Chemotherapy of CNS-trypanosomiasis: the combined use of diminazene aceturate or pentamidine with DL-alpha-difluoromethylornithine (DFMO). The chemotherapy of CNS-trypanosomiasis with DL-alpha-difluoromethylornithine (Eflornithine, DFMO) with the diamidine, pentamidine (Lomidine) or diminazene aceturate (Berenil) was examined using the mouse model for CNS-trypanosomiasis. Although combined DFMO/pentamidine therapy can give complete cures, one or more doses of 100 mg/kg pentamidine was required with continuous administration of DFMO for 14-16 days, and even this treatment failed to cure the mice in a repeat experiment. Diminazene aceturate was more efficient and provided a 40 mg-kg dose was utilised, it was possible to reduce the period of DFMO to approximately 12 days. Attempts to reduce the dose rate of diminazene to less than 40 mg-kg failed. Of the two compounds, diminazene aceturate was the more successful and could possibly be used in combination with DFMO in the treatment of CNS-trypanosomiasis.


Pharmacomodulations on new organometallic complexes of Ir, Pt, Rh, Pd, Os: in vitro and in vivo trypanocidal study against Trypanosoma brucei brucei. New organometallic complexes have been synthesized by association of an active organic molecule with a metallic element such as Pt, Rh, Ir, Pd, Os. Their trypanocidal activity was studied in vitro and in vivo against T. b. brucei. The more active compounds were pentamidine derivatives. The Ir- COD-pentamidine complex, and Iridium (I) cationic and organometallic complex showed and in vitro activity at 60 micrograms/l. Moreover, all infected mice were cured by this compound subcutaneously administered in a single dose at 0.5 mg/kg (0.317 mumol/kg). In the same conditions, pentamidine cured all the mice at 5 mumol/kg. Ir-COD-pentamidine (or P1995) was 16 fold more efficient than pentamidine. Since the chemotherapeutic index of this molecule was 7.5 fold higher than those of pentamidine, P1995 can be considered as a potential trypanocidal drug of the future.


Experimental infection of Friesian Holstein calves with an Indonesian isolate of Trypanosoma evansi. The effect of a single, primary, artificial infection with Trypanosoma evansi was studied in nine Friesian Holstein calves. Body temperature, packed cell volume (PCV) and parasitaemia measurements were obtained daily from each of the infected calves for up to 90 days after parasites were injected, body weights were monitored weekly. T. evansi infection had a marked depressive effect on PCV profiles and the rate of body weight gain.


Proposals for a new therapeutic strategy for simple Plasmodium falciparum malaria attacks in Cameroon. From simplified in vivo tests, authors set up a cartography of the sensitivity of Plasmodium falciparum to amino-4-quinolines in Cameroon; they also evaluated the clinical and parasitological efficacy of different therapeutic protocols which make use of amino-4-quinolines, quinine, mefloquine and halofantrine. All these drugs are administered orally. They recommend maintaining home medication with chloroquine at the dose of 25 mg/kg over 3 days, conserving quinine for use in the case of a possible failure. The use of most recent antimalarials can be proposed only as a last resort.


The prevalence of trachoma in preschool and school children in Olimpia, Guaraci and Cajobi, Sao Paulo, Brazil. A school-based prevalence survey of trachoma was conducted in three rural municipalities in the state of Sao Paulo, Brazil, in 1989. A total of 950 children aged 4-11 years were examined. The prevalence of inflammatory trachoma was found to be 6.3%, peaking at 24.1% in the 4 year-old age group. The prevalence of trachomatous scarring was 2.7% and was more prevalent in older children. Risk factors included household sleeping arrangements and nasal discharge.


Evaluation of a simple screening test for the quality of drinking water systems. A simple and inexpensive assay for detection of H2S producing bacteria in drinking water was evaluated in Paraguay. Using an improved preparation procedure, results were basically temperature independent in the range of 22-37 degrees C and correlated well with the presence of total coliform bacteria (96%, 28 degrees C). The assay was not suitable for control of surface water and dug well water due to the frequent presence of non-faecal coliforms. However, it was very suitable for routine control of high quality water systems, like treated community water systems or deep-tube well water, where complete absence of coliforms is required. The H2S-test is very inexpensive and does not require a laboratory technician or special equipment. Its use permits a cost-effective routine control of high quality community water systems in developing countries. In addition, this test turned out to be an effective educational tool for heightening the awareness of people towards dangers of unclean drinking water.


Cutaneous myiasis caused by tumbu fly larvae, Cordylobia anthropophaga in southwestern Saudi Arabia. Seven cases of human cutaneous myiasis caused by maggots of the tumbu fly, Cordylobia anthropophaga are reported from Asir region, southwestern Saudi Arabia. Boil-like swellings infested with individual fly larvae, varied from one to four and occurred in both unprotected and usually protected areas of the skin. Twenty five fly maggots were retrieved from separate furunculoid lesions on the body surface of a massive case of a 4-year old boy. The present observations confirm that this calliphorine species is not restricted to tropical Africa.


Differential recognition of Dirofilaria immitis antigens by human IgG and IgM positive sera. Preliminary data based on EITB analysis. Preliminary data are presented on the differential recognition of Dirofilaria immitis antigens by sera positive for IgG and IgM (detected by enzyme linked immunosorbent assay, ELISA) using the enzyme-linked immunoelectrotransfer technique (EITB). The sera were followed prospectively over a year to detect seasonal variations. IgG mainly recognized antigens with a molecular weight (MW) lower than 74 kDa, while IgM recognized those with a MW higher than 43 kDa. The antigens with MW between 74 and 61 kDa were recognized by both isotypes. In IgG positive sera all bands were recognized throughout the year, albeit more mildly in summer. For IgM it is noteworthy that antigens with a MW between 43 and 20 kDa were not recognized in spring. These data are in accordance with those obtained with ELISA in the seasonal follow-up of positive sera.


IgA immunoassay for the diagnosis of bancroftian filariasis. In some parasitic infection such as toxoplasmosis, specific IgA is a highly reliable marker of active infection. In bancroftian filariasis, only 10 of 20 (50%) and 3 of 20 (15%) of the microfilaremic patients were positive for IgA anti-Brugia malayi using respectively indirect ELISA and immunocapture ELISA tests. As regard to these low sensitivities, the detection of specific IgA is unlikely to be a useful test for the diagnosis of active Wuchereria bancrofti infection.


Ocular onchocerciasis and the intensity of infection in the community. IV. The degraded forest of Sierra Leone. To assess the pattern of onchocercal ocular disease and blindness in south Sierra Leone, ophthalmological surveys were carried out in 13 highly infected villages located in various river basins. The most important finding was the blinding potential of onchocerciasis in the degraded forest area where the prevalence of onchocercal blindness reached levels of up to 6%. This is remarkable since previous studies have claimed onchocerciasis in the forest to cause little blindness. Ocular onchocerciasis undoubtedly constitutes a problem of public health importance in south Sierra Leone. The rates of onchocercal ocular disease and blindness, however, were significantly lower than those found in savanna villages with similar levels of endemicity. The community pattern of ocular onchocerciasis was not significantly different from the classical pattern in the forest but this could be explained by the low endemicity levels in the forest villages studied. It is therefore not possible to deduce from this study whether the pattern of ocular onchocerciasis in south Sierra Leone is of the forest type, or a pattern on its own.


Onchocerciasis prevalence in previously known foci in western Uganda: results from a preliminary survey in Kabarole district. A prevalence survey of onchoceriasis was done in Kabarole district, Uganda, in 1990. The objective was to determine the prevalence of onchocerciasis among communities living in previously known foci. A total number of 1186 persons was included in the study. The infection rate among the communities studied ranged from 0% to 67%. The most frequent clinical signs and symptoms of onchocerciasis were: pruritus (80%), rough skin (46%), skin rash (30%), leopard skin (6%) and sclerosing keratitis (7%). 3.6% of all cases with onchocercasis were found to have no perception of light. The total number of cases in the district was estimated to be 32,000. The study showed that the foci, where Simulium neavei is the vector, are still active. In contrast, very few infections with Onchocerca volvulus were found in the Rwenzori focus, where S. damnosum s. 1. was the vector. The results indicate that onchocerciasis is of public health importance in Kabarole district and needs to be controlled.


