Exploring the implementation of role extension for Namibian radiographers: Perspectives on intravenous injection of contrast media.

INTRODUCTION: Role extension to include intravenous (IV) injection of contrast media has been formally embraced by radiographers and their regulatory bodies in developed countries. The revised scope of practice, in our Namibian context, has formalised IV injection as an extended role for radiographers. This study aimed to explore the perspectives of radiographers regarding this new role of IV injection of contrast media. METHODS: A qualitative design with a descriptive phenomenological approach was employed to collect data from 15 radiographers working in both public and private radiology facilities. Participants were purposively selected to participate in focus group discussions and individual interviews. An interview guide was used to facilitate the discussions and interviews, and a voice recorder was used for recording. Data were transcribed verbatim and analysed using Tesch's 8-step method. RESULTS: From the 15 participants, three themes were developed: enhanced service delivery with two subthemes (improved departmental workflow and patient care), training needs with two subthemes (inadequate contrast media reaction training and standardised training requirement), and medical-legal issues with two subthemes (regulatory blurriness and role conflict distress). CONCLUSION: The participants expressed mixed perceptions towards the IV injection role of radiographers, emphasising the benefits for the department and patients while raising concerns regarding standardisation of training and associated medico-legal issues. Furthermore, a large-scale evaluation is necessary to uncover the challenges and barriers to the successful adoption of this new role. IMPLICATIONS FOR PRACTICE: The role extension for radiographers to include IV injections is a long-awaited development, but it should be accompanied by the necessary training and guidelines to fully realise its benefits.

Higher sustained virological response rates at 12 weeks in HIV-HCV co-infection; a tertiary centre experience.

OBJECTIVES: The advent of direct-acting antivirals (DAAs) has revealed high rates of sustained virological response at 12 weeks (SVR 12) in Hepatitis C (HCV) treatment. Since the introduction of DAAs, in our centre, 42% of patients treated for HCV are HIV co-infected. Our study aimed to identify the SVR 12 rates between this group and HCV mono-infected patients. METHODS: Retrospective data analysis of HCV mono-infection and HIV-HCV co-infection patients between 1st July 2015 and 30th November 2018, who had a SVR at 12 weeks post treatment. Co-infected patients were only referred for HCV treatment if they had well controlled HIV. Patients treated with Pegylated Interferon and Ribavirin were excluded. RESULTS: During this period, 724 patients were treated for HCV and had data on SVR 12. Of those, 303 (41.8%) were co-infected with HIV. The SVR 12 was achieved in 386 (91.6%) of the HIV negative patients and 288 (95%) of the HIV positive patients (χ²= 3.10 p = 0.078). Cirrhotic patients had poorer SVR 12 in both groups (90% in co-infection and 88.4% in HCV mono-infection). CONCLUSIONS: Our results demonstrate a higher SVR 12 in co-infected patients compared to patients with HCV mono-infection. We hypothesise that adherence to HIV treatment could increase compliance and success of HCV treatment.

Hoarse voice in adults: an evidence-based approach to the 12 minute consultation.

