Brain abscesses caused by Burkholderia pseudomallei

Burkholderia pseudomallei is an important human pathogen in tropical areas, particularly South East Asia and Northern Australia. A fatal case of meliodosis presenting as brain abscesses is described. The patient deteriorated despite treatment and died 21 days after admission. Burkholderia pseudomallei was only isolated after administration of corticosteroids, whilst on treatment with antibiotics to which the organism later showed in vitro sensitivity. Magnetic resonance imaging was more sensitive than computed tomography in diagnosing early brainstem infection in this patient. Physicians working outside the endemic areas must be attuned to the possibility of melioidosis in any patient with an appropriate history of travel to endemic areas. The combination of striking early, extensive, confluent T2 hyperintensity with disproportionately small enhancing lesions may be characteristic of meliodosis.

Brain and abdominal temperatures at fatigue in rats exercising in the heat

We measured brain and abdominal temperatures in eight male Sprague-Dawley rats (350-450 g) exercising voluntarily to a point of fatigue in two hot environments. Rats exercised, at the same time of the day, in three different trials, in random order: rest 23 degrees C, exercise 33 degrees C; rest 23 degrees C, exercise 38 degrees C; and rest 38 degrees C, exercise 38 degrees C. Running time to fatigue was 29.4 +/- 5.9 (SD), 22.1 +/- 3.7, and 14.3 +/- 2.9 min for the three trials, respectively. Abdominal temperatures, measured with intraperitoneal radiotelemeters, at fatigue in the three trials (39.9 +/- 0.3, 39.9 +/- 0.3, and 39.8 +/- 0.3 degrees C, respectively) were not significantly different from each other. Corresponding brain temperatures, measured with thermocouples in the hypothalamic region (40.2 +/- 0.4, 40.2 +/- 0.4, and 40.1 +/- 0.4 degrees C), also did not differ. Our results are consistent with the concept that there is a critical level of body temperature beyond which animals will not continue to exercise voluntarily in the heat. Also, in our study, brain temperature was higher than abdominal temperature throughout exercise; that is, selective brain cooling did not occur when body temperature was below the level limiting exercise.

Fatal Legionella longbeachae infection following heart transplantation

A case of fatal Legionella longbeachae infection following heart transplantation is described. Gram stains of respiratory secretions on day 17 posttransplant revealed leucocytes and gram-negative bacilli, but there was no growth on routine bacterial culture. Legionella longbeachae serogroup 1 was isolated from respiratory specimens, blood, and postmortem lung tissue. Legionella longbeachae is a common cause of legionellosis in Australia, and infection has been associated with exposure to potting mixes. Specific culture for Legionella spp. should be performed for any patient who develops pneumonia following organ transplantation.

Risk reversals in predictive testing for Huntington disease

The first predictive testing for Huntington disease (HD) was based on analysis of linked polymorphic DNA markers to estimate the likelihood of inheriting the mutation for HD. Limits to accuracy included recombination between the DNA markers and the mutation, pedigree structure, and whether DNA samples were available from family members. With direct tests for the HD mutation, we have assessed the accuracy of results obtained by linkage approaches when requested to do so by the test individuals. For six such individuals, there was significant disparity between the tests. Three went from a decreased risk to an increased risk, while in another three the risk was decreased. Knowledge of the potential reasons for these changes in results and impact of these risk reversals on both patients and the counseling team can assist in the development of strategies for the prevention and, where necessary, management of a risk reversal in any predictive testing program.

The principles of aseptic technique in wound care

Research evidence on asepsis is patchy, ambivalent and cannot always be generalised. There is no substitute for assessment of the individual circumstances before each procedure. Handwashing is vital, well researched and uncontroversial.

Parvovirus B19 in HIV infection: a treatable cause of anemia

We describe the case of an adult male patient with AIDS who presented with severe anemia and on investigation was found to have red cell aplasia due to parvovirus B19 infection. Bone marrow examination revealed absence of erythroid development and rare giant pronormoblasts. Repeated serological examinations revealed a low level of parvovirus IgM but no IgG. Viremia was demonstrated by electron microscopy and by the polymerase chain reaction (PCR). The patient's initial hemoglobin was 45 g/l and over a four month period he required twenty units of blood. He was treated with intravenous immunoglobulin (Intragam, CSL) at a dose of 400 mg/kg/day for five days. This led to an increase in his hemoglobin to 135 g/l. Parvovirus remained detectable by PCR but not by electron microscopy. Six months later the patient relapsed (Hb 65 g/l). Again he was transfused and treated with intravenous immunoglobulin for five days. His hemoglobin rose to 153 g/l and remained stable. He subsequently received maintenance treatment with 30 g of intagram once a month. We recommend that parvovirus be considered in any HIV infected patient with recurrent anemia.

