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This article reviews recent literature on the physical and psychosocial correlates of head and neck cancer, with a focus on quality-of-life issues, rehabilitation outcomes, and changes in the literature from the previous decade. These studies have shown that head and neck cancer has an enormous impact on the quality of life of patients. The most important physical symptoms are speech problems, dry mouth and throat, and swallowing problems. Pain is also frequently reported. Disturbances in psychosocial functioning and psychological distress are reported by a considerable number of patients; worry, anxiety, mood disorder, fatigue, and depression are the main symptoms. Cancer of the head and neck has a negative effect on social, recreational, and sexual functioning. Despite a growing number of longitudinal studies, little is known about the rehabilitation outcomes over a longer period of time. Future research is necessary to form a consensus about the further development and use of specific instruments to study patients with cancer of the head and neck, to conduct more prospective studies, and to develop programs that are aimed at maximizing rehabilitation outcomes and evaluate these programs with randomized designs.

If rheumatoid arthritis (RA) patients with a mild disease course could be identified early in the phase of the disease, therapy with less aggressive and probably less toxic antirheumatic drugs seems to be rational. The aim of this study was to investigate which factors at baseline could predict a clinical response (American College of Rheumatology preliminary response criteria) after treatment with chloroquine for 16 weeks. Two hundred and three early RA patients with active disease were treated with oral chloroquine sulphate (Nivaquine) at a daily dose of 300 mg during the first 4 weeks, 200 mg during the second 4 weeks and 100 mg thereafter. One hundred and eighty-three patients (90%) completed the study and 20 patients prematurely discontinued treatment. Of all the patients, 43 patients (21%) met the response criteria. A low level of C-reactive protein (CRP) was the only independent predictor for clinical response [relative risk: 0.97 (95% confidence interval: 0.95-0.98)]. It was concluded that a clinical response to chloroquine therapy in early RA patients can be predicted by a low CRP level at baseline.

Background: Studies that have examined correlations between psychosocial factors and survival in cancer patients do not permit any definitive conclusions. To the authors' knowledge, to date no study has examined the relation between medical as well as quality of life variables and survival in head and neck carcinoma patients. The current study focused on the complex interactions among psychosocial, medical, behavioral, and demographic variables as they relate to prognosis in these patients., Methods: A total of 133 consecutive head and neck carcinoma patients were included in a prospective study at pretreatment. In addition to clinical variables, psychosocial and physical functioning was assessed by means of a self-report questionnaire., Results: During the observation period 57 patients died whereas 76 were still alive at 6 years after treatment. Results of the multivariate survival analysis indicated that patients without head and neck metastasis had a better prognosis than patients with positive cervical lymph nodes. Pretreatment smoking showed a negative correlation with overall survival. Patients who were more physically self-efficacious (i.e., higher perceived physical abilities) were more likely to survive and less likely to develop a recurrence. In addition, patients who expressed intense psychosocial complaints prior to treatment had a better prognosis than had those who did not express such negative feelings., Conclusions: The current findings linking physical self-efficacy and prognosis are promising, but clinical trials are necessary to examine the direct and indirect mediational pathways of the variables that underlie physical efficacy and influence survival and recurrence. Also, the negative correlation between pretreatment smoking and survival suggests a need for increased efforts to address smoking in newly diagnosed patients.

Leprosy is a disease which has struck fear into human beings for thousands of years. This is partly because it causes considerable deformities and disabilities. In 1991, the 44th World Health Assembly adopted a resolution to eliminate the disease as a public health problem by the year 2000. However, one of the major obstacles to achieving this objective is the stigma associated with the disease. Stigma against leprosy patients affects all aspects of leprosy control. This paper describes a model of the stigmatization process in leprosy. The process of stigmatization can be divided into two stages. The first stage describes how certain cognitive dimensions of leprosy lead to a variety of affective responses towards the disease. The second stage involves how these affective responses contribute to social devaluation of the leprosy patient and consequently, the adoption of negative behaviours towards them.

