Community mental health program efficiency

Six urban community mental health centers participated in a capitated payment system designed for persons with severe mental illness who frequently used the state hospital. The centers and their funding agency agreed that a chief outcome measure would be the length of time clients were able to remain enrolled in the outpatient program. Clients of the six agencies were quite similar to one another. During the 18-month study length of enrollment in the outpatient program did not vary among the agencies whereas agency expenditures varied by more than three-fold. Although some of this expenditure variation was due to economies of scale at larger agencies, different practice styles also contributed to variable efficiency.     

Doppler assessment of pulmonary artery pressure in neonates at risk of chronic lung disease

AIM: To evaluate the pulmonary artery pressure (PAP) change in very low birth-weight (VLBW) infants at risk of chronic lung disease (CLD). METHODS: The time to peak velocity:right ventricular ejection time (TPV:RVET) ratio calculated from the pulmonary artery Doppler waveform, which is inversely related to PAP, was used. The TPV:RVET ratio was corrected for different heart rate (TPV:RVET(c)). Seventy three VLBW infants studied on days 1, 2, 3, 7, 14, 21 and 28 were enrolled for the analysis. RESULTS: Twenty two infants developed CLD with a characteristic chest radiograph at day 28. Fifty one did not, of whom 17 were oxygen dependent on account of apnoea rather than respiratory disease, and 34 were non-oxygen dependent. The TPV:RVET(c) ratio rose progressively in all three groups over the first three days of life, suggesting a fall in PAP. In the oxygen and non-oxygen dependent groups, the mean (SD) ratio rose to 0.53 (0.09) and 0.57 (0.09), respectively, on day 7, then remained relatively constant thereafter. The CLD group rose more slowly after day 3 and had a significantly lower mean ratio from day 7 onwards compared with the other two groups (day 7: P < 0.001, days 14-28: P < 0.0001), and fell significantly from 0.47 (0.11) on day 7 to 0.41 (0.07) on day 28 (P = 0.01), suggesting a progressive rise in PAP. The mean (SD) ratios at day 28 of all infants were: CLD group 0.41 (0.07); oxygen dependent group 0.66 (0.15); and the non-oxygen group 0.67 (0.11). The CLD group had a significantly lower ratio than the oxygen dependent group and the non-oxygen group (P < 0.0001). Using the TPV:RVET(c) ratio of < 0.46, infants at risk of developing CLD could be predicted on day 7 (predictive value 82.8%, sensitivity 54.5%, specificity 94.1%). CONCLUSION: The non-invasive assessment of PAP using the TPV:RVET(c) ratio may be useful in the longitudinal monitoring of PAP change in VLBW infants, and for prediction of chronic lung disease.     

A comprehensive panel of near-full-length clones and reference sequences for non-subtype B isolates of human immunodeficiency virus type 1

Non-subtype B viruses cause the vast majority of new human immunodeficiency virus type 1 (HIV-1) infections worldwide and are thus the major focus of international vaccine efforts. Although their geographic dissemination is carefully monitored, their immunogenic and biological properties remain largely unknown, in part because well-characterized virological reference reagents are lacking. In particular, full-length clones and sequences are rare, since subtype classification is frequently based on small PCR-derived viral fragments. There are only five proviral clones available for viruses other than subtype B, and these represent only 3 of the 10 proposed (group M) sequence subtypes. This lack of reference sequences also confounds the identification and analysis of mosaic (recombinant) genomes, which appear to be arising with increasing frequency in areas where multiple sequence subtypes cocirculate. To generate a more representative panel of non-subtype B reference reagents, we have cloned (by long PCR or lambda phage techniques) and sequenced 10 near-full-length HIV-1 genomes (lacking less than 80 bp of long terminal repeat sequences) from primary isolates collected at major epicenters of the global AIDS pandemic. Detailed phylogenetic analyses identified six that represented nonrecombinant members of HIV-1 subtypes A (92UG037.1), C (92BR025. 8), D (84ZR085.1 and 94UG114.1), F (93BR020.1), and H (90CF056.1), the last two comprising the first full-length examples of these subtypes. Four others were found to be complex mosaics of subtypes A and C (92RW009.6), A and G (92NG083.2 and 92NG003.1), and B and F (93BR029.4), again emphasizing the impact of intersubtype recombination on global HIV-1 diversification. Although a number of clones had frameshift mutations or translational stop codons in major open reading frames, all the genomes contained a complete set of genes and three had intact genomic organizations without inactivating mutations. Reconstruction of one of these (94UG114.1) yielded replication-competent virus that grew to high titers in normal donor peripheral blood mononuclear cell cultures. This panel of non-subtype B reference genomes should prove valuable for structure-function studies of genetically diverse viral gene products, the generation of subtype-specific immunological reagents, and the production of DNA- and protein-based subunit vaccines directed against a broader spectrum of viruses.     

