Attitudes, practices, and preferences of pediatricians regarding initiation of hepatitis B immunization at birth

OBJECTIVES

To explore practices and attitudes of pediatricians toward administration of the first dose of hepatitis B vaccine to infants, and to identify factors influencing the decision of pediatricians to initiate immunization at birth versus at 1 to 2 months of age.

METHODS

A random sample of 600 pediatricians obtained from the American Academy of Pediatrics membership database was surveyed by mail.

RESULTS

Three hundred eighty (68%) of the 563 pediatricians who were located responded to the survey. Of these 380 pediatricians, 279 provided routine immunizations to children. Of the 270 pediatricians who vaccinated children with hepatitis B vaccine and indicated their practice regarding the birth dose, 50% offered the first dose of hepatitis B vaccine at birth to all infants; the rest either offered the vaccine at birth only to infants of hepatitis B surface antigen-positive mothers and mothers whose serostatus is unknown, or did not offer the birth dose to any infants at all. Practicing in the inner city, working for a medical school or government hospital, and living in a state with universal immunization supply policies were associated with the respondent giving the birth dose. The strongest perceived barriers to giving the birth dose in the hospital were the difficulty tracking these vaccines (39%), the increased cost (27%), and the lack of reimbursement from insurance companies (26%). If a combination vaccine that includes hepatitis B; diphtheria, tetanus, pertussis (diphtheria and tetanus toxoids and acellular pertussis vaccine); and polio (inactivated poliovirus vaccine) antigens become available in the near future, then 38% of physicians who currently give the birth dose to all infants would prefer to wait until 2 months of age to initiate hepatitis B immunization.

CONCLUSIONS

Efforts to achieve high implementation of hepatitis B birth dose administration may falter once a hepatitis B-containing pentavalent combination vaccine becomes available. Programmatic efforts should ensure prevention of perinatal hepatitis B virus transmission through universal prenatal hepatitis B surface antigen screening and immunoprophylaxis of high-risk newborn infants.

A lower incidence of left-handed writing among young adults in Bulgaria than in the USA

The incidence of left-handed writing among 590 young Bulgarian adults was 6.4%, significantly lower than that reported in two studies of students in the United States. Of those writing with the right hand, 10.8% stated that they had been forced to change their preferred hand for writing. The parents of the Bulgarian sample had a similar low incidence of left-handed writing (5.9%). Left-handed writing was almost three times more likely if one or both of the parents wrote with the left hand.

Massive intraperitoneal hemorrhage from a pancreatic pseudocyst

Massive bleeding from a pancreatic pseudocyst is a rare condition that poses a diagnostic and therapeutic challenge. A 36-yr-old woman presented with acute pancreatitis due to gallstones. Twenty-two days later, she developed severe abdominal pain and hypotension. CT scan revealed hemorrhage into a pancreatic pseudocyst and a large amount of free blood in the peritoneal cavity. At laparotomy, 8 L of blood was evacuated from the peritoneal cavity and 14 units of blood were transfused. The gastroduodenal artery was found to be the cause of the bleeding and was undersewn. A pancreatic necrosectomy was performed and the cavity was packed. The packs were removed the following day. Postoperatively, pancreatic collections were aspirated under ultrasound guidance on three occasions. She was discharged 50 days after admission and had an open cholecystectomy 1 month later. She remains well 1 yr after surgery.

Efficacy and safety of delavirdine mesylate with zidovudine and didanosine compared with two-drug combinations of these agents in persons with HIV disease with CD4 counts of 100 to 500 cells/mm3 (ACTG 261). ACTG 261 Team

To evaluate the antiretroviral activity of delavirdine mesylate, a non-nucleoside reverse transcriptase inhibitor of HIV-1, we performed a phase II, randomized, double-blind, multicenter trial comparing the three-drug combination of delavirdine with zidovudine and didanosine to two-drug combinations of these drugs. Patients with CD4 cell counts between 100 and 500 cells/mm3 without prior or <6 months of monotherapy with zidovudine or didanosine were randomized to one of four arms and observed on a follow-up basis for 48 weeks. In total, 544 patients were evaluated. In those assigned to the three-drug regimen, mean short-term (weeks 4-12) and long-term (weeks 40-48) change in CD4 cells from baseline were 49.3+/-8.1 and 65.4+/-13.4 cells/mm3, respectively; mean short-term and long-term HIV-1 RNA changes from baseline were -1.13 log10+/-0.12 and -0.73+/-0.12 copies/ml, respectively. These responses in CD4 cell counts and HIV-1 RNA levels were better in comparisons with each of the two-drug arms at all study points; however, differences were not consistently significant. Gastrointestinal side effects were experienced by 33% of patients (178 of 544), and 30% (121 of 407) receiving delavirdine experienced rash, only one case of which was severe. In this study, therapy with delavirdine + zidovudine + didanosine was safe and showed modest, but not always significant, antiviral activity and CD4 cell count benefit compared with two-drug regimens with these agents. Key

Ultrasonographic evaluation of renal autografts in normal cats

The purpose of this study was to determine changes in resistive index (RI) and renal size that occur in normal feline kidney autografts in the immediate post-transplant period. Qualitative changes in renal parenchymal echogenicity and pelvic dilation were also noted, although this was not a major focus of the study. Fourteen domestic short-haired cats underwent bilateral nephrectomies followed by an autograft of the right kidney to either the aorta or external iliac artery. Due to post-operative complications, only nine of these cats completed the study. Ultrasonographic determination of the RI and renal size was made before transplantation and on days 1, 4, 7, 10, and 13 following transplantation. No significant changes in renal RI were identified during the study. Renal size increased significantly, peaking at 63% above baseline on day 7, and stayed elevated at 50% above baseline on day 13. There was no evidence of rejection or other abnormalities found on histologic evaluation of the transplanted kidneys. It was concluded that the RI of normal feline renal autografts does not significantly change in the immediate post-operative period. However, significant renal enlargement, likely due to a combination of post-operative edema and hypertrophy, does occur. This study provides baseline information for comparison with feline allografts in the immediate post-transplant period.

