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Education of the asthmatic patient by an appropriate program is an important tool in achieving optimal management. The program should include not only lectures on the physiopathology and treatment of asthma, but also self-management skills through a behavioural approach to the disease. The education program aims to assist the patient in preventing symptoms and coping with asthma attacks.
We report here an evaluation of a program for thalassemia-disease prevention, comprising education, population screening for heterozygotes, and reproductive counseling; the evaluation includes cost analysis. A preprogram survey in 1978 of 3,247 citizens in the high-risk communities (85% were high-school students) showed that 88% favored a program but that only 31% considered fetal diagnosis as an acceptable option. Screening in high school or before marriage was preferred by 56%. In a 25-month period (December 1979-December 1982), we screened 6,748 persons, including 5,117 senior high-school students, using MCV/HbA2 indices. The participation rate was 80% in the high-school group. The frequency for beta-thalassemia heterozygosity was 4.7% with 10-fold variation among ethnic groups at risk; the overall frequency for all variants found was 5.4%. We surveyed 60 carriers and 120 noncarriers after screening high-school students (response rate 77%): most carriers told parents (95%) and friends (67%) the test result; and 38% of the carriers' parents (vs. 18% of the noncarriers' parents) were also screened. Carriers would ascertain their spouses' genotype (91%) and approved uniformly (95%) the high-school screening experience and its goal. We performed 11 fetal diagnoses in a 25-month interval (greater than 75% participation in target population) either by fetoscopy and globin-chain analysis or by amniocentesis and genomic DNA analysis; two of three affected fetuses were aborted at parental request, there was one spontaneous abortion (after fetoscopy), and seven live births. The at-risk couples claimed pregnancy would not be contemplated without the fetal-diagnosis option. We analyzed economic costs of the program: cost per case prevented is approximately equal to $ 6,700, slightly less than cost-per-patient-treatment-year or about 4% of undiscounted treatment cost incurred in the first 25 years of life for an affected individual. These findings indicate: collective acceptance of the program, appropriate attitudes among carriers, general acceptance and efficacy of fetal diagnosis, and global cost-effectiveness.
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First experience is reported in the application of computerized tomography to tumorous diseases in childhood, being localized in the mediastinum, lungs, abdomen, bones and soft tissue. In the majority of cases the indication for CT was to identify or exclude tumors. In a little part the method served to determine the extent of the tumor for therapy planing. Despite the known difficulties in abdominal diagnosis encountered with computerized tomography a satisfactory result has been achieved by means of appropriate programs. There were difficulties in diagnosis of tumors in the small pelvic starting from the ovariens or the uterus and in diagnosis of recidivtumors. Using special possibilities of computerized tomography, e.g. measuring absorption values, the kind of disease can be diagnosed in some cases and specific therapeutical measures be planned. The limitations of this technic will be pointed out too.
Cost-benefits of hospital education and training; delineation of hospital educators' roles; and development of appropriate programs, particularly health promotion and continuing medical education programs, continued at issue in 1980.
A comprehensive neuropsychological test battery was administered to 37 long-term survivors of acute lymphoblastic leukemia and 18 newly diagnosed acute lymphoblastic leukemia patients in an attempt to identify patterns of neuropsychological performance. Newly diagnosed patients between 7 and 15 years of age generally obtained scores within normal limits. On most measures of intelligence long-term survivors within the same age range obtained mean test scores approximately 1 standard deviation below the population mean. Fourteen of 30 long-term survivors under 16 years of age exhibited a pattern of test scores suggestive of memory deficits and distractibility which may have interfered with academic achievement. Only one patient over 8 years of age at diagnosis produced a similar pattern of scores. We conclude that young children treated for acute lymphoblastic leukemia are at risk for the development of neuropsychological dysfunction and that appropriate programs for identification and academic remediation should be instituted.
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Obesity is the common expression of several diverse interacting genetic, familial and environmental factors. In addition to having hypertrophic fat cells because of inordinate triglyceride accumulation, many patients with childhood-onset obesity and those who are massively obese regardless of age at onset have an excessive number of adipocytes. Several endocrinologic and metabolic abnormalities are associated with obesity. Triglyceride formation in and lipid mobilization from hypertrophic adipocytes are exaggerated. The increased availability of free fatty acids to the liver contributes to the excessive synthesis of triglycerides and very-low-density lipoproteins; thus, hypertriglyceridemia is frequently associated with obesity. Hepatic synthesis and biliary excretion of cholesterol are also increased. Most of the excess cholesterol is stored in fat cells. The plasma concentrations of high-density lipoproteins are decreased. Hyperinsulinemia, which is characteristically found in the obese, leads to a decreased number of insulin receptors in target cells. The relative insulin insensitivity of the obese frequently results in glucose intolerance. The endocrinologic and metabolic abnormalities are correctable by an appropriate program of meal planning and physical activity.
