A novel principle for assessment of stimulated fibrinolysis.

After venous occlusion (VO), D-dimer levels were measured by means of an ELISA technique, in citrated plasma clotted by thrombin and in serum from whole blood. D-dimer levels increased with duration of incubation (30 min to 24 hours). D-dimer values, both in clotted plasma and in serum (n = 12), incubated 4 hours at room temperature, correlated well with euglobulin clot lysis time (ECLT) (r = -0.85 and -0.89, respectively, p less than 0.002) and tissue plasminogen activator (t-PA) activity, (r = 0.82 and 0.83, respectively, p less than 0.002). D-dimer concentrations from plasma and serum (n = 25) were compared (r = 0.90, p less than 0.001). Healthy volunteers (n = 65) were tested to establish reference values in serum from post-occlusive whole blood samples incubated 4 hours prior to centrifugation. Finally, a patient group (n = 62) was examined. For the whole material (n = 152) such D-dimer concentrations correlated well with both ECLT (r = -0.85, p less than 0.001) and t-PA activity (r = 0.81, p less than 0.001). D-dimer levels in serum were determined by a latex agglutination test as well. These semi-quantitative values also correlated significantly with both ECLT (r = -0.86, p less than 0.001) and t-PA activity (r = 0.87, p less than 0.001). We conclude that measurement of D-dimer as described above, represents a simple and accurate method for assessment of global fibrinolytic activity following VO. The latex agglutination test is particularly suitable as a screening procedure.

Comparison of thrombin-antithrombin complex (TAT) levels and fibrinopeptide A following thrombin incubation of human plasma using hirudin as an inhibitor of TAT formation.

Following incubation of citrated plasma with human thrombin, the interaction of thrombin with antithrombin III was measured as thrombin-antithrombin complex (TAT) concentration. Comparison was made to thrombin activity on fibrinogen, assayed as fibrinopeptide A (FPA). Light scattering studies were included to evaluate polymerization of fibrin. Hirudin, at a final concentration of 100 U/ml, effectively inhibited TAT generation at final thrombin concentrations below 0.4 NIH U/ml. Hirudin by itself did not affect the TAT ELISA analysis. TAT and FPA values correlated closely (r = 0.83, p less than 0.001) and may equally well represent in vitro thrombin activity.

Can psychological traits predict the outcome of lumbar disc surgery when anamnestic and physiological risk factors are controlled for? Results of a prospective cohort study.

In a prospective study 122 patients with herniated lumbar disc pre-operatively completed psychological questionnaires. Surgical outcome was evaluated 12 months post-operatively mainly by a composite clinical overall score (COS), and by its separate elements. Anxiety (HAD-A scale) and psychosomatic symptoms (MSPQ) had predictive value: fewer symptoms favoured a satisfactory overall outcome, and vice versa. The HAD-A Scale had a predictive power of poor (ppp) and satisfactory (pps) outcome of 28 and 81%, respectively. Correspondingly, for the MSPQ, the ppp and pps were 42 and 85%. Anamnestic and biological variables (including fibrinolytic variables: ECLT and PAI-1) predicted 20% of the outcome. By adding all psychological variables the prediction increased only to 24%, but the HAD-A Scale and the MSPQ were still significant. The results suggest that in order to further improve prediction of outcome, future studies should combine biological variables sensitive to the mental state of the patient, with psychometric assessments.

Influence of fibrinolytic factors on scar formation after lumbar discectomy. A magnetic resonance imaging follow-up study with clinical correlation performed 7 years after surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To assess the amount of scar tissue by viewing magnetic resonance images, and to evaluate the correlation between the amount of scar tissue and clinical outcome, surgical technique, and fibrinolytic factors. SUMMARY OF BACKGROUND DATA: The influence of fibrinolytic factors on magnetic resonance images has not been investigated previously. The relation between clinical outcome and findings on magnetic resonance imaging remains uncertain. METHODS: Magnetic resonance imaging at 0.5 Tesla was performed to produce sagittal and axial spin-echo T1-weighted images before and after contrast enhancement on 78 patients 7 years after traditional lumbar discectomy with partial or full laminectomy. Before surgery all patients had been tested for fibrinolytic factors. RESULTS: The overall clinical success rate of the surgery was 73%. No evidence of scar formation was seen in 19 patients, a small amount was seen in 36 patients, a moderate amount in 17 patients, and a large amount was observed in 6 patients. Ten patients who had undergone surgery at two disc levels and 18 who had been treated with full laminectomy exhibited more scar tissue than those patients who had undergone surgery on a single level (P = 0.033) and those who had undergone a partial laminectomy, respectively (P = 0.017). The amount of scar formation also was associated with a poor outcome (P = 0.017) and with low preoperative values of tissue plasminogen activator antigen (P = 0.003) and tissue plasminogen activity (P = 0.048) in samples collected after venous occlusion. The intensity of contrast enhancement, however, was not influenced by these or any other parameters. CONCLUSION: The amount of scar formation after lumbar discectomy seems to be related to the clinical outcome, the size of the surgical exposure, and some fibrinolytic factors.

