Current clinical evidence is insufficient to support HMME-PDT as the first choice of treatment for young children with port wine birthmarks

BACKGROUND

Port wine birthmark (PWB) is a congenital vascular malformation of the skin. Pulsed dye laser (PDL) is the "gold standard" for the treatment of PWB globally. Hematoporphyrin monomethyl ether (HMME or hemoporfin)-mediated photodynamic therapy (HMME-PDT) has emerged as the first choice for PWB treatment, particularly for young children, in many major hospitals in China during the past several decades.

AIM

To evaluate whether HMME-PDT is superior to PDL by comparing the clinical efficacies of both modalities.

METHOD

PubMed records were searched for all relevant studies of PWB treatment using PDL (1988-2023) or HMME-PDT (2007-2023). Patient characteristics and clinical efficacies were extracted. Studies with a quartile percentage clearance or similar scale were included. A mean color clearance index (CI) per study was calculated and compared among groups. An overall CI (C0), with data weighted by cohort size, was used to evaluate the final efficacy for each modality.

RESULT

A total of 18 HMME-PDT studies with 3910 patients in China were eligible for inclusion in this analysis. Similarly, 40 PDL studies with 5094 patients from nine different countries were eligible for inclusion in this analysis. Over 58% of patients in the HMME-PDT studies were minors (<18 years old). A significant portion (21.3%) were young children (<3 years old). Similarly, 33.2% of patients in the PDL studies were minors. A small proportion (9.3%) was young children. The overall clearance rates for PDL were slightly, but not significantly, higher than those for HMME-PDT in cohorts with patients of all ages (C0, 0.54 vs. 0.48, p = 0.733), subpopulations with only minors (C0, 0.54 vs. 0.46, p = 0.714), and young children (C0, 0.67 vs. 0.50, p = 0.081). Regrettably, there was a lack of long-term data on follow-up evaluations for efficacy and impact of HMME-PDT on young children in general, and central nervous system development in particular, because their blood-brain barriers have a greater permeability as compared to adults.

CONCLUSION

PDL shows overall albeit insignificantly higher clearance rates than HMME-PDT in patients of all ages; particularly statistical significance is nearly achieved in young children. Collectively, current evidence is insufficient to support HMME-PDT as the first choice of treatment of PWBs in young children given: (1) overall inferior efficacy as compared to PDL; (2) risk of off-target exposure to meningeal vasculature during the procedure; (3) administration of steriods for mitigation of side effects; -and (4) lack of long-term data on the potential impact of HMME on central nervous system development in young children.

Endothelial cells differentiated from patient dermal fibroblast-derived induced pluripotent stem cells resemble vascular malformations of port-wine birthmark

Lesional induced pluripotent stem cell-derived endothelial cells can resemble pathological vascular phenotypes of port-wine birthmark (PWB). Our data demonstrate that multiple pathways, including Hippo and Wnt, NFκB, TNF, MAPK and cholesterol metabolism, are dysregulated. These data suggest new therapeutics can be developed to target such dysregulated pathways in the treatment of PWB.

Supporting materials: Endothelial cells differentiated from patient dermal fibroblast-derived induced pluripotent stem cells resemble vascular malformations of Port Wine Birthmark

Background

Port wine birthmark (PWB) is a congenital vascular malformation resulting from developmentally defective endothelial cells (ECs). Developing clinically relevant disease models for PWB studies is currently an unmet need.

Objective

Our study aims to generate PWB-derived induced pluripotent stem cells (iPSCs) and iPSC-derived ECs that preserve disease-related phenotypes.

Methods

PWB iPSCs were generated by reprogramming lesional dermal fibroblasts and differentiated into ECs. RNA-seq was performed to identify differentially expressed genes (DEGs) and enriched pathways. The functional phenotypes of iPSC-derived ECs were characterized by capillary-like structure (CLS) formation in vitro and Geltrex plug-in assay in vivo .

Results

Human PWB and control iPSC lines were generated through reprogramming of dermal fibroblasts by introducing the "Yamanaka factors" (Oct3/4, Sox2, Klf4, c-Myc) into them; the iPSCs were successfully differentiated into ECs. These iPSCs and their derived ECs were validated by expression of a series of stem cell and EC biomarkers, respectively. PWB iPSC-derived ECs showed impaired CLS in vitro with larger perimeters and thicker branches as compared to control iPSC-derived ECs. In the plug-in assay, perfused human vasculature formed by PWB iPSC- derived ECs showed bigger perimeters and greater densities than those formed by control iPSC- derived ECs in severe combined immune deficient (SCID) mice. The transcriptome analysis showed that dysregulated pathways of stem cell differentiation, Hippo, Wnt, and focal adhesion persisted through differentiation of PWB iPSCs to ECs. Functional enrichment analysis showed that Hippo and Wnt pathway-related PWB DEGs are enriched for vasculature development, tube morphology, endothelium development, and EC differentiation. Further, members of the zinc finger (ZNF) gene family were overrepresented among the DEGs in PWB iPSCs. ZNF DEGs confer significant functions in transcriptional regulation, chromatin remodeling, protein ubiquitination, and retinoic acid receptor signaling. Furthermore, NF-kappa B, TNF, MAPK, and cholesterol metabolism pathways were dysregulated in PWB ECs as readouts of impaired differentiation.

Conclusions

PWB iPSC-derived ECs render a novel and clinically-relevant disease model by retaining pathological phenotypes. Our data demonstrate multiple pathways, such as Hippo and Wnt, NF-kappa B, TNF, MAPK, and cholesterol metabolism, are dysregulated, which may contribute to the development of differentiation-defective ECs in PWB.

Bulleted statements

What is already known about this topic?: Port Wine Birthmark (PWB) is a congenital vascular malformation with an incidence rate of 0.1 - 0.3 % per live births.PWB results from developmental defects in the dermal vasculature; PWB endothelial cells (ECs) have differentiational impairments.Pulse dye laser (PDL) is currently the preferred treatment for PWB; unfortunately, the efficacy of PDL treatment of PWB has not improved over the past three decades.What does this study add?: Induced pluripotent stem cells (iPSCs) were generated from PWB skin fibroblasts and differentiated into ECs.PWB ECs recapitulated their pathological phenotypes such as forming enlarged blood vessels in vitro and in vivo.Hippo and Wnt pathways were dysregulated in PWB iPSCs and ECs.Zinc-finger family genes were overrepresented among the differentially expressed genes in PWB iPSCs.Dysregulated NF-kappa B, TNF, MAPK, and cholesterol metabolism pathways were enriched in PWB ECs.What is the translational message?: Targeting Hippo and Wnt pathways and Zinc-finger family genes could restore the physiological differentiation of ECs.Targeting NF-kappa B, TNF, MAPK, and cholesterol metabolism pathways could mitigate the pathological progression of PWB.These mechanisms may lead to the development of paradigm-shifting therapeutic interventions for PWB.

A review of the effects of insulin-like growth factor and platelet derived growth factor on in vivo cartilage healing and repair

Growth factors may enhance current cartilage repair techniques via multiple mechanisms including recruitment of chondrogenic cells (chemotaxis), stimulation of chondrogenic cell proliferation (mitogenesis) and enhancement of cartilage matrix synthesis. Two growth factors that have been studied in cartilage repair are insulin-like growth factor (IGF) and platelet derived growth factor (PDGF). IGF plays a key role in cartilage homeostasis, balancing proteoglycan synthesis and breakdown. Incorporating IGF into a fibrin clot placed in an equine cartilage defect improved the quality and quantity of repair tissue and reduced synovial inflammation. PDGF is a potent mitogenic and chemotactic factor for all cells of mesenchymal origin, including chondrocytes and mesenchymal stem cells. Resting zone chondrocytes cultured with PDGF demonstrated increased cell proliferation and proteoglycan production, while maturation of these cells along the endochondral pathway was inhibited. Pretreating chondrocytes with PDGF promotes heterotopic cartilage formation in the absence of any mechanical stimulus. PDGF has also been shown to be a potent stimulator of meniscal cell proliferation and migration. These studies and others suggest a potential role for these potent biological regulators of chondrocytes in cartilage repair. More work needs to be performed to define their appropriate dosing and the optimum delivery method. Combining tissue growth factors with a biological matrix can provide a physical scaffold for cell adhesion and growth as well as a means to control the release of these potent molecules. This could result in biological devices that enhance the predictability and quality of current cartilage repair techniques.