Compared efficacy of repeated annual and semi-annual doses of ivermectin and diethylcarbamazine for prevention of Wuchereria bancrofti filariasis in French Polynesia. Final evaluation. In October 1989, 58 apparently healthy Polynesian Wuchereria bancrofti carriers, in whom microfilarial (mf) density was greater than or equal to 100 mf/ml, were randomly allocated to treatment groups receiving single doses of either ivermectin at 100 mcg/kg or diethylcarbamazine (DEC) at 3 and 6 mg/kg. Six months later, half of the carriers initially treated with ivermectin 100 mcg/kg or DEC 3 mg/kg were given a second similar dose while the rest were given a placebo. Six months later again, all of the carriers received a last treatment dose similar to the initial one. The results observed during the 12-month period which followed this last treatment have confirmed that (i) in terms of immediate clearance or complete negativation of microfilaremia, the efficacy of ivermectin is higher than that of DEC (at dosage of 3 or 6 mg/kg), (ii) DEC is more effective than ivermectin in sustaining the reduction of microfilaremia over a longer period of time and (iii) the efficacy of repeated single doses of either DEC 3 mg/kg or ivermectin 100 mcg/kg is much higher when given semi-annually than annually.(ABSTRACT TRUNCATED AT 250 WORDS)


In vitro and in vivo effect of diethylcarbamazine on the activity of acetylcholinesterase from Wuchereria bancrofti infected human serum. The acetylcholinesterase (AChE) activity was measured in human serum from persons infected with the filarial parasite Wuchereria bancrofti. The asymptomatic microfilaremic serum showed five times increase in AChE-activity as compared with normal serum, whereas only little difference was observed in serum from patients with elephantiasis. Similar results were obtained when the enzyme activity was measured in the immune complexes precipitated with polyethyleneglycol. Further, the effect of the antifilarial drug diethylcarbamazine (DEC), on the AChE activity of infected and normal serum was studied in in vivo and in vitro experiments. In vitro, DEC was found to be effective only with respect to AChE from asymptomatic microfilaremic serum where 75% decrease in enzyme activity was observed at 100 mumol. The oral administration of DEC (5 mg/kg of body weight/day) effected the activity of AChE from microfilaremic serum as shown after 1 hr, 1 and 3 weeks. A regular decrease in enzyme activity of asymptomatic microfilaremic serum was observed. By increasing time periods and after three weeks the level of AChE reaches the normal value. In vitro and in vivo the same concentration of DEC has negligible effect on the normal serum suggesting that in case of asymptomatic microfilaremic serum the increased activity of AChE is different in nature than the host acetylcho-[abstract incomplete in journal]


Biological control of the snail intermediate hosts of Schistosoma mansoni in Martinique, French West Indies. In Martinique water-cress beds constituted the last transmission sites for schistosomiasis. The competitor snail, Melanoides tuberculata, was introduced at the beginning of 1983 to a group of water-cress beds and eliminated the snail hosts, Biomphalaria glabrata and B. straminea, in less than two years. Following this first success, M. tuberculata was introduced to the other groups of beds which were inventoried at the beginning of the eighties. At the present time, B. glabrata and B. straminea have totally disappeared from eight sites and only a few individuals have been recorded from 12 sites. The two remaining water-cress beds have dried up and were abandoned.


Antibodies against secreted and non-secreted antigens in mice after infection with live Mycobacterium tuberculosis. Mice from four different inbred strains were infected with live Mycobacterium tuberculosis and the immune response to M. tuberculosis was followed for 24 weeks, using Western blotting. Nearly all mice, irrespective of H-2 type, reacted with the 38-kDa protein band. Antibodies against this secreted 38-kDa protein were the first to appear, 4 weeks after infection. Thereafter the secreted 19-kDa protein and non-secreted antigens, such as the 65-kDa and 33-kDa proteins, were recognized. The immune response against the non-secreted antigens was influenced by the mouse strain. However, the 33-kDa protein band was recognized by all mouse strains after a second injection with live M. tuberculosis. The specificity of the antibodies was analysed in Western blot using sonicates of M. tuberculosis, M. kansasii, M. avium, M. terrae, M. gordonae and Escherichia coli. Antibodies against the 38-kDa and 33-kDa protein bands seemed to be specific for M. tuberculosis, while antibodies against the 19-kDa protein band showed limited cross-reactivity. Antibodies against the 65-kDa protein were strongly cross-reactive. These results suggest that the 38-kDa protein is secreted in vivo and, therefore, may be available to the humoral immune system at an early stage of infection. The non-secreted 33-kDa protein is only recognized by all mouse strains after prolonged contact with M. tuberculosis.


The effects of deoxyspergualin on the development of diabetes in diabetes-prone BB rats. The effects of the administration of the recently discovered immunosuppressant 15-Deoxyspergualin (DSP) on the development of insulin-dependent diabetes mellitus (IDDM) in diabetes-prone BB rats were studied. The data show that 2 mg/kg body weight DSP, administered six times a week from the 30th day up to the 105th day of age, significantly reduced the incidence of diabetes in diabetes-prone BB rats as compared with the PBS-injected controls. The drug was also able to reduce the signs of pancreatic insulitis and the percentages of W3/25+ and OX6+ splenocytes. Interruption of the treatment resulted in a later onset of diabetes in a high percentage of animals within 41 days. These findings suggest that 15-DSP may temporarily reverse the pathogenic mechanisms leading to beta cell destruction and autoimmune diabetes in a well-known experimental model of human insulin-dependent diabetes mellitus.


Involvement of interleukin-2 and interferon-gamma in the immune response induced by influenza virus iscoms. Splenocytes from mice primed with influenza virus envelope proteins incorporated in iscoms, as micelles or as infectious virus, were restimulated in vitro with the same antigen. Interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) were assayed in the supernatants of such cultures. Influenza virus iscoms induced IL-2 and IFN-gamma responses in restimulation experiments that were antigen specific and significantly higher than those induced by micelles or infectious virus. Serum samples collected at the end of the experiments were analysed for the antibody response and profile. The antibody titres induced by iscoms were of a similar order of magnitude as those induced by infectious virus, and were about 18 times higher than the titres induced by micelles. In mice immunized with iscoms or infectious virus the most abundant antibodies were of the IgG1 and IgG2a isotype, and the IgE response was low. We conclude that immunization with iscoms stimulates the Th1-like subtype of murine T lymphocytes.


Alteration in T cell/macrophage ratio may reveal lymphocyte proliferation specific for the triggering antigen in reactive arthritis. It has previously been shown that synovial fluid (SF) mononuclear cells (MNC) from patients with reactive arthritis (ReA) and some patients with undifferentiated oligoarthritis (UOA) respond specifically to the triggering bacterium (specific responders). However, in some patients there is a response to two or more bacteria (non-specific responders) and in a third group no response is found (non-responders). We assessed whether the proportion of synovial MNC which were macrophage-monocyte (MaMo) differed among the specific responder, non-specific responder and non-responder groups. There was no difference between the specific (33 +/- 9) and the non-specific (32 +/- 26) groups; non-responders had a higher percentage of MaMo (61.3 +/- 31%) although the difference was not significant. We also investigated whether the specificity of the response to antigen in ReA or UOA SF was altered by changing the T-cell/MaMo ratio. In all five specific responders the immune response remained specific whatever the ratio tested. However, four of the five non-specific responders, but none of the non-responders, developed a specific response to one of the tested antigens by increasing the T cell/MaMo ratio. We conclude that in some patients with a non-specific response, alteration of the T cell/MaMo ratio uncovers a specific response which may identify the triggering antigen.


Unusual sequence of immunoglobulin L-chain rearrangements in a gamma heavy chain disease patient. Patients with gamma heavy chain disease (gamma-HCD) generally produce incomplete immunoglobulin (Ig) gamma-heavy chains (gamma-HCD protein) which cannot associate with light chains (IgL). In most patients Bence Jones proteins (BJP) are not observed. However, in the 61-year-old patient WIN we found gamma l-HCD proteins and lambda BJP in serum and urine. WIN gamma l-HCD protein does not carry the Ig Fd region, has a molecular weight of 33.5 kDa, and the seven N-terminal amino acid residues are not translated from any of the known immunoglobulin heavy chain (IgH) gene sequences. These residues are followed by the C gamma l-hinge region. In DNA from peripheral blood lymphocytes of patient WIN we found bands representing dominant rearrangements in one of the two alleles of the IgH, Ig kappa and Ig lambda locus. Taken together, the data from protein and DNA analysis strongly suggest, albeit do not formally prove, that one dominant B-cell clone which carries a rearranged and a non-rearranged allele of each Ig locus produces gamma-HCD protein and lambda BJP. The productive lambda-gene rearrangement in this clone thus has not been preceded by abortive rearrangements in both kappa-locus alleles. Lymphocytes with an unusual sequence of IgL-chain gene activation seem to be involved in the case of gamma-HCD described here.


Immunohistology of joint inflammation induced in rats by cell wall fragments of Eubacterium aerofaciens. After a single intraperitoneal injection of cell wall fragments of Eubacterium aerofaciens, a main resident from the human intestinal flora, an acute arthritis develops within 2 days which is followed by a chronic arthritis that lasts at least 90 days. In an earlier report the histological appearance of the joint inflammation during this period has been described. In this study we investigated in more detail the cell types that are involved in the development of arthritis by using cell-type-specific monoclonal antibodies in an immunohistological assay. In the acute phase of arthritis, T-helper cells appeared in the synovial tissue together with ED1-positive (ED1+) and ED3-positive (ED3+) macrophages. After a temporary decline at day 12 all macrophage subsets, as well as T-helper cells, reappeared or increased again at day 33. Later, in the chronic phase (days 47-90), an increased number of ED1-positive (ED1+) cells in the synovial tissue and a decreased number of ED2-positive (ED2+) cells in the synovial lining was the most prominent finding when compared with control rats. These results indicate that, apart from T lymphocytes, macrophages also play an important role in the development and continuation of chronic arthritis in this model.


Moving Out Services for Education and Support (MOSES): a model program for individuals with spinal cord injury. A comprehensive educational, social, and community integrated program for individuals with spinal cord injury (SCI) was established at Mount Sinai Medical Center. The need for this program was evident from patients' responses to mailed questionnaires and staff's direct observations of the difficulties encountered by SCI patients when they left the hospital's protected environment and began to cope with living in their communities. The program, Moving Out Services for Education and Support (MOSES), provides relevant information and support to individuals with spinal cord injury as they make the transition from patient to community member. The goal of the program is to foster independence and initiative and to develop leadership skills which enhance successful community reintegration. This article describes the program development, content and training requirements for implementation of these services.


Experiments on the effects of several factors on the 1-hydroxypyrene level in human urine as an indicator of exposure to polycyclic aromatic hydrocarbons. The concentration of 1-hydroxypyrene in human urine was determined in six volunteers who lived under the same conditions. Samples were collected four times per day for three consecutive days; the maximum concentration of 1-hydroxypyrene was found in the samples collected late in the evening (21:00-23:00 h) which is the time recommended as suitable for determination of urinary 1-hydroxypyrene for the purpose of evaluating human exposure to polycyclic aromatic hydrocarbons (PAHs). Statistical tests show that the influence of sex, age, and smoking on urinary 1-hydroxypyrene is statistically insignificant.


