Search

Purpose: To explore the reasons why some Chinese women travel to the United States on a tourist visa specifically to give birth, also known as birth tourism., Study Design: Qualitative, exploratory design., Methods: Using convenience and snowball sampling, Chinese women were recruited from the waiting rooms of obstetricians known to care for birth tourists. Participants completed demographic data and provided answers to questions about their reasons for traveling to give birth and their birth experience while in the United States. Qualitative content analysis methods were used to extract themes from participant narratives., Results: Twelve married, college-educated women, aged between 26 and 39 years, self-identifying as birth tourists from China participated in this study. Content analysis revealed two themes: (1) positive perceptions of childbirth in the United States; and (2) securing a future for their child., Clinical Implications: Study findings suggest Chinese birth tourists come to the United States for a better childbirth experience, and to secure future opportunities for their children. Nurses should be aware of the current political climate on immigration and birth tourism in order to promote a safe and judgment-free environment when providing care to this unique population of women.

The objectives of this study were determine the quality of life (QoL) for patients with nasopharyngeal carcinoma (NPC) after treatment with different advanced technologies in radiotherapy (RT). A total of 150 patients with NPC were consecutively treated using curative RT in the Department of Radiation Oncology at Tri-service General Hospital in Taiwan. Data were collected prospectively from medical records and questionnaires. We used the Short-Form-36 (SF36) health survey questionnaire to evaluate general QoL, and a modified EORTC QLQH& N35 questionnaire to evaluate the correlation of xerostomia with QoL. The selection of RT methodology among two-dimensional radiotherapy (2D-RT), three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) was a significant factor for predicting difficulty of speech (P = 0.003), difficulty in chewing (P = 0.012), swallowing ability (P = 0.004), dry throat sensation during meals (P = 0.006) and the frequency of drinking water to maintain a moist mouth (P = 0.01). Our data suggest that the intensity-modulated radiotherapy technique plays a significant role in improving the QoL of NPC patients in our study.

Background: Electronic patient-reported outcomes (PRO) provide quick and usually reliable assessments of patients' health-related quality of life (HRQL)., Objective: An electronic version of the Patient-Reported Outcomes Quality of Life-human immunodeficiency virus (PROQOL-HIV) questionnaire was developed, and its face validity and reliability were assessed using standard psychometric methods., Methods: A sample of 80 French outpatients (66% male, 52/79; mean age 46.7 years, SD 10.9) were recruited. Paper-based and electronic questionnaires were completed in a randomized crossover design (2-7 day interval). Biomedical data were collected. Questionnaire version and order effects were tested on full-scale scores in a 2-way ANOVA with patients as random effects. Test-retest reliability was evaluated using Pearson and intraclass correlation coefficients (ICC, with 95% confidence interval) for each dimension. Usability testing was carried out from patients' survey reports, specifically, general satisfaction, ease of completion, quality and clarity of user interface, and motivation to participate in follow-up PROQOL-HIV electronic assessments., Results: Questionnaire version and administration order effects (N=59 complete cases) were not significant at the 5% level, and no interaction was found between these 2 factors (P=.94). Reliability indexes were acceptable, with Pearson correlations greater than .7 and ICCs ranging from .708 to .939; scores were not statistically different between the two versions. A total of 63 (79%) complete patients' survey reports were available, and 55% of patients (30/55) reported being satisfied and interested in electronic assessment of their HRQL in clinical follow-up. Individual ratings of PROQOL-HIV user interface (85%-100% of positive responses) confirmed user interface clarity and usability., Conclusions: The electronic PROQOL-HIV introduces minor modifications to the original paper-based version, following International Society for Pharmacoeconomics and Outcomes Research (ISPOR) ePRO Task Force guidelines, and shows good reliability and face validity. Patients can complete the computerized PROQOL-HIV questionnaire and the scores from the paper or electronic versions share comparable accuracy and interpretation.