Obesity leads to several complications that affect many body systems. This paper focuses mainly on the cardiovascular complications, which include coronary heart disease, cerebrovascular disease and stroke, and congestive heart failure; the last may be secondary not only to advanced coronary atherosclerosis, but also to other pathogenetic factors. The increased frequency of coronary heart disease in the obese is largely attributable to the commonly associated hypertension, diabetes mellitus and lipoprotein abnormalities, rather than the adiposity. The lipoprotein disorders that have a role in atherogenesis are decreased plasma concentrations of high-density lipoproteins and elevated plasma concentrations of low-density lipoproteins. Abnormalities in cholesterol metabolism are responsible for the increased frequency of cholelithiasis in obese persons. The factors that mediate the development of cardiovascular and gallbladder complications are correctable by an appropriate program of meal planning and physical activity.
Moving-field irradiation of malignant tumors in the region of the facial bones makes possible the application of high focal doses along with optimal sparing of radiosensitive organs and is yielding very good cosmetic results. An indispensable condition, however, is a correctly scaled, exact representation of bone structures in the medium plane of pendulum irradiation. Standardized transversal sections of the skull or radiometric techniques mostly do not satisfy, being deficient in precision and demanding too much time. Every pendulum plane desired can be represented in the picture obtained by addition from the series of transversal sections with the help of appropriate programming of the computer for tomography. By means of an objective representation of the osseous skeleton, of cavities, soft tissues, and of the tumor contours, individually optimized irradiation planning is possible.
Major advances have been made in the therapy of chronic viral hepatitis B during the past several years. This period has witnessed the publication of large, multicenter trials of recombinant interferon alfa for chronic hepatitis B in the United States and the completion of several similarly designed studies in North America, Europe and Asia. These studies have defined an initial response rate of approximately 40% to 50%. In contrast to the experience with chronic hepatitis C, loss of viral replication is generally sustained. Repeat courses of therapy are likely to result in the same type of response as that observed initially. Quantitative assessment of viral replication (HBV DNA, HBeAg) is important in predicting the likelihood of response and in monitoring patients during therapy. Perhaps the most compelling reason to treat chronic hepatitis B with interferon is the disappearance of circulating HBsAg in one third of responders with a further increase in frequency of this phenomenon as follow-up continues. Another important advantage to treatment is the striking degree of histologic improvement that is frequently observed years after a response has been achieved. Although a substantial number of patients do not respond to interferon, several promising agents that should allow for a greater degree of success, when used either alone or in combination with interferon, are under study. A short course of corticosteroids prior to interferon appears to improve response rates in patients who have low ALT levels at baseline and has been the preferred approach for these patients at our medical center. Progress is being made in the development of safer interferon regimens for patients with mild-to-moderate hepatic decompensation. Nonetheless, even patients with marginal synthetic function, as reflected by albumin levels within the low-normal range, appear to be at greater risk for complications during therapy and should preferably be referred for inclusion in research programs. Appropriate patient selection remains a critical step for maximizing the safety as well as efficacy of interferon treatment.
Recently, a variety of growth factor-dependent subclones of the murine interleukin-3 (IL-3)-dependent cell line 32D have been isolated. These subclones include those dependent for growth on erythropoietin (Epo) (32D Epo), granulocyte-macrophage colony-stimulating factor (GM-CSF) (32D GM), or granulocyte colony-stimulating factor (G-CSF) (32D G). 32D Epo1.1 is a revertant of 32D Epo and is capable of growing in IL-3. These cell lines express the differentiation program appropriate to the specific growth factor and depend on the growth factors not only for proliferation but also for survival. To determine how the signal for proliferation is triggered by various growth factors, we examined the DNA histograms and the expression of cell cycle-specific genes in the different cell lines. The cell cycle-specific genes analyzed were myc (early G1), myb (late G1), and the structural genes for the calcium-binding protein 2A9 (middle G1) and histone H3 (G1-S boundary). The DNA histogram analysis of cells in the logarithmic phase of growth showed that approximately 40% of 32D, 32D GM, 32D G, and 32D Epo1.1 (growing in IL-3) were cells with a 2N DNA content (and therefore in G0/G1), and another 40% have a DNA content intermediate between 2N and 4N (in S phase). In contrast, 32D Epo and 32D Epo1.1 (growing in Epo) had fewer cells in the G0/G1 phase of the cell cycle compared with the number of cells that were in the S phase (19% to 31% v 69% to 78%, respectively). Because all the cell lines have comparable doubling times (15 to 18 hours), the cell distribution among the phases of the cell cycle is proportional to the length of the phase. Therefore, cells growing in IL-3 (32D and 32D Epo1.1), GM-CSF (32D GM), or G-CSF (32D G) progress along the cycle in a manner typical of previously reported nontransformed cell lines. In contrast, cells growing in Epo (32D Epo or 32D Epo1.1) spend relatively less time in G0/G1 and correspondingly more time in S. These data were confirmed by the analysis of the tritiated thymidine (3H-TdR) suicide rate and of the expression of cell cycle-specific genes. The 32D and 32D Epo1.1 cells growing in IL-3 had a suicide rate of congruent to 50%, whereas the suicide rate of 32D Epo and 32D Epo1.1 growing in Epo was higher than 75%.(ABSTRACT TRUNCATED AT 400 WORDS)
The authors were the first to test the breaking process of tablets in home respect. In experiments on the breaking of tablets a tablet hardness tester developed by the Chemical and Pharmaceutical Works Ltd. Chinoin (Budapest) was used. With an appropriate program, this permitted not only a qualitative evaluation of the breaking curves (Fig. 2-4.) also an assessment of the breaking work relating to the breaking strength and even the work needed for various deformation processes (Tab. I-II.). The concept of the breaking factor was introduced: this allows a differentiation of tablets even if the breaking strengths are the same (see Tab. III. 1-2 tablets; with two samples analysis; p < 0.05.) It is concluded that such breaking strength examinations contribute to a better understanding of the behaviour of substances during compression. These results can be very useful both in preformulation examinations and in tests on the prepared products.