This qualitative study aims to assess health education practice in sexually transmitted infection (STI) clinics in South Africa with a view to develop improved health education programs in such clinics. Health workers' knowledge of and attitudes towards health education practice, their perceived health education skills, the content of health education in STI clinics and the organizational structure as context for health education were investigated. In-depth interviews were conducted with 18 health care workers practicing in the area of STI control. A lack in knowledge and skills required for effective health education practice was reported. The constraints posed by health workers' current knowledge and skills around health education and the organizational structure in terms of the absence of policy and protocols to govern health education, limited time, space and resources, impede on the actual practice of health education. It seems that these obstacles to health education facilitate a biomedical approach to STI management. This approach is further portrayed in the power dynamics between the health workers as well as between health workers and patients. The data suggest that a health education intervention needs to be directed at an individual level namely at health workers and at the organizational level, i.e. the clinic that provides the context for health education. The newly adopted district health system which equally embraces medical care and health promotion augers well for a holistic management of STIs in South Africa. This would ensure the recognition of all categories of health workers' contributions to health education within their own functions, strengths and time limitations.

Objective: To evaluate the cyclosporin A (CSA)-attributed risk of developing malignancies in general and malignant lymphoproliferative diseases (LPDs) and skin cancers in particular, as well as the CSA-attributed incidence of mortality in patients with rheumatoid arthritis (RA)., Methods: In a retrospective, controlled cohort study, the incidence of malignancies and mortality was evaluated in 208 CSA-treated patients with RA compared with 415 matched control patients with RA between 1984 and 1995. Patients were followed up for a median of 5.0 years (range 1.4-12.0)., Results: Forty-eight cases of malignancy (8 in the CSA group and 40 in the control group; relative risk [RR] 0.40, 95% confidence interval [95% CI] 0.19-0.84) were identified, of which 8 were malignant LPDs (2 CSA versus 6 control; RR 0.67, 95% CI 0.14-3.27) and 14 were skin cancers (2 CSA versus 12 control; RR 0.33, 95% CI 0.08-1.47). Seventy-three patients died (16 CSA versus 57 control; RR 0.56, 95% CI 0.33-0.95) due primarily to cardiovascular diseases (4 CSA versus 22 control; RR 0.36, 95% CI 0.13-1.04) or a malignancy (3 CSA versus 8 control; RR 0.67, 95% CI 0.18-2.43). Proportional hazards regression analysis with correction for potential confounding factors did not significantly change the results., Conclusion: The study findings suggest that CSA treatment in RA patients does not increase the risk of malignancies in general or the risk of malignant LPDs or skin cancers in particular. Moreover, the incidence of mortality in CSA-treated RA patients was comparable to that in matched control RA patients.

Objective: To investigate whether there is interaction between chloroquine and cyclosporine (CyA) at the level of efficacy and toxicity in patients with recent onset rheumatoid arthritis (RA)., Methods: Eighty-eight patients with recent onset RA, who had shown a suboptimal clinical response on low dose chloroquine monotherapy, were randomly assigned to additional treatment with placebo, CyA 1.25 mg/kg/day, or CyA 2.50 mg/kg/day (fixed doses) for another 24 weeks. The tender joint count was the primary outcome assessment of efficacy and the serum creatinine of toxicity. The 1995 preliminary ACR response criteria for improvement were applied to evaluate individual clinical responses., Results: Two patients in the placebo group (n = 29), 7 patients in the CyA 1.25 mg group (n = 29), and 8 patients in the CyA 2.50 mg group (n = 30) (p = 0.06) discontinued study medication prematurely for inefficacy or adverse events. The intention-to-treat analysis revealed that the tender joint count decreased 2.2 +/- 6.1 (mean +/- SD) joints in the placebo group, 2.2 +/- 6.6 joints in the CyA 1.25 mg group, and 5.0 +/- 5.8 joints in the CyA 2.50 mg group (p = 0.04). The 1995 preliminary ACR response criteria for clinical improvement were met by 8 (28%) patients in the placebo group, 10 (34%) patients in the CyA 1.25 mg group, and 15 (50%) patients in the CyA 2.50 mg group (p = 0.07). The serum creatinine increased 2 +/- 7 micromol/l in the placebo group, decreased 1 +/- 8 micromol/l in the CyA 1.25 mg group, and increased 10 +/- 15 micromol/l in the CyA 2.50 mg group (p < 0.001)., Conclusion: The addition of low dose CyA is moderately effective in patients with early RA already treated with low dose chloroquine, but results in statistically significant renal function loss.

