Sexual minority status, social adversity and risk for psychotic disorders-results from the GROUP study

BACKGROUND

Lesbian, bisexual, or gay individuals (LBGs) have an increased risk for mental health problems compared to heterosexuals, but this association has sparsely been investigated for psychotic disorders. The aim of this study was: (1) to examine whether LBG sexual orientation is more prevalent in individuals with a non-affective psychotic disorder (NAPD) than in people without a psychotic disorder; and if so, (2) to explore possible mediating pathways.

METHODS

Sexual orientation was assessed in the 6-year follow-up assessment of the Dutch Genetic Risk and Outcome of Psychosis study (GROUP), a case-control study with 1547 participants (582 patients with psychotic disorder, 604 siblings, and 361 controls). Binary logistic regression analyses were used to calculate the risk of patients with a psychotic disorder being LBG, compared to siblings and controls. Perceived discrimination, history of bullying, childhood trauma (CT), and sexual identity disclosure were investigated as potential mediating variables.

RESULTS

The proportion of individuals with LBG orientation was 6.8% in patients (n = 40), 4.3% in siblings (n = 26), and 2.5% in controls (n = 10). The age- and gender-adjusted odds ratio of LBG for patients was 1.57 (95% CI 1.08-2.27; p = 0.019), compared to siblings and controls. Discrimination, bullying, and CT all partially mediated this association.

CONCLUSIONS

Adverse social experiences related to sexual minority status may increase the risk for NAPD. Sexual identity, behavior, and difficulties need more attention in everyday clinical practice.

Imaging pulsed laser deposition oxide growth by in situ atomic force microscopy

To visualize the topography of thin oxide films during growth, thereby enabling to study its growth behavior quasi real-time, we have designed and integrated an atomic force microscope (AFM) in a pulsed laser deposition (PLD) vacuum setup. The AFM scanner and PLD target are integrated in a single support frame, combined with a fast sample transfer method, such that in situ microscopy can be utilized after subsequent deposition pulses. The in situ microscope can be operated from room temperature up to 700 °C and at (process) pressures ranging from the vacuum base pressure of 10^-6 mbar up to 1 mbar, typical PLD conditions for the growth of oxide films. The performance of this instrument is demonstrated by resolving unit cell height surface steps and surface topography under typical oxide PLD growth conditions.

Neural response during attentional control and emotion processing predicts improvement after cognitive behavioral therapy in generalized social anxiety disorder

BACKGROUND

Individuals with generalized social anxiety disorder (gSAD) exhibit attentional bias to salient stimuli, which is reduced in patients whose symptoms improve after treatment, indicating that mechanisms of bias mediate treatment success. Therefore, pre-treatment activity in regions implicated in attentional control over socio-emotional signals (e.g. anterior cingulate cortex, dorsolateral prefrontal cortex) may predict response to cognitive behavioral therapy (CBT), evidence-based psychotherapy for gSAD.

METHOD

During functional magnetic resonance imaging, 21 participants with gSAD viewed images comprising a trio of geometric shapes (circles, rectangles or triangles) alongside a trio of faces (angry, fearful or happy) within the same field of view. Attentional control was evaluated with the instruction to 'match shapes', directing attention away from faces, which was contrasted with 'match faces', whereby attention was directed to emotional faces.

RESULTS

Whole-brain voxel-wise analyses showed that symptom improvement was predicted by enhanced pre-treatment activity in the presence of emotional face distractors in the dorsal anterior cingulate cortex and dorsal medial prefrontal cortex. Additionally, CBT success was foretold by less activity in the amygdala and/or increased activity in the medial orbitofrontal gyrus during emotion processing.

CONCLUSIONS

CBT response was predicted by pre-treatment activity in prefrontal regions and the amygdala. The direction of activity suggests that individuals with intact attentional control in the presence of emotional distractors, regulatory capacity over emotional faces and/or less reactivity to such faces are more likely to benefit from CBT. Findings indicate that baseline neural activity in the context of attentional control and emotion processing may serve as a step towards delineating mechanisms by which CBT exerts its effects.

Integrated care for MS patients

PURPOSE

The problem of complex healthcare to MS patients, together with the rising prevalence of MS and escalating costs, has caused healthcare policy makers to consider innovative approaches to controlling costs and improving the quality of care. An integrated care approach may provide a means for better coordination and delivery of care. The aim is to review recent integrated care initiatives and their significance for MS patients.

METHOD

A literature search was conducted to trace relevant literature on integrated care for MS patients published between 1995 and 2003.

RESULTS

Although integrated care appears to offer potential for eliminating fragmentation and discontinuity in healthcare for MS patients, there are few published studies which have evaluated its implementation with MS patients.

CONCLUSIONS

Even though the potential advantages of integrated care are well known, the applicability of this approach for MS patients has still to be demonstrated.