Background: In Taiwan, the policy of catastrophic illness certificates has benefited some populations with specific diseases, but its effect on the use of medical services and the sequence of public health has not been examined. As a pilot of a series of studies, focused on emergency department (ED) visits, the present study aimed to compare medical utilization and various diagnostic categories at EDs between the elderly with an identified catastrophic illness and the elderly without., Methods: A cross-sectional study, based on a large-sample nationwide database (one million of the population, randomly sampled from Taiwan's National Health Insurance Research Database (NHIRD)), was performed in Taiwan. The 2008 insurance records of ambulatory medical services for subjects aged 65 years or more among the above one million of the population were further selected and analyzed. Taiwan's registered catastrophic illness dataset for 2008 was linked in order to identify the target subgroup., Results: The prevalence of certificated catastrophic illness in Taiwan's elderly utilizing ambulatory medical services was 10.16%. On average, 61.62 emergency department (ED) visits/1,000 persons (95% CI: 59.22-64.01) per month was estimated for the elderly Taiwanese with catastrophic illness, which was significantly greater than that for the elderly without a catastrophic illness (mean 33.53, 95% CI: 32.34-34.71). A significantly greater total medical expenditure for emergency care was observed in the catastrophic illness subgroup (US$145.6 ± 193.5) as compared with the non-catastrophic illness group (US$108.7 ± 338.0) (p < 0.001). The three most common medical problems diagnosed when visiting EDs were injury/poisoning (14.22%), genitourinary disorders (11.26%) and neoplasm-related morbidity (10.77%) for the elderly population with a catastrophic illness, which differed from those for the elderly without a catastrophic illness., Conclusions: In Taiwan, the elderly with any certificated catastrophic illness had significantly more ED visits and a higher ED medical cost due to untypical medical complaints.

The triangular fibrocartilage complex (TFCC) is an anatomically and biomechanically important structure. Repair of radial-sided TFCC tear has previously been challenging. We designed a new method of radial-sided TFCC tear repair and found that it was also applicable for ulnar-sided TFCC tear repair. From October 2006 to December 2010, 10 patients underwent this operation and were reviewed: 9 men and 1 woman, with a mean age of 33.9 years. Average postoperative follow-up was 8 months. We graded results according to the Mayo modified wrist score. We rated 2 of the 10 patients (20%) as "excellent," 3 (30%) as "good," and 5 (50%) as "fair." The 5 patients who were rated as "fair" returned to regular jobs or had restricted employment. Based on this small sample, we recommend that this technique be considered an alternative method for TFCC repair., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Workplace air samples from sintering, cokemaking, and hot and cold forming processes in the integrated iron and steel industry were analyzed to determine their volatile organic compound (VOC) concentration. Sixteen VOC species including three paraffins (cyclohexane, n-hexane, methylcyclohexane), five chlorinated VOC species (trichloroethylene, 1,1,1-trichloroethane, tetrachloroethylene, chlorobenzene, 1,4-dichlorobenzene), and eight aromatics (benzene, ethylbenzene, styrene, toluene, m,p-xylene, o-xylene, 1,2,4-trimethylbenzene, 1,3,5-trimethylbenzene) were selected to measure their noncancer risk for workers. Concentrations of toluene, xylene, 1,2,4-trimethylbenzene, 1,3,5-trimethylbenzene, dichlorobenzene, and trichloroethylene were high in all four processes. Carbon tetrachloride and tetrachloroethylene concentrations were high in the hot and cold forming processes. The noncancer risk followed the increasing order: cokemaking > sintering > hot forming > cold forming. 1,2,4-trimethylbenzene and 1,3,5-trimethylbenzene contributed 44% to 65% and 13% to 20% of noncancer risk, respectively, for the four processes. Benzene accounted for a high portion of the noncancer risk in cokemaking. The hazard index (HI: 17-108) of the average VOC concentrations suggests that health risks can be reduced by improving workplace air quality and protecting workers.

Objective: Poly(methyl methacrylate) (PMMA) is commonly processed in dentistry by thermally initiating the free-radical polymerization of methyl methacrylate (MMA). Residual MMA, a tissue irritant, is a concern. The concentration of MMA ([MMA]) versus time and temperature was studied to identify optimum processing conditions., Materials and Methods: One hundred milligram portions of plain and dental PMMA powders were incubated (10-170 degrees C, 1-384 h), with and without 6.0 microL MMA added. After incubation, [MMA] was determined by GC., Results: For plain PMMA alone, equilibrium was attained in about 100 h. The equilibrium data for log[MMA] versus 1/T was better fitted by a quadratic than a straight line, and formed an upper bound to the values of [MMA] when PMMA was incubated with MMA at temperatures > approximately 120 degrees C. The response surface for [MMA] versus log(time) and reciprocal temperature was fitted. An 'overshoot' in the equilibration process was identified, and postulated to be due to a rapidly formed intermediate of unknown chemistry., Significance: Minimization of the residual MMA in acrylic denture bases prepared by processing a mixture of PMMA and MMA is important for reasons of mechanical properties and irritancy. The response surface mapped here allows direct identification of the optimum processing conditions.