Sexually transmitted diseases (STDs) are widespread in South Africa and contribute to the growing HIV epidemic. As an important step in curtailing the spread of STDs, this study explores STD patients' illness representations within its socio-cultural context, particularly gender relationships. In-depth interviews were conducted with Xhosa- and Zulu-speaking patients in clinics in Cape Town, Western Cape (N = 67) and in rural areas of Kabokweni, Mpumalanga (N = 21) The findings suggest that STD patients' illness representations are reflections of their socio-cultural understanding of disease and of culturally defined gender relations. This, in turn, impacts on their general perceptions of the cause of STDs, their perceptions of the risk of contracting STDs, them entering and using formal and traditional medical treatment and on their ideas of prevention. Thus, healthy behaviours need to be facilitated through multiple educational strategies focusing on an improved understanding of the cause of the STD in its context of gender relations, the development of interpersonal and technical skills, as well as focusing on cues for action.

The value systems of hypercompetitive and personal development competitive individuals were examined in a sample of university undergraduates. As expected, people higher in hypercompetitiveness and in personal development competitiveness were both more likely to endorse values related to self-contained individualism such as achievement, hedonism, and a striving for an exciting and challenging life, but only hypercompetitives endorsed the value of power and control over others. Moreover, the data indicated that people higher in personal development competitiveness were more prone to endorse values related to ensembled individualism. In particular, they strongly endorsed values associated with social concern, that is, with caring about the well-being of others and with treating them with respect and as equals, whereas hypercompetitives expressed a lack of such concern. Discussion centered on the socialization process and how it can foster the development of different competitive orientations.

A cumulative total of 41,298 AIDS cases have been reported in Zimbabwe as of March 1995. Of concern is the growing evidence of high levels of seroprevalence among rural farm workers. A pre-intervention survey was conducted by interview in one district to examine behavioral factors likely to place farm workers in marginalized rural communities at risk for sexually transmitted diseases (STD) and HIV infection. Seven hundred seventy commercial farm workers from 17 randomly selected commercial farm participated in the study. We found that farm worker communities, which are characterized by educationally disadvantaged women when compared with men (p < .001), have had little exposure to AIDS prevention activities. Beliefs that AIDS is brought about by divine or ancestral retribution were upheld by less education women (p < .001). A significant association was found with respect to perceived risk to HIV and low self-efficacy among uneducated women who articulated helplessness and an inability to protect themselves from HIV infection. Among more educated men, we found acknowledgment about multipartnering and that changes in behavior are more likely to develop as a result of changes in normative values (p = .075). Condom use among men, which is probably the most effective barrier against STD infection, was shown to be associated with age (p < .01) and education (p < .01). The study concludes with recommendations for an appropriate intervention.

Interventions to promote health that have been developed over the last 20 years in the relatively new scientific health education tradition, have often been evaluated for their effectiveness. Meta-analyses of effect studies on various subfields, show that these interventions generally have quite substantial effects (mean effect sizes, ES, of 0.46 for primary prevention and 0.49 for secondary prevention and patient education). A planned and systematic application of social science theory in intervention development is a strong determinant of effectiveness. However, learning principles such as rewards and feedback, that have been shown to increase effectiveness, are often not or not adequately applied. Also, too few interventions focus on possibilities to facilitate the desired behavior (such as reminders, financial stimuli, and skills improvement). The potential effectiveness of interventions in practice may be increased by systematic development of adoption and implementation strategies, including the creation of 'linkage systems' between intervention developers and representatives of the target and user systems.