Fibrinolytic activity as a predictor of the outcome of prolapsed intervertebral lumbar disc surgery with reference to background variables: results of a prospective cohort study.

In a prospective study 122 patients with a slipped lumbar disc and no previous surgery were preoperatively examined for fibrinolytic activity. Surgical results for these patients were evaluated 12 months postoperatively by clinical overall assessment. In a multiple linear regression analysis fibrinolytic variables, euglobulin clot lysis time and plasminogen activator inhibitor 1, were shown to have predictive value regarding outcome of surgery; that is, normal fibrinolytic activity favors a satisfactory outcome and vice versa. Background variables and lipid profile were also recorded preoperatively. Body mass index, gamma-glutamyl transpeptidase, triglycerides and smoking were of statistical significance in relation to euglobulin clot lysis time and plasminogen activator inhibitor 1. Postoperative fibrinolytic re-examination of 20 patients seem to confirm that patients at risk of surgical failure have a prolonged depression of fibrinolytic activity.

Mapping the literature of dental hygiene.

Despite the long history of the dental hygiene profession, little research has been conducted on the characteristics of its literature. In this study, the bibliometric method was used to identify the core journals in the discipline and the extent of indexing of these journals. The study was a part of the Medical Library Association (MLA) Nursing and Allied Health Resources Section's project to map the allied health literature. Five journals were found to provide one-third of all references studied. Forty-two journals yielded an additional one-third of the references. MEDLINE had the best indexing coverage with 87% of the journals receiving indexing for at least one-half of the articles included. Limited coverage was provided by EMBASE/Excerpta Medica (11%) and the Cumulative Index to Nursing and Allied Health Literature (9%). The findings identified titles that should be added by indexing services as well as those that should have more complete coverage.

Introducing Health Workers for Change: from transformation theory to health systems in developing countries.

This introductory paper provides the theoretical basis behind the Health Workers for Change methodology, and the role of interactive, participatory learning approaches in promoting social change. The methodology has its origins in Latin America and Kenya, where participatory research methods have been used widely to raise social consciousness and promote change. The paper discusses the resistance of health institutions to participatory ways of learning and the reasons why this occurs. It also presents the logic for the subsequent papers in this special issue and provides a summary of their respective contributions.

Evidence of decreased fibrinolytic activity in hypertensive premenopausal women.

In 29 lean, premenopausal, never-treated hypertensive women (142 +/- 2/93 +/- 1 mmHg, mean +/- SEM) plasminogen activator inhibitor (PAI-1) was elevated (11.0 +/- 1.5 U/ml vs 6.3 +/- 1.0 U/ml, p less than 0.05) compared to healthy, normotensive women (113 +/- 2/71 +/- 2 mmHg). Euglobulin clot lysis time tended to be longer in the hypertensive than in the normotensive women (p = 0.06). PAI-1 was positively correlated to triglycerides (r = 0.60, p less than 0.001), haematocrit (r = 0.45, p less than 0.05), insulin (r = 0.38, p less than 0.05) and body mass index (r = 0.38, p less than 0.05), and inversely correlated to HDL cholesterol (r = -0.43, p less than 0.05) in the hypertensive women. Fibrinogen was not significantly different in the hypertensive and normotensive women, while the hypertensive smokers had higher fibrinogen than the hypertensive non-smokers (3.01 +/- 0.17 g/l vs 2.54 +/- 0.10 g/l, p less than 0.05). All participants were investigated in the same phase of the menstrual cycle. Despite that, oestradiol was significantly lower in the hypertensive than in the normotensive women (0.57 +/- 0.06 vs 0.81 +/- 0.09 nmol l-1, p less than 0.05), while progesterone was similar in the two groups. These results suggest that premenopausal, never-treated hypertensive women are characterized by low oestradiol levels as well as decreased fibrinolytic activity. PAI-1 seems to be associated with other risk factors for cardiovascular disease in hypertensive women.