A controlled comparison of brachial artery flow mediated dilation (FMD) and digital pulse amplitude tonometry (PAT) in the assessment of endothelial function in systemic lupus erythematosus

The utility of flow mediated dilation (FMD) a measure of endothelial function is limited by operator dependence. Pulse amplitude tonometry (PAT) is a novel, less operator-dependent technique to assess endothelial function. This study compares PAT to FMD in SLE and controls. Thirty women with SLE and 31 controls were enrolled. Medications, cardiovascular disease and risk factors, SLE activity (SLAM-R) and damage (SLICC-DI) were recorded. FMD and PAT were performed simultaneously. Endothelium-independent function was assessed with nitroglycerin. Average age was 48.3 +/- 10.1 years, SLE duration 16.2 years, SLAM-R 8.3 and SLICC-DI 1.0. Framingham Risk Scores were < or =2% in most subjects. There were no differences between SLE cases and controls in FMD, PAT or response to nitroglycerin. This study found no association between FMD and PAT in SLE or controls. In the 17 SLE cases with a history of Raynaud's, correlation between FMD and PAT was 0.50 (P = 0.04). There was no difference in endothelial function assessed by FMD or PAT in SLE cases versus controls. FMD did not correlate with PAT except in SLE cases with a history of Raynaud's. Correlation between FMD and PAT may be stronger in populations with greater variation in endothelial function and more cardiovascular risk factors.

Fringe multiplication in three-dimensional photoelasticity

Isochromatic fringe multiplication by a factor of up to 17 is demonstrated for slices from three-dimensional frozen-stress models. With this method, sensitivity is increased by an order of magnitude, the taking of data is quick and easy and the interpretation of data is less subject to errors than compensation techniques.

Steroid Avoidance Immunosuppression in Low-Risk Kidney Transplant Recipients

Recent clinical trials have documented the short-term safety of steroid avoidance (SA) in kidney transplant recipients. Since July 2003, we have used a SA immunosuppression protocol for low-risk kidney transplant recipients. Eligibility criteria are age > or = 18, primary transplant (living or deceased donor), and tacrolimus started by postoperative day 3. Recipients were excluded if peak/current PRA was >50%/20%, or if they had a positive flow crossmatch, or if they had the recent use of corticosteroids (<6 months). All recipients received induction with rabbit anti-thymocyte globulin, total dose 6 mg/kg, or basiliximab. Recipients received 5 daily doses of corticosteroid and mycophenolate mofetil 1 gm twice daily starting on the day of transplantation. Tacrolimus was started when the serum creatinine level decreased by 20%, or by postoperative day 3. The goal for trough tacrolimus levels was 10-15 ng/mL for the first month, 8-12 ng/mL for months 2-3, and 5-10 ng/mL after month 3. Protocol biopsies (bx) were performed at reperfusion, 1 month, 4 months, and 12 months. Ninety-four kidney transplantations were performed during the study period. Sixty-seven recipients (71%) were eligible and enrolled in SA. Characteristics of the 67 SA recipients: mean age, 53 years (range, 26-70); 41% female; 67% Caucasian; 24% Hispanic; 15% African American; and 5% Native American. Also, 77% received a living donor kidney. The mean follow-up was 180 days (range, 10-360). At last follow-up, 91% remained steroid-free. Biopsy-proven acute rejection (BPAR) occurred in 5 recipients (7.5%). Three recipients (4.5%) had clinical BPAR and 2 had subclinical. One recipient died with pneumonia 4 months following transplantation. Posttransplantation diabetes mellitus (PTDM) occurred in 2 (5%) of 38 recipients. In the initial 41 recipients, 27 had protocol bx at 1 month and 13 at 4 months available for analysis. Chronic allograft nephropathy (CAN) was present on protocol bx in 48% at 1 month and 69% at 4 month. Actuarial (Kaplan-Meier method) patient and graft survival rates at 351 days were 97.8% and 96.8%, respectively. SA with anti-thymocyte globulin induction in low-immunologic risk kidney transplant recipients is safe and is associated with a low risk of BPAR. The incidence of PTDM appears to be lower.

People with intellectual disability and their health problems: a review of comparative studies

BACKGROUND

The transition of people with intellectual disability (ID) from care institutions to the community - according to Western policy - results in a shift of responsibility towards primary health care services. In order to provide optimal care to people with ID living in the community, general practitioners need to be aware of the specific health problems of this patient category. The aim of this paper is to present an overview of recent studies on the specific health problems of people with ID, in particular on health problems of people with ID in the community, compared to those of the general population.

METHOD

To reliably compare health problems of individuals with and without ID, this review is limited to comparative research using a control group of individuals without ID. The focus of the review concentrates on international literature, published between 1995 and 2002.

RESULTS

Most comparative research among people with ID presents higher prevalence rates for epilepsy, diseases of the skin, sensory loss and (increased risk of) fractures. These health problems are specific for people with ID, both in general and living in the community in particular.

CONCLUSIONS

there are only few studies focusing on health problems in people with ID in which a control group of individuals without ID is included. Most comparative studies on health problems in people with ID are based on comparison with reported prevalence rates of general health surveys.

