Screening for carbon monoxide in children

OBJECTIVE

Carbon monoxide (CO), a colorless, odorless gas, accounts for the majority of fatal poisonings in the United States. To date, few screening studies that evaluate pediatric exposure are available. The objectives of this study were to determine the value of a CO breath analyzer for detecting pediatric CO exposure and to identify potential CO sources.

DESIGN

Prospective screening study.

SETTING

Emergency department of an urban children's hospital.

PATIENTS

A convenience random sample of 470 noncritically ill children, aged five to 20 years, who presented to a pediatric emergency department and could blow into a CO breath analyzer.

INTERVENTION

After informed consent and demographic and clinical variables were ascertained, eligible patients blew into a CO breath analyzer. Those with breath CO levels > or = 9 ppm underwent confirmatory cooximetric analysis of capillary blood. Sources of CO exposure were determined by history and a home-site evaluation by the local gas company. Patients with carboxyhemoglobin (COHb) levels of more than 5% were given normobaric 100% oxygen until their COHb levels were less than 5%.

RESULTS

1.9% (9/470) of patients had elevated breath CO levels and COHb levels by cooximetry. Putative sources of CO exposure were active cigarette smoking for five patients and a faulty furnace in the home for one patient. On the basis of the history, we believe environmental tobacco smoke or automobile exhaust or both contributed to the elevated COHb levels in the other three patients. There was a good correlation between COHb by cooximetry and breath analysis (concordance correlation = 0.739) CONCLUSION: Breath analysis for CO is a convenient tool to estimate exposure and identify older children at risk.

Outpatient continuous intravenous interleukin-2 or subcutaneous, polyethylene glycol-modified interleukin-2 in human immunodeficiency virus-infected patients: a randomized, controlled, multicenter study. Australian IL-2 Study Group

The safety and activity of outpatient-based continuous intravenous interleukin-2 (CIV IL-2) or a slow-release, polyethylene glycol (PEG)-modified IL-2 were studied in human immunodeficiency virus (HIV)-infected persons with CD4 cell counts between 200 and 500/mm3. One hundred fifteen patients were randomized to antiretroviral therapy plus cyclical CIV IL-2 (n = 27), subcutaneous PEG IL-2 (n = 58), or no IL-2 (n = 30). Toxicity withdrawal rates were low (4% for CIV IL-2 and 7% for PEG IL-2). There were median CD4 cell count increases of 359 and 44 cells/mm3 and a decline of 46 cells/mm3 in the 3 groups, respectively, over 1 year (P < .0001 for each intergroup comparison). CD4 cell count increases were greatest in those with lower HIV RNA load. Delayed-type hypersensitivity scores increased and HLA-DR expression on CD8 cells decreased significantly with IL-2 therapy. HIV RNA levels were unaffected. IL-2 therapy may expand the existing immune repertoire but not immediately reconstitute lost immune function.

Chronic multisymptom illness affecting Air Force veterans of the Gulf War

CONTEXT

Gulf War (GW) veterans report nonspecific symptoms significantly more often than their nondeployed peers. However, no specific disorder has been identified, and the etiologic basis and clinical significance of their symptoms remain unclear.

OBJECTIVES

To organize symptoms reported by US Air Force GW veterans into a case definition, to characterize clinical features, and to evaluate risk factors.

DESIGN

Cross-sectional population survey of individual characteristics and symptoms and clinical evaluation (including a structured interview, the Medical Outcomes Study Short Form 36, psychiatric screening, physical examination, clinical laboratory tests, and serologic assays for antibodies against viruses, rickettsia, parasites, and bacteria) conducted in 1995.

PARTICIPANTS AND SETTING

The cross-sectional questionnaire survey included 3723 currently active volunteers, irrespective of health status or GW participation, from 4 air force populations. The cross-sectional clinical evaluation included 158 GW veterans from one unit, irrespective of health status.

MAIN OUTCOME MEASURES

Symptom-based case definition; case prevalence rate for GW veterans and nondeployed personnel; clinical and laboratory findings among veterans who met the case definition.