[Idiopathic hypereosinophilic syndrome. Two patients with multiple organ damage]. / Idiopatisk hypereosinofilt syndrom. To pasienter med affeksjon av flere organer.

The idiopathic hypereosinophilic syndrome is a disorder characterized by sustained overproduction of eosinophils with undetectable etiology in addition to specific organ damage. Multiple organ systems may be involved in this condition, including the heart, lungs, skin and nervous system. The most important cause of mortality is myocardial involvement combined with valvular insufficiency. However, the prognosis for these patients has been to a large extent improved by greater awareness of this condition, combined with better surgical techniques. We describe two cases that illustrate the complex clinical situations that may be encountered in these patients.

Seven-year clinical follow-up after lumbar disc surgery: results and predictors of outcome.

This study evaluates the 7-year outcome of lumbar disc surgery and the predictive value of pre- and perioperative risk factors. The 7-year follow-up rate of a sample of 122 patients was 93% (n = 114). Six per cent of the patients had undergone repeat surgery. Approximately 90% reported that they were satisfied with having undergone surgery. The clinical outcome was evaluated in 96 patients (54 men and 42 women) by means of patient-scores (VAS) of low back and leg pain, and a Clinical Overall Score (COS). In multivariate regression analyses, women were shown to have poorer outcome than men. Preoperative psychological distress and impaired fibrinolytic activity were predictors of poor 7-year outcome. Age, weight, smoking habits and physical fitness had no statistically significant prognostic value. Whether the patients were operated for one or two herniated discs, or whether surgery involved a full or partial laminectomy, did not influence the outcome significantly.

Optimal assessment of gastrointestinal side effects induced by non-steroidal anti-inflammatory drugs. Endoscopic lesions, faecal blood loss, and symptoms not necessarily correlated, as observed after naproxen and oxindanac in healthy volunteers.

Gastrointestinal side effects caused by naproxen and oxindanac (a developmental non-steroidal anti-inflammatory drug) were compared by combined endoscopy and determination of faecal blood loss in 16 healthy male volunteers in a randomized, double-blind, crossover study. Individual daily faecal blood loss was determined by means of 51Cr-labelled erythrocytes. Gastroduodenoscopy was performed before and after administration of naproxen, 750 mg/day, and oxindanac, 600 mg/day, for 1 week each. A washout period of at least 3 weeks was inserted between drug periods. Visual analogue scales (VAS) were used for endoscopic assessment of lesions and subjective complaints. Mean faecal blood loss increased from a base line 0.48 ml/24 h to 1.59 ml/24 h with naproxen (p less than 0.01) and from 0.56 ml/24 h to 1.31 ml/24 h with oxindanac (p less than 0.01). VAS scores for gastroduodenal lesions increased significantly with both drugs. Naproxen caused a significantly greater increase than oxindanac (p less than 0.05). There was no correlation between gastrointestinal blood loss and endoscopic findings. Subjective symptoms were correlated to faecal blood loss with naproxen, but not to endoscopic findings. No such correlations were observed for oxindanac. Naproxen caused a significant prolongation of bleeding time (p less than 0.01), whereas the increase caused by oxindanac was not significant (p = 0.09).

Evaluating the community education programme of an insecticide-treated bed net trial on the Kenyan coast.