Determinants of adolescents' smoking behaviour: a literature review

A review of studies focused on determinants of adolescents' smoking behaviour (ASB) published between 1990-2000 is presented. Determinants were divided into three groups: individual factors, social factors and societal factors. Individual factors include knowledge, intentions, attitudes, health-related behaviour, personality characteristics and school-related variables. Social factors include smoking behaviour of parents, siblings, peers and significant adults, but also family characteristics, social support, and socio-economic status. Societal factors include restrictions on smoking, tobacco advertisement, and smoking behaviour of adolescents' role model.

Self-reported health problems of Slovak adolescents

This paper describes self-reported health problems among 2616 Slovak adolescents (52.4% boys, 47.6% girls). Adolescents consider their health as very good in general. They often feel 'vital', and rarely feel depressed or irritated. However, the psychological health of more than 20% of the boys and 40% of the girls was unsatisfactory. Furthermore, a sizeable number suffered from separate physical complaints, chronic diseases or used medical services. Findings are more unfavourable for girls in comparison with boys. Our findings indicate that adolescence is not such a healthy period in human life as is often considered. The Slovak Republic, a Central European country, does not differ in this respect from Western European countries.

[Which objectively assessed limitations in health status, activities of daily living, or in psychological and social spheres are decisive for referral to a nursing home or to a home for the aged]

Which type of limitation is most decisive for a positive indication for a residential home or a somatic or psycho-geriatric nursing home, and to what extent do data on living situation (independent, adapted or intramural) and the social situation (alone or living together) influence this qualification? To obtain an answer to this question three experiments with an integrated, objective and independent assessment-for-care system were set up in the Netherlands. We studied one of them, in the town of Meppel, started in 1996. The study population consisted of all older people living in and around Meppel who had a positive indication for either a residential home, or a somatic or psycho-geriatric nursing home (N = 206 in 1998). Differences in limitations were computed by means of analysis of variance and the types of limitation and their impact on the type of allocated institutions were computed by logistic regression. The limitations only partially explain the types of indication. Indication for a residential home is based on physical limitations. When these increase they become a contra-indication for a residential home and a somatic nursing home indication is given. Mental limitations primarily yield indications for psycho-geriatric nursing homes. Social limitations have a higher incidence among persons with an indication for a somatic nursing home but cannot fully explain this indication. Persons with a residential home indication were significantly more often from an adapted living situation background. The living situation -alone or together-does not have an impact on the indication. We may not conclude that the assessment took place objectively, for, based on the registration it is impossible to conclude for what criteria a person was indicated for a specific type of institution. The objective of assessment, the allocation and distribution of collectively financed care in residential homes and nursing homes based on verifiable assessment methodology could not be realised.

Follow-up study of workers in a nylon carpet yarn plant after remedial actions taken against a contaminated humidification system

OBJECTIVE

To investigate the effectiveness of remedial actions taken against a contaminated humidification system, after an outbreak of humidifier disease in a nylon carpet yarn plant.

METHODS

Two and 6 years after modification, a follow-up investigation of a stratified (age, smoking habits) sample of exposed (n = 75) and non-exposed (n = 56) workers was carried out. Outcome-parameters were: respiratory symptoms, spirometry, skin tests and serology with various humidifier fungi. In addition, the yearly incidence of work-disability because of chronic respiratory disease during the 2 years before, and 11 years after the modification was compared.

RESULTS

At follow-up, exposed workers, who remained at the same workplace no longer had significantly more frequent chronic respiratory symptoms. The prevalence of positive serology was still higher (P < 0.05) in exposed workers after 2 years, but at the 6 year follow-up investigation, the difference was no longer significant. Prevalence of positive skin tests after 2 years no longer differed from that of the non-exposed workers. Slopes (ml/years) of the graphs of forced vital capacity (FVC) and one-second forced expiratory volume (FEV1) during the 6 year follow-up after the first investigation did not differ between exposed and non-exposed workers, both before and after adjustment for age, smoking habits and results of skin tests and serology before modification. Before modification, exposed workers with a positive late skin test had a lower FVC than non-exposed workers. After 6 years of follow-up their FVC was still lower, but the difference was no longer significant. There were no indications of selective loss to follow-up. After remedial actions no new cases of humidifier disease occurred. Moreover, the yearly incidence of work-disability in this plant because of chronic respiratory disease, decreased from 1.30% to 0.27% compared with a decrease from 0.30% to 0. 12% in other synthetic fibre plants.

CONCLUSION

Follow-up investigation of exposure-effects demonstrated the effectiveness of remedial actions taken against a contaminated humidification system.

Exposure and acute exposure-effects before and after modification of a contaminated humidification system in a synthetic-fibre plant

OBJECTIVE

Follow-up study of exposure and acute exposure-effects after modification to steam humidification of a contaminated cold water system which had caused an outbreak of humidifier fever in a synthetic-fibre plant.

