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The many faces of systemic mastocytosis.

OBJECTIVE: This short review article will augment the reader's knowledge of mast cell physiology and will offer an overview of current information on the pathophysiology, heterogeneity, and treatment of human mastocystosis. DATA SOURCES AND STUDY SELECTION: Articles published since 1980, textbooks, information from computerized databases, references identified from bibliographies of relevant articles, and books published in the last 10 years. RESULTS AND CONCLUSIONS: Mastocytosis is a complex disease with a multitude of clinical presentations, often misdiagnosed, which can embrace characteristics of other diseases and generate a chameleon-like picture. Mast cells possess many important physiologic functions in the human body, but as a consequence of poorly understood events, they can also start a cascade of pathologic reactions. Although a great deal is known about mechanisms involved in physiologic and pathologic processes of mast cells, many areas are waiting to be explored in this millennium.

Female↗

Biphasic versus monophasic oral contraceptives for contraception: a Cochrane review.

BACKGROUND: Side-effects caused by oral contraceptives discourage compliance with and continuation of oral contraceptives. Three approaches have been used to decrease these adverse effects: reduction of steroid dose, development of new steroids, and new formulas and schedules of administration. The third strategy led to the biphasic oral contraceptive pill. We compared biphasic oral contraceptives with monophasic oral contraceptives in terms of efficacy, cycle control and discontinuation due to side-effects. Our a priori hypotheses were: (i) biphasic oral contraceptives are less effective in preventing pregnancy than monophasic oral contraceptives, and (ii) biphasic oral contraceptives cause more side-effects, give poorer cycle control and have lower continuation rates. METHODS: We searched computerized databases Medline, Embase, Popline and the Cochrane Controlled Trial Register. Additionally, we searched the reference lists of all potentially relevant articles and book chapters. We also contacted the authors of relevant studies and pharmaceutical companies in Europe and the USA. We included randomized controlled trials comparing any biphasic oral contraceptive with any monophasic oral contraceptive when used to prevent pregnancy. We examined the studies found during the various literature searches for possible inclusion and assessed their methodological quality using the Cochrane guidelines. We contacted the authors of all included studies and of possibly randomized studies for supplementary information about the study methods and outcomes. We entered the data in RevMan 3.1, imported the data into RevMan 4.1, and calculated Peto odds ratios for the incidence of intermenstrual bleeding, absence of withdrawal bleeding and study discontinuation due to intermenstrual bleeding. RESULTS: Only one trial of limited quality compared a biphasic and monophasic preparation. This trial examined 533 user cycles of a biphasic pill (norethindrone 500 microg/ethinyl estradiol 35 microg for 10 days, followed by norethindrone 1000 microg/ethinyl estradiol 35 microg for 11 days) and 481 user cycles of a monophasic contraceptive pill (norethindrone acetate 1500 microg/ethinyl estradiol 30 microg daily). The study found no significant differences in intermenstrual bleeding, amenorrhoea and study discontinuation due to intermenstrual bleeding between the biphasic and monophasic oral contraceptive pills. CONCLUSIONS: Conclusions are limited by the identification of only one trial, the methodological shortcomings of that trial and the absence of data on accidental pregnancies. However, the trial found no important differences in bleeding patterns between the biphasic and monophasic preparations studied. Since no clear rationale exists for biphasic pills and since extensive evidence is available for monophasic pills, the latter are preferred.

Contraception↗

Organisation and cost-effectiveness of antenatal haemoglobinopathy screening and follow up in a community-based programme.

OBJECTIVE: To consider the organisation cost and effectiveness, of universal, community-based antenatal screening for the haemoglobinopathies, and to estimate the cost-effectiveness of programmes at different levels of prevalence and mix of haemoglobinopathy traits. DESIGN: Retrospective review of laboratory and Sickle Cell and Thalassaemia Centre worksheets with costing of capital equipment, consumables, salaries and overheads, and estimation of costs in a range of circumstances. SETTING: A haematology department, including a Sickle Cell and Thalassaemia Centre, providing antenatal and neonatal screening programmes in Inner London. PARTICIPANTS: Two thousand one hundred and one women booking at the antenatal clinic whose samples were referred for screening during 1994. MAIN OUTCOME MEASURES AND RESULTS: In addition to assessing the cost-effectiveness of antenatal haemoglobinopathy screening in a number of settings, the following specific financial information was assembled for the service in Brent: 1. cost of identifying abnormal haemoglobin in mother (ł209); 2. cost of identifying at-risk fetus before confirmation by prenatal diagnosis (ł2,455); 3. cost of providing genetic information and counselling to mother with abnormal haemoglobin (ł109); 4. programme savings from cases averted (ł61,000). Conclusions Antenatal screening with follow up counselling can be self-financing at most prevalences of haemoglobinopathy traits, with greater savings where a high proportion of the traits are beta thalassaemia. There is a net financial cost (ł1,350) only at prevalences below 2.5% of traits if these are mainly for sickle cell disease. Since there are other benefits is it likely that antenatal screening will be considered cost-effective even at quite low levels of trait prevalence.

