Appropriateness of computed tomography and magnetic resonance imaging scans in a rural regional hospital in South Africa: A 6-year follow-up study.

BACKGROUND: Requests for computed tomography (CT) and magnetic resonance imaging (MRI) scans by doctors with different levels of experience have cost and risk implications globally. Evidence-based appropriateness criteria guide doctors to the suitable use of radiology imaging. There are few studies regarding appropriateness of CT requests in the South African (SA) context. Previous research in the Garden Route district of Western Cape Province, SA, evaluated the appropriateness of scans. OBJECTIVES: To review the appropriateness of CT and MRI scans done in a 6-year follow-up study at one facility. METHODS: This was a retrospective descriptive study. All CT and MRI scans performed during October 2018 at George Hospital were classified according to American College of Radiology guidelines as: usually appropriate (UA), might be appropriate (MBA), or not appropriate (NA). Stratified analysis allowed simple statistics and some comparison with the previous study. RESULTS: A total of 515 CT and MRI scans were included, of which 81.4% were UA, 7.4% MBA and 11.2% NA. Most scans were requested by medical officers (n=255), followed by consultants (n=126) and junior doctors (n=70). Medical officers made the majority of inappropriate requests. Second-year interns requested the lowest number of inappropriate scans, with registrars not requesting any inappropriate scans. Most of the inappropriate scans were requested after hours. Thirty-seven of the 123 (30.1%) after-hours scans were inappropriately requested compared with 21 of 392 (5.4%) scans during normal working hours, which were inappropriate. CONCLUSIONS: Although the majority of scans were being ordered appropriately, pre-authorisation by experienced physicians and incorporation of guidelines would make requests more complete and possibly more appropriate, especially after hours.

Tuberculosis infection control in a South African rural regional hospital emergency centre: Prioritisation for patients and healthcare workers.

South Africa (SA) is in the midst of a tuberculosis (TB) epidemic and has one of the highest TB incidence rates globally. Despite increasing global commitment to eliminate TB, SA appears to be falling behind in this regard. This article examines key challenges to effective TB infection control from a rural regional hospital perspective. It uses the Eden District in Western Cape Province as an example to share lessons learnt. This quality-improvement project identifies four priorities for improving TB infection control in George Hospital and the Eden District: (i) prioritising TB infection control in local policy; (ii) improving the quality of TB screening in the emergency centre; (iii) increasing the number of TB patients followed up; and (iv) implementing TB infection control training for all staff. This project demonstrates the role of an emergency centre in TB screening, highlighting that this should not only be a priority for primary care, but also for secondary and tertiary care. Simple interventions, such as training of local healthcare workers in TB infection control and good-quality TB screening, can initiate a behavioural change. It also stresses the importance of good communication and co-ordination of care across primary and secondary care, ensuring that patients are not lost to follow-up. Local policy needs to reflect these straightforward interventions, empowering local healthcare workers and managers to increase responsibility and accountability for TB infection control.TB is preventable, and infection control needs to become a priority throughout SA primary, secondary and tertiary care. This project highlights that simple interventions, such as engaging local healthcare workers in a co-ordinated multisystem and multidisciplinary approach, could help to reduce the number of missing TB cases and bring SA's TB epidemic under control.

Appropriateness of computed tomography and magnetic resonance imaging scans in the Eden and Central Karoo districts of the Western Cape Province, South Africa.