Topiramate and metabolic acidosis

Topiramate (TPM) is a novel antiepileptic medication (AED) with at least three mechanisms of action. A possible fourth mechanism, that of a carbonic anhydrase inhibitor, also may contribute to its antiepileptic properties. We report a patient with intractable epilepsy and normal renal function who developed a normal anion gap metabolic acidosis, which worsened during elective surgery for temporal lobectomy. We believe this side effect of TPM can become clinically significant during surgery, concomitant use of another carbonic anhydrase inhibitor, and potentially with the ketogenic diet.

Mixed deaf-hearing families: maximizing benefits and minimizing risks

This article examines certain dynamics that may occur in families where the parent(s) and one or more children differ in hearing status (i.e., 'mixed deaf-hearing families'). The essay has proved useful in promoting discussion during parenting workshops we have led. Hearing status differences between parents and children can be a cherished aspect of a family's diversity or a stage upon which family conflicts are acted out. We explore dynamics that lead to healthy versus unhealthy management of these hearing differences, especially as they relate to parental confidence, problem attribution, stages of child development, and information management.

Paediatrics and medication administration. Some practical issues

Promotion of safe administration of medication to children can be enhanced by expanding pharmacokinetics in paediatric practice. The absorption, distraction metabolism and excretion of medications vary with the developmental changes that accompany a child's growth. Application of paediatric pharmacokinetics to nursing practice when administering medications to children promotes safety in practice.

The regulation of burn-associated infections with herpes simplex virus type 1 or Candida albicans by a non-toxic aconitine-hydrolysate, benzoylmesaconine. Part 2: Mechanism of the antiviral action

In the accompanying paper, the resistance to infections with HSV type 1 (HSV-1) and Candida albicans was improved in thermally injured mice treated with benzoylmesaconine (BEN), an aconitine-hydrolysate isolated from heated Aconiti tuber, or inoculated with splenic CD4+ T cells from BEN-treated mice (BEN T cells). In this paper, therefore, the antiviral mechanism of BEN T cells (or BEN) on the improved resistance of burned mice to the HSV-1 infection was studied. Burn-associated CD + CD11b+ TCRgamma/delta+ type-2 T cells have been shown to be a key on the increased susceptibility of thermally injured mice to infection with HSV-1 or C. albicans. The susceptibility of T6S-mice, mice inoculated with 1 x 10(6) cells/mouse of T6S cells (a clone of burn-associated type-2 T cells), to HSV-1 infection was similar to that of thermally injured mice. The adoptive transfer of BEN T cells to T6S-mice restores their impaired resistance to HSV-1 infection. The type-2 cytokine levels in sera of T6S-mice were decreased after inoculation of BEN T cells. BEN T cells inhibited the type-2 cytokine production by T6S cells when they were cocultured in vitro. BEN T cells, characterized as CD4+ CD28+ TCRalpha/beta+ Vicia villosa (VV) lectin-adherent T cells, showed non-specific ability to inhibit the cytokine production by various type-2 T cells. From the results of the cytokine-producing profile, BEN T cells were shown to be a different subset of CD4+ T cells from Th1 and Th2 cells, although these three CD4+ T cells had similar properties phenotypically. BEN T cells were induced in normal mice 1-4 days after the oral treatment of BEN (1 microg/kg or more). These results suggest that, through the induction of antagonistic CD4+ T cells against burn-associated type-2 T cells, BEN may improve the resistance of T6S-mice (or thermally injured mice) to the infection of HSV-1.

Clinical assessment of the single use laryngeal mask airway--the LMA-unique

We conducted a clinical comparison of the laryngeal mask airway (LMA) and the new single use PVC LMA (LMA-Unique) in 100 fasted adult patients undergoing elective surgery. Patients were allocated to one of two groups: group 1 (n = 50) was managed by two consultants and group 2 by two trainee anaesthetists. Airway management was randomized prospectively within each group, and cuff pressure in both devices was maintained at a maximum of 50 mm Hg with upward size substitution if leaks persisted during intermittent positive pressure ventilation (IPPV). Insertion with the recommended technique was successful in all patients (85 first attempt). One patient (group 1) required four attempts for insertion of the LMA-Unique and in one patient (group 2) the LMA-Unique was replaced by a tracheal tube because of persistent leaks during IPPV. In 99 patients IPPV was uneventful. The adjusted mean volume of air for cuff inflation in the LMA-Unique was significantly less in group 1 (P = 0.0013). At fibreoptic laryngoscopic examination, the vocal cords or arytenoids, or both, could be seen in 92% of patients in group 1 and in 90% of patients in group 2. Immediate throat soreness was reported in four patients in group 1 and in seven in group 2. The results suggest that the LMA-Unique was similar in clinical performance to the LMA.

