A review of bilateral sudden sensorineural hearing loss in pediatric patients

OBJECTIVE

Bilateral, sudden sensorineural hearing loss (SSNHL) in the pediatric population is a rare phenomenon potentially detrimental to language acquisition and social development. This study comprehensively reviews and analyzes existing literature to determine any correlation or commonality in etiologies, presentations, and management of this condition.

METHODS

PubMed, Cochrane, Scopus, and Web of Science databases were systematically searched for articles related to pediatric SSNHL from 1970 to 2021. Case series, case reports, and cohort studies were included. Data on patient demographics, etiology, diagnostic testing, management, and hearing recovery were collected.

RESULTS

Excluding duplicates, 553 unique titles were identified by established search criteria, of which 342 titles were relevant to pediatric sudden hearing loss. Forty-six papers reported cases of bilateral SSNHL, totaling 145 individual cases. Not included in the analysis were 45 cases documented as non-organic hearing loss. The average age of the total 145 included patients was 8.5 years and 51 were male. Reported etiologies included cytomegalovirus (n = 3), meningitis (n = 13), mumps (n = 5), ototoxin exposure (n = 13), and enlarged vestibular aqueduct (n = 9). Tinnitus (n = 30) was the most reported concurrent symptom, followed by vertigo (n = 21). Systemic steroid therapy was the most common treatment and, when follow up was reported, most patients (51.2%) had complete or partial recovery of hearing.

CONCLUSIONS

This is a comprehensive review of pediatric bilateral SSNHL. Though often idiopathic, etiologies also include infectious, structural, and autoimmune. Treatment largely consists of systemic steroid therapy, with variables rates of recovery. Further studies on intratympanic administration of steroids may guide future treatment.

Abstract 1266: Downregulation of PD-L1 by NSAID administration augments the effects of a multi-antigen vaccine for the prevention of adenomatous polyps in APC(Min/+) mice

Introduction: We have shown that treatment of APC(Min/+) mice with NSAIDs will inhibit development of adenomatous polyps and induce significant levels of polyp-infiltrating CD8 T-cells. We sought to identify the mechanism of NSAID induced immune stimulation and questioned whether administration of NSAIDs concurrent with vaccination could further reduce polyp formation.

Methods: PD-L1 expression and T-cell infiltrates were assessed by IHC and flow cytometry. MC38 and RKO (murine/human colorectal carcinoma cell lines) were treated with naproxen (200uM-1000 uM) and harvested at 24, 48 and 72h. At 4-6 weeks, APC(Min/+) mice were given a multi-antigen peptide vaccine (COX2, CDC25B, EGFR) with CFA/IFA or adjuvant alone. Two groups received 400ppm naproxen orally 7d/wk for 18 weeks. Polyps were quantified at ≤24 weeks. Spleens and polyps were collected for IFN-gamma ELISPOT, flow cytometry, and IHC.

Results: Polyps from the APC(Min/+) mouse and both cancer cell lines highly express PD-L1. PD-L1 expression was significantly decreased in MC38 (p<0.01) and RKO (p<0.01) as compared to control after incubation with naproxen at all doses. The inhibitory effect of NSAIDs on PD-L1 expression was both time and dose dependent. We evaluated the in vivo effect of combination immunoprevention in the APC(Min/+). Animals receiving vaccine alone showed a 33% inhibition of polyp formation while naproxen alone showed 54% inhibition (p<0.0001) compared to adjuvant alone. Combination treatment demonstrated significantly greater inhibition of polyps than either modality (p<0.001), 81% inhibition vs. adjuvant. Antigen specific T-cells could be detected at higher levels than control antigen in both the vaccine alone (p=0.0001) and combination-treated animals (p<0.0001). The antigen specific responses seen in combination treated animals were nearly two-fold that of vaccine alone (p=0.008). No antigen specific immunity was detected in naproxen and adjuvant only treated mice. The magnitude of the immune response was significantly correlated with lower polyp counts, with a Pearson correlation coefficient of -0.55 (p=0.0014). Detailed immunologic analysis of tumors will be presented.

Conclusions: NSAIDs, via modulation of PD-L1, synergize with vaccines to increase immunogenicity and enhance influx of polyp infiltrating lymphocytes. This synergy results in superior prevention of polyp formation compared to treatment with NSAID or vaccine alone and has high potential for clinical application.

Citation Format: Mary L. Disis, Lauren R. Corulli, Clinton Grubbs, Ronald A. Lubet, Paul Cowan, Ekram Gad. Downregulation of PD-L1 by NSAID administration augments the effects of a multi-antigen vaccine for the prevention of adenomatous polyps in APC(Min/+) mice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1266.