Effects of storage time on quantitative and qualitative platelet function after transfusion

BACKGROUND

Platelet transfusions are being used increasingly in patients with thrombocytopenia to improve hemostatic function before surgery and invasive procedures. However, there are limited data on the immediate quantitative and qualitative platelet response after transfusion. Some authors have suggested that transfused platelets require time in vivo to regain maximal function, which is dependent on the duration of platelet storage. Therefore, the timing of surgery and invasive procedures with optimal platelet function may not be occurring.

METHODS

Twenty-five patients with thrombocytopenia from ablation chemotherapy and total body irradiation (before bone marrow transplantation), were randomized to receive either 1-day (fresh) or 4-day stored platelets. No patient had infection, organ system dysfunction, or previous platelet transfusion. Single-donor platelets were transfused (1 unit/10 kg body weight) over 60 min. Whole blood from an indwelling central venous catheter was obtained before, immediately after, and 1, 2, and 24 h after transfusion. Platelet number was measured on a Coulter counter and platelet reactivity was measured on a Coulter counter and platelet reactivity was measured using agonist-induced whole blood impedance aggregometry (ohms) and dense granule release (adenosine triphosphate [ATP]).

RESULTS

Platelet number increased similarly (21,000 +/- 2,000/mm3 to 76,000 +/- 7,000/MM3 AND 20,000 +/- 1,000/MM3 TO 65,000 +/- 4,000/MM3) after transfusion in the 1- and 4-day stored platelets, respectively. These levels were maintained for 2 h after transfusion in both groups and then decreased similarly (26% and 27%) at 24 h. Agonist-induced platelet aggregation increased immediately after transfusion to 5 micrograms/ml collagen (0.7 +/- 0.4 to 11.4 +/- 1.0 ohms and 0.1 +/- 0.1 to 5.2 +/- 1.0 ohms), 10 micrograms/ml collagen, (1.5 +/- 0.7 to 18.0 +/- 1.9 ohms and 0.6 +/- 0.4 to 10.0 +/- 1.6 ohms) and ristocetin (0.7 +/- 0.4 to 10.1 +/- 1.7 and 0.1 +/- 0.7 to 6.2 +/- 1.0 ohms), in 1- and 4-day, stored platelets, respectively and persisted unchanged in both groups for 2 h. Fresh platelets were hyperaggregable compared to 4-day stored platelets for collagen-induced (5 micrograms/ml and 10 micrograms/ml) aggregation. Agonist-induced platelet dense granule release (ATP) increased immediately after transfusion to 5 micrograms/ml collagen (42 +/- 18 to 410 +/- 49 picomoles ATP and 20 +/- 7 to 186 +/- 22 picomoles ATP), 10 micrograms/ml collagen (60 +/- 22 to 449 +/- 53 picomoles ATP and 44 +/- 13 to 219 +/- 25 picomoles ATP in 1- and 4-day platelets, respectively. Ristocetin-induced ATP release increased immediately after transfusion of fresh platelets only (0 +/- 0 to 69 +/- 17) and remained unchanged for 2 h. Fresh platelets also demonstrated greater dense granule release to collagen (5 micrograms and 10 micrograms/ml) and ristocetin than 4-day stored platelets.

CONCLUSIONS

In patients with chemotherapy-induced thrombocytopenia, platelet transfusion causes an immediate increase in number and function, which is independent of storage time. This quantitative and qualitative increase persists unchanged for 2 h after transfusion, suggesting that there is no acute "warm-up-time" necessary for transfused platelets to regain maximal function. Fresh platelets demonstrate increased aggregation and dense granule release compared to 4-day stored platelets and may impart improved hemostatic function in vivo.