Pharmacokinetics of oral ganciclovir alone and in combination with zidovudine, didanosine, and probenecid in HIV-infected subjects

The aim of this study was to determine whether oral ganciclovir interacted pharmacokinetically with zidovudine (AZT), didanosine (ddI), or probenecid. A multicenter, open-label, randomized, crossover pharmacokinetic study with four phases was undertaken at an outpatient private research center and at university research clinics. Twenty-six HIV-infected adults (23 men, 3 women) with cytomegalovirus (CMV) seropositivity and CD4+ T-lymphocyte count > or =100 cells/microl were studied. Patients had to be stable on antiretroviral therapy for at least 4 weeks. Patients with a history of opportunistic infection or gastrointestinal symptoms were excluded. Measurements included serial blood and urine samples during the dosing intervals at steady state. The steady-state pharmacokinetics of ganciclovir were determined after the participants had stabilized and were tolerating AZT or ddI therapy. When a 1000-mg dose of oral ganciclovir was taken every 8 hours, there was a significant mean increase in Cmax and dosing interval area under the serum concentration time curve over a dosing interval (AUC) for the two antiretroviral drugs: for AZT, 61.6% and 19.5%, respectively; for ddI when administered sequentially (2 hours before ganciclovir), 116.0% and 114.6%; and for ddI administered simultaneously with ganciclovir, 107.9% and 107.1%, respectively. There was no significant change in renal clearance for either antiretroviral drug, suggesting that the interaction did not occur through a renal mechanism. There was no significant change in mean ganciclovir Cmax and AUC(0-8) when coadministered with AZT. Mean increases in Cmax and AUC(0-8) of oral ganciclovir averaged 40.1% and 52.5%, respectively, when coadministered with probenecid, but decreased by 22.1% and 22.7%, respectively, when oral ganciclovir was administered 2 hours after ddI. There was no change in the mean ganciclovir Cmax or AUC(0-8) when administered simultaneously with ddI. The mean renal clearance of oral ganciclovir was not affected by AZT or ddI coadministration intake, but there was a mean decrease of 19% when coadministered with probenecid. We conclude the increased serum concentration and reduced renal clearance of ganciclovir suggests competition with probenecid for secretion at the renal tubule. The mechanism of the interaction of oral ganciclovir with either AZT or ddI remains to be determined. The magnitude of the effect of oral ganciclovir on ddI pharmacokinetics may result in an increase in ddI concentration-related toxicities. Similarly, the small but significant decrease in ganciclovir concentration with sequential combination ddl therapy may impair the efficacy of oral ganciclovir. For HIV-infected patients receiving ganciclovir and ddI, clinicians should recommend administering the two drugs simultaneously, and patients should be monitored closely for ddI-associated toxicities.

Homeostasis, stress, trauma, and adaptation. A neurodevelopmental view of childhood trauma

All experiences change the brain, but not all experiences affect the brain equally. Because the brain is developing and organizing at such an explosive rate in the first years of life, experiences during this period have more potential to influence the brain in positive and negative ways. Traumatic events disrupt homeostasis in multiple areas of the brain that are recruited to respond to the threat. Use-dependent internalization of elements of the traumatic experience can result in the persistence of fear-related neurophysiologic patterns affecting emotional, behavioral, cognitive, and social functioning. A neurodevelopmental view of childhood trauma can help future clinical and research efforts to define and use child-specific and developmentally informed models to guide assessment, intervention, education, therapeutics, and policy.

Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy

BACKGROUND

In previous natural history studies and clinical trials, AIDS-related cytomegalovirus (CMV) retinitis has occurred primarily in patients with absolute CD4 counts of 50 cells/microL or less (0.05 x 10(9)/L) at the time of diagnosis.

METHODS

We report five patients identified from our clinical practices who were diagnosed with CMV retinitis while their CD4 counts were above 195 cells/microL. We also analysed, based on CD4 counts, 76 AIDS patients with newly diagnosed CMV retinitis whose CD4 lymphocyte enumerations were done in laboratories that maintained certification in a common external quality control programme.

FINDINGS

5-24 weeks before retinitis was diagnosed, all five patients had had absolute CD4 lymphocyte counts of less than 85 cells/microL, and 4-7 weeks before diagnosis, all five patients had started taking highly active antiretroviral treatment (HAART) regimens. Only one (4%) of 27 patients enrolled in the trial between July, 1995, and February, 1996, had an absolute CD4 count of more than 50 cells/microL, and none of 27 had an absolute CD4 count of more than 100/microL on entry to the trial. However, from March, 1996 (when indinavir and ritonavir were approved by the FDA for marketing in the USA), to August, 1996, 14 (29%) of 49 patients had CD4 counts of more than 50/microL and seven (14%) of 49 had a CD4 count of more than 100 cells/microL on entry.

INTERPRETATION

These findings suggest that the early immunological effects of HAART may not provide sufficient protection to prevent CMV retinitis in patients who have very low CD4 counts when therapy is started. Clinicians should note that CMV retinitis may now occur in patients who have CD4 counts of more than 100 cells/microL.