INTRODUCTION: Computed tomography (CT) and magnetic resonance imaging (MRI) are an essential part of modern healthcare. Marked increases in clinical demand for these imaging modalities are straining healthcare expenditure and threatening health system sustainability. The number of CT and MRI scans requested in the Eden and Central Karoo districts of the Western Cape Province, South Africa (SA), almost doubled from 2011 to 2013. OBJECTIVE: To determine the appropriateness of CT and MRI scans and relate this to the requesting department and clinician. METHODS: This was a retrospective analytical cohort study. All scans during October 2012 were analysed as a sample. Appropriateness of scans was determined using the American College of Radiologists (ACR) Appropriateness Criteria and the Royal College of Radiology Guidelines. Appropriateness was also correlated back to the requesting department and clinician. RESULTS: Of a total of 219 scans, 53.0% were abnormal. Overall 6.4% of scans were considered inappropriate. Interns and registrars requested no inappropriate scans. The orthopaedics department scored the highest rate of appropriate scans (80.0%) and the oncology department the highest rate of inappropriate scans (20.8%). CONCLUSION: The limited resources available for healthcare in a developing country like SA should be a motivation to implement control mechanisms aimed at appropriate utilisation of imaging examinations. The Eden and Central Karoo districts have a low rate of inappropriate scans (6.4%). We recommend that the current preauthorisation system by consultants and other senior clinicians continues, but with increased clinician awareness of the ACR Appropriateness Criteria and the Royal College guidelines.

Drug Interactions in Primary Health Care in the George Subdistrict; South Africa: a Cross-Sectional Study

Objectives: To investigate the prevalence of potential drug-drug interactions in primary healthcare clinics in the George subdistrict; to determine which drugs were involved; and to identify associated risk factors. Design: A cross-sectional retrospective folder review was performed.Setting and subjects: Four hundred randomly selected patient files from four primary care clinics in the George subdistrict. Outcome measures: The prevalence of potential drug-drug interactions in primary care; drugs involved in potential drug-drug interactions and associated risk factors. Results: The prevalence of scripts containing at least one moderate potential interaction was 42; severe potential interaction; 5.25; and contraindicated combinations; 0.5. The most common drugs involved were enalapril; aspirin; ibuprofen; furosemide and fluoxetine. The most common implicated drugs in potentially severe interactions were warfarin; aspirin; fluoxetine; tramadol and allopurinol. Two contraindicated combinations were found; namely verapamil plus simvastatin; and hyoscine butyl bromide plus oral potassium chloride. Advancing age and polypharmacy were associated with an increased risk of potential drug-drug interactions. Input from the regional hospital specialist departments greatly increased the risk of a patient being given a prescription that contained a potential drug-drug interaction. Eighty one per cent of severe interactions were from this group. Conclusion: The potential for drug-drug interactions occurring was common in primary healthcare clinics in the George subdistrict. Drug interactions are predictable and preventable. The risk factors identified in this study may assist in the design of interventions that reduce the risk

Psychological reactions among family members of patients with implantable defibrillators.

OBJECTIVE: To describe psychological reactions among family members of patients receiving an implantable cardioverter/defibrillator (ICD) during the first 9 months after implantation. METHODS: Eighty-two family members (age 56+/-12 years, 74 percent female, 79 percent married, 88 percent Caucasian) of ICD patients completed questionnaires regarding their mood (Profile of Mood State), cognitive illness appraisals (Meaning of Illness Questionnaire) and coping strategies (Jalowiec Coping Scale) prior to ICD implantation, and as well as 1 and 9 months postoperatively. RESULTS: Total mood disturbance score (TMD), threat appraisal, and emotion- and problem-focused coping were highest prior to ICD implantation, and decreased during the first postoperative month showing stable values thereafter. There was no change in challenge appraisal. Multiple regression analysis found that the use of psychotropic drugs (anxiolytics, sedatives; Beta = .25), emotion-focused coping (Beta = .37), and challenge appraisal (Beta =-.21) at 1 month accounted for 26 percent of variance in TMD at 9 mon ths. CONCLUSION: A spouse's ICD implantation is a major stressful event for family members leading to a diminished mood state prior ICD implantation. Reduction in emotion-focused coping and the use of challenge appraisal may improve mood state in family members of ICD patients during early follow-up.

Emphasis courses: preparing baccalaureate students for transition to the workforce.

