An interdisciplinary health team training program for school staff in Minnesota.

This paper describes an interdisciplinary health team training program for school-based clinic staff in Minnesota. The project sought to improve team functioning, level of practice, and health care services at the school sites. Participants were interdisciplinary staff members from clinics in senior high, middle, and elementary schools. The program consisted of further development in team training knowledge and skills and educational sessions on issues identified by participants. Evaluations indicated participants reported greater knowledge and improved team functioning experiences from the team training. Gains also were shown in knowledge and skills in specific school topic areas such as violence, resiliency, working with resistant families, and self-care. The program could serve as a model for other interdisciplinary school health team training.

The prevalence of substance abuse among pregnant women in Utah.

OBJECTIVE: To determine the rate of substance use among Utah's pregnant women, who are primarily white and middle class, for comparison to rates reported in studies of inner-city populations. METHODS: Urine specimens and demographic data were obtained anonymously from women who delivered infants at ten hospitals in urban and suburban Utah. Urine samples were screened by enzyme immunoassay for amphetamines, marijuana, cocaine, methadone, opiates, benzodiazepines, and ethanol. RESULTS: Among 792 women screened, the mean age was 26.2 years, 86.1% were white, 62.9% were multigravidas, and 66.3% had private insurance. Cocaine was detected in nine samples (1.1%), illicit amphetamines in five (0.6%), marijuana in 23 (2.9%), ethanol in 32 (4.0%), over-the-counter amphetamines in 51 (6.4%), and benzodiazepines in seven (0.9%). The prevalence rate for women positive for illicit drugs and alcohol combined was 7.8%. Cocaine-positive and marijuana-positive women were more likely to be non-white or Hispanic and to have Medicaid or no insurance than were women negative for either substance. Women with Medicaid or no insurance were four times more likely to be positive for illicit substances (10.7%) than were those with private insurance (2.3%) (P = .0001). CONCLUSION: The rates and patterns of substance use differ between Utah's pregnant women and inner-city populations. The patterns in Utah may be more representative of many communities in the United States that have a predominantly middle-class, white population.

Herpes simplex viral hepatitis in adults: two case reports and review of the literature.

Herpes simplex viral (HSV) hepatitis is uncommon in adults. Two new cases are reported herein; a literature review revealed an additional 33 patients. Ages ranged from 13 to 87 years; the mean age was 32.6 years, and the median was 28 years. HSV hepatitis usually occurs as part of disseminated HSV infection and is characterized by fulminant hepatic necrosis with serum transaminase levels frequently elevated 100- to 1,000-fold. Disseminated intravascular coagulation was present in 90% of the cases. Outcome was poor; 86% of the patients died. Eighty-six percent of the patients had an underlying condition associated with impaired host defenses. Renal transplantation (26%), steroid use other than in renal transplant patients (26%), and pregnancy (23%) were the most frequent underlying conditions. Early recognition and prompt initiation of antiviral therapy may offer a chance for improved survival rates.

Tuberculous esophagitis with erosion into aortic aneurysm.

An 87-year-old woman with a known atherosclerotic thoracic aneurysm died suddenly from a massive esophageal hemorrhage. Prior to death, tuberculous esophagitis was diagnosed by biopsy. At autopsy, a fistulous tract was found extending from the esophagus to the aortic aneurysm; this fistula proved to be the site of fatal hemorrhage. The tract was surrounded by a granulomatous inflammatory reaction, in which acid-fast bacilli were found. To our knowledge, this is the first reported case of tuberculous esophagitis extending to an aortic aneurysm resulting in hemorrhage and death.

Overwhelming pneumonia.

Overwhelming pneumonia may be caused by a large number of different organisms in both immunocompetent and compromised hosts. In this article, the most common etiologies of overwhelming pneumonia are considered from an epidemiologic and clinical point of view.

Gross anatomy in medical education.

The present state of human gross anatomy in medical education can generally be characterized as the presentation of a large bolus of information that is swallowed and only partly digested during the first year of medical school. The subject is often taught in a depth beyond that which would be relevant to all physicians irrespective of their future professional careers. This condition has resulted from adaptive adjustments to the escalating discrepancy between a rapidly expanding knowledge base in science and technology and the relatively fixed time period for education of a physician. Initially, traditional courses retained their comprehensive character, and new information was simply piled on top of existing departmental offerings. It soon became obvious that there would have to be a reduction in time devoted to established courses and a reciprocal expansion of time to accommodate newly developing sciences. Such adjustments were painful and often led to conflicts about what comprises essential knowledge in medical education. Thus, the curriculum time devoted to human gross anatomy has been significantly reduced to accommodate new knowledge in cellular and sub-cellular structures and other disciplines. That common foundation of knowledge, skills, values, and attitudes essential to all physicians regardless of specialty is ever-changing and often debated by medical school faculty members. However, two facts are generally agreed upon: that today's medical student with a broad but perhaps thin base in science and limited direct clinical experience is not competent upon graduation to assume patient care responsibilities without supervision and that as a result, the formal education of a physician has expanded into the graduate domain.(ABSTRACT TRUNCATED AT 250 WORDS)

Skin and soft-tissue coverage--retrospective.