Immunologic synergy between intermittent NSAID administration and antigen specific vaccination in inhibiting the development of intestinal polyps in the APC(Min/+)

Introduction

Studies from our group have shown that administration of NSAIDs in mouse models of Familial Adenomatous Polyposis results in a decrease in polyp formation and a significant increase in CD8 tumor infiltrating lymphocytes with downregulation of PD-L1 expression in tumors. We questioned whether a short course of NSAID could be used in combination with vaccination to even further reduce the development of intestinal polyps.

Methods

At 4–6 weeks of age, APC(Min/+) male/female mice were given CFA/IFA adjuvant with or without a multi-antigen (EGFR, COX2, CDC25B) peptide vaccine. Upon start of vaccinations, normal food or 400ppm naproxen mixed with food was provided either continuously (CON; 18w on) or intermittently (INT; 3w on + 3w off for 3 cycles). Animals were euthanized at 22±1 weeks and tumors quantified. Systemic and tissue specific immunity was measured by ELISPOT, FACS, and direct tumor staining.

Results

Tumor development was significantly inhibited both by vaccine alone and naproxen alone (p<0.0001). Combining naproxen (INT or CON) with vaccine was additive compared to vaccine alone (p<0.0001) and naproxen alone (INT+Vaccine p<0.0007; CON+Vaccine p<0.0003). INT naproxen was as effective as CON, with or without vaccine (p>0.999). Mice with greater tumor inhibition demonstrated higher magnitude antigen specific T-cell responses (p=0.0441, r=−0.423) and CD8+ T-cell infiltration (p<0.0001, r=−0.506) than those with less protection.

Conclusions

Data demonstrates that short-term administration of NSAIDs may be as effective as the more toxic long-duration alternative. Further, a short course of NSAID significantly synergizes with antigen specific vaccination to inhibit the development of polyps.

Delaware coast Delaware surf zone injury demographics

INTRODUCTION

Beaches are a popular destination for recreation activities. Surf zone injuries (SZI) can occur resulting from a variety of in-water activities. Little is known regarding the sustained injury types, or demographics of injured persons and activities leading to injuries.

METHODS

This study examines the distribution of SZI types, activities and populations occurring on Delaware Beaches as recorded by a local level III trauma center (Department of Emergency Medicine at Beebe Healthcare in Lewes, Delaware).

RESULTS

There were 2021 injuries over the eight study years (2010-2017). The relative demographics of the injured population are similar despite fluctuating injury totals (mean [SD], 253.1 [104.4]). Non-locals (n=1757) were 6.7 times more likely to be injured as their local (n=264) counterparts (RR, 2.62; 95% CI, 2.08-3.31). Males (n=1258) were 1.7 times more likely to be injured than their female (n=763) counterparts (RR, 1.29; 95% CI, 1.21-1.37). Serious injuries, defined as patients requiring admission to a trauma service, represented 9.1% (n=184) of injuries. Fatal SZI (n=6) were categorized as serious injuries. Wading (50.1%) was found to be the dominant activity associated with injury followed by body surfing (18.4%), and body boarding (13.3%).

CONCLUSION

To the authors' knowledge, this study is one of the first to investigate long-term trends in SZI data, injury activity, and demographics. Better understanding of the characteristics of injuries will allow for improved awareness techniques, targeted at populations with higher injury rates.

A systematic approach to evaluating and ranking the relative animal welfare impacts of wildlife control methods: poisons used for lethal control of brushtail possums (Trichosurus vulpecula) in New Zealand

Context Control of unwanted wildlife (‘pest’ animals) is undertaken for conservation and economic reasons, and when such animals are considered a nuisance. Such control should be undertaken using approaches that minimise, as far as possible, detrimental impacts on the welfare of the animals. Using a scientific framework based on the Five Domains model, the relative welfare impacts of pest control methods can be compared across methods and pest species. Aims We demonstrate the application of a modified version of this framework to evaluate the relative impacts of seven Vertebrate Toxic Agents (VTAs) used to control brushtail possums (Trichosurus vulpecula) in New Zealand. The evaluation is used to produce a ranking of the seven VTAs based on their relative impacts on possum welfare. Methods Scientific literature describing mode of toxic action, specific effects in possums or other animals and reports from human poisonings was collated as reference material for a panel of six experts. The panel produced a median welfare impact score (‘none’ to ‘extreme’) for each of the Five Domains. The ‘Overall Grade’ (1 to 8) reflected the intensity and duration of all impacts of a VTA on possums. Key results All VTAs evaluated have at least moderate impacts on possum welfare, lasting for at least minutes. Cyanide was assessed as having the lowest welfare impacts (median grade 4), and cholecalciferol and the anticoagulants the highest impacts (7.5 to 8). Zinc phosphide was assigned an intermediate grade (6) with high confidence. While the overall impacts of sodium fluoroacetate (1080) and phosphorus were also assessed as intermediate (6), the panel’s confidence in these scores was low. Conclusions From an animal welfare perspective, anticoagulant poisons and cholecalciferol should be the least preferred options for controlling possums in New Zealand, as VTAs with less severe welfare impacts are available. Implications The results of such assessments allow animal welfare impacts to be integrated with other factors in wildlife management decision-making and policy development, and are thus useful for managers, researchers, regulators and operators. Evaluation of welfare impacts aligns with the goals and mandates of ethical wildlife control and may also be valuable in wider wildlife research and management activities.