Antisocial, an intracellular adaptor protein, is required for myoblast fusion in Drosophila

Somatic muscle formation in Drosophila requires fusion of muscle founder cells with fusion-competent myoblasts. In a genetic screen for genes that control muscle development, we identified antisocial (ants), a gene that encodes an ankyrin repeat-, TPR repeat-, and RING finger-containing protein, required for myoblast fusion. In ants mutant embryos, founder cells and fusion-competent myoblasts are properly specified and patterned, but they are unable to form myotubes. ANTS, which is expressed specifically in founder cells, interacts with the cytoplasmic domain of Dumbfounded, a founder cell transmembrane receptor, and with Myoblast city, a cytoskeletal protein, both of which are also required for myoblast fusion. These findings suggest that ANTS functions as an intracellular adaptor protein that relays signals from Dumbfounded to the cytoskeleton during myoblast fusion.

A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities

IMPLICATIONS

Tracheal lacerations are rare, but potentially fatal, complications of intubations. Diagnosis of such conditions is difficult, and thus a high level of suspicion must be kept. We present a case and review the literature for factors that indicate high-risk patients.

Health status of mothers of adults with intellectual disability

A cross-sectional survey was conducted to describe the health of mothers of adults with intellectual disability (ID), and the influence of the mother's and her adult child's characteristics on her health. The sample consisted of 108 mothers divided into mid-life and later-life groups. Four service agencies mailed SF-36 forms and demographic questionnaires to their clients. The return rate from primary caregivers was 70%. The physical and the mental components of health of both groups of mothers were found to be similar to or better than those of their counterparts in the US national norms. Arthritis was found to influence the physical health of both groups of mothers. Employment was found to influence physical health of the mid-life mothers, while family income was found to influence mental health of the later-life mothers. The characteristics of adults with ID did not influence the mothers' health significantly. Mothers' caregiving for their adult children with ID might not be as detrimental to the mid-life mothers' physical component of health as it might be to the later-life mothers. Further studies are needed.

Breast and cervical cancer screening among Chinese American women

PURPOSE

The purpose of this study was to describe breast and cervical cancer screening knowledge and practices of a representative sample of Chinese American women and to examine the factors associated with screening practices.

DESCRIPTION OF STUDY

A random sample of 332 Chinese American women, 40 to 69 years of age, from the Chinatown area of Chicago, Illinois, were interviewed face to face, using both Chinese Mandarin (or Putunghua) and Cantonese versions of the National Health Interview Survey (NHIS) Cancer Control Supplement Questionnaire. Knowledge and use of mammogram, clinical breast examination (CBE), breast self-examination (BSE), and Pap smear test were assessed.

RESULTS

The results showed a low level of knowledge of cancer screening tests and low use rates. Multiple logistics regression analysis showed that women with spoken English fluency were more likely to have knowledge and use of CBE, BSE, Pap test, and mammograms. Women with better than an elementary education were more likely to have knowledge and use of CBE, BSE, and Pap test. The source of medical care was statistically significant for having had a mammogram. Knowledge of cancer warning signs and symptoms was significant for knowledge of mammogram and BSE and for the use of BSE.

CLINICAL IMPLICATIONS

Multiple strategies are needed. These might include the following: 1) integration of research with population-based care by physicians and scientists; 2) coordinated public health education on cancer screening and postscreening support in Chinese languages; and 3) replication of the NHIS survey methodology and adaptive application of these instruments across several states and regions, combined with the assessment of screening performance in Chinese American populations.

Nutritional status of Korean Americans: implications for cancer risk

PURPOSE/OBJECTIVES

To examine nutrient intake of Korean Americans, especially those foods and supplements implicated in cancer.

DESIGN

Cross-sectional survey and descriptive analysis.

SETTING

Chicago, IL.

SAMPLE

103 Korean Americans who were between 40 and 69 years of age.

METHODS

An Instrument, culturally and linguistically adapted from the Health Habits and History Questionnaire, was administered to assess nutrient intake from food and vitamin and mineral supplements. Bilingual interviewers collected data at respondents' homes.

FINDINGS

Relative to their diet in Korea, more than one-third of the respondents reported an increase in the consumption of beef, dairy products, coffee, soda, and bread, as well as a decrease in the intake of fish and rice and other grains. Compared to the general U.S. population included in the National Health Interview Survey (NHIS), Korean Americans had a greater intake of carbohydrates and vitamins A and C and lower intake of total fat, cholesterol, and saturated fat. Moreover, the percentages of calories were higher from carbohydrates and lower from fat, sweets, and alcohol for Korean Americans than those reported by NHIS respondents. Gender, education, and marital status were significantly associated with nutrient intake. The use of daily vitamin and calcium supplements was similar between respondents and those from NHIS.

CONCLUSIONS

At their stage of cultural adaptation, the incorporation of a larger quantity of Western food items did not make for a less healthy dietary pattern among respondents. Data showed that Korean Americans continued to consume diets more consistent with Korean than with American food patterns, in as much as greater than 60% of their calories came from carbohydrates and about 16% of calories from fat. As a group, respondents met the recommended dietary guidelines for most nutrients, except for dietary fiber and calcium.

IMPLICATIONS FOR NURSING PRACTICE

Variation in dietary intake by age, culture, gender, and years in the United States is well accepted. Effective cancer prevention and initiatives for dietary reform call for the incorporation of available research findings and considerable attention to data gaps regarding Korean Americans and other Asian Americans and Pacific Islander populations. Culturally competent, community-based programs should include the reinforcement of positive traditional dietary habits, encourage the adaptation of healthy Western food items, as well as assist minority populations in developing strategies that will effectively correct likely deficiencies in diet.

[Expression of CD44s and CD44v6 in laryngeal squamous cell carcinoma and their significance]

OBJECTIVE

To study the correlation between the expression of CD44s, CD44v6 and the clinicopathological characters of laryngeal squamous cell carcinoma (LSCC) so as to analyze the role of them in occurrence and progression of LSCC.

METHOD

Expression of CD44 and CD44v6 in 46 cases of LSCC and 20 cases of adjacent normal tissues was inspected with immunohistochemical SP method.

RESULT

The expression of CD44s increased significantly in lymphnode metastasis group (94.4%) and stage III-IV group (96.2%), but decreased in non-lymphnode metastasis group (67.9%) and stage I-II group (55.0%). The expression of CD44v6 was lower (21.7%), which wasn't associated with any clinicopathological characters.

CONCLUSION

The role of CD44 and CD44v6 in carcinoma maybe dependent on the species, type of carcinoma, and the expression of CD44s may be a biologic marker to evaluate metastasis of LSCC.

TNFalpha-308A allele in juvenile dermatomyositis: association with increased production of tumor necrosis factor alpha, disease duration, and pathologic calcifications

OBJECTIVE

To characterize the association between the TNFalpha-308A allele and 1) duration of active disease, 2) peripheral blood mononuclear cell (PBMC) synthesis of tumor necrosis factor alpha (TNFalpha) in vitro, and 3) pathologic calcifications in patients with juvenile dermatomyositis (DM).

METHODS

The TNFalpha-308 alleles were determined by polymerase chain reaction in 37 white patients with juvenile DM and in 29 control subjects. Patients were grouped according to duration of immunosuppressive therapy: long (> or =36 months) or short (<36 months). Unstimulated PBMC were examined by enzyme-linked immunosorbent assay for TNFalpha production in vitro. Sixty-five white patients with juvenile DM were examined for pathologic calcifications.

