Frequency and significance of immediate contact reactions to peanut in peanut-sensitive children.

BACKGROUND: Parents of atopic children frequently report, and are alarmed by, contact reactions to foods. Some schools restrict foods due to concerns regarding possible systemic reactions following contact in allergic children. OBJECTIVE: We aimed to determine the frequency with which peanut-sensitive children exhibited contact sensitivity to peanut butter and to assess the significance of such reactions. METHODS: One gram of peanut butter was applied directly to the skin of 281 children who were skin prick test (SPT) positive to peanut (immediate skin application food test; I-SAFT). The test was considered positive if one or more weals were present when the patch was removed after 15 min. A subset of children then underwent an open-label oral challenge with graded amounts of peanut protein. RESULTS: During 3515 clinic visits, 330 I-SAFT tests for peanut contact sensitivity were performed; 136 (41%) were positive. The mean SPT diameter was 10 mm in the I-SAFT-positive children and 8.5 mm in the I-SAFT-negative children (t-test, P<0.0001). No child had a systemic reaction following topical application of peanut butter. Eighty-four children had 85 oral challenges after blinded, placebo-controlled I-SAFT testing. Challenge was positive in 26/32 of those with a positive I-SAFT and negative in only 6/32. Challenge was also positive in 26/53 but negative in 27/53 of those with a negative I-SAFT (sensitivity 50%, specificity 82%, chi2, P=0.003). CONCLUSION: A minority of children sensitized to peanut (positive SPT) develop localized urticaria from prolonged skin contact with peanut butter. No tested subjects, including ones with systemic reactions upon oral challenge, developed a systemic reaction to prolonged skin exposure to peanut. Therefore, systemic reactions resulting from this mode of contact with peanut butter appear highly unlikely.

Copying general practitioner referral letters to patients: a study of patients' views.

Over the past decade there has been a significant shift towards greater involvement of patients in their health care and this has highlighted many areas relating to doctor-patient communication. One area of communication that has not been extensively researched is the referral letter between general practitioners (GPs) and their patients. This small study of patients' views suggests that patients value receiving a copy of their GP outpatient letter, appreciating greater understanding of, and involvement in, the referral process.

Making research relevant to the primary health care team.

There is, as yet, no strong culture of research in primary care and much of the existing research is conceived and undertaken by people outside primary care. The poor implementation of research findings may, in part, be owing to the fact that those delivering the service are not involved in asking or answering questions that are relevant to their practice. This paper reports how three practices constructed a research agenda based on the unanswered questions of their primary care teams. The research questions prioritised by the teams tended towards patient behaviour and service organisation rather than clinical issues. This contrasts with national research priorities. The process has contributed towards the development of a culture of enquiry among team members. Other primary care teams may benefit from a similar approach. National research priority setting in primary care should take more account of the unanswered questions of primary care teams.

Effect of newborn screening for congenital adrenal hyperplasia.

OBJECTIVE: To compare the incidence of diagnosis and morbidity in newborns who were screened with newborns who were not screened for congenital adrenal hyperplasia (CAH). DESIGN: A retrospective cohort study. SETTING: Arkansas, Oklahoma, and Texas. PATIENTS: An unscreened population in Arkansas and Oklahoma (n = 400118) was compared with a screened population in Texas (n = 1613378) during a 5-year period. Simultaneous data were collected on the incidence of diagnosis and associated morbidity in patients with CAH. MAIN OUTCOME MEASURES: Diagnosis of CAH, age (in days) at diagnosis, and frequency and length of initial hospitalization. RESULTS: The incidence of diagnosis of classic CAH per 100000 newborns in the unscreened cohort (5.75) and in the screened cohort (6.26) was similar (relative risk, 0.92; 95% confidence interval, 0.58-1.44). The unscreened group had 0.73 fewer male newborns with salt-wasting CAH diagnosed per 100000 newborns (relative risk, 0.73; 95% confidence interval, 0.35-1.56). The median age at diagnosis was 26 days for male newborns with salt-wasting CAH in the unscreened cohort vs 12 days in the screened cohort (z = 2.49; P = .01). Male newborns with simple-virilizing CAH and newborns with nonclassic CAH were detected only in the screened cohort. CONCLUSIONS: There was not a statistically significant (P = .73) increase in the diagnosis of salt-wasting CAH in the screened cohort. Male newborns benefited as a result of significantly (P = .01) earlier diagnosis, reduced morbidity, and shorter lengths of hospitalization. Large collaborative studies or meta-analyses are needed to determine the life-saving benefits of screening.

