Genomic and functional analyses of Rhodococcus equi phages ReqiPepy6, ReqiPoco6, ReqiPine5, and ReqiDocB7.

The isolation and results of genomic and functional analyses of Rhodococcus equi phages ReqiPepy6, ReqiDocB7, ReqiPine5, and ReqiPoco6 (hereafter referred to as Pepy6, DocB7, Pine5, and Poco6, respectively) are reported. Two phages, Pepy6 and Poco6, more than 75% identical, exhibited genome organization and protein sequence likeness to Lactococcus lactis phage 1706 and clostridial prophage elements. An unusually high fraction, 27%, of Pepy6 and Poco6 proteins were predicted to possess at least one transmembrane domain, a value much higher than the average of 8.5% transmembrane domain-containing proteins determined from a data set of 36,324 phage protein entries. Genome organization and protein sequence comparisons place phage Pine5 as the first nonmycobacteriophage member of the large Rosebush cluster. DocB7, which had the broadest host range among the four isolates, was not closely related to any phage or prophage in the database, and only 23 of 105 predicted encoded proteins could be assigned a functional annotation. Because of the relationship of Rhodococcus to Mycobacterium, it was anticipated that these phages should exhibit some of the features characteristic of mycobacteriophages. Traits that were identified as shared by the Rhodococcus phages and mycobacteriophages include the prevalent long-tailed morphology and the presence of genes encoding LysB-like mycolate-hydrolyzing lysis proteins. Application of DocB7 lysates to soils amended with a host strain of R. equi reduced recoverable bacterial CFU, suggesting that phage may be useful in limiting R. equi load in the environment while foals are susceptible to infection.

Gastric precancerous lesions and Helicobacter pylori infection in relatives of gastric cancer patients from Northeastern Brazil.

BACKGROUND: Helicobacter pylori infection predisposes to gastric cancer. First-degree relatives of patients with gastric cancer have an increased risk of developing the disease. AIM: To evaluate the prevalence of gastric precancerous gastric lesions and H. pylori infection in first-degree relatives of non-cardia gastric cancer patients. METHODS: Gastric cancer relatives (n = 104) from a region with high prevalence of H. pylori infection and gastric cancer were invited for screening endoscopy; 80% of them had dyspeptic symptoms. The control group was composed of patients (n = 118) who concurrently underwent upper gastrointestinal endoscopy for investigation of dyspepsia with no family history of gastric cancer. The groups were matched for gender, age and social class. H. pylori status was evaluated by urease test, and histology and histological parameters were assessed according to the Houston Updated Sydney System. RESULTS: The prevalence of H. pylori infection was high in both the relative (84.7%) and the control (75.9%) groups. Corpus-predominant gastritis was more frequently observed in the relative group, whereas antral gastritis predominated in the controls. The density of lymphoid follicles was higher among the relatives. Also, intestinal metaplasia in the corpus and dysplasia were more prevalent in the cancer relative group than in the control group. Early gastric cancer was detected in 1 relative of gastric cancer patient with high-grade dysplasia. CONCLUSION: Individuals with a family history of non-cardia gastric cancer need to be routinely screened for H. pylori infection and precancerous gastric lesions.

The behavioural research agenda in global health: an advocate's legacy.

Two of the disciplines that have come to infuse global health with some of its current vibrancy are epidemiology and anthropology, disciplines that focus, in one way or another, on the causal importance of human behaviour in socio-political, ecological, evolutionary, and cultural context. One of the little-known stories in the history of twentieth century global health involves the works of a number of pioneering interdisciplinary scholar-practitioners, who urged a synthesis of epidemiological and anthropological perspectives in what was then called 'tropical medicine'. One of these pioneers was Frederick L. Dunn, who forwarded lasting insights about the importance of human behavioural research in understanding infectious disease. This article provides a historical-biographical accounting of Dunn's contributions to public health in the second half of the twentieth century, arguing that his persistent advocacy of multi-level, social behavioural research and his notion of 'causal assemblages' were critical in the early development of the twentieth century discipline of global health.

Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context.

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.