METHODS

Before and after modification of the system aerobiological measurements were performed. Concentrations of fungi and bacteria, in colony forming units (cfu) per m3, were measured by stationary air sampling with an Andersen sampler. Endotoxin levels (pg/m3) were determined by Limulus Amoebocyte Lysate (LAL) assay in pooled dust from personal air sampling. An indication of exposure levels of oil-mist was obtained by monitoring with a direct reading optical photometer. Changes as acute exposure-effects in spirometry and white blood cell count, during an afternoon shift were compared in exposed and non-exposed workers before and after modification.

RESULTS

Measured levels of fungi, total bacteria, Gram-negative bacteria and endotoxins both before and after modification were below levels which would be expected to be associated with the exposure-effects. However, after modification, we found that the statistically significant differences in levels of bacteria and endotoxins with a department without humidification no longer existed. Mean oil-mist concentrations were below 1 mg/m3, with short-time peak exposure during certain tasks of up to 5 mg/m3. Before modification, in exposed workers there was significantly more decline of spirometry, and more increase of white blood cell count during the first afternoon shift, compared with non-exposed workers. In exposed workers, the white blood cell count increase was positively associated with decline of spirometry. After modification, differences between exposed and non-exposed workers no longer existed.

CONCLUSION

Follow-up investigation of acute exposure-effects demonstrated the effectiveness of remedial actions taken against a contaminated humidification system. Follow-up of exposure-effects in particular is recommended when there is doubt about the interpretation of exposure measurements.

The effects of patient communication skills training on compliance

OBJECTIVE

To examine the relationship between communication skills training for patients and their compliance with recommended treatment.

DESIGN

A randomized control design was used, with patients nested within physicians. Each physician was audiotaped with 6 patients, 2 patients in each of the 3 intervention conditions: (1) a trained group (n = 50) received a training booklet in the mail 2 to 3 days prior to the scheduled appointment, (2) an informed group (n = 49) received a brief written summary of the major points contained in the training booklet while in the waiting room prior to the scheduled appointment, and (3) an untrained group (n = 51) did not receive any form of communication skills intervention.

SETTING

Participants included physicians and patients from 9 different primary care, family practice locations. Two locations were clinics associated with a large, university-based medical school and hospital, while 7 were private practice offices in the community.

PARTICIPANTS

The sample included 25 family physicians (averaging 11 years postresidency) and 150 patients. Patients were randomly selected from appointment records and randomly assigned to 1 of 3 intervention conditions.

INTERVENTION

A training booklet designed to instruct patients in information seeking, provision, and verification.

MAIN OUTCOME MEASURE

Patients' compliance with medications, behavioral treatment (e.g., diet, exercise, smoking cessation), and/or follow-up appointments and referrals.

RESULTS

Trained patients were more compliant overall than untrained or informed patients. Training positively influenced compliance with behavioral treatments and follow-up appointments and referrals.

CONCLUSION

Training patients in communication skills may be a cost-effective way of increasing compliance and improving the overall health of patients.

Polychromatic percepts during hypergravity

Future helmet mounted systems and cockpit displays will rely on color graphics and information that high performance aircraft pilots will need to discern and understand. Color in displays may help reduce pilot workload. The effect of high G and reduced eye level blood pressure on field-of-view has been study extensively. The effect of high sustained acceleration on color vision, however, is unknown. Research on visual contrast sensitivity, night vision, and visual acuity under acceleration in a human centrifuge has demonstrated changes in vision. We began by having normal color vision subjects view a magnified color aerial map and describe what they saw as we slowly ramped up the G profile from baseline (1.4 G) at 0.1G/sec until they experienced almost complete blackout. At that point subjects began straining and the centrifuge was rapidly decelerated. Several subjects described the river fading away before much else happened. Then the yellow and green features of the terrain faded together. Reds and dark blues appeared to change to black but remained legible until the entire image also faded to black. Computer types call the color of a river on a map cyan. So a display was created that resembled a device know as a "light bar" that is routinely used in centrifuge research. It consisted of a 45 degree wide square projection of green dots in the periphery and a red dot in the center on a white background. Due to our new curiosity about cyan we added dots halfway between the green and red that were cyan. We then ran several people through the same slow onset ramp until near blackout. Several reported that the cyan disappeared completely, significantly before the green. Then the green disappeared, and finally the central red dot. For those who experience it, it is a very useful and repeatable early end point where vision is affected but still available. Next we borrowed a color wheel from the hypobaric chamber and taped it to the wall of the cab. Several subjects reported discomforting angular optical vection due to torsional nystagmus. Thus, a vertical bar arrangement of colors was selected that minimized disruption from involuntary eye movements.

