the self-reported health of adult family members. Exploratory and confirmatory cluster analyses conducted separately by gender classified 97% of the sample into four parallel types for husbands and wives: Balanced, Traditional, Disconnected, and Emotionally Strained. A 1-way MANOVA indicated that all 11 family variable composites significantly differentiated the four family types for husbands and wives. Significant differences among the four family types were also found on 10 demographic and other family variables, using ANOVA. Using MANOVA, we compared the four family types on 12 self-reported health and well-being variables by gender. Both husbands and wives from Balanced and Traditional families reported higher health scores than spouses from Disconnected and Emotionally Strained families, but no single profile of health scores was unique to a particular family type. The four family types provide an integrated and comprehensive framework for describing the family in health research.

An empirically derived typology of families: II. Relationships with adolescent health

In this report from the California Family Health Project, we describe the relationship between an empirically derived family typology based on parent data, and the self-reported health and well-being of 151 adolescent offspring. The typology is comprised of four family types: Balanced, Traditional, Disconnected, and Emotionally Strained. Three adolescent health indices were constructed from 13 self-reported health variables using principal components and multidimensional scaling analyses: Physical Health, Emotional Health, and Alcohol Abstinence. ANOVA indicated that Physical Health was significantly different among adolescents in the four family types. The findings varied, however, depending upon whether the typology was based on mothers' or fathers' appraisals of the family. In the father-based typology, adolescents from Traditional families scored highest while those from Emotionally Strained and Balanced families scored lowest. In the mother-based typology, adolescents from Balanced, Traditional, and Emotionally Strained families scored equally high, while those from Disconnected families scored significantly lower than those from the other three family types. Differences on Abstinence were significant only in the father-based typology. Adolescents from Traditional and Emotionally Strained families drank less than adolescents from Disconnected families. No significant differences among adolescents were found for Emotional Health, and adolescent gender did not interact significantly with family type to affect any of the three health indices. Traditional and Disconnected family types had offspring who clearly stood apart with higher and lower health scores, respectively. The results are discussed in terms of the current literature on social environment and health.

Fungal liver infection in marrow transplant recipients: prevalence at autopsy, predisposing factors, and clinical features

To determine the prevalence of fungal liver infection at autopsy in marrow transplant recipients, we reviewed autopsy results for the period 1980-1989. Cases were compared to randomly chosen autopsied controls without fungal infection. Fungal liver infection was found in 67 (9%) of 731 patients. Fungal cultures of liver lesions were positive for 34 of 67 patients, most of whom had been culture-positive for the same fungal species (largely Candida) during life. Multivariate analysis revealed that independent predictors of fungal liver infection were deep fungal infection after transplantation (RR, 35), colonization or superficial infection after transplantation (RR, 13), and severe liver dysfunction caused by veno-occlusive disease of the liver and/or graft-versus-host disease (RR, 7). Clinical and laboratory findings during the last month of life revealed no differences between cases and controls. Liver imaging studies performed during the last 15 days of life had a sensitivity of only 18% for detecting fungal liver lesions.

Blepharophimosis syndrome is linked to chromosome 3q

Blepharophimosis syndrome (BPES, blepharophimosis eyelid syndrome) is a distinctive congenital eyelid malformation which can occur sporadically or be inherited in an autosomal dominant fashion. Previous reports have described associated cytogenetic abnormalities on chromosome 3q. We have ascertained and sampled two BPES families with apparent autosomal dominant inheritance and have tested for linkage with 17 polymorphic markers on 3q. Multipoint analysis generated a maximum LOD score of 3.23 using the markers RHO, ACPP and D3S1238. No evidence of genetic heterogeneity was observed. These studies provide the first non-cytogenetic evidence that a defective gene responsible for BPES is located on 3q22.

Aural tuberculosis

Since the advent of antituberculous therapy, tuberculosis of the ear has decreased in incidence; but of late, cases of both pulmonary and otologic tuberculosis are on the rise. In addition, the treatment of aural tuberculosis is now more difficult due to resistance to one or more of the routinely used antituberculous pharmacotherapeutic agents. Urban areas and selected populations have been particularly endangered by the re-emergence of this disease. In light of this developing situation, three cases of aural tuberculous infections are presented. Typical and atypical presentations of the disease, including history, signs, symptoms, and radiographic findings are discussed, as are treatment options. The importance of aural tuberculosis as part of the general increase in incidence and resistance of the disease is examined.