RESULTS

TNFalpha-308A was identified in 18 of 37 patients with juvenile DM, in contrast with 5 of 29 controls (P = 0.009). Sixteen of the 18 patients with juvenile DM who had the TNFalpha-308A allele had a disease course > or =36 months, compared with 6 of 19 patients with TNFalpha-308G (P = 0.001). PBMC from 16 of the 18 juvenile DM patients with TNFalpha-308A synthesized more TNFalpha (median 53 pg/ml) compared with PBMC from 9 of 19 patients with TNFalpha-308G (median 19 pg/ml) (P = 0.007). Nineteen of 22 juvenile DM patients requiring therapy for > or =36 months produced more TNFalpha (median 20.5 pg/ml) in comparison with 6 of 15 juvenile DM patients with a <36-month treatment course (median TNFalpha 0.0 pg/ml) (P = 0.005). Detectable calcifications were present in 3 of 8 children with juvenile DM who had TNFalpha-308AA, compared with 2 of 21 children with TNFalpha-308AG and 1 of 36 children who had TNFalpha-308GG (P = 0.017).

CONCLUSION

A long course of juvenile DM and the presence of pathologic calcifications were associated with the TNFalpha-308A allele and with the increased production of TNFalpha, which may perpetuate the inflammatory response.

Smoking behavior, knowledge, and beliefs among Korean Americans

PURPOSE

The purpose of the study was to examine smoking behavior, knowledge, and beliefs among Korean Americans.

DESCRIPTION OF STUDY

One hundred four Korean American men and 159 women, 40 to 69 years old, living in Chicago, Illinois, served as study respondents. The National Health Interview Survey (NHIS) Cancer Control Supplement Questionnaire was used to collect data. The NHIS was translated into Korean with minor modifications to develop a culturally appropriate instrument.

RESULTS

This study suggests that smoking is almost exclusively a male behavior (38.5%) and that Korean American men smoke mostly cigarettes. Almost 90% of women have never smoked, whereas 23% of men reported never smoking. Respondents with a non-Christian background or no religious affiliation were 16.5 times more likely to be current smokers. Respondents who had lived in the United States less than 10 years were 12.5 times more likely to be current smokers. More than 90% of men, regardless of smoking status, were able to identify an association between smoking and major chronic diseases.

CLINICAL IMPLICATIONS

The prevalence of smoking among these Korean American men places them at considerable risk for smoking-related disease. Healthcare providers must be better informed about smoking behavior in this group, and specific attention to recently migrated men and those reporting religions other than Christianity is recommended. Health-protecting strategies for women and children who fall victim to secondhand smoke, or who may be targeted by tobacco advertising, are also an important step in disease prevention for this population.

Importance of the MKK6/p38 pathway for interleukin-12-induced STAT4 serine phosphorylation and transcriptional activity

Interleukin-12 (IL-12) is a key immunoregulatory cytokine that promotes Th1 differentiation and cell-mediated immune responses. The transcription factor STAT4 (signal transducer and activator of transcription 4) is an important element in mediating IL-12 signals, as evidenced by the fact that STAT4(-/-) mice display impaired responsiveness to IL-12 and deficient Th1 differentiation. STAT4 is inducibly phosphorylated on tyrosine and serine in response to IL-12, but the kinase(s) responsible for the latter event is unknown. Here we show that IL-12 induces STAT4 phosphorylation on serine 721 and that mutation of serine 721 interferes with STAT4 transcriptional activity. In addition, we show that mutation of tyrosine 693 abrogates IL-12-induced STAT4 tyrosine phosphorylation and transcriptional activity. Although the site surrounding serine 721 is an optimum consensus sequence for mitogen-activated family of protein kinases (MAPKs)-mediated phosphorylation, we demonstrate that IL-12 does not induce extracellular signal-regulated kinase (ERK) or c-Jun N-terminal kinase (JNK) activation in T and natural killer (NK) cells and that IL-12-induced STAT4 transcriptional activity is not affected by these kinases. Rather, we show that IL-12 induces p38 activation. Moreover, we demonstrate that p38alpha and its upstream activator, MKK6, phosphorylate STAT4 on serine 721, and are required for STAT4 full transcriptional activity induced by IL-12, establishing the MKK6/p38alpha/STAT4 pathway as an important mediator of IL-12 actions. (Blood. 2000;96:1844-1852)

Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group

OBJECTIVES

To determine the prevalence of symptoms associated with gastroesophageal reflux (GER) in 3- to 17-year-old children, to describe the prevalence of factors associated with GER in these children, and to determine the percentage of symptomatic children who have been treated.

DESIGN

A cross-sectional survey.

SETTING

Sixteen pediatric practice research group practices in the Chicago, Ill, area (urban, suburban, and semirural).

PARTICIPANTS

A total of 566 parents of 3- to 9-year-old children, 584 parents of 10- to 17-year-old children, and 615 children aged 10 to 17 years.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Reported frequency of symptoms associated with GER.

RESULTS

Parents of 3- to 9-year-old children reported that their children experienced a sensation of heartburn ("burning/painful feeling in middle of chest"), epigastric pain ("stomachache above belly button"), and regurgitation ("sour taste or taste of throw up") 1.8%, 7.2%, and 2.3% of the time, respectively. Parents of 10- to 17-year-old children reported that their children experienced the same symptoms 3.5%, 3.0%, and 1.4% of the time, while children aged 10 to 17 years reported the symptoms 5.2%, 5.0%, and 8.2% of the time, respectively. Complaints of abdominal pain ("stomachache") were most common, reported by 23.9% and 14.7% of parents of 3- to 9-year-old and 10- to 17-year-old children and by 27.9% of children aged 10 to 17 years. In those aged 10 to 17 years, heartburn reported by the children was associated with reported cigarette use (odds ratio, 6.5; 95% confidence interval, 2-21); no other complaint was associated with cigarette, alcohol, or caffeine consumption or passive smoking exposure. In 3- to 9-year-old children, no complaint was associated with caffeine consumption or passive smoking exposure. Reported treatment in the past week with antacids was 0.5% according to parents of children aged 3 to 9 years and 1.9% and 2.3% according to parents of children aged 10 to 17 years and children aged 10 to 17 years, respectively. Treatment with over-the-counter histamine receptor blockers was 0% for children aged 3 to 9 years and 10 to 17 years, as reported by their parents, and 1.3% for those aged 10 to 17 years, as reported by themselves.

CONCLUSIONS

Symptoms suggestive of GER are not rare in childhood, yet only a fraction of children with symptoms are treated with over-the-counter antacids or histamine2 antagonists. Prospective longitudinal data are needed to determine which children with symptoms of GER actually have GER disease and are at risk of developing complications.

Application of modified CHIP-AE in a vocational high school

Adolescent health behaviors tend to cluster and vary by such factors as grade, age, and racial/ethnic background. A population-based instrument was needed to assess health behaviors of the students in a vocational high school in the City of Chicago. To reduce respondent burden, Child Health and Illness Profile--Adolescent Edition (CHIP-AE) was modified by omitting seven subdomains. Ninety-three boys and 245 girls voluntarily participated in the study. Pearson correlation coefficients, MANOVA, and ANOVA were used in data analysis. Modified CHIP-AE was found to have acceptable reliability and detect the expected differences of adolescent health behaviors by gender and age. Modified CHIP-AE can be used to assess adolescent health behaviors in an urban vocational high school. It can also be used to target the subgroups of students with specific needs for health services.