BACKGROUND: The hoarse voice is a common presentation in the adult ENT clinic. It is estimated that otolaryngology/voice clinics receive over 50 000 patients with dysphonia each year. Good vocal function is estimated to be required for around 1/3 of the labour force to fulfil their job requirements. The assessment and management of the patient with a hoarse voice is potentially a complex and protracted process as the aetiology is often multi-factorial. This article provides a guide for the clinician in the general ENT clinic to make a concise, thorough assessment of the hoarse patient and engage in an evidence based approach to investigation and management. METHOD: Literature search performed on 4 October 2008 using EMBASE, MEDLINE, Cochrane databases using subject headings hoarse voice or dysphonia in combination with diagnosis, management, investigation, treatment, intervention and surgery. RESULTS: General vocal hygiene is beneficial for non organic dysphonia but the evidence base for individual components is poor. There is a good evidence base for the use of voice therapy as first line treatment of organic dysphonia such as vocal fold nodules and polyps. There is little evidence for surgical intervention as first line therapy for most common benign vocal fold lesions. Surgery is, however, the treatment of choice for hoarseness due to papillomatosis. Both CO(2) laser and microdissection are equally acceptable modalities for surgical resection of common benign vocal fold lesions. Laryngopharyngeal reflux is commonly cited as a cause of hoarseness but the evidence base for treatment with gastric acid suppression is poor. Despite the widespread use of proton pump inhibitors for treating laryngopharyngeal reflux, there is high quality evidence to suggest that they are no more effective than placebo. CONCLUSION: A concise and thorough approach to assessment in the general ENT clinic will provide the diagnosis and facilitate the management of the hoarse voice in the majority of cases. Voice therapy is an important tool that should be utilised in the general ENT clinic and should not be restricted to the specialist voice clinic. If there is no improvement after initial measures, the larynx appears normal and/or the patient has failed initial speech & language therapy, referral to a specialist voice clinic may be helpful. More research is still required particularly with regard to laryngopharyngeal reflux which is often cited as an important cause of hoarseness but is still poorly understood.

Effects of dissolved polymer on the transport of colloidal particles through a microcapillary.

The effect of water-soluble polymer on the transport of latex particles through a microcapillary was investigated. Capillary hydrodynamic fractionation (CHDF) experiments were performed using polystyrene (PS) particles and poly(ethylene oxide) (PEO) solutions as the eluant. Generally, the average particle velocities were greater than those corresponding to a polymer-free eluant. A decrease in the sample axial dispersion was also observed using the PEO solutions. In addition, increasing the polymer molecular weight resulted in lower particle residence times in the capillary tube. The enhanced particle transport arises primarily from an increase in the particle diameter resulting from the adsorption of PEO onto the PS surfaces, and, more importantly, from the migration of particles toward the capillary axis due to the normal stress of the PEO solution.

Optimal ratios of biliary glycoprotein isoforms required for inhibition of colonic tumor cell growth.

Rodent biliary glycoprotein (Bgp), also known as C-CAM, has recently been shown to function as a tumor suppressor in colon, prostate, and bladder cancers. This glycoprotein is a member of the carcinoembryonic antigen family and is one of the only proteins in this family to encode either a long (71-73 amino acids) or short (10 amino acids) cytoplasmic domain. We and others have shown that the growth-inhibitory properties of Bgp depend upon the expression of its long cytoplasmic domain. However, the two Bgp isoforms normally coexist in most cell types surveyed; the longer variant is usually present in lower amounts than the shorter one. In this study, we have examined the in vitro and in vivo growth properties of both mouse Bgp variants separately and in combination. To determine the physiologically relevant expression levels and ratios of the two Bgp variants, we have quantified the amount of the longer variant in normal colonic epithelial cells and showed that it constitutes 15-20% of total Bgp expressed in this tissue. To mimic the in vivo situation, we have generated double transfectant cell lines expressing the longer and shorter Bgp isoforms coordinately in tumorigenic CT51 mouse colonic carcinoma cells and demonstrated that the longer Bgp isoform exhibits a dominant tumor growth inhibition phenotype over that of the shorter variant within physiological levels of expression of Bgp. Unexpectedly, significant overexpression of the longer Bgp isoform alone led to reversal of the tumor inhibition phenotype. These results, therefore, suggest that there may be a limiting threshold of Bgp expression or Bgp-associating proteins mediating the tumor inhibition phenotype.

Association of biliary glycoprotein with protein tyrosine phosphatase SHP-1 in malignant colon epithelial cells.

Biliary glycoprotein (Bgp) is a member of the immunoglobulin superfamily and the carcinoembryonic antigen family. Previous studies have shown that Bgp functions as an intercellular adhesion molecule and a canalicular bile salt transporter. Moreover, we and others demonstrated that Bgp can inhibit colonic and prostatic tumor cell growth in vivo, through a mechanism which depends on sequences present in its cytoplasmic domain. In this study, we have examined the possibility that the cytoplasmic domain of Bgp can interact with signal transduction molecules. We showed that tyrosine phosphorylated Bgp, expressed in mouse colon carcinoma CT51 cells, could reversibly associate with protein tyrosine phosphatase SHP-1. Mutation of either of two tyrosine residues present in the cytoplasmic domain of Bgp abrogated SHP-1 binding, suggesting that this association was mediated by both tyrosine residues. Similarly, we noted that either of the two SH2 domains of SHP-1 could bind tyrosine phosphorylated Bgp in vitro. It is therefore conceivable that some of the functions of Bgp are mediated through its ability to induce intracellular protein tyrosine dephosphorylation.