A phase-I study of the safety, pharmacokinetics, and antiviral activity of combination didanosine and ribavirin in patients with HIV-1 disease. AIDS Clinical Trials Group 231 Protocol Team

A phase-I study was conducted to examine the safety, pharmacokinetics, and activity of combination 2',3'-dideoxyinosine (ddI) and ribavirin against human immunodeficiency virus type 1 (HIV-1)-positive individuals with CD4+ cell counts of < or = 500/microliter. Nineteen patients were enrolled into the study in which ddI monotherapy (200 mg p.o.b.i.d.) was administered for the first 4 weeks, followed by the coadministration of ribavirin (600 mg p.o.q.d.) and ddI (200 mg p.o.b.i.d.) for 8 or 20 additional weeks. The combination regimen was safe and well tolerated. Three patients did not complete 12 weeks of the study because of adverse events or voluntary withdrawal. The pharmacokinetic studies performed at weeks 4, 6, and 12 on specimens collected from the 15 individuals who completed 12 weeks of therapy revealed no pharmacokinetic interaction between ddI and ribavirin. A significant decline from baseline in HIV-1 titer as measured by quantitative HIV-1 culture was detected both during the ddI-monotherapy phase (week 4, p < 0.001) and during the combination-therapy ddI + ribavirin phase (week 12, p < 0.001); the median drop observed was 0.90 log10 at week 4 and 0.92 log10 at week 12. While the addition of ribavirin did not result in further reductions in viremia in the following weeks on study treatment, 13 (81%) of the 16 patients had at least a -0.5 log10 change in viral titer at week 12. The median decline in plasma viral RNA was 0.68 log10 at week 4(p < 0.001) and 0.67 log10 at week 12 (p = 0.005). CD4+ cell counts increased above baseline significantly during the ddI-monotherapy phase of the study (p = 0.0038). The median increase was +26 cells/mm3 at week 4 and +11 cells/mm3 at week 12; for patients who remained on treatment through 24 weeks, the median CD4+ cell count increase was +10 cells/mm3. The L74V ddI resistance-conferring HIV-I reverse-transcriptase mutation emerged in 53% of the patients. Patients with non-syncytium-inducing HIV variants demonstrated greater responses to treatment with larger decreases in virus load and greater increases in CD4+ cell count. Our results reveal that the combination of ddI and ribavirin in HIV-positive patients is safe, well tolerated, without adverse pharmacologic interaction, and associated with significant and sustained declines in virus load over 12 weeks of therapy.

Ethnic variation of twinning rates in Malawi

Malawi is a country in South-East Africa with a population of approximately 10 million, over 95% of whom are negro of Bantu origin. The country is divided into 24 administrative districts, each of which provides details of births which are compiled centrally at the Ministry of Health. Using data reported annually by health facilities from 1987-1990, most districts had twinning rates in the range 16 to 24 per 1000 maternities, figures consistent with those of other negro populations in Africa. Two adjoining districts (Rumphi and Mzimba) had rates which were considerably higher, almost 30 per 1000. Although ethnic origin is not recorded in the latest Malawi census, language spoken in the home, which was last recorded in 1966, can be used as a proxy. Rumphi and Mzimba are the only districts with an overwhelming majority of Tumbuka speaking population. These people, who are of both Tumbuka and Ngoni ethnic origin, therefore have an unusually high twinning rate (29.57 per 1000 maternities). The rate for the main ethnic group in Malawi, the Chewa people, was 21.21 per 1000. The district of Thyolo, with a mixed ethnic population, had by far the lowest rate (13.75 per 1000).

Conceptualizing and conducting preoperative psychological assessments of cochlear implant candidates

A review of literature pertaining to psychosocial research on cochlear implantation is embedded in this formulation of how preoperative psychological assessments should be comceptualized and conducted. This article considers various purposes of such assessments, including those relevant to candidate selection, exclusion, and readiness. Particular attention is directed to the conceptualization and operational investigation of candidate readiness, which includes aspects of motivation and informed consent. Assessment in this context is framed as both a data collection and an intervention procedure. The article describes specific methodologies useful in preoperative psychological assessment, including questionnaires, interviews, and psychological tests.

Ethnic comparison of twinning rates in California

A meaningful comparison of the twinning rates of different populations can be hindered by several factors that may influence the rates. Chief among these factors are the sources of data from which the rates are derived and the maternal age structure of the populations. The effects of such factors were minimal when the twinning rates of 14 ethnic groups in California were compared. After standardization for maternal age, twinning rates per 1000 maternities for the main ethnic groups were 13.20 for blacks, 10.05 for whites, and 7.18 for Asians. There were significant differences within the Asian group. The highest rate was for Cambodians (8.57). This rate compares with rates of approximately 6 for Koreans, Thai, and Vietnamese. These rates are similar to those found in Asia but lower than those for Californian Chinese, Japanese, and Filipinos, who have been established in the state for longer. In general, the results provide support for previous reports that twinning rates are modified by both migration and interethnic mixing. Rates for Indians from India were lower than those reported from the Indian subcontinent, whereas the twinning rates for Native Americans (10.15) and Pacific Islanders (10.60) were similar to the rate for US whites.

A difference in heights and weights between right-handed and left-handed bowlers at cricket

Right-handed pitchers have been shown to be significantly taller and heavier than left-handed pitchers. An analysis of 113 professional cricketers in England showed a similar difference between right-handed and left-handed bowlers. On average the right-handers were 1.05 in. taller and 8.30 lb. heavier than the left-handers, differences which were close to significance at the 5% level with this small n.

