Ideal Cardiovascular Health Index and Its Determinants in a Rural South African Population.

Background: The ideal cardiovascular health index (CVHI) is a measure to summarize cardiovascular (CV) health, and includes smoking, body-mass index, physical activity, blood pressure, glucose, total cholesterol, and diet. Objective: This study aimed to assess CV health using the CVHI and determinants on CV health in a rural African population, and correlate carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis, with CVHI. Methods: A cross-sectional analysis was performed on baseline data of the Ndlovu Cohort Study, located in rural South Africa. CVHI score (CVHIs) was calculated by the sum of favourable CVHI factors (range 0 to 7). Logistic regression was performed to examine the association of age, sex, HIV-status, education level, employment status, and income with good CV health (5-7 favourable health factors). Mean CIMT was displayed by poor, intermediate and good CV health. Results: The study included 1927 participants with a mean age of 38.7 years (SD ± 12.8). Of the factors contributing to the CVHI, glucose and total cholesterol scored best; diet least good. Average CVHIs for the population was 4.4 (SD ± 1.2) and 53% of the population had a good CV health. Determinants associated with good CV health were younger age, higher educational attainment, and HIV positivity. CVHIs showed good agreement with CIMT. Conclusion: CVHIs showed that more than half of the participants had a good CV health. Agreement between CVHIs and CIMT indicates potential use of CVHIs as a surrogate marker for CV risk. The study highlights the importance of education for health promotion; good CV health in HIV-positive participants may in part be attributed to more frequent health care contact and provision of chronic disease care. Highlights: Good cardiovascular health (CVH) was observed in 53% of the study population.In global comparison, rural African study participants showed a good CVH score.HIV positivity was associated with a good CVH score.CVH score showed good agreement with carotid intima-media thickness.

The Montreal Cognitive Assessment-Basic (MoCA-B) is not a reliable screening tool for cognitive decline in HIV patients receiving combination antiretroviral therapy in rural South Africa.

BACKGROUND: HIV-associated neurocognitive disorders (HAND) are frequently occurring comorbidities in HIV-positive patients, diagnosed by means of a neuropsychological assessment (NPA). Due to the magnitude of the HIV-positive population in Sub-Saharan Africa, easy-to-use cognitive screening tools are essential. METHODS: This was a cross-sectional clinical trial involving 44 HIV-positive patients (on stable cART) and 73 HIV-negative controls completing an NPA, the International HIV Dementia Scale (IHDS), and a culturally appropriate cognitive screening tool, the Montreal Cognitive Assessment-Basic (MoCA-B). HAND were diagnosed by calculating Z-scores using internationally published normative data on NPA, as well as by using data from the HIV-negative group to validate the MoCA-B. RESULTS: One hundred and seventeen patients were included (25% male, median age 35 years, median 11 years of education). A moderate correlation was found between the MoCA-B and NPA total Z-score (Pearson's r=0.36, p=0.02). Area under the curve (AUC) values for MoCA-B and IHDS were 0.59 and 0.70, respectively. The prevalence of HAND in HIV-positive patients was 66% when calculating Z-scores using published normative data versus 48% when using the data from the present HIV-negative cohort. CONCLUSION: The MoCA-B appeared not to be a valid screening tool for HAND in this setting. The prevalence of HAND in this setting is high, but appeared overestimated when using published norms.

[Mental and physical health problems of, and the use of healthcare by, Afghan, Iranian and Somali asylum seekers and refugees]. / Psychische en lichamelijke gezondheidsproblemen van en gebruik van zorg door Afghaanse, Iraanse en Somalische asielzoekers en vluchtelingen.