The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case studies

BACKGROUND

Core stability training is popular in the management of people with multiple sclerosis (MS); however, scientific evidence to support its effectiveness is scarce.

OBJECTIVE

To explore the effectiveness of core stability training on balance and mobility.

METHOD

A multi-centre series of eight single case studies was undertaken. Eight ambulant individuals with stable MS participated in 16 face-to-face core stability training sessions, delivered by a neurophysiotherapist, plus a daily home exercise programme. A range of outcomes were measured: 10-m timed walk, 12-item MS walking scale, timed get up and go, functional reach tests, timed single leg stance, visual analogue scales of two activities, and the Activities-specific Balance Confidence Scale.

RESULTS

Visual analysis of trend, level and slope demonstrated improvement in five subjects (62%) in seven measures. This was confirmed by the two standard deviation band method of analysis for six measures. Analysis of group data (repeated measures within subjects analysis of variance) indicated significant improvement between baseline and intervention phases for timed walk (p = 0.019), MSWS-12 Scale (p = 0.041), forward (p = 0.015) and lateral reach (p = 0.012). In general, no further improvements were made following withdrawal of the intervention.

CONCLUSIONS

This study provides preliminary evidence of the effectiveness of an 8-week core stability training programme in improving balance and mobility in ambulant people with MS. Variations in response to intervention are evident. Assessor-blinded randomized controlled studies are required to confirm these findings and determine patient characteristics which identify those who benefit most from this intervention.

Assessing the scientific accuracy, readability, and cultural appropriateness of a culturally targeted smoking cessation program for American Indians

This study assesses educational materials developed for the All Nations Breath of Life smoking cessation program (targeted for American Indians and Alaska Natives) for scientific accuracy, readability and other literacy factors, and cultural appropriateness. The authors used a scientific review panel of experts in smoking cessation representing epidemiology, medicine, and psychology; the suitability assessment of materials (SAM) and the simplified measure of gobbledygook (SMOG) reading grade level formulas; and review by Native program facilitators and pilot participants. Materials were scientifically accurate and culturally appropriate. The mean SAM score was 80% (superior rating), and the average reading grade level was 7.1 using the Fry formula (part of the SAM) and 8.4 using the SMOG formula (difference was not statistically significant). Based on this project, the SAM can be used in combination with scientific review and input from community members during formative research to assess and modify educational materials for a targeted population.

Postgraduate training options in dentistry--the RCSI roadmap

This paper presents the RCSI roadmap for postgraduate training in dentistry. The importance of an approved training element is stressed in all aspects of this pathway to ensure that the trainee is provided with the best teaching and will emerge with the highest standards. It is critical in today's world that all healthcare professionals enter into lifelong learning in order to maintain the best level of care for our patients.

Prevention of hyperacute rejection in a model of orthotopic liver xenotransplantation from pig to baboon using polytransgenic pig livers (CD55, CD59, and H-transferase)

INTRODUCTION

The search for alternative sources for transplant organs leads us to the search for animals as an inexhaustible source of organs. The objective of this study was to analyze whether livers from polytransgenic pigs expressing the human complement regulatory proteins CD55 (hDAF), CD59, and alfa alpha1,2-fucosyltransferase (H-transferase), protected against hyperacute rejection after orthotopic liver xenotransplantation to a baboon and also to study pig liver function in a nonhuman primate.

MATERIALS AND METHODS

Nine liver transplants from pig to baboon were divided into two groups: a control group (n = 4) of genetically unmodified pigs and an experimental group (n = 5) of pigs transgenic for CD55, CD59, and H-transferase as donors. All the donating piglets obtained through hysterectomy were maintained in specific pathogen-free conditions. The selection of transgenic pig donors followed demonstration of transgene expression using monoclonal antibodies (antiCD55, antiCD59) and immunohistological studies on liver biopsies.

RESULTS

All animals in the control group developed hyperacute rejection with survival rates less than 16 hours without function of transplanted livers. In the experimental group none of the animals suffered hyperacute rejection. Survival in this group was between 13 and 24 hours. The livers were functional, producing bile and maintaining above 35% prothrombin activity. Only in one case was there primary dysfunction of the xenograft.