In response to identified needs for stronger preparation of baccalaureate graduates to enter the workforce, the University of Maryland School of Nursing created, implemented, and evaluated the use of Clinical Emphasis Seminars and Practicum. A sequence of 3 courses was ultimately developed for students to take during the final year of their upper-division nursing curriculum. The courses, totaling 5 credits, allow students to develop their knowledge and experience in a focus area within 1 specific type of clinical nursing. These courses follow up completion of required foundational clinical courses. Emphasis areas include all clinical areas offered within the nursing curriculum such as cardiovascular, critical care, and community health. Courses begin and end with 1-credit seminars and include one 3-credit clinical Practicum. In the latter course, students work with a clinical preceptor, following the preceptor's work hours for a minimum of 9 hours a week over the 15-week semester. Advantages of the Emphasis Courses are many: students develop an in-depth knowledge and clinical skills in a selected area of clinical practice. Potential employers have an opportunity to observe students in a preemployment setting and to evaluate the fit of skills and personal attributes to the specific setting. Students are provided with "value-added" knowledge and experience. The emphasis course model offers advantages to students transitioning into the workforce, to employers, and, ultimately, to clients served.

Tachycardia-related cardiomyopathy: a common cause of ventricular dysfunction in patients with atrial fibrillation referred for atrioventricular ablation.

OBJECTIVE: To determine the frequency of tachycardia-related cardiomyopathy in patients with atrial fibrillation and systolic dysfunction referred for atrioventricular node ablation. PATIENTS AND METHODS: This prospective multicenter cohort study was conducted at 16 tertiary care centers. The ejection fraction was measured before and 3 and 12 months after atrioventricular node ablation. Patients with reduced systolic function (ejection fraction < or = 45%) before atrioventricular ablation were included in this study. Patients whose ejection fraction increased by at least 15 percentage points and to higher than 45% were considered to have tachycardia-related cardiomyopathy. RESULTS: Of 63 patients with systolic dysfunction, 48 had at least 1 adequate follow-up echocardiographic study. Sixteen (25%) of the 63 had marked improvement in the ejection fraction (mean +/- SD change, 27 +/- 8 percentage points) to a value higher than 45% after ablation. CONCLUSIONS: Tachycardia-related cardiomyopathy is common in patients with atrial fibrillation and systolic dysfunction referred for atrioventricular node ablation. This diagnosis should be considered in all patients in whom systolic dysfunction occurs subsequent to or concomitant with onset of atrial fibrillation.

Testing the reliability and validity of the Self-Efficacy for Exercise scale.

BACKGROUND: The measure for self-efficacy barriers to exercise was developed for adults and revised on the basis of quantitative and qualitative research with older adults so it would be more appropriate for that age group. OBJECTIVES: To test the reliability and validity of the Self-Efficacy for Exercise (SEE) Scale. METHODS: Initial reliability and validity testing was performed using a sample of 187 older adults living in a continuing care retirement community. The average age of the participants was 85 +/- 6.2 years, and most were White (98%), female (82%), and unmarried (80%). Face-to-face interviews were completed and included the SEE, the 12-item Short Form Health Survey (SF-12), and the Expected Outcomes and Barriers for Habitual Exercise scale. Exercise activity was based on verbal report of participation in aerobic exercise (walking, swimming, biking, or jogging). RESULTS: There was sufficient evidence of internal consistency (alpha = 0.92), and a squared multiple correlation coefficient using structural equation modeling provided further evidence of reliability (R2 ranged from 0.38 to 0.76). There was evidence of validity of the measure based on hypothesis testing: Mental and physical health scores on the SF-12 predicted efficacy expectations, and efficacy expectations predicted exercise activity. Lambda X estimates (all estimates > or = 0.81) provided further evidence of validity. CONCLUSION: Preliminary testing provided evidence for the reliability and validity of the SEE scale. Future testing of the scale needs to be done with young old adults and subjects from different socioeconomic and cultural groups.

Path analysis of efficacy expectations and exercise behaviour in older adults.

