Fc-binding molecules specific for human IgG1 and IgG3 are present in Echinococcus granulosus protoscoleces

In this work we describe the presence of Fc-binding activity on the suckers and tegument of E. granulosus protoscoleces. A fraction (PSA-Fc+) from protoscolex somatic antigens was isolated by affinity chromatography on human Fc-gamma1-Sepharose. Analysis by SDS-PAGE of PSA-Fc+ showed that it contained two major components. Using mouse F(ab')2-human Fc chimaeric monoclonal antibodies we verified that PSA-Fc+ bound mainly to human Fc-gamma1 and Fc-gamma3 isotypes. In addition, one of the components of PSA-Fc+ showed proteolytic activity. Both, Fc-binding and proteolytic activities localized on the protoscolex surface, may play a relevant role in the host-parasite interaction.

The value of routine posttracheostomy chest radiography

OBJECTIVE

This study proposes to evaluate the efficacy of routine posttracheostomy chest radiography.

DESIGN

A retrospective chart review provided the framework of this study.

SETTING

The study took place at a university teaching hospital-level one trauma center.

PATIENTS

The study included 293 patients undergoing elective tracheostomy between 1989 and 1993.

MEASUREMENTS AND RESULTS

Data extracted from the charts included indication for tracheostomy, immediate preoperative and postoperative chest radiograph reports, management changes made secondarily to radiographic findings, including chest tube placement, institution of chest physiotherapy, and need for tracheal tube reposition. Complications were defined as findings not noted on the preoperative radiographs; these were pneumothorax, tube malposition, atelectasis, or clinical information resulting in management changes. All patients received postoperative chest radiographs in the trauma ICU. Statistical analysis of our data was carried out using the chi2 test. Patients with chest tubes in place at the time of surgery were the only group who were excluded so as not to confuse whether pneumothorax developed postoperatively. Of the initial 293 patients, 25 patients were excluded on the basis of having a chest tube. The remaining 268 charts were analyzed; 220 (82%) patients underwent tracheostomy for ventilator-dependent respiratory failure, 31 (12%) due to multiple facial fractures, 6 (2.1%) secondary to penetrating neck wounds, and 11 (4%) as a result of refractory vocal cord edema. One (0.3%) patient was found to have a postoperative 10% apical pneumothorax. Eight (2.4%) patients were found to have postoperative subsegmental atelectasis. There were no significant (p>0.05) management changes implemented as a result of these findings. No new infiltrates, effusions, or malpositioned tubes were noted. Deletion of routine posttracheostomy radiographs would save $52.39 per patient (cost) or $15,350 for 293 patients and $35,453 in total patient charges.

CONCLUSIONS

Abnormalities revealed by routine chest radiography after tracheostomy did not appear to alter patient management frequently enough to warrant the costs. A randomized, prospective study should be performed to analyze the safety of abandoning this practice.

Investigating the relationship between stress and worker behaviour

Direct care staff working in six residential group homes for people with intellectual disability were asked to complete a questionnaire which asked for information on levels of stress (anxiety and depression), the types of demand experienced by the staff, the support they received and the constraints they faced at work. Staff were also observed at work using a schedule which detailed who they interacted with, the content and type of interaction, and what activities staff were involved in. Measurement of workers' anxiety and depression levels confirmed management assessments of staff stress levels in the homes: two residential group homes were classified as 'low stress' and four as 'high stress'. A number of differences emerged between the two groups. Staff in the high stress homes reported greater demands and less support than those in the low stress homes. Higher levels of interaction were found between staff and residents in low stress houses, where more of the interaction was given as assistance and positive interactions. However, activities in higher-stress group homes appeared to be more community oriented, with staff spending a much greater amount of time out of the house. The importance of these results for both staff and residents is discussed, and suggestions for further work are made.

Tardive dyskinesia in older out-patients: a follow-up study

Tardive dyskinesia (TD) is a long-term potential adverse effect of neuroleptic treatment, and older age has been correlated with the development of TD. We conducted a chart review of current out-patients and examined annual Abnormal Inventory Movement Scale (AIMS) evaluations for the period 1987-1995 for 43 patients who started neuroleptic treatment after the age of 35 years. Patients (mean age 67 years) began neuroleptic treatment at a mean age of 46 years and were taking neuroleptics for 18 years on average. A total of 18 patients (42%) met the research criteria for TD, of whom all cases were mild except for three, which were moderate. Although TD was common, it rarely progressed in this naturalistic setting, suggesting that even for older patients maintenance neuroleptic treatment may be feasible for chronic psychosis.