CONCLUSION

Polytransgenic livers for complement regulatory proteins prevent hyperacute rejection when xenotransplanted into a baboon.

The launch of MCBEND 10

MCBEND 10 is the latest release of the general radiation transport Monte Carlo code from the ANSWERS Software Service of Serco Assurance. MCBEND is developed within a Nuclear Code Development (NCD) partnership between Serco Assurance and BNFL. The ANSWERS vision is 'to provide easy-to-use software that meets the current and emerging needs of the user community'. In the case of MCBEND, this vision focuses on the key areas of accuracy, understanding of uncertainties, efficiency and user-friendliness. MCBEND 10 is a major launch of the code with many new and enhanced features. New developments in MCBEND 10 include automatic splitting mesh generation, point energy adjoint for neutrons, calculation of uncertainty in the results due to material cross section uncertainties and a unified source facility. Enhanced features include improved temperature treatment, extended scoring of sensitivity to geometry perturbations, geometry improvements, extensions to formulae and improved user guide image. The user-friendliness of the MCBEND code has been further enhanced by recent developments to the visualisation tools, VISAGE and VISTA-RAY. Developments have been made to the three-dimensional visualisation tool, VISTA-RAY, to simplify the detailed checking of a model, with the option to use a mouse-pointer to select regions of interest for further detail and to visually highlight incorrectly defined areas. A further development to VISTA-RAY is the inclusion of the capability to overlay a representation of a user-designated set of results from a MCBEND analysis on the model. Improvements have also been made to the graphical user interface LaunchPad for submitting and controlling calculation submission, with a common user-image across all the systems. Recent enhancements to LaunchPad include a job-scheduler to simplify processing multiple tasks. A selection of the new developments in MCBEND 10, VISTA-RAY and LaunchPad will be described in this paper.

Mortality rate and movements of brushtail possums with clinical tuberculosis (Mycobacterium bovisinfection)

AIM

To describe the mortality rate and movements of brushtail possums (Trichosurus vulpecula) with clinical tuberculosis (Mycobacterium bovis) from a site in native podocarp/hardwood forest, in the Orongorongo Valley, Wellington.

METHODS

Possums with clinical tuberculosis (Tb) were identified through routine trapping on live capture grids and were fitted with radio-collars, and located at approximately monthly intervals for 2.5 years. The survival times of radio-collared tuberculous and non-diseased possums were used to estimate the instantaneous additional mortality rate due to clinical Tb. The spatial behaviour of clinically tuberculous possums was compared with that of non-diseased possums, using both den and trap locations. The frequency of long-distance movements of both tuberculous and non-diseased possums was also determined. A possum was defined as having undertaken along-distance movement when it moved at least 200 m from the centre of its activity range and then returned to its established activity range or died.

RESULTS

The mean survival time of clinically tuberculous possums was 4.7 (SE 0.79) months. The instantaneous additional mortality rate due to clinical Tb was estimated to be between 1.08 year-1 and 2.38 year-1, with the lower figure including an unknown portion of the incubation period in the estimate. Estimates of denning and activity ranges of tuberculous possums were approximately 22-30% larger, on average, than the ranges of non-diseased possums, but the differences were not significant. Both tuberculous and non-diseased possums undertook long-distance movements up to 700 m from the centre of their activity range. However, the majority of tuberculous possums died within or near their established activity range.

CONCLUSIONS

This study estimated the mortality rate during the clinical stages of Tb and, as such, did not represent a true estimate of the disease-induced mortality rate (alpha) used in most epidemiological models of possums and Tb. However, the lower estimate of the additional mortality rate due to clinical disease could be considered an approximation to alpha. The movement patterns of clinically tuberculous possums were, overall, not substantially different from non-diseased possums. The occurrence of long-distance movements by tuberculous possums sometimes coincided with the advanced stage of clinical disease. However, the majority of tuberculous possums died within their established activity area. Long-distance movements by resident possums during the terminal stages of disease represent a direct risk for transmission of Tb to livestock on farms within approximately 1 km of infected possum populations.

Eighteen years of experience with adult and pediatric liver transplantation at the University of Tennessee, Memphis

1. Since its inception, the liver program at UT Memphis has been striving to serve its population by stressing access, technical innovation, and by its focus on quality of life. The results for both adult and pediatric transplants over the past 18 years demonstrate that small and medium-sized programs can function efficiently and are valuable for their local communities. 2. Patient and graft survival rates exceeded 85% in the pediatric population in the first year with the 5-, 10-, and 15-year results above 75%. 3. Patient and graft survival rates in adults were 83% at one year, 68% at 5 years, and 60% at 10 years. 4. Innovative techniques in liver transplantation have had a dramatic impact on accessibility of pediatric recipients to liver transplantation and recently are becoming crucial for select populations of adults requiring expedited transplantation.