Increased interest in the potential contribution of insecticide-impregnated bed nets (ITBN) to malaria control has led to research efforts to determine the impact and sustainability of ITBN programmes in differing environments. There is a need to develop effective, feasible educational strategies that will both inform and motivate community members, and thus maximize the correct usage of ITBN. This is especially true in communities where indigenous usage of bed nets is low. This paper describes the educational component of a randomized controlled community intervention trial of ITBN, with childhood malaria morbidity as an outcome. The educational approach and messages for the ITBN trial were developed from anthropological survey data collected 4 years before the trial, and from community surveys conducted by project researchers. Low levels of understanding amongst mothers of the aetiological link between mosquitos and malaria led to the exclusion of the term 'malaria' from the initial educational messages promoting the use of ITBN. Appropriate individuals within the existing district health care structure were trained as community educators in the project. These educators conducted intensive teaching in the community through public meetings and group teaching in the first 6 months of the trial. The impact of these initial activities was assessed through interviews with a random sample of 100 mothers and 50 household heads. This allowed the identification of messages which had not been well understood and further educational methods were chosen to address the areas pinpointed. The community assessment also demonstrated that, in 1994, over 90% of mothers understood a protective role for bed nets against malaria and the ITBN education messages were changed to take account of this. The school programme was evaluated through determining outreach (the number of households accessed), changes in participant children's knowledge, post-teaching assessment of mothers' knowledge and discussions with parent-teacher associations. It was shown that 40% of intervention homes with children in the target group were accessed, participant children learned the educational messages well (scores increased from a pre-teaching mean of 59% to a post-teaching mean of 92%) and a high level of awareness of the ITBN trial was achieved in these homes (75%). However, specific messages of the education programmed were not well transferred to the home (30%). The discussion emphasises the need for allocation of adequate resources for education in programmes dependent on achieving a change in community practices. We also describe the value of ongoing communication between programme planners and a target population in maximizing the effectiveness of messages and methods used.

PIP: In Kenya, public health officers, public health technicians, and field staff implemented the education component of the insecticide-treated bed net (ITBN) trial in Kilifi District along the coast. The education strategy was based on anthropological survey data collected 4 years before the trial and from community surveys. It included teaching about the intervention to household heads at public meetings (June 1993), individual instruction at the time of bed net delivery (June-July 1993), follow-up education with bed net contacts in a small group format after net delivery (June-August 1993), follow-up education with mothers in a small group format after net delivery (September 1993), house-to-house education at the time of ITBN redipping (April-May 1994), and a teaching program in primary schools (June-July 1994). In September 1993, 98% of mothers understood the important of using bed nets year-round but 29% would not use them when it was too hot. Educators changed ITBN education messages to account for the high level of understanding about the importance of bed net use. Since mothers had low levels of understanding of the etiological link between mosquitoes and malaria, the educators excluded the term malaria from the initial educational messages promoting ITBN use. The researchers evaluated the school program through determining outreach (the number of households accessed), changes in participant children's knowledge, post-teaching assessment of mothers' knowledge, and discussions with parent-teacher associations. 40% of the intervention homes were accessed. Learning the educational messages progressed well with the participant children (mean score, 59% at pre-test and 92% at post-test). At the end of the school program, members of 75% of intervention homes were aware of the ITBN trial. Yet, only 30% of homes understood specific messages of the school program. In conclusion, there is a need for allocation of adequate resources for education to achieve a change in community practices and for ongoing communication to maximize the effectiveness of messages and methods used.

Background variables (medical history, anthropometric and biological factors) in relation to the outcome of lumbar disc surgery.

In a prospective cohort study 122 patients with herniated intervertebral lumbar disc and no previous low back surgery preoperatively were assessed regarding medical history, anthropometric and biological background variables. The outcome of surgery (traditional methods) was evaluated one year postoperatively, mainly using a composite Clinical Overall Score (COS), including pain intensity, physical signs, functional capacity and analgesics. Return to work was also assessed. In regression analyses, low body height, high values of weight and body mass index, as well as long duration of sickness absence were shown to be significantly related to a poor outcome, as evaluated by the COS. However, after controlling for modifying effects of previously determined predictive fibrinolytic and psychological variables, the background variables lost their significance. Female sex, low stature, long duration of sickness absence and physically strenuous work activities were statistically significantly related to lower frequencies of return to work.

Monday and non-Monday concentrations of lifestyle-related blood components in the Oslo Diet and Exercise Study.

OBJECTIVE: We hypothesized that participants of intervention studies have an unfavourable lifestyle at the weekend compared with the rest of the week, thus affecting the concentrations of components in samples drawn on Mondays. DESIGN: The hypothesis was examined using data from the Oslo Diet and Exercise Study, a 2 x 2 randomized intervention trial on diet and exercise involving 209 participants. Each person chose which day of the week to attend for blood sampling, both before and after the 1 year of intervention. MAIN OUTCOME MEASURES: Comparison of mean concentrations of the components measured, in samples drawn on Mondays vs. non-Mondays, both at the start and at the end of intervention. RESULTS: At the start, nine components, from haemostasis, carbohydrate and lipid metabolism, showed a difference of more than 10% between Monday and non-Monday values, all Monday values differing from the non-Monday values in a cardiovascularly unfavourable direction. Participants starting and ending on a Monday showed the unfavourable profile both times, and those who were examined both times on a non-Monday showed a consistently favourable profile, whereas those who changed the day of examination at the start and end changed profile accordingly. CONCLUSION: The lifestyle-related components examined here showed differences between Monday and non-Monday values, which were not due to a selection bias. We suggest they may be related to a different lifestyle at the weekend compared with ordinary working days. If such effects are not recognized and properly taken into account, they may markedly affect the outcome of intervention studies.