Physician desire for euthanasia and assisted suicide: would physicians practice what they preach?

PURPOSE: Euthanasia is a pressing public issue. We sought to assess how frequently physicians could perceive of a desire for euthanasia themselves and whether they would be willing to provide patients the same interventions. METHODS: We interviewed 355 randomly selected oncologists from the United States and interviewed them about their attitudes and practices related to euthanasia and assisted suicide. RESULTS: Of the 355 oncologists, 48.1% could imagine a situation in which they might desire euthanasia or assisted suicide for themselves. Oncologists who were Catholic and more religious were significantly less likely to desire these interventions for themselves. Of those oncologists who could imagine a situation in which they might desire euthanasia or assisted suicide for themselves, 85.8% found euthanasia and/or assisted suicide acceptable for their patients. Of the oncologists who could not imagine a situation in which they might desire euthanasia or assisted suicide for themselves, 41.7% still found these interventions ethical for their patients. Only 6.8% of oncologists could imagine a situation in which they might desire euthanasia or assisted suicide for themselves but found these interventions unacceptable for their patients. CONCLUSION: Almost half of surveyed oncologists could imagine a situation in which they would desire euthanasia or assisted suicide. However, in many cases, this was for nonterminal illness which would be prohibited by proposed laws. When physicians desire euthanasia or assisted suicide for themselves, they are willing to provide these interventions for their patients; therefore, most physicians would practice what they preach. Indeed, when they deviate, oncologists overwhelmingly respect patient autonomy rather than impose their own views on patients.

Stability of attitudes regarding physician-assisted suicide and euthanasia among oncology patients, physicians, and the general public.

PURPOSE: Attitudes regarding the ethics of physician-assisted suicide (PAS) and euthanasia have been examined in many cross-sectional studies. Stability of these attitudes has not been studied, and this is important in informing the dialog on PAS in this country. We evaluated the stability of attitudes regarding euthanasia and PAS among three cohorts. METHODS: Subjects included 593 respondents: 111 oncology patients, 324 oncologists, and 158 members of the general public. We conducted initial and follow-up interviews separated by 6 to 12 months by telephone, regarding acceptance of PAS and euthanasia in four different clinical vignettes. RESULTS: The proportion of respondents with stable responses to vignettes ranged from 69.2% to 94.8%. In comparison to patients and the general public, physicians had less stable responses concerning the PAS pain vignette (69.1% v 80.8%; P =.001) and more stable responses for all euthanasia vignettes (P <.001) except for pain. Over time, physicians were significantly more likely to change toward opposing PAS and euthanasia in all vignettes (P <.05). Characteristics previously associated with attitudes regarding PAS and euthanasia, such as Roman Catholic religion, were not predictive of stability. CONCLUSION: Up to one third of participants changed their attitudes regarding the ethical acceptability of PAS and euthanasia in their follow-up interview. This lack of consistency mandates careful interpretation of referendums and requests for physician-assisted suicide. Furthermore, in this study, we found that physicians are becoming increasingly opposed to PAS and euthanasia. The growing disparity between physicians and patients regarding the role of these practices is large enough to suggest possible conflicts in the delivery of end-of-life care.

Attitudes and practices concerning the end of life: a comparison between physicians from the United States and from The Netherlands.