Managing faecal retention and incontinence in neurodisability

The large number of patients with faecal retention and/or incontinence in continuing care wards and rehabilitation units presents a considerable challenge. In order to maintain dignity and minimize the unpleasant odour so commonly associated with these wards and units, effective bowel management should be planned for individual patients. For an effective bowel management regime a team approach should be adopted, involving, where possible, the patient and carer as well as all the health professionals administering the care. Two case studies illustrate the use of assessment and management of bowel problems in patients with severe complex neurodisability. Bowel dysfunction in this patient population, in general, is poorly covered in the literature. The present article, by relating theory to practice, offers information and guidance for nurses working with patients who have bowel-related problems.

Naturally acquired anti-alpha Gal antibodies in a murine allograft model similar to delayed xenograft rejection

Antibodies directed against galactose-alpha1,3-galactose (alphaGal) are believed to play an important role in the pathogenesis of delayed xenograft rejection (DXR). This study was designed to determine whether alpha1,3-galactosyltransferase-deficient (Gal KO) mice can naturally acquire a sufficient anti-alphaGal titre to cause the delayed type rejection of alphaGal-expressing hearts. Gal KO mice of various ages were assessed for anti-alphaGal antibody levels. alphaGal-expressing hearts were transplanted heterotopically into these mice and monitored daily. Rejecting and surviving hearts were evaluated histologically. In Gal KO mice greater than 6-month-old, 64% had an anti-alphaGal antibody titre above the background level. When wild-type alphaGal-expressing hearts were transplanted into this group, 45% of grafts rejected within 5 to 13 days. Histological examination of the rejected hearts displayed marked tissue damage and an inflammatory infiltrate of predominantly macrophage/monocytes. Surviving grafts showed preserved morphology. Like humans, Gal KO mice naturally develop anti-alphaGal antibodies with age. The titre in these mice was sufficient to cause a "delayed-type" rejection of a significant proportion of alphaGal-expressing cardiac grafts. This model thus provides an opportunity to investigate the role of naturally acquired anti-alphaGal antibodies in the pathogenesis of DXR.

Protection against hyperacute xenograft rejection of transgenic rat hearts expressing human decay accelerating factor (DAF) transplanted into primates

BACKGROUND

Production of transgenic pigs for multiple transgenes is part of a potential strategy to prevent immunological events involved in xenograft rejection. Use of a genetically engineerable rodent as a donor in primates could allow testing in vivo of the effects of different transgenes on controlling xenograft rejection. As a first step in the development of a donor containing multiple transgenes, transgenic rats for human decay-accelerating factor (DAF) were used as heart donors to test their resistance against complement (C)-mediated rejection by non-human primates.

MATERIALS AND METHODS

Transgenic rats were generated by using a construct containing the human DAF cDNA under the transcriptional control of the endothelial cell (EC)-specific human ICAM-2 promoter. DAF expression was evaluated by immunohistology and by FACS analysis of purified ECs. Resistance of transgenic hearts against C-mediated damage was evaluated by ex vivo perfusion with human serum and by transplantation into cynomolgus monkeys.

RESULTS

Immunohistological analysis of DAF expression in several organs from two transgenic lines showed uniform expression on the endothelium of all blood vessels. ECs purified from transgenic hearts showed 50% DAF expression compared to human ECs and >70% reduction of C-dependent cell lysis compared to control rat ECs. Hemizygous transgenic hearts perfused with human serum showed normal function for >60 min vs. 11. 2 +/- 1.7 min in controls. Hemi- or homozygous transgenic hearts transplanted into cynomolgus monkeys showed longer survival (15.2 +/- 7 min and >4.5 hr, respectively) than controls (5.5 +/- 1.4 min). In contrast to hyperacutely rejected control hearts, rejected homozygous DAF hearts showed signs of acute vascular rejection (AVR) characterized by edema, hemorrhage, and an intense PMN infiltration.

CONCLUSIONS

We demonstrate that endothelial-specific DAF expression increased heart transplant survival in a rat-to-primate model of xenotransplantation. This will aid in the analysis of AVR and of new genes that may inhibit this form of rejection, thus helping to define strategies for the production of transgenic pigs.