P52PAI-1 gene expression in butyrate-induced flat revertants of v-ras-transformed rat kidney cells: mechanism of induction and involvement in the morphological response.

Sodium n-butyrate-induced flat reversion in v-K-ras oncogene-transformed rat kidney (KNRK) cells is associated with transcriptional activation of the p52PAI-1 gene (which encodes the type-1 inhibitor of plasminogen activator). Butyrate-initiated expression of p52PAI-1 mRNA and protein correlated with induced cell spreading and preceded development of cell-to-substrate focal adhesions. Such undersurface matrix contact structures, which are absent from parental KNRK cells, require proximal PAI-1 deposition for their stabilization. Stimulated p52PAI-1 expression by flat revertants (approximating 25-fold that of control cells) and the accompanying cytoarchitectural reorganization appeared to be programmed responses to butyrate as both events required de novo RNA and protein synthesis, metabolic characteristics consistent with a secondary pathway of gene regulation. To assess the relevance of p52PAI-1 induction to the process of flat reversion more critically, a molecular genetic approach was designed to maintain high-level constitutive p52PAI-1 synthesis in the absence of butyrate. KNRK cells transfected with a Rc/CMVPAI plasmid construct, in which expression of a p52PAI-1 cDNA insert was driven by enhancer-promoter sequences from the immediate-early gene of human cytomegalovirus, formed colonies comprised of flat-revertant-like cells with a greater frequency than did cells transfected with the Rc/CMV vector alone (24.8% and 1.7% respectively). Comparative analysis of randomly selected Rc/ CMVPAI clones indicated that a 10-fold increase in immunoreactive p52PAI-1 protein, relative to Rc/CMV isolates, correlated with generation of the flat phenotype. These data suggest that induced p52PAI-1 expression probably functions in the development of morphological revertants in the KNRK cell system.

FH Tulsa-1 and -2: two unique alleles for familial hypercholesterolemia presenting in an affected two-year-old African-American male.

A two-year-old African American boy presented with cutaneous xanthomata and extreme hypercholesterolemia. Subsequent studies revealed that the LDL-cholesterol was 1,001 mg/dl and apoB 507 mg/dl. LDL-receptor activity was almost undetectable, which is compatible with the finding of two newly described defective alleles on exon 4 of the LDL-receptor gene coding for part of the ligand-binding domain. One allele contained a 21 base-pair insertion from codon 200 to 207 whereas the other had a point mutation at codon 207. The rarity of genes for FH reported in individuals of African ancestry is discussed.

The uptake of preventive and curative child health services in Maputo, Mozambique.

This study seeks to analyse the uptake of preventive and curative child health services in three health centres in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to Primary Health Care as the driving force of its newly developed National Health Service, with a principal focus on maternal and child health. Three health centres were selected from areas of contrasting environmental quality. Data were collected from over 6000 women attending the curative and preventive child health services at these centres. It was found that the women using curative services had significantly higher child mortality rates, had lived less time in Maputo City and had children of lower weight status than their counterparts attending for preventive care. Additionally, levels of child mortality were found to increase as environmental quality decreased. It is argued that the lower users of preventive care are, as in the U.K., precisely those who appear to have an increased risk of mortality and morbidity. It is concluded that integration between the curative and preventive health services must be increased in order to overcome the user inertia which militates against the poorer population using the facilities for prevention to the best advantage. This would fit in both with national strategies (1) and WHO recommendations (2-4) in the field of primary health care.

Pertussis: what percentage of children can we immunise?

The immunisation records of 584 children who were born between 1978 and 1982, in a general practice of average social class distribution, were examined: 3.5% of the children would have been excluded from starting a course of vaccination including pertussis using contra-indications established by the Department of Health and Social Security. A further 3.5% had reactions to immunisation that were judged severe enough to prevent completing the course of vaccination. In 1981 and 1982 13% of parents refused pertussis vaccination, considerably fewer than from 1978 to 80. Concomitantly, immunisation against pertussis rose from 51% to 84% over the five year period. Given the incidence of contra-indications and the level of parental refusal, it is concluded that a pertussis uptake of 80% would be a reasonable target for any population.

