Circadian pattern of plasma 17-hydroxycorticosteroid: alteration by anticholinergic agents.

Atropine, administered to cats just prior to the time of the expected circadian rise in levels of 17-hydroxycorticosteroid in plasma, blocks this rise. Atropine does not alter this circadian pattern when administered at other times in the circadian cycle. Results similar to those obtained with atropine have been observed with short-acting barbiturates. Dibenzyline administered just prior to the time of the expected circadian rise is ineffective in blocking this rise. These findings support the hypothesis that the circadian pattern of plasma 17-hydroxycorticosteroid levels reflects activation, by the central nervous system, of the hypothalamicpituitary-adrenal axis during a "critical time period" in the circadian cycle.

[Discussing and evaluating professional behaviour. 1. Academic Centre for Oral Health Groningen]. / Bespreken en beoordelen van professioneel gedrag. 1. Centrum voor Tandheelkunde en Mondzorgkunde Groningen.

Professionalism is considered as a core competency for dentists. As a result of changes in the healthcare sector, it is becoming increasingly important for dentists to be more transparent to the community in their delivery of care. The ability'to provide justification' thus becomes an important skill. To train dentists to become professionals who can account for their actions, we developed an educational programme in Groningen which trains students in the following professional skills: 1. make explicit; 2. concretize; 3. analyze; 4. diagnose; 5. generalize; and 6. formulate learning points and experiment with them. This educational programme is given, under the supervision of a coach (generally a practicing dentist), during the entire curriculum, in small groups. Professionalism is integrated with other course programmes (work placement, working in the clinic), because professionalism is a competency which is only expressed by practicing other competencies. The professionalism of the student is also assessed.

[Electives at the dental school in Groningen]. / Keuzeonderwijs binnen de opleiding Tandheelkunde Groningen.

To offer a more comprehensive curriculum in various dental topics, the dental school of the University of Groningen developed electives. This article gives an overview of the learning objectives of the different electives, the program and the way in which students are examined. Attention is also paid to some experiences of students and teachers with this kind of education. The electives seem to effectively prepare students for specific parts of dentistry, and they give an orientation on the scientific aspects of dentistry. Students and teachers are positive about the electives. The electives give good opportunities to the assessment of professional behavior.

Lack of evidence of a major gene acting on postaxial polydactyly in South America.

Data on polydactyly were obtained from two large samples: the Latin American Collaborative Study of Congenital Malformations (ECLAMC), and from a migrant Northeastern Brazilian population of rural origin (Hospedaria). ECLAMC is a case-control clinical epidemiological program comprising 10,035 individuals distributed among 2,030 segregating nuclear families. Hospedaria data consisted of 6,586 examined individuals belonging to 1,040 nuclear families. Using complex segregation analysis methodology we found no evidence of two loci (a major gene and a modifier locus) acting on postaxial polydactyly in the present study. Very high heritability values (in a classical multifactorial model) of postaxial polydactyly were detected, for several sets of analyses in ECLAMC and in Hospedaria. For the whole ECLAMC sample there is a peculiar suggestion of a major recessive gene effect responsible for the trait; however, no comparison with a model involving transmission probabilities (tau) was possible in this highly heterogeneous sample. If the whole ECLAMC sample is divided in subsamples, according to Black admixture proportions, the same multifactorial picture emerges. Two different inheritance patterns were verified for hand (HP) and foot (FP) postaxial polydactyly: For HP there is evidence of a non-Mendelian transmission mechanism, while for FP the parental/sib transmission appears to be due only to multifactorial causes.

Familial aggregation of Leishmania chagasi infection in northeastern Brazil.

A sample of 1,604 individuals belonging to 243 nuclear families from an endemic area of visceral leishmaniasis (Jacobina, Bahia State, Brazil) was studied to disclose the intrafamilial pattern of infection. Significant father to offspring, mother to offspring, and sibling to sibling associations, in contrast a with nonsignificant father to mother association, clearly indicate a familial aggregation of the infection, with a strong suggestion of at least partial genetic involvement.

Unstable hypoendemic malaria in Rondonia (western Amazon region, Brazil): epidemic outbreaks and work-associated incidence in an agro-industrial rural settlement.