BACKGROUND: This study compares attitudes and practices concerning the end-of-life decisions between physicians in the United States and in the Netherlands, using the same set of questions. METHODS: A total of 152 physicians from Oregon and 67 from the Netherlands were interviewed using the same questions about (1) their attitudes toward increasing morphine with premature death as a likely consequence, physician-assisted suicide (PAS), and euthanasia; and (2) their involvement in cases of euthanasia, PAS, or the ending of life without an explicit request from the patient. Odds ratios, with 95% confidence intervals, were calculated to investigate relation between attitudes and various characteristics of the respondents. RESULTS: American physicians found euthanasia less often acceptable than the Dutch, but there was similarity in attitudes concerning increasing morphine and PAS. American physicians found increasing morphine and PAS more often acceptable in cases where patients were concerned about becoming a burden to their family. There was a discrepancy between the attitudes and practices of Dutch physicians concerning PAS. The proportions of physicians having practiced euthanasia, PAS, or ending of life without an explicit request from the patient differ more between the countries than do their attitudes, with American physicians having been involved in these practices less often than the Dutch. CONCLUSIONS: In this study of American and Dutch physicians, 2 important differences emerge: different attitudes toward the patient who is concerned over being a burden, and different frequency of euthanasia and PAS in the two countries.

Mycobacterium tuberculosis infection in pregnant and nonpregnant women infected with HIV in the Women and Infants Transmission Study.

BACKGROUND: Prevalence of Mycobacterium tuberculosis (TB) infection and anergy were evaluated in a cohort of pregnant and nonpregnant women infected with the human immunodeficiency virus who were enrolled in a prospective natural history study (the Women and Infants Transmission Study) conducted in New York, NY; Boston and Worcester, Mass; Chicago, Ill; and San Juan, Puerto Rico. METHODS: One hundred eighty-three women (65 pregnant, 118 nonpregnant) were evaluated for TB. The TB history and risk factors were assessed by interview and medical record review. Intradermal skin testing with tuberculin, mumps, and tetanus antigens and CD4+ lymphocyte count were performed. RESULTS: Overall prevalence of TB infection or disease by documented medical history and/or a tuberculin skin test induration of 5 mm or more was 14% (26 of 183). History of TB infection or disease was documented in 11% of the women who were interviewed. Tuberculin and anergy skin test results were evaluable for 124 women; 6% (seven of 124) had tuberculin skin test induration of 5 mm or more, including 11% (five of 46) of the pregnant women who were tested. Induration between 2 and 5 mm was observed in four more women, three of whom were pregnant. Anergy was observed in 42% (52 of 124); prevalence of anergy was higher in nonpregnant women (38 [49%] of 78) than in pregnant women (14 [30%] of 46). While anergy was more common in women with a CD4+ cell count of 0.5 x 10(9)/L or less, 27% of those with a CD4+ cell count of more than 0.5 x 10(9)/L were also anergic. CONCLUSION: These data support current Public Health Service recommendations for tuberculin skin testing in persons infected with the human immunodeficiency virus, and emphasize that evaluation should include pregnant as well as nonpregnant women. The prevalence of anergy does not appear increased in pregnancy in women infected with the human immunodeficiency virus. Health care providers should include tuberculin and anergy skin testing as part of the standard prenatal care for women infected with the human immunodeficiency virus.

The isolation of newly formed bone associated cells in vitro: preliminary observations on origin and morphology.

Agar-medium suspensions were used to culture guinea-pig femoral bone fragments which had been physically depleted of marrow. A sequential study of the histological events occurring within the regenerating shaft, in the agar wholemount preparations and on the underlying coverglass allowed (1) the localization of the early regenerative cells within the endosteal crevices and their rapid proliferation to fill and 'encapsulate' the explant; (2) the detection of residual marrow granulocytic and mononuclear precursors amidst the regenerative non-hemopoietic cells within the endosteal crevices of bone; (3) a study of the development of the adherent cells on the coverglasses. Cumulative labeling studies indicated that almost all the migrating cells were newly formed cells with a small fraction (less than 5%) within the endosteal crevices observed as unlabeled cells after 5 days of culture. The adherent mononuclear cells were derived directly from the regenerating bone fragment and showed similar morphology and proliferative characteristics (97% cumulative labeling index) to the bone associated cells. A unique feature of these monolayers was the formation of an extensive network of extracellular material between cells. These observations have not been described in monolayers derived from marrow suspensions and appear to be a characteristic of the monolayers derived from regenerating bone fragments.