The prevalence of a family history of cancer in general practice

The presence of a family history of cancer of the colorectum, breast, uterus and ovary is associated with an increased risk for that type of cancer. The aim of this study was to assess the prevalence of a family history of these cancers in the community. Nurses asked all attenders at health checks aged 35-64 about the presence of a history in close relatives of cancer diagnosed under the age of 70. Information was obtained from 8109 patients. Of the sample, 3.1% had a family history of colorectal cancer; 4.8% of women had a family history of breast cancer, whilst 1.9% had a family history of uterine or ovarian cancer. Projecting the results to a population of 2000 demonstrated that a general practitioner with a list size of 2000 could expect to have 30-40 patients in whom an appropriate management strategy would need to be considered.

Diagnosis of Huntington disease: a model for the stages of psychological response based on experience of a predictive testing program

Persons diagnosed as affected with Huntington's disease (HD) may have similar stages of psychological response to the clinical presentation of the illness. Here we describe a model of these stages of response based on our experience during a predictive testing program for HD. During the Warning Stage, asymptomatic persons are aware of their risk status for HD and develop defenses which favor adaptation to their genetic risk. In response to the initial signs and symptoms of HD (the Incipient Stage) unconscious working through of this realization occurs while it is still kept out of conscious awareness. When symptoms become obvious such that recognition of disease onset is inevitable (Breakthrough Stage) the possibility of the diagnosis of HD is assimilated. After the delivery of the diagnosis during the Adjustment Stage, short- and long-term adaptive responses to living with HD occur. Recognition of the stage of psychological response of a patient who presents with HD is important prior to delivering a clinical diagnosis. In a significant minority of cases, the psychological readiness lags behind the clinical symptomatology and premature presentation of a diagnosis may result in significant untoward adverse events. Understanding of the stages of response may provide a framework for evaluating the psychological state of the person with HD and determining their readiness to receiving the diagnosis. This model may have relevance to the psychological responses of patients to the diagnosis of other late onset autosomal dominant disorders.

Effect of instructions to simulate a back injury on torque reproducibility in an isometric lumbar extension task

The purpose of this study was to investigate the differences in test-retest reliability between maximal and "simulated back injury" efforts in an isometric lumbar extension task and to test the hypothesis that voluntary attempts to "simulate" a back injury would yield less consistent torque production than maximal efforts. Twenty subjects were asked to undergo lumbar extensor testing at seven different positions in a lumbar extension machine. Each subject was tested twice in a maximal effort condition and twice with instructions to "simulate" a back injury. The order of the conditions was counterbalanced across subjects so that half of the subjects performed the maximal effort tests first and half performed the "simulated" effort first. Results indicated high test-retest correlations at all angles in both conditions. There were no differences in test-retest reliability between effort conditions. Therapist ratings of consistency did not differ between conditions and therapists could not discriminate between conditions on the basis of effort consistency. In the "simulated" condition subjects produced reliable, submaximal torque plots consistent with previous data indicating similar reliability at submaximal levels. It was concluded that use of test-retest torque consistency as a measure of sincerity of effort is premature and may be misleading.

Motivational effect of cholesterol measurement in general practice health checks

A randomized trial was conducted in five general practices in and around Aylesbury, Buckinghamshire to assess the motivational effect of cholesterol measurement on compliance with advice to reduce dietary fat intake and to stop smoking. The advice was given by practice nurses during health checks for cardiovascular risk factors. A total of 578 patients were recruited to the study and randomized into two groups. Both groups were given the same advice and were followed up after a median of three months, but the intervention group was also given immediate feedback on their cholesterol concentration. Follow up was completed for 88.2% of subjects, and those who were not followed up were assumed not to have changed their behaviour. The mean fall in total cholesterol at follow up was 0.11 mmol l-1 (95% confidence interval 0.03 to 0.18) in the intervention group who were told their cholesterol result and 0.02 mmol l-1 (95% CI -0.06 to 0.10) in the control group who were not. The proportion of smokers who were not smoking at follow up was 10.7% and 10.1% in the two groups, respectively. Patients in the intervention group with an initial total cholesterol level of 6.50 mmol l-1 or greater showed a mean fall of 6.2% in cholesterol level whereas those with an initial cholesterol level of less than 5.20 mmol l-1 experienced a mean increase of 3.6%, but as differences of this magnitude were also seen in the control group they probably reflect regression to the mean rather than an effect of knowledge of cholesterol level.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute intramedullary spinal cord abscess: case report

We report the first case of an acute pyogenic intramedullary cervical spinal cord abscess, brain abscesses and meningitis due to an unusual anerobe, Bacteroides disiens. The importance of spinal magnetic resonance imaging for establishing the diagnosis is emphasized.