The benefits of regular exercise for older adults are well documented and include improvements in physical, functional, as well as psychological, health. The purpose of this descriptive study was to test a theoretically and empirically based model describing the factors that influence exercise behaviour of older adults in the United States of America. The hypothesized model suggested that age, gender, and mental and physical health have an effect on self-efficacy and outcome expectations, and that all these variables influence exercise behaviour. Exercise behaviour was hypothesized to have a reciprocal relationship with self-efficacy expectations and mental and physical health. The convenience sample was 187 older adults living in a continuing care retirement community (CCRC) in Baltimore, Maryland. A one-time health interview was conducted which included a measure of self-efficacy and outcome expectations related to exercise, a measure of health status (SF-12), and gathering of information from participants about their actual exercise behaviour. Of the 187, 71 (38%) reported participating in 20 minutes of continuous aerobic exercise at least three times per week over the previous 3 months. Six hypothesized paths were significant. The model fitted the data and accounted for 32% of the variance in exercise behaviour. Interventions that focus on strengthening self-efficacy and outcome expectations can improve exercise behaviour in older adults.

Common trisomy mosaicism diagnosed in amniocytes involving chromosomes 13, 18, 20 and 21: karyotype-phenotype correlations.

Karyotype-phenotype correlations of common trisomy mosaicism prenatally diagnosed via amniocentesis was reviewed in 305 new cases from a collaboration of North American cytogenetic laboratories. Abnormal outcome was noted in 10/25 (40%) cases of 47,+13/46, 17/31 (54%) cases of 47,+18/46, 10/152 (6.5%) cases of 47,+20/46, and in 49/97 (50%) cases of 47,+21/46 mosaicism. Risk of abnormal outcome in pregnancies with less than 50% trisomic cells and greater than 50% trisomic cells were: 26% (4/15) versus 60% (6/10) for 47,+13/46, 52% (11/21) versus 75% (6/8) for 47,+18/46, 4.5% (6/132) versus 20% (4/20) 47,+20/46, and 45% (27/60) versus 59% (22/37) for 47,+21/46. Phenotypically normal liveborns were observed with mean trisomic cell lines of 9.3% for 47,+13/46, 8.6% for 47,+18/46, 27% for 47, +20/46, and 17% for 47,+21/46. Cytogenetic confirmation rates were 46% (6/13 cases) for 47,+13/46 mosaicism, 66% (8/12 cases) for 47, +18/46, 10% (10/97 cases) for 47,+20/46, and 44% (24/54 cases) for 47,+21/46. There were higher confirmation rates in pregnancies with abnormal versus normal outcome: 50% versus 44% for 47,+13/46 mosaicism, 100% versus 33% for 47,+18/46, 66% versus 7% for 47, +20/46, and 55% versus 40% for 47,+21/46. Repeat amniocentesis is not helpful in predicting clinical outcome. It may be considered when there is insufficient number of cells or cultures to establish a diagnosis. Fetal blood sampling may have a role in mosaic trisomy 13, 18, and 21 as the risk for abnormal outcome increases with positive confirmation: 1/5 (20%) normal cases versus 5/8 (62%) abnormal cases. High resolution ultrasound examination(s) is recommended for clinical correlation and to facilitate genetic counselling.

Factors associated with outcomes 3 months after implantable cardioverter defibrillator insertion.

BACKGROUND: Adjustment to living with an implantable cardioverter defibrillator (ICD) is a dynamic process that varies among individuals. The purpose of this study was to describe patterns of recovery and to examine the relationships among demographic and clinical factors, illness appraisal and coping behaviors, and outcomes of physical and emotional function in the early recovery period of the first 3 months after initial ICD insertion. METHODS: Data were collected in the acute care setting and again at 1 and 3 months after ICD insertion. Subjects were 213 patients (83% men), ages 24-85 (mean 59.6) years. Demographic and clinical variables representing personal and situational factors, illness appraisal, and coping variables were examined using hierarchical multiple-regression analyses to predict outcomes of mood disturbance and functional status. RESULTS: The data revealed that symptoms, illness appraisal, and coping behaviors significantly explained additional variance in both functional status and mood disturbance above that accounted for by the less modifiable demographic and clinical variables. CONCLUSIONS: Symptoms, illness appraisal, and coping behaviors were predictors of outcomes in ICD patients. These factors are modifiable aspects of the recovery process, and interventions aimed at symptom management, appraisal reframing, and coping training should be tested to improve mood and functional outcomes for ICD patients.