Neonatal haematology in Zimbabwe. II: The red cell and white cell parameters

Red cell and white cell parameters were determined in 600 (310 male and 290 female) normal Black Zimbabwean neonates with a mean +/- sd birth weight of 3.0 +/- 0.4 (range 2.04 to 4.50, median 3.0) kg using a Coulter Counter Model S Plus. Cord anaemia (cord Hb < 13.5 gdl-1) was detected in 60 (10 pc) of the neonates. Although the male babies were significantly heavier than the females (p = 0.004), there were no significant differences (p > 0.05) in the red cell and white cell indices between the two sexes. When the haematological parameters of the 540 (90 pc) non-anaemic (cord Hb > or = 13.5 gdl-1) neonates were analysed, the mean +/- sd values which may serve as local reference standards were: Hb 15.2 +/- 1.8 (range 13.5 to 19.4) gdl-1, Hct 47.3 4.9 (range 38.6 to 60.3) pc, MCV 107.8 +/- 9.4 (range 88.8 to 134.3) fl, MCH 31.9 +/- 3.4 (range 25.2 to 45.2) pg, MCHC 32.9 +/- 1.3 (range 30.0 to 38.3) gdl-1, nucleated red blood cells 6.1 +/- 5.9 (range 0 to 55) per 100 white blood cells, reticulocyte count 5.0 +/- 1.9 (range 0 to 24.0) pc, total leucocyte count 13.8 +/- 4.4 (range 4.6 to 132.8) x 10(9)l-1; differential count: neutrophils 7.30 +/- 2.90 (range 1.72 to 18.02) x 10(9) l-1, lymphocytes 5.67 +/- 2.47 (range 0.98 to 16.14) x 10(9) l-1, monocytes 0.81 +/- 0.83 (range 0 to 5.58) x 10(9) l-1, 1 and eosinophils 0.08 +/- 0.13 (range 0 to 0.72) x 10(9)l-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Didanosine compared with continuation of zidovudine in HIV-infected patients with signs of clinical deterioration while receiving zidovudine. A randomized, double-blind clinical trial. The Bristol-Myers Squibb AI454-010 Study Group

OBJECTIVE

To determine the benefits of switching to didanosine compared with continuing zidovudine among patients infected with human immunodeficiency virus (HIV) who have previously used zidovudine and have signs of clinical deterioration.

DESIGN

Randomized, double-blind, two-armed, parallel, comparative clinical trial with a blinded, compassionate crossover provision at 12 weeks.

SETTING

Outpatient clinics at 19 tertiary care medical centers.

PATIENTS

312 patients infected with HIV who had received zidovudine for 6 months or more, had CD4 cell counts of 300/mm3 or less, and had signs of clinical deterioration within 12 weeks before study entry.

INTERVENTION

Peroral didanosine tablets (600 mg/d adjusted for weight, "high dose") or zidovudine capsules (600 mg/d).

MEASUREMENTS

Primary study end points were death, a new acquired immunodeficiency syndrome (AIDS)--defining event, or the combination of two new or recurrent HIV-related diagnoses with a 50% decrease in CD4 cells.

RESULTS

Switching to didanosine was associated with fewer end points than continuing zidovudine (relative risk [RR] for zidovudine:didanosine = 1.5; 95% Cl, 1.1 to 2.0). This benefit was consistent across subgroups of patients with either AIDS-related complex or AIDS and was most apparent among those with a CD4 count at entry of 100/mm3 or more (RR = 2.2; Cl, 1.1 to 4.4).

CONCLUSIONS

This study shows a positive treatment effect for switching from zidovudine to didanosine among patients with either AIDS-related complex or AIDS and validates the common practice of using clinical signs or a decrease in the CD4 count as an indication for changing therapy.

Papaverine hydrochloride: effects on HIV replication and T-lymphocyte cell function

Papaverine hydrochloride (PAP) has previously been shown to have a potent inhibitory effect on the replication of viruses such as cytomegalovirus (CMV) and measles. In this report the effect of PAP on human immunodeficiency virus (HIV) replication and T lymphocyte cell function were examined. MT4 cells infected with HIV strain 3b were incubated with serial dilutions of PAP (1-30 microM). At selected times postinfection HIV replication was measured by reverse transcriptase activity (RT) or HIV p24 Ag. PAP significantly inhibited HIV replication by more than 99% at doses of 30 microM with an CD50 and ED50 of 32 microM and 5.8 microM respectively. The mechanism of inhibition of HIV caused by PAP appeared independent form its ability to increase intracellular levels of cAMP and was not mediated via a direct effect on RT activity. To examine T cell function, peripheral blood mononuclear cells (PBMC) from normal donors were stimulated with phytohemagglutinin (PHA) or CMV Ag in the presence or absence of PAP (1-30 microM). At selected times proliferative response to PHA and CMV Ag were determined by [3H]thymidine uptake. In addition, interferon (IFN) gamma and interleukin 2 (IL2) response to mitogens were measured by radioimmunoassay (RIA). PAP enhanced PHA induced IFN production at doses of 1-10 microM and CMV Ag induced IFN production at doses of 1-3 microM. Higher doses were inhibitory. PAP did not affect IL-2 production or IL2 receptor expression and had an inhibitory effect on mitogenic responses.

Malpractice litigation against child and adolescent psychiatry residency programs, 1981-1991

A national survey was conducted to investigate malpractice litigation at United States child and adolescent psychiatry residency programs between 1981 and 1991. Fourteen percent of the directors of child and adolescent psychiatry reported at least one malpractice claim during this period. The highest percentage of lawsuits reported was in the northeast. Suicide and sexual abuse of latency age patients by other patients accounted for the most litigation. The mean monetary award was $167,000, and the largest award was $500,000 for discharge of a patient who killed his mother. There has been an increase in malpractice litigation during the past 10 years. Risk management strategies should be implemented to address areas of liability in child and adolescent psychiatry training programs.

