Short report: treatment of snake envenomations by a new polyvalent antivenom composed of highly purified F(ab)2: results of a clinical trial in northern Cameroon

A clinical trial was conducted in 2 health centers in northern Cameroon to assess the safety and efficacy of a new polyvalent antivenom composed of highly purified and pasteurized F(ab')2 (FAV-Africa). Forty-six patients with objective signs of envenomation, including 67% with hemorrhage, were included in the study. Each patient received at least 20 ml of FAV-Africa by direct, slow intravenous injection; 172 10-ml ampules were administered. All patients were clinically cured after treatment. Two patients (4.3%) showed minor immediate adverse events that may have been related to FAV-Africa (induration, light-headedness); no other treatment-related adverse event occurred. No patient had serum sickness. This trial confirms the safety of FAV-Africa administered by intravenous injection and its efficacy in the treatment of snake envenomations in sub-Saharan Africa.

Intercalibration of SUMER and CDS on SOHO. I. SUMER detector A and CDS NIS

The results of an intercalibration between the extreme ultraviolet spectrometers Coronal Diagnostic Spectrometer (CDS) and Solar Ultraviolet Measurements of Emitted Radiation (SUMER) onboard the Solar and Heliospheric Observatory (SOHO) are presented. During the joint observing program Intercal_01, CDS and SUMER were pointed at the same locations in quiet Sun areas and observed in the same wavelength bands located around the spectral lines He i 584 A, Mg x 609 A, and Mg x 624 A. The data sets analyzed here consist of raster images recorded by the CDS normal-incidence spectrometer and SUMER detector A and span the time from March 1996 to August 1996. Effects of the different spatial and spectral resolutions of both instruments have been investigated and taken into account in the analysis. We find that CDS measures generally a 30% higher intensity than SUMER in the He i 584-A line, while it measures 9% and 17% higher intensities in Mg x 609 A and Mg x 624 A, respectively. Both instruments show very good temporal correlation and stability, indicating that solar variations dominate over changes in instrumental sensitivity. Our analysis also provides in-flight estimates of the CDS spatial point-spread functions.

B-cell-receptor-dependent positive and negative selection in immature B cells

This review touches on only a small part of the complex biology of B cells, but serves to illustrate the point that the antigen receptor is the most important of many cell-surface receptors affecting cell-fate decisions. Receptor expression is necessary, but not sufficient, for cell survival. It is also essential that a B cell's antigen-receptor specificity be appropriate for its environment. The need to balance reactivity with self tolerance has resulted in an intricate feedback control (affected by both the recombinase and cell survival) that regulates independent selection events at the level of the receptor and the cell.

Impact of nonlinear heat transfer on temperature control in regional hyperthermia

We describe an optimization process specially designed for regional hyperthermia of deep-seated tumors in order to achieve desired steady-state temperature distributions. A nonlinear three-dimensional heat transfer model based on temperature-dependent blood perfusion is applied to predict the temperature. Using linearly implicit methods in time and adaptive multilevel finite elements in space, we are able to integrate efficiently the instationary nonlinear heat equation with high accuracy. Optimal heating is obtained by minimizing an integral objective function which measures the distance between desired and model predicted temperatures. A sequence of minima is calculated from successively improved constant-rate perfusion models employing a damped Newton method in an inner iteration. We compare temperature distributions for two individual patients calculated on coarse and fine spatial grids and present numerical results of optimizations for a Sigma 60 Applicator of the BSD 2000 Hyperthermia System.

[Cost of tetanus toxoid injection using a jet-injector (Imule) in collective immunization in Senegal: comparison with injection using a syringe and resterilizable needle]