OBJECTIVE: To estimate the prevalence rates of mental and physical health problems and the use of healthcare services among adult asylum seekers and recognised refugees from Afghanistan, Iran and Somalia in the Netherlands. DESIGN: Cross-sectional study. METHOD: Asylum seekers were approached in 14 reception centres and refugees were interviewed in 3 municipalities (Arnhem, Leiden and Zaanstad). Respondents were interviewed in their own language and asked questions pertaining to: general health, chronic complaints, symptoms of post-traumatic stress disorder (PTSD), symptoms of depression/ anxiety, the use of healthcare services (general practitioner, medical specialists, hospitalisation, mental-health services, medication) and background variables. RESULTS: A total of 232 asylum seekers and 178 refugees participated (response rates of89% and 59%, respectively). Of these, 142 (61%) and 99 (56%), respectively were males and the average age was 34.4 (SD: 11.o) and 40.3 (SD: 13.3) years, respectively. Compared to refugees, asylum seekers more often considered their health to be poor (42% and 59%, respectively), had more symptoms of depression/anxiety (39% and 68%, respectively), and had more symptoms of PTSD (11% and 28%, respectively). No differences were found between refugees and asylum seekers in the self-reported use of healthcare services. CONCLUSION: This study showed that asylum seekers have more health problems than refugees, but that there are no differences in the self-reported use of healthcare services. More research is needed to answer the question ifasylum seekers have sufficient access to the healthcare system.

Prognostic value of the expression of p53, bcl-2, and bax oncoproteins, and neovascularization in patients with radically resected non-small-cell lung cancer.

PURPOSE: To assess the prognostic value of p53, bcl-2, bax, and neovascularization in radically resected non-small-cell lung cancer (NSCLC) patients. PATIENTS AND METHODS: Tumors from 116 patients were assessed by immunohistochemistry for expression of p53 (DO7 and PAb1081), bcl-2, and the quantification of microvessel density (CD-31). In addition, the expression of bax was assessed in 61 stage I tumors. The median levels of expression of each marker were used as cutoff points. RESULTS: p53 was not correlated to any patient or tumor characteristic, whereas bcl-2 showed higher expression in squamous cell carcinomas (P < .001). bax expression was significantly related with male sex (P = .006) and adenocarcinoma type (P = .0013). p53 status, assessed with one monoclonal antibody (MoAb), was not predictive for survival; however, the combination of staining results obtained with two MoAbs identified the DO7-/PAb1801+ tumors as those with the worst prognosis. bcl-2 expression was associated with longer survival in stage I patients (P = .0169). The combined group expressing p53+(PAb1801)/bcl-2- had the worst survival in stage I patients (P = .034) and in the whole series in comparison with the other combinations of the two oncoproteins. bax expression alone had no influence on survival of stage I patients, but patients with bax+/bcl-2- tumors had the worst prognosis (P = .02 in comparison with bax+/bcl-2+). Tumor neovascularization was not related with other factors, and patients with CD-31+ tumors had a shorter survival duration than those with CD-31- tumors only in stage II (P = .0283). By multivariate analysis including all patients, the presence of p53+/ bcl-2- tumor expression and large tumor diameter (> or = 4cm) were independent prognostic factors for shorter survival duration. For stage I, only the presence of bax+/ bcl-2- tumor expression had a significant negative influence on survival. CONCLUSION: The interaction and the regulation of new biologic markers, such as those involved in the apoptotic pathway, are complex. Combinations of the expression of several of them may give more valuable information than the study of just one. Prognostic influence of p53 staining varied depending on the choice of antibody and the combination of bcl-2- together with p53+ (PAb1801) or with bax+ had the worst influence on survival for patients with stage I NSCLC.

The differentiation inducing effect of bryostatin 5 on human myeloid blast cells is potentiated by vitamin D3.

Bryostatin 5 is a macrocyclic lactone which activates protein kinase C (PKC). PKC activation has been implicated in leukemic cell differentiation. We have examined the effect of PKC activation by bryostatin 5 on human acute myeloid cell differentiation in the presence and absence of vitamin D3. In vitro treatment of 20 patient samples of acute myeloid leukemias in a 4 days culture system with 10 nM bryostatin 5 induced strongly adherent macrophage-like cells in all cases. Bryostatin 5 induced a significant (p = 0.00006) increment in esterase activity in a majority of the samples, which was further enhanced by vitamin D3. CD14 expression was significantly (p = 0.035) enhanced with the combination of bryostatin 5 and vitamin D3. Nitroblue tetrazolium (NBT) reducing ability was, however, nearly abolished (p = 0.0007). A loss of CD34 expression occurred during cell culture; this loss was enhanced by vitamin D3, but prevented partly by bryostatin 5. Together these findings indicate that exposure to bryostatin 5 leads to a strong macrophage-like cell differentiation in human myeloid leukemia and that VD3 has an additional effect. These findings strengthen the potential role of bryostatins as possible antileukemic agents.