X-irradiation enhances in vitro human immunodeficiency virus replication correlation with cellular levels of cAMP

Total body x-irradiation has been utilized in the treatment of several human diseases, including leukemia, where it is followed by bone marrow transplantation, and in some autoimmune disorders. Recently, it was reported that total body irradiation appeared useful in the treatment of Friend leukemia virus infection in mice. In this report, the effect of x-irradiation on the replication of human immunodeficiency virus (HIV) in vitro in CD4+ cells was examined. MT-4 cells and HIV strain human T cell lymphotropic virus Type IIIB were used to conduct this study. Infected MT-4 cells were irradiated at the time of infection or following infection with x-ray doses of 25-300 cGy. Doses of 50, 150, and 300 cGy enhanced HIV replication by 1.6-, 2-, and 4.8-fold, respectively. Irradiating the cells prior to infection also resulted in similar enhancement of HIV replication. This phenomenon was also observed with wild-type HIV isolates grown in peripheral blood mononuclear and in HIV chronically infected cells. In addition, the enhancement was associated with a radiation-induced increase in intracellular levels of cAMP. The use of the cAMP-dependent protein kinase A inhibitor, H-8, inhibited HIV replication by 65%. These data suggest that in vitro exposure to low doses of x-ray enhances HIV replication partially via a cAMP-dependent pathway.

In vivo administration of tumor necrosis factor-alpha is associated with antiviral activity in human peripheral mononuclear cells

Tumor necrosis factor-alpha (TNF-alpha) has a spectrum of biologic effects and has been shown to exert antiviral effects in fibroblasts in vitro. The in vivo administration of TNF-alpha (40-160 micrograms/m2 intravenously over 2 hr) and its effects on vesicular stomatitis virus (VSV) replication in peripheral blood mononuclear cells (PBMC) from patients with malignancy was investigated. Blood was obtained before, during, and after infusion. The PBMC were separated and infected with VSV at a multiplicity of infection of 0.005 plaque-forming units/cell and virus yields were determined 72 h later. The TNF-alpha inhibited VSV yields by as much as 99% in a dose-dependent manner with the inhibition initially observed during the first hour of infusion. Despite a rapid reduction in TNF-alpha serum levels, the higher doses still produced antiviral effects 4 hr after the infusion. Sera obtained at identical times had no interferon activity. Human gamma-interferon (25 micrograms/ml) added in vitro augmented the TNF-alpha-induced inhibitory activity in both magnitude and duration. Percentages of lymphocytes and monocytes in peripheral blood were reduced at 4 hr after TNF-alpha administration and the monocyte to lymphocyte ratio was diminished and temporally coincided with the loss of TNF-induced antiviral state. These data suggest that the in vivo administration of TNF has a direct inhibitory activity on VSV replication in human peripheral blood mononuclear cells that was enhanceable by gamma-interferon and possibly monocyte mediated.

Human immunodeficiency virus infection: association with altered intracellular levels of cAMP and cGMP in MT-4 cells

T-cells from human immunodeficiency virus (HIV)-infected patients are characterized by a number of qualitative deficiencies including defective T-cell activation. The latter has previously been shown to be normally regulated by cAMP. In this study the patterns of cAMP and cGMP induction in MT-4 cells following HIV infection were investigated. The MT-4 cells were infected with HIV (strain IIIb) and at selected times postinfection (p.i.), culture supernatants were tested for HIV replication by reverse transcriptase activity or HIV P24 Ag. The cells were also examined for their intracellular levels of cAMP and cGMP by radioimmunoassay. HIV infection was associated with an increase in intracellular levels of cAMP and cGMP. The cAMP was increased 40-fold by Day 8 and cGMP 4-fold by Day 4 Pl. The increase in intracellular levels of the cyclic nucleotides (CN) were virus specific, dependent on virus dosage, genetically conserved among the two fresh patient isolates tested, and were abolished by uv inactivation. An increase in cAMP and cGMP was also observed in other cell lines infected with HIV. The sustained elevation in CN level observed could certainly influence cell activation and HIV replication and may potentially have clinical relevance.

Recombinant alfa interferon in renal cell carcinoma: a randomized trial of two routes of administration

Ninety-seven patients with recurrent or metastatic renal cell carcinoma were randomized to receive recombinant interferon (IFN) alfa-2b (Intron A; Schering-Plough, Kenilworth, NJ) by either the subcutaneous (SC) or intravenous (IV) route. The SC dosage was 2 X 10(6) IU/m2 three times weekly, and the IV dose 30 X 10(6) IU/m2 for five consecutive days every 3 weeks. Dose escalation to a maximum of 10 X 10(6) IU/m2 SC and 50 X 10(6) IU/m2 IV was allowed for patients with minimal or absent toxicity. Five of 51 of the SC-treated patients (10%) and three of 46 of the IV-treated patients (7%) had a partial response (PR) or complete response (CR). Patients with prior nephrectomy, no prior treatment, and lack of bone metastases were most likely to respond, and a retrospective analysis of this subgroup revealed a 23% response rate. Achievement of response took from 3 weeks to 11 months, while response duration lasted from 3 to 31+ months. All responders had prior nephrectomy; six of eight had no prior chemotherapy or hormonal therapy; five had lung metastases, and none had bone metastases. Regardless of route, almost all patients developed a flu-like syndrome; however, grade 3 or greater toxicity was much more common for IV-treated patients. This trial demonstrates modest, but definite antitumor activity for recombinant interferon in advanced renal cell carcinoma. SC administration with lower dose and toxicity is as effective as treatment administered IV.