Algorithms↗

Developing a mandate for change: planning as a political process.

The three main questions dealt with in this article are: 'why have community participation in planning?' 'what is community participation?' and 'how can community participation be practised?' Planning in this context should be understood in a strategic sense as social policy development and implementation at a regional level. In answer to the first question, two common approaches to social planning and their shortcomings are briefly discussed, with reference to a taxonomy from Alan Walker's book Social Planning, A Strategy for Socialist Welfare. Community participation in social planning is a key characteristic of an alternative approach which addresses or avoids altogether the fundamental shortcomings of the other two. Issues of the practice of community participation in regional planning are examined through a description and analysis of the planning process undertaken by the Western Metropolitan Region of the Health Department Victoria. Some general conclusions regarding current trends in policy formation and public sector administration are also drawn.

Community Participation↗

Persons with severe mental illness in jails and prisons: a review.

OBJECTIVE: The presence of severely mentally ill persons in jails and prisons is an urgent problem. This review examines this problem and makes recommendations for preventing and alleviating it. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1970, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Clinical studies suggest that 6 to 15 percent of persons in city and county jails and 10 to 15 percent of persons in state prisons have severe mental illness. Offenders with severe mental illness generally have acute and chronic mental illness and poor functioning. A large proportion are homeless. It appears that a greater proportion of mentally ill persons are arrested compared with the general population. Factors cited as causes of mentally ill persons' being placed in the criminal justice system are deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support for persons with mental illness, mentally ill offenders' difficulty gaining access to community treatment, and the attitudes of police officers and society. Recommendations include mental health consultation to police in the field; formal training of police officers; careful screening of incoming jail detainees; diversion to the mental health system of mentally ill persons who have committed minor offenses; assertive case management and various social control interventions, such as outpatient commitment, court-ordered treatment, psychiatric conservatorship, and 24-hour structured care; involvement of and support for families; and provision of appropriate mental health treatment.

Commitment of Persons with Psychiatric Disorders↗

Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review.

OBJECTIVE: Very large numbers of severely mentally ill persons now fall under the jurisdiction of the criminal justice system. A number of conditions are placed on those who are returned to the community, including specific ones related to treatment. This paper reviews the principles and practice of forensic outpatient mental health treatment. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1978, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of nonoffenders, which focuses on alleviation of symptoms. Patients must comply with legal restrictions on their behavior, and treatment first addresses a patient's risk of harm to the community. Mentally ill offenders are often resistant to treatment. The mental health system may be disinclined to treat them due to their resistance and their criminal history, especially a history of violence. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals, a close liaison between treatment staff and the criminal justice system, adequate structure and supervision, treatment staff who are comfortable with using authority, interventions for managing violence, incorporation of the principles of case management, appropriate and supportive living arrangements, and a recognition of the role of family members and significant others in treatment.

Case Management↗

Benefits of parenteral deferoxamine for acute iron poisoning.

OBJECTIVE: To review the benefits of deferoxamine for the treatment of iron poisoning. METHODS: Both the basic science and clinical literature on deferoxamine were reviewed by comprehensive computer literature search. This was supplemented by references identified from bibliographies of pertinent articles and books. RESULTS: The basic science literature supports deferoxamine as an attractive antidote for iron poisoning. There were no dose response studies in the human or animal literature. There were no randomized controlled trials or case controlled studies of patients with toxicity (serum iron concentration > 500 micrograms/dL). All data were descriptive and anecdotal. Therefore fundamental parameters such as indications for administration, dose, route and duration of therapy are unclear and efficacy is unproven. CONCLUSION: Deferoxamine is attractive for the treatment of iron poisoning despite the lack of knowledge for its optimal use and remains the drug of choice for the treatment of significant iron poisoning.