[Consideration of mental symptoms and physical disabilities in deciding upon placement in a residential home versus a nursing home]

This study analysed 235 applications of elderly people for residential home and nursing home care. The applications were submitted to a Dutch municipal care allocation board. Based on the 1994 registration data from this board the impact of physical restrictions and mental problems on the care allocation for residential or nursing homes and connected care was studied. Physical complaints were measured with an adl and an hdl scale (Activities of Daily Living and Household Activities of Daily Living), mental problems were assessed by means of the Reality, Orientation and Restlessness Scales. Persons with an admission allocation for a nursing home (both psychogeriatric and somatic) had the highest scores on all scales; persons allocated to the residential home and related care had significantly lower scores. Above-mentioned scales have been combined into care level categories. Fifty seven persons, however, appeared not to have any physical or mental problems despite a care allocation to the residential home or related care. Contextual problems (housing, social contacts, endurance-capacity of relatives and friends) were particularly decisive in this case. Moderately severe problems, both physical and mental, generally resulted in an allocation to the residential home or related care. Serious problems usually result in allocation to the somatic or the psychogeriatric nursing home. Combined serious problems (75%) tended to result in an allocation to the psychogeriatric nursing home. This study is preliminary to the development of a care allocating instrument.

Follow up investigation of workers in synthetic fibre plants with humidifier disease and work related asthma

OBJECTIVE

To investigate the clinical and sociomedical outcome in patients with various clinical manifestations of humidifier disease and work related asthma after removal from further exposure.

METHODS

Follow up investigation (range 1-13 years) of respiratory symptoms, spirometry, airway responsiveness, sickness absence, and working situation in patients with (I) humidifier fever (n = 12), (II) obstructive type of humidifier lung (n = 8), (III) restrictive type of humidifier lung (n = 4), and (IV) work related asthma (n = 22). All patients were working at departments in synthetic fibre plants with microbiological exposure from contaminated humidification systems or exposure to small particles (< 1 micron) of oil mist.

RESULTS

At follow up patients with work related asthma were less often symptom free (37%, 7/19) than patients with humidifier disease (I, II, III) (67%, 16/24). Mean forced expiratory volume in one second (FEV1) of patients with obstructive impairment had been increased significantly at follow up but still remained below the predicted value. Mean forced vital capacity (FVC) of patients with initially restrictive impairment had returned to normal values at follow up. Airway hyperresponsiveness at diagnosis persisted in patients with obstructive impairment (II + IV 14/17, but disappeared in patients with humidifier fever (3/3) and restrictive type of humidifier lung (2/2). In patients with obstructive impairment (II + IV), FVC and FEV1 at diagnosis were negatively associated with the duration between onset of symptoms and diagnosis and the number of years of exposure. Those with positive pre-employment history of respiratory disease had a lower FEV1 at diagnosis. Sickness absence due to respiratory symptoms decreased in all groups of patients after removal from further exposure, but this was most impressive in patients with the humidifier lung (II, III) and patients with work related asthma (IV). At follow up 83% of the patients were still at work at the same production site, whereas 11% received a disability pension because of respiratory disease.

CONCLUSION

In patients with work related respiratory disease caused by exposure from contaminated humidification systems or oil mist, removal from further exposure resulted in clinical improvement, although, especially in those with obstructive impairment, signs persisted. Because of the possibility of transferring patients to exposure-free departments most patients could be kept at work.

Use of pyrrolidonyl peptidase to distinguish Citrobacter from Salmonella

In the routine testing of foods for Salmonella, Citrobacter and other members of the Enterobacteriaceae often produce colonies which are almost indistinguishable from Salmonella on commonly used selective agars. Biochemical confirmation of such colonies can be expensive and time-consuming. It has been suggested that the enzyme pyrrolidonyl peptidase (PYRase) could be used as a rapid test to distinguish Citrobacter colonies (PYRase-positive) from Salmonella (PYRase-negative). Pure cultures of Salmonella, Citrobacter and other Enterobacteriaceae were tested for PYRase activity; all strains of Salmonella tested were PYRase-negative, and all Citrobacter tested were PYRase-positive. Inoculated and naturally contaminated food samples were tested for the presence of Salmonella by a standard cultural method. A PYR test was used to test Salmonella-like colonies isolated on selective agar and potentially, eliminate PYR-positive isolates from further biochemical testing. The test was able to screen out 6% of colonies selected from samples inoculated with Salmonella, and 43% of colonies selected from uninoculated samples.

Use of the health history as a psychiatric screening tool

BACKGROUND

Numerous studies indicate that most mental health services are provided in the primary care medical setting and that problems exist with misdiagnoses and lack of recognition of mental health disorders. The purpose of our investigation was to determine whether patient responses on a typical medical health history form could be used to predict depression or anxiety.

METHODS

New adult patients at a university community family practice clinic were surveyed during a 6-month period. Study patients completed a health history form and standardized inventories of anxiety and depression.

RESULTS

The study sample included 187 patients. Positive responses to mood-related symptoms reported on the health history best predicted anxiety and depression. Nonmood symptoms were also significant, although not as powerful, predictors of these disorders. A significant relation existed between total number of positive symptoms and psychiatric diagnoses, which continued when mood symptoms were removed from the analyses. Results were used to develop physical, nonmood primary care symptom profiles that could be used to screen for anxiety and depression.

CONCLUSION

Providing physicians the means to improve mental health diagnostics can help advance patient care and health care system outcomes.