Hydrocarbons and fatty acids in surficial sediments (French Mediterranean coastal zones). A detailed study has been made of hydrocarbons and fatty acids in nine surficial Mediterranean sediments. The hydrocarbon concentrations are generally low. The nature and the distribution of the hydrocarbons found in these sediments indicate that they originate from several different sources (terrestrial, biogenic, pyrolytic) and petroleum inputs are usually not the main source of hydrocarbons. Fatty acid concentrations vary in the range 2-52 mg.kg-1 dry sediment. Fatty acid distributions, between C14 and C20 show the biogenic autochthonous inputs. Branched and cyclopropanic fatty acids reflect a bacterial origin. These distributions are markedly different in oxic and anoxic sediments.


Strengthening the Montreal protocol: does it cool down the greenhouse? Strengthening of the Montreal Protocol is recently being negotiated in London in 1990 in order to achieve further reductions of the regulated CFCs and to include possibly more substances. In this article the implications of different policies with respect to control of ozone depleting substances for climate change are analysed, including the proposed substitution by HCFCs and HFCs, carbon tetrachloride and methylchloroform. A special halocarbon module was developed within the framework of RIVM's Integrated Model to Assess the Greenhouse Effect (IMAGE). IMAGE is a parameterized science based policy model and has been developed to give policy agencies a concise overview of the quantitative aspects of the greenhouse problem, to evaluate various policy options concerning climate change and to serve as a means of communication. It is concluded, from simulations with the halocarbon module, that it is of primary importance to achieve a further reduction of the regulated CFCs compared to the Montreal Protocol with compliance by as many countries as possible. From the perspective of the greenhouse effect the inclusion of longer lived halocarbons, such as carbon tetrachloride and HCFC-22 in the protocol comes second. The application of methylchloroform, halons and HCFCs and HFCs with lower global warming potentials (GWPs) than HCFC-22 contributes only marginally to the greenhouse effect in comparison with the much more important greenhouse gases carbon dioxide, methane, ozone and nitrous oxide. Especially if further growth of the total production of HCFCs after complete replacement of the present CFCs can be avoided by using these alternatives with a lower GWP, these substances could therefore be tolerated in a transition period, from the perspective of global warming.


The isotopic composition of lead in man and the environment in Finland 1966-1987: isotope ratios of lead as indicators of pollutant source. The isotopic composition of lead was determined in samples collected between 1966 and 1987, mainly from the Helsinki area, in emission sources (gasoline, incinerator and lead smelter emissions, coal), air, in samples representing long-term deposition (lichen, soil, lake sediments), and in human tissue. Isotope ratios were determined by thermal ionization mass spectrometry after chemical separation of lead by anion exchange and cathodic electrodeposition. The origin of lead in man and the environment in the Helsinki area was evaluated by using the differences in the measured isotope ratios as an indicator. The mean of the ratio in gasoline (206Pb/207Pb 1.124 +/- 0.026) and the ratios in other emission sources in Helsinki (1.149-1.226) were significantly different. However, the wide range of isotope ratios in gasoline (1.063-1.173) reduced the accuracy when assessing the contribution of the different sources. Lead in air samples from Helsinki (1.123 +/- 0.013) could be attributed to gasoline, as could lead in soil near a highway (1.136 +/- 0.003). By contrast, isotope ratios measured in lichen (1.148 +/- 0.006) indicated considerable amounts of lead from sources with higher 206Pb abundances, evidently industrial sources. The isotope ratios in human liver, lung, and bone from individuals dying between 1976-79 (206Pb/207Pb ratio 1.142 +/- 0.015, 1.151 +/- 0.011, and 1.156 +/- 0.013, respectively) reflect the large lead emissions from the incinerators and lead smelters in the Helsinki area in the 1960s and 1970s. In lake sediment cores a correlation was found between the isotope ratios, lead concentration, and depth. The nonanthropogenic lead of high isotope ratios from bedrock was the major component at depths dated older than 100 years. At the surface of the sediment atmospheric lead prevailed, with ratios similar to those of gasoline, air samples and lichen. In the post-1900 layers, anthropogenic lead made up about 40-95% of the total sedimentary lead.


Distribution, accumulation and depuration of administered lead in adult honeybees. In this study the Pb concentration in honeybees was determined by graphite furnace AAS after peroral administration of PbCl2. The Pb concentration, expressed on a dry weight base was determined in relation to the distribution over the body, the accumulation time, the clearance and the exposure dose. Pb is concentrated in the digestive system with the midgut accounting for 67% and the rectum for 27% of the accumulated metal. The barrier function of this system is thus corroborated in honeybees. Pb accumulation happens slowly in young bees which feed mainly on pollen; once they switch from pollen to nectar there is a sharp rise in their Pb content. After the 26th day a limit of tissue accumulation seems to be reached. Pb accumulation is equally efficient when the contamination starts at a forager age. Pb clearance is slower than expected; after 12 days only one third of the initial lead burden has been cleared. The Pb concentration in the animals increases significantly with the Pb concentration in the sugar syrup which they are fed, except at the highest dose of 50 mg/l. The possible use of honeybees as biomonitors for Pb pollution seems promising from these results.


Specification of subunit assembly by the hydrophilic amino-terminal domain of the Shaker potassium channel. The functional heterogeneity of potassium channels in eukaryotic cells arises not only from the multiple potassium channel genes and splice variants but also from the combinatorial mixing of different potassium channel polypeptides to form heteromultimeric channels with distinct properties. One structural element that determines the compatibility of different potassium channel polypeptides in subunit assembly has now been localized to the hydrophilic amino-terminal domain. A Drosophila Shaker B (ShB) potassium channel truncated polypeptide that contains only the hydrophilic amino-terminal domain can form a homomultimer; the minimal requirement for the homophilic interaction has been localized to a fragment of 114 amino acids. Substitution of the amino-terminal domain of a distantly related mammalian potassium channel polypeptide (DRK1) with that of ShB permits the chimeric DRK1 polypeptide to coassemble with ShB.


Controlling cardiac chaos.

Controlling cardiac chaos. The extreme sensitivity to initial conditions that chaotic systems display makes them unstable and unpredictable. Yet that same sensitivity also makes them highly susceptible to control, provided that the developing chaos can be analyzed in real time and that analysis is then used to make small control interventions. This strategy has been used here to stabilize cardiac arrhythmias induced by the drug ouabain in rabbit ventricle. By administering electrical stimuli to the heart at irregular times determined by chaos theory, the arrhythmia was converted to periodic beating.


Target enzyme recognition by calmodulin: 2.4 A structure of a calmodulin-peptide complex. The crystal structure of calcium-bound calmodulin (Ca(2+)-CaM) bound to a peptide analog of the CaM-binding region of chicken smooth muscle myosin light chain kinase has been determined and refined to a resolution of 2.4 angstroms (A). The structure is compact and has the shape of an ellipsoid (axial ratio approximately 2:1). The bound CaM forms a tunnel diagonal to its long axis that engulfs the helical peptide, with the hydrophobic regions of CaM melded into a single area that closely covers the hydrophobic side of the peptide. There is a remarkably high pseudo-twofold symmetry between the closely associated domains. The central helix of the native CaM is unwound and expanded into a bend between residues 73 and 77. About 185 contacts (less than 4 A) are formed between CaM and the peptide, with van der Waals contacts comprising approximately 80% of this total.


Deactivation of visual transduction without guanosine triphosphate hydrolysis by G protein. G proteins couple receptors to their target enzymes in many signal transduction cascades. It has generally been thought that deactivation of such cascades cannot occur without the hydrolysis of guanosine triphosphate (GTP) by G protein. This requirement has now been reexamined in both vertebrate and invertebrate phototransduction. Results indicate that GTP hydrolysis is not required for deactivation. Evidence is presented for an alternative model in which the target enzyme is deactivated by an inhibitory factor that is available even when GTP hydrolysis is blocked.


Requirement for the adenovirus type 9 E4 region in production of mammary tumors. Oncogenic viruses demonstrating a strict tropism for the mammary gland provide special opportunities to study the susceptibility of this tissue to neoplasia. In rats, human adenovirus type 9 (Ad9) elicits mammary fibroadenomas that are similar to common breast tumors in women, as well as phyllodes-like tumors and mammary sarcomas. By constructing recombinant adenoviruses between Ad9 and Ad26 (a related nontumorigenic virus), it was shown that the Ad9 E4 region was absolutely required to produce these mammary tumors. This indicates that an adenovirus gene located outside the classic transforming region (E1) can significantly influence the in vivo oncogenicity of an adenovirus. Consistent with a direct role in mammary gland oncogenesis, the Ad9 E4 region also exhibited transforming properties in vitro. Therefore, the Ad9 E4 region is a viral oncogene specifically involved in mammary gland tumorigenesis.


SV2, a brain synaptic vesicle protein homologous to bacterial transporters. Synaptic vesicle protein 2 (SV2) is a membrane glycoprotein specifically localized to secretory vesicles in neurons and endocrine cells. As a first step toward understanding the function of SV2 in neural secretion, a rat brain complementary DNA (cDNA) that encodes SV2 was isolated and characterized. Analyses of this cDNA predict that SV2 contains 12 transmembrane domains. The NH2-terminal half of the protein shows significant amino acid sequence identity to a family of bacterial proteins that transport sugars, citrate, and drugs. Expression of the SV2 cDNA in COS cells yielded a high level of SV2-like immunoreactivity distributed in a reticular and punctate pattern, which suggests localization to intracellular membranes. Its localization to vesicles, predicted membrane topology, and sequence identity to known transporters suggest that SV2 is a synaptic vesicle-specific transporter.