Nighttime insulin kinetics and glycemic control in type 1 diabetes patients following administration of an intermediate-acting lispro preparation.

OBJECTIVE: To determine insulin kinetics and overnight glycemic control after bedtime administration of a new intermediate-acting insulin preparation called neutral protamine lispro (NPL). RESEARCH DESIGN AND METHODS: We studied 12 patients with well-controlled type 1 diabetes. The study had a double-blind, randomized, crossover design. After a lead-in period of 10-14 days two experiments were carried out with an interval of 2-7 days. During these experiments overnight insulin kinetics and fasting blood glucose levels were studied after evening administration of NPH insulin and NPL. Blood glucose levels < 3.8 mmol/l were treated by means of a variable infusion of a 20% glucose solution. RESULTS: A trend toward a shorter time to peak insulin concentration was observed after administration of NPL (P = 0.07). No differences between NPH and NPL were detected in the total area under the curve (AUC) for insulin, in insulin levels before breakfast, or in glucose levels before breakfast (P = 0.5, 0.6, and 0.4, respectively). CONCLUSIONS: We detected no major differences between NPH and NPL in the total AUC for insulin, prebreakfast glucose levels, or prebreakfast insulin levels. Therefore, we conclude that NPH and NPL are equally effective in controlling overnight glycemia.

Well-being and symptoms in relation to insulin therapy in type 2 diabetes.

OBJECTIVE: To determine the influence of insulin therapy on physical symptoms, emotional and general well-being, and treatment satisfaction in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A descriptive prospective 2-year cohort study was performed. The study population consisted of 272 eligible NIDDM patients of Dutch origin > or = 40 years of age who had a known diabetes duration > or = 3 months and who were treated with diet and/or oral hypoglycemic agents. Dependent variables in the logistic regression analysis were scores on the Type 2 Diabetes Symptom Checklist, the Profile of Mood States, and questions regarding general well-being and treatment satisfaction. Potential determinants under study were age, sex, known diabetes duration, insulin dose, duration of insulin therapy, comorbidity, baseline and change in metabolic parameters and cardiovascular risk factors. RESULTS: A baseline and 2-year questionnaire were available for 157 patients (58%). During follow-up, 39 of them (24.8%) were treated with insulin. Initiation of insulin therapy was significantly associated with improved glycemic control (mean HbA1c 8.2 +/- 1.4 [SD] to 7.4 +/- 0.9%, P = 0.001) and weight gain (BMI 27.1 +/- 3.9 to 28.6 +/- 4.3 kg/m2, P = 0.000). Of all symptom and well-being scores, only feelings of emotional fatigue worsened significantly, although modestly (0.4-1.7 on a scale of 0.0-10.0, P = 0.02). Although diabetes management with insulin was experienced as more demanding (P = 0.04), treatment satisfaction scores were not adversely influenced (2.5-1.9, P = 0.39). High insulin doses were significantly and independently associated with high symptom scores (total score, hypoglycemic score) and with low mood (displeasure score, anger, tension, emotional fatigue) and perceived state of health. CONCLUSIONS: Initiation of insulin therapy in type 2 diabetes improves glycemic control effectively, has little influence on physical and psychological well-being dimensions, and does not affect treatment satisfaction.

Metabolic efficacy of preprandial administration of Lys(B28), Pro(B29) human insulin analog in IDDM patients. A comparison with human regular insulin during a three-meal test period.