Carcinomas basocelulares múltiples posradioterapia: presentación de cinco pacientes / Multiple basal cell carcinoma developing after radiotherapy: report of five patients

Los efectos secundarios más perniciosos en la piel, a largo plazo, producidos por las radiaciones ionizantes, son la aparición de tumores y úlceras. Actualmente se considera el carcinoma basocelular como el cáncer de piel posradioterapia más frecuente y, como se evidencia en la bibliografía revisada, no es infrecuente la aparición de carcinomas basocelulares múltiples en áreas de piel previamente irradiadas, tras largos períodos de latencia. En su génesis influyen la dosis total de irradiación, la edad del paciente y la exposición a otros factores carcinógenos. Presentamos los casos de 5 pacientes con carcinomas basocelulares múltiples localizados en áreas de piel previamente irradiadas. (AU)

Using focus groups to assess primary care patients' satisfaction.

The present report describes the use of patient focus groups by a primary health care facility. We review our rationale for using focus groups and the process we used to prepare for and conduct them. We then highlight the results and lessons learned through this experience. Focus groups can be an excellent method for primary care practices to assess the complexities of patient satisfaction issues and engage patients in the continuous quality improvement process. Focus groups can uncover unanticipated issues that surveys fail to identify. Our experience demonstrated that this benefit can be critical in identifying and prioritizing quality of care improvements and that focus group results can be used to make immediate improvements in the quality of care, even though this type of study is not intended to generalize.

Cost analysis of a provincial drug program to guide the treatment of upper gastrointestinal disorders.

BACKGROUND: Concerned with the rising costs of its drug programs for seniors and social-assistance recipients, the government of Newfoundland and Labrador requested physicians and pharmacists at the Memorial University of Newfoundland, and members of the Newfoundland and Labrador Medical Association and the Newfoundland Pharmaceutical Association to provide guidance to the health care community for the use of drugs to treat upper gastrointestinal disorders. METHODS: Algorithms for the management of dyspepsia and gastrointestinal reflux disease were created and distributed to all physicians and pharmacists in the province in June 1996. On July 1, 1996, the provincial government implemented a program to restrict payment for proton-pump inhibitors through its drug programs to situations defined by the algorithms. Restrictions were not applied to the prescribing of cimetidine, ranitidine and prokinetic agents. The status of famotidine and nizatidine was changed from "open benefit" to "special consideration," which requires prescribers to request authorization of their use on a case-by-case basis. RESULTS: Between July 1 and Dec. 31, 1996, 973 of 1078 requests for a proton-pump inhibitor were approved (679 for gastroesophageal reflux, 186 for Helicobacter pylori eradication, 55 for ulcer treatment and 53 for other reasons). The program resulted in a sustained reduction in drug expenditures. Total drug expenditures, which had risen from $39.0 million in 1992/93 to $50.8 million in 1995/96, fell after implementation of the program to $46.4 million in 1996/97 because of a decrease of more than 80% in the use of proton-pump inhibitors. Expenditures on proton-pump inhibitors, which had increased from $0.7 million for the 6 months ending March 1993 to $1.6 million for the 6 months ending March 1996, decreased to $0.3 million for the 6 months ending March 1997. The use of H2-antagonists, but not prokinetic agents, increased concomitantly with the decline in proton-pump inhibitor use. Compared with the year preceding implementation of the program, annual combined expenditures in the subsequent 3 years for H2-antagonists, prokinetic drugs and proton-pump inhibitors were reduced by $1.6 million, $1.7 million and $1.0 million, respectively. Feedback from physicians and pharmacists was supportive for the clinical information and prescribing guidelines. Concerns were mostly limited to process issues. INTERPRETATION: The program, designed by health care professionals, approved by health care associations and implemented by the province of Newfoundland and Labrador to guide the treatment of upper gastrointestinal disorders, has achieved a substantial reduction in drug expenditures.

Memory in pregnancy. II: Implicit, incidental, explicit, semantic, short-term, working and prospective memory in primigravid, multigravid and postpartum women.

This study, using an information processing model of memory, made a detailed examination of the possible locus (loci) of any memory change in gravid and postpartum women using a battery of seven objective memory tests: implicit, incidental, explicit, semantic, short-term, working, and prospective memory. In addition, links were sought both between (a) self-reported data on sleep, health, and memory performance, and (b) these variables and objective memory performance. Five groups of women were tested (n = 22/23 per group), (1) primigravid, (2) multigravid, (3) postpartum, (4) non-pregnant parents with children, and (5) never been pregnant, on self-report and objective memory tests. The gravid and postpartum groups reported significantly more everyday forgetting than the non-pregnant groups but on the objective tests performed no differently from the non-pregnant groups on all tests. Sleep loss was a significant predictor of reported memory change, but not of any memory test performance, and may contribute to a perceived memory change. Pregnant women and new mothers generally should be confident of performing to their normal cognitive capabilities, but may be more affected than usual by a high cognitive load.