Pressure-limited ventilation of infants with low-compliance lungs: the efficacy of an adult circle system versus two free-standing intensive care unit ventilator systems using an in vitro model

We compared the efficacy of a Drager Narkomed GS (North American Drager, Telford, PA) equipped with an adult circle system with two free-standing infant ventilator systems (Servo 300; Siemens Medical Systems, Danvers, MA and Babylog 8000; North American Drager) to deliver minute ventilation (VE) using pressure-limited ventilation to a test lung set to low compliance. To simulate a wide variety of potential patterns of ventilation, VE was measured at peak inspiratory pressures (PIP) of 20, 30, 40, and 50 cm H2O and at respiratory rates (RR) of 20, 30, 40, and 50 breaths/min. Each measurement was made three times; the average was used for data analysis using the multiple regression technique. Delivered V(E) was positively correlated with both PIP (P = 0.001) and RR (P = 0.001). Only minimal differences in VE were observed between the circle and the two free-standing systems. At lower RR and PIP, the Babylog 8000 system delivered slightly higher VE than the circle system, whereas at higher RR and PIP, the Babylog 8000 delivered slightly lower VE than the circle system; these differences in VE were not statistically significant (P = 0.45). The Servo 300 delivered slightly higher VE than the circle system in all test conditions, but these differences were not statistically significant (P = 0.09). None of the differences in delivered VE between the Servo 300 and the circle system are of clinical importance.

IMPLICATIONS

Our laboratory investigation suggests that pressure-limited ventilation delivered by a standard adult circle system compares favorably with that of freestanding infant ventilators used in pressure-limited mode. Changing from an adult circle system to a free-standing pressure-limited ventilator may not substantially improve ventilation of a low-compliance infant lung; the efficacy of such a practice should be investigated.

Cervical cancer screening knowledge and practices among Korean-American women

Cervical cancer is one of the most common cancers of American women. The Papanicolaou (Pap) smear test for cervical screening is a widely used and effective means to reduce the morbidity and mortality rate from cervical cancer through early detection. Despite these benefits, many women have never been screened or are not screened at regular intervals. The purpose of this study was to examine cervical cancer screening knowledge and practices of Korean-American women. The sample consisted of 159 Korean-American women, 40 to 69 years of age. The 1987 Cancer Control Supplement questionnaire was translated into Korean and used to collect data. Twenty-six percent of the respondents never heard of the Pap smear test. Only 34% of respondents reported having had a Pap smear test for screening. The most frequently cited reason for not having had a Pap smear test was absence of disease symptoms. Results indicate that education and usual sources of health care were significant factors related to having heard of or having had a Pap smear test. The findings from this study have important implications for health practitioners and policy makers who serve this ethnic population.

Efficacy of media enriched with nonlactate-generating substrate for organ preservation: in vitro and clinical studies using the cornea model

BACKGROUND

Using a rabbit cornea model, our recent study demonstrated that Chen Medium (CM), an isotonic media enriched with nonlactate-generating high-energy substrates, is very effective for organ preservation. In the present study, the efficacy of CM is further evaluated with human corneas

METHODS

The effectiveness of CM and Optisol for preserving the endothelial integrity of human corneas in vitro was evaluated by scanning electron microscopy. Clinical efficacy was evaluated in a total of 83 patients: 10 patients with keratoconus grafted randomly with either CM- or Optisol-stored cornea of the same donor, and 73 patients with various conditions grafted with CM-stored corneas. After surgery, visual acuity and quality of the graft were monitored for up to 4.6 years.

RESULTS

The scanning electron microscopic study revealed that after 11-day storage at 4 degrees C, the CM-stored cornea had only marginal disruptive changes, 9.4+/-1.1%, in endothelial cells, as opposed to 42.4+/-4.6% of the Optisol-stored cornea. All 78 CM-stored corneas, including 67 with 12.2- to 17.7-hr death-to-storage time, 3-7.6 days of storage time, and initial marginal quality before storage, were successfully transplanted. These grafts were thin and clear, with an excellent epithelial integrity and without significant changes in endothelial cell density. Five Optisol-stored corneas were also successfully grafted; one of them, however, was edematous for about 4 weeks, and all the grafts were slightly thicker with substantial endothelial cell loss.

CONCLUSION

Using a cornea model, present and recent studies show that CM is very effective for preserving tissue viability and endothelial integrity. Previous study revealed that CM-stored tissues maintained high levels of ATP and metabolic function, with suppression of lactate formation and accumulation. Thus, these findings support the concept that preservation of tissue viability is closely associated with the ability of the tissues to retain metabolic activity, to generate ATP efficiently, and to prevent acidosis effectively during storage.

An adult system versus a Bain system: comparative ability to deliver minute ventilation to an infant lung model with pressure-limited ventilation

We compared the efficacy of an adult circle system versus a Bain system to deliver minute ventilation (V(E)) to an infant test lung model using pressure-limited ventilation. To simulate a wide variety of potential infant clinical states, V(E) was measured with two compliances: at peak inspiratory pressures (PIP) of 20, 30, 40, and 50 cm H2O and at respiratory rates (RR) of 20, 30, 40, and 50 breaths/min. Each measurement was made three times, and their average was used for analysis. Data were analyzed using the multiple regression technique. In both normal and low-compliance lung models, V(E) was nearly identical between adult circle and Bain systems (P = 0.67 for normal compliance model, P = 0.89 for low-compliance model). V(E) positively correlated with RR (P < 0.001), PIP (P < 0.001), and lung compliance (P < 0.001). Very high PIP or RR were required to deliver V(E) to the low-compliance lung model. The adult circle system is equivalent to the Bain system in its ability to ventilate an infant test lung over a wide range of RR, PIP, and two compliances during pressure-limited ventilation. V(E) is dependent of PIP, RR, and lung compliance. With low-compliance lungs, both systems require a high PIP. We conclude that both anesthetic systems deliver ventilation over a wide range of respiratory variables during pressure-limited ventilation in infants.

IMPLICATIONS

We obtained results from this infant test lung study that indicate that either an adult circle breathing system or the Bain system can reliably deliver ventilation over a wide range of respiratory variables during pressure-limited ventilation in infants.

Use of emergency departments by elder patients: a five-year follow-up study

OBJECTIVE

To compare the use of emergency medical care by elders in the United States in 1995 with that previously described for 1990.

METHODS

A computerized billing database of 88 EDs in 21 states was retrospectively reviewed for 1995, comparing elder and nonelder patients, estimating national use of emergency medical services by elders, and comparing the 1995 data with previously published results for 1990.

RESULTS

From 1990 to 1995, the number of ED visits in the United States increased from 92 million to 100 million. The number of visits made by patients aged 65 years or older increased from 13,639,400 (15%) to 15,666,300 (15.7%), but this increase did not reach statistical significance (p = 0.17). The admission rate for elder ED patients increased from 32% to 46% over the five-year interval (p<0.01). This represents more than 7 million hospital admissions for elder patients in 1995. The rate of intensive care unit (ICU) admission for elders decreased from 7% to 6% over the five-year interval (p = 0.56), compared with 1.3% for nonelder patients for both years. Thirty percent of elder ED patients arrived by ambulance in 1990, compared with 33% in 1995 (p = 0.02). Based on 1995 data, elders comprised 39% of patients arriving by ambulance [odds ratio (OR) 4.75, 95% confidence interval (CI) = 4.71 to 4.79], 43% of all admissions (OR 6.59, 95% CI = 6.54 to 6.64), and 47% of ICU admissions (OR 5.00, 95% CI = 4.91 to 5.09). The comparable ORs in 1990 were 4.4, 5.6, and 5.5, respectively.

CONCLUSIONS

From 1990 to 1995, the overall number of ED visits increased. The rate of increase was somewhat greater for elder patients. The use of ambulance services also disproportionately grew among elder patients, as did the rate of hospital admission. The overall rate of ICU admission was stable, but actually fell modestly for elder patients. Of these changes, only the increase in the rate of hospital admission for elders reached statistical significance.

One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatric Practice Research Group

OBJECTIVES

1) Determine what percentage of infants outgrow regurgitation over 1 year. 2) Determine whether they develop feeding or mealtime problems. 3) Determine whether they develop frequent respiratory illnesses, including ear, sinus, and upper respiratory infections, or wheezing episodes.