A longitudinal study was conducted from January 1991 to January 1992 on the Urupa farm, a rural agro-industrial forestry settlement in Rondonia state (Western Amazon Region, Brazil) to define the parasitologic and clinical profile of malaria. Three cross-sectional, parasitologic, and clinical surveys were performed. In the intervals between surveys, malaria cases were monitored by twice a week medical visits to the farm and permanent local surveillance. The population of residents was approximately 170 and was characterized by high mobility. The slide positive rates found in the cross-sectional surveys were 0.5, 4.2 and 2.1, respectively, for the total population (Plasmodium vivax plus P. falciparum). Spleen rate values in children 2-9 years old were always less than 1%. However, this basically hypoendemic malaria situation was unstable, with occurrence of a typical epidemic outbreak at the end of the dry season. The total number of malaria cases recorded from January to December 1991 was 163, giving an annual parasite index of 970 per 1,000 inhabitants. However, sex and age distribution of cases showed rare incidence of malaria in infants and low incidence in children less than the age of 10. Male adults 16-40 years of age represented the main risk group. The observed clustering of cases allowed us to identify the place of work as a factor responsible for high incidence of malaria among adults. The general epidemiologic profile indicated that indoors transmission of malaria by the local Anopheles vector was low or absent.

Use of recombinant antigens for the accurate immunodiagnosis of Chagas' disease.

We tested two Trypanosoma cruzi recombinant antigens in a diagnostic test for Chagas' disease. These antigens were a cytoplasmic repetitive antigen (CRA) and a flagellar repetitive antigen (FRA). The results indicate that the recombinant antigens give better results when used in combination than when used separately, and that the removal of the beta-galactosidase portion of the recombinant fusion proteins increases the specificity of the diagnostic test for Chagas' disease. In addition, a direct enzyme-linked immunosorbent assay (ELISA), which involves the use of peroxidase-labeled antigens to detect the immune-complexes, was developed and compared with a conventional ELISA. The results indicate that the recombinant (CRA+FRA) ELISA is better than the conventional ELISA in the diagnosis of Chagas' disease, providing 100% specificity and sensitivity in all sera tested to date. The recombinant ELISA was compared with conventional serologic tests (hemagglutination and immunofluorescence) for Chagas' disease diagnosis, and the results show that the recombinant ELISA does not give rise to false-positive results that are observed with the two other tests. The use of the recombinant ELISA should be useful in the prevention of transmission of Chagas' disease by blood transfusions.

Hypoendemic malaria in Rondonia (Brazil, western Amazon region): seasonal variation and risk groups in an urban locality.

A longitudinal epidemiologic survey (1989-1991) plus a cross-sectional parasitologic, clinical, and sociodemographic survey (July-October 1990) were conducted in Candeias do Jamary, a village with approximately 7,000 inhabitants in Rondonia, Brazil. Analysis of the results revealed hypoendemic malaria with a complex epidemiology. Plasmodium vivax predominated over P. falciparum infections while infections with P. malariae were absent. Malaria is present throughout the year but was clearly seasonal with epidemic outbreaks in the dry season from June to August. Malaria prevalence was lower in children less than 10 years of age and significantly higher in young adult males, which represent the high-risk group. The incidence of locally acquired infections (autochthonous cases) was significantly lower in the rainy season as compared with the dry season. This is not true with respect to heterotochthonous (imported) malaria cases, that is, malaria acquired elsewhere by Candeias residents, most of whom are male adults working outside the town. In both cases, however, the age and sex distribution of prevalence and its relationship with occupational activities indicate a predominance of outdoor transmission. The results of the cross-sectional survey are in agreement with those of the longitudinal passive survey and, in addition, disclose the absence of asymptomatic infection.

The epidemiology of malaria in Rondonia (Western Amazon region, Brazil): study of a riverine population.