Patient compliance with colorectal cancer screening in general practice

A randomized controlled trial to test patient compliance with screening for colorectal cancer in association with general practice health checks was carried out in six practices (three urban and three rural). A total of 1588 patients aged 45-64 years were randomized to one of four intervention groups. In the first group patients were posted a Haemoccult test (Kline Beckman) kit. This group was not invited for a health check. In the second group patients were posted the Haemoccult test kit, together with an invitation to attend for a health check. In the third group patients were posted an invitation for a health check, which explained that the patient would be offered the Haemoccult test kit by the nurse at the health check. In the fourth group patients were just invited for a health check. It was found that combining faecal occult blood testing with the health check did not reduce attendance at the health check--43.5% of patients attended when the Haemoccult test kit was offered by the nurse at the health check, 43.6% attended when a test kit was included with the invitation to attend the health check and 42.9% attended when the health check invitation was posted on its own. Overall, compliance with Haemoccult testing was not significantly increased by associating it with a health check (26.2% versus 25.5%) but compliance was higher when the faecal occult blood testing kit was enclosed with the health check invitation than when it was offered at the health check (31.7% versus 20.6%, P less than 0.001). It is easier and cheaper to combine various screening procedures. Although the overall use of the Haemoccult test in the study population was low, there is no reason why the relatively higher compliance rate obtained on posting the test kit with a health check invitation cannot be achieved in previously unscreened populations with higher expected compliance rates. However, faecal occult blood screening for colorectal cancer should not be undertaken on a population basis until its effectiveness in reducing mortality has been proven by randomized trial.

Reproducibility of maximal versus submaximal efforts in an isometric lumbar extension task

The purpose of this study was to investigate the differences in test-retest reliability between maximal and submaximal efforts in an isometric lumbar extension task and to test the hypothesis that submaximal efforts would be less consistent than maximal efforts. Twenty subjects were asked to produce maximum voluntary contractions at seven different positions in a lumbar extension machine. Each subject was tested twice in a maximal-effort condition and twice in a 50% effort condition. The order of the effort conditions was counterbalanced across subjects so that half of the subjects performed the maximal-effort tests first and half performed the submaximal effort first. Results indicated high test-retest correlations at all angles in both conditions. There were no differences in test-retest reliability between effort conditions. Therapist ratings of consistency did not differ between conditions, and therapists could not discriminate between conditions on the basis of effort consistency. Because subjects could reliably reproduce a submaximal effort, it was concluded that consistency interpretations of isometric strength testing may be misleading.

Factors affecting women's response to an invitation to attend for a second breast cancer screening examination

A survey was conducted to study the impact of women's previous experiences of breast cancer screening on their subsequent readiness to reattend. Women aged 45-64 years from three general practices were invited to attend for a second breast cancer screening test at a mobile clinic. Of the 1582 women who were invited, 1408 (89.0%) reattended. A questionnaire about their experience of the previous screening test was completed by 641 women who attended and 124 who did not attend the second test. Twenty six per cent of the women had found the previous test painful, and a minority also reported embarrassment (7%) or distress (6%). Women who did not reattend were significantly more likely than those who did to report the previous screening test as embarrassing or distressing and were significantly less likely to have found the clinic staff helpful or attendance for screening worthwhile or reassuring. No significant difference was found in the reattendance rate of women who had experienced a false positive result at the previous screening test compared with the remaining women. These results show that there may be substantial scope for reducing non-attendance by improving the way the service is provided, thereby enhancing the overall impact of breast cancer screening.

Patient participation in general practice: who participates?