The importance of leukotrienes in airway inflammation in a mouse model of asthma

Inhalation of antigen in immunized mice induces an infiltration of eosinophils into the airways and increased bronchial hyperreactivity as are observed in human asthma. We employed a model of late-phase allergic pulmonary inflammation in mice to address the role of leukotrienes (LT) in mediating airway eosinophilia and hyperreactivity to methacholine. Allergen intranasal challenge in OVA-sensitized mice induced LTB4 and LTC4 release into the airspace, widespread mucus occlusion of the airways, leukocytic infiltration of the airway tissue and broncho-alveolar lavage fluid that was predominantly eosinophils, and bronchial hyperreactivity to methacholine. Specific inhibitors of 5-lipoxygenase and 5-lipoxygenase-activating protein (FLAP) blocked airway mucus release and infiltration by eosinophils indicating a key role for leukotrienes in these features of allergic pulmonary inflammation. The role of leukotrienes or eosinophils in mediating airway hyperresponsiveness to aeroallergen could not be established, however, in this murine model.

Intraabdominal pressure and gastric intramucosal pH: is there an association?

This study evaluated the potential association between increased intraabdominal pressure (IAP) and abnormally low gastric intramucosal pH (pHi) (</= 7.32) in postoperative patients and assessed its effect on patient outcome. Altogether 73 patients undergoing major abdominal surgery over a 9-month period were studied prospectively. All underwent gastric tonometry and intravesical IAP measurements three time daily. An IAP of >/= 20 mmHg and a pHi of </= 7.32 were considered abnormal. The development of the following complications were also documented: hypotension [mean aortic pressure (MAP) < 80 mmHg], abdominal sepsis, renal impairment, and death. The median APACHE II score was 16 (range 5-34). Twenty-two patients had upper gastrointestinal (GI) surgery, 27 lower GI surgery, and 24 aortic surgery; 44 of these patients underwent emergency surgery. Abnormal pHi (</= 7.32) occurred in 36 patients while on the intensive care unit. Compared to patients with normal pHi, abnormal pHi patients were 11.3 times (3.2-43.5) [odds ratio +/- 95% CI] more likely to have an increased IAP. Abnormal pHi was significantly associated with hypotension (chi2 = 6.8;p = 0.009), sepsis (chi2 = 3.7;p = 0.06), renal impairment (chi2 = 28.3;p = 0. 0000001), relaparotomy (chi2 = 4.1;p = 0.04), and death (chi2 = 9. 7;p = 0.002). This study demonstrated a significant clinical association between increased IAP and abnormal pHi. An abnormally low pHi was associated with poor outcome.

Marine waters contaminated with domestic sewage: nonenteric illnesses associated with bather exposure in the United Kingdom

OBJECTIVES

This study identified possible dose-response relationships among bathers exposed to marine waters contaminated with domestic sewage and subsequent risk of nonenteric illness.

METHODS

Four intervention follow-up studies were conducted within the United Kingdom. Healthy volunteers (n = 1273) were randomized into bather and nonbather groups. Intensive water-quality monitoring was used to assign five bacteriological indices of water quality to individual bathers. Illnesses studied were acute febrile respiratory illness, and eye, ear, and skin ailments.

RESULTS

Fecal streptococci exposure was predictive of acute febrile respiratory illness, while fecal coliform exposure was predictive of ear ailments. Estimated thresholds of effect occurred at bather exposures above 60 fecal streptococci and 100 fecal coliform per 100 ml of water, respectively. Although no relationship was found between eye ailments and indicator organism exposure, compared with nonbathers, bathers were at higher risk for eye ailments.

CONCLUSIONS

Nonenteric illness can be transmitted via recreational contact with marine waters contaminated with sewage. These results argue against the use of a single indicator to establish water quality standards.

Frequency-domain measurement of vibrotactile driving responses in first-order afferent populations

Surface recordings made at the wrist during moderate vibrotactile stimulation of a digit display rhythmic activity at the frequency of the driving stimulus. This activity is abolished by local anesthesia of the stimulated digit and by substitution of the corresponding digit of the opposite hand with the recording geometry and the load on the stimulator unchanged. Several additional features of the response are similarly incompatible with an artifactual origin in properties of the stimulus motion or the associated electromagnetic field, but consistent with previous neurophysiological observations. The frequency-domain analysis extends readily to the single-trial level, making the technique potentially useful for a variety of basic research and clinical purposes.

Copper in drinking water--an investigation into possible health effects

A study was carried out to examine the possible relationship between levels of copper in drinking water and the incidence of specified childhood liver complaints presenting at a major UK paediatric liver unit. Public drinking water supplies were generally found to have levels of copper which were well below the EC standard of 3,000 micrograms/l. In private supplies, a slightly greater number of samples were found to exceed the prescribed concentration; in one instance a value of 26,000 micrograms/l was recorded. Data describing infant patients reporting to Kings College Hospital, London with specified liver complaints were examined. Where the address of patients could be determined (220 out of 240 cases), all patients were found to live in areas served by public drinking water supplies and were, thus, unlikely to have experienced elevated drinking water copper concentrations.