Objectives: Residual monomer ([MMA](R)) in denture base acrylic continues to be of concern. The response surface of concentration vs. time and temperature for the equilibration of methyl methacrylate (MMA) and its polymer (PMMA) allows a prediction of the time to the minimum at any temperature for a closed system. It was the purpose here to determine whether this prediction applies to normal denture base processing, and whether optimum conditions could be identified., Methods: Denture bases were processed following normal laboratory procedures, including pre-cure for 3 h at 70 degrees C for all tests. Commercial powder and liquid were used at either 95 or 100 degrees C, or a plain PMMA powder and the same liquid at 95 degrees C, for times ranging from 5 to 192 h. Residual MMA was determined by gas chromatography., Results: [MMA](R) decreased steadily from approximately 0.25% to as low as approximately 0.07% with increasing time at temperature, but did not approach equilibrium. The rate of diffusive loss of MMA appears to exceed the rate of depolymerization., Significance: Residual monomer is inevitable for all PMMA-based products no matter what the curing conditions are. However, extended time at high temperature can allow low values to be attained, and the time allowed can compensate for processing temperatures somewhat lower than the ordinarily recommended 100 degrees C. It is suggested that overnight processing at 95 degrees C should be adopted to minimize [MMA](R) and save energy. This result is of importance for work at high altitude.

Clostridium botulinum neurotoxin type A (BTx-A) is known to inhibit the release of acetylcholine at the neuromuscular junctions and synapses and to cause neuroparalysis and death. In this study, we have identified two monoclonal antibodies, BT57-1 and BT150-3, which protect ICR mice against lethal doses of BTx-A challenge. The neutralizing activities for BT57-1 and BT150-3 were 10(3) and 10(4) times the 50% lethal dose, respectively. Using immunoblotting analysis, BT57-1 was recognized as a light chain and BT150-3 was recognized as a heavy chain of BTx-A. Also, applying the phage display method, we investigated the antibodies' neutralizing B-cell epitopes. These immunopositive phage clones displayed consensus motifs, Asp-Pro-Leu for BT57-1 and Cys-X-Asp-Cys for BT150. The synthetic peptide P4M (KGTFDPLQEPRT) corresponded to the phage-displayed peptide selected by BT57-1 and was able to bind the antibodies specifically. This peptide was also shown by competitive inhibition assay to be able to inhibit phage clone binding to BT57-1. Aspartic acid (D(5)) in P4M was crucial to the binding of P4M to BT57-1, since its binding activity dramatically decreased when it was changed to lysine (K(5)). Finally, immunizing mice with the selected phage clones elicited a specific humoral response against BTx-A. These results suggest that phage-displayed random-peptide libraries are useful in identifying the neutralizing epitopes of monoclonal antibodies. In the future, the identification of the neutralizing epitopes of BTx-A may provide important information for the identification of the BTx-A receptor and the design of a BTx-A vaccine.

Objective: This article presents information on the important impact the lack of adherence to prescribed treatments has on the morbidity and mortality of asthma. After reading this article, readers should have an understanding of the significant role clinicians, as well as patients and their families, play in promoting adherence., Data Sources: A detailed literature search was conducted. Relevant studies were used. Only literature in the English language was reviewed., Study Selection: Material was taken from academic/scholarly publications, appropriate reviews, and published abstracts., Results: Over the last decade, many researchers have examined ways to improve adherence to asthma therapy, including improving clinician-patient communication, educating the patient, and simplifying the treatment regimen. Nonadherence is a problem in pediatric and adolescent patients, whose needs are different from those of adult patients. Because proper technique is essential with metered-dose inhalers and peak flow meters, special efforts are required by clinicians to promote adherence to these devices., Conclusions: Promoting adherence involves a good clinician-patient relationship, as well as provision of personalized, practical, and repeated education.