A postal survey of 4066 men and women aged between 16 and 64 years was carried out in a general practice in Oxfordshire which had a patient participation group, established in 1972. The aim of the survey was to ascertain the knowledge and use of the group among adults aged 16-64 years. The adjusted response rate was 73%. Despite the length of the group's existence only 45% of these patients were aware of it and only 7% had ever attended a meeting. Awareness of the group and sometime attendance were significantly less in men, patients aged between 16 and 29 years, those in social classes 4 and 5, single people and those who smoked. Patients who consulted more than four times per year were more likely to be aware of the group than less frequent consulters. The possible reasons for the unrepresentative nature of the patients attending the group are discussed, together with implications for practice policies and development. Various strategies for making the group more representative are proposed, including advertising within the practice and elsewhere, and the formation of special interest groups for patients with defined medical and social needs, in the hope that this will make the concept of patient participation more relevant.

Experiences of patients with false positive results from colorectal cancer screening

A survey was conducted to study the experiences of patients with false positive results for colorectal cancer. The study patients were participants in a randomized trial of compliance with different methods of colorectal cancer screening by faecal occult blood testing. Fifty four out of fifty six patients (96.4%) with false positive results agreed to be interviewed. An age and sex matched control group of 112 patients with negative test results was identified --92 (82.1%) returned questionnaires. Thirteen of the patients with false positive results (24.1%) and 19 controls (20.7%) were to some extent distressed by the initial letter inviting them to participate in the screening programme. Thirty seven of the patients with false positive results (68.5%) felt some degree of distress at the initial positive test result and 19 (35.2%) some distress because of delays experienced in the process of being screened. Ten false positive patients had colonoscopy and the median waiting time for this procedure was 10 days--half of the patients found this wait distressing. Nevertheless, 53 of the patients with false positive results (98.1%) felt that it had been worthwhile to have had the test. Generally, colorectal screening was as acceptable to the patients who experienced false positive results as to those with negative results.

An Australia-wide epidemic of Pseudomonas pickettii bacteraemia due to contaminated "sterile" water for injection

Nineteen cases of Pseudomonas pickettii bacteraemia and one case of Pseudomonas cepacia bacteraemia were identified in an Australia-wide outbreak of nosocomial sepsis associated with contaminated water for injection. The contamination was limited to one batch of commercially produced water for injection. Four different organisms were identified (three biotypes of P. pickettii and one of P. cepacia). However, P. pickettii biotype 1 appeared to be relatively more virulent than the other biotypes as it was the only identified organism in blood cultures in nearly all cases of sepsis. The ampoules of "sterile" water were each contaminated with approximately 10(3) organisms per millilitre. The lack of an Australian central reporting system for bacteraemia delayed the recognition of this outbreak.

Childhood accidents: a practice survey using general practitioners' records and parental reports

A survey of accidents in children under 16 years of age from one general practice (list size 6400) was carried out using a postal questionnaire to parents and an audit of medical records. Incidence rates were estimated by audit of medical records as 97% of accidents 'other than minor cuts and bruises' reported by parents had resulted in a medical consultation, and parental reporting was incomplete. For 1986, these rates were 254 per 1000 patients at the age of four years or less, 218 per 1000 at age five to nine years and 238 per 1000 at age 10 to 15 years. However, parental reports of accidents provided better detail of the circumstances of accidents than the medical records: in the latter, the circumstances of accidents were noted in 75% of records and the location in only 40%. Various options for monitoring accidents and near accidents utilizing parental information which could be administered by general practitioners are proposed, including the use of parent-held child health record cards and a 'yellow card' system analogous to that used for reporting adverse drug reactions.

Health checks in general practice: another example of inverse care?

OBJECTIVE

To assess attendance at and the characteristics of patients attending health checks for cardiovascular disease offered in a general practice over a period of five years (1984-9).

DESIGN

Medical record audit and postal questionnaire survey.

SETTING

One general practice in Oxfordshire with a socially diverse population.

PARTICIPANTS

1101 Men and 1110 women aged 35-64 registered with the practice.

MAIN OUTCOME MEASURES

Age, sex, marital state, social class, smoking habits, alcohol consumption, and diet.

RESULTS

Of the 2211 men and women in the target age group (35-64) in 1989, 1458 (65.9%) had been offered screening and 963 (43.6%) had attended for a health check. Attenders were more likely to be women, aged greater than or equal to 45, married, non-smokers, and of higher social class than patients who did not respond to the invitation. The relative likelihood of non-attendance was 1.24 for smokers, 1.20 for the overweight, 1.16 for heavy drinkers, and 1.28 for those with a less healthy diet, even after adjustment for age, sex, marital state, and social class.