Inhibition of long-term potentiation by NMDA-mediated nitric oxide release. Activation of N-methyl-D-aspartate (NMDA) receptors before tetanic stimulation blocks long-term potentiation (LTP) in the CA1 region of the hippocampus. This NMDA-mediated inhibition of LTP can be reversed by the nitric oxide (NO) inhibitors L-NG-monomethyl-arginine or hemoglobin and mimicked by sodium nitroprusside. These results indicate that the timing of NO release relative to high-frequency activation of CA1 synapses may be an important determinant of LTP generation and suggest that NO may play a positive or negative modulatory role in LTP depending on prior events at the tetanized synapse and the ambient concentration of excitatory amino acids.


Modulation of neural stereoscopic processing in primate area V1 by the viewing distance. Accurate binocular depth perception requires information about both stereopsis (relative depth) and distance (absolute depth). It is unclear how these two types of information are integrated in the visual system. In alert, behaving monkeys the responsiveness of a large majority of neurons in the primary visual cortex (area V1) was modulated by the viewing distance. This phenomenon affected particularly disparity-related activity and background activity and was not dependent on the pattern of retinal stimulation. Therefore, extraretinal factors, probably related to ocular vergence or accommodation, or both, can affect processing early in the visual pathway. Such modulations could be useful for (i) judging true distance and (ii) scaling retinal disparity to give information about three-dimensional shape.


[Locked rotational dislocation of the cervical spine]. There is no generally accepted treatment protocol for dislocations of single articular processes of the cervical spine. However, the data in our own series and a survey of the literature show that in this type of injury the primary diagnosis rate is low (around 50%), that closed reduction maneuvers can be neurologically hazardous, and that operative fusion prevents certain complications. Among the 20 patients treated at the authors' institution the injury was located in the lower cervical spine in all but one patients and it was caused by a high-speed traffic accident in 14 patients. Four patients had no therapy at all; the others were fused by an anterior approach in 8, a dorsal approach in 6, and a combined method in 2 patients. There was one death due to intimal tearing of a vertebral artery. Closed reduction caused a transient neurological lesion in 2 patients. In 6 patients whose dislocation was neither reduced nor fused, 3 developed chronic instability. In our new treatment protocol dislocation of a single articular process is only reduced after a diskectomy to prevent extrusion of the disc. If reduction from the anterior approach fails or if it cannot be achieved due delayed treatment, the entrapped nerve root is decompressed. Fusion of the injured segments is carried out by bone blocks and plates or hooks.


[Emergency diagnosis of sternum fracture with ultrasound]. Fractures of the sternum often are not discernable on X-rays. The standard lateral X-ray of the sternum may allow the diagnosis. The aim of this study was to find out whether sternal fractures can be visualized by ultrasound. The flat, plane and broad bone provides an ideal rest for a linear scanner; the one used in our study had 5 MHz. We show that sternal fractures can easily be diagnosed by means of ultrasound, and because of an interruption of the cortical reflex, possibly better than on radiographs. We also wanted to show whether sonography, which is in widespread use for the diagnosis of blunt abdominal trauma, can also be used in an emergency situation of blunt thoracic injury (e.g. seat belt injury). In 16 cases of fractures of the sternum already diagnosed by X-ray, an examiner unacquainted with the X-ray results was able to locate and diagnose all fractures by ultrasound within 1 min.


[What modifies the outcome of abdominal trauma? An analysis of 558 patients]. A consecutive series of 558 patients with abdominal trauma were treated at "Bergmannsheil" Trauma Center in Bochum between 1974 and 1989. The most common patient group was traffic casualties with an age of up to 30 years a total of 218 (31.1%) patients underwent surgery, in which can the diagnosis was made only by surgeons. Isolated injuries were predominantly in the spleen (33%), liver (29%), mesenterium (16.1%), bowel (14.2%), and bladder and urethra (10.1%). Eighty-three of the patients who were operated on had multiple intra-abdominal injuries; 208 (37.3%) patients were included with polytrauma. Despite the increasing number of patients with multiple injuries mortality decreased from 27.1% between 1974 and 1979 to 19.7% between 1980 and 1989. This emphasizes the progress that has been made in diagnostic methods, surgical intensive care and the improved education of trauma surgeons.


Conventional radiography and CT examination of pelvic ring fractures. A comparative study of 90 patients. In a retrospective study, we compared the interpretation of conventional X-ray films of the pelvis and the CT images for 90 patients who were treated in our department for a pelvic ring fracture and who had a CT examination between January 1987 and December 1990. The conventional X-ray films and CT scans were interpreted independently by a team of two surgeons and one radiologist. Following Dunn, Berry and Connally, we classified the CT images as very helpful, quite helpful or no help at all. Only 52 of 105 (49.5%) existing bony or ligament lesions of the pelvic ring were recognized in routine X-ray films; 11 of them resulted in a false diagnosis. In 14 cases important additional information about the associated-soft tissue lesions was acquired. In the same CT session, 30 additional CT examinations were performed. Using the Dunn, Berry and Connally classification, only 18 (or 20%) of all CT images were classified as "not helpful". Fifty-nine examinations (or 65.5%) were "quite helpful" and 13 (or 14.5%) were "extremely helpful." In our retrospective study we demonstrated that a complete evaluation of the pelvic ring is not possible with a series of pelvic overviews alone. Fractures of the sacral body and lateral part of the sacrum are overlooked especially often, but second-degree lesions of sacroiliac joint are also often not seen.


[Sonographic diagnosis of the injured acromioclavicular joint. A standardized examination procedure]. The possibility of using ultrasound leads to an improvement and extension of the methods conventionally used for diagnostic examination of the injured acromio-clavicular (AC) joint. Periarticular soft tissues can be assessed, as well as the osseous parts making up the joint. Coraco-clavicular ligaments in particular can be visualized well, and the coraco-clavicular distance can be measured precisely. Evaluation of the ultrasound findings makes classification of the grade of severity of injury according to Tossy much easier. We examined 35 injured AC joints of all grades of severity. With two standard planes of examination--a frontal and a sagittal plane--it was possible to obtain information about the grade severity of the injury in every case. Instability of the joint is diagnosed by measuring the coraco-clavicular distance with and without weights pulling on each arm. Standard X-rays of the shoulder remain mandatory to exclude fractures. When ultrasound examination is possible, however, X-ray examination of the shoulder with weights pulling on the arms is unnecessary.


[Long-term results of treatment of supra-condylar humerus fractures in children]. From 1982 to 1986, a total of 106 children with supracondylar fractures of the humerus were treated at the trauma surgery clinic in Braunschweig. Undisplaced or slightly displaced fractures were treated with plaster casts. More severely displaced fractures were initially treated by closed reduction under general anesthesia and percutaneous Kirschner wiring. In 72 cases (= 85.7%) a follow-up examination revealed a very good or good result. In 9 cases (= 10.7%) satisfactory results were found and in 3 cases (= 3.6%) unsatisfactory results. The most common complication prejudicing the result was cubitus varus. It was found in 27 cases (= 32.1%), most often with a varus under 10 degrees (19 of the 27 cases). A retrospective study of the 12 cases in which the results were classified as satisfactory or unsatisfactory showed 8 insufficient reductions in fractures with severe instability.


[Arthroscopy of the elbow joint. Long-term results, complications and indications]. Based on the results of a retrospective study of 67 patients who had diagnostic and surgical arthroscopy of the elbow from 1977 until 1990, we present the technique, results, complications, and indications for elbow arthroscopy. The average age of the patients was 26 years (range: 11-59). At follow-up, the patients were examined both clinically and radiologically. The results were scored according to Figgie's score, which contains the criteria of pain, function, power, and range of motion. The overall score increased significantly from 61.6 preoperatively to 85.3 postoperatively. The age of the patient did not influence the results. However, patients who were laborers had a poorer outcome than the others. Patients with a preoperative pain of 4 months to 2 years had better results than patients with a preoperative course of more than 2 years. With respect to the criteria (pain, function, power, range of motion), the pain improved significantly, whereas the other parameters showed no significant improvement. Breaking the diagnosis down into three categories (specific diagnosis, degeneration, unclear diagnosis), only patients with a specific and clear preoperative diagnosis showed significant improvement. The high number of neurological complications was especially striking. According to our results, patients with loose bodies, early rheumatoid arthritis, and joint infection seem to be good candidates for elbow arthroscopy. However, patients with severe degeneration or patients with unclear preoperative diagnosis will rarely benefit from this procedure. In general, the patients' pain can be treated effectively, but range of motion or power will not increase after elbow arthroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)


[Primary sonographic diagnosis and follow-up of muscular and tendon injuries of the lower extremity]. Ultrasound examination has become an important diagnostic method in muscle and tendon injuries. In addition dynamic ultrasound examination allows evaluation of the course of healing from various aspects. Starting with the sonoanatomy, the pathologic ultrasound patterns typical for injuries to muscle and to Achilles, patellar and quadriceps tendons are demonstrated. As complement to clinical examination, ultrasonography enables appropriate adaptation of the therapy concept to the course of healing. In the hands of experienced operators, ultrasound examination has reached a high level of sensitivity and specificity in these injuries and can justifiably be routinely performed.