Memory in pregnancy. I: Subjective experiences and objective assessment of implicit, explicit and working memory in primigravid and primiparous women.

This study investigated the belief held by over 50% of parous women that they are more forgetful during pregnancy and postpartum relative to other times. Comparisons were made between both the reported and objective memory performances of three groups of women (n = 20 per group), (1) primigravid, (2) primiparous (baby younger than 12 months), and (3) never been pregnant, matched on age and education levels. Participants completed a questionnaire on demographic, health, and sleep details, the Inventory of Memory Experiences, and tests of implicit, explicit, and working memory. The groups did not differ on self-rated levels of physical or emotional health, or anxiety level. The primigravid and primiparous groups reported overall poorer memory performance since pregnancy relative to controls. The primigravid group also reported significantly more sleep disruption, with this being a significant predictor of reported memory change. On the objective tests, there were no differences between groups on the implicit and explicit memory tests, but the primigravid and primiparous groups scored significantly lower on a test of working memory. Self-reports of memory change during pregnancy and postpartum may be related to life changes, such as sleep change, and may reflect changed perceptions rather than objective changes.

The health transition, global modernity and the crisis of traditional medicine: the Tibetan case.

The epidemiologic and demographic consequences of the health transition, coupled with worldwide pressures for health care reform according to neoliberal tenets, will create new opportunities, and well as new problems, for organized systems of indigenous medicine. Spiraling costs of biomedically-based health care, coupled with an increasing global burden of chronic, degenerative diseases and mental disorder, will produce significant incentives for the expansion of indigenous alternatives. Yet this expansion will be accompanied by pressures to rationalize and modernize health care services according to the structurally dominant scientific paradigm. Without concerted effort to maintain native epistemologies, indigenous medical systems face an inevitable slide into narrow herbal traditions and a loss of those elements of diagnosis and therapy which may be the most valuable and effective. Analyzing the case of Tibetan medicine and other Asian medical systems, I show how this process occurs and how it is resisted. I conclude by discussing the policy dimensions of this problem.

Imagined lives, suffering, and the work of culture: the embodied discourses of conflict in modern Tibet.

This article explores the cultural epidemiology of rlung ("loong") disorder among Tibetans living in the cities and towns of the modern Chinese state of Tibet. Rlung, glossed as air or wind, is the most important of the three humors of the classical Tibetan ethnomedical system. Considered by Tibetans to be contingent upon multiple social, emotional, and religious phenomena, rlung disorders are fertile ground for the development of etiological discourses that incorporate the social and political crises that are part of the rapidly changing Tibetan plateau. In this essay I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkage, in which rlung stands as the chief symbolic mediator, with ethnic conflict, rapid economic development, and the localization of global debates over Tibetan suffering and human rights.

The Claxton Elementary School Health Program: merging perceptions and behaviors to identify problems.

The Claxton Elementary School Health Program was developed to improve the health of a school community in a western North Carolina city of 60,000. Using the principles of Community-Oriented Primary Care (COPC) in fall 1991, a health advisory board composed of interested parents, teachers, and physicians was organized. A comprehensive needs assessment was implemented, including focus groups with teachers and parents, a self-administered health behavior survey for children in grades three-five, and a self-administered survey of parents' health problems. Teachers, children, and parents agreed on perceived problems requiring attention. The Board then prioritized health problems, selecting nutrition and self-concept as the most critical areas in which to develop programs. Using target population members to identify needs can be a valuable approach to the development of community-based programs for improving children's health behaviors.

Role of hyperbilirubinemia in the impairment of osteoblast proliferation associated with cholestatic jaundice.