Retinoic acid (RA), a derivative of vitamin A, is essential for normal patterning and neurogenesis during development. Until recently, studies have been focused on the physiological roles of RA receptors (RARs), one of the two types of nuclear receptors, whereas the functions of the other nuclear receptors, retinoid X receptors (RXRs), have not been explored. Accumulating evidence now suggests that RXRalpha is a critical receptor component mediating the effects of RA during embryonic development. In this study, we have examined the expression profiles of RXRalpha and RARs during the RA-induced neuronal differentiation in a human embryonal carcinoma cell line, NT2. Distinct expression profiles of RXRalpha, RARalpha, RARbeta, and RARgamma were observed following treatment with RA. In particular, we found that RA treatment resulted in a biphasic up-regulation of RXRalpha expression in NT2 cells. The induced RXRalpha was found to bind specifically to the retinoid X response element based on gel mobility retardation assays. Furthermore, immunocytochemical analysis revealed that RXRalpha expression could be localized to the somatoaxonal regions of the NT2 neurons, including the tyrosine hydroxylase- and vasoactive intestinal peptide-positive neurons. Taken together, our findings provide the first demonstration of the cellular localization and regulation of RXRalpha expression in NT2 cells and suggest that RXRalpha might play a crucial role in the cellular functions of human CNS neurons.

This paper discusses the relation between fractal dimension and roughness index for fractal surfaces of solids. The applicability of the relation to fracture of Mode III+Mode I complex loading is shown. The applicability to other rough surfaces is discussed.

The relative motion of 3 different bipolar endoprostheses was evaluated in vitro. A paired fresh acetabulum was frozen at 0 degrees C and defrosted 12 hours before the experiment. Three bipolar endoprostheses were evaluated: UNIQHIP system (United Orthopedics), UHR system (Osteonics), and AML system (Depuy). The surface roughness and spherical roundness of outer shells and inner heads of the bipolar prostheses were measured before the experiments. The acetabulum and outer shell of the bipolar prostheses were fixed on a Bionix 858 material testing system axially by separate fixation tools. The axial load of 1,400 N and 2,800 N was than applied on the specimen. The axis was rotated from 0 degrees to 90 degrees at the speed of 1 degree/s. All 3 outer shells were tested to this paired acetabulum randomly and separately. The frictional torque on the outer bearing surface of the different prostheses was recorded by the material testing system. The frictional torque on the inner bearing surface was also measured by the same procedure as was done for the outer bearing. The final results were statistically compared by the 1-way analysis of variance test method. Bipolar prostheses of the UHR system showed the largest frictional torque on outer bearing when it was loaded with 1,400 N and 2,800 N. The final results showed that all the bipolar prostheses had ideal motion behavior when functioning under the loading of 1,400 N. The frictional torque on the inner bearing was found to be larger than the frictional torque on the outer bearing in some prostheses when the loading was increased to 2,800 N. Thus, the bipolar endoprostheses functioned as unipolar prostheses. The only relative motion remained between the outer bearing surface and the acetabulum. This effect causes complications, such as implant protrusion in the acetabulum.

Background: Nasopharyngeal carcinoma (NPC) is a prevalent malignant tumor among Southern Chinese. Previously, the authors described the prognostic significance of a serum antibody assay to a recombinant Epstein-Barr virus Bam HI-Z replication activator protein (ZEBRA) in NPC patients with long term follow-up. In this study, the authors further reported the use of DNA flow cytometry (DNA-FCM) as an additional technique for determining the prognosis of NPC patients in the same series., Methods: One hundred and forty-three archival biopsies from 110 NPC patients were deparaffinized and subjected to DNA-FCM analysis. DNA ploidy state and various proliferative indices (PI) of the tumors were correlated with patient survival and frequency of recurrence., Results: Among the biopsies analyzed, 119 were histologically positive NPC and 24 were negative. Fifty-one tumor biopsies that fulfilled the guideline criteria of the DNA Cytometry Consensus Conference were correlated with the clinical manifestations of the patients. Among them, 43 tumors (84%) were DNA diploid and 8 (16%) were aneuploid. Two PI, S-phase fraction (SPF) and proliferation fraction (PF), appear to be potentially useful prognostic indicators. For example, PF in patients who developed locoregional recurrence (15.1%) and distant recurrence (16.4%) after radiation therapy both were significantly higher than PF in patients who were in complete remission (8.2%) (P = 0.0005 and P = 0.004, respectively). Significant differences in SPF between patients with distant recurrence (10.6%) and those in remission (5.7%) also was found (P = 0.005). Using Kaplan-Meier analysis, patients with high PF, high SPF, and aneuploid tumors had significantly poorer 12-year survival rates (35%, 26%, and 28%, respectively) than those patients with low PF, low SPF, and diploid tumors (77%, 67%, and 59%, respectively) (P < 0.0009, P < 0.004, and P < 0.01, respectively)., Conclusions: Determination of tumor PI and DNA ploidy state by DNA-FCM at diagnosis of NPC can be potentially useful in selecting a poor prognostic subgroup of NPC patients. These parameters may enable oncologists to plan for more stringent treatment strategies such as hyperfractionated and accelerated radiation therapy or concomitant chemoradiotherapy for these patients.