OBJECTIVE: The objective of this study was to compare the efficacy of the rapid-acting Lys(B28), Pro(B29) human insulin analog, insulin lispro, with currently available short-acting human insulin in a multiple injection therapy (MIT) regimen with respect to blood glucose and plasma insulin profiles and to serum metabolites (lactate, free fatty acids, glycerol, and beta-hydroxybutyrate) in 12 well-controlled type 1 diabetic subjects (8 male, HbA1c 6.8 +/- 0.9% [mean +/- SD]). RESEARCH DESIGN AND METHODS: After a run-in period of 4 weeks, patients were treated with either lispro at mealtime or human insulin 30 min before the meal for two periods of 4 weeks in a randomized open-label crossover study. Intermediate-acting insulin (NPH insulin) was given at bedtime. At the end of both study periods, metabolic profiles were assessed from 10:00 P.M. to 7:00 P.M. the next day. RESULTS: During the treatment periods, glycemic control was stable during lispro but improved during human insulin (delta HbA1c lispro 0.1 +/- 0.48, NS; human insulin -0.41 +/- 0.34%, P < 0.05). Glucose excursions, as measured by the incremental AUC, during the day and for the 2-h postprandial periods, were lower, although not significantly, for lispro. Insulin profiles demonstrated a faster rise after administration of lispro as compared with human insulin, peaking at 61 +/- 11.9 and 111 +/- 48.1 min (P < 0.01). Glycerol levels showed a slight increase before lunch and dinner, suggestive of enhanced lipolytic activity and compatible with the lower insulin levels. CONCLUSIONS: Lispro insulin applied in an MIT regimen creates more physiologic insulin profiles and tends to lower the glycemic excursions during the day compared with short-acting insulin. The analog can be applied safely in an MIT regimen, with mealtime intervals up to 5 h.

Optimized basal-bolus therapy using a fixed mixture of 75% lispro and 25% NPL insulin in type 1 diabetes patients: no favorable effects on glycemic control, physiological responses to hypoglycemia, well-being, or treatment satisfaction.

OBJECTIVE: To investigate the effects of a multiple injection regimen with a mixture of 75% lispro and 25% intermediate-acting insulin (lispro high mixture [HM]) before meals on glycemic control, physiological responses to hypoglycemia, well-being, and treatment satisfaction. RESEARCH DESIGN AND METHODS: We studied 35 type 1 diabetes patients. After an 8- to 10-week lead-in period, patients were randomized to HM or human regular insulin therapy for 12-14 weeks. During the lead-in and treatment periods, HbA1c levels and hypoglycemic frequencies were measured, and patients completed the Well-Being Questionnaire and the Diabetes Treatment Satisfaction Questionnaire. In 19 patients, responses to hypoglycemia were tested during stepped euglycemic-hypoglycemic clamps. RESULTS: HM treatment improved postprandial glycemia but had no effect on HbA1c, frequency of hypoglycemia, well-being, or treatment satisfaction. During experimental hypoglycemia, HM therapy was associated with a slightly lower total adrenaline response and a higher autonomic symptom threshold (i.e., the autonomic symptom response occurred at a lower blood glucose level) than human regular insulin therapy. We speculate that this effect resulted from an accumulation of insulin during the night. CONCLUSIONS: Multiple injection therapy with HM rather than human regular insulin before meals does not offer advantages regarding glycemic control, frequency of hypoglycemia, well-being, or treatment satisfaction. In addition, this regimen causes an attenuation of the adrenaline and autonomic symptom responses to hypoglycemia.

The effect of one-year cross-sex hormonal treatment on bone metabolism and serum insulin-like growth factor-1 in transsexuals.