Characteristics of synthesis and distribution of 3H-fucose-containing glycoproteins by marrow stromal cells cocultured with hemopoeitic cells in gelfoam sponges. An electron microscope radioautographic study.

Gelfoam sponge cultures of stromal cells, derived from guinea pig marrow-depleted bone fragments, support the growth of myeloid precursors in the absence of exogenous stimulants. EM radioautographic studies were undertaken to identify active synthesis and distribution of 3H-fucose-containing glycoproteins within the 3-D organization of cultured hemopoietic tissue. Labeling of 5-14 day cultures with tritiated fucose for 20 min revealed an intracellular localization of silver grains over the endoplasmic reticulum and Golgi bodies of all stromal cells. Cumulative labeling (1-48 h) of similar cultures indicated that (i) silver grains subsequently accumulated in plasma membranes, large cytoplasmic granules and also within lipid droplets, (ii) primitive and myeloid cells were also labeled. Localized extracellular concentrations of silver grains were facilitated by the multiple inter-stromal cell contacts and by the accumulation of fine labeled cytoplasmic processes. Mechanisms whereby stromal cells may actively influence physiochemical changes in the hemopoietic inductive microenvironment are suggested.

Ultrastructural observations on the three-dimensional reorganization and growth of newly-formed candidate stromal cells and residual hemopoietic cells in culture.

Gelfoam sponges were used as three-dimensional culture supports to allow the migration, reorganization and growth of regenerative cells derived from bone fragments previously depleted of marrow by curettage. The explants and sponges, cultured in 0.3% agar-medium, were analysed ultrastructurally throughout a 14 day culture period. By day 5 the gelfoam sponge was infiltrated by large cells with extensive cytoplasmic processes (stromal cells) and primitive round cells. The stromal cells were pleomorphic and varied in their content of rough endoplasmic reticulum, mitochondria, cytoplasmic granules, microfilaments, lipid droplets and glycogen. The cytoplasmic processes made multiple intercellular contacts with other stromal cells thereby forming a stromal network. Close and direct associations of stromal cells with primitive hemopoietic cells and various stages of myeloid cells were identified. The identification of proliferating granulocytes and mononuclear phagocytes on days 7--14 in these unstimulated cultures suggests that the organization of stromal cells is able to maintain primitive cells and supports the proliferation and differentiation of myeloid cells. It is proposed that this three-dimensional culture technique (i) allows the development of primitive stromal precursors and primitive residual hemopoietic cells; (ii) provides a model for the analysis of early stromal cell-hemopoietic cell interactions.

Ethnic differences in bone density in female South African nurses.

In the United States, the higher prevalence of osteoporosis and the higher incidence of fractures in whites than in blacks may be attributed to the finding of lower bone density (BD) in both white children and adults. In South Africa, osteoporosis and fractures also occur more frequently in whites than in blacks. Appendicular BD has been found to be similar in black and white children in South Africa, but there is little information available on BD of adults in South Africa. This cross-sectional study aimed to assess changes in BD with age in adult females in South Africa and to assess possible differences in peak BD and in the rate of postmenopausal bone loss between blacks and whites. Data for 180 black and 184 white female nurses aged 20-64 years were analyzed. The distal radius bone density (RBD) was measured by single photon absorptiometry. The lumbar spine bone density (SBD) and the femur bone density (FBD) were measured by dual-energy X-ray absorptiometry. Blacks were shorter than whites (p = 0.0001), and blacks' weight, body mass index, and skinfold thickness increased with age. Peak SBD and RBD were similar in blacks and whites, but peak FBD was higher in blacks (p = 0.0001). This ethnic difference in peak FBD became apparent in the fourth decade. Peak FBD was similar in black and white subjects with normal body mass indices (p = 0.09), but in overweight subjects peak FBD was higher in blacks than in whites (p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute tolbutamide administration alone or combined with insulin enhances glucose uptake in the perfused rat hindlimb.