The genetic analysis of human behavior: a new era? Recent developments in DNA-based techniques may revolutionize the study of human behavioral genetics. However, unless these methods are used with great care, many of the same mistakes which have plagued non-molecular genetic analyses of behavior will reoccur. Errors in the application of genetic approaches and in the interpretation of results have been a common feature of published studies in this field. We review studies in human behavioral genetics, focusing on those using identical twins and DNA-based linkage techniques in order to draw attention to recurrent problems in molecular and non-molecular studies. We suggest possible guidelines for future research in the area of the biological basis of human behavior.


Community health promotion programs.

Community health promotion programs. The theory behind several community-based health promotion/disease prevention programs was reviewed, together with the way theory was put into practice and the outcomes of various interventions. Much has been published on theoretical bases and mechanics of these programs, but evidence linking theory, practice and outcome is limited. Conceptual overlap between theories and models make it difficult to test them with scientific rigour. More basic research is needed to evaluate the relations between the process of change, the target of change and both short- and long-term outcomes.


The negotiation of death: clinical decision making at the end of life. The ability of medical science to prolong biological life through the use of technology raises the question of how far physicians should go in treating the terminally ill patient. In clinical decision making involving the dying patient, physicians, patients and families bring various perceptions and interpretations to the situation. These different realities must be negotiated in order to define the meaning of the situation and the meaning of various medical technologies. The patient's demise becomes a negotiated death, a bargaining over how far medical technology should go in prolonging life or in prolonging death. A case study of the process of ethical decision making in the foregoing of life-supporting therapy in an intensive care setting is presented and analyzed. The decision making process in this case follows a 'cascade' pattern rather than a controlled, reflective model. While ethicists view the withholding and withdrawing of life-supporting treatment as morally equivalent, physicians tend to make a distinction based on the perceived locus of moral responsibility for the patient's death. In the author's interpretation the moral responsibility for the patient's death by withdrawing treatment is shared with family members, while the moral responsibility for the patient's death by withholding treatment is displaced to the patient. The author suggests that an illusion of choice in medical decision making, as offered by the physician, begins a negotiation of meanings that allows a sharing of moral responsibility for medical failure and its eventual acceptance by patient, family and physician alike.


The psychosocial review of systems.

The psychosocial review of systems. Psychosocial problems have a significant impact on the course and cost of medical illness. However, many of these areas are generally neglected in medical interviews. This manuscript presents a condensed review of the major psychosocial domains, which together constitute what we term a psychosocial review of systems (PROS). Selected references are provided which document the importance of these areas to medical care, and serve as background reading for further inquiry. The psychosocial areas which are covered include: substance use, stress and life events, subjective views of symptoms, daily activity, social support, sexual concerns, finances, psychiatric history and symptoms, cultural issues, and functional status. The Psychosocial Review of Systems (PROS) can serve as a basic overview for the psychosocial aspects of medical education, and also as a content based instrument which has potential for development as an assessment tool to measure physician competence in eliciting relevant psychosocial data.


Determinants and dimensions involved in self-evaluation of health. This study explores mechanisms involved in self-evaluation of health by making specifications of linkages among various dimensions of health status, physiological measures, social and behavioral factors or characteristics. The proposed structural equation model is tested by using data from a comprehensive health survey of the population of Finnmark county, Norway (1987-88), including 4549 men and 4360 women aged 30-62. The findings suggest the burden of physical distress and reliance on permanent disablement benefit to play the key role in reducing self-evaluated health. The seemingly strong labelling impact of permanent work disability, contrasted the modest effect of diagnoses of chronic disease. Moreover, the impact of both these key factors and other important determinants is strongly socially patterned. Positive health related life-style appeared to have a positive impact on self-rated health, while preoccupation with health had a negative impact. This finding adds some credibility to the suggestion that the growing occupation and fascination with health have some negative health outcomes.


Varied potential risks of HIV infection among prostitutes. To date, most HIV prevention programs targeting North American prostitutes have focused on individual behaviour change, and in particular, the consistent use of condoms between prostitutes and their clients. The organizational and societal level issues which may influence high risk practices within the working and private spheres have received relatively little attention. In addition, most prevention efforts have been limited to targeting the sub-population of street prostitutes. We outline here three different types of prostitutes (street prostitutes, escorts, and prostitutes who work part time in the service sector, i.e. barmaids and erotic massage therapists) known to work in many North American centres. In doing so, we suggest that potential risks of infection vary according to the type of prostitution, and that prevention programs must recognize the diversity in potential risk practices. Differences in the organization of work and working conditions of varied types of prostitutes may, in particular, influence risk practices while working. Some of the individual, organizational and societal level issues which influence risk practices among different types of prostitutes are presented. Much of the research involving HIV and prostitutes has accessed prostitutes at sites where street prostitutes are over-represented. Other studies are based on potentially baised samples as they have recruited prostitutes from medical clinics. Methodologic problems that influence attempts to obtain a representative sample of the prostitute population are discussed.


Responses to the institution among elderly patients in hospital long-stay care. The theory of the 'total institution' argues that institutions deliberately create dependency in individuals who would otherwise be self-determining. We examine the significance of this concept for patients in long-stay geriatric wards. All such patients in the South West Thames Region (808) were located and assessed for levels of physical dependency and mental confusion. 87% were profoundly disabled, 53% were severely confused and 23% were seriously ill or unable to communicate. Those capable of responding (291) were interviewed. Three quarters or more were satisfied with 'staff relations', 'autonomy', 'amenities' and 'privacy' and three fifths were satisfied with the 'social environment'. Results suggest that: (a) patients in long-stay geriatric wards who were not severely confused were able to make realistic assessments of their situation and (b) the majority were not passively institutionalized. In terms of institutionalization theory, it is their physical frailty that appears to differentiate this group from other categories of 'inmates'. We conclude that appropriate policy for the long-term ill necessitates consideration of the actual as well as the attributed needs of patients.


Physician satisfaction, professional characteristics and behavior formalization in hospitals. In this paper, an analysis is presented of professional and bureaucratic predictors of physician satisfaction. Results from 210 physicians in 17 medical departments of university hospitals support the hypotheses that both professional attitudes and formal structuring of work activities have a positive effect on physician satisfaction. It is shown that behavior formalization, preference for professional autonomy and the time spent on patient care activities within medical departments are positive predictors of satisfaction with work environment, while 'traditional' professional attitudes like craftsmanship and client service have more impact on satisfaction with patient demand. Certification is a strong positive predictor of work load satisfaction. Satisfaction with work environment was the most important factor in explaining other satisfaction dimensions. This finding supports the hypothesized 'buffering' effect of the affective climate or 'feel' of the professional work environment in hospitals. The implication of the findings is, that in the process of bureaucratization of medical practice in hospitals, specific attention should be paid to the maintenance of professional values as guidelines for professional work and to the maintenance of a good affective work environment for professionals in order to prevent dissatisfaction with patient demand and work load.


A comparative study of abused and neglected American Indian children in the southwest. Samples of target and control American Indian children in the Southwest United States are compared for child abuse/neglect and family alcohol abuse. Alcohol abuse is present in virtually all families that abuse/neglect children. However, alcohol abuse exists exclusive of the association with child abuse/neglect. The study demonstrates that alcohol abuse is a necessary, but not sufficient, condition for child abuse/neglect.


Do Australian researchers accept committee review and conduct ethical research? We sought researchers' views on the ethics of research practice and the Australian system of review of research proposals by research ethics committees (RECs). Researchers were found to be supportive of review of research proposals, even though they thought that the process of review was time consuming and demanding. However, our findings suggest that not all researchers present their research proposals for review by committees, and that some researchers deviate from their approved proposals without seeking approval for those deviations from an REC. Researchers supported monitoring of research by RECs.


Joining a healing community for cancer: who and why? This paper provides a description and evaluation of selected aspects of The Wellness California. Based upon participant observation, TWC's philosophy and program are described. The ways in which charismatic leadership is used to create a sense of 'healing charisma' is specified. Interviews were conducted at 3 points over a 10 month period with 65 individuals who initiated contact with TWC. Thirty-seven eventually became participants at TWC, while the 28 who did not were used as a comparison group. Participants were healthier, more oriented toward self-care and less satisfied with their existing social support networks. The findings indicate the role, and limitations, of healing communities for people with chronic physical illness.


Indigenous mortality: placing Australian aboriginal mortality within a broader context. The purpose of this study was to evaluate whether contemporary Australian Aboriginal mortality patterns are different from those exhibited by Canadian Registered Indians, New Zealand Maoris, and American Indians and Alaskan natives. Data on Australian Aborigines were procured from published studies conducted in New South Wales, the Northern Territory, Queensland, and Western Australia; while data on Canadian Registered Indians, New Zealand Maoris, and American Indians and Alaskan natives were obtained respectively from unpublished tables produced by Health and Welfare Canada, the National Health Statistics Centre, and the Indian Health Service. Mortality patterns were compared by evaluating differences in life expectancy and in age- and cause-specific patterns of death. This analysis demonstrates that although Australian Aborigines, Canadian Registered Indians, New Zealand Maoris, and American Indians and Alaskan natives have similar patterns of high adult mortality, Australian Aborigines are generally characterized by lower life expectancies at birth and higher age- and cause-specific death rates. Overall, these findings suggest that the mortality patterns of Australian Aborigines are strikingly different from those exhibited by the other three indigenous populations and that existing information on risk, psychosocial, and genetic factors does not really explain why Australian Aborigines as compared to these other indigenous groups have such high rates of death and low life expectancy.


Verbal exchanges in medical interviews: concepts and measurement. The verbal exchange theory of medical interviews (consultations) proposes that patients and clinicians employ a joint repertoire of exchanges to accomplish their goals in the encounter. The skeleton of each exchange is a set of speech acts that tend to be used together in interviews, for example, (a) clinician questions and patient yes/no answers, or (b) clinician directives and patient agreements to comply. We describe seven principal exchanges, each of which has been identified empirically in multiple studies of interviews: Exposition, Closed Question, Checking, Direction, Inquiry, Explanation, and Instruction/Contracts.