Occupational factors in multiple sclerosis: an analysis of occupational mortality statistics for men and married women in Great Britain

This paper presents an exploratory study based on occupational mortality statistics for Great Britain. It examines disease concordance between marital partners for multiple sclerosis (MS). Previous studies have revealed that a married woman's life expectancy and her specific cause of death is reliably associated with the occupational mortality of her husband. This relationship exists across a wide range of occupations but is particularly marked in the case of MS. The present study examines the mortality rates for MS for a large number of occupations (taking into account possible sources of statistical bias) and considers the relationship of these findings with existing hypotheses about the aetiology of MS. It is suggested that there should be more consideration of occupational and psychological factors in multicausal explanations of the disease.

Evidence that cytokine-mediated immune interactions induced by Schistosoma mansoni alter disease outcome in mice concurrently infected with Trichuris muris

In murine models of Schistosoma mansoni infection, egg production is associated with a switch from T helper cell (Th)1- to Th2-type responses to both schistosome-specific and unrelated antigens. Polyparasitism is common in human populations within S. mansoni endemic areas. We have, therefore, examined whether coinfection with S. mansoni could affect the outcome of a second parasitic infection, through Th2 cytokine-dependent modifications to the host immune response. We find that when mice susceptible to infection with the gut nematode Trichuris muris are coinfected with S. mansoni, they acquire the capacity to resolve T. muris infection, thus demonstrating a resistant phenotype. This ability to expel T. muris is associated with the production of Th2-associated cytokines, and corresponding antibody isotypes, in response to S. mansoni egg antigens. The Th2 response shows that there is no compartmentalization between spleen and mesenteric lymph nodes, and that the expulsion of T. muris is not caused by any changes in the host intestine associated with excretion of schistosome eggs. This influence of schistosome infections may be important, not only for the outcome of infections with unrelated pathogens in endemic areas, but also for the efficacy of vaccines in such areas.

Predicting likelihood of gastroenteritis from sea bathing: results from randomised exposure

The health effects of bathing in coastal waters is an area of scientific controversy. We conducted the first ever randomised "trial" of an environmental exposure to measure the health effects of this activity. The trial was spread over four summers in four UK resorts and 1216 adults took part. Detailed interviews were used to collect data on potential confounding factors and intensive water quality monitoring was used to provide more precise indices of exposure. 548 people were randomised to bathing, and the exposure included total immersion of the head. Crude rates of gastroenteritis were significantly higher in the exposed group (14.8 per 100) than the unexposed group (9.7 per 100; p = 0.01). Linear trend and multiple logistic regression techniques were used to establish relations between gastroenteritis and microbiological water quality. Of a range of microbiological indicators assayed only faecal streptococci concentration, measured at chest depth, showed a significant dose-response relation with gastroenteritis. Adverse health effects were identified when faecal streptococci concentrations exceeded 32 per 100 mL. This relation was independent of non-water-related predictors of gastroenteritis. We do not suggest that faecal streptococci caused the excess of gastrointestinal symptoms in sea bathers but these microorganisms do seem to be a better indicator of water quality than the traditional coliform counts. Bathing water standards should be revised with these findings in mind.

Domestic violence in America

Domestic violence is an underrecognized problem of immense cost. It is a crime; its victims must be identified and protected. The medical and judicial communities share responsibility in addressing this issue and providing support for victims. The role of health care workers in recognizing and preventing domestic violence cannot be overestimated. Direct questioning of patients, especially about the source of any injuries and about safety at home, is the first step in uncovering abuse. Educational programs for health care providers and the general public can change society's view and tolerance of this problem. Physicians must take an active role in changing community attitudes about domestic violence and in instituting programs to reduce its incidence. Medical treatment of the injuries resulting from domestic violence is not sufficient. Abused women need the care of a team of professionals who can address psychological, emotional, and physical injuries. They must also be provided with safe housing and financial and legal assistance in order to escape the abusive relationship. Physicians and legislators must work together to effect change. Domestic violence is a public health menace. We need to break the cycle of abuse that has become an integral part of our society.

Baby friendly care

In 1991, the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) launched a global campaign called the Baby-Friendly Hospital Initiative (BFHI). The initiative encourages health professionals to promote, protect and support breastfeeding as the optimal method of infant nutrition and enables families to make an informed choice about infant feeding. Hospitals that serve perinatal families are the focus, because what starts in the hospital carries on into the community. Recognizing the vital role of nurses as patient advocates and health promoters, and their position as the largest group of hospital-based health care workers, WHO and UNICEF are asking nurses to facilitate the implementation of the initiative in their hospitals.

