Switching patients with glaucoma or ocular hypertension from dual therapy to monotherapy: evaluation of brimonidine as a model.

A multicenter open-label study investigated the clinical effectiveness and economic feasibility of switching 142 patients from dual therapy to twice-daily monotherapy with brimonidine for glaucoma or ocular hypertension. Evaluations were performed at baseline and 2 (visit 2) and 8 (visit 3) weeks after the switch. Patients completed a questionnaire that rated medication-related visual function and satisfaction (comfort, convenience, vision, ease of remembering to use drops) at each visit. At visit 3, investigators, taking into account IOP measurements, safety, and responses on the questionnaire, recommended whether the patient should remain on brimonidine. A pharmacoeconomic analysis, including the number of visits, cost of medication, and success rates, compared the cost of dual therapy with that of switching to brimonidine monotherapy. Of the 131 patients who completed the study, 77 (59%) had no change or a decrease in IOP from baseline, and 53 (41%) had an increase. Investigators recommended that 77% of the study completers continue to take brimonidine monotherapy. Extending treatment with brimonidine for 12 months would achieve a significant cost savings of 16%. Brimonidine monotherapy is an efficacious and cost-effective alternative to dual therapy for glaucoma and ocular hypertension. Appropriate monotherapy may be as effective as dual therapy for many patients, and a clinically relevant trial such as this may be economically advantageous for testing a switch.

A comparison of violence exposure and perpetration in recruits and high school students.

This study compared the rates of violence perpetration from two groups of young adults. Samples of 782 recruits at U.S. Army basic combat training were surveyed by the author, and 3,700 adolescents from inner-city and suburban schools were surveyed by another researcher to assess levels of premilitary exposure to violence and levels of violence perpetration. Results showed that there is a significant positive correlation between levels of violence exposure and levels of violence perpetration in both populations (r = 0.71, p < 0.001 for recruits; r = 0.68, p < 0.001 for civilian high school males). Comparison of the two samples showed that levels of exposure and perpetration were nearly identical at lower levels of violence. However, for more severe forms of violence, the civilian high school sample showed much greater exposure and perpetration levels than the sample of Army recruits. Perpetration of the most lethal forms of violence (attack with a knife or firearm) was 2.6 times greater for the civilian high school sample than for basic training recruits. Selection criteria used by the military to screen out individuals who have felony convictions may be the most likely explanation for this difference.

The view from the shore: Central America's Indians encounter the quincentenary.

PIP: Indigenous peoples of the Caribbean, except in small areas of the Dominican Republic and Cuba, have vanished through the years since Columbus landed. In the South, indigenous populations were "largely broken and demoralized, and political institutions shattered." In the 500-year celebration of Christopher Columbus's voyage to the Americas, many materials have been produced. In this article, the focus is on the unknown Indian of Latin America, who is invisible and usually isolated. The 40 million surviving Indians make up various percentages of a country's population, from among 50% in Peru to as little as under 1% in Brazil. The political upheavals of the 1980s have propelled Central America into the public eye. Central America's indigenous population is 4-5.5 million people in 43 different ethnic/linguistic groups (16-22% of Central America's total population of 25 million). Population growth of indigenous people has increased in the last 20 years. Most live in the difficult to reach regions of the jagged volcanic highlands of Guatemala and the densely forested Caribbean coastal plains from Belize to the Colombian border. These isolated locations were selected as protection from the colonists; these regions now are threatened by loggers, cattle ranchers, and landless peasants. In Guatemala, the 4.5 million Indians belong to 22 different Mayan language groups, who have been studied extensively by scientists. In Costa Rica, Indians receive limited protection in 21 reservations, and in El Salvador there is a denial of the "naturales" existence and what was owned before the Conquest is long gone. Most of the Indians are poverty stricken and lack basic social services. Indian organizations have appeared; their involvement in Indian welfare is recounted, e.g., the Kuna of Panama organized the first Indigenous Congress on Natural Resources and the Environment in 1989. An obstacle to the Indians survival is the legacy of Conquest: subjugation, humiliation, and discrimination; Indians are perceived to be obstacles to economic and social progress. Concern about deforestation should provide the basis for collaboration with the Indians. Conservation schemes must recognize Indian's beliefs about the sacredness of the earth and community spirit. The Columbus celebration should mark the beginning of the discovery of who Indians are.^ieng

The seduction of models. Chinampa agriculture in Mexico.

PIP: Considerable excitement accompanied Mexico's plan in the mid-1970s to build "Chinampas," in the swampy region of Veracruz and Tabasco, that is, agriculture involving the construction of raised farming beds in shallow lakes or marshes. The plan was devised by Mexico's Instituto Nacional de Investigaciones sobre los Recursos Bioticos (INIREB). Perfected by the inhabitants of the Valley of Mexico before the Spanish Conquest, chinampas had nearly vanished except in a few isolated and shrinking areas around Mexico City. The chinampas have been steadily constricted in recent years as Mexico City has extended out and swallowed the best known of them, Xochimilco. The introduction of chinampa technology in Tucta, a Chontal village of approximately 300 families in 1978, began on a grand scale. The INI's objectives for the project were: to provide the landless Chontale Indians with permanent employment; to bring about self-sufficient food production in the area; to ensure a constant production of vegetables for the internal market of Villahermosa; to strengthen indigenous cultural identity; and to develop a real alternative for the incorporation of swampland into productive activities. In 1979, INIREB became involved in a 2nd chinampa project in the "ejido" of El Castillo, Veracruz. El Castillo was selected as an experimental project site because of the lake as well as the village's proximity to INIREB's central office in Xalapa, rather than community interest in chinampas. The examples of chinampa technology transfer presented had different outcomes, but they shared several crucial defects. In both cases, the stated and unstated objectives of project managers had little fit with the interests and needs of the farmers. The 2 projects were designed and implemented by outside technicians without significant local participation, and both rapidly fell apart when "beneficiaries" failed to cooperate. The Chontal case is notable because, after a series of failures, it finally worked. This was accomplished only after INIREB technicians broke free from preconceived programs and began listening to the Chontales. Then, the project became consistent with Chontal interests and achieved harmony with local social and economic structures as well as Tabasco's physical environment.^ieng

Respiratory syncytial virus (RSV) infection rate in personnel caring for children with RSV infections. Routine isolation procedure vs routine procedure supplemented by use of masks and goggles.