Changing home treatment of childhood fevers by training shop keepers in rural Kenya.

BACKGROUND: Malaria control in Africa relies primarily on early effective treatment for clinical disease, but most early treatments for fever occur through self-medication with shop-bought drugs. Lack of information to community members on over-the-counter drug use has led to widespread ineffective treatment of fevers, increased risks of drug toxicity and accelerating drug resistance. We examined the feasibility and measured the likely impact of training shop keepers in rural Africa on community drug use. METHODS: In a rural area of coastal Kenya, we implemented a shop keeper training programme in 23 shops serving a population of approximately 3500, based on formative research within the community. We evaluated the training by measuring changes in the proportions of drug sales where an adequate amount of chloroquine was purchased and in the percentage of home-treated childhood fevers given an adequate amount of chloroquine. The programme was assessed qualitatively in the community following the shop keeper training. RESULTS: The percentage of drug sales for children with fever which included an antimalarial drug rose from 34.3% (95% CI 28.9%-40.1%) before the training to a minimum of 79.3% (95% CI 71.8%-85.3%) after the training. The percentage of antimalarial drug sales where an adequate amount of drug was purchased rose from 31.8% (95% CI 26.6%-37.6%) to a minimum of 82.9% (95% CI 76.3%-87.3%). The percentage of childhood fevers where an adequate dose of chloroquine was given to the child rose from 3.7% (95% CI 1.2%-9.7%) before the training to a minimum of 65.2% (95% CI 57.7%-72.0%) afterwards, which represents an increase in the appropriate use of over-the-counter chloroquine by at least 62% (95% CI 53.7%-69.3%). Shop keepers and community members were strongly supportive of the aims and outcome of the programme. CONCLUSIONS: The large shifts in behaviour observed indicate that the approach of training shop keepers as a channel for information to the community is both feasible and likely to have a significant impact. Whilst some of the impact seen may be attributable to research effects in a relatively small scale pilot study, the magnitude of the changes support further investigation into this approach as a potentially important new strategy in malaria control.

Synthesis of silicon-based infrared semiconductors in the Ge-Sn system using molecular chemistry methods.

Growth reactions based on a newly developed deuterium-stabilized Sn hydride [(Ph)SnD(3)] with Ge(2)H(6) produce a new family of Ge-Sn semiconductors with tunable band gaps and potential applications in high-speed, high-efficiency infrared optoelectronics. Metastable diamond-cubic films of Ge(1-x)Sn(x) alloys are created by chemical vapor deposition at 350 degrees C on Si(100). These exhibit unprecedented thermal stability and superior crystallinity despite the 17% lattice mismatch between the constituent materials. The composition, crystal structure, electronic structure, and optical properties of these materials are characterized by Rutherford backscattering, high-resolution electron microscopy, and X-ray diffraction, as well as Raman, IR, and spectroscopic ellipsometry. Electron diffraction reveals monocrystalline and perfectly epitaxial layers with lattice constants intermediate between those of Ge and alpha-Sn. X-ray diffraction in the theta-2theta mode shows well-defined peaks corresponding to random alloys, and in-plane rocking scans of the (004) reflection confirm a tightly aligned spread of the crystal mosaics. RBS ion-channeling including angular scans confirm that Sn occupies substitutional lattice sites and also provide evidence of local ordering of the elements with increasing Sn concentration. The Raman spectra show bands corresponding to Ge-Ge and Sn-Ge vibrations with frequencies consistent with random tetrahedral alloys. Resonance Raman and ellipsometry spectra indicate a band-gap reduction relative to Ge. The IR transmission spectra suggest that the band gap decreases monotonically with increasing Sn fraction. The synthesis, characterization, and gas-phase electron diffraction structure of (Ph)SnD(3) are also reported.