RESULTS

We defined a case as having 1 or more chronic symptoms from at least 2 of 3 categories (fatigue, mood-cognition, and musculoskeletal). The prevalence of mild-to-moderate and severe cases was 39% and 6%, respectively, among 1155 GW veterans compared with 14% and 0.7% among 2520 nondeployed personnel. Illness was not associated with time or place of deployment or with duties during the war. Fifty-nine clinically evaluated GW veterans (37%) were noncases, 86 (54%) mild-to-moderate cases, and 13 (8%) severe cases. Although no physical examination, laboratory, or serologic findings identified cases, veterans who met the case definition had significantly diminished functioning and well-being.

CONCLUSIONS

Among currently active members of 4 Air Force populations, a chronic multisymptom condition was significantly associated with deployment to the GW. The condition was not associated with specific GW exposures and also affected nondeployed personnel.

Genomewide search for dehydrated hereditary stomatocytosis (hereditary xerocytosis): mapping of locus to chromosome 16 (16q23-qter)

Dehydrated hereditary stomatocytosis, also known as "hereditary xerocytosis," is caused by a red blood cell-membrane defect characterized by stomatocytic morphology, increased mean corpuscular hemoglobin concentration, decreased osmotic fragility, increased permeability to the univalent cations Na+ and K+, and an increased proportion of phosphatidylcholine in the membrane. The clinical presentation is heterogeneous, ranging from mild to moderate hemolytic anemia associated with scleral icterus, splenomegaly, and choletithiasis. Iron overload may develop later in life. The disease is transmitted as an autosomal dominant trait. We recruited a large three-generation Irish family affected with DHS and comprising 23 members, of whom 14 were affected and 9 were healthy. Two additional, small families also were included in the study. The DNA samples from the family members were used in a genomewide search to identify, by linkage analysis, the DHS locus. After the exclusion of a portion of the human genome, we obtained conclusive evidence for linkage of DHS to microsatellite markers on the long arm of chromosome 16 (16q23-q24). A maximum two-point LOD score of 6.62 at recombination fraction .00 was obtained with marker D16S520. There are no recombination events defining the telomeric limit of the region, which therefore is quite large. No candidate genes map to this area.

Effects of hydrotherapy on pressure ulcer healing

Pressure ulcers are a prevalent and potentially serious medical problem encountered in both the medical and rehabilitation settings. Because the progress of rehabilitation is often interrupted by the presence of pressure ulcers, the efficient care of these wounds is of great interest to the rehabilitation team. Patients in two acute care facilities with Stage III or IV pressure ulcers were identified and consented to participate in the study contained herein. All wounds were mechanically debrided of necrotic tissue, and then the patients were randomly assigned to the conservative treatment group (A; n = 18) or the conservative treatment plus whirlpool group (B; n = 24). Conservative treatment included measures to maximize pressure relief and wound care with wet-to-wet dressings using normal saline. The dressings were changed twice daily and when they became soiled. Whirlpool was administered for 20 min per day in Group B patients. Only those patients whose ulcers were followed-up for 2 or more wk were included in the study. Ulcers were then measured by a physician who was blinded as to the treatment groups. Ulcer dimension changes over time were compared between groups. The results indicate that the conservative treatment plus whirlpool group improved at a significantly faster rate than did the conservative treatment only group (P < 0.05).

The new variant form of Creutzfeldt-Jakob disease

A new phenotype of Creutzfeldt-Jakob disease termed new variant Creutzfeldt-Jakob disease (nvCJD) was first described in March 1996. This differs from other forms of CJD in terms of its epidemiology, clinical features and neuropathology. To date 24 cases of this new form of CJD have been described, 23 within the UK. This article describes nvCJD discussing clinical and epidemiological features and discusses possible links with the bovine spongiform encephalopathy epidemic in cattle in the UK.

Influence of polymorphism Q3405E and mutation A3371V in the apolipoprotein B gene on LDL receptor binding

Familial defective apolipoprotein B (FDB) is due to mutations in the apolipoprotein B (apo B) gene at codon 3500 or 3531 that affect low density lipoprotein (LDL) receptor binding. From sequence analysis the putative receptor binding site was believed originally to be upstream from this at residues 3147-3157 and 3357-3367