DESIGN

One-year follow-up survey of parents of children identified at 6 to 12 months of age as those who regurgitate (case subjects) and matched control subjects.

PARTICIPANTS

Sixty-three case subjects and 92 control subjects attending 12 different (urban, suburban, and rural) practices in the Pediatric Practice Research Group in the Chicago area.

PRIMARY OUTCOME MEASURES

The Infant Gastroesophageal Reflux Questionnaire-Shortened and Revised Form and the Children's Eating Behavior Inventory (CEBI).

RESULTS

At 1-year follow-up, no parents of case or control subject described spitting up as currently a problem. The parent of only one control subject (and no case subject) reported spitting up one or more times a day. Parents of subjects were more likely than those of control subjects to report frequent feeding refusal: odds ratio = 4.2, adjusted by age (95% confidence interval: 1.4-12.0). Case and control subjects had comparable average total CEBI scores (case subjects, = 83 +/- 10 vs control subjects, = 82 +/- 11) and comparable average proportion of items identified as a problem (8% +/- 11% case subjects vs 6% +/- 9% control subjects). Case subjects were more likely to respond positively to two CEBI questions indicating specific feeding problems: 1) "my child takes more than an hour to eat his/her meals" (8% case subjects vs 0% control subjects) and 2) "I get upset when I think about our meals" (14% case subjects vs 4% control subjects). The frequencies of ear, sinus, and upper respiratory infections and of episodes of wheezing were comparable in both groups.

CONCLUSIONS

1) Infants with daily or problematic regurgitation at 6 to 12 months of age outgrew this within the following year. 2) Infants with daily or problematic regurgitation were more likely to develop feeding problems. 3) There was no increase in respiratory illnesses in infants with a history of regurgitation.

A comparison of three modes of ventilation with the use of an adult circle system in an infant lung model

We examined the efficiency of an adult circle system with adult bellows to deliver minute ventilation (VE) to an infant test lung model. A Narkomed 2B system (North American Drager, Telford, PA) using three modes of ventilator setup were used: A = time-cycled, volume-controlled using bellows excursion to control delivered volume; B = time-cycled, pressure-controlled using inspiratory pressure limit adjustment to control delivered volume; C = time-cycled, pressure-controlled using the inspiratory flow adjustment to control delivered volume. VE was measured with two compliances (normal and low) and four endotracheal tube (ETT) sizes (2.5-, 3.0-, 3.5-, and 4.0-mm inner diameter). VE was measured at peak inspiratory pressures (PIP) of 20, 30, 40 or 50 cm H2O while respiratory rate (RR) was held constant at 20 breaths/min. VE was measured as RR was set at 20, 30, 40, or 50 breaths/min while target PIP was held constant at 20 cm H2O. Data were analyzed using the multiple regression technique. With the low compliance model, VE was nearly identical regardless of the ventilator setup. With the normal compliance model, minor differences in VE were observed, especially at the highest RR and PIP. VE was dependent on RR, PIP, and lung compliance. Overall, the ventilator setup resulted in minor changes in VE. Very high PIPs were required to deliver VE to the low compliance model. ETT size did not affect VE when lung compliance was low; however, smaller ETT size was a factor when test lung compliance was normal, decreasing delivered VE at higher PIP and RR. We conclude that with a Narkomed 2B adult circle system VE is dependent on PIP, RR, and lung compliance, but not on mode of ventilator setup.

IMPLICATIONS

The results of this laboratory investigation indicate that when an adult circle system is used during infant anesthesia, the ventilation delivered depends primarily on the respiratory rate, peak inspiratory pressure, and the compliance of the lung being ventilated, rather than on the specific mode of ventilator setup.

Colorectal cancer screening. Knowledge and practices among Korean Americans

PURPOSE

The purpose of this study was to examine knowledge and practices of colorectal cancer screening among Korean Americans.

DESCRIPTION OF STUDY

The sample consisted of 104 Korean American men and 159 women, 40 to 69 years of age, living in the Chicago area. The National Health Interview Survey (NHIS) Cancer Control Supplement Questionnaire, prepared by the National Center for Health Statistics, was used to collect data regarding colorectal cancer screening knowledge and practices. The NHIS questionnaire was translated into Korean with minor modification.

RESULTS

The percentage of male respondents ever having had a digital rectal exam (DRE) and fecal occult blood test (FOBT) were 13.5% and 10.6%, respectively. Only 11.3% of women reported DRE and 8.8% FOBT. Multiple logistic regression analysis results indicate that gender, education, knowledge of the seven cancer warning signals, and length of residence in the United States were significantly related to having heard of DRE. For those having had DRE, knowledge of the seven cancer warning signals, and length of residence in the United States were the only significant variables. Gender and education were significantly related to having heard of FOBT. None of the variables were found to be significantly related to having had FOBT. The findings indicate that a majority of respondents were unaware of these cancer screening examinations and forego these tests due to an underestimation of their importance.

CLINICAL IMPLICATIONS

The findings of this study underscore the importance of cancer education and further research addressing the cancer screening needs of Korean Americans. Currently, Korean Americans do not see healthcare providers or health brochures as valuable sources of health information. Therefore, healthcare professionals need to target this population by 1) coordinating their efforts with church and other community leaders and 2) developing health brochures that are in the Korean language and sensitive to the Korean culture.

The effect of circuit compliance on delivered ventilation with use of an adult circle system for time cycled volume controlled ventilation using an infant lung model

This in vitro study examined the effect of circuit compliance on delivered ventilation (VE) using a time-cycled, volume controlled circle system in an infant lung model. A Bio-Tek ventilator tester set to simulate normal and abnormal lung compliance measured VE delivered by the Narkomed 2B system. Circle circuits of varied compliance (2.75, 1.22 and 0.73 microliters.cm H2O-1) were tested. Tidal volume was adjusted to peak inflation pressures (PIP) of 20, 30, 40, and 50 cm H2O with three circuits, two lung compliances, and four different size tracheal tubes (TT) (2.5, 3.5, 4, 4.5 mm ID). Data were analysed using the multiple regression technique. Delivered VE was directly related to PIP and lung compliance. Delivered VE was not affected by the choice of circuit. TT size had minimal effects on VE when lung compliance was low; TT size was a more important factor when test lung compliance was normal. Extrapolating this data to the clinical setting, adequate ventilation of infants can be achieved with an adult circle system if an appropriate PIP is chosen, regardless of the compliance of the circuit used. Infants with poor lung compliance may require very high PIP for adequate ventilation.

Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group

OBJECTIVES

To determine the prevalence of symptoms associated with overt gastroesophageal reflux (GER) during the first year of life, to describe when most infants outgrow these symptoms, and to assess the prevalence of parental reports of various symptoms associated with GER and the percentages of infants who have been treated for GER.

DESIGN

Cross-sectional survey.

SETTING

Nineteen Pediatric Practice Research Group practices in the Chicago, Ill, area (urban, suburban, and semirural).

PARTICIPANTS

A total of 948 parents of healthy children 13 months old and younger.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Reported frequency of regurgitation.

RESULTS

Regurgitation of at least 1 episode a day was reported in half of 0- to 3-month-olds. This symptom decreased to 5% at 10 to 12 months of age (P < .001). Peak reported regurgitation was 67% at 4 months; the prevalence of symptoms decreased dramatically from 61% to 21% between 6 and 7 months of age. Infants with at least 4 episodes daily of regurgitation showed a similar pattern (P < .001). Peak regurgitation reported as a "problem" was most often seen at 6 months (23%); this prevalence decreased to 14% at 7 months of age. Parental perception that regurgitation was a problem was associated with the frequency and volume of regurgitation, increased crying or fussiness, reported discomfort with spitting up, and frequent back arching. Reported treatment for regurgitation included a change in formula in 8.1%, thickened feedings in 2.2%, termination of breast-feeding in 1.1%, and medication in 0.2%.