Primary health care in practice: a study in Mozambique.

This study investigates the delivery of all aspects of Primary Health Care (PHC) in a case study of one urban health centre in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to primary health care as the driving force in its newly developed National Health Service. The urban and rural health centres are intended to be the principal vehicles for PHC delivery, and in this study one of Maputo's recently opened health centres was investigated by observing all clinic sessions, interviewing all health centre workers and collecting data from health centre records. It was found that a dichotomy exists between the tasks ascribed to the health centre in the PHC framework, and the feasibility of their execution given existing personnel and material resources. This derives in part from lack of involvement of PHC practitioners in the organisation and planning of PHC, plus resource allocation which remains in favour of secondary and tertiary rather than primary care. Prevention is accorded priority in PHC theory, yet investigation showed that the major demand on the health centre is for curative care. The quality of both curative and preventive care was evaluated and the need for training in specialist diagnostic skills, and a more socially-based understanding of the determinants of health status and risk emerged, respectively for the groups of workers in the two sectors. The level of contact between the curative and preventive sectors was investigated as was the integration of the health centre into the health service as a whole. The problems arising in these areas must be viewed in the context of the very recent development of a National Health Service in a country where, previously, curative care was available only in urban areas and virtually no preventive programmes existed. This study shows that significant steps are being taken to develop a comprehensive PHC programme in Maputo. More important still will be the extension of this level of care provision to the country as a whole.

Preventive health care for mothers and children. A study in Mozambique.

This study seeks to evaluate the delivery of preventive mother and child health services in Maputo, Mozambique. Mozambique has given priority to primary health care in the development of its new National Health Service, with a principal focus on maternal and child health (MCH). Three health centres were selected, from areas of contrasting urban ecology. Prenatal and under-fives' clinics were observed at each health centre. It was found that at a technical level the preventive services were operating efficiently, with a coverage of over two-thirds of the target population. However, frequency of attendance at both clinics was much lower in the poorer areas of the city. Additionally, it was observed that women and children identified as having a high risk status were rarely given more care and support. Nurses and midwives, frequently adopted an attitude more punitive than supportive to those most at risk. Notwithstanding these shortcomings, it is clear that significant advances in preventive MCH care are being achieved in a country where 6 years previously the only available health services were curative, and confined to the better-off urban districts.

PIP: This study sought to evaluate the delivery of preventive maternal and child health services (MCH) in Maputo, Mozambique. Mozambique has given priority to primary health care in the development of its new National Health Service, with a principal focus on MCH. 3 health centers were selected, from areas of contrasting urban ecology. Prenatal and under-5s clinics were observed at health care center. It was found that at a technical level, the preventive services were operating efficiently, with a coverage of over 2/3 of the target population. However, frequency of attendance at both clinics was much lower in the poorer areas of the city. Additionally, it was observed that women and children identified as having a high risk status were rarely given more care and support. Nurses and midwives, frequently adopted an attitude more punitive than supportive to those most at risk. Notwithstanding these shortcomings, it is clear that significant advances in preventive MCH care are being achieved ina country where only 6 years previously, the only available health service were curatuve, and confined to the more affluent urban districts.

Antenatal care in Maputo, Mozambique.

Mozambique, within its plan for overall social and economic change, has given priority to primary health care with a principal focus on maternal and child health. In 1980 an antenatal control form was introduced into all Maputo's antenatal clinics to monitor pregnancies and to help direct specialist care to mothers at greatest risk--a strategy known by WHO as the "risk approach." In this study three health centres were selected from contrasting areas of the city. Almost 1000 completed antenatal forms were analysed to determine incidence of risk and to evaluate the implementation of this strategy. It was found that: (1) a considerable number of women at risk were identified, referred, and successfully monitored through their pregnancy. (2) Of those women at risk who were identified by the health centres, fewer than half were actually referred for specialist care. (3) Those women at greatest risk were not the highest users of the services, and many of them underused the services compared with those at lower risk. (4) The level of risk and child mortality varied with a measure of urban quality of the areas in which the centres were located.