Socio-economic differences in health risk behavior in adolescence: do they exist?

Socio-economic differences in risk behaviors in adolescence can be seen as a prelude to the re-emergence of socio economic health differences in adulthood. We studied whether or not socio-economic differences in health risk behaviors are present in male and female adolescents in The Netherlands. The relation between socio-economic status (SES) and health risk behaviors was examined, by testing both the main and interaction effects of SES and gender on separate health risk behaviors on one hand, and on the behaviors cumulatively on the other. The data were derived from 1984 adolescents in the four northern provinces of The Netherlands. SES was measured by means of the educational level and the occupational status of both parents. Four health risk behaviors were included in this study: smoking, alcohol consumption, soft drug use, and (no) physical exercise. We found that the relationships between SES and health risk behaviors are not as linear as is often found in adulthood. Our findings can be characterised overall by an absence of relationship between SES and health risk behaviors. The only exception applies to sport, which is linearly related to SES. Adolescents in the lower SES groups engage in sport less than adolescents in the higher SES groups. There was an irregular relationship between the father's occupational status and the adolescents' smoking and drinking. Adolescents in the highest, lowest and middle of the six SES groups have the highest rates of health risk behaviors. All observed relationships are similar for both male and female adolescents. A relationship between gender and the separate health risk behaviors was found only for alcohol consumption and drug use. For both male adolescents showed higher rates of risk behavior. Males also scored higher on the cumulative health risk behaviors than their female counterparts. The findings of this study do not support the hypothesis of latent differences in adolescence.

['Public health status and perspectives' 1997. VII. Health care needs and health care consumption]

In the 'Public health status and forecasts' 1997 attention is given to the relationship between health status and health care. The theme report 'Health care need and health care consumption' integrates information about both phenomena and about waiting lists in the different sectors of health care. It is difficult to quantify the need for health care, because statements about need always imply a judgment by parties involved. In the literature need for health care is often operationalized by historical data on health care consumption or by health status indicators. At the national level only limited quantitative information is available to support policy on waiting lists and waiting times. The data are seldom disease-specific. Changes in size and distribution (by age and sex) of the population will increase health care cost over the period 1994-2015 in the Netherlands by 0.9-1.0% per year. More detailed demographic projections, however, indicate that there are large disease-specific differences.

A genetically engineered strain of Saccharopolyspora erythraea that produces 6,12-dideoxyerythromycin A as the major fermentation product

The erythromycin producer, Saccharopolyspora erythraea ER720, was genetically engineered to produce 6,12-dideoxyerythromycin A, a novel erythromycin derivative, as the major macrolide in the fermentation broth. Inspection of the biosynthetic pathway for erythromycin would suggest that production of this compound could be achieved simply through the disruption of two genes, that encoding the erythromycin C-6 hydroxylase (eryF) and that encoding the erythromycin C-12 hydroxylase (eryK). The double mutant, however, was found to produce a mixture of 6,12-dideoxyerythromycin A and the precursor, 6-deoxyerythromycin D. Complete conversion to the desired product (to the limit of detection by TLC) was achieved by inserting an additional copy of the eryG gene, encoding the erythromycin 3"-O-methyltransferase and driven by the ermE* promoter, into the S. erythraea chromosome.

Teenagers: mental health and psychological issues

Adolescence is a developmental period marked by multiple challenges and demands which create a heightened vulnerability to the development of emotional disorders. Primary care physicians are in an ideal position to intervene in the early stages and prevent the tragic consequences which can occur with an untreated mental health disorder. This article reviews the assessment and treatment of adolescent mental health in the primary care medical setting. Knowledge of these disorders and their manifestations in the primary care environment will enable clinicians to provide higher quality medical care and will reduce the potential for continual life disruptions into the adult years.

The clinical spectrum of humidifier disease in synthetic fiber plants

In a synthetic fiber production site with recirculating cold water humidification systems and small-size-particle (> 0.1 mu < 1 mu) oil mist exposure, humidifier disease was diagnosed in several workers. The patients could be divided into three groups illustrating the clinical spectrum of humidifier disease: humidifier fever (toxic inhalation fever) (12 patients): an asthma-like syndrome (8 patients); and allergic alveolitis (4 patients). Natural challenge at the work place, monitored by parameters such as peak-flow, spirometry, blood leucocyte count, and body temperature, provided important diagnostic information. In patients with chronic allergic alveolitis, a gradual recovery during an exposure-free period indicated a work-related causation, more than changes during challenge in normal work. In some patients, the fungus Sporothrix schenckii, hitherto unknown as a sensitizer, may have been at least one of the causative antigens. Measured levels of viable fungi (< or = 100 CFU/m3) and endotoxin (64 pg/m3) in air samples were much lower than those at which health effects usually are reported. Small-size-particle oil mist exposure may have underestimated the exposure to microorganisms, but otherwise an adjuvant role to this type of co-exposure might also be postulated. In contrast to allergic alveolitis, the asthma-like syndrome appeared to be more common in patients with a history of atopy and of smoking.