Objective: The efficacy of both chloroquine and hydroxychloroquine in rheumatoid arthritis (RA) has been proved in controlled clinical trials. Despite similar chemical characteristics, it is believed the clinical efficacy of chloroquine is superior to that of hydroxychloroquine in patients with RA. Excessive production of proinflammatory cytokines was shown to contribute to the pathogenesis of RA. From different studies testing either chloroquine or hydroxychloroquine, it could be concluded that both drugs differentially inhibit cytokine production., Methods: We compared the effects of both chloroquine and hydroxychloroquine on stimulated peripheral blood mononuclear cells (PBMC) with respect to cytokine production. Therefore, PBMC were tested for tumor necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6), and interferon-gamma (IFN-gamma) by specific ELISA, after stimulation with phytohemagglutinin (PHA) or lipopolysaccharide (LPS) in the presence or absence of different concentrations of chloroquine or hydroxychloroquine., Results: We observed that chloroquine and hydroxychloroquine equally inhibit PHA induced TNF-alpha and IFN-gamma production, and LPS induced TNF-alpha and IL-6 production, while PHA induced IL-6 production was not affected., Conclusion: Chloroquine and hydroxychloroquine display similar effects on PHA and LPS induced cytokine production by PBMC under identical in vitro conditions. These findings may help in understanding the mechanism of action of these drugs on RA.

Electrically evoked stapedius reflex measurements were obtained in 19 children during surgery for cochlear implantation. They all received the Nucleus device. Stapedius reflexes could be elicited in all the children with congenital deafness but not in all the children with an etiology of meningitis. The intraoperative stapedius reflex thresholds were compared with postoperative values obtained after fitting of the speech processor and with the children's long-term behavioral most comfortable levels (C-levels). The intraoperative reflex thresholds were considerably higher than the postoperative reflex thresholds (44 "stimulus level steps" on the average), which could in part be ascribed to the influence of anesthetics used during surgery. It was concluded that, especially in children with an etiology of meningitis, the intraoperative stapedius reflex threshold (even after corrections for the concentration of the volatile anesthetics used) was a weak predictor of the C-level.

Combination therapy in rheumatoid arthritis (RA) with 2 or more disease modifying antirheumatic drugs (DMARD) is theoretically attractive if the drugs exert additional or even synergistic effects and have different toxicity patterns to avoid cumulative toxicity. The combination of cyclosporin A (CsA) with chloroquine has shown in in vitro studies a synergistic ability to inhibit the proliferation of peripheral blood mononuclear cells and clonal T cells and the production of interferon gamma by clonal T cells. This synergy is probably based on different mechanisms of action of the 2 drugs: CsA primarily inhibits the production of interleukin 2 (IL-2) (and other cytokines) at the level of transcription, whereas chloroquine primarily inhibits the responsiveness of T cells to IL-2 stimulation. To evaluate whether these in vitro data can be extrapolated in vivo, a large 2 phase trial has been initiated in the Netherlands in which the combination of CsA with chloroquine is evaluated in patients with RA.

Forty-four patients with early RA who had participated in a six months double-blind trial, comparing cyclosporine A (CsA) (n = 22) with chloroquine (Chl) (n = 22), were followed for a further 18 months irrespective of their treatment status. At two years follow up, the mean CsA dose was 2.7 +/- 1.1 mg/kg/day (n = 15) and the dose of Chl (n = 11) was 100 mg/day in every patient. Maximal difference in efficacy (represented by the percentage of patients who fulfilled the Paulus 50% response) was reached at one year (CsA group: 68% and Chl group: 36%; p = 0.07). At two years, the differences in efficacy and toxicity between the two groups had diminished. The conclusions of this follow-up study are: 1. maximal efficacy of low dose CsA in early RA patients is reached after one year of therapy. 2. CsA can maintain clinical efficacy and safety comparable to Chl for a period of at least two years.

End-point evaluations are still the most commonly used method of assessing the success or failure of interventions. This article describes how a process evaluation was used to measure "what happened" during an HIV/AIDS prevention program for farm workers in Zimbabwe. The intervention was developed according to the Paulo Freirian theory of Social Change and the Ecological Model for health promotion. The stages of the intervention were cyclical; in the first stage innovative methods were used to encourage appraisal of vulnerability to HIV/AIDS through activities which raised critical thinking and dialogue. In the next phase, emphasis was placed on developing cognitive and attitude change in the target group. Self-protective behavior was encouraged through condom use and an increase in self-efficacy with respect to negotiating safe sex, especially among women. In the last stage of the intervention, efforts were made to create a climate for maintenance of behavior and socially responsible action within the community. The process evaluation provided valuable insight into factors which, when aggregated, provided an overview of a program whose successes and failures may well have been determined by issues outside the scope of the intervention. The effect of seasonal fluctuations of labor, income, and farming activity on program activity, patterns of STD, and condom demand were marked. This leads back to the researchers' initial question: "Was the intervention implemented as planned?" and the answer-only partially.