CONCLUSIONS

After five years of offering health checks, opportunistically (to men) and in the context of cervical smear tests (to women), less than half of the eligible patients had attended. The likelihood of acceptance of an invitation to attend was inversely related to the patient's cardiovascular risk for all factors measured except age. A coherent strategy to reduce cardiovascular disease depends on more careful targeting of scarce health service resources and more emphasis on public health measures (such as dietary regulation and tobacco taxation). Doctors should be careful not to absolve the government of its public health obligations by substituting unproved preventive interventions aimed at the individual patient.

Randomized controlled trial of anti-smoking advice by nurses in general practice

Practice nurses are playing an increasingly prominent role in preventive care, including the provision of anti-smoking advice during routine health checks. A randomized controlled trial was designed to assess the effectiveness of anti-smoking advice provided by nurses in helping smokers to stop smoking. A total of 14,830 patients aged 16-65 years from 11 general practices completed a brief questionnaire on general health, including smoking status, at surgery attendance. The doctor identified 4330 smokers and randomly allocated 4210 to control or intervention groups. The doctor asked those in the intervention group to make an appointment with the practice nurse for a health check. The attendance rate at the health check was 26%. Smokers were sent follow-up questionnaires at one month and one year, and those who did not respond to two reminders were assumed to have continued to smoke. There was no significant difference in reported cessation between the intervention and control groups at one month or one year. However, there was a significant difference in the proportion of patients who reported giving up within one month and who had not lapsed by one year--0.9% in controls and 3.6% in the intervention group (P less than 0.01). Nevertheless, the effect of the nurse intervention itself may be small as the sustained cessation rate in attenders was only 42.4% higher than in non-attenders. The deception rate in reporting cessation, as measured by urinary cotinine, was of the order of 25%.

The "Help Your Patient Stop" initiative. Evaluation of smoking prevalence and dissemination of WHO/UICC guidelines in UK general practice

The World Health Organisation and the International Agency against Cancer in 1988 published joint guidelines on smoking cessation for primary health care teams. A booklet entitled Help Your Patient Stop was produced in the United Kingdom as a model for the international dissemination of these guidelines. This booklet was sent to UK general practitioners by post; about 4 weeks later, a random sample of 5000 were asked to complete a postal questionnaire about the booklet and their smoking habits. The response rate was 75%. About half (50.5%) remembered receiving the booklet, 27.7% had read it, and only 8.8% could write down any of the three essential activities in smoking cessation which the booklet was intended to promote and which were printed in bold letters on the inside back cover. Although the booklet itself might be an adequate model for other countries, unless dissemination and marketing of the information it contains can be improved, its achievement will be limited. However, the survey did have one optimistic feature: only 13.5% of general practitioners reported that they smoke; and only a third of those who gave full details of their smoking habit smoke cigarettes.

Three year follow up of patients with raised blood pressure identified at health checks in general practice

OBJECTIVE

To assess the extent of three year follow up of blood pressure, weight, and smoking habit in patients with raised blood pressure identified at health checks.

DESIGN

Retrospective audit of medical and nursing records.

SETTING

Three general practices in Oxfordshire.

PATIENTS

386 of 448 patients with raised blood pressure (diastolic greater than or equal to 90 or systolic greater than or equal to 160 mm Hg) identified from 2935 patients aged 35-64 attending health checks in 1982-4.

MEASUREMENTS AND MAIN RESULTS

All records of blood pressure, weight, and smoking habit in the medical record were abstracted for three years after the initial health check. All 42 patients with an initial diastolic blood pressure greater than or equal to 105 mm Hg and 316 of 344 patients with an initial pressure of 90-104 mm Hg had at least one further measurement of their blood pressure. Follow up of smoking habit and of weight was less complete with only half of the 100 smokers and 67 of the 87 obese patients (body mass index greater than or equal to 30) having any documented follow up of these risk factors. Annual follow up in the second and third years occurred in 228/297 (76.8%) and 232/320 (72.5%) in patients with blood pressure greater than 95 mm Hg at the beginning of each year. For patients who smoked annual follow up in these years occurred in fewer than a third and for those who were obese in just over half. On the assumption that those not followed up had not changed, at the end of three years the proportion of patients with diastolic blood pressure greater than or equal to 100 mm Hg had fallen from 61 patients (15.8%) to 31 (8.1%); the proportion of smokers had fallen from 103 (26.7%) to 94 (24.4%); and the proportion of obese patients had fallen from 87 (22.5%) to 79 (20.5%).