Step treadmill exercise training and blood pressure reduction in women with mild hypertension

Stepping as an exercise modality has gained increasing popularity. The step treadmill is an exercise machine which simulates actual stair-climbing. The purpose of this study was to determine the effectiveness of a 16-week supervised aerobic step treadmill exercise training protocol in reducing resting blood pressure in women with unmedicated mild hypertension. During the training protocol, subjects exercised during a self-selected appointment three times a week on the step treadmill, increasing from 20 minutes up to 60 minutes per session, at a target heart rate corresponding to 70-80% heart rate reserve for 16 weeks. Utilizing paired t-test analysis, mean resting systolic blood pressure decreased from 142.2 +/- 9.1 to 132.7 +/- 8.2 mm Hg (p < .01) and mean resting diastolic blood pressure decreased from 93 +/- 4.9 to 87.4 +/- 5.4 mm Hg (p < .01) during the 16-week protocol. Mean maximal oxygen uptake was significantly increased, whereas mean body weight did not change significantly over the 16-week period. Large scale trials are needed to further delineate the effectiveness of stepping as a health care intervention in adults with unmedicated mild hypertension, especially in women.

Regulation and characterization of the interferon-alpha present in patients with advanced human immunodeficiency virus type 1 disease

To examine a possible association between plasma viremia and interferon-alpha (IFN-alpha) in patients with the acquired immunodeficiency syndrome (AIDS), we performed IFN plasma immunoadsorption by apheresis (IFN-alpha apheresis) in four volunteers with AIDS who had sustained levels of endogenous plasma IFN-alpha. IFN-alpha apheresis with two plasma volume exchanges was performed daily for 5 days. Clinical signs and symptoms and hematologic, virologic, and immunologic parameters were monitored. Two subjects developed anemia from phlebotomy, and one had a catheter++-associated bacteremia. The IFN-alpha apheresis was effective only in transiently removing IFN-alpha: depletion of IFN-alpha led only to its rapid reconstitution. Cell-associated HIV-1 was unchanged, but three of four subjects had a modest decrease in culturable plasma virus burden following the procedures. The recovery of in vivo HIV-1-related IFN-alpha by apheresis allowed its biologic and biochemical characterization. The HIV-1 IFN-alpha showed characteristics on ELISA, western blot, and biologic assays similar to two subspecies of the natural protein. The natural, recombinant, and HIV-1-induced IFN-alpha s demonstrated nearly identical antiviral activities. The HIV-1 IFN-alpha eluted from the column was not acid labile. The inability of large amounts of plasma IFN-alpha found in some patients with AIDS to affect viral burden likely reflects properties of the virus or of host factors independent of IFN-alpha.

[What determines waiting time for cataract surgery, knee arthroscopy and total hip arthroplasty and how satisfied are the patients?]

OBJECTIVE

To gain an insight into the waiting periods for cataract, arthroscopic knee and total hip operations and the patients' opinion on this subject.

DESIGN

Retrospective study.

SETTING

The district of Groningen, the Netherlands.

METHOD

A study population of 300 national health insurants who underwent a cataract operation (100), an arthroscopic knee operation (100) or a total hip operation (100) in 1992 and 50 private insurants who underwent a cataract operation in 1992, was obtained by a select sampling. By a structured questionnaire, information about basic variables (age, gender, education, occupation, perceived urgency and form of insurance), waiting periods and opinions on the waiting periods was gathered.

RESULTS

The waiting periods between the specialist consultation and the operation were 5.2 and 7 months for eye, knee and hip patients respectively. The waiting period per hospital varied from 4-7 months for an eye operation, 1-4 months for a knee operation and 2.5-12 months for a hip operation. The waiting period was not affected by basic variables, except the waiting period for hip operation which benefited from a high urgency declaration by the specialist. 60% of the eye patients, 45% of the knee patients and 47% of the hip patients were satisfied about the waiting period. 15% of all patients were dissatisfied about it.

CONCLUSION

Waiting periods for operations in this study were not determined by patient-specific basic variables, varied strongly between hospitals and did not cause discontent among the majority of the patients, despite durations of mostly several months.

[Outpatient preoperative examination by the anesthesiologist. II. Patient satisfaction]

OBJECTIVE

To determine patient satisfaction after the reorganisation of the preoperative screening.

SETTING

General Hospital De Weezenlanden, Zwolle, The Netherlands.

DESIGN

Retrospective patient interview.

METHOD

Before the reorganisation, the preoperative screening was performed clinically under the responsibility of the consultant surgeon. Thereafter it was performed in the outpatient department by the anaesthesiologist. Patients who had had two similar operations within two and a half years, one before and one after the reorganisation, were interviewed at home regarding the different methods of preoperative screening (n = 94).