Association of mood disturbance and arrhythmia events in patients after cardioverter defibrillator implantation.

BACKGROUND: Life stresses and negative emotions, such as anxiety and depression, are associated with adverse cardiac events, including arrhythmia. Patients undergoing implantation of an automatic internal cardioverter defibrillator provide a unique opportunity to characterize these relationships since all tachyarrhythmia episodes are recorded by the device. OBJECTIVES: The purpose of this study was to examine the association of emotional status after internal cardioverter defibrillator (ICD) implantation and subsequent arrhythmia events. METHODS: An analysis of data obtained in a prospective longitudinal study of responses to the ICD measured mood disturbance (Profile of Mood States; POMS) before implant and at 1, 3, 6, and 9 months postoperatively. Subjects included 144 men and 32 women with a mean age of 60 +/- 13 years and a mean left ventricular ejection fraction (LVEF) of 33 +/- 12%. Arrhythmia events were measured by self-report of shocks and by ICD device interrogation to obtain the number and type (defibrillation, cardioversion, and antitachycardia pacing) of therapies delivered by the ICD. For each time point, POMS scores of subjects who had arrhythmia events were compared with those who did not. For subjects who had ICD shocks, pre-event and post-event POMS scores were also compared. Multiple logistic regression was used at each time point to determine if clinical, demographic and psychological data could predict arrhythmia events. RESULTS: Patients with arrhythmia events had higher POMS scores throughout the 9 months of follow-up. Higher level of mood disturbance (specifically anxiety, fatigue, and confusion) at 1 and 3 months were independent predictors of subsequent arrhythmia events at 3 and 6 months after controlling for LVEF, the presence of coronary artery disease, pre-implant arrhythmia history, and the use of amiodarone and beta-blocking agents. There were no differences in POMS scores before and after ICD shocks, reinforcing the notion that negative emotions were a cause, rather than a consequence, of arrhythmia events. CONCLUSIONS: Mood disturbances, such as anxiety, may increase the risk for arrhythmia events after ICD insertion.

The Ablate and Pace Trial: a prospective study of catheter ablation of the AV conduction system and permanent pacemaker implantation for treatment of atrial fibrillation. APT Investigators.