Needle-less jet injectors were developed by the US army after World War II. Their principal use, however, has been in the administration of lyophilized vaccines from multidose vials to at-risk populations in developing countries. In 1983, a hepatitis B epidemic occurred among customers of a beauty clinic in California (USA) following the use of jet-injectors, demonstrating a clear risk of cross-contamination associated with this technique. As a result, the WHO and Unicef stopped recommending jet-injectors for collective immunizations in developing countries. To eliminate the risk of contamination, Pasteur Mérieux Sérums et Vaccins (now Aventis Pasteur) developed, in 1990, jet-injectors for use with single-use vaccine cartridges. These injectors were tested for tetanus toxoid, DTP, influenza, hepatitis A and typhoid Vi vaccination. The immunogenic reaction was as strong and the injection as well tolerated as for injections using a standard needle and syringe. The additional cost of the Imule technique was evaluated in a district-wide (127,000 inhabitants) tetanus toxoid immunization program at Velingara, Senegal in 1993. The total cost was estimated to be 1.51 FF (76 F CSA, 0.32 US dollars) for one dose of tetanus vaccine given by needle and syringe and 2.41 FF (121 F CSA, 0.56 US dollars) for one dose given by Imule. Thus, the additional cost of injection by ImuleTM was 0.90 FF (45 F CSA, 0.21 US dollars). The cost of cross infection in sub-Saharan Africa has been estimated to be 2.37 FF (118 F CSA, 0.55 US dollars) per injection if injection practices are not supervised. Therefore, the Imule technique may be considered to be cost-effective. However, the technique is still not completely reliable, as shown by the total breakdown of four jet injectors during this vaccination session. Lyophilized vaccines have also not been tested in the field. Vaccinators prefer Imule, training is easy and immunization can be carried out on a day-to-day basis with no vaccine wastage. Imule is not yet in mass production, which would reduce costs. In the face of the ever-increasing risk of cross-contamination during vaccination sessions in sub-Saharan Africa, the Imule technique deserves considerable attention.

[Vaginal hysterectomy for large uterus]

OBJECTIVE

The technique and experience of vaginal hysterectomy for large uterus of 25 cases was reported.

METHODS

Vaginal hysterectomy for 25 cases of uterine fibroids and adenomyosis were performed. The uterine sizes enlarged as large as 6-16 weeks of pregnancy, mobile, no adhesion by estimation. The technique used for reducing the uterine bulk included bisection, myomectomy, morcellation and coring. The most common way to reducing the uterine bulk was bisection combined with myomectomy and morcellation.

RESULTS

Twenty four cases of vaginal hysterectomy were performed successfully. The average weight of uterus for the 25 cases was 360 g(range from 155 g to 755 g), the mean time for the operation was 95 minutes(range from 60 to 150 minutes), the average quantity of blood loss was 150 ml (range from 50 to 400 ml), the average admission duration of postoperation was 5.3 days(range from 3 to 8 days).

CONCLUSION

Vaginal hysterectomy is a safe and effective option for removing enlarged uterus. The successful operation was related to the uterine sizes, mobile, operator' skill and experiences.

[Diagnosis, treatment and prevention of postoperative deep venous thrombosis in gynecologic onocology]

OBJECTIVE

To describe the clinical profile of deep venous thrombosis (DVT) after operation on pelvic tumours and to study how to choose the methods of diagnosis, treatment and prevention of DVT.

METHODS

The clinical characteristics, the methods of diagnosis, treatment and prevention of 11 cases with DVT and 18 cases with the tendency to DVT were analyzed retrospectively.

RESULTS

Old age, fatness and oringinal pelvic malignant tumours were the high risk factors for postoperative DVT. Especially the patients with endometrial carcinoma were with the high incidence of DVT. Colour-code Doppler ultrasonography was the best choice to diagnose DVT. Heparin or low molecule weight heparin (LMWH) anticoagulation was effective treatment in postoperative DVT.

CONCLUSIONS

Old age, fatness and gynecologic malignant tumours should be considered as highrisk factors for postoperative DVT. Preoperative or postoperative prophylatic treatment of DVT should be considered in high risk population. Anticoagulation was effective in postoperative DVT.

A new Vero cell rabies vaccine: results of a comparative trial with human diploid cell rabies vaccine in children

We evaluated the immunogenicity and safety of a chromatographically purified rabies vaccine (CPRV) compared with human diploid cell rabies vaccine (HDCV) after pre-exposure immunizations (both primary and booster). Intramuscular doses of either 0.5 mL of CPRV or 1.0 mL of HDCV were given to 400 schoolchildren on days 0, 7, 28, and 365 (booster). Adequate titers of antibody (> or = 0.15 IU/mL, as defined by the Centers for Disease Control and Prevention) were observed in serum samples from all children 14 days after primary immunization with CPRV and HDCV; the antibodies persisted in all but one child up until 1 year. Fourteen days after the primary immunization series (day 42) and 7 days after booster immunization (day 372), all children had antibody titers of > or = 0.5 IU/mL. Local and systemic reactions after primary and booster immunizations occurred significantly less frequently in the CPRV group. A severe allergic reaction (angioedema) was reported in only one child after booster immunization with HDCV. CPRV has adequate immunogenicity for primary and booster pre-exposure immunizations in children and has a better safety profile than does HDCV.