Administration, Oral↗

Optimising collection of autologous blood. A pilot study of the use of recombinant human erythropoietin and parenteral iron.

OBJECTIVE: To optimise collection of sufficient autologous blood for elective surgery. METHODS: Prospective study of 40 patients referred for donation of autologous blood, who were booked for elective orthopaedic surgery in the period August 1992 - September 1994. Patients received recombinant erythropoietin (r-EPO) to stimulate erythropoiesis, and sufficient iron by injection so that iron deficiency did not limit the bone marrow response to the r-EPO. RESULTS: Thirty-eight of the 40 patients treated with this protocol stored an average of 3.7 units each on a twice-weekly donation schedule. Only one patient required supplemental homologous blood (two units) in subsequent surgery. One patient developed persistent hypotension, and one a late reaction to parenteral iron (which was controlled with corticosteroids). There were no other adverse events. CONCLUSIONS: r-EPO in combination with parenteral iron is a safe and effective method of ensuring the collection of optimal amounts of autologous blood before surgery.

Adult↗

Prescription assistance programs: options for assisting the uninsured and underinsured.

The objectives of the study were to determine the prevalence of indigent patient or reimbursement assistance programs for prescription drugs sponsored by the pharmaceutical industry and to collect data describing them. A questionnaire was mailed to 121 manufacturers or marketers of prescription drugs selected from the 1990 edition of the Red Book and 1991 edition of the Physicians' Desk Reference. The availability of free drug to qualified indigent patients or the availability of experts to solve reimbursement issues was then ascertained. The general application procedures and features of both types of programs were documented. The authors found that indigent patient and reimbursement assistance programs are offered for many products by numerous pharmaceutical companies, although not always on a formal basis. Of the 69 (57%) companies responding to the survey, 46 (67%) offer indigent patient assistance programs and 31 (45%) offer reimbursement assistance programs. Application procedures and services provided vary considerably between companies. These findings suggest that the pharmaceutical industry is a potential source of assistance in procuring drugs for the indigent or underinsured patient populations and a resource for resolving insurance issues. It is essential to contact a sponsor to determine current program availability and application procedures. Further study is required to appraise the merit of such programs.

Directories as Topic↗

Echinacea for upper respiratory infection.

OBJECTIVES: To review the evidence regarding the effectiveness of orally ingested Echinacea extracts in reducing the incidence, severity, or duration of acute upper respiratory infections (URIs). SEARCH STRATEGIES: Information from a wide range of sources was used as background material. More than 100 articles, books, and book chapters were reviewed for content and further references. Database searches, bibliographic reviews, and conversations with experts were carried out iteratively from January 1997 to February 1999. SELECTION CRITERIA: Published or unpublished reports of all blinded placebo-controlled randomized trials of any Echinacea formulation used as a treatment or for the prevention of URIs. DATA COLLECTION AND ANALYSIS: Review considerations included randomization, blinding, power, validity and clinical relevance of outcome measurements, inclusion and exclusion criteria, indistinguishability of treatment and placebo, and appropriateness of conclusions for the data presented. MAIN RESULTS. Nine treatment trials and 4 prevention trials fitting the selection criteria were found. Eight of the treatment trials reported generally positive results, and 3 of the prevention trials reported marginal benefit. Methodologic quality of the majority of the trials was modest. CONCLUSIONS: Evidence from published trials suggests that Echinacea may be beneficial for the early treatment of acute URIs. The influence of publication bias on those results is unknown. Echinacea preparations vary widely in composition, and are often found in combination with other potentially active constituents, making specific dose recommendations problematic. There is very little evidence supporting the prolonged use of Echinacea for the prevention of URIs.

Acute Disease↗

Receptor structure and function: an exploratory approach using the thyrotropin receptor as a vehicle.

The purpose of this chapter is not to present the final or even correct model of TSH receptor structure and function. Rather, the current speculative model presented is used to open the door to a more broad view of the receptor problem and controversy as it has evolved today. Questions of how we define a receptor are clearly very much in flux and much more difficult than initially considered when a chemical approach is taken. Numerous binding components will be described and their relevance to the physiologic state will be debated. Some will be clearly erroneous in concept--yet the very debate and data will open new ideas and approaches other than repetitive membrane binding or response measurements. The remainder of this book will explore numerous other aspects of receptor structure, regulation and function. The reader may be disturbed by the complexity and extrapolations of data and the weakness of the models. The reader should, however, remember that the receptor is the key link of the cell to its environment. The complexities of this linkage are evident in our continued concern with knowledge of the mechanisms our bodily senses utilize. The controversy that will exist is evident in the arguments we have today over the agents in our environment which affect us and the mechanisms of these effects. It is hoped that this chapter and book will provide both the desire and some reference to follow and review the data in all receptor fields as they emerge in the next several years.