Inoculum composition and Salmonella pathogenicity island 1 regulate M-cell invasion and epithelial destruction by Salmonella typhimurium

In the mouse model of Salmonella typhimurium infection, the specialized antigen-sampling intestinal M cells are the primary route of Salmonella invasion during the early stages of infection. Under certain experimental conditions, M-cell invasion is accompanied by M-cell destruction and loss of adjacent regions of the follicle-associated epithelium (FAE), although the conditions responsible for expression of the cytotoxic phenotype in a proportion of previous studies have not been defined. In the present study, we have demonstrated that the cytotoxic effect exerted by wild-type S. typhimurium on mouse Peyer's patch FAE is dependent on the inoculum composition. We have also demonstrated that the extent of FAE destruction correlates with the extent of M-cell invasion. Bacteria inoculated in Luria-Bertani (LB) broth induce extensive FAE loss and exhibit efficient M-cell invasion, whereas bacteria inoculated in phosphate-buffered saline fail to induce significant FAE disruption and invade M cells at significantly lower levels. Similarly, inoculation in LB significantly enhances invasion of Madin-Darby canine kidney cells by wild-type S. typhimurium. Mutants defective for expression of invA, a component of Salmonella pathogenicity island 1 which is vital for efficient invasion of cultured cells, fail to induce FAE destruction and, when inoculated in LB, are attenuated for M-cell invasion. Variation in inv gene expression is, therefore, one possible mechanism by which inoculate composition may regulate the virulence of wild-type S. typhimurium. Our findings suggest that the composition of the gut luminal contents may be critical in determining the outcome of naturally acquired Salmonella infections and that both vaccine formulation and dietary status of vaccine recipients may significantly affect the efficacy and safety of live Salmonella oral vaccine delivery systems.     

Breast cysts and solid lesions: the role of fine-needle aspiration

Breast cyst aspiration and fine-needle or needle-core biopsy of palpable and nonpalpable breast masses can be cost-effective and in some situations provide instant resolution of cystic masses. The limitations of the techniques must be known if the benefits are to be exploited. New evaluations on cyst fluid demonstrating proteins (common to breast cancer) have been demonstrated, as well as assessment of electrolyte ratios in fluid. These may give additional information regarding cyst character and potential risks for breast cancer. Physicians involved in the treatment of breast disease must be aware of these advances as well as being clinically adept in fine-needle aspiration.     

Cystic fibrosis: a disease of altered protein folding

Patch clamp technique was employed to record single Na channel currents in isolated guinea-pig ventricular myocytes. Burst mode could be elicited by step depolarization and terminates immediately after repolarization. The unitary current of burst mode was not only dependent on Na concentration in the pipettes but also on the test voltage. The open time constant increased as testing voltage becomes more positive. The results from stepwise-depolarization and ramp depolarization experiments showed that the more steps or the faster the upstroke velocity of depolarization used, the more the burst mode would occure.     

Current trends in endodontic treatment: report of a national survey

The authors surveyed 360 general dentists and 291 endodontists to obtain information on routine, nonemergency endodontic treatments adapted to clinical practice. Frequent practices and recent advances in treatment modalities-including instrumentation, obturation, intracanal preparations, medications and restorations-are highlighted.     

Occult lumbar lateral spinal stenosis in neural foramina subjected to physiologic loading

PURPOSE: To measure the effect of extension, flexion, lateral bending, and axial rotation loads applied to the spine on the anatomic relationship of the spinal nerves in the neural foramen to the ligamentum flavum and the intervertebral disk, anc to determine the effect of disk degeneration on the response to loading. METHODS: Cadaveric lumbar motion segments were examined with CT and MR imaging, loaded with pure moment forces, frozen in situ, reexamined with CT, and sectioned with a cryomicrotome. The morphology of the intervertebral disks was classified on the basis of the appearance of the cryomicrotome sections. The neural foramina were classified as having no evident stenosis, as being stenotic, as having occult stenosis, or as showing resolved stenosis on the basis of the images and sections before and after loading. The stenotic and nonstenotic foramina were stratified by disk level, intervertebral disk classification, and type of loading applied. The effect of spinal level, disk type, and load type on the prevalence of stenosis was studied. RESULTS: On average, extension, flexion, lateral bending, and axial rotation resulted in the ligamentum flavum or intervertebral disk contacting or compressing the spinal nerve in 18% of the neural foramina. Extension loading produced the most cases of nerve root contact, and lateral bending produced the fewest cases. Each of the loading types resulted also in diminished contact between the spinal nerve and the intervertebral disk or ligamentum flavum in some cases. Disk degeneration significantly increased the prevalence of spinal stenosis. All foramina associated with advanced disk degeneration and half of the foramina associated with disks having radial tears of the annulus fibrosus either developed occult stenosis or were stenotic before loading. CONCLUSIONS: The study supports the concept of dynamic spinal stenosis; that is, intermittent stenosis of the neural foramina. Flexion, extension, lateral bending, and axial rotation significantly changed the anatomic relationships of the ligamentum flavum and intervertebral disk to the spinal nerve roots.     

Aortic intimal changes in aging swine

Aortic intimal lesions in aging swine contained smooth muscle, monocyte-like and unclassifiable cells. The most frequent cellular constituent was the smooth muscle cell that had slightly different features than those in the media. Monocyte-like and unclassified cells appeared largely in the innermost layer of the intima; both types of cells were ultrastructurally similar in appearance except the former had heterophagic vacuoles and overall resemblance to circulating monocytes in shape and size. These cells seemed to preexist in aortic lesions of untreated, aging swine. The intima-media strips of the grossly normal thoracic aortas in 3 1/2 year old swine showed significantly higher contents of cholesterol, triglycerides, phospholipids and total lipids than those of a 6 month old swine. Three to four month old cultured aortic cells accumulated extracellular components, such as fibriles, electron dense substances and cellular debris, which appeared similar to the extracellular matrix of aortic plaques in aged swine.