Assessment of the outcomes of health intervention. In this article we discuss basic assumptions of health interventions with regard to their underlying concepts and selected strategies. Particularly, the lifestyle model of health promotion is presented and its consequences for health promotion and health interventions are discussed. Reference is made to two fields of interventions: prevention of cardiovascular diseases and worksite health promotion. It is concluded that health interventions have to clarify their concepts and strategies in detail before an evaluation of their outcomes can be carried out reasonably.


Assessment of outcomes of health intervention. This paper proposes that the most comprehensive current approach to the assessment of health interventions is exemplified in the expanding field of research into health-related quality of life. The paper initiates discussion of 11 conceptual and methodological issues which should be dealt with explicitly rather than by default in any such research study. Decisions about these 11 issues will shape the future directions of the field of health outcomes research. Health policy decisions will increasingly be based on outcome studies of health-related quality of life.


Changes in disease patterns and related social trends. Both the material and non-material aspects of social life are viewed as determinants of major transformations in the patterns of fatal disease and injury. A 'worst case' scenario for the burden of fatal disease is taken as a poor agrarian society precariously dependent on starchy staples and a narrow range of other foods. In such a society life expectancy may be as low as 20. However in many 'pre-modern' societies the regime of roughly matching fertility and mortality levels was set at a 'submaximal' level, with completed fertility rates moderated by marriage conventions. The relative importance of the factors contributing to the historical decline in fatal infection continues to be debated. Evidence on the central role of maternal literacy in the recent decline in Third World mortality suggests the importance of changes in the body of civil society as well as the activities of professionals and public agencies. The decline in fatal infections has been offset to varying extents by an increase in non-communicable disease (NCD): the Mediterranean and East Asia having smaller epidemics of NCDs and Eastern Europe having sustained rises of NCDs. Most industrialised countries have experienced declines in overall NCD mortality in the last 2 decades. Both the fall in fatal infection and the rise and early fall of NCDs can usefully be viewed against the baseline of hunter gatherer cultures. When this is done, the relationship between economic development and disease is seen to be complex. Much 'progress' has been achieved by countering (and then doing better than countering) the adverse effects of earlier developments. Although most members of the generation now alive have experienced marked health benefits from economic and technical advance, it is unclear whether these gains can be both sustained and generalised. It is possible that adverse lagged effects of current industrial (and military) activities will disrupt the habitat of future generations of our species through processes such as stratospheric ozone depletion, global warming and others as yet unpredicted. Modern hygienists have dealt successively with influences on survival mainly operating in early life (infection) and influences operating across the lifespan (determinants of chronic disease). They have now to deal with even greater separations in time and space between potential health determinants and their ultimate effects. To a high level of scientific uncertainty is added the ethical problem of equity between generations.


Changes in disease patterns and related social trends. Social environment is a major determinant of health and disease patterns in any community. The 19th century revolution in public health had as its cornerstone the improvement of social and physical environment. The favorable social development has since that time significantly contributed to the decrease of traditional health hazards in developed countries. New public health problems, chronic diseases have emerged in these countries. In some of these nations a new trend has started that may be called the second revolution in public health, i.e. the reduction of chronic diseases. However, the major part of the world's population still suffers from the traditional illnesses that should and could have been set aside by the 19th century revolution. Obviously, the social environment has not been altered sufficiently in these areas to have the desired impact on the health status. The observations from the Eastern European countries stress the need for a purposeful avoidance of deprivation in the social and physical environment as prerequisites for the prevention and control of diseases. Generally, low socio-economic status has been found to relate to an increased risk in many diseases. Usually there is a definite time lag between changes in social trends and disease patterns which causes difficulties for research in this area. The same fact generates problems for the planning and implementation of interventions to prevent the socially affected diseases. Changes in disease patterns are not only determined by altered social trends, but disease patterns can also influence social tendencies in several ways. Studying the interaction of social and health trends quantitatively and experimentally has yielded results which are hard to interpret. Therefore, observational and 'soft' methods are employed here to describe the relationship of social and health trends more aptly.


On the epistemology of risk: language, logic and social science. 'Risk' is a widely used concept in literatures related to health, health care and medicine. In recent decades, three bodies of literature have emerged in which 'risk' is the primary focus of concern: Health Risk Appraisal, the Risk Approach and Risk Analysis/Assessment/Management. These literatures overlook important concepts and theoretical developments in contemporary social science. They also lack conceptual coherence. Reduction of incoherence will require re-examination of the epistemology of risk in relation to both its language and its logic in light of developments in social science.


Cultural influences in community participation in health. The adoption of Primary Health Care in developing countries brought a new interest in the influence of cultural factors in community health programs. This paper traces the changes in the way that the role of culture has been analyzed in relation to community health issues and in particular with respect to 'community participation'. A look at recent perspectives shows that the fate of community health programs has come to be seen as relying more on structural factors in health care systems than on cultural factors within local communities. There has also been an increasing emphasis on political factors or power relationships within and between health agencies, governments, and various levels of national health care systems. These perspectives raise new questions for community health programs and the strategy of community participation.


The effects of family position and status on health. In the last couple of decades there has been a considerable amount of research, mainly in the U.S.A., on the effects of family position on health. This paper reviews material on (a) the impact of family of origin on health and (b) adult family position and health. Parental divorce is shown to be related to a range of adverse outcomes in childhood, adolescence and adulthood. Marriage and parenthood are associated with longevity and good mental and physical health. This paper argues for more research in other cultural settings, for panel studies, for more direct measures of the roles and processes often inferred from structural variables, and for the use of measures of physical development and functioning.


Cultural and structural influences in the creation of and participation in community health programmes. Community participation in health care programmes is considered axiomatic in health development. Cultural and structural influences are discussed in relation to community participation with the intention of highlighting some critical issues affecting its generation and sustainability. These influences include structurally defined perspectives and perceptions of community participation, limitations of the necessary supportive systems, the structural and cultural factors of marginalization, community stratification and organization, mobilization, and the political context. It is concluded that given these factors against a situation of a financial and economic crisis, of economic restructuring and the values of competition and individualization, community participation will be increasingly difficult to generate and sustain.


Substance abuse and control in the United States: ethical and legal issues. In 1986, the United States began to wage its most recent War on Drugs. This has involved establishing various policies and making investments to implement these policies and approaches. In general, the U.S. has taken a tough-guy stand to drug abuse and control that emphasizes punishment, restriction, and 'social warfare', as opposed to a public health oriented position. Current policy reflects a 'quick fix' solution to a complex problem, which may partially explain its failure and why we appear to be losing the War on Drugs. In this review I summarize the current debates and controversies surrounding drug abuse in the U.S. regarding the extent of the drug problem, the need for drug control, prevention efforts, legalization controversy, workplace strategies, treatment dilemmas, and maternal drug abuse. I argue that a radically different approach must be taken that is grounded in public health methods and an appreciation of the larger social context in which drug abuse occurs. We must look for a long-term solution to this complex problem that is integrated into society, and which is certainly resistant to the current quick fix approaches.


Birth Order and health: major issues.

Birth Order and health: major issues. Birth Order has been described as a variable with a complex relationship to child and adult outcomes. A review of the medical literature over the past 5 years identified 20 studies that investigated the relationship between Birth Order and a health outcome. Only one of the studies established a relationship between Birth Order and a health outcome: third and fourth-born children have a higher incidence of accidents that result in hospitalization. The other demonstrated relationships are each explained by intervening variables or methodological limitations. Although Birth Order is not a strongly independent explanatory factor in understanding health outcomes, it is an important marker variable. Statistically significant relationships between Birth Order and health outcomes yield insights into the ways a family influences an individual's health.


To die with dignity.

To die with dignity. This paper examines the conundrum facing an individual with a terminal disease who wishes to end his or her life in a manner that maintains a minimum of dignity. The State's interest versus the individual's right to live or die is examined in its various aspects. The interference by the State supplanting the Church as the authority that interprets the boundaries between life and death, with the individual losing his voice as well as his body to the impersonality of maintaining a life not worth living, is studied, as well as the implicit dangers when the freedom to decide when and who should die is measured against the present international economic situation. The need to listen to the language of the dying as well as to their need for a 'closure' is approached with a view to future study.


Ethical and legal issues in the control of drug abuse and drug trafficking: the Nigerian case. This paper presents a general review of drug law and policy in Nigeria beginning with the international attempts to control the traffic in liquor during the pre-colonial and colonial periods. The paper assesses the impact of penal policy on trafficking and use of illicit drugs at different stages in the transformation of Nigeria from a colonial outpost to an independent nation. One persistent feature of drug control mechanisms in Nigeria has been the emphasis on the reduction of supply with the imposition of harsh though inconsistent punishment including, at one time, the death penalty for trafficking. Consequently, initiatives aimed at demand reduction through education, treatment and rehabilitation have been neglected. One reason for this is that, to a great extent, drug control strategy in modern Nigeria has been a response to international demands; another is that they were formulated under military regimes with an overriding concern for law and order. Other features of the Nigerian drug problem are presented and the need for the reform of current laws is stressed. It is argued that an enduring solution lies in the implementation of a comprehensive but clearly defined policy aimed both at the control of supply and reduction of demand. While the state has the duty and the right to protect its citizens from drug-related harm, it is an ethical imperative to institute control measures which do no harm to the citizens they are meant to protect.


Equity and efficiency in health care.