BACKGROUND: The Ablate and Pace Trial (APT) prospectively assessed the effects of catheter ablation of the AV conduction system and permanent pacemaker implantation on health-related quality of life, survival, exercise capacity, and ventricular function in 156 patients with symptomatic atrial fibrillation. METHODS: All patients referred for catheter ablation and permanent pacemaker implantation because of medically-refractory atrial fibrillation at 16 centers were screened for enrollment in a prospective registry. Baseline assessment prior to ablation included measurement of quality of life, including the Health Status Questionnaire, the Quality of Life Index and the Symptom Checklist: Frequency and Severity. Exercise capacity was assessed with metabolic treadmill exercise testing and ventricular function was quantitated with echocardiography. The quality of life instruments, exercise capacity, and echocardiography were repeated at 3 and 12 months after catheter ablation. RESULTS: The APT population included 90 men and 66 women (66.1 +/- 11.5 years of age) with either chronic (n = 70), recurrent (n = 31), or paroxysmal atrial fibrillation (n = 55). Structural heart disease was present in 78.2% of patients. Successful ablation of AV conduction was achieved in 155 of 156 patients (99.4%). Survival at 1 year was 85.3%, with 5 of 23 deaths being sudden cardiac deaths. Survival over the first year of follow-up was significantly lower for patients with a baseline left ventricular ejection fraction (LVEF) < 0.45 (0.73) than for patients with a LVEF > or = 0.45 (0.88, p = 0.03). The NYHA functional class improved from 2.1 at baseline to 1.8 at 3 months and 1.9 at 12 months of followup (p = 0.0001). Significant improvement in quality of life scores were noted for all 8 subscales of the Health Status Questionnaire, for the overall rating of the Quality of Life Index, the Health and Function subscales; Arrhythmia-related symptoms were markedly reduced as measured by the Symptom Checklist: Frequency and Severity scale. The mean LVEF improved from 0.50 +/- 0.20 at baseline to 0.54 +/- 0.20 at 3 months (p = 0.03). The LVEF 12 months after ablation was 0.52 +/- 0.20, not statistically different from baseline. Individuals with reduced systolic function at baseline had the greatest improvement, from LVEF 0.31 +/- 0.20 at baseline to 0.41 +/- 0.20 at 3 months and 0.41 +/- 0.30 at 12 months (p = 0.0001). There were no significant changes in treadmill exercise duration (10.0 +/- 4.3 min at baseline and 11.6 +/- 3.6 min at 12 months) or VO2max (1467 +/- 681 ml O2 min baseline and 1629 +/- 739 ml O2 min at 12 months). CONCLUSIONS: Catheter ablation of the AV conduction system and permanent pacemaker implantation were associated with improved quality of life and left ventricular function in this population of highly symptomatic patients with atrial fibrillation refractory to medical therapy.

Quality of life at baseline: is assessment after randomization valid? The AVID Investigators. The Antiarrhythmics Versus Implantable Defibrillators.

OBJECTIVES: The purpose of this report is to examine whether differences existed between patients who completed a baseline quality of life (QoL) form before being informed about their randomized assignments versus those who completed it after knowing their randomization assignments. METHODS: In the pilot phase of the Antiarrhythmics Versus Implantable Defibrillators (AVID) study (n = 200), 113 patients completed a baseline QoL battery prior to randomization (drug versus defibrillator), 49 additional patients completed this battery after randomization, and 38 patients did not complete this battery. Baseline demographic, clinical and QoL data were compared for these groups. RESULTS: Although the two groups with QoL data were not significantly different regarding various clinical and demographic characteristics, they did have significantly different QoL profiles. Patients with QoL collected before randomization had better overall QoL scores and mental health scores. CONCLUSIONS: These data suggest that patients with worse QoL may be less willing to complete a baseline QoL form in a timely manner or that knowledge of the randomization assignment may have an effect on QoL.

Self-efficacy expectation, behavior performance, and mood status in early recovery from percutaneous transluminal coronary angioplasty.

OBJECTIVE: To describe levels of self-efficacy expectation and performance of selected cardiac recovery behaviors and mood state in patients recovering from percutaneous transluminal coronary angioplasty (PTCA) and to describe the nature of the relationships among these variables. DESIGN: Descriptive, correlational. SETTING: Hospital (postprocedure, predischarge) and home (2 weeks postdischarge). MEASURES: Jenkins Self-Efficacy Expectation Scales and Activity Checklists for Walking Various Distances, Following a Dietary Restriction, Maintaining Health, Resuming Roles and Working; and the Profile of Mood States (POMS) Inventory (McNair, Lorr, and Doppleman). PATIENTS: Adult patients (N = 90; 79% men; mean age = 61 years; 50% working preprocedure) who had undergone a PTCA (first procedure 71.1% and elective procedure 77.8%). Mean hospital stay was 3.9 days. RESULTS: Mean self-efficacy expectation scores were moderately high postprocedure for all behaviors and all, except scores for role resumption, increased significantly (p < 0.01) by 2 weeks postdischarge. Self-efficacy expectation scores were significantly and positively related to behavior performance for all study behaviors except work at 2 weeks, with r values ranging from 0.26 to 0.85. Mean total mood state (POMS) scores improved significantly (p < 0.01) over the 2-week period. Those with higher efficacy expectation scores tended to have higher behavior performance scores and lower levels of mood disturbance. It was noted that the level of mood disturbance was low at both data collection points. CONCLUSIONS: These findings demonstrate the predictive ability of self-efficacy expectation related to behavior performance and describe the relationships of these variables with total mood state as measured by the POMS. Clinical implications drawn from these findings support the individualization of patient teaching needed for this population and point to the need for further research, including development of more clinically useful instruments for assessing these variables.