We examined the effects of acute administration of tolbutamide on glucose uptake in the non-cyclically perfused rat hindlimb. During the hour of study, 500 microunits boluses of insulin were given every ten min in the presence or absence of 3 X 10(-3)M tolbutamide. Tolbutamide by itself increased glucose uptake; however at no time was this increase significantly different from that seen in the group which received insulin alone. After 42 min of perfusion, the insulin-stimulated uptake was 26% and the tolbutamide was 20% greater than control (1.90 +/- 0.08, 1.80 +/- 0.06, and 1.50 +/- 0.05 mumol/min/100 g respectively). After 20 min of perfusion, the increase in glucose uptake seen with the combination of insulin + tolbutamide was significantly greater than that obtained with either tolbutamide or insulin alone. At the termination of perfusion, the glucose uptake with the combined treatment was 59% greater than control, 35% greater than tolbutamide, and 19% greater than insulin alone (2.67 +/- 0.10, vrs. 1.68 +/- 0.07 vrs. 1.97 +/- 0.07 vrs. 2.16 +/- 0.07 mumol/min/100 g). These results demonstrate not only a direct effect of tolbutamide, but also a potentiation of insulin-stimulated glucose uptake in the rat hindlimb. Therefore, tolbutamide has extra-pancreatic effects which probably contribute to the hypoglycemic action of this sulfonylurea.

Patterns of thought disorder associated with right cortical damage, schizophrenia, and mania.

The authors used the Thought Disorder Index to measure thought disorder in 23 patients with unilateral right hemisphere cortical damage, 20 patients with bipolar mania, and 25 patients with schizophrenia. There were no differences in the total amount of thought disorder in these groups, but each showed a unique pattern of thought disorder. Patients with right hemisphere damage displayed fragmented thinking, manic patients displayed playful thinking, and schizophrenic patients displayed idiosyncratic thinking. These findings support the view that thought disorder is manifested in different forms that are relatively specific to psychiatric or neurological condition.

Bone disease in African children with slipped capital femoral epiphysis: histomorphometry of iliac crest biopsies.

African teenagers with slipped capital femoral epiphysis (SCFE) not infrequently also have genu valgum (knock-knee). Because we had previously demonstrated metabolic bone disease attributable to dietary calcium deficiency in black teenagers with genu valgum, we examined 29 black teenagers (15 male, 14 female) with SCFE for metabolic bone disease. Each patient had an iliac crest bone biopsy taken (after double tetracycline labeling) for routine histomorphometry, and blood and urine samples for bone biochemistry. Spinal bone mineral density was measured in 13 patients. Compared to reported data, we found our patients to be sexually more immature, older, at least as obese, and to have more severe and more frequently bilateral hip disease. Eighty percent of the children took dairy products only once or twice a week or less frequently, and 37.9% had genu valgum. Compared with race- and age-matched South Africans, bone biopsies in our patients showed lower bone volume (BV/TV, p = 0.0003), wall thickness (p = 0.0002), and trabecular thickness (Tb.Th, p = 0.0002), and a tendency to greater trabecular spacing (Tb.Sp, p = 0.053). Lower osteoid volume (OV/BV, p = 0.0001), osteoid surface (OS/BS, p = 0.0001), osteoid thickness (O.Th, p = 0.0002), double labeled surface (dLS/BS, p = 0.029), and bone formation rate (BFR/BS, p = 0.037) suggested poorer bone forming capacity in our patients. No evidence of hyperparathyroid bone disease or osteomalacia was found. BV/TV was below the reference range (14.2%) in 65.5% of cases; these patients had lower values for Tb.Th (p = 0.037) and Tb.N (p = 0.0003), greater Tb.Sp (p = 0.0002), a tendency to lower adjusted apposition rate (Aj.AR, p = 0.057), and had had less frequent intake of dairy products than those with normal BV/TV (p = 0.024). Furthermore, months since menarche correlated with histomorphometric variables BV/TV (r = 0.667, p = 0.009), Tb.Th (r = 0.745, p = 0.002), Tb.Sp (r = -0.549, p = 0.042), O.Th (r = 0.784, p = 0.0009), and Aj.AR (r = 0.549, p = 0.042). The correlation between Tb.Th and spinal bone mineral content (r = 0.656, p = 0.015) suggests that the reduced trabecular thickness reflected a generalized bone condition. A greater than normal proportion of patients had spinal bone mineral density values below -1 standard deviation (SD) of the mean (osteopenia) (p = 0.001). Patients tested for parathyroid hormone and 25-hydroxyvitamin D levels were found to have normal values. Parathyroid hormone correlated with Aj.AR (r = 0.661, p = 0.038) and serum phosphorus (r = -0.764, p = 0.010). We conclude that sexual immaturity and possibly past dietary calcium deficiency contributed to osteopenia, and that this, together with obesity, led to the development of more severe and more frequently bilateral SCFE in our patients than in reported series of black and white children.