We report on a longitudinal study concerning the incidence of malaria in a riverine population (Portuchuelo) settled on the riverbanks of Rio Madeira, in the State of Rondonia, Brazil. We found the incidence of malaria to be seasonal, prevailing in the dry months of June and July. The Annual Parasite Index (API) was 292/1000 inhabitants, almost three times that of the state of Rondonia for the same period. In contrast with other studied Rondonian populations, malaria in Portuchuelo was more prevalent in youngsters < 16 years old, particularly in the 0-1 year age group. Adults were relatively spared, particularly those over 50 years. Besides being indicative of indoor transmission, these facts may suggest the existence of a certain degree of acquired resistance to infection and/or of lessened symptoms in older people. Riverine populations are spread over the entire Amazon region where most of its members were born. Due to the permanent presence of malaria among riverine populations, we are proposing that they may act as perennial reserves of malaria and, therefore, as sources of infection for migrants or eventual settlers at their vicinity. To date, the opposite view has been generally held. Anopheles darlingi, the main vector species in the area, is essentially sylvatic, which contributes to make the control of malaria highly problematic. The only hopes for control rest on permanent surveillance and the prompt treatment of patients, which are also problematic considering the vastness of the Amazon region and the remoteness of some of its riverine settlements.

IMA-graft patency control by thermal coronary angiography during coronary bypass surgery.

Thermal coronary angiography (TCA) was evaluated for the intraoperative assessment of graft patency and flow in internal mammary artery (IMA) bypass grafts. TCA was performed in 210 patients undergoing 460 vein and 153 IMA bypass grafts after completion of the distal anastomoses. The IMA grafts and the recipient coronary arteries were delineated by the temperature differential between a cold epimyocardium and the perfusing warm blood after bulldog clamp release. TCA provided information about graft and anastomosis patency, initial flow patterns, and native coronary stenoses. TCA was performed in all studied IMA bypass grafts: 142 grafts were patent. Low flow but patency was observed in 24 IMA grafts and 11 IMA grafts showed no flow. Subsequently, 8 anastomotic failures and 3 proximal IMA graft occlusions were encountered. Based on these findings, 8 anastomoses were successfully revised and 7 additional vein grafts were added. One low flow IMA graft was not revised leading to postoperative ST elevation. Thirty-one distal native coronary stenoses were detected in the recipient LADs, 3 of which were not seen in the preoperative cineangiogram. In 20 instances, TCAs were obscured by an excess of fat or myocardium impeding image analysis. In 8 cases, TCA results were confirmed by conventional angiography postoperatively showing an excellent correlation in all cases. We conclude that intraoperative TCA demonstrates early IMA graft function and initial flow patterns. During our study, TCA documented a 7.2% IMA graft early failure rate. Intraoperative decision making was aided by TCA in 9.2% of all IMA grafts; this confirmed the clinical relevance of TCA.

Diagnosis of CNS lymphoma using immunofluorescent phenotyping of CSF mononuclear cells.

We describe the use of a panel of monoclonal antibodies, directed against leukocyte surface antigens to characterize CSF mononuclear cells with regard to malignancy when cytopathology was inconclusive. Cytocentrifuged preparations from three patients in which traditional modalities had not yielded a diagnosis were studied, utilizing a panel of antibodies for B and T cell antigens. All three patients were found to have B cell lymphoma of the CNS. Rapid institution of the appropriate therapy resulted in marked improvement of CNS symptoms in each case. Our results indicate that in patients with CNS disease and CSF pleocytosis of undefined nature, this technique may provide rapid and precise diagnostic information.

Objectives for an internship internal medicine: from the Dutch Blueprint (Raamplan 1994) to implementation into a practical logbook.

BACKGROUND: The Dutch Blueprint 1994 (Raamplan 1994) describes the objectives of undergraduate medical education. The Blueprint, developed in order to improve medical education in the Netherlands, is accepted by all Dutch medical schools and has been legislated. AIM: Translation of global objectives of the Blueprint into specific requirements of a Logbook (guideline and evaluation tool) for the internship Internal Medicine. DESCRIPTION: The Blueprint as such is impracticable as a guideline during the Internal Medicine internship. The content covers the objectives for the entire field of medicine, and the volume dedicated to Internal Medicine is too large to fit in with a twelve week internship. The practicability of the Blueprint leaves much to be desired because it is complex, and not easily accessible. So, the Blueprint was adapted on three points: (1) selecting those objectives out of the whole content, which are specifically relevant to Internal Medicine; (2) decreasing the volume Internal Medicine by clustering and defining the requirements; (3) making the Logbook usable as a guideline and evaluation instrument. CONCLUSION: The Logbook is a good starting-point to evaluate whether students meet the objectives of the Blueprint related to the discipline Internal Medicine.