The effects of treatment with estrogens and antiandrogens in male to female (M-->F) transsexuals and androgens in female to male (F-->M) transsexuals on their respective bone metabolism, bone mineral density (BMD), serum insulin-like growth factor I (IGF-I) and IGF-binding protein-3 (IGFBP-3) levels were investigated. BMD and variables of bone turnover in serum were measured at baseline and after 3 months (except for BMD) and 1 yr of treatment in 56 M-->F and 35 F-->M transsexuals. Serum IGF-I, IGFBP-3, and propeptide of type I procollagen (P1CP) were measured at baseline and after 1 yr of treatment in 10 M-->F and 10 F-->M transsexuals. In M-->F, BMD increased significantly. Bone turnover decreased, as shown by a significant decline in levels of osteocalcin, alkaline phosphatase, P1CP, and fasting urinary calcium/creatinine and hydroxyproline/creatinine ratios. Serum IGF-I levels decreased significantly without significant changes in IGFBP-3 levels. In F-->M, BMD did not change. Bone formation increased, as suggested by an increase in alkaline phosphatase and a borderline increase in P1CP values. IGF-I levels increased significantly, whereas no significant changes were seen in IGFBP-3 levels. We conclude that in males, estrogens (in combination with antiandrogens) decrease bone turnover, with a subsequent increase in BMD and a decrease in serum IGF-I. In females, testosterone administration increases bone formation, but this is not reflected in an increased BMD, whereas serum IGF-I increases.

Diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography in the follow-up of papillary or follicular thyroid cancer.

Positron emission tomography with 18F-fluorodeoxyglucose is a relatively new nuclear imaging technique in oncology. We conducted a systematic review to determine the diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography in patients suspected of recurrent papillary or follicular thyroid carcinoma. Two reviewers independently selected, extracted, and assessed data from relevant literature found in computerized databases and by reference tracking. Prospective and retrospective studies with 10 human subjects, or more, that evaluated the accuracy of ring positron emission tomography, using 18F-fluorodeoxyglucose in follicular and papillary thyroid cancer, were included. Studies on 18F-fluorodeoxyglucose imaging using gamma cameras, reviews, case reports, editorials, letters, and comments were excluded. The methodological quality was assessed by applying the criteria for diagnostic tests recommended by the Cochrane Methods Group on Screening and Diagnostic Tests. A rating system was used for qualitative analysis consisting of four levels of evidence (1 = highest level; 4 = lowest level). Fourteen studies met the inclusion criteria. All studies claimed a positive role for positron emission tomography but, at evidence levels 3 or 4, precluding quantitative analysis. Methodological problems included poor validity of reference tests and a lack of blinding of test performance and interpretation. The reviewed material was heterogeneous with respect to patient variation and validation methodology. The most consistent data were found on the ability of 18F-fluorodeoxyglucose positron emission tomography to provide an anatomical substrate in patients with elevated serum Tg and negative iodine-131 scans. In conclusion, the results seem to support the potential of 18F-fluorodeoxyglucose positron emission tomography to identify and localize foci of recurrent cancer in the latter patient subset. However, implementation of positron emission tomography in a routine diagnostic algorithm requires additional evidence.

Risk factors for back pain incidence in industry: a prospective study.

The objective of this study was to examine the relationship between physical and psychological risk factors on the one hand, and the occurrence of new episodes of back pain on the other hand. A prospective study was conducted with 12 months follow-up by means of self-administered questionnaires. The study took place in the Cargo Department of a major Dutch airline company. The subjects for this study were 270 workers involved in heavy physical work. Only workers without back pain at baseline were included. Self-reported back pain and sick leave due to back pain during the follow-up period were measured. Of the 238 workers included in the analysis, 73 (31%) developed a new episode of back pain during the follow-up period, and 27 (11%) subjects reported sick leave due to back pain. Multiple logistic regression analysis showed that the history of back pain was the best predictor for the occurrence of a new episode of back pain during follow-up (OR 9.8; 95% CI 2.8-34.4 for subjects who had back pain more than twice in the past year). Low job satisfaction was also associated with an increased risk for the occurrence of back pain during follow-up (OR 1.2; 95% CI 1.01-1.4). Riding a forklift truck appeared to be a protective factor for the occurrence of back pain (OR 0.7; 95% CI 0.5-0.99). In this study the best predictors for the occurrence of back pain were the history of back complaints and low job satisfaction. Although it needs to be confirmed by future intervention studies, the results indicate that increasing job satisfaction may be a successful (co-)intervention for the prevention of back pain at the workplace.

Publications on diagnostic test evaluation in family medicine journals: an optimal search strategy.