Osteolytic Paget's bone disease in a young man. Rapid healing with human calcitonin therapy.

Paget's bone disease is rare in young adults. Severe osteolytic Paget's bone disease in a 28-year-old man was found to respond, clinically, biochemically, and radiographically, within one month to daily subcutaneous injections of 0.5 mg of synthetic human calcitonin. After two years of therapy, he remains asymptomatic and has no biochemical evidence of Paget's bone disease while receiving injections three times a week. Despite aggressive disease, young patients may rapidly demonstrate the same beneficial response to synthetic human calcitonin therapy as has been observed in middle-aged or elderly patients with Paget's bone disease.

Underestimation of Mycobacterium tuberculosis infection in HIV-infected subjects using reactivity to tuberculin and anergy panel.

BACKGROUND: This study aimed to evaluate purified protein derivative (PPD) reactivity and its interrelationship with anergy panel and CD4+ lymphocytes in HIV-infected subjects as compared to PPD reactivity in HIV-uninfected individuals in a tuberculosis endemic and high Bacillus Calmette-Guérin (BCG) coverage environment. METHODS: Clients of four Mexico City HIV detection centres were screened for HIV-1 antibodies (ELISA or haemagglutination, Western Blot); reactivity to PPD (Mantoux PPD, 5TU RT-23), Candida (1:1000, 0.1 ml), and tetanus toxoid (10Lf, 0.1 ml); and CD4+ T cells. Active tuberculosis was excluded. Informed consent was obtained. RESULTS: From 5130 clients 1168 subjects were enrolled; of these 801 (68.6%) were HIV positive. Reactivity to PPD among HIV-positive subjects was found in 174 (22%), 261 (32.6%), and 296 (37%), at PPD cutoff levels of > or =10 mm, > or =5 mm, and > or =2 mm as compared to 224 (61%) of 367 HIV-negative individuals' reactors to PPD (> or =10 mm) (P < 0.001). After exclusion of anergic individuals using two cutoff levels for cutaneous allergens (< or =2 mm and < or =5 mm), PPD reactivity between HIV-infected and uninfected individuals continued to be significantly different. Only HIV-infected individuals with CD4+ T cells > or =500 cells/mm3 had similar reactivity to PPD as HIV-uninfected individuals. Variables associated with PPD reactivity were CD4+ T cell counts, BCG scar, HIV infection and age. CONCLUSIONS: PPD reactivity was useful to diagnose tuberculosis infection only among HIV-infected individuals with CD4+ counts > or =500 cells/mm3. Among individuals with lower counts, lowering cutoff levels or using anergy panel did not permit comparable reactivity as that observed among HIV-uninfected individuals.

The development of a palliative care program for managed care patients: a case example.

Palliative care is emerging as an important new field. Although programs are developing in hospital environments, little is known about development of programs in outpatient practices or those serving large managed care populations. This article provides a framework for the development of a comprehensive palliative care program in a large multispecialty group practice that serves managed care patients. The article addresses guiding principles, the need for obtaining baseline data, how the clinical consultation service was established, development of outcomes measures, and information on current program status. Five themes emerged as key to successful program development, most importantly the close collaboration between administrative and clinical staff in all aspects of program development.