Genetically variable triplet repeats in a RING-finger ORF of Helicoverpa species baculoviruses

Nucleotide sequence analysis of the Helicoverpa zea S-type nucleopolyhedrovirus (HzSNPV) genomic interval between the polh and iel genes has revealed an open reading frame (HOAR ORF) that contains a complex A 1-T rich triplet repeat region (RAT-repeats). HOAR ORF is predicted to encode an acidic, arginine residue rich. 712 aa protein, with a C3HC4 (RING-finger) zinc binding motif. RAT-repeats, distributed over 450 bp. consist of GAT. AAT, and GTT codons, correspond to Asp, Asn and Val residues which display an extreme codon bias not seen with nine other genes of this virus. A survey of four other (field) isolates of Helicoverpa sp. NPVs confirms a high incidence of mutation in the RAT-repeat region. A 158-bp conserved block, homologous to the pe38-ien promoter of AcMNPV, was identified upstream of HOAR ORF. The sub-region of the genome in which HOAR ORF is located is susceptible to rearrangement.

A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic

OBJECTIVE

To compare the impact of group outpatient visits to traditional "physician-patient dyad" care among older chronically ill HMO members on health services utilization and cost, self-reported health status, and patient and physician satisfaction.

DESIGN

A 1-year randomized trial.

SETTING

A group model HMO in the Denver Metropolitan area.

PARTICIPANTS

Three hundred twenty-one members aged 65 and older, randomized to a group visit intervention (n = 160) or to usual care (n = 161).

INTERVENTION

Patients with high health services utilization and one or more chronic conditions had monthly group visits with their primary care physician and nurse. Visits included health education, prevention measures, opportunities for socialization, mutual support, and for one-to-one consultations with their physician, where necessary.

MEASUREMENTS

Health services utilization and associated cost, health status, and patient and physician satisfaction.

RESULTS

Outcome measures obtained after a 1-year follow-up period showed that group participants had fewer emergency room visits (P = .009), visits to subspecialists (P = .028), and repeat hospital admissions per patient (P = .051). Group participants made more visits (P = .021) and calls (P = .038) to nurses than control group patients and fewer calls to physicians (P = .019). In addition, a greater percentage of group participants received influenza and pneumonia vaccinations (P < .001). Group participants had greater overall satisfaction with care (P = .019), and participating physicians reported higher levels of satisfaction with the groups than with individual care. No differences were observed between groups on self-reported health and functional status. Cost of care per member per month was $14.79 less for the group participants.

CONCLUSIONS

Group visits for chronically ill patients reduce repeat hospital admissions and emergency care use, reduce cost of care, deliver certain preventive services more effectively, and increase patient and physician satisfaction.

Who's got the power? Gender differences in partners' perceptions of influence during marital problem-solving discussions

Previous research on marital communication indicates that women have more influence in marital problem solving because they raise the issues and shape the discussion. Other studies suggest that men have the power in marital problem solving. This study re-examines power and influence from the partners' point of view. Twenty-seven couples-18 with a first child under 2, and 9 undecided about having children-were videotaped while working on a self-selected problem concerning their division of family labor. Data sources included: (a) transcribed audiotaped accounts given by each partner while viewing a videotape of their problem-solving discussion; (b) self-report questionnaires; and (c) ratings by a research team of the concordance between spouses' accounts. Husbands and wives were perceived as having a primary influence on different aspects of the discussion. Women tended to raise the issues and draw men out in the early phase of the discussion, while men controlled the content and emotional depth of the later discussion phases, and largely determined the outcome. The women's accounts emphasized that their influence in the early phase was often illusory: their behavior was shaped primarily by the effort to choose strategies that would avoid upsetting their husbands. In terms of overall satisfaction with marriage, wives had greater tolerance than their husbands for conflict in the area of division of domestic labor, but less tolerance for their husbands' domination of the discussion process. Women's marital satisfaction was higher when there was concordance between spouses in their accounts of their problem-solving discussion. This research highlights the importance of eliciting spouses' own perceptions and definitions in understanding the impact of gender-linked power differences in martial communication.

Development of exclusivity in perceptually based categories of young infants

The exclusivity of perceptually defined categorical representations for natural animal categories in young infants was investigated. Previously, as well as in Experiment 1, evidence was obtained for a categorical representation for cats in 3- and 4-month-old infants that excluded dogs but included perceptually similar female lions after a number of different familiarization procedures. However, in Experiment 2 both dogs and female lions were found to be excluded when the initial familiarization with cats alone was followed by six pairings of familiar cats and novel lions intermingled with two added pairings of familiar cats. The present results indicate that a categorical representation can attain a high level of exclusivity during early infancy as a consequence of experience with exemplars of the contrasting categories that accents the perceptual similarities among members of a category and the perceptual differences among exemplars from different categories.