Respiratory syncytial virus (RSV) infections in hospitalized children were identified by indirect fluorescent antibody technique. Patients with RSV infections were assigned to one of two isolation categories. In one category, the health care workers entering the child's room did not wear masks and goggles; in the other category, the workers did wear masks and goggles. The RSV illness rate in health care workers using masks and goggles was 5%, but the rate for those not using masks and goggles was 61%. In the no mask/goggles group, the RSV illness rates in the health care workers correlated directly with the number of exposures. In this modest study, the use of masks and goggles was associated with a significant reduction of RSV illnesses in pediatric health care workers.

Dientamoeba fragilis, a protozoan parasite in adult members of a semicommunal group.

Dientamoeba fragilis is an intestinal protozoan parasite associated with gastrointestinal symptoms. This study was undertaken in a semicommunal group reported to have a high prevalence of this parasite. Stools were collected from 81 adult group members. Intestinal parasites were observed in stool specimens of 45 (56%) of the 81 adults; D. fragilis was found in 33 (41%) subjects. This paper describes the clinical findings and treatment of 26 adults with D. fragilis alone or with a commensal. Gastrointestinal symptoms were observed in 22 (85%) of infected subjects; abdominal pain and excessive flatus were significantly more common in this group. diiohydroxyquin 650 mg three times a day for 20 days eliminated the parasite in 10 (83%) of the 12 treated, although three subjects required a second course of therapy. Parasitic infection should be considered in patients with vague gastrointestinal symptoms, especially those living in endemic areas, in close proximity, or with a history of foreign travel.

Intestinal protozoan infection in a semicommunal group.

A survey was conducted to determine the prevalence of protozoan parasites in a large semicommunal group in Los Angeles. Protozoan parasites were observed in 151 (69%) of the 220 group members in the study. Parasites were observed in stool specimens from 105 (76%) of the 138 children and 46 (56%) of the 82 adults. Dientamoeba fragilis was observed in 115 (52%), Giardia lamblia in 50 (23%), Entamoeba histolytica in 9 (4%), and commensals in 61 (28%). Parasitic infection was infrequent in infants less than 1 year old, was demonstrated in 33 (89%) of the 2- to 4-year-olds, 69 (78%) of the 89 school age children 8-15 years of age, and in 46 (56%) of the 82 adults. G. lamblia was most prevalent in children younger than 6 years; whereas D. fragilis was common in all age groups. The fecal-oral route was the most likely means for parasite transmission. Since the group at times serves meals to the public, spread of parasites outside the community is a potential public health problems. Diagnosis of parasitic infection is dependent on optimal stool collection, proper laboratory techniques and trained personnel.

Coagulase-negative staphylococcal bacteremia in patients receiving immunosuppressive therapy.

From January 1977 to June 1980, coagulase-negative staphylococci caused bacteremia in 22 (17%) of 130 patients receiving immunosuppressive therapy and were the most common cause of all bacteremias. Sixteen (73%) of the 22 patients had granulocytopenia, and eight were isolated in a laminar air-flow room. A Broviac or Hickman central intravenous (IV) catheter was present in 20 (91%) of 22 patients, and soft-tissue inflammation at the catheter exit site was a significant risk factor for bacteremia. Except for debilitating fevers and local mucocutaneous infections, there were no distinguishing clinical features in patients with bacteremia. Most infections responded to cefazolin sodium or vancomycin hydrochloride therapy; catheter removal was necessary in only seven patients. These data show that coagulase-negative staphylococci can be important pathogens in patients receiving immunosuppressive therapy, even when the patients are isolated in a laminar air-flow room, if normal mucocutaneous, host-defence barriers are interrupted by IV catheter-insertion or chemotherapy.

Dientamoeba fragilis: a gastrointestinal protozoan infection in adults.

Dientamoeba fragilis is a protozoan parasite of the large intestine of man. Individuals with infection may be asymptomatic or have gastrointestinal and systemic symptoms. We report a patient with symptomatic D. fragilis infection and negative extensive laboratory and radiological workup, with resolution of symptoms after diiodohydroxyquin therapy. No parasites were detected in three follow-up stool examinations. We then undertook retrospective study to define and describe further clinical symptoms in adults with this infection by analysis of data from medical records of 50 subjects with this parasite.

Dientamoeba fragilis. An intestinal pathogen in children?

A retrospective study was conducted of 35 children in whom Dientamoeba fragilis was the only parasite found in the gastrointestinal (GI) tract. Gastrointestinal symptoms were present in 32 (91%) of these children; diarrhea was the most common finding in patients with acute symptoms, whereas abdominal pain was more common in children with chronic symptoms. Peripheral eosinophilia was present in half of the children examined and was statistically more significant in patients with D fragilis than in a control group of children admitted for elective surgery. Therapy with diiodohydroxyquin or metronidazole was effective; children's symptoms were diminished or were eliminated on follow-up evaluation after treatment. From this association between therapy and symptomatic relief, D fragilis should be considered pathogenic in those children with GI symptoms.