Search strategies for articles reporting on diagnostic test evaluations have been subjected to less research than those in the domain of clinical trials. We set out to develop an optimal search strategy for publications on diagnostic test evaluations in general, that could be added to keywords describing the specific diagnostic test at issue. Nine Family Medicine journals were searched from 1992 through 1995 for primary publications on diagnostic test evaluation by hand searching and a Medline search strategy published earlier. Additionally, new search strategies have been developed with stepwise logistic regression, using Mesh terms and free text words related to diagnosis and test evaluation as independent variables. Hand searching identified 75 primary publications on diagnostic test evaluation from a total of 2467 primary publications. The previously published search strategy had a sensitivity of 73%, a specificity of 94%, and a positive predictive value of 29%. The most accurate new search strategy had a sensitivity of 80.0% (60/75; 95% CI: 71.0-89.1), a specificity of 97.3% (2327/2392; 95% CI; 96.6-97.9%), a positive predictive value of 48% (95% CI: 40-56) and diagnostic odds ratio of 149. All four new strategies used the Mesh term "sensitivity and specificity" (exploded with the Mesh terms "predictive value" and "ROC")and cumulatively added the text words "specificity," "false negative," "accuracy," and "screening." The search strategy using the Mesh term "sensitivity and specificity" (exploded) and the text words "specificity," "false negative," and "accuracy" has both higher sensitivity and specificity than the previously published strategy. The increase in specificity in three strategies reduces the absolute number of false-positive articles that have to be screened by 50-75%, compared to the number of false positives in the earlier strategy.

Atmospheric pressure changes and outdoor temperature changes in relation to spontaneous pneumothorax.

STUDY AIMS: To examine the influence of atmospheric pressure (AP) and temperature changes on the incidence of idiopathic spontaneous pneumothorax (SP). METHODS: From December 1991 through November 1993, 115 consecutive SP cases were selected. Patients were included after being in Amsterdam at least 1 full day before contracting the SP. Differences in air temperature and AP (provided hourly by the national weather bureau) for the days of the SP occurrence and the days previous to it were recorded to measure influences of air temperature and AP. The correlation between days with lightning and SP and clustering of SP was evaluated. RESULTS: SP occurred on 14.7% of the days in the 2-year period. There was no relationship between SP and a rise or fall in AP (Poisson regression). There was an average temperature rise of 0.57 degrees C from the day prior to the day of the SP, compared with a 0.08 degrees C fall on the days without SP. This difference is statistically significant and was consistent over the four seasons and both years. Seventy-three percent of the SP cases were clustered. A relationship between SP and thunderstorms was found. CONCLUSIONS: AP differences do not seem to influence the chance of developing SP. SP occurs in clusters, and more often 1 to 2 days after thunderstorms. Whether the identified temperature rise prior to the SP is a causative factor is unlikely; coexisting weather phenomena might explain this unexpected finding and should be studied in the future.

Serological markers to differentiate between ulcerative colitis and Crohn's disease.

AIM: To assess prospectively the value of three serological tests for differentiating between ulcerative colitis and Crohn's disease, used either alone or combined. METHODS: Coded serum samples from 63 patients with ulcerative colitis and 67 patients with Crohn's disease were analysed. Detection assays for the presence of perinuclear antineutrophil cytoplasmic antibodies (pANCA), serum agglutinating antibodies to anaerobic coccoid rods, and specific IgG antibodies against a Kd-45/48 immunological crossreactive mycobacterial antigen complex (ImCrAC) were studied. Sensitivity, specificity, pre- and post-test probabilities, likelihood ratios, and predictive values of each of these serological tests were determined. RESULTS: The sensitivity and specificity of the pANCA test for the diagnosis of ulcerative colitis were 61 and 79%, respectively. The serum agglutination test for anaerobic coccoid rods had a sensitivity of 42% and a specificity of 89% for a diagnosis of Crohn's disease. The sensitivity of specific IgG antibodies against Kd-45/48 ImCrAC in diagnosing Crohn's disease was 70% and specificity 60%. Although 100% specificity was achieved by combining all three tests in a small group of patients with Crohn's disease (n = 20), combining two or more tests had no additive clinical value. No correlation was found between the presence of any one of these antibodies and disease activity, duration, or localisation of disease. Surgery or medical treatment did not influence the presence of antibodies or the antibody titre. CONCLUSIONS: The value of these tests in the differential diagnosis between ulcerative colitis and Crohn's disease is limited, but the high predictive values and specificities of different tests for both diseases suggest that these tests may be of help in studying disease heterogeneity and in defining different subgroups of patients with different pathogenesis.