Most patients with esophageal cancer present late with regional or distant metastases and have a poor prognosis. They have many debilitating physical and psychosocial problems. Proper symptom management improves quality of life. The continuity of health care in advanced disease can be best provided by hospice home care programs. Appropriate comfort measures will alleviate terminal restlessness in a dying patient and permit them to die with dignity.
The sympathetic nervous system evokes complex effects at multiple target organs in response to external, internal as well as mental stimuli. This output involves an interplay between the actions of a number of transmitters and modulators and at the postsynaptic and presynaptic sites of the autonomic ganglia and the sympathetic preganglionic neurons (SPNs). This review concerns particularly the SPNs of the cat and neonatal rat, studied by means of electrophysiological and immunohistochemical methods. Four types of responses may be elicited, the fast EPSP and IPSP, and their currents, and the slow EPSPs and IPSPs, and their currents. Glutamate and glycine appear to mediate the fast excitatory and inhibitory responses, respectively; peptides and amines seem to be responsible for generating the slow excitatory response, while the slow inhibitory response, found so far only in the cat, appears to be mediated by norepinephrine. Finally, glutamate, enkephalin and GABA, but not glycine attenuate the release of the inhibitory and excitatory transmitters from the nerve terminals abutting on the SPNs. The supraspinal efferent and afferent projections which may release the transmitters and modulators in question are discussed, as well the mechanisms that ensure appropriate programming and moment-to-moment regulation of the autonomic output.
This study is a companion to our 4-year study (Birenbaum, Guyot, & Cohen, 1990) on financing health care for individuals with autism or severe mental retardation. We reported on nonmedical expenditures and opportunity costs pertaining to maintaining a child or young adult with serious developmental disabilities in the home or in residential care and discussed policy implications for assisting their families. We proposed that (a) personal care and family support should be included in health care requirements, (b) family-centered care should be promoted, (c) appropriate programs and care should be provided for young adults no longer in school, (d) financing and organizing of family supports and subsidies should be administratively simple, (e) Medicaid should be expanded to increase use of home- and community-based services, and (f) financial support should be provided to families.
The purpose of this paper is to present a broadly based theory of adolescent decision making including all the necessary components of the subject: cognitive development, social and psychological factors, and, perhaps most importantly, cultural and societal influences. Previous theories and applications have often focused on only one or two aspects. This theory is then applied to the problem of prevention of early pregnancy at an inner-city high school. Use of this theory, combined with an open-ended data-gathering format made possible some of the unexpected findings of this study: most of the young women at this school desire their pregnancies; many of them prefer single parenthood to traditional family structure; and low academic skills and poverty often result in pregnancy, rather than pregnancy causing high school dropouts and a life of poverty. Prevention programs will necessarily differ for sexually active adolescents who do and do not want pregnancy and for younger versus older adolescents. In designing such programs, we need to focus on pregnancy as the problem rather than on adolescent sexuality.
OBJECTIVE: To introduce the newly developed AVERT model by describing the purpose, logic, advantages and limitations of the model, to validate the model's estimates against seroconversion data from a large randomized controlled trial, and to provide practical examples of its applications. DESIGN: Static, deterministic spreadsheet-type model based on per sex act HIV-1 transmission probabilities. METHODS: Data from a recently completed trial carried out in Cameroon were used to validate the estimated number of new HIV infections generated by the AVERT model. A relatively limited set of biological and behavioral parameters was used to estimate the impact of a targeted HIV/sexually transmitted disease (STD) prevention intervention in a South African mining community. RESULTS: The comparison of AVERT estimates with actual seroincidence data from the Cameroon trial not only confirmed the validity of the model's outputs but also illustrated its potential to provide additional options in data analysis. Modeling the pre-and post-intervention scenarios for the South African mining community with AVERT provided estimates of the number of HIV infections averted due to targeted periodic presumptive STD treatment and community-based peer education. CONCLUSIONS: With a small number of accessible input variables, AVERT can provide plausible and defendable impact estimates of intervention effects on the reduction of HIV transmission. The AVERT model may be a helpful tool for decision-makers and planners in setting appropriate program priorities and analysing the cost-effectiveness of different intervention packages.