Background: Little is known about the rehabilitation outcomes of long-term survivors following treatment for head and neck cancer. There are, for example, no studies on physical and psychosocial rehabilitation outcomes of T1 glottic larynx carcinoma, despite the fact that these form the majority of head and neck cancer sites. Thus, this investigation afforded a unique opportunity for examining similarities and differences among T1 glottic larynx patients, laryngectomy patients, and those who had surgery for cancer of the oral cavity and/or oropharynx along a variety of physical and psychosocial dimensions., Methods: To describe the impact of these three types of head and neck cancer and their treatment on the physical and psychosocial functioning of long-term survivors, a self-report questionnaire was completed by 110 patients treated between 2 and 6 years previously in a major cancer center., Results: Data indicate that a higher percentage of patients treated with laryngectomy or commando procedures still experience severe psychosocial distress between 2 and 6 years after their last treatment than do patients treated with radiotherapy for a T1 carcinoma of the glottic larynx. Psychosocial and physical complaints are still reported by many laryngectomy patients, apparently the result of problems in effective communication with others. Many commando procedure patients experience problems with respect to food intake, and with disfigurement and its consequences. T1 larynx patients mainly experience a considerable number of physical complaints. The greater the time that had elapsed since treatment, the fewer the psychosocial problems associated with head and neck tumors. Open discussion of the illness in the family, social support, and perceptions of adequate information from the specialist are the most important predictors of positive rehabilitation outcomes., Conclusions: This study indicates that T1 larynx patients report many physical complaints even though several years had elapsed since treatment. Also, laryngectomy patients may need psychosocial guidance for a longer posttreatment period and that health care personnel must involve the partner as much as possible in all communications. Commando procedure patients in particular feel hindered by their disfigurement and its consequences. Future research with respect to validation of the specific head and neck modules is needed.

The relative bioavailability of cyclosporin A (CsA) from a new microemulsion oral formulation (NEO) and the currently used soft gelatine capsule (SGC) was determined at steady state in 12 patients with rheumatoid arthritis. The AUC(0,12 h) values of cyclosporin A were significantly greater after NEO than SGC (2873 +/- 848 ng ml-1 h (mean +/- s.d.) vs 2355 +/- 1128 ng ml-1 h; P = 0.02, 95% CI (confidence interval of the difference: 81 to 955 ng ml-1 h). Cmax values were significantly higher after NEO than after SGC (811 +/- 244 ng ml-1 vs 495 +/- 291 ng ml-1, P < 0.0001, 95% CI of the difference: 209 to 422 ng ml-1).

Evoked auditory brainstem responses (EABR) and stapedius reflex thresholds were established in 7 experienced users of the Nucleus cochlear implant. Even using biphasic 400 microseconds/phase clicks for the EABR, responses were observed in only 5 patients; no stapedius reflex (SR) was seen in 3 patients, 2 of whom had a history of middle-ear disorder. The EABR threshold varied widely between subjective threshold and uncomfortable loudness level (ULL) for the same stimulus. The average SR threshold was found somewhat more consistently at 66% of the dynamic range between threshold and ULL, but grossly overestimated the most comfortable level (MCL) in most cases. To obtain equal loudness at the same current level we suggest that broad clicks (300 microseconds/phase) be used for EABR measurements, thus compensating for the lower repetition rate of EABR stimulus compared with the device fitting stimulus.

The English form of the Cancer Locus of Control Scale was administered to an heterogeneous sample of 68 cancer patients. A principal components analysis confirmed the three subscales described in the original Dutch form, however, with five items excluded. Correlations with other measures indicated that high internal control over the course of the illness was associated with a tendency to adopt an attitude toward cancer of 'fighting spirit' whereas high internal control over the cause of the illness was associated with an 'anxious preoccupation' about cancer. No specific relationship was found between scale scores and either depression and anxiety or the tendency to be emotionally controlled. It was concluded that the scale provides a valid measure of perceptions of control of cancer patients and is a useful method of assessing these important psychological responses.