Equity and efficiency in health care. Adam Smith's belief that markets will make society more equitable and efficient is examined in the case of reforms to make health care more competitive. Eight ways in which health care does not often satisfy the requirements for competitive markets, and nine ways in which providers can manipulate markets are identified. The concept of 'embedded inefficiencies' is introduced to explain why competition may not increase efficiency.


Dying with dignity.

Dying with dignity. Death is a theme of central importance in all cultures, but the manner in which it is interpreted varies from society to society. Even so, traditional cultures, including Christian, Hindu and Jain religious traditions, exhibited a positive attitude to death and did not look upon it in a dualistic framework of good vs bad, or desirable vs undesirable. Nor was pessimism the dominant mood in their thinking about death itself. A fundamental paradigm shift occurred in the West in the eighteenth century when death was desacralized and transformed into a secular event amenable to human manipulation. From those early beginnings, dying and death have been thoroughly medicalized and brought under the purview of high technology in the twentieth century. Once death is seen as a problem for professional management, the hospital displaces the home, and specialists with different kinds and degrees of expertise take over from the family. Everyday speech and the religious idiom yield place to medical jargon. The subject (an ageing, sick or dying person) becomes the object of this make-believe yet real world. As the object of others' professional control, he or she loses the freedom of self-assessment, expression and choice. Or, he or she may be expected to choose when no longer able to do so. Thus, not only freedom but dignity also is lost, and lawyers join doctors in crisis manipulation and perpetuation. Although the modern medical culture has originated in the West, it has gradually spread to all parts of the world, subjugating other kinds of medical knowledge and other attitudes to dying and death.(ABSTRACT TRUNCATED AT 250 WORDS)


Ethical and legal implications of the new genetics: issues for discussion. The so-called 'new genetics,' a phrase sometimes associated with The Human Genome Initiative, poses no really new ethical problems, but exacerbates old ones. The issues of most concern to geneticists and their patients are summarized under the eleven headings below. These issues emerged from a 19-nation study of ethics and genetics in 1985-86 and from preliminary work on a forthcoming 36-nation study by the same authors.


Health and social problems of refugees.

Health and social problems of refugees. Today over 15 million refugees are scattered around the world, most of them in poor Third World countries [New Sci., pp. 14-15, September 1991]. But whether they seek 'safe havens' in rich or poor countries they continue to suffer from the malaise of being uprooted, struggling to survive in new and alien environments. Their health and social problems extend beyond the obvious emergency short-term phase. It is now clear that the number of refugees has increased beyond expectations and most have stayed long enough to expect final resettlement in their countries of asylum, a process which requires wider, more comprehensive and long-term management and rehabilitation interventions. This paper will attempt to highlight issues of health and social problems in their wider context, surveying comprehensive and integrated approaches in assessing the needs of refugees, whether they are in developing or industrialised countries, with emphasis on the latter and, when appropriate, using the United Kingdom experience as an example.


New paradigms for refugee health problems. Two paradigms that have shaped our understanding of refugee health are identified: the objectification of refugees as a political class of excess people, and the reduction of refugee health to disease or pathology. Alternative paradigms are recommended: one to take the polyvocality of refugees into account, and one to construe refugees as prototypes of resilience despite major losses and stressors. The article is organized into three sections, mirroring the life history of refugees from internal displacement in the country of origin to asylum in a second (usually neighboring) country, and for some, to permanent resettlement in a third country. In each of the three sections, the primary topics that are treated in the literature are identified, and key problems identified for discussion.


Health care consequences of the European economic community in 1993 and beyond. Generally, health services are not covered by the treaties of the European Community. However, to an increasing extent the EC has and will have an influence on national health systems. In particular the effects of regulations made for other sectors have repercussions for health. For example the free movement of labour and the harmonization initiatives have direct effects on the educational curricula for health professions and may, in time increase professional migration within the community. Within the EC research programmes health related topics have been included to an increasing extent. This goes in particular for medical informatics, standardization, quality assurance systems and pharmaceuticals. Indirect effects of the single market will probably appear within the area of insurance, public purchasing and building and other types of construction works. Other areas that probably will be influenced are record security and occupational health benefits.


Impediments to basing government health policies on science in the United States. In the U.S., there is no consistent relationship between what health scientists find and public policy. Some scientific findings are heralded and quickly incorporated into individual and political action. Other findings are ignored, and others are contradicted by policy. This paper explains this inconsistency in terms of individual reaction to hazards, media coverage of hazards, and different ability of individuals to respond to health information; political leaders' preference for high-technology science, distortion and opposition by commercial interests, bureaucratic maneuvering for power and resources; and uncertainty and asymmetry of some scientific findings.


Realities of Health For All by the year 2000. The European Region of the World Health Organisation (WHO) took the global lead on Health For All when the Regional Committee in 1980 approved a European Health For All Strategy. This was an important breakthrough for WHO as it was the first time Member States in a Region endorsed a common health policy and agreed to be monitored on their progress towards attainment of the strategy. The paper reviews the progress of Member States to date towards the Regional Health For All goal. Progress is discussed within the context of the six fundamental principles which underpin the Health For All concept, vis: equity; health promotion; community involvement; multisectoral participation; primary (local) health care; and, international cooperation. The paper argues that the commitment of Member States to the Health For All Strategy has been patchy with only moderate success towards meeting the 38 Regional Targets. Poor progress is attributed to changing national and international political and economic circumstances and limited resources but perhaps most importantly to a lack of political will to take the strategy seriously.


The role of doctors as health care managers: an international perspective. The participation of physicians in health care management has followed different paths in developed and developing countries. However, we can say that in most of the countries the physicians have had cyclical patterns of participation and withdrawal from health care management. It is readily apparent that these patterns are different in each country. We propose to take into account three different levels of analysis in which different factors interact to define the country specific pattern of physician involvement in health care management, as well as to assess the international convergence and divergence paths on physician participation. We present here a conceptual framework that could facilitate the analysis of this theme under a comparative perspective. We start by discussing a conceptual framework of the determinants of physician participation in health care management. Then, we assess the current trends and perspectives in both developed and Latin American countries of physician participation in health care management.


Doctors as managers: poachers turned gamekeepers? Doctors in health care systems of different types are coming under increasing pressure to take on active roles in management. Mounting concern among governments over the escalating costs of health care, coupled with a desire to improve the quality of care and render services more responsive to user preferences has resulted in management being viewed as offering an effective means of tackling these issues. Until recently, the favoured strategy was to strengthen management in order to curb doctors' discretionary decision-making. There is now a shift towards creating managers out of doctors with all that this implies for the future shape of health services. There are also issues about the training and development required for a management role, the stratification of roles within the medical profession, and the future status of lay, or non-medical managers. The paper reviews the debate about doctors and managers and their distinctive value bases. It suggests that doctors can be involved in management as managers at two levels--meso and micro--and considers the issues raised at each level. The paper presents an analysis of the wider context in which the debate about doctors as managers is taking place. The main thesis put forward is that far from managers incorporating doctors, the end result may prove to be the other way round with 'provider capture' of the management agenda in health services a distinct possibility. In contrast to managers, doctors retain enormous public respect and support. As long as it is so doctors will remain powerful stakeholders in defining and controlling the shape and range of health services available. Their active involvement in management could lead to a strengthening of their position. It is argued that, paradoxically, this could make it more difficult for governments to challenge doctors' work practices. Medicine's traditional preoccupations and its resilience to change are likely to remain as strong as ever thereby disappointing advocates of a health and social care system located in a broader policy framework which emphasises health gain and a holistic approach to health.


High cost technology in health care: a benefit or a burden? The influence of high cost technology goes beyond its consequences for the selected patient groups that benefit from its application. Past and future technological developments have a variety of social, economic and ethical implications which have to be taken into account when balancing its costs and benefits to society. Departing from an economic perspective we describe a number of mechanisms underlying the emergence of high cost technology which help us to understand some of the characteristics of high cost technology, such as its focus on quality enhancement rather than on economy. To assess the actual performance of high cost technology in terms of efficiency and equity is difficult as there may be debate about the perspective guiding such assessment and as there still is scarce information on high cost technology in terms of these economic indicators. The increasing technological opportunities have triggered a wider debate on the desired evolution of our health care systems. In some countries there is a tendency to diminish government involvement in health care and emphasize private (for profit) enterprise as a reaction to not being able to finance all new high cost technology. The risks of such strategies are discussed briefly. We conclude that the main actors in health care should adjust their behaviour in order to accomplish the introduction of more cost-effective technologies and to achieve a more socially efficient distribution of their benefits.


Challenges to understanding spatial patterns of disease: philosophical alternatives to logical positivism. Most studies of disease distribution, in medical geography and other related disciplines, have been empirical in nature and rooted in the assumptions of logical positivism. However, some of the more newly articulated philosophies of the social sciences, and of social theory, have much to add in the understanding of the processes and mechanisms underlying disease distribution. This paper represents a plea for creative synthesis between logical positivism and realism or structuration, and uses specific examples to suggest how disease distribution, as a surface phenomenon, can be explained using deeper analysis.


Threats to the world eco-system: a role for the social scientists. This paper seeks to identify some of the major threats to our fragile eco-system through human actions. We have sought to highlight that since these threats to our composite ecological heritage are global in nature, our responses shall have to be at the global level. We have tried to analyse a role the social scientists can exercise in response to these threats. We have merely shown possible responses within their professional disciplines. Can they play an activist's role? The paper does not prescribe any push-button role while emphasizing role of social scientists in environmental education. Every discipline among the social sciences will need to carve out its own role keeping in view local conditions. The current stocktaking of the situation under the UNCED process may require the international community to review existing institutional structures in the field or create new ones.