Home advantage in soccer: a retrospective analysis

The existence of home advantage has been established for all major professional team sports in England and North America. The advantage was found to be greatest in soccer, with the home team currently obtaining about 64% of all points gained in the English Football League. Home advantage has changed very little since the formation of the League in 1888 and there are only small variations between the four Divisions of the League. The advantage is less marked in local derbies, in the FA Cup and in nonprofessional competitions. It is greater in the European Cup and increases as the stages of the competition progress. The allocation of three points, instead of two, for a win in the Football League has not changed home advantage, but its effect has been greatly reduced in the GM Vauxhall Conference where an away win gains more points than a home win. The statistical evidence suggests that crowd support and travel fatigue contribute less to home advantage in soccer than do the less easily quantifiable benefits of familiarity with conditions when playing at home. Further possible explanations for the advantage are discussed in the light of findings in other sports.

Human cytomegalovirus: development and progression of nuclear inclusions by primary clinical isolates and laboratory-adapted strains

The morphogenesis of cytomegalovirus (CMV) nuclear inclusions (NIs) was investigated using unadapted clinical isolates and adapted laboratory strains. Both adapted and unadapted strains of CMVs induced NIs whose morphologic appearance was similar in human fibroblastic cells. Early NIs appeared as ring-like structures composed of dense granular and fibrillar material, while late NIs appeared to consist of multiple electron-lucent areas containing coarse granules and bounded by electron-dense fibrillar material (cellulae). Capsids and nucleocapsids were associated primarily with the electron-dense fibrillar material; however, developing nucleocapsids were most often observed at the interface of the electron-dense and -lucent areas. Although there was some variation in the rate of development and maturation of the NIs with the intensity of infection, all CMVs examined produced late NIs with similar organizational patterns consisting of cellulae. Substitution of human fibroblastic cells derived from various tissues as cellular substrate did not appreciably affect the results. Thus, the unique organization of the CMV late NI, consisting of multiple cellulae, appears to be an intrinsic feature of CMV replication since it seems to be independent of the extent of laboratory adaptation, the virus strain, the intensity of infection, or the cell type.

Twinning rates in Fiji

The incidence of twins in Fiji has been investigated using birth registrations for the years 1976-81. The twinning rate for the indigenous Fijians is found to be 9.4 per 1000 live maternities, (based on 407 sets of twins), and for Indians, descendants of immigrants who began to arrive in Fiji in 1879, 6.2 per 1000 (based on 350 twins). After standardizing for maternal age, the difference between the two ethnic groups decreases slightly, but the Fijian rate remains almost 40% above that of the Indians. This difference is consistent over the 6 years of the study, is found for mothers of all age groups under 40 and at all levels of parity. An analysis of hospital records in Fiji produces higher twinning rates for both Fijians and Indians, but a similar difference is found between the two ethnic groups. Although the twinning rate for Fijians is lower than that reported for other Melanesian people, it is well above reliable rates found for Mongoloid races from whom the Fijian is descended. The sparse information on twinning rates among Polynesians suggests rates not dissimilar from Melanesians, so that no support for the hypothesis of low twinning rates in the Pacific is evident. The twinning rate for Indians in Fiji is lower than rates reported from the Indian subcontinent.

Nutritional status, body size and severity of diarrhoea associated with rotavirus or enterotoxigenic Escherichia coli

Children with severe malnutrition have an increased risk of death from diarrhoea. To determine if the clinical manifestations of specific types of diarrhoea differed according to the nutritional status or size (weight and length) of the patient, we studied children with acute diarrhoea associated with rotavirus or enterotoxigenic Escherichia coli. In this study we found that a child's body size, which was determined by his age and nutritional status, was a significant predictor of his rate of stool output per kilogram of body weight. Thus, children who are small because of young age and/or malnutrition appear to lose a greater proportion of their total fluid volume during diarrhoea and might be expected to have a higher frequency of severe dehydration and death, if untreated.

Combination chemotherapy with mitomycin C, adriamycin, and cyclophosphamide (MAC) in stage III and IV ovarian cancer

Twenty-nine patients with stages III and IV epithelial carcinomas of the ovary were treated with a combination of mitomycin-C, adriamycin, and cyclophosphamide (MAC). A 62% response rate (CR + PR) was observed in previously untreated patients with a median survival of responding patients of 100+ weeks, compared to 29 weeks for nonresponding patients (p less than 0.001). Toxicity was acceptable with moderate to severe but manageable myelosuppression. Prospective, randomized trials comparing this drug combination to others with demonstrated efficacy are indicated.

A study of school children who had identified virus infections of the central nervous system during infancy

Forty-nine children who had a virus infection of the central nervous system (CNS) when under 1 year of age were studied. One child had died during the initial illness and three of the survivors were severely disabled. The other survivors, more than 5 years after the initial illness, were all attending normal schools. These 45 children, together with 45 matched controls, were examined. We confirm the findings of other studies that virus infections of the CNS in infancy may cause severe disabilities in some cases, and may depress intellectual abilities in others, even though they appear to have recovered fully. Many of the children who had a virus infection of the CNS in infancy had adverse birth and social histories and so were exceptionally vulnerable, but these factors did not account fully for the findings, and when their influence was included in the analysis, the index children still had a mean performance IQ (WISC) 6 points lower than the control children (P less than 0.05), whereas there was less than 1 point difference between the verbal IQs. Attention is drawn to the problem of virus infections in neonatal units.

Antibody to cytomegalovirus in Malta

Antibody to cytomegalovirus (CMV) was sought in sera from Malta using immunofluorescence. Seven per cent of the infants, 36% of the school children, increasing to 100% of the adults aged over 40 years were found to have antibody. Most infection occurred in pre-school children and adults over 25 years of age. This pattern of antibody acquisition appears different from that described for other countries.

