Brock over a Decade

Book reviewed in this article: Life and Death: Philosophical Essays in Biomedical Ethics. By Dan W. Brock.     

Elephantiasis: a disease of development in north east Ghana.

A reconnaissance survey for the presence of lymphatic filariasis is made in 41 chiefdoms of north east Ghana. Four disease levels are identified culminating in hyperendemic disease foci associated with two Government-introduced rice irrigation projects. Attention is also drawn to the disease effects of small village dams. Multiple concurrent infections are noted. Within the most stricken irrigation villages, aspects of concealment, stigma and marriage are considered. Failure to control lymphatic filariasis has led to hospital avoidance and neglect of the disease jointly by patients, physicians and nurses. Culpability rests with the irrigation authority and Government health services. An outline is given of possible measures for disease control. A multisectoral policy of 'prevention before development' is strongly advocated.     

Clinical trial of a prevention and treatment protocol for skin breakdown in two nursing homes.

OBJECTIVE: Our objective was to assess the effectiveness of skin care protocols, including a body wash and skin protectant, on skin breakdown in 2 nursing homes. DESIGN: This was a quasi-experimental pretest/posttest design study.Setting and subjects Adult residents (n = 136) of 2 skilled nursing homes consented to participate in this study. Seventy percent were women; the sample average age of 82 years. INSTRUMENTS: A researcher-designed data recording form documented resident demographics, incidence and type of skin breakdown or pressure ulcer, presence of urinary or fecal incontinence, and assessment of the effectiveness of body wash and skin protectant. METHODS: Baseline data on prevalence of pressure ulcers and skin protocol were collected weekly for a 3-month period followed by a week-long educational program by the researchers about skin care and the body wash and skin protectant. During the 3-month trial with the body wash and skin protectant incorporated into routine care, research assistants recorded resident data weekly and researchers again assessed prevalence and incidence of pressure ulcers and skin breakdown weekly. RESULTS: Incorporation of a body wash and skin protectant into a skin care prevention and early intervention protocol in 2 nursing homes documented a decrease in skin breakdowns from 68 pre-intervention to 40 postintervention; the decrease in agency B was statistically significant. There was a statistically significant decrease in stage I and II pressure ulcer incidence overall (pre-intervention = 19.9%, postintervention = 8.1%). Nurses evaluated the body wash and skin protectant as effective for 98% of the time used. CONCLUSION: Implementation of a protocol for skin care along with staff education, including the prophylactic use of a body wash and skin protectant, reduced the incidence of skin breakdown, including pressure ulcers and perineal dermatitis, in 2 long-term care facilities.     

Ancillary Community Pharmacy Services Provided to Older People in A Largely Rural and Ethnically Diverse Region: A Survey of Consumers in West Texas

Little is known about the quality of pharmacy services provided to the rural elderly population. This exploratory study examines rural/urban and ethnic differences in perceived access to ancillary pharmacy services among elderly people. Two telephone surveys were conducted using directory listings in West Texas to generate a longitudinal sample. Persons aged 65 years and older who were not cognitively impaired were asked to complete the survey. The number of participants in both rounds of the survey was 3,689. Seven ancillary pharmacy services were examined: delivery of medications, medication counseling, written medication information, blood pressure monitoring, blood glucose monitoring, osteoporosis screening, and immunization. The sample was stratified by county of residence (urban, rural, or frontier) and racial/ethnic background. Chi-square tests were performed to detect rural/urban and racial/ethnic differences in access to the seven ancillary services. The association between proficiency in English and access to the services was also examined. Rural residents were more likely than urban residents to report that their pharmacies provide delivery of medications, medication counseling, and immunization services, but they were less likely than their urban counterparts to report that their pharmacies provide blood pressure monitoring. Access to ancillary pharmacy services was reported as poorer by older Hispanic people compared with non-Hispanics. Deficiency in English was significantly related to inequality in reported access to ancillary pharmacy services. It is essential to consider the special needs of rural and Hispanic elderly people to ensure equitable access to ancillary pharmacy services.     