Correlates of self-efficacy expectation and prediction of walking behavior in cardiac surgery elders.

As the number of elderly patients undergoing cardiac surgery (coronary artery bypass and valve replacement) continues to increase, evidence is growing that they can do so with improved health status, functional status, longevity, and life quality. In this article, we used self-efficacy theory to explore one of the most common recovery behaviors--walking various distances. In preoperative data collected in-hospital through data collection at one, two, three, six, and twelve months postoperatively, we explored: (a) the trajectories of self-efficacy expectation (SEE) and self-reported (SR) behavior performance over the first postoperative year; (b) the relationships between SEE and SR behavior; (c) predictors of SEE; and (d) using hierarchical multiple regression, identified predictors of SR behavior at each point of time. The sample (N = 199) was primarily male (76%) with a mean age of 75.8 years. SEE and SR behavior increased over time though with different trajectories; at all points in time, females had lower scores. Correlations between SEE and SR behavior were statistically significant (r values ranging from 0.67 to 0.89; p < .01) for both males and females. Predictors of SEE and SR identified were a mix of physiologic and psychologic constructs. The amount of explained variance in SR behavior scores ranged from a low of 23% at one month to a high of 64.7% at six months. The gender differences sustained one year after cardiac surgery are striking; elder females may need targeted interventions to enhance recovery.

Factors influencing exposure of children to major hazards on family farms.

On family farms, parents are usually knowledgeable of high-risk activities, yet they allow their children to be active participants in (or bystanders to) hazardous work for reasons not well-documented. A two-phase descriptive study, based on the theory of planned behavior and using mail survey research methods, was carried out to understand factors that influence parents' decisions to expose children to major hazards on family farms. A representative sample of 1,255 Wisconsin dairy farm fathers provided data about factors that influence their decisions to expose children younger than 14 years to risks of injury. Multivariate analyses revealed that attitudes, subjective norms, and perceived control accounted for up to three-fourths of the variance in fathers' behavioral intentions. Fathers' attitudes were stronger predictors of behavioral intentions than subjective norms (i.e., perceived social pressure) or perceived control. Grandparents and mothers exerted a limited influence. Other groups, such as health care providers, 4-H, Future Farmers of America, and insurers, exerted only a modest influence on fathers' feelings of social pressure. Few demographic characteristics of the family or farm were predictive of fathers' intentions to expose children to hazards.

Rare trisomy mosaicism diagnosed in amniocytes, involving an autosome other than chromosomes 13, 18, 20, and 21: karyotype/phenotype correlations.