RESULTS

The preoperative screening had a reassuring effect on patients. 72% considered preoperative anaesthesia information important. The number of hospital visits before the operation did not significantly increase after the screening was reorganised. There was little objection to attending the hospital for preoperative screening (12%). Most patients (60%) had no preference for the previous or the present method of screening. Patients who remembered the interview with the anaesthesiologist (56%) preferred the new method (score: 8.2 on a scale 0-10; score of the former method: 7.6; p < 0.01). A larger number of these had the opportunity to ask questions (p = 0.01) and more patients had received attention from the anaesthesiologist (p < 0.01). 75% of the patients had received sufficient preoperative anaesthesia information. 28% of the patients wanted to see the anaesthesiologist again after admission.

CONCLUSIONS

Preoperative screening reassures and informs the patient. The patients who could remember the interview with the anaesthesiologist preferred the preoperative screening in the outpatient department. A considerable number of the patients wanted to see the anaesthesiologist again after admission.

[Outpatient preoperative examination by the anesthesiologist. I. Fewer procedures and preoperative hospital days]

OBJECTIVE

To study the effect of the reorganisation of the preoperative screening on the volume of laboratory and function tests, and on preoperative hospital days.

SETTING

General Hospital De Weezenlanden, Zwolle, The Netherlands.

DESIGN

Retrospective study.

METHOD

In The Netherlands the surgeon is responsible for the preoperative screening (anamnesis and general examination). In 1992 the preoperative screening was reorganised and it was carried out in the outpatient department under the responsibility of the anaesthesiologist. Laboratory and function tests were only performed if indicated. Data on 3122 patients, operated in 1991, were compared with the data on 3258 patients from 1992. Multiple regression analysis and chi-square test were used.

RESULTS

The proportions of the patients subjected to laboratory tests, ECG or a chest X-ray decreased from 90%, 55%, and 50% respectively in 1991 to 53%, 43% and 10% in 1992 (p < 0.05). Admission on the day of surgery increased from 13% in 1991 to 21% in 1992 (p < 0.01). Clinical preoperative evaluation with admission more than 1 day before surgery, decreased from 5% in 1991 to 4% in 1992 (p = 0.02). The mean duration of the hospital stay before the operation decreased from 0.79 day per patient in 1991 to 0.65 in 1992 (p = 0.02).

CONCLUSION

If the preoperative screening is carried out by the anaesthesiologist, all the patients have the opportunity to meet the anaesthesiologist before the operation. The number of preoperative hospital days can be reduced by outpatient preoperative screening. Laboratory and function testing on only if indicated reduces the volume of the laboratory tests, ECGs and chest X-rays.

[Appropriate use of balloon angioplasty; a study in the Eindhoven region]

OBJECTIVE

To gain insight in the volume of PTCAs in the region of Eindhoven and in the appropriateness of the intervention.

DESIGN

Descriptive.

SETTING

Department of Cardiology in the Catharina Hospital at Eindhoven.

METHODS

The number of PTCAs was counted in Eindhoven and surrounding area. Peer review was carried out of 50 randomly chosen patients. General practitioners were asked about their opinion of the appropriateness of the intervention in their patients.

RESULTS

In the region of Eindhoven 91.5 PTCA's are done per 100,000 inhabitants yearly (the national average in 1993 in the Netherlands is 71), 38 in the rural and 133 in the urban subregions. Peer review (by two (intervention) cardiologists, three public health doctors) showed that in 82% of the cases the indication for PTCA was appropriate. According to the Working Group for Interventional Cardiology 34% of the cases were classic indications, 64% were indications in development, and 2% were wrong. In the urban region there were more indications in development than in the rural regions. The general practitioners agreed with the cardiologists about the appropriateness of the PTCAs in their patients.

CONCLUSION

Although the number of PTCAs is relatively large in the Eindhoven region, the indications for the intervention were in accordance with accepted rules.

[Determinants of medical consumption in older subjects covered by national health insurance]

OBJECTIVE

Investigating to what extent the medical consumption of persons aged 50-80 yr covered by the Dutch National Health Service is explained by their health condition and sociodemographic factors like age, gender, marital status and education.

DESIGN

Questionnaire.

SETTING

15 general practices (3 in each of 5 municipalities) in the provinces Drenthe and Overijssel, the Netherlands.

METHOD

A one-time prestructured health questionnaire (in writing) was sent to 1875 persons aged 50-80 yr covered by the Dutch National Health Service (125 randomly selected persons from each practice). The response was 55% (n = 1022). The objective and subjective health conditions and the sociodemographic factors were tested in relation to the medical consumption (visiting a general practitioner, a specialist, or hospitalization) with a type of regression analysis with which both direct and indirect relations with medical consumption could be calculated.

RESULTS

The medical consumption was explained for 17% by the health condition, the age and the level of education of patients. Elderly, single women with little education had the highest medical consumption. This was mainly determined by the higher probability of health problems in this group. Apart from this there was an age-related increase in medical consumption.

CONCLUSION

Only part of the medical consumption can be explained by the main literature determinants of medical consumption. Refinement in research can be achieved by relating the care demand to research into referral behaviour of general practitioners and specialists, which can result in supplementary knowledge on determinants of medical consumption.