Prognostic models and the propensity score

Subjects in observational studies of exposure effects have not been randomized to exposure groups and may therefore differ systematically with regard to variables related to exposure and/or outcome. To obtain unbiased estimates and tests of exposure effects one needs to adjust for these variables. A common method is adjustment via a parametric model incorporating all known prognostic variables. Rosenbaum and Rubin propose adjustment by the conditional exposure probability given a set of covariates which they call the propensity score. They show that, at any value of the propensity score, covariates are on average balanced between exposure groups. Thus matching on the propensity score leads to unbiased estimators and tests of exposure effect. However, the validity of the method depends on knowing the exposure probability. This quantity is usually not known in observational studies and needs to be estimated.

The impact of chronic illness on the health and well-being of family members

Examined is the impact of dementia on the physical and mental health of all family members caring for an ill parent/spouse. The sample included 97 spouses of patients diagnosed with either Alzheimer's disease or vascular dementia, 186 offspring, and 97 offspring spouses or "in-laws." Multiple regression tested the association between severity of the illness and family member health and well-being. Severity was significantly associated with health and well-being for spouses, offspring, and in-laws, regardless of the amount of caregiving, demonstrating the potential cascading effect of the illness through the family. Use of services displayed no direct association with spouse health and well-being, but service utilization interacted with illness severity. The relationship between severity of illness and spouse health was lower under conditions of high service utilization than under conditions of low service utilization.

Alzheimer's disease: the impact of the family on spouses, offspring, and inlaws

This article reports the findings from a study designed to identify qualities of the multigeneration family system that affected the relationship between the demands of Alzheimer's disease on the family and the health and well-being of (a) spouses, (b) offspring, and (c) offspring's spouses or "inlaws." Members of 97 families of patients with Alzheimer's disease, recruited from four University-affiliated Alzheimer's Centers, completed detailed questionnaires and participated in a 45-minute telephone interview to assess care-strain, personal stress, appraisals of three major domains of family life (World View, Structure/Organization, and Emotion Management), and three health and well-being indices (Anxiety/Depression, Somatic Symptoms, and Well-Being). Multivariate multiple regression equations, run separately for each of the three groups of family respondents and each of the three family domains, indicated: (1) no significant associations between the severity of the elder's disease and family member health and well-being; (2) female family members reported poorer health and well-being than male family members; and (3) caregiver strain was negatively associated with family member health and well-being. Further, appraised family qualities were associated with the health and well-being of the three groups of respondents differently: directly for offspring, interactively with severity of patient disorder for inlaws, and not at all for spouses. The data suggested that some family qualities served a protective function, whereas others exacerbated the negative effects of caregiving by affecting personal health and well-being. The findings are interpreted in terms of the different roles and expectations for care-giving placed on spouses, offspring, and inlaws. It is suggested that programs of intervention for patients with Alzheimer's and other chronic diseases should focus on the multigeneration family as the context for care, rather than only on the primary caregiver.

Risk factors for repeatedly reactive HIV-1 EIA and indeterminate western blots. A population-based case-control study

OBJECTIVE

Causes of indeterminate results of Western blot testing (IWB) for human immunodeficiency virus (HIV) type 1 include seroconversion, HIV-2 cross-reactivity, and autoimmune disease, but most IWB results remain unexplained. This case-control study assessed risk factors for IWB results, including early HIV infection, other retroviral infection, autoantibodies, and other medical conditions.

DESIGN

Prospective study to determine HIV seroconversion rate, with a case-control design to assess other risk factors for IWB. Cases (persons with one or more repeatedly reactive HIV-1 enzyme immunoassay with IWB), their current sexual partners, and controls (persons with negative enzyme immunoassay and Western blot results) were recruited from blood banks, health department and prenatal clinics, and private providers in Washington and Oregon.

RESULTS

Of 244 cases enrolled, 206 were followed up for 6 months or longer, and six (3.0%; 95% confidence interval [CI], 0.7% to 5.3%) with recent HIV risk behaviors seroconverted. The Western blot banding patterns differed among groups; cases usually had p17 or p24 bands, while controls and cases' sexual partners usually had polymerase bands. Conditional logistic regression indicated that independent risk factors for IWB among male cases and controls were a tetanus booster in the past 2 years (odds ratio, 3.2; 95% CI, 1.2 to 8.6) and sexual contact with a prostitute (odds ratio, 3.0; 95% CI, 1.0 to 9.5). Independent risk factors for women were parity (odds ratio, 1.2; 95% CI, 1.02 to 1.4) and autoantibodies, either rheumatoid factor or antinuclear antibodies (odds ratio, 2.3; 95% CI, 1.03 to 5.6). No cross-reactivity was detected with HIV-2, human T-lymphotrophic virus type 1, feline immunodeficiency or feline leukemia, or bovine immunodeficiency viruses.