In order to determine the significance of trisomy mosaicism of an autosome other than chromosomes 13, 18, 20, and 21, 151 such cases diagnosed prenatally through amniocentesis were reviewed. These rare trisomy mosaicism cases include 54 from 17 cytogenetic laboratories, 34 from a previous North American mosaicism survey, and 63 from published reports. All were cases of true mosaicism with information available on pregnancy outcome, and with no evidence of biased ascertainment. There were 11 cases of 46/47, +2; 2 of 46/47, +3; 2 of 46/47, +4; 5 of 46/47, +5; 3 of 46/47, +6; 8 of 46/47, +7; 14 of 46/47, +8; 25 of 46/47, +9; 2 of 46/47, +11; 23 of 46/47, +12; 5 of 46/47, +14; 11 of 46/47, +15; 21 of 46/47, +16; 7 of 46/47, +17; 1 of 46/47, +19; and 11 of 46/47, +22. As to the risk of an abnormal outcome, the data showed a very high risk (> 60 per cent) for 46/47, +2, 46/47, +16, and 46/47, +22; a high risk (40-59 per cent) for 46/47, +5, 46/47, +9, 46/47, +14, and 46/47, +15; a moderately high risk (20-39 per cent) for 46/47, +12; a moderate risk (up to 19 per cent) for 46/47, +7 and 46/47, +7 and 46/47, +8; a low risk for 46/47, +17; and an undetermined risk, due to lack of cases, for the remaining autosomal trisomy mosaics. Most cases were evaluated at birth or at termination, so subtle abnormalities may have escaped detection and developmental retardation was not evaluated at all. Comparison of the phenotypes of prenatally diagnosed abnormal cases and postnatally diagnosed cases with the same diagnosis showed considerable concordance. Since the majority of anomalies noted are prenatally detectable with ultrasound, an ultrasound examination should be performed in all prenatally diagnosed cases. In cytogenetic confirmation studies, the data showed much higher confirmation rates in cases with abnormal outcomes than in cases with normal outcomes [81 per cent vs. 55 per cent for fibroblasts (from skin, fetal tissue, and/or cord); 88 per cent vs. 46 per cent for placental cells; 22 per cent vs. 10 per cent for blood cells]. The confirmation rate reached 85 per cent when both fibroblasts and placental tissues were studied in the same case (with trisomic cells found in one or the other, or both). Therefore, one must emphasize that both fibroblasts and placental tissues should be studied. Except for 46/47, +8 and 46/47, +9, PUBS is of limited value for prenatal diagnosis of rate trisomy mosaicism. DNA studies for UPD are suggested for certain chromosomes with established imprinting effects, such as chromosomes 7, 11, 14, and 15, and perhaps for chromosomes 2 and 16, where imprinting effects are likely.

Quality of life in patients with atrial fibrillation.

Quality of life is discussed with focus on the importance of individual patient perspectives. Eight studies including at least one aspect of quality of life in patients with atrial fibrillation are reviewed with three approaches evident in assessing quality of life: patient interview, self-reported symptoms, and multidimensional assessment. What has been learned about quality of life to date has been from generally highly symptomatic patients refractory to traditional pharmacotherapy; no studies describe quality of life in minimally symptomatic patients with atrial fibrillation. Rationale for extending this knowledge is discussed.

Reduction of the current of injury leaving the amputation inhibits limb regeneration in the red spotted newt.

Immediately following amputation of the limb in salamanders, a strong, steady, and polarized flow of ionic current is produced by the injury. Current flows in a proximodistal direction within the limb stump and is associated with a fall in electrical potential of about 50 mV/mm near the stump's end. This current is electrogenically driven by the Na(+)-dependent, internally positive transcutaneous voltage of the intact skin of the limb stump. Reduction of this EMF, the skin's battery, by topical application of Na+ blocking agents leads to inhibition or disruption of normal limb regeneration. This suggests electrical factors are a critical control of limb regeneration. Here we test another means to reduce the injury current and its associated electrical field within the forelimb stump of red spotted newts. A fine (40 gauge), insulated, multistrand wire was inserted beneath the skin of the animal's back, with the uninsulated portion terminating either at the shoulder region or at the base of the tail. When this cathodal (negative) electrode is connected to a regulated current source, sufficient current was pulled into the stump end from an external anode (placed in the water the animal was immersed in) to markedly reduce or null the endogenous current for the first 8 days following amputation. The extent of limb regeneration in sham-treated and experimentally treated animals was determined 1 month following amputation at the elbow. Sham-treated animals regenerated normally, with most producing digits within this time. Limb regeneration was completely arrested, or caused to be strikingly hypomorphic, in half of the experimentally treated animals. This effect was independent of where the subcutaneous electrode was placed and suggests that electrical (physiological) factors are indeed a critical control of limb regeneration in urodeles.