A potential mechanism for the increased sensitivity of inflamed tissues to bradykinin is the upregulation of bradykinin receptor expression. We report that recombinant human IFNgamma stimulated a concentration-dependent increase in cell surface bradykinin receptor expression in intact T24 human epithelial-like cells, determined by radioligand binding analysis. Analysis of specific [3H]-bradykinin binding revealed that IFNgamma-treated cells had a two- to threefold increase in bradykinin receptor number compared to the controls with no effect on receptor affinity. The ability of IFNgamma to stimulate increased bradykinin receptor expression was abrogated by treatment with either the transcription inhibitor actinomycin D or the protein synthesis inhibitor cycloheximide. IFNgamma enhanced steady-state human B2 bradykinin receptor mRNA expression in the T24 cells in a dose-dependent manner. B2 bradykinin receptor mRNA expression was increased as early as 1 h following IFNgamma stimulation, and continued to accumulate for 24 h. Bradykinin-stimulated intracellular calcium mobilization was also increased in IFNgamma-treated T24 cells compared to controls. The ability of IFNgamma to upregulate B2 bradykinin receptors in primary epithelial cells was demonstrated using cultured human airway epithelial cells. These observations suggest that increasing IFNgamma levels during inflammation may upregulate the expression of B2 bradykinin receptors, leading to increased sensitivity to bradykinin.

Objective: To identify a Golgi complex autoantigen bound by Sjögren's syndrome (SS) autoantibodies., Methods: Serum from a patient with secondary SS and anti-Golgi antibodies was used as a probe to isolate a complementary DNA (cDNA) insert from a HeLa cDNA library., Results: A 3.7-kb cDNA encoding a 56-kd recombinant protein was immunoprecipitated by the human anti-Golgi serum and immune rabbit serum. Western blot analysis showed that the immune rabbit sera recognized a protein of 97 kd (golgin-97), suggesting that the isolated clone contained a partial cDNA. The 5' upstream sequence was obtained by rapid amplification of the cDNA ends. The complete cDNA contained 4,860 basepairs, encoding a protein with a calculated Mr of 88 kd. Antibodies to golgin-97 were found in 12 (20%) of 60 sera known to have anti-Golgi autoantibodies, and the majority of these sera (8 of 12, or 75%) were from patients who had secondary SS., Conclusion: Golgin-97 is a unique Golgi complex antigen that appears to be a target of SS autoantibodies.

The B2 bradykinin receptor (B2BKR) mediates most of the inflammatory actions of bradykinin. To evaluate its potential role in allergic diseases, we assessed the structure of the human B2BKR gene. Screening a human placenta genomic DNA library identified only clones containing exons 2 and 3. Human placenta and colon tissues were used for 5' rapid amplification of complementary DNA ends to identify nine exon 1 clones, each containing one 9 bp and two 1 bp deletions compared with published sequences. Exon 1 genomic polymerase chain reaction of human leukocyte DNA revealed two distinct products, which were shown to differ by the presence or absence of the 9 bp deletion. Alleles with the 9 bp deletion were designated as (-)21-29, whereas alleles without the deletion were designated as (+)21-29. Genomic polymerase chain reaction in 39 Caucasian, 31 African-American, and 32 Asian normal subjects revealed a highly significant difference in the allelic frequency of the two genotypes, primarily because of an absence of the (+)21-29 allele in Asian subjects. Analysis of steady-state B2BKR messenger RNA levels by reverse-transcription polymerase chain reaction in heterozygous normal subjects revealed consistently higher expression of (-)21-29 transcripts. To investigate the potential clinical significance of the exon 1 polymorphism, 21 patients with angioedema and C1 inhibitor deficiency were genotyped. None were homozygous for the (+)21-29 allele (p = 0.0088 compared with normal subjects). In contrast, two patients with immunochemical evidence of hereditary angioedema without history of clinical angioedema were (+)21-29 homozygous. These results suggest that the B2BKR genotype may influence clinical status in diseases characterized by involvement of bradykinin.

