Latinas,Amniocentesis and the Discourse of Choice

Little attention has been paid to the impact of theincreasingly routine use of fetal diagnosis on howU.S. minority women experience their pregnancies anddecide whether to have their fetuses tested. Usingnarrative analysis, we offer the account of one Latinawho, despite considerable turmoil, ultimately acceptedan offer of amniocentesis. We describe her reasoningin choosing a course of action. Data from interviewswith 147 Latinas who were faced with the same decisionare used to contextualize the case study material. Weseek to illuminate how a blending of Mexican andEuropean American cultural influences helped shape thewoman's experience and define the dilemma she facedwhen she learned her fetus might be born with a graveor incurable condition because she was ideologicallyopposed to abortion.     

Cutting Edge: IL-1 receptor-associated kinase 4 structures reveal novel features and multiple conformations

IL-1R-associated kinase (IRAK)4 plays a central role in innate and adaptive immunity, and is a crucial component in IL-1/TLR signaling. We have determined the crystal structures of the apo and ligand-bound forms of human IRAK4 kinase domain. These structures reveal several features that provide opportunities for the design of selective IRAK4 inhibitors. The N-terminal lobe of the IRAK4 kinase domain is structurally distinctive due to a loop insertion after an extended N-terminal helix. The gatekeeper residue is a tyrosine, a unique feature of the IRAK family. The IRAK4 structures also provide insights into the regulation of its activity. In the apo structure, two conformations coexist, differing in the relative orientation of the two kinase lobes and the position of helix C. In the presence of an ATP analog only one conformation is observed, indicating that this is the active conformation.     

The cytoarchitecture of the torus semicircularis in the golden skink Mabuya multifasciata

The skink, Mabuya multifasciata, torus semicircularis was subdivided into the central (CN), the laminar (LN), and the superficial (SN) nuclei using Golgi and Nissl methods. The central nucleus consisted of small ovoid neurons surrounding a core of fewer large ovoid-triangular and fusiform neurons. The ovoid cells had scant cytoplasm and two to five dendritic trunks. Most of these processes were directed around the periphery of the central nucleus. The large neurons had clumped, darkly staining Nissl substance and a central nucleus. The sparse dendritic spine population on these cells increased distally on the three to five radiate dendrites. The laminar nucleus was present caudal and ventral to the central nucleus. At more rostral levels it was medial and dorsomedial to the central nucleus. The NL had three to five layers of ovoid and fusiform neurons. Scattered within these layers were a few ovoid-triangular neurons. Ovoid neurons had eccentric or central nuclei. The arborization of their dendrites was generally medial and lateral but was frequently oriented caudomedial and rostrolateral. Fusiform neurons had pale Nissl substance, central nuclei, and one to two dendritic processes. The ovoid-triangular neurons had dense, clumped Nissl substance and at least two dendritic trunks with few spines. The superficial nucleus was dorsal, lateral, and caudal to the central nucleus. Extending ventrolaterally around the central nucleus, the superficial nucleus became confluent with the laminar nucleus, ensheathing the central nucleus ventrally, laterally, and dorsally. Rostrally the central nucleus was covered by the layers of the laminar nucleus. Within the superficial nucleus were ovoid, fusiform and sparse ovoid-triangular neurons. The study indicated that the morphology of the torus semicircularis in the golden skink was similar to that in other lizards. This similarity correlates with the degree of development as it relates to the auditory function, but was independent of the type of inner ear restraint mechanism.     

Plagiarism of the host immune system: lessons about chemokine immunology from viruses

In their attempts to evade the host immune response, mammalian viruses have evolved a wide range of strategies. These include the expression and modification of various host cytokines and receptors. Understanding the mechanism of action of these virally encoded proteins will clearly deepen our insights into immunology. In the past few months several new virally encoded chemokines have been described which can modify both the host immune and antiviral response. Their manipulation of the cytokine structure-function relationship may also be useful in the development of reagents for treating immune and proliferative diseases.     

Compliance and the patient's perspective: Controlling symptoms in everyday life

Non-compliance with medical advice is poorly understood. Most of the existing literature considers the problem only from the doctor's point of view. We undertook a diachronic, qualitative study of the illness experiences of 19 women to try to understand non-compliance from the patient's perspective. Three-fourths of our study group had ceased to follow their doctor's recommendations by four months postdiagnosis. Their non-compliance could not be explained by the fact that the women held understandings of their illnessses which were incongruent with their physicians'; nor were they unable to understand the diagnosis they received A consideration of the roles that their diagnosis and treatments played in their daily lives proved more useful in explaining their failure to follow physicians' recommendations. Patients' use of treatments reflected their desire to control symptoms within the constraints of their daily routines.     

Prognosis of mechanically ventilated patients.

In this Department of Veterans Affairs cooperative study, we examined predictors of in-hospital and 1-year mortality of 612 mechanically ventilated patients from 6 medical intensive care units in a retrospective cohort design. The outcome variable was vital status at hospital discharge and after 1 year. The results showed that 97% of patients were men, the mean age was 63 +/- 11 years (SD), and hospital mortality was 64% (95% confidence interval, 60% to 68%). Within the next year, an additional 38% of hospital survivors died, for a total 1-year mortality of 77% (95% confidence interval, 73% to 80%). Hospital and 1-year mortality, respectively, for patients older than 70 years was 76% and 94%, for those with serum albumin levels below 20 grams per liter it was 92% and 96%, for those with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score greater than 35 it was 91% and 98%, and for patients who were being mechanically ventilated after cardiopulmonary resuscitation it was 86% and 90%. The mortality ratio (actual mortality versus APACHE II-predicted mortality) was 1.15. Conclusions are that patient age, APACHE II score, serum albumin levels, or the use of cardiopulmonary resuscitation may identify a subset of mechanically ventilated veterans for whom mechanical ventilation provides little or no benefit.     

On the Medicalization of Medical Anthropology

The following address was presented at the Annual Meeting of the Society for Medical Anthropology (SMA), November 21,1997, Washington, DC, by outgoing SMA president Carole Browner. It has been edited slightly for publication.     

Predictors of screening for hypercholesterolemia in a general internal medicine practice.

We compared current practice with the National Cholesterol Education Program (NCEP) guidelines for the detection and evaluation of hypercholesterolemia and analyzed the association of various patient and provider factors with screening. Using a retrospective medical records review of 1,000 randomly selected patients between the ages of 18 and 70 in a university-based general internal medicine practice--faculty, residents (categorical and primary care), and nurse practitioners--we found that 80% of patients were screened for hypercholesterolemia. Patients older than 35 were more likely to be screened than younger patients (87% versus 77%; P = .001), and, among younger patients, nonwhites were less likely to be screened than whites (58% versus 77%; P = .0001). Lipoprotein analysis was done in 60% of the 235 patients in whom it was indicated; older patients were significantly more likely to have these measurements. Among patients taking medications for hypercholesterolemia, 92% had lipoprotein analyses done beforehand. No differences were detected in screening by provider characteristics. We conclude that providers in our practice are appropriately aggressive in screening high-risk patients for hypercholesterolemia. The finding that young whites are screened much more often than nonwhites was surprising. Finally, although there is a high rate of screening overall, many patients with elevated cholesterol levels are not appropriately classified as to their low-density-lipoprotein levels.