Because the osteoporosis occurring in chronic cholestatic liver disease (CCLD) is associated with decreased bone formation and is reversible by liver transplantation, substances retained in plasma during cholestasis may impair osteoblast function. This hypothesis was tested using a new bioassay that measures plasma mitogenic activity (PMA) for normal human osteoblast-like (hOB) cells. In 29 jaundiced patients, mean PMA was 56.4% (P < 0.001) of that in 29 age- and sex-matched normal subjects, and the decrease in PMA was similar in the 14 with CCLD and the 15 with other causes of jaundice. Bile acids and bilirubin are the two major groups of products retained during cholestasis. The common conjugated bile acids and bilirubin were added to normal human plasma in concentrations simulating those found in patients with CCLD. Various bile salts had no effect on PMA whereas unconjugated bilirubin decreased PMA in a dose-dependent fashion (r = -0.98, P < 0.0001) without affecting cell viability. Relatively selective removal of bilirubin from the plasma by photobleaching normalized the decreased PMA in five jaundiced patients but produced no apparent change in five normal subjects. These data support the hypothesis that hyperbilirubinemia or possibly other photolabile substances impair osteoblast proliferative capacity and thus may play a major role in the pathogenesis of the osteoporosis associated with CCLD.

The transformations of Tibetan medicine.

This article presents a cultural and historical analysis of 20th-century Tibetan medicine. In its expansion into the state bureaucracy, Tibetan medicine has acceded to institutional modernity through transformations in theory, practice, and methods for training physicians. Despite Chinese rule in Tibet, however, Tibetan medicine has not yielded completely to state interests. With the collapsing of the traditionally pluralistic Tibetan health system into the professional sector of Tibetan medicine, contemporary Tibetan medicine has become to the laity a font of ethnic revitalization and resistance to the modernization policies of the Chinese state. These processes are particularly evident in the elaboration of disorders of rlung, a class of sicknesses that, collectively, have come to symbolize the suffering inherent in rapid social, economic, and political change.

Psychosocial functioning of transsexuals in Belgium.

Male-to-female (M-F) transsexuals differ consistently from female-to-male (F-M) transsexuals in their sociodemographic characteristics, cross-gender and sexual history and the degree to which personality disorder is concomitant to their transsexuality. As a group, female-to-male transsexuals are more homogeneous. Both groups are impaired in their mental functioning, but the male-to-female population is more mentally disordered. In a comparison between Dutch transsexuals and their Belgian counterparts, the latter were shown to have more mental problems.

Bone disease in primary biliary cirrhosis: does ursodeoxycholic acid make a difference?

Ursodeoxycholic acid (UDCA) has been proposed as beneficial therapy for patients with primary biliary cirrhosis (PBC). The effects of UDCA on metabolic bone disease, a major source of morbidity in patients with PBC, are essentially unknown. Preliminary information suggests that UDCA may improve biochemical indices of bone disease, although information about the effects of UDCA on bone density is lacking. In this study, we describe the effects of UDCA on lumbar spine bone mineral densities over a 3-year period during which patients were enrolled in a randomized, double-blind, therapeutic trial of UDCA for the treatment of PBC. Lumbar spine dual-photon densitometry was measured at entry and annually. Eighty-eight patients, 50 in the UDCA group and 38 in the placebo group, had serial measurements available for up to 3 years. There was no statistical difference between the two treatment groups at entry with respect to histological stage, total bilirubin, age, use of calcium supplement, vitamin D levels, or estrogen. After 3 years of treatment, there was no significant difference in the lumbar spine bone densitometry measurements between the UDCA-treated and placebo groups. We conclude that, after 3 years of treatment, UDCA is not associated with statistically significant differences in the rate of bone loss from the lumbar spine in patients when compared with placebo despite beneficial effects of treatment on the underlying liver disease. Further efforts to define effective treatments for the bone disease need to be pursued.

Efficacy of ThinPrep preparation of cervical smears: a 1,000-case, investigator-sponsored study.

The diagnoses of 1,000 pairs of conventional Papanicolaou (Pap) smears and ThinPrep preparations were compared. Cervical cells were collected using an Ayre spatula and endocervical brush. The conventional smear was made first, the collection devices were rinsed into PreservCyt solution, and the slides were prepared using the ThinPrep Processor. The diagnoses of the paired smears agreed in 988 of the 1,000 cases (98.8%), including 949 negatives, 28 atypicals, 9 low grade squamous intraepithelial lesions (LGSIL), and 2 high grade squamous intraepithelial lesions (HGSIL). Five cases where LGSIL or HGSIL was found on the ThinPrep slide were negative or atypical on the conventional smear. No conventional smear abnormalities were missed on the ThinPrep slide. Although not statistically significant, this difference indicates that the ThinPrep method gives a better diagnosis of abnormalities than the conventional method. The ThinPrep method was acceptable to participating physicians and ThinPreps were easier and faster to screen than conventional smears.