CONCLUSIONS

Complaints of regurgitation are common during the first year of life, peaking at 4 months of age. Many infants "outgrow" overt GER by 7 months and most by 1 year. Parents view this symptom as a problem more often than medical intervention is given.

Validity of three lumbar sagittal motion measurement methods: surface inclinometers compared with radiographs

Three surface methods for measuring lumbar sagittal motion (LSM) were tested for validity using radiographs as the "gold standard" reference. The three methods used were the Pleurimeter V double inclinometer, the carpenter double inclinometer, and the computerized sensor single inclinometer. In this study, 30 volunteers were examined independently by three occupational health professionals. Each volunteer rotated twice through three stations at which LSM was measured by each of the three methods. Radiographs were made during the first rotation. Predictability of the skin marks of T12 and S1 for the corresponding bone measures was acceptable for one examiner, mixed for another, and unacceptable for a third. The intraclass correlation coefficients (ICCs) ranged from 0.81 to 0.99, with half above the acceptable level of 0.90. However, the skin marks and the bone measures showed a linear relationship for all examiners (r > or = 0.89). For flexion and extension, all ICCs between the radiograph and each surface method were far below 0.90, indicating poor validity for each surface method. We concluded that skin placement of T12 and S1 has a linear relationship to bony landmarks, and that each of the tested surface methods does not validly measure LSM.

Reliability of three lumbar sagittal motion measurement methods: surface inclinometers

Three surface methods for measuring lumbar sagittal motion (LSM) were tested for reliability. The three methods used were the Pleurimeter V double inclinometer, the carpenter double inclinometer, and the computerized single sensor inclinometer. In this study, 30 volunteers were examined independently by three occupational health professionals. Each volunteer rotated twice through three stations at which LSM was measured by each of the three methods. The intra- and interexaminer reliabilities in identifying the skin levels of T12 and S1 were acceptable, having intraclass correlation coefficients (ICC) greater than or equal to 0.75. With a single exception, all ICC values for the intraexaminer reliability of LSM measurements fell below 0.90 (a clinically desirable level). The interexaminer reliability was poor, with all ICC values below 0.75. The largest source of measurement error was attributable to the examiner and its associated factors. We concluded that the intra- and interexaminer reliabilities varied greatly, limiting the clinical usefulness of the three surface methods.

Compartmental organization of the Drosophila genital imaginal discs

We have investigated the anterior and posterior compartmental organization of the genital imaginal disc. Unlike the thoracic discs, the genital disc is a compound disc consisting of three primordia--the female genital, male genital, and anal primordia. Here we provide evidence that each primordium is divided into anterior and posterior compartments. Genes that are known to be expressed in compartment-specific manners in other discs (engrailed, hedgehog, patched, decapentaplegic, wingless and cubitus interruptus) are expressed in analogous patterns in each primordium of the genital disc. Specifically, engrailed and cubitus interruptus are expressed in complementary domains, while patched, decapentaplegic and wingless are expressed along the border between the two domains. Mitotic clones induced at the beginning of the second larval instar do not cross the boundary between the engrailed-expressing and cubitus interruptus-expressing domains, indicating that these domains are true genetic compartments. Furthermore, we examined the phenotypes of mutant clones of the cAMP-dependent protein kinase A and engrailed-invected, genes that are known to play compartment-specific functions in other discs. These experiments demonstrate that the anterior/posterior patterning functions of these genes are conserved in the genital disc. The adult clonal phenotypes of protein kinase A and engrailed-invected mutants also provide a more detailed map of the adult genitalia and analia with respect to the anterior/posterior compartmental subdivision. Our results lead us to propose a new model to describe the anterior and posterior compartmental organization of the genital disc.

Environmental Exposure to Organic Mercury among the Makuxi in the Amazon Basin

Gold mining in the savannah region of northern Brazil (Roraima) has increased dramatically since 1989. Elemental mercury is used to extract gold from sediment. Mercury released into the Amazon aquatic ecosystem may convert into the organic form and bioconcentrate in the food chain, posing a hazard for fish-eating peoples such as some of the Makuxi. This survey compared blood organic mercury levels among Makuxi villagers along mined (Rio Cotingo) and unmined (Rio Surumu) rivers. Seventy-five blood samples were obtained from villagers who did not participate in gold mining or processing procedures in three Makuxi villages: Maravilha (heavily exposed), Limão (limitedly exposed), and Matarucca (minimally exposed). Blood was analyzed for total and inorganic mercury content by cold vapor spectrophotometry. Mean blood organic mercury levels among the villagers of Maravilha, Limão, and Matarucca were 31.3 mg/L, 9.3 mg/L, and 2.0 mg/L, respectively (p = 0.001). The authors conclude the gold mining process is contaminating the environment of Roraima and may pose a health hazard to its fish-eating populations, such as the Makuxi people.

Practice satisfaction, occupational stress, and attrition of emergency physicians. Wellness Task Force, Illinois College of Emergency Physicians

OBJECTIVE

To define sources of job satisfaction and stress among emergency physicians and assess self-projected career longevity.

DESIGN

A survey containing questions regarding emergency medicine (EM) practice satisfaction was mailed to 1,317 diplomates of the American Board of Emergency Medicine (ABEM). Specific sources of practice satisfaction and dissatisfaction, self-reported burnout or impairment, and plans for remaining in the specialty were assessed. Data were compared between two groups of physicians, namely, those residency-trained in EM and those attaining certification through the practice or special category tracts.

RESULTS

Of the physicians returning the survey, 25.2% stated that they felt burned out or impaired and 23.1% planned to leave the practice of EM within five years. Perceptions of burnout/impairment and plans to stop practice were associated with less overall practice satisfaction but were not significantly different between the two groups of physicians. Burnout/impairment was linked with psychiatric, drug, or alcohol problems and the feeling that EM had contributed to that problem.

CONCLUSION

This study confirms the relatively high levels of projected attrition in EM and supports the perception that stress and burnout are associated with the specialty. Differences in job satisfaction and stress between those ABEM diplomates who were residency-trained in EM and those who became eligible for the board examination through practice or special-category eligibility appear minor.

Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population

OBJECTIVE

To determine the seroprevalence of the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) in patients of an urban level I trauma center.

DESIGN

Prospective, blinded point prevalence study of serum HIV and HBV antibody and antigen.

SETTING

An urban level I trauma center that participates in a trauma system serving three million people.

PATIENTS

The study included 994 (94.8%) of 1049 consecutive trauma service patients treated between June 6, 1988 and September 22, 1988. The patients were 82.2% male and 73.1% black, with a mean age of 28.8 +/- 12.3 years. Blunt trauma was seen in 65.4% of patients, 5.2% were in shock, and 96.2% survived their trauma.

MAIN OUTCOME MEASURES

HIV and HBV seroprevalence, using both antibody and antigen testing.

RESULTS

HIV infection was seen in 43 patients (4.3%); 41 (95.3%) were HIV Ab+ and two (4.7%) were HIV Ab-/HIV Ag+. Infection with the HBsAg was seen in 31 patients (3.1%). Infection with either virus was seen in 70 patients (7%); four patients (0.4%) were infectious for both viruses. Infection was related to age 20 to 49 years, i.v. drug use, a hepatitis or sexually transmitted disease history, prior HIV testing, shock, and death (p < 0.05). Penetrating trauma was not predictive of infection. In a logistic regression model, IV drug use was the single significant predictor of infection (p < 0.05).