CONCLUSIONS

Evaluation of persons with reactive HIV-1 enzyme immunoassays and IWB should include an assessment of HIV risk and other possible risk factors, such as alloimmunization (ie, parity or recent immunization) or autoantibodies (ie, antinuclear antibodies and rheumatoid factor). The relationship of IWB among men who reported sex with prostitutes is intriguing and warrants further study.

A case-management system for coronary risk factor modification after acute myocardial infarction

OBJECTIVE

To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification.

DESIGN

Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction.

SETTING

5 Kaiser Permanente Medical Centers in the San Francisco Bay area.

PATIENTS

585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction.

INTERVENTION

In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy.

OUTCOME

Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction.

RESULTS

In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 +/- 0.69 mmol/L and 3.41 +/- 0.90 mmol/L (107 +/- 30 mg/dL and 132 +/- 30 mg/dL) (P = 0.001), and functional capacities were 9.3 +/- 2.4 METS and 8.4 +/- 2.5 METS (P = 0.001), respectively.

CONCLUSION

In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.

Risk factors for transmission of Mycobacterium tuberculosis in a primary school outbreak: lack of racial difference in susceptibility to infection

Recent data have suggested that there are racial differences in the susceptibility to infection by Mycobacterium tuberculosis. An opportunity to test this suggestion was afforded by an outbreak of tuberculosis in a racially mixed elementary school in St. Louis County, Missouri. A physical education teacher was discovered to have cavitary pulmonary tuberculosis. Of 343 students in the school, 176 (51 percent) were found to be tuberculin skin test positive (> or = 5 mm induration by Mantoux method); 32 children had abnormal chest radiographs. More frequent contact with the physical education teacher was associated with infection (p < 0.001). Black children were no more likely to be infected than were white children (relative risk (RR) = 0.98, 95% confidence interval (CI) 0.78-1.22). However, black children who were tuberculin positive had larger skin reactions than did white children (mean, 18.9 vs. 16.6 mm, p < 0.001) and were more likely to have abnormal chest radiographs (RR = 2.76, 95% CI 1.44-5.27). Among tuberculin-positive children, low body mass index (less than 10th percentile) was associated with active disease (RR = 2.90, 95% CI 1.45-5.80). The analysis of race was unchanged after controlling for sex, body build, and level of contact with the physical education teacher. Widespread tuberculous infection resulted from contact with a highly infectious staff person. Thin body build was a risk factor for active disease. Black children were no more susceptible to infection than were white children, although they more commonly developed radiographic evidence of active disease.

B-scan ultrasonic measurement of the lumbar spinal canal as a predictor of industrial back pain complaints and extended work loss

B-scan ultrasonic measurements of lumbar spinal canal diameter were examined as predictors of industrial back pain complaints and extended work loss. Baseline data were collected on 3,020 Washington State aircraft manufacturing workers, and over a mean 3.7-year follow-up period 352 subjects reported industrial back pain complaints. Mean canal measurements of subjects with industrial back pain complaints were smaller at all spinal levels than in subjects without complaints. The mean differences between the groups, however, were extremely small (0.07 mm to 0.51 mm), and not all levels were statistically significant. The relative risk for an L5-S1 measurement 2 standard deviations below the mean was 1.4, yet the measurement explained less than 1% of the uncertainty in predicting complaints. No association was found between canal measurements and claims with extended work loss of greater than one month. The imprecision of the measurements and poor predictive ability indicate that B-scan ultrasonography, as used in this study, is of dubious screening value.

Circulating Borrelia burgdorferi in patients with acute Lyme disease: results of blood cultures and serum DNA analysis

To determine the usefulness of blood culture and polymerase chain reaction (PCR) analysis in detecting circulating Borrelia burgdorferi or its DNA, blood and serum from untreated patients with acute Lyme disease were examined. None of the cultures of blood or serum from the 7 patients tested demonstrated spirochetes. Similarly, all patient serum samples, assayed in two laboratories, were negative for B. burgdorferi DNA using PCR amplification. These results suggest that in patients with acute Lyme disease, spirochetes, spirochete DNA, or both circulate early, only intermittently, or at low levels and that neither culture nor PCR testing of blood or serum, as currently done, appears likely to prove generally useful in the diagnosis of Lyme disease.