Previous studies have shown that lipid peroxidative processes may play a role in disease pathogenesis in lupus-prone MRL/lpr mice. Studies were thus performed to determine if an immune response against malondialdehyde (MDA), a highly reactive byproduct of lipid peroxidation, was present in these mice. By using MDA-modified mouse serum albumin (MSA) as antigens in ELISA, we found that these mice produce high levels of MDA-specific antibodies in the complement-fixing IgG2a and IgG2b subclasses. Anti-MDA antibodies were also found in MRL/+ mice but in significantly lower levels. The specificity of these antibodies was verified by inhibition ELISA. MDA may contribute to disease pathogenesis in these mice by altering the immunogenicity of self molecules, eliciting an immune response and forming immune complexes that may deposit in tissues.

The serum from a Sjögren's syndrome patient with anti-Golgi antibodies was used as a probe to isolate a 4.6-kilobase pair cDNA insert from a HeLa cDNA library. Expression of the cDNA in Escherichia coli and the in vitro translation products of the cDNA yielded a recombinant protein that migrated in SDS-polyacrylamide gel electrophoresis at 180 kDa. This protein was immuno-precipitated by the human anti-Golgi serum and by immune rabbit serum but not by normal human serum or preimmune rabbit serum. Western blot analysis showed that the prototype human and immune rabbit sera recognized a 245-kDa protein, suggesting that the isolated clone contained a partial cDNA. The 5'-upstream sequence obtained by the rapid amplification of cDNA ends methodology using human placental cDNA and the combined HeLa cDNA contained 6965 base pairs and combined HeLa cDNA contained 6965 base pairs and encoded a protein of 245 kDa and, like other Golgi autoantigens described earlier, is highly rich in coiled-coils. The deduced amino acid sequence included the decapeptide ESLALEELEL, which was identified as one of two signature sequences previously reported in a family of peptide hormones and neuropeptides known as "granins". This is the first report of a Golgi complex autoantigen that bears structural similarities to the granin family of proteins.

The purpose of this study was to determine factors associated with the development of a persistently depressed cardiac output during the first year after cardiac transplantation. With this aim in mind, the records of 133 consecutive patients undergoing orthotopic cardiac transplantation and surviving for > or = 1 year after transplantation were reviewed. For each patient, the mean cardiac index for each of the 3-month periods, 0-3, 4-6, 7-9, and 10-12 months after transplantation was calculated. Of the 133 patients, 19 (14%) had a mean cardiac index < 2.4 l/min/m2 during > or = 3 of these 3-month periods. The pre- and post-transplantation clinical, immunologic, and hemodynamic data of these 19 patients (study group) were compared with the remaining 114 patients (control group). Compared with the control group, the patients in the study group were older (56 +/- 5 vs. 46 +/- 15 years; p = 0.0001), more frequently had ischemic heart disease as the original diagnosis (58 vs. 37%; p < 0.05), had a lower preoperative cardiac index (1.91 +/- 0.53 vs. 2.71 +/- 1.0 l/min/m2; p = 0.0001), more frequently did not receive perioperative anti-T cell therapy (47 vs. 25%; p = 0.046), and had a greater median number of infections during the first year after transplantation (5 vs. 3; p = 0.027). However, only one factor--a low preoperative cardiac index--emerged as an independent predictor of the development of a persistently depressed cardiac index during the first year after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

In the conclusion of a three-part series on patient-centered asthma care, the authors describe the program developed at National Jewish Center for Immunology and Respiratory Medicine. Beginning at the time of diagnosis, the interdisciplinary intervention team works in tandem with the patient and family to build confidence, skill, and motivation in self-management.