CONCLUSIONS

Young urban trauma patients, because of drug-related intentional violence, are 15.3 to 17.6 times more likely to be HIV infected and 3.9 to 7.9 times more likely to be infectious for HIV or HBV than the trauma population overall. The 12 to 21% infection rates in critically injured patients who require shock resuscitation and/or die reinforces the need for mandated universal precautions and for clear policies which govern the performance of procedures by physicians in training. Primary HIV infection in critically injured patients may worsen their outcome and may adversely affect the exposed health care worker. Emergency departments and trauma units should develop a referral system to HIV primary care services (HIV counselling and testing) for high risk patients and for adversely exposed health care workers.

Characterization of the deoxycytidine kinase promoter in human lymphoblast cell lines

Deoxycytidine kinase (dCK) phosphorylates 2'-deoxycytidine, as well as the purine deoxyribonucleosides and a number of nucleoside analogues that are important in the chemotherapy of leukemias. The enzyme is highly expressed in the thymus relative to other tissues and may play an important role in the T cell depletion associated with adenosine deaminase and purine nucleoside phosphorylase deficiencies. To characterize the dCK promoter region and to determine whether it mediates higher levels of gene expression in T lymphoblasts, we have analyzed a 700-bp genomic fragment encompassing 548 bp of 5' flanking region for functional activity and for transcription factor binding using T and B lymphoblast cell lines and nuclear extracts. The regions of the promoter that were defined as important to its function include a 5' GC box, and E box, a 3' GC box, and an E2F site. The transcription factor Sp1 binds to both GC boxes, activating at the 5' site but repressing at the 3' site. MLTF/USF activates transcription through the E box, whereas E2F activates through the E2F site, but binds weakly to this site in vitro and does not appear to mediate cell cycle-specific expression of dCK in vivo. No significant differences in promoter activity or transcription factor binding were observed between Jurkat T and Raji B lymphoblasts. The promoter of the dCK gene is thus regulated by a number of ubiquitously expressed transcription factors. DCK expression in cultured lymphoblast cell lines is not solely a function of the T or B lineage derivation.

Adequacy of prenatal care of urban high school students

Relationships of five selected variables to the adequacy of prenatal care of pregnant students in urban public high schools were studied. These five variables were: the age of the baby's father, mother's education, parity, living arrangement, and functional areas of support. From 1986 to 1989, a convenience sample of 244 African American, unmarried, pregnant students completed a prenatal questionnaire. The Resource Size scale, a subscale in the questionnaire, was tested on pregnant students, and its coefficient alpha for internal consistency was .86. Additional data were obtained from the state's live birth certificate tape. Results showed that the age of the baby's father was significantly associated with adequacy of prenatal care. Because 51% of the babies' fathers are age 15-19 and most likely in school, the community and school health nurses may encourage them to get involved in the care of pregnant students. Other implications are also drawn.

Family and community support for urban adolescent mothers

The family and community support of adolescent mothers who returned to school was described. One hundred and nine African American, unmarried, primiparous, postpartum students, enrolled in 20 public high schools of a large midwestern city from 1986 to 1989, completed the questionnaire. The Cronbach alpha for internal consistency was .90 for the Resource Size Scale. Results showed that (a) the support from professionals in community agencies was less frequently mentioned by the postpartum students than support from the family, (b) more than 20% of the students had no one available to provide positive feedback and assist with household tasks, (c) the student's mother and the baby's father were most involved in providing support, but differed by support functions, and (d) the baby's father's family was involved in providing support. The school nurses and other professionals need to assist adolescent mothers in seeking support from both the family and the community systems.

Teen voices on a proposed telephone health service

The purpose of this study was to elicit information, feelings, and perceptions of middle and high school students concerning a proposed telephone service for adolescents. Sixteen boys and 33 girls were recruited from six schools. Debriefing summaries from nine focus group sessions were analyzed. Most participants had access to a telephone and privacy during phone calls. Overall response to the proposed telephone service was favorable. The participants voiced needs for evening and night service hours, minimal or no service charges and skilled and caring operators. They also suggested catchy names and marketing strategies for the telephone service. Implications for designing a telephone service for adolescents were drawn.

Hereditary overexpression of adenosine deaminase in erythrocytes: studies in erythroid cell lines and transgenic mice

Overexpression of adenosine deaminase (ADA) in red blood cells is characterized by a marked, tissue-specific increase in levels of structurally normal ADA mRNA and enzymatic activity in the erythrocytes of affected individuals, leading to adenosine triphosphate (ATP) depletion and hemolytic anemia. This autosomal dominant trait is linked to the ADA gene. To investigate the molecular mechanism responsible for this disorder, we examined relative reporter gene activity using constructs containing 10.6 kb of 5' flanking sequence and 12.3 kb of the first intron of the ADA gene from the normal and mutant alleles. No differences in chloramphenicol acetyltransferase (CAT) activity were found in transient transfection experiments using erythroleukemia cell lines. Transgenic mice containing the ADA constructs expressed CAT in the appropriate tissue-specific fashion, with 10(2)- to 10(4)-fold higher activity in the thymus. However, CAT activities in erythrocytes and bone marrow of mice containing high transgene copy numbers did not differ between the normal and mutant alleles. These results indicate that the mutation responsible for ADA overexpression is unlikely to reside in the 5' and promoter regions or in the regulatory regions of the first intron. It is possible that the erythroid-specific overexpression of ADA results from a mutation at some distance from the gene or requires an interaction of a proximal mutation with more distal DNA elements.

Hereditary overexpression of adenosine deaminase in erythrocytes: evidence for a cis-acting mutation

Overexpression of adenosine deaminase (ADA) in red blood cells is inherited as an autosomal dominant trait and causes hemolytic anemia. The increased ADA activity in erythrocytes is due to an increase in steady-state levels of ADA mRNA of normal sequence. Increased ADA mRNA may be due to a cis-acting mutation which results in increased transcription or a loss of down-regulation during erythroid differentiation. Alternatively, it is possible that the mutation is in a trans-acting factor which interacts with normal ADA transcriptional elements to cause overexpression in red blood cells. To discriminate between a cis-acting and a trans-acting mutation, we took advantage of a highly polymorphic TAAA repeat located at the tail end of an Alu repeat approximately 1.1 kb upstream of the ADA gene. Using PCR to amplify this region, we identified five different alleles in 19 members of the family. All 11 affected individuals had an ADA allele with 12 TAAA repeats, whereas none of the 8 normal individuals did. We conclude that this disorder results from a cis-acting mutation in the vicinity of the ADA gene.

Do chart reviews and interviews provide the same information about breast and cervical cancer screening?

The National Cancer Institute of the United States has set a goal for the year 2000 that 80-90% of eligible women should have a Pap smear every 3 years and that 80% of women aged 50-70 should receive an annual breast examination and mammogram. Very few studies have examined how we might best measure our progress towards this goal. Specifically, should we employ interview data or data derived from medical records? To respond to this question, data were gathered at two different public health clinics in poor areas of Chicago using both techniques. The interviews estimated significantly higher proportions of women receiving Pap smears, breast examinations, and mammograms in the previous 12-month interval than were estimated from randomly selected medical records. A review of the literature suggests the same pattern exists when other studies using these two data gathering processes are compared. We are thus left with a serious problem, one that must be resolved before we will be able to fully assess our progress in increasing breast and cervical cancer screening.

Use of emergency departments by elderly patients: projections from a multicenter data base

STUDY OBJECTIVES

To assess the use of emergency medical care by the elderly in the United States, including emergency department visits, level of ED care required, ambulance services, and hospital admission rate.

SETTING AND PARTICIPANTS

A multicenter computerized data base of 70 hospitals in 25 states.

DESIGN

A retrospective review of elderly patients seeking ED care and comparison of elderly and nonelderly patients. The data were then used to estimate the use of emergency medical services nationally.