Estimation of serial interval and incubation period of tuberculosis using DNA fingerprinting.

OBJECTIVE: To determine the frequency distributions of serial interval and incubation period of tuberculosis within 4 years of transmission, and to identify correlates of serial intervals and incubation periods. METHODS: DNA fingerprints were obtained for all isolates from all culture-positive patients notified in The Netherlands from 1993 to 1996. Patient information was obtained from the National Tuberculosis Register. Results from contact investigations were provided by public health services. Source cases and secondary cases of tuberculosis were identified, based on 1) identical DNA fingerprints, and 2) epidemiological confirmation of contact. Under-representation of long intervals were corrected for by weighting cases. RESULTS: A total of 69 source-secondary case couples were identified. The geometric mean serial interval was 29.5 weeks (95% confidence interval [CI] 22.8-38.2 weeks) and the geometric mean incubation period 20.8 weeks (95% CI 15.5-27.8 weeks). Serial intervals and incubation periods tended to increase with age (P > 0.05). Three secondary cases with human immunodeficiency virus infection showed very short incubation periods (P > 0.05). CONCLUSION: Using a new methodology, the distribution of incubation periods of tuberculosis gave results consistent with earlier studies.

Diet or diuretic? Treatment of newly diagnosed mild to moderate hypertension in the elderly.

The aim of this study was to assess the effectivity of dietary measures in the treatment of hypertension. Therefore, a single-blind randomised clinical trial was carried out in elderly persons with recently diagnosed hypertension. Patients were recruited from a general practice (6555 persons) during visits or after written invitation or invitation by phone. New hypertensive patients (with measurements taken on three different occasions >159 mm Hg systolic and/or >94 mm Hg diastolic), aged 60-80 years, without target-organ damage, dementia, diabetes mellitus or malignant disease entered a 3-month intervention programme of either intensive dietary counselling, receiving a sodium-reduced (<100 mmol/24h), potassium-enriched (>75 mmol/24h), and weight-reducing diet (BMI <25), or only 25 mg chlorthalidone a day. Forty-two newly diagnosed hypertensive subjects met the inclusion criteria. Two dropped out from the chlorthalidone group, one with side effects and another after a myocardial infarction. Although blood pressure (BP) in the diet group decreased less than in the drug group, of the patients in the diet group 45% fell back to a normal systolic and 50% to a normal diastolic BP (drug treatment group, systolic 75% and diastolic 85%). In contrast with the diet group, lipid spectrum and blood glucose concentration in the diuretic group, however, deteriorated slightly. The dietary intervention was effective in elderly patients with a systolic or diastolic BP in the range of 160-180 and 95-100 mm Hg, respectively. Reduction in weight should be the primary aim. It is argued that sodium reduction can be achieved better by collective measures. In patients with a BP of more than 180 mm Hg systolic or 100 mm Hg diastolic, dietary advice and drug treatment should be combined.

A randomized controlled trial of rubber band ligation versus infra-red coagulation in the treatment of internal haemorrhoids.