The transfer of autogenous tissues in man has its origins in antiquity. Movement of composite tissues using pedicle techniques, which assured that such tissues were never deprived of vital blood supply, preceded free grafting. The ultimate refinement of carrying pedicles was reached in the vascularized island pedicle flap, which carried composite tissues solely on an intact vascular leash. An enormous increase in the versatility of composite transfers occurred when microvascular surgery made transfer with immediate vascularization a reliable procedure. This opened the door to free functioning muscle and musculocutaneous transfers with motor reinnervation at the recipient site--the supreme tissue transfers.

Sensitivity and specificity of an HIV antibody assay.

We have evaluated a new enzyme immunoassay (EIA) to measure IgG antibodies (Abs) to HIV in patients with AIDS, AIDS-related complex (ARC), AIDS contacts (AC), and low risk controls. Twenty-nine (94%) of 31 AIDS, 27 (96%) of 26 ARC, 12 (54%) of 22 AC, and 1 (2%) of 60 control patients were anti-HIV Ab positive by this assay. Positive results were confirmed by Western blot analysis. The EIA for anti-HIV evaluated in this study is sensitive and specific in identifying individuals who have been infected by this retrovirus.

Historical review of skin and soft tissue coverage of the upper extremity.

This review recounts the known historical development of techniques to achieve soft tissue coverage using free skin grafts, pedicle flaps of various types, and composite tissue transfers with immediate revascularization. There is documentation of an incremental emphasis on muscle-containing pedicle flaps and free revascularized composite tissue transfers in the world literature.

Comparative toxicities of alpha- and beta-N-oxalyl-L-alpha, beta-diaminopropionic acids to rat spinal cord.

alpha- and beta-N-oxalyl-L-alpha, beta-diaminopropionic acids, isolated from Lathyrus sativus seed, which is implicated in the pathogenesis of human neurolathyrism, were injected into rat lumbar cerebrospinal fluid. The alpha-isomer was neither acutely nor chronically toxic, whereas the beta-isomer was both an acute and a chronic neurotoxin in this test system. These results are relevant to the aetiology of neurolathyrism and suggest that the conversion of the beta- to the alpha-isomer that occurs during boiling of the seed prior to human consumption reduces the neurotoxicity of the seed.

Costs, risks, and benefits of hand surgery.

The major criticism of all medicine today is spiraling cost of health care. This is fanned in intensity by economists, politicians, and social scientists who add up the costs, which, in fact, have skyrocketed, and they have concluded that it "isn't worth it." The major basis for that conclusion is that despite the fact that health care costs are gobbling up 11% of the gross national product (+189 billion), there has been an increase in life expectancy of only 1 year. Use of life expectancy as the outcome measure is simple-minded, misleading, and inappropriate, and it is used only because the objective data are clear-cut and available. Mortality is a clear endpoint. Some of the greatest advances in medicine and all of those in the field of hand surgery have nothing to do with duration of survival (quantity of life), but contribute with major impact to the productivity, adjustment, and self-satisfaction of patients (quality of life). We have the opportunity to challenge and counter some of the adverse public image that is the current portrait of all of medicine. Much of that image is based on flimsy, inaccurate data that are extrapolated into gross untruth by nonmedical, short-sighted adversaries. Hand surgeons must collect objective evidence of the rehabilitation benefits of hand surgery care to persons suffering deformity and associated disability. Such data may be extrapolated to show the true cost-risk-benefit ratios produced by hand surgeons.

In vivo demethylation of chicken embryonic beta-type globin genes with 5-azacytidine.

We have studied the in vivo effects of the methyl-blocking cytotoxic pyrimidine analog 5-azacytidine upon DNA methylation and expression of the normally inactive embryonic beta-type globin genes in adult chickens. We find that 5 daily treatments with intravenous 5-azacytidine is capable of converting the normally completely methylated embryonic rho gene to a greater than 75% demethylated state as assayed by the restriction endonucleases HpaII, MspI, and HhaI. However, this change in methylation is not accompanied by activation of the embryonic rho gene at the level of globin protein or globin RNA. Although our analysis does not exclude a few copies of embryonic globin RNA per cell, this result is still in contrast with the results seen with the fetal gamma-globin genes in baboons and humans [17; see also other chapters in this volume]. Hence demethylation by 5-azacytidine treatment alone is not sufficient to activate the chicken embryonic beta-globin genes. We propose that these seemingly disparate results can be reconciled by a model in which certain genes in specific cell types (eg, human and baboon gamma-globin in adult erythroid cells, chicken ev-1 in MSB cells, mouse metallothionein-1 in lymphoblastoid cells) are in a poised state such that removal of specific methyl cytosines results in a high level of transcription. In contrast other genes (including chicken rho and epsilon embryonic globin genes in adult erythroid cells) are in a suppressed state that overrides activation by demethylation. Alternatively, 5-azacytidine could activate certain genes by a mechanism totally independent of DNA methylation. For instance, selection of specific early erythroid cell types could account for the results seen in baboon fetal globin gene activation. The availability of various eukaryotic DNA transformation systems, characterization of eukaryotic DNA methylases, and development of large-scale cultures of erythropoietic precursor cells should facilitate detailed examination of these various states of gene activation and allow the elucidation of the precise role of DNA methylation in the regulation of globin gene switching.