MEASUREMENTS AND MAIN RESULTS

Fifteen percent of the 1,193,743 ED visits were made by patients 65 years or older. Thirty-two percent of elderly patients seen in EDs were admitted to the hospital, compared with 7.5% of nonelderly patients. Seven percent of elderly patients were admitted to ICUs, compared with 1% of nonelderly patients. Thirty percent of elderly patients seeking emergency care used ambulance transports compared with 8% of nonelderly. It is estimated that 13,693,400 elderly patients were seen in EDs in 1990, with more than 4 million patients admitted to hospitals. Compared with the nonelderly, the elderly are 4.4 times more likely to use ambulance transport, 5.6 times more likely to be admitted to the hospital, 5.5 times more likely to be admitted to an intensive care bed, and 6.1 times more likely to be classified as a comprehensive ED level of service. In our sample, 36% of all patients arriving by ambulance to the ED, 43% of all ED admissions, and 48% of all intensive care admissions were geriatric patients.

CONCLUSION

With the rapid growth of the size of the elderly population, it is important that we assess the emergency medical resources needed to care for the geriatric population.

Factors influencing visits to school nurses by pregnant adolescents

The influence of five factors on the first visit to school nurses by pregnant adolescents and adequacy of prenatal care was analyzed. Only one factor, age of baby's father, was found to be associated with adequacy of prenatal care.

Effects of a school nurse prenatal counseling program

To determine the effects of a school-based, nurse-run prenatal counseling program, records of prenatal care visits of students and their infants' birth weights (i.e., cases) were obtained from the state live birth certificate tape for 1985-1987. From the same tape, a mother residing in the same community but not enrolled in the program was matched with each case on eight criteria to serve as a control. A total of 288 matched case-control pairs were obtained. Using McNemar's test, a significantly higher percentage of the cases received adequate prenatal care than did the controls.

Patterns of breast and cervical cancer screening at three public health centers in an inner-city urban area

In an effort to examine breast and cervical cancer screening patterns among poor African-American urban women, medical records were abstracted at three public health centers located in the inner city of Chicago. The proportions of eligible women at these three centers who received Pap smears, breast examinations, and mammograms were computed. These proportions were notably low and differed significantly among the three centers. Because the literature is now suggesting that an appropriate sequence best defines adequate screening, sequences of screenings were also determined and were found to be lacking. All of these screening histories fall far below the screening objectives set by the National Cancer Institute for the year 2000. This information suggests that interventions are needed that will help health centers serving poor women to deliver more frequent cancer screening.

Differential regulation of two glucose transporters by chronic growth hormone treatment of cultured 3T3-F442A adipose cells

New methods for the analysis of glucose transporters were used to analyze the molecular mechanisms involved in the insulin-antagonistic effects of growth hormone (GH), which is known as a diabetogenic hormone. The ability of GH to alter the number and mRNA levels of two different glucose transporters in cultured 3T3-F442A adipocytes was investigated using specific antibodies and cDNA probes. At concentrations of GH as low as 0.5 and 5 ng/ml and at incubation times as short as 4 h, GH decreased rates of 2-deoxyglucose uptake in 3T3-F442A adipocytes. 3-O-Methyl-D-glucose uptake was inhibited to an extent similar to that of 2-deoxyglucose uptake (60-80%) after a 24-h incubation with GH (500 ng/ml), indicating that GH inhibits glucose metabolism specifically at the step of glucose transport. To determine whether reduced rates of glucose transport might result from reduced numbers of glucose transporters, whole cell lysates were prepared from GH-treated cells and subjected to immunoblotting using antibodies that identify Glut 1 (HepG2/rat brain) and Glut 4 (muscle/adipose) transporters. GH caused a time- and dose-dependent decrease in the number of Glut 1 transporters in the cell. Northern and slot-blot analyses showed a GH-induced dose-dependent decrease in levels of Glut 1 mRNA. In contrast, levels of Glut 4 transporter and mRNA were unchanged by GH. These data suggest that GH regulates Glut 1 and Glut 4 transporters differentially and that it exerts its inhibitory effect on glucose uptake at least in part by decreasing the synthesis of Glut 1 transporters. These studies provide the first evidence that GH regulates a key gene in metabolic regulation and can interfere with gene expression.

Toxicology screening in urban trauma patients: drug prevalence and its relationship to trauma severity and management

Although toxicology screening is often used when treating trauma patients, its utility and significance remain controversial. Data from 623 toxicology screens performed in urban trauma center patients with mental status alterations are reported. The study patients were predominantly black and male, with a mean age of 32 (+/- 22) years. Overall, 86% of screens were positive. Substances of abuse, including ethanol, were noted in 525 (84%) of urine toxicology screens. Ethanol, cannabinoids, and cocaine were the drugs most commonly found in urine, with positivity noted in 53%, 37%, and 34% of screens. Serum analysis was 44% positive, with ethanol noted in 41% of patients. In blacks, the odds ratio of illicit drug use before trauma ranged from 1.9 to 4.2 (p less than 0.005), and in those aged 17 to 40 years, the odds ratio for illicit urine drugs ranged from 4.7 to 16.8 (p less than 0.001). In patients older than 40 years, the odds of a positive serum ethanol level were 1.7 times greater than in younger patients, and a level above 300 mg% was 3.8 times more likely in this age group (p less than 0.001). When serum ethanol was detected, the odds ratio of a head injury was 1.4 relative to patients without serum ethanol (p less than 0.06), and the odds ratio for abdominal injury was 1.6 for patients with serum ethanol (p less than 0.03). The odds of a TS less than 12 were 1.8 (p less than 0.05), and the odds of a GCS less than 12 were 3.3 (p less than 0.001) with ethanol levels greater than 100 mg%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary nephrotic syndrome treated with urokinase--a report of 20 cases]

Twenty cases of primary nephrotic syndrome were treated with urokinase at a dosage of 60,000 units per day for two successive weeks. The results showed that after treatment the concentrations of fibrinogen, urine FDP, alpha 2-plasma inhibitor and plasminogen were significantly decreased (P value less than 0.01, less than 0.01, less than 0.001, less than 0.005 respectively). The concentration of antithrombin III was significantly increased (P less than 0.05). It is suggested that the treatment obviously increased the fibrinolytic activity and improved the hypercoagulated state. The clinical data showed that in addition to decrease of proteinuria and obvious increase of urine volume, the clinical manifestations and laboratory parameters showed no significant difference. Further study on the dosage and indications of urokinase is needed and the activity of coagulation and fibrinolysis in patients with deep vein thrombosis of lower extremities was also discussed.

The emergency department ECG and immediately life-threatening complications in initially uncomplicated suspected myocardial ischemia

The emergency physician's disposition of patients with suspected myocardial ischemia is currently debated; some physicians believe that a subgroup of patients can be managed safely outside the coronary care unit. Clinical predictors are needed in assessing the patient with suspected myocardial ischemia to help identify this subgroup. Through a retrospective cohort study, we investigated the value of the initial emergency department ECG in discriminating between chest pain patients with low and high risk for immediately life-threatening complications. Two hundred eleven initially uncomplicated consecutive coronary care unit admissions with suspected unstable angina or myocardial infarction were studied. Patient outcome, including the incidence of myocardial infarction, complications, and mechanical and pharmacologic interventions, was reviewed. Immediately life-threatening complications included ventricular fibrillation, ventricular tachycardia, shock, 2 degrees and 3 degrees block, and death. Mechanical interventions included electrocardioversion or defibrillation, endotracheal intubation, intra-aortic balloon pump, Swan-Ganz catheter, or pacemaker insertion. Pressors, antiarrhythmics, and vasodilators were the reviewed pharmacologic interventions. A positive ECG was defined by the presence of ST elevation or depression, T wave inversion, left ventricular hypertrophy, left bundle branch block, paced rhythm, or new Q waves. All other ECG interpretations were considered negative. Patients were divided into two groups based on this initial emergency physician ECG interpretation and their complication incidences compared. Of the 211 patients, 96 had a positive ECG; 115 had negative ECGs. Patients with positive ECGs were older, had a greater history and concurrent incidence of myocardial infarction, and more complications and intensive interventions.(ABSTRACT TRUNCATED AT 250 WORDS)