OBJECTIVE: Despite the presence of numerous non-surgical therapies for the treatment of haemorrhoids, none of these therapies has clearly been proven to be superior. The effectiveness and patient tolerance of rubber band ligation (RBL) and infra-red coagulation (IRC) in the treatment of haemorrhoids was assessed. DESIGN: Prospective randomized trial. SETTING: Academic hospital (tertiary care). PARTICIPANTS: A total of 133 consecutive patients (73 males, 60 females, mean age 48 years (range 19-82)) with internal haemorrhoids, and without concomitant anorectal disease, were randomized to rubber band ligation (RBL, n = 65) or infra-red coagulation (IRC, n = 68). INTERVENTIONS: Rubber band ligation or infra-red coagulation was performed in one or more sessions with four-week intervals until symptoms had resolved. Treatment outcome and side-effects were assessed after each treatment session and one month after the last treatment by proctological examination and a questionnaire, including a pain score (visual analogue scale from 0 to 10). Recurrence of complaints was assessed by telephone questionnaire [mean follow-up of 19.2 months (SD 7.8)]. RESULTS: Treatment outcome was assessed in 124 patients (60 RBL, 64 IRC). The mean number of treatment sessions was 1.6 (SD 0.9) for both therapies. For RBL, 58 patients (97%), and for IRC, 59 patients (92%) were symptom-free or had satisfactorily improved. Only third-degree haemorrhoids seemed to respond better to RBL (five of five patients symptom-free) than to IRC (two of four patients symptom-free). Pain following treatment was more common and more severe after RBL (VAS 5.5 +/- 3.7) than after IRC (VAS 3.3 +/- 3.3, P= 0.018). The telephone questionnaire was answered by 105 patients. Nine of 50 patients (18%) treated with RBL and 11 of 55 patients (20%, P= 0.81) treated with IRC had experienced symptomatic relapse to pre-treatment levels. CONCLUSIONS: Infra-red coagulation and rubber band ligation are equally effective in the treatment of haemorrhoids. The rate and severity of pain is higher after rubber band ligation. Infra-red coagulation should be the first-line treatment for haemorrhoids.

Carcinoma of the soft palate and anterior tonsillar pillar.

The results after treatment of a total of 52 patients between 1974 and 1990 for squamous cell carcinoma of the soft palate and anterior tonsillar pillar by surgery, radiotherapy, or a combination of the two are reported in the present study. Of the 45 patients who were treated for cure, 38 were treated by surgery, followed by radiotherapy in 19 patients (50%). Five patients received definitive radiotherapy only, and 2 were treated by other modalities such as intra-arterial methotrexate and carbon dioxide (CO2) laser. Absolute and determinant 5-year survival rates were 62% and 77%, respectively. Sixty-four percent of patients survived 5 years recurrence-free, and 27% developed multiple primary tumors in the head and neck. Tumor stages III and IV were shown to decrease survival by half compared to stages I and II. A 42% occult nodal metastases rate was observed, and 3 of 11 patients experienced regional relapse in an untreated neck. From this review it appears that surgery, combined with postoperative radiotherapy when indicated, is an effective form of treatment for carcinoma of the soft palate and anterior tonsillar pillar.

The inter-observer reproducibility of Lasègue's sign in patients with low back pain in general practice.

BACKGROUND: The spectrum of low back pain patients in general practice differs significantly from that in an orthopaedic clinic. The most frequent specific cause of low back pain is nerve-root irritation or compression caused by intervertebral protrusion, and the diagnosis is still problematic. Testing for Lasègue's sign could be a useful way of detecting high-risk patients, but so far the reproducibility of the test has been measured only in hospital-based studies. AIM: To assess the inter-observer reproducibility of Lasègue's sign in general practice. METHOD: Fifteen General practitioners from Amsterdam and the surrounding areas tested all consecutive low back pain patients who visited them during a period of two years for Lasègue's sign. The test was repeated within two weeks in two samples: sample I consisted of 50 consecutive low back pain patients; sample II consisted of all patients who had pelvic tilt, scoliosis, or positive Lasègue's sign. RESULTS: In sample I, the observation was repeated in 49 patients. The Kappa coefficient was 0.33, and the proportions of positive and negative agreement were 33% and 96%, respectively. In sample II, the observation was repeated in 48 patients. The Kappa coefficient was 0.56, whereas the proportion of positive agreement was 67% and the proportion of negative agreement was 91%. CONCLUSIONS: The reproducibility of Lasègue's sign in routine general practice seems to be low, but may be similar to the reproducibility observed in hospital settings in selected patients who have a high chance of low back pain owing to a specific disease.