Nucleotide sequence of the polyhedrin gene region of Helicoverpa zea single nucleocapsid nuclear polyhedrosis virus: placement of the virus in lepidopteran nuclear polyhedrosis virus group II

The polyhedrin gene (polh) of Helicoverpa zea single nucleocapsid nuclear polyhedrosis virus (HzSNPV) was identified and shown by sequence analysis of the EcoRI I genomic fragment to encode a 246 amino acid polypeptide that has greater than 80% sequence identity to known polyhedrins. It is preceded by an AT-rich region containing the conserved late promoter motif TAAG, which was identified as a transcription start point. Downstream of polh there were several similarities in genome arrangement to other nuclear polyhedrosis viruses (NPVs). These include open reading frame (ORF) 8, immediately downstream of polh, encoding a 412 amino acid protein with multiple tandem proline residues, which is homologous to ORF8 (ORF1629) of Autographa californica multiple nucleocapsid NPV. Phylogenetic analysis of the polh gene region shows that HzSNPV is a member of the previously described lepidopteran NPV group II and that it is most closely related to polh of the NPVs of Malacosoma nuestria, Spodoptera littoralis, Orgyia pseudotsugata (single nucleocapsid-type virus) and Buzura supressaria.

Going home: easing the transition for the mentally ill

Health care in the 90s dictates an increased pressure to discharge patients from the hospital into the community, placing much of the burden of care on families. With budget constraints in effect and bed shortages and closures a reality, the health care system is keenly aware of the need to prevent illness relapse and to promote safe functioning in the community, especially for people who suffer from persistent mental health problems.

American Chronic Pain Association: strategies for surviving chronic pain

The American Chronic Pain Association (ACPA) is a nonprofit, self-help organization designed to help individuals suffering with chronic nonmalignant pain. The program is directed toward educating the individual about a multidimensional view of pain, identifying pain-illiciting and pain-aggravating situations and behaviors, and teaching various coping skills. The techniques that are used include exercise, relaxation instruction, goal selection, priority setting, self-awareness sensitization, and assertiveness training.

Blood glucose control determines the renal haemodynamic response to angiotensin converting enzyme inhibition in type 1 diabetes

Elevation of glomerular filtration rate (GFR) is a feature of diabetes mellitus in humans and in animal models. Angiotensin II has been implicated as a mediator of GFR in diabetes. The acute effect of inhibition of angiotensin converting enzyme with captopril on renal haemodynamic and endocrine parameters was therefore studied in 14 normotensive male Type 1 diabetic patients, and the responses compared with those in five normal male control subjects. Following captopril 12.5 mg orally the diabetic patients exhibited an acute fall in GFR from 122 +/- 3.8 to 113 +/- 4.5 ml min-1 1.73-m-2 (p less than 0.02) and a rise in renal plasma flow (RPF) from 670 +/- 57 to 797 +/- 46 ml min-1 1.73-m-2 (p less than 0.01) which resulted in a fall in filtration. This did not occur in normal control subjects. Natriuresis occurred only in normal control subjects. There was no change in urinary excretion of PGE2 or kallikrein in either group but excretion of 6-keto-PGF1 alpha fell in the diabetic patients. There was a significant correlation between glycosylated haemoglobin and baseline RPF (rs = -0.79, p less than 0.001) and filtration fraction (rs = 0.83, p less than 0.001) that persisted when the change in these variables following captopril was analysed. Our results are compatible with the response to ACE inhibition in diabetic patients being secondary to inhibition of angiotensin II and suggest that this response may be related to blood glucose control.

Reversal of insulin resistance in type 1 diabetes following initiation of insulin treatment

The biological action and pharmacokinetics of insulin were assessed in nine type 1 (insulin-dependent) diabetic patients before and after 3 months conventional insulin treatment, and in seven age and weight-matched non-diabetic controls, by means of the euglycaemic insulin clamp technique. The mean (+/- S.E.) metabolic clearance rate of insulin, when infused at 1 mU/kg/min, was similar in untreated and treated diabetic patients and in controls (22.7 +/- 2.0, 19.3 +/- 3.8, and 22.9 +/- 3.3 ml/kg/min) but, when infused at 6 mU/kg/min, was greater (p less than 0.01 and less than 0.01) in untreated patients (18.0 +/- 2.5 ml/kg/min) than in treated patients (11.5 +/- 1.4 ml/kg/min) and controls (12.7 +/- 1.3 ml/kg/min). Insulin-mediated glucose disposal was reduced (p less than 0.01 and less than 0.01) at insulin infusion rates 1 and 6 mU/kg/min in untreated patients (18.5 +/- 1.9 and 33.8 +/- 4.5 mumol/kg/min) when compared with controls (35.8 +/- 3.4 and 62.0 +/- 4.7 mumol/kg/min) and was improved (p less than 0.01 and less than 0.01) following insulin treatment (36.1 +/- 4.6 and 64.8 +/- 4.2 mumol/kg/min). Daily insulin requirement fell by 33% following 3 months insulin treatment with improvement in mean HbA1 from 16.3 +/- 0.7 to 8.2 +/- 0.4%, but without significant increase in endogenous insulin secretion. The 'honeymoon phenomenon', which has traditionally been attributed exclusively to resurrection of endogenous insulin release, may also be related to normalization of insulin action following institution of insulin treatment.