Existential ecology: the human/natural world. Medicine and ecology share the concern for reconciling human aims and natural processes. That reconciliation is attempted through analogous approaches in the two fields. A dialectical model, described here, provides conceptual organization of those approaches into a coherent progression of paradigms, both existential and theoretical: (1) vulnerability, the immediacy of human exposure to nature's power and the futility of human ascendancy; (2) disengagement, the rational and the romantic objectification of nature; (3) dissection, the scientific and cultural reduction of nature to specimens; (4) holism, the conceptualization of the ecosystem; (5) inherence, the human involvement with nature as home, entailing a local rather than colonial ethic and epistemology. Culmination of the dialectic in ecology, as in medicine, is reconcilation with the otherness of nature, recovering both environment and embodiment as forms of human existence.


The use and value of qualitative methods in health research in developing countries. Qualitative and quantitative research methods for public health were integrated in the past. Work at the Polela Health Center and the Institute of Family and Community Health (South Africa) in the 1940's epitomized how true integration was possible. Since the 1950's the growth of disciplines and boundaries between them; the growing emphasis by funding agencies on quantitative research that yields results rapidly at low cost and the dominance of the medical profession in public health together resulted in a separation of approaches. Recently, recognition of the need for integrated approaches has reemerged but the capacity to conduct appropriate research in developing countries is weak and they have relied on importing both researchers and their methods. Examples are given (mainly using focus group methods) of how innovative integrated approaches in developing countries have been used to implement community diagnoses, understand factors affecting health service utilization and identify factors amenable to intervention. It is concluded that while qualitative methods are needed (and used) in developing countries, their use will only increase if appropriate training initiatives in developing countries are undertaken.


Women's access to health care in developing countries. Women in developing countries are frequently confronted with a myriad of socio-cultural factors which negatively impinge upon physical well-being and accessibility to appropriate health care services. Institutional, economic, and educational barriers effect and lowers their standard of living when compared to their male counterparts. Women must become agents of change to improve their situation. Factors such as access to income, legal rights, social status, and education may prove far more important in determining women's access to health care than technology distribution and governmental strategies.


Neuro-endocrine tumours--their origin and classification. The neuro-endocrine cell is an integral component of many organ systems, and it is therefore not unexpected that this cell is identified in a variety of tumours. The embryology of this cell is uncertain and the recent literature indicates the presence of more than one type of neuro-endocrine cell. The classification of neuroendocrine tumours is addressed, a working classification is proposed and attempts made to clarify the concept of neuro-endocrine neoplasia.


Occlusive versus semi-open dressings in the management of skin graft donor sites. In a prospective, randomised study we compared the efficacy of a new occlusive dressing (Granuflex-E) with a semi-open dressing (tulle gras) in the management of skin-graft donor sites. The study examined 10 patients with burns, each with two donor sites. Each patient acted as his or her own control. The donor sites were mirror images of each other, the anterior surface of the thighs. One donor site was dressed with Granuflex-E and the other with tulle gras. The sites dressed with the occlusive dressing healed significantly faster and were more comfortable than the sites with the semi-open dressing.


The effect of hypovolaemia on healing of the right and the left colon. An experimental study. An experimental study was carried out to investigate the effect of a period of hypovolaemia prior to surgery on healing of the right and left colon of the baboon. Colonic healing was assessed in three ways: in terms of (i) anastomotic leakage, (ii) hydroxyproline concentrations and (iii) breaking strength. The results suggest that hypovolaemia before surgery affects the right and left colon similarly.


Penetrating cardiac injury--to close the pericardium or not? A case report. Many trauma surgeons who treat penetrating cardiac injuries do not routinely suture the pericardium closed after repairing the heart. The patient reported here died from exsanguination during attempts to mobilise the heart which had adhered to the sternum. With the increasing demand for coronary artery surgery and the high incidence of carcinoma of the oesophagus in South Africa, both of which require access to the mediastinum, we recommend that in the trauma setting, the pericardium be closed to facilitate future surgery if required.


Linear stapling device in partial resection of abdominal parenchymatous organs. The use of the linear stapling device (LSD) is well-established in hollow-organ gastro-intestinal surgery. Its use in operations performed on parenchymatous viscera is less common. We present our experiences with the LSD in partial resection of the spleen (2 cases), pancreas (5 cases), liver (2 cases) and kidney (2 cases). To the best of our knowledge the use of the LSD for partial nephrectomy and resectional debridement of the liver has not been previously described. We suggest that LSDs are useful aids in the resection of parenchymatous organs, and allow rapid resection if applied to healthy tissues and in regions with an intact capsule.


Functional improvement following thrombo-endarterectomy for chronic pulmonary thrombo-embolic disease. A case report. Pulmonary thrombo-endarterectomy for chronic pulmonary thrombo-embolic disease is an underutilised and potentially lifesaving therapeutic manoeuvre. This case study describes the functional improvement that can be attained by such a procedure.


Drugs in sport--results of the past 6 years of dope testing in South Africa. Screening procedures were performed on 2,066 urine specimens collected from competitors in 17 different sports during the period 1986-1991. Samples were tested by gas chromatography and gas chromatography/mass spectrometry for the presence of stimulants, narcotics and anabolic steroids. Drugs classified as forbidden substances by the International Olympic Committee were detected in 113 (5.5%) of the samples. Nineteen-nortestosterone and fencamfamine were the anabolic steroid and stimulant most frequently detected. The ephedrines as a group accounted for 35 (31.0%) of the positive samples. This high incidence of the use of banned substances indicates that the dope testing programme to curb use of banned substances by competitors in sport should continue and be expanded to other sports.


Androgenic anabolic steroid use in matric pupils. A survey of prevalence of use in the western Cape. A survey was undertaken to determine the prevalence of use of androgenic anabolic steroids (AAS) by matric pupils in the western Cape. A cluster sample, stratified by language and a subjective assessment of sporting status, of 13 schools in the area was selected, and 1,361 pupils completed a questionnaire containing questions about sports participation and the use of AAS. The prevalence of use of AAS in the sample was 5.9/1,000 and prevalences in subgroups were 11.7/1,000 for males, 12.5/1,000 for male sports participants and 25.4/1,000 for Afrikaans-speaking male sports participants. A significant amount of under-reporting (AAS users denying their status as such) occurred. General knowledge about AAS was poor, particularly among females and non-sports participants. AAS users experienced more pressure to perform well at sport than did non-users; the drugs were obtained mostly from peers and no user indicated that they were legally obtained. Because there is much evidence regarding the detrimental effects of AAS on health, it is clear that a strategy must be adopted to decrease the prevalence of their use in the schoolgoing population.


Detection of Chlamydia pneumoniae in coronary arterial fatty streaks and atheromatous plaques. There is serological evidence that a recently described new strain of Chlamydia, namely Chlamydia pneumoniae TWAR, is associated with coronary artery disease. This study describes the detection of TWAR organisms in the coronary arterial fatty streaks and atheromatous plaques in 7 autopsy cases. TWAR-like organisms were observed ultrastructurally in the lipid-rich core area of fibrolipid plaques and in intimal smooth-muscle cells. In 5 cases, immunoperoxidase staining showed positive reactions to Chlamydia genus- and C. pneumoniae species-specific monoclonal antibodies.


South African obstetricians' views on caesarean section. The widespread increase in the rate of caesarean sections performed in the Western world has become a cause for concern. In this country, two systems of health care exist, one provided by the State and the other based on private practice. A high incidence of caesarean sections has been reported, especially among private practitioners. This study investigated doctors' perceptions of caesarean section practices and explored the availability of facilities which could help to reduce the high caesarean section rate. Questionnaires were mailed to all registered obstetricians. Of these 45.2% (233) responded. Findings indicate that private obstetricians are more likely to perform caesarean sections even though they do have good facilities available to monitor or assess difficult deliveries. Other factors influencing their practice are also explored.


Tracheobronchial foreign bodies. Experience at Red Cross Children's Hospital, 1985-1990. Ninety-six children with suspected tracheobronchial foreign bodies were referred to the Department of Cardiothoracic Surgery at Red Cross War Memorial Children's Hospital, Cape Town, between February 1985 and February 1990. Foreign bodies were removed by rigid bronchoscopy from 63 patients, 79% of whom were under 5 years of age. The majority of patients (59%) presented more than 24 hours after aspiration of the foreign body, and this delay in definitive management was associated with an increased incidence of complications (P = 0.01). Complications occurred in 28 patients, and there was one fatality at bronchoscopy due to overwhelming aspiration of an unanticipated release of pus, following the removal of a chronically impacted foreign body. The complete classic diagnostic triad (sudden onset of coughing, wheezing and decreased air entry) was seldom present, and we recommend diagnostic bronchoscopy in children presenting with either a history of sudden choking or a witnessed aspiration of a foreign body, an unexplained acute wheeze or cough or a chronic pulmonary infection. This report also highlights the continued need for increased awareness on the part of both parents and medical practitioners of the need for early referral if a foreign body is suspected. Furthermore, public education is needed as regards the dangers of allowing young children to eat peanuts. Peanuts were the commonest foreign bodies removed.


Infantile hypertrophic pyloric stenosis in a Third-World environment. Sixty-two consecutive patients with hypertrophic pyloric stenosis, presenting over a 6-year period, are reported. The sequelae of late presentation and diagnostic delay are outlined. Clinical diagnosis may be difficult. Barium meal examination has proved a more useful single investigation than ultrasonography, although these methods of investigation are complementary. Management difficulties include severe biochemical derangement, correction of which delays surgery. In black communities pyloric stenosis remains a rare condition and heightened clinical awareness remains the most important means of achieving earlier diagnosis.