Effects of intensive lipid-lowering therapy on the coronary arteries of asymptomatic subjects with elevated apolipoprotein B

BACKGROUND

Do the benefits of intensive lipid-lowering therapy seen in symptomatic patients extend to high-risk subjects who have never had symptoms?

METHODS AND RESULTS

Of 120 men completing the FATS trial, 91 were symptomatic and 29 asymptomatic. All had apolipoprotein B > or = 125 mg/dL, a positive family history, and coronary atherosclerosis. All were counseled in diet and randomized to intensive therapy: colestipol 10 g TID plus either niacin 1 g QID or lovastatin 20 mg BID or to conventional therapy: placebos, or colestipol if low-density lipoprotein cholesterol was elevated. End points included quantitative arteriographic disease change and clinical events over a 2.5-year interval. At baseline, symptomatic and asymptomatic patients had comparable risk profiles, but proximal stenosis severity averaged 36% for symptomatic and 23% for asymptomatic patients (P < .001). Among the 91 symptomatic patients, those in the intensive group experienced definite (> or = 10%S) proximal lesion progression less frequently than conventional (24% of intensive versus 48% of conventional) and definite regression more frequently (36% of intensive versus 15% of conventional) (P = .009). Similarly, among the 29 asymptomatic patients, 19% of intensive versus 38% of conventional had progression and 31% of intensive versus 0% of conventional, regression (P = .04). Ischemia on baseline exercise tolerance testing was associated with significantly greater proximal disease progression among the asymptomatic patients. Clinical cardiovascular events (death, infarction, or revascularization) occurred in 10 of 38 symptomatic patients originally assigned to conventional therapy, compared with 5 of 76 symptomatic patients assigned to intensive (P < .01); no asymptomatic patient had an event.

CONCLUSIONS

Asymptomatic subjects with this high-risk profile have less coronary disease at baseline than comparable symptomatic patients, and they have an excellent short-term clinical prognosis. However, asymptomatic subjects are indistinguishable from symptomatic patients in terms of their arterial disease progression with conventional therapy and their regression with intensive. These findings may justify an active treatment strategy in such subjects, particularly those with provokable ischemia.

Autologous bone marrow transplantation for acute lymphoblastic leukemia

Between December 1979 and February 1991, 89 patients with ALL received autologous BMT. Median patient age was 18.4 years. Ten patients were in first remission, 52 were in second or greater remission and 27 were in relapse at the time of transplant. Conditioning regimens utilized chemotherapy alone (5 patients) or in combination with 10-15.75 Gy total body irradiation (84 patients). Disease-free survival at 1 year is 50% for patients transplanted in first remission, 27% for those in > or = second remission and 8% for patients in relapse. Pre- and post-transplant variables were evaluated in univariate and multivariate analyses for their effect on survival and relapse. Factors significantly associated with improved survival were being transplanted in first remission and achieving a self-sustained platelet count > or = 20 x 10(9)/l in a shorter period of time. A decreased relapse rate after transplant was associated with a lower white blood count at diagnosis, being transplanted in first remission and not being transplanted in relapse.

Tachykinin receptors in the rat isolated uterus

Tachykinin receptors mediating uterotonic effects were examined in preparations from oestrogen-primed rats. In the absence of peptidase inhibitors [Lys5-MeLeu9-Nle10] NKA (4-10) was 14-fold more potent than neurokinin A (NKA), but the two peptides were equipotent in the presence of phosphoramidon alone and in combination with amastatin. The NK-2 receptor antagonist SR 48968 antagonised responses to the tachykinins. These findings indicate that an NK-2 receptor is present in the oestrogen-primed rat uterus and that endopeptidase 24.11 plays a major role to inactivate NKA in this tissue.

Decreased weight gain in BB rats before the clinical onset of insulin-dependent diabetes

Inbred specific pathogen-free diabetes-prone (DP) and diabetes-resistant (DR) BB rats were crossed to produce F1 and intercrossed to produce F2 rats. Diabetes segregates in these crosses as a recessive trait on rat chromosome 4. The weight gain of genetically diabetes-prone rats born to F1 healthy parents was studied to avoid effects of maternal diabetes. The weight gain of the F2 rats was initially not different from the F1 parents. The F2 rats later developing diabetes grew in parallel with their non-affected siblings up until the last 9 days before onset. During these 9 days they showed a decreased weight gain compared to their healthy litter-mates regardless of age. We conclude that decreased weight gain precedes the abrupt clinical onset of diabetes in BB rats and that it may be due to processes associated with the selective loss of beta cells.