To determine the effect of diabetes mellitus on cerebral microvessel protein composition, post translational modification of proteins with glucose and malondialdehyde (MDA) was determined and the abundant protein species found in cerebral microvessels isolated from control and streptozotocin-induced diabetic rats were studied. Two dimensional gel electrophoresis and computer assisted densitometry revealed that only one out of 25 quantitated proteins was significantly altered in diabetic rats after 5 weeks of uncontrolled hyperglycemia. The level of glycosylation of cerebral microvessel protein mixture was significantly increased in diabetic rats compared to control rats (168.8 +/- 25 vs 109.5 +/- 4.8 nmol/mg) (p < 0.05). Western blot analysis of cerebral microvessel proteins from diabetic rats using a specific antibody against MDA-modified proteins revealed three protein spots with molecular weights of approximately 60,000 Kd. These were shown not to be contaminants from cerebral tissue or plasma proteins modified with MDA. It is concluded that short duration of streptozotocin-induced diabetes mellitus in rats is associated with some qualitative changes in protein composition of cerebral microvessels. These changes may contribute to the diabetes-related alterations in the blood-brain barrier.

In the second part of a three-part series on patient-centered asthma care, the authors describe the eight critical elements of multidisciplinary care management for patients with moderate to severe asthma.

In this first part of a three-part series, the authors discuss a treatment program for patients with chronic, severe asthma. Of all chronic diseases, asthma has proven to be one of the most expensive--financially, physically, and psychologically. Although the symptoms are usually reversible, they can be severe if left untreated. Physicians, nurses, and case managers across the country are recognizing the total value of treatment at "centers of excellence." In referring their toughest asthma cases to these centers, health care professionals and patients alike are experiencing the positive benefits received from a patient-centered, multidisciplinary approach.

Only recently has it been appreciated that the considerable morbidity of asthma can be reduced with tools readily available to every physician who treats children. The pharmacotherapeutic armamentarium has been strengthened by better understanding of the pathogenesis of asthma, the impact of inflammation, and the role of preventive therapy. The task remains to put this expanded knowledge to use to help a larger number of children with asthma and their families to diminish the impact that the disease has on their lives. Concomitant with increased understanding of the pathophysiology of asthma and the medications used to control the process has been a greater appreciation of the role of co-management or self-management. Several programs have been developed to help parents and children with asthma gain better control over the disease, thus decreasing morbidity and significantly improving quality of life. These programs are available to physicians and health care organizations, and it is strongly recommended that asthma education, both as a formal course and in the physician's office, be regularly incorporated into the care plan for every child with asthma.

Malondialdehyde (MDA), a product of lipid peroxidation, can bind to and modify proteins by adduct formation. To determine whether MDA adducts were immunogenic, MDA was added to rabbit serum albumin (RSA) in order to characterize MDA-proteins and to immunize rabbits. Bound MDA was proportional to the concentration of MDA added in the range of 2.5-20 mM as measured by thiobarbituric acid reactivity. MDA adducts of RSA migrated further toward the anode than native serum protein in zone and immunoelectrophoresis indicating increased negative charge. Rabbits immunized with MDA-RSA produced high titers of IgG antibodies to MDA-RSA as measured by enzyme-linked immunosorbent assay (ELISA). Hapten specificity of the antibody was demonstrated by antisera reactivity with MDA-RSA but not with unaltered RSA. Our findings support the possibility that MDA may serve as a hapten to form neoantigens which may represent a pathway by which lipid peroxidation could produce tissue damage via an immunologic mechanism.

Acetaldehyde (A), an ethanol metabolite, was incubated with rabbit serum albumin (RSA) and human serum albumin (HSA) to form the corresponding soluble haptenized proteins, A-RSA and A-HSA respectively. Both protein adducts showed conjugation with acetaldehyde evidenced by more rapid anodal migration compared to RSA and HSA. A-RSA immunized rabbits produced titers greater than 1:100,000 by enzyme-linked immunosorbent assay (ELISA). Rabbit serum antibodies to A-RSA diluted 1:10,000 showed high specificity for the hapten when reacted with acetaldehyde conjugates of RSA, HSA, bovine serum albumin, bovine gamma globulin and human gamma globulin. Our findings support the possibility that acetaldehyde may serve as a hapten to form neoantigens relevant to an immunologic mechanism which might be associated with alcoholic liver disease.