Water and non-water-related risk factors for gastroenteritis among bathers exposed to sewage-contaminated marine waters

All previously published epidemiological studies of the health effects of bathing in marine waters contaminated with domestic sewage contain three major methodological weaknesses in study design: (1) failure to control for the substantial amount of temporal and spatial variation in indicator organism densities shown to occur within just a few hours at marine water bathing locations; (2) failure to relate indicator organism density directly to the individual bather; and (3) failure to rigorously control for non-water-related risk factors on previously reported associations between bathing in marine waters and illness among such bathers. We report the results of two intervention follow-up studies specifically designed to address these methodological weaknesses. We restricted study outcome to bathing-associated gastroenteritis since this is the illness most consistently reported to be associated with bathing in marine waters, and upon which both current US Marine Water Quality Criteria and other standards used worldwide are based. Our results show that faecal streptococci was the only indicator organism to predict the occurrence of gastroenteritis among bathers, and this occurred at only one of the three water quality sampling depths used in our study. The consumption of three different foods known or suspected to act as vectors in the transmission of gastroenteritis, as well as one non-food, non-water-related risk factor for gastroenteritis were found to significantly increase the risk of gastroenteritis among bathers. Multiple logistic regression modelling showed that these non-water-related risk factors confounded the relationship between exposure to marine waters of varying faecal streptococci densities and the occurrence of gastroenteritis among bathers to a moderate degree. Moreover, these analyses showed that the risk of gastroenteritis to the individual bather caused by these non-water-related risk factors, approximated the risk of gastroenteritis among bathers exposed to waters containing relatively high faecal streptococci densities. The implications of these findings with regard to the validity of present marine water quality criteria and on the need for, and design of, future epidemiological studies of bathing water associated illness are discussed.

Disease concordances amongst marital partners: not 'way of life' or mortality data artifact

Mortality statistics for Great Britain (1979-80, 1982-3) for more than 500 occupations and 20 different causes of death were examined. The paper demonstrates that there is clear concordance of cause of death between men and married women which can be linked to the occupation of the male. Various possible explanations are considered including shared social class and way of life and the suggestion that the associations reported are the result of various forms of statistical bias inherent in Standardized Mortality Ratio statistics. It is proposed that this is consistent with a psychosocial hypothesis, although longitudinal empirical research would be required to establish this.

Health effects of white-water canoeing

There is little quantitative information on the relation between water quality and disease attack rates after recreational activities in fresh water. We conducted a prospective cohort study to measure the health effects of white-water and slalom canoeing in two channels with different degrees of microbial contamination. Site A, fed by a lowland river, showed high enterovirus concentrations (arithmetic mean 198 pfu per 10 litre and moderate faecal coliform concentrations (geometric mean 285/dl); at site B, from an upland impoundment, all samples were free of enteroviruses and the geometric mean faecal coliform concentration was 22/dl. Between 5 and 7 days after exposure canoeists using site A had significantly higher incidences of gastrointestinal and upper respiratory symptoms than canoeists using site B or non-exposed controls (spectators). Like seawater bathers, fresh-water canoeists can be made ill by sewage contamination. The hazard of fresh water may be best measured by counting of viruses rather than bacteria.

Primary care in New York State: report and recommendations of the associated medical schools of New York

Medical education in New York is unique in the country in its scope and its diversity. It is important, as we go forward, that these strengths be neither eroded nor compromised. The AMS member institutions are making a collective commitment to work together to promote changes that will improve medical education for all students by providing them with enriched experience in primary care. Our major resource is faculty. To whatever degree medical schools can influence career choice, it is essential to this aim that the best possible people are placed in the settings in which primary care is taught. The schools will intensify their efforts to recruit and retain such faculty and, in whatever way is appropriate to each institution, provide them with the stature needed to emphasize the value which the school places on primary care. The schools will also work to provide exposure to primary care early in a student's academic career given anecdotal evidence, at least, that such early experience can influence subsequent specialty choice. Finally, the medical schools will assume greater responsibility for graduate medical education. If, with state support, ambulatory teaching sites are developed, the schools will make every effort to assure that they are staffed with high-quality faculty. Residents and students must see primary care practiced with total commitment to quality. It is hoped that, with state-initiated improvements in the practice environment, the ultimate outcome will be an increase in the number of our graduates selecting primary care disciplines for their practices and locating in areas in need of physicians.2+ Corporation, and the Greater New York Hospital Association. We are ready to work with others toward our common objectives, and we call on all of those who share these concerns to participate with us.