Southern hip exposure

The efficacy of the posterior approach to the hip was analyzed in a retrospective study of 168 consecutive procedures performed by the author. Surgical technique is redefined historically and described in detail. Results are studied in two subgroups of hip surgery patients: endoprosthetic replacement (98) and total joint replacement (70). The factors evaluated were surgical time and blood loss, morbidity (dislocation, infection, pain, and limp), mortality, and complications of surgery. The posterior approach to the hip allowed excellent exposure without transecting tissue planes and creating dead spaces. Operative time averaged less than one hour for all cases, and blood loss, less than 500 cc. The four dislocations that occurred postoperatively were in patients with pre-existing flexion contractures. One superficial infection was noted but there was no increase in morbidity due to pain, limp, or loss of motion. Two total joint replacements were complicated by hematoma formation but occurred in patients who had extensive capsule resection and acetabuloplasty. Excellent and rapid exposure with minimal soft tissue destruction or blood loss coupled with few postoperative complications should encourage orthopedic surgeons to include the posterior approach in their treatment of hip problems.     

Diet and chronic atrophic gastritis: a case-control study

A hospital-based case-control study of gastric cancer precursor lesions was conducted in a high-risk black population in southern Louisiana. Ninety-three subjects with biopsy-proved advanced chronic atrophic gastritis were compared to two control series: a gastroscopy clinic series and a general hospital-admission series. Dietary case-control differences indicated a protective effect associated with fruit and vegetable intake and with dietary vitamin C and a risk elevation associated with milk consumption. The protective effect associated with consumption of fruits, vegetables, and vitamin C is consistent with findings for gastric cancer and with the etiologic hypothesis of intragastric nitrosation. A twofold increased risk was associated with cigarette smoking. Gastric juice pH, NO3-, and NO2- were determined for subjects undergoing gastroscopy, and comparisons were made between this high-risk U.S. group and a Colombian population with a much greater magnitude of risk; the latter had higher NO3- and NO2- levels. An increase in pH was associated with increasing severity of gastric lesions. Levels of pH and NO2- concentration were significantly correlated (P less than .0005); however, in Louisiana the large difference in NO2- concentration associated with pH elevation is not associated with histopathologic severity. Divergent trends with severity of lesions for NO3- concentration were seen in the two populations.     

Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder

The purpose of this study was to test the hypothesis that specific cytokines are involved in the initiation and evolution of the fibrotic process in adhesive capsulitis of the shoulder. After approval from the Institutional Review Board, biopsies of shoulder capsule and synovium were collected during shoulder arthroscopy from 19 patients with adhesive capsulitis, 14 patients with nonspecific synovitis and no fibrosis or clinical evidence of adhesive capsulitis, and seven patients undergoing surgery for another pathology who had a normal capsule and synovium. Immunohistochemical localization with monoclonal antibodies to transforming growth factor-β and its receptor, platelet-derived growth factor and its receptor, basic fibroblast growth factor, interleukin-1β, tumor necrosis factor-α, and hepatocyte growth factor was performed using standard immunoperoxidase techniques. The frequency of cytokine staining was correlated with the clinical diagnosis Synovial cells, fibroblasts, T-cells, and B-cells were identified with specific antibodies, and newly synthesized matrix was examined for type-I and type-III collagen by immunohistochemical staining. The predominant cell types present were synovial cells and fibroblasts. Staining for type-III collagen in adhesive capsulitis tissues indicated new deposition of collagen in the capsule. There was staining for transforming growth factor-β and its receptor, platelet-derived growth factor and its receptor, interleukin-1β, and tumor necrosis factor-α in adhesive capsulitis and nonspecific synovitis tissues, compared with minimal staining in normal capsule. Staining was more frequent in snovial cells than in capsular cells. The frequency of cell and matrix staining for transforming growth factor-β, platelet-derived growth factor, and hepatocyte growth factor was greater in adhesive capsulitis tissues than in those from patients with nonspecific synovitis. No difference in the frequency of staining between primary (idiopathic) and secondary adhesive capsulitis was found. The results of this study indicate that adhesive/capsulitis involves both synovial hyperplasia and capsular fibrosis. Cytokines such as transforming growth factor-β and platelet-derived growth factor may be involved in the inflammatory and fibrotic processes in adhesive capsulitis. Matrix-bound transforming growth factor-β may act as a persistent stimulus, resulting in capsular fibrosis. Understanding the basic pathophysiology of adhesive capsulitis is an important step in the development of clinically useful antifibrotic agents that may serve as novel treatments for patients with this condition.