Influence of insulin antibodies on pharmacokinetics and bioavailability of recombinant human and highly purified beef insulins in insulin dependent diabetics

Sixteen insulin dependent diabetics of long standing, with undetectable fasting plasma C peptide concentrations, and eight non-diabetic controls were each infused intravenously with biosynthetic human and highly purified beef insulin (1 mU/kg/min) while euglycaemia was maintained by a Biostator. No difference was observed between the two insulins in respect of insulin pharmacokinetics or biological action. The diabetics showed appreciable insulin resistance, manifested by a 40% reduction in the rate of insulin mediated glucose disposal, which was unrelated to the presence of insulin antibodies. Insulin binding antibodies, however, increased insulin's clearance rate and distribution space and prolonged its pharmacological and biological half lives. The rate at which insulin action was lost, after an intravenous infusion, was more rapid in diabetics without insulin antibody binding than in controls. In respect of their influence on insulin pharmacokinetics, moderate concentrations of insulin antibodies may be of positive advantage to all diabetics without endogenous insulin secretion and are not responsible for the insulin resistance of type 1 diabetes.

Insulin action and pharmacokinetics in insulin treated diabetics during the third trimester of pregnancy

Insulin action and pharmacokinetics were compared, using the euglycaemic insulin clamp technique, in seven insulin-treated diabetics during the third trimester of pregnancy and one to three weeks post-partum. At an insulin infusion rate of 1 mU/kg/min, insulin mediated glucose disposal was significantly greater (p less than 0.02) following delivery (1.194 +/- 0.138 mmol/m2/min) than in pregnancy (0.761 +/- 0.072 mmol/m2/min) and the rate of decline in insulin mediated glucose disposal, at the end of the insulin infusion, was significantly greater (p less than 0.02) following delivery (24.78 +/- 4.22 mumol/m2/min2) than in pregnancy (15.17 +/- 2.00 mumol/m2/min2). The metabolic clearance rate, distribution space and pharmacological half-life of insulin were not significantly altered by pregnancy. These findings show that the third trimester of pregnancy is associated with steady state insulin resistance accompanied by a reduced rate of insulin deactivation, but normal insulin pharmacokinetics.

A comparison of the biological actions and pharmacokinetics of intravenously infused highly purified beef and biosynthetic human insulins in normal man

By means of the euglycaemic insulin clamp technique the rate of insulin-mediated peripheral glucose disposal (GDR) was compared in response to intravenous infusions of highly purified beef insulin (BI) and biosynthetic human insulin (BHI), infused at 1 and 6 mU/kg/min, in healthy volunteers. The metabolic clearance rates of BI and BHI were similar at the lower insulin infusion rate and were both greater than those observed at the higher insulin infusion rate, which were also similar, implying the process of insulin clearance to be saturable. The GDRs were similar in response to infusions of BI and BHI at each insulin infusion rate. The rates of insulin deactivation were similar, having discontinued BI and BHI infusions at 1 mU/kg/min.

Prevalence of antibody to hepatitits B surface antigen among staff in an Edinburgh hospital

Antibody to hepatitis B surface antigen was detected by radioimmunoprecipitation in 74 (5-5%) of 1336 staff members in a large general hospital in Edinburgh, in 14 (2-9%) of 480 volunteer blood donors in the area, and in 12 (6-1%) of 197 pregnant women attending for the first time at the ante-natal clinic in the hospital. Rates of antibody prevalence rose with age in the sample of hospital staff and in that of the blood donors, particularly among males. On the other hand, in the ante-natal patients antibody prevalence declined with age. The rates in hospital staff were higher than those in blood donors of comparable age and sex, and high titres of antibody were more common in the staff group. However, no association was found between antibody prevalence and a history of clinical hepatitis, blood transfusion, or recognized contact with cases of hepatitis. Staff who had previously worked in an infectious disease hospital did not show increased antibody prevalence, indicating that simple isolation measures have been adequate to minimize exposure to hepatitis B. No particular prevalence of infection was seen in physicians and surgeons, in the nursing staff, or in workers in clinical diagnostic laboratories, hospital administration or other areas. One group clearly showing increased antibody prevalence was staff currently working, or who had worked, in the Haemodialysis Unit; this correlated with the outbreak of dialysis-associated hepatitis in 1969--70. However, no evidence suggested that significant dissemination of infection had occurred to other defined groups of hospital staff. Elevated rates were also observed in a small sample of kitchen and portering staff, and in obstetric medical and nursing staff; the latter observation indicate a need for further investigation to identify unsuspected exposure to hepatitis B virus.