CONCLUSIONS

These changes were modest and in the absence of a control group cannot be attributed necessarily to health checks. Although the standard of follow up was better than in previously reported studies of the management of hypertension, the results emphasise the need to develop formal protocols for dietary and antismoking interventions and to evaluate formally the effectiveness (and cost effectiveness) of health checks.

Antibody reactivity with Skinner HSV vaccine

Antibody reactivity against herpes simplex virus (HSV) was investigated in 15 subjects who received three subcutaneous immunisations with Skinner HSV vaccine. Humoral antibody responses were detected against type 1 HSV in every subject and against type 2 HSV in all but one subject; immuno-precipitating antibody responses were infrequently detected. There was no antibody reactivity against host-cell (MRC-5), foetal calf serum or rubella virus antigen. None of the vaccinated subjects developed clinical evidence of herpes genitalis.

Follow-up report on 50 subjects vaccinated against herpes genitalis with Skinner vaccine

Fifty subjects at risk of herpes genitalis received 109 immunizations with Skinner herpes vaccine and were assessed after a follow-up period of 4-48 months, representing a total follow-up period of 694 patient months. There was no evidence of contraction of herpes genitalis in 49 subjects. The risk of virus transmission and rate of contraction of disease was quantified by construction of two functions, namely a unit of exposure risk calculated per year (UYE) and standard contraction rate (SCR); in this study the SCR was 0.02. There was no evidence of significant side-effects from vaccination. Administration of Alhydrogel adjuvant with vaccine induced temporary granuloma formation in most subjects but was only detectable beyond 1 year of follow-up in one subject, in whom a painless swelling of 0.2 cm was detected 3 years after vaccination. There was no evidence of immunological reactivity to host cell or calf serum antigens in any of the subjects vaccinated.

Malignant schwannoma of the ovary. Report of a case

A malignant schwannoma, apparently arising in the left ovary of a 71-year-old woman is described. The patient had no stigmata of von Recklinghausen's disease. The tumor was located in the position of the left ovary and had metastasized throughout the peritoneal cavity. The neural sheath origin of the tumor was confirmed by electron microscopic examination. The tumor is thought to have arisen from small nerves in the ovarian hilus.

Naproxen in otitis media with effusion

The levels of prostaglandin E2 (PGE2) were measured in aspirates of the effusion fluid from children suffering from secretory otitis media. The effects of naproxen 5 mg./kg. twice daily for eight weeks on the condition were studied in a placebo-controlled double-blind trial. Nineteen middle-ear aspirates from 13 children, six of whom had bilateral aspirations were examined. Detectable levels of PGE2 (greater than 1.0 ng. per ml.) were present in seven aspirates from seven children and ranged from PGE2 1.0 to 14.4 ng. per ml. In four of the six patients who had bilateral aspirations, PGE2 was detectable in the aspirate from one ear but not the other. However, the severity of otalgia and hearing loss was almost identical in the ears with detectable levels of PGE2 and those without. In a separate trial of naproxen, 11 patients received active drug and 13 received placebo. Naproxen had no significant effect on otalgia or hearing loss compared to placebo. These findings suggest that it is unlikely that non-steroidal anti-inflammatory drugs will be of therapeutic benefit in secretory otitis media.

Further studies on the epitopes of HLA-B7 defined by murine monoclonal antibodies

Monoclonal antibodies reactive with polymorphic epitopes of HLA-B7 were analyzed by direct and indirect cytotoxicity assays on established panels of HLA typed lymphocytes. This permitted further refinement of their specificity and the identification of various novel reactions. The topographic relationship of polymorphic epitopes on the surface of the B7 molecule was assessed with various serological assays using cell surface B7 or papain solubilized B7 as the antigenic target. These studies focused on monoclonal antibodies recognizing B27 and B7. The results, in combination with those of previously published studies, are used to provide a current assessment of the epitope map of HLA-B7 as defined with mouse monoclonal antibodies. This is compared to the results obtained with alloantisera.