Cardiomyopathy in dystrophin-deficient hypertrophic feline muscular dystrophy

A colony of cats affected with hypertrophic feline muscular dystrophy was used to study the occurrence of cardiomyopathy associated with dystrophin deficiency. Affected male and female cats, obligate carrier females, and unaffected healthy littermates were followed from 12 weeks of age into adulthood. Thoracic radiography, 2-D echocardiography, and 2-D-derived M-mode echocardiography were performed at 3-month intervals until 12 months of age and regularly thereafter. From 9 months of age, all affected cats had larger hearts than normal and carrier animals. Left ventricular wall thickness in systole and in diastole and interventricular septal thickness in systole were greater in affected cats 12 months and older when compared with normal or heterozygous animals (P < .05). The myocardium of affected cats was diffusely hypoechoic and thickened. Multiple hyperechoic foci were in the myocardium and papillary musculature. Shortening fraction was normal in all cats. Changes seen in carrier females included enlargement and hyperechogenicity of the papillary musculature after the age of 2 years. Gross and light microscopic examination revealed left ventricular wall thickening with multiple foci of mineralization in 2 of 5 hearts from dystrophin-deficient cats. Although approximately 10% of the normal dystrophin amount was present in the skeletal muscle, dystrophin could not be detected in the myocardium. Early onset concentric myocardial hypertrophy was present in all adult cats. Lesions were mainly localized in the myocardium of the left ventricular free wall and interventricular septum, papillary musculature, and the endocardium. Clinical signs of heart failure developed only infrequently in cats with hypertrophic feline muscular dystrophy.

Alpha2-adrenoceptor agonists stimulate high-affinity GTPase activity in a receptor subtype-selective manner

Transfected Chinese hamster ovary cells expressing human alpha2A-, alpha2B- and alpha2C-adrenoceptor subtypes were used to monitor alpha2-adrenoceptor-stimulated GTP hydrolysis. Incubation with 100 microM (-)-adrenaline resulted in stimulation of pertussis toxin-sensitive GTPase by 380% after activation of the alpha2A-subtype, by 320% after activation of the alpha2B-subtype and by 110% after activation of the alpha2C-subtype. The agonists dexmedetomidine, UK14,304 (5-bromo-6-[2-imidazoline-2-ylamino]quinoxaline) and oxymetazoline showed subtype-dependent efficacy. Dexmedetomidine was a full agonist at the alpha2B-subtype and a partial agonist at the alpha2A- and the alpha2C-subtypes. UK14,304 was a full agonist at the alpha2A-subtype and a partial agonist at the other two. Oxymetazoline showed strong partial agonism at the alpha2B-subtype (63% of adrenaline), but did not significantly activate the alpha2A- and the alpha2C-subtypes. These results agreed with cAMP accumulation experiments carried out with cell lines endogenously expressing the alpha2A-subtype (human erythroleukemia, HEL) or the alpha2B-subtype (neuroblastoma-glioma, NG108-15). The GTPase assay may thus provide a valuable tool for the identification of subtype-selective alpha2-adrenoceptor agonists.

Comparison of the immunogenicity and safety of two 17D yellow fever vaccines

As part of the clinical validation process of a new working seed of a licensed yellow fever vaccine (new working seed PV26, Stamaril; Pasteur Mérieux Connaught, Lyon, France), the immunogenicity and safety of two batches of this vaccine (PM-YF) were compared with those of another commercially available vaccine (Arilvax; Evans Medical-Wellcome, Liverpool, United Kingdom) in 211 healthy adults. While the geometric mean titer values at days 10-14 and day 28 after vaccination were higher in the PM-YF group, the vaccines provided equivalent seroprotection (titers > or = 1/10) one month after a single vaccine dose (100% PM-YF versus 99% W-YF; P = 0.001, by one-sided equivalence test). Both vaccines were safe. There were no serious local or systemic reactions reported, nor any clinically significant hepatic function abnormalities associated with the use of either vaccine. These two 17D yellow fever vaccines from different European vaccine manufacturers were highly immunogenic and safe, and provided equivalent seroprotection.

The quality of psychiatric residency : the assessment of programs and options for distributing psychiatric residents in the service of health care reform

Recent health care reform initiatives proposed training fewer medical specialists, including psychiatrists, and determining the size and location of training programs via centralized regulatory mechanisms. Facing such potential future developments, the American Association of Directors of Psychiatric Residency Training appointed a Task Force on the Quality of Residency Programs to develop informed recommendations for the field. This paper describes the Task Force's considerations and recommendations concerning how the least damaging and most effective decisions could be made regarding the distribution of residency positions, program size, and the future funding of training stipends. The recommendations emphasize voluntary decisions, feedback from local and regional stakeholders regarding perceived needs and demands for psychiatrists, and Federal or regional funding of postgraduate training stipends that are not primarily tied to providing clinical services.