A complete response in metastatic malignant thymoma to cis-platinum, doxorubicin and cyclophosphamide: a case report

Systemic chemotherapy as a mode of therapy in metastatic malignant thymoma has never been systematically evaluated. Chemotherapeutic agents, including doxorubicin, cyclophosphamide, cis-platinum, nitrogen mustard, prednisone or combination of agents like MOPP have produced tumor remission. A case report of complete remission of malignant thymoma in which the combination of cyclophosphamide, doxorubicin and cis-platinum (CAP) was used is reported.

Vigorous exercise in leisure-time: protection against coronary heart disease

1138 first clinical episodes of coronary heart disease (CHD) in 17 944 middle-aged male office workers in the Civil Service are reported. Men who engaged in vigorous sports, keep-fit, and the like during an initial survey in 1968-70 had an incidence of CHD in the next 8 1/2 years somewhat less than half that of their colleagues who recorded no vigorous exercise. The CHD rates of men who took such vigorous exercise were lower in both fatal and non-fatal clinical manifestations, though more so in fatal; throughout the age-range studied, though more striking in later middle age and early old age; and in all other sub-groups examined, including men with a family history of CHD, the obese, the short of stature, cigarette smokers, and men with severe hypertension and subclinical angina, as well as in those in favourable situations for CHD or neutral. The generality of the advantage suggests that vigorous exercise is a natural defence of the body, with a protective effect on the ageing heart against ischaemia and its consequences.

T-cell lymphomas of large cell type. A variety of malignant lymphomas: "histiocytic" and mixed lymphocytic-"histiocytic"

Clinical and morphologic features of seven T-cell lymphomas of the large cell type are described. The tumors were grouped into those with irregular (3 cases) and those with round and regular nuclei (4 cases). In both groups, variation in cell size, numerous histiocytes and vessels, and many mitoses were distinguishing features. In only 1 case in the round and regular nucleus group was there relatively little variation in cell size and a paucity of histiocytes. Abundant polyribosomes, long strands of rough endoplasmic reticulum, and lysosomal granules were prominent electron microscopic features in both groups of tumors. The clinical presentations and courses varied considerably, especially in patients with tumors of the round nucleus type. One patient presented initially with chronic lymphocytic leukemia, 1 with Lennert's lymphoma, another with bone marrow infiltration, and a fourth with subcutaneous tumors. Two patients with the round nucleus type are still alive one and a half and two years after the original diagnosis. Two patients died two years after the onset of symptoms. Each of the 3 patients with tumors of the irregular nucleus type had a rapid clinical course and died within ten months.

Relation between vaccination and notification rates for whooping cough in England and Wales

The number of notified cases of whooping cough in the 1977-79 outbreak in England and Wales was the largest for over 20 years. The percentage of children receiving pertussis vaccine has declined sharply since 1974. Area Health Authorities with low vaccination acceptance had notification-rates 60% above those with higher acceptance. There was a partial correlation coefficient of -0.57 (p less than 0.001) between vaccination and notification rates after elimination of the effects of social class and overcrowding. The 1-4 year age-group, which contained the children most affected by the decline in vaccination-rates, showed a much bigger increase in notifications than other age-groups. The evidence suggests a direct relation between the decline in vaccination-rate and the increase in notifications.

Turtle-associated salmonellosis in the United States. Effect of Public Health Action, 1970 to 1976

We examined the effect of state and federal legislative actions on the incidence of human salmonellosis associated with pet turtles. Using the Salmonella Surveillance System of the Center for Disease Control, we identified Salmonella serotypes that were and were not specifically turtle associated. From 1970 to 1976, there was a 77% reduction in frequency of turtle-associated serotypes and no consistent trend among non-turtle-associated serotypes. Decrease in frequency of turtle-associated serotypes correlated best with decrease in total production of pet turtles. Reduction in turtle-associated sertotypes temporally correlated with an 18% reduction in frequency of salmonellosis in children, aged 1 to 9 years. Frequency of turtle-associated serotypes rapidly fell in states importing turtles, in contrast to states producing them. Continued although infrequent occurrence of salmonellosis in children with pet turtles counsels against relaxing legislation concerned with its control.

Vaccination against influenza: a five-year study in the Post Office

An injection of influenza vaccine was offered to approximately 60 000 Postal and Telecommunications staff at the beginning of five successive winters. The sickness absence of this group, which included those who accepted the offer of vaccine as well as those who did not, was compared throughout the winter with that of a similar number of employees who were not offered vaccine. The two groups, ;vaccinated' and control, comprised the staff of nearly 400 Post Office units scattered throughout Great Britain, the units of the two groups being matched as far as practicable for numbers employed, type of work, region and type of location.The proportion who accepted vaccine fell from 42% in the first year (when only 26 000 Telecommunications employees were offered vaccine) to 35% in the second year, and 25% by the fifth year.With the exception of Telecommunications employees in 1972-73, the sickness absence rate of the group offered vaccine was less than that of the group not offered vaccine, and the difference was evident during the winter observation periods both when influenza was prevalent and when it was not. In the last four years of the study the average difference in sickness absence between the ;vaccinated' and control groups was 1.26 days per 100 employees per week during and 1.12 days outside the influenza periods. Moreover, the difference during the influenza periods was greater than could be expected from the acceptance rate of vaccine and the estimated attack rate of influenza. The apparent reduction in sickness absence of the group offered vaccine in comparison with the group not offered vaccine represented an appreciable saving in cost.It is suggested than an annual influenza vaccination campaign in industry may produce financial benefit, but that only a proportion of the benefit is due to an improvement in health.