Adenylyl Cyclases↗

[Migration of the wire after osteosynthesis].

In a 20 year old woman, sudden death due to hemopericardium ensued on osteosynthesis with Kirschner wire of a dislocated sternoclavicular joint. The wire moved to the aorta ascendens and to the right auricle thus causing lethal bleeding into the pericardium. The pathogenesis of the wandering wire is discussed and compared with observations in the literature describing causes, history and clinical phenomena. Wandering after osteosynthesis due to dislocation of the sternoclavicular joint is particularly dangerous, whereas in the case of broken clavicle, dislocation of the acromioclavicular joint, fracture of the humereus or in the region of the hips, no serious complications occur as a rule. Present-day text-books on surgery do not make sufficiently detailed reference to the wandering wire syndrome.

Adult↗

[Herbalogical study of Chinese drug guijiu and xiaoyelian].

Through a critical study of ancient Chinese herbals, it is concluded that the botanical origin of Guijiu should be Dysosma versipellis or D. pleiantha instead of Sinopodophyllum emodi, and that Xiaoyelian was originated from the latter. In Chinese Pharmacopoeia and many other books, the botanical origin of Xiaoyelian was erroneously referred to as Podophyllum emodi.

China↗

Chronic opioid analgesic therapy for chronic low back pain.

BACKGROUND: Eleven percent of American adults have chronic low back pain- and many of these individuals have severe, disabling, refractory pain. Many texts recommend against using opioids for these patients without citing original research. METHODS: A MEDLINE literature search was conducted for original research on the use of opioids for chronic noncancer pain. Additional references were also sought from review articles and book chapters. Based on this research and the authors' clinical experience, recommendations were formulated for implementing chronic opioid analgesic therapy (COAT) for patients with chronic low back pain. RESULTS: No controlled studies were found. Case series reports on a total of 566 patients suggest that COAT is safe and effective for many patients with recalcitrant chronic low back pain. Preexisting substance use disorders, personality disorders, certain medical conditions, and certain occupational factors are relative contraindications to COAT. Methods to prevent and monitor for drug problems among COAT recipients include contracts, family interviews, and drug testing. Pain and overall function are the key monitoring parameters. Once patients attain some relief, an exercise regimen should be initiated. Other nonpharmacologic treatments and nonopioids are also recommended. CONCLUSION: Physicians are encouraged to consider COAT for selected patients with severe chronic low back pain who respond inadequately to other treatments.

Adult↗

Outcome of pregnancies referred to a general practitioner maternity unit in a district hospital.

OBJECTIVE: To audit the outcome of pregnancies booked for confinement in a general practitioner maternity unit in a district general hospital. DESIGN: Retrospective review of case records. SETTING: General practitioner maternity unit in a district general hospital. PATIENTS: 685 Women referred to a general practitioner unit in 1987. RESULTS: 315 Nulliparous women and 330 multiparous women were booked for confinement; 202 women transferred to consultant care before delivery and a further 104 during labour or after delivery. Recognised risk factors, other than nulliparity, rarely predicted the need for transfer. Confinement in the general practitioner unit was associated with low intervention and good fetal outcomes. CONCLUSIONS: The general practitioner maternity unit provides a safe alternative for confinement in low risk pregnancies. High rates of transfer deny this facility to many women who desire confinement in a low technology environment.

Apgar Score↗

[Illustrated medical books in Graeco-Roman Egypt].

The paper deals with the illustrated medical texts from Hellenism to Byzantine age. It refers particularly to the two herbaria of Tebnytis and Antinoopolis, reconstructing the history and production techniques of scientific illustrated books of antiquity.

Egypt↗

[Ludovicus Nonnius (1553-1645) Marrano physician in Antwerp, author of the 'Diaeteticon'].