Control of herpes simplex virus infections of the genital tract by vaccination

The apparent increasing incidence of herpes simplex virus infections of the genital tract has focused attention on the efficacy of vaccination in preventing infection or modifying established disease. Results of an 'open trial' using a DNA-free inactivated virus subunit vaccine have shown that vaccination of subjects at risk of contracting infection from their sexual partner reduced the transmission rate from 34% in unvaccinated controls to 0.5%. In a separate study, vaccination of patients who had experienced their first overt attack of herpes genitalis (the initial clinical episode) had significantly fewer recurrences over the follow-up period of 12 months than the unvaccinated control group. The results, we feel, justify a placebo controlled trial.

New approaches to donor crossmatching and successful transplantation of highly sensitized patients

A class I HLA molecule may bear not only a private or unique determinant, but a shared, yet discrete, public epitope. These public determinants occur with a much higher frequency in the random donor population than the associated private determinants--and thus, are encountered more often in random donor blood transfusions and in renal transplantation. Sera from highly sensitized dialysis patients have been reported to contain a restricted number of antibodies to public determinants rather than a diverse array of antibodies directed against the private HLA-AB epitopes. As detailed in this report, comprehensive serum analysis of the public antibodies in highly sensitized transplant candidates has optimized identification of potential crossmatch-compatible donors and has avoided needless crossmatches. During the past two years, the incidence of renal transplantation from cadaveric donors to highly sensitized recipients has doubled at this institution. At 10-25 months following transplantation, 70% of these allografts are functioning. Private HLA class I antigen incompatibility was not a barometer for exclusion in the final donor crossmatch of these highly sensitized recipients. Furthermore, positive donor T cell crossmatches with sera obtained more than six months prior to transplantation may not represent an impediment to successful transplantation. We conclude that the approach of detailed antibody analysis can result in an improved outlook for successful transplantation of more dialysis patients who are highly sensitized to the class I HLA alloantigens.

Efficacy of vaccine Ac NFU1 (S-) MRC 5 given after an initial clinical episode in the prevention of herpes genitalis

A subunit antigenoid vaccine, Ac NFU1 (S-) MRC 5, was used in patients who had had a clinical episode of herpes genitalis. The rate of recurrence was compared with that in unvaccinated patients to determine the efficacy of vaccination in preventing recurrence and spread of the virus in the community. Seven of 22 (31%) vaccinated patients had eight recurrences after the initial clinical episode; in contrast there were 51 recurrences in 17 of 20 (85%) unvaccinated patients. Although further studies are needed, the results indicate that the vaccine may prevent recurrent episodes of herpes genitalis and thereby reduce the dissemination of this virus in the population.

The relative infrequency and low levels of neutralising and immunoprecipitating antibody to herpes simplex viruses types 1 and 2 in patients with a history of recurrent herpes genitalis

Twenty-seven per cent of 70 patients with a history of recurrent herpes genitalis but no concomitant history of recurrent oral or peri-genital disease, had no detectable neutralising antibody against type 1 or type 2 herpes simplex virus; the prevalence and levels of neutralising antibody were similar to 53 patients with no history of herpetic disease and significantly lower than 67 patients with a history of recurrent herpes genitalis in association with oral or peri-genital disease all of whom had neutralising antibody against both virus types. There were similar differences between groups for immunoprecipitating antibody where 80% of patients were herpes genitalis alone had no detectable immunoprecipitating antibody. The results indicate that the failure to detect immunising and immunoprecipitating antibody in an individual's serum is compatible with a long and even severe history of recurrent herpes genitalis and consequently that the development of neutralising antibody does not necessarily indicate an episode of primary herpetic disease.

Preparation and immunogenicity of vaccine Ac NFU1 (S-) MRC towards the prevention of herpes genitalis

A subunit antigenoid vaccine, Ac NFU1 (S-) MRC, was used to prevent primary herpes genitalis in 60 subjects considered to be at risk of this infection. There was no evidence of serious local or general side effects. Neutralising antibody responses were detected in 59% and 90% of subjects receiving the low and high doses of vaccine respectively; immunoprecipitating antibody was detected at a lower frequency, namely in 23% and 43% of subjects receiving the low and high doses respectively. After a mean follow-up period of 18 months none of the vaccinated subjects contracted herpes genitalis after completing the vaccination course.