Cytokine gene expression following neural grafts

A reverse-transcription polymerase chain reaction study of molecular events following solid neural tissue xenogeneic and syngeneic grafts into the mouse caudate nucleus was made between 1 day and 30 days post-grafting. Constitutive expression of interleukin (IL)-1 and transforming growth factor (TGF)-beta1 mRNAs was detected. The sham operation produced minimal cytokine upregulation, indicating that surgical trauma caused minimal damage. A similar picture was seen with syngeneic grafts, which showed good graft survival. Xenografts, however, were rejected within 30 days and cytokine mRNAs for IL-2, IL-2R, IL-4, IL-10 and interferon (IFN)-gamma were detected from 7 days post-graft, correlating with histological identification of a leukocytic infiltrate. This method provides a quick, comparative screen for detecting cytokine mRNA profiles in neural grafts and may assist the diagnosis of early rejection phenomena. As such, it is a potential analytical tool for strategies aimed at depleting/blocking the activity of different cell types and/or cytokines in future neural transplant therapy.

Mutational analysis of cysteine-string protein function in insulin exocytosis

Cysteine-string proteins (Csps) are vesicle proteins involved in neurotransmission. They contain at least four domains: an N-terminal J-domain which can interact with the chaperone Hsc70, an adjacent linker region, the defining cysteine rich domain and a variable C terminus. As the relevance of these domains for the function of Csps in exocytosis is unknown, we have performed a mutational analysis of Csp domains using insulin release by large dense core vesicles (LDCVs) as a model of regulated exocytosis. All mutants were apparently palmitoylated and their subcellular distribution was similar to endogenous Csp. Point mutations within the highly conserved HPD motif of the J-domain abolished activation of Hsc70. However, these mutations altered the effect of Csp on exocytosis only after additional truncation of the extreme C terminus as found in the Csp splice variant Csp2. Furthermore, the strikingly conserved linker region adjacent to the J-domain was important for Csp function in exocytosis, but not for the activation of Hsc70 ATPase. The effects of Csp wild-type or mutants were preserved in permeabilized cells excluding an effect on transmembrane ion fluxes. These observations demonstrate a functional difference between the two isoforms and suggest a role for the J-domain co-chaperone function as well as for the newly defined linker region in LDCV exocytosis.

Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery

OBJECTIVES

This study investigated the association of intrapartum temperature elevation with cesarean delivery and assisted vaginal delivery.

METHODS

Participants were 1233 nulliparous women with singleton, term pregnancies in vertex presentations who had spontaneous labors and were afebrile (temperature: 99.5 degrees F [37.5 degrees C]) at admission for delivery. Rates of cesarean and assisted vaginal deliveries according to highest intrapartum temperature were examined by epidural status.

RESULTS

Women with maximum intrapartum temperatures higher than 99.5 degrees F were 3 times as likely to experience cesarean (25.2% vs 7.2%) or assisted vaginal delivery (25.2% vs 8.5%). The association was present in epidural users and nonusers and persisted after birthweight, epidural use, and labor length had been controlled. In adjusted analyses, temperature elevation was associated with a doubling in the risk of cesarean delivery (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5, 3.4) and assisted vaginal delivery (OR = 2.1, 95% CI = 1.4, 3.1).

CONCLUSIONS

Modest temperature elevation developing during labor was associated with higher rates of cesarean and assisted vaginal deliveries. More frequent temperature elevation among women with epidural analgesia may explain in part the higher rates of cesarean and assisted vaginal deliveries observed with epidural use.

The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Critical Care Trials Group

OBJECTIVE

To evaluate the clinical utility of bronchoscopy with protected brush catheter (PBC) and BAL for patients with ventilator-associated pneumonia (VAP).

DESIGN

Prospective cohort study.

SETTING

Ten tertiary care ICUs in Canada.

PATIENTS

Ninety-two mechanically ventilated patients with a clinical suspicion of VAP who underwent bronchoscopy were compared with 49 patients with a clinical suspicion of pneumonia who did not.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We compared antibiotic use, duration of mechanical ventilation, ICU stay, and mortality. In addition, for patients who received bronchoscopy, we administered a questionnaire (before and after bronchoscopy) to evaluate the effect of PBC or BAL on (1) physician perception of the probability of VAP, (2) physician confidence in the diagnosis of VAP, and (3) changes to antibiotic management. After bronchoscopy results became available, from the physician's perspective, the diagnosis of VAP was deemed much less likely (p < 0.001), confidence in the diagnosis increased (p = 0.03), and level of comfort with the management plan increased (p = 0.02). Following the results of invasive diagnostic tests, in the group that underwent bronchoscopy, patients were receiving fewer antibiotics (31/92 vs 9/49, p = 0.05) and more patients had treatment with all their antibiotics discontinued (18/92 vs 3/49, p = 0.04) compared with the group that did not undergo bronchoscopy. Duration of mechanical ventilation and ICU stay were similar between the two groups, but mortality was lower in the group that underwent bronchoscopy with PBC or BAL (18.5% vs 34.7%, p = 0.03).

CONCLUSIONS

Invasive diagnostic testing may increase physician confidence in the diagnosis and management of VAP and allows for greater ability to limit or discontinue antibiotic treatment. Whether performing PBC or BAL affects clinically important outcomes requires further study.

Intrathoracic tracheal rupture

This paper reports five new cases of intrathoracic tracheal rupture in cats, and summarizes these cases in conjunction with 11 cases from the literature. Most cats had no obvious respiratory signs at the time of injury, and in half of them the tracheal rupture was the only injury. The interval from trauma to onset of dyspnoea ranged from 1 to 28 days (median 12.5 days). Radiographic findings include loss of continuity of the trachea, often with a gas-filled diverticulum present between separated tracheal rings. With careful attention to surgical technique and anaesthetic management the prognosis for these cats is excellent. All eight of the cats reported in the last 14 years having surgical correction survived and returned to normal. The surgical anatomy, approach and tracheal anastomosis technique is described and recommendations for anaesthetic management are made.

Immunogenicity and safety of low-dose intradermal rabies vaccination given during an Expanded Programme on immunization session in Viet Nam: results of a comparative randomized trial

The World Health Organization recently recommended a rabies vaccine pre-exposure schedule using 3 intradermal (i.d.) injections of one-fifth the standard intramuscular (i.m.) dose of current cell culture vaccines as a cost-reducing alternative for developing countries. As a strategy to improve further the acceptability of childhood rabies immunization, we assessed, in a controlled, randomized trial performed in 240 Vietnamese infants, the possibility of associating i.d. administration of a one-fifth dose of purified Vero-cell rabies vaccine (PVRV) with routine Expanded Programme on Immunization vaccines given at 2, 3 and 4 months of age (diphtheria, tetanus, whole-cell pertussis and inactivated poliomyelitis combined vaccine, DTP-IPV). Safety and immunogenicity results were compared with a group of infants given 2 i.m. doses of PVRV (2, 4 months) in association with DTP-IPV (2, 3, 4 months). After i.d. injection, more infants experienced local reactions, particularly redness, but these reactions were generally mild and transient. The rate of systemic reactions was the same in both groups. Although the rabies antibody titres (rapid fluorescent focus inhibition test) were higher 1 month after the third vaccine dose in the i.m. group (30.6 IU/mL vs 12.0 IU/mL in the i.d. group), all infants in both groups had achieved WHO-acceptable protective antibody titres (> or = 0.5 IU/mL) at this time. There was no evidence for any interference between DTP-IPV and rabies vaccine, supporting the interest of a low-dose i.d. PVRV pre-exposure regimen in infants living in rabies-endemic developing countries.

Neutralization, by a monospecific Bothrops lanceolatus antivenom, of toxic activities induced by homologous and heterologous Bothírops snake venoms

A monospecific Bothrops lanceolatus antivenom, currently used in Martinique, was tested for its efficacy in the neutralization of several toxic and enzymatic activities of the venoms of B. lanceolatus, B. atrox and B. asper. When tested by the i.p. route in mice, B. lanceolatus venom had an LD50 of 12.8 microg/g. In addition, it induced local tissue damage (hemorrhage, edema and myotoxicity) and showed indirect hemolytic activity, but was devoid of coagulant effect on human plasma in vitro and of defibrinating activity in mice. Antivenom was fully effective in the neutralization of lethal, hemorrhagic, edema-forming, myotoxic and indirect hemolytic effects of B. lanceolatus venom in assays involving preincubation of venom and antivenom. When tested against the venoms of B. asper and B. atrox, the antivenom completely neutralized the lethal, hemorrhagic, myotoxic and indirect hemolytic effects, and was partially effective in neutralizing edema-forming activity. In contrast, the antivenom was ineffective in the neutralization of in vitro coagulant and in vivo defibrinating effects induced by these two venoms.