In 1492 and 1497 respectively the King of Spain and the King of Portugal promulgated decrees expelling jewish families from the Iberic Peninsula. The Nuñes family, that came to live in Antwerp at about 1550, was of marranic iberian descent. Alvarez Nuñes, Luis's (Ludovicus) father was for some time professor of medicine at the Louvain University and he practised private medicine in Antwerp for 30 years. He belonged to the group of Portuguese-marranic physicians who in Antwerp gave medicine a new impulse in the XVIth century, thanks to the return to Arabic-Islamic sources and consequently to the Greek tradition. The art of printing, in full expansion in Antwerp (e.g. Christophe Plantin), had also a stimulating influence. Ludovicus Nonnius was born in Antwerp in 1553; he obtained his medical degree in about 1577 in Louvain and settled down in his native town. He built up an important practice and became in 1620 a cofounder of the first medical society in the Southern Netherlands, the 'Collegium Medicum Antverpiense'. As physician, naturalist, writer, latin poet, numismatist and connaisseur of the Greek and Latin authors, this man is a good example of a Renaissance humanist. He died in 1645 at the age of 92. Numerous data point to his friendship with Rubens. Firstly, the frontispieces of two of Nonnius' books were signed by the Antwerp master. Secondly, there is Nonnius' portrait by Rubens. Thirdly, Rubens asked several times for Nonnius' medical advice. The artist appreciated especially his dietary prescriptions. Numerous writings from the hand of Ludovicus Nonnius have been preserved: his correspondence with Justus Lipsius and with the physician and writer from Dordrecht, Jan van Beverwyck, his comments on Latin classics, books on geography and history and several books on numismatics. A special merit of the author is that he can be considered to be the founder of medical dietetics. He was the first to systematically study foods from a medical and hygienic point of view. His work, however, is based upon empiricism and the booklearning of his century. The first of Nonnius' books on dietetics, "Ichthyophagia", describes 37 species of noble fish. He asserts that eating fish is very healthy. The main work of Nonnius is his "Diaeteticon sive de re cibaria libri IV" (first edition 1627, second edition 1645). The four parts of the "Diaeteticon" are full of references to and comments on numerous authors. In his first book he exposes the basic principles of a healthy feeding. Then follows the description of four kinds of bread, an enumeration of vegetables and fruit, with a description of their action upon the body humors. Finally a praise of salt, the universal preserving substance. The second part treats meat, even pork, that, according to Nonnius, may be eaten moderately. In the third book the produce of sea and rivers are examined, in fact a new version of the "Ichthyophagia". Finally in the "Liber Quartus" Nonnius discusses beverages: he describes several sorts of wine and the advises against the mixing of wines. Nonnius gave a great importance to the curative properties of mineral water, for instance by kidney stones. This subject was also dealt with in the correspondence between Nonnius and van Beverwyck. The mild pinotherapy was in any case more advisable than the lithotomy applied in season and out of season at that time. Nonnius' works had a great notoriety which was a rare fact for books about medicine. Nowadays, the general principles the author formulated about 'healthy food' are still valuable. In his view they evidently lean only on empirism; that is why many of his counsels cannot be followed any longer. Nevertheless the insistence of Nonxius on eating fish and drinking mineral water may still be fully agreed with.

Belgium↗

Influence of a nurse practitioner on non-attendance rate for barium enema.

Non-attendance for barium enema investigation wastes resources, prolongs waiting times and delays diagnosis of colorectal carcinoma. In an inner-city hospital with a previous non-attendance rate of over 20% for barium enema we investigated the value of systematic personal contact with a nurse practitioner at the time of booking. We compared two groups of patients, all of whom received an explanation of the procedure from the referring clinician. Patients referred from the colorectal clinic were accompanied by the colorectal nurse practitioner to the radiology department for booking, an appointment being sent later by mail. The nurse practitioner reiterated the details of the procedure, provided supplementary information, confirmed the patient's contact details and provided a telephone number in case further information or assistance was needed. Patients referred from the gastroenterology clinic were managed as previously, making their own way to the radiology department and receiving supplementary information only on request. The patients referred from the two clinics were closely similar; however, the non-attendance rate for the intervention (colorectal) clinic was 4/157 (2.5%) compared with 17/110 (15.5%) for the comparison clinic (P<0.001). A year previously the non-attendance rates in these clinics had been 23% and 20%, respectively. These results indicate that personal contact, with supplementary information, can substantially reduce the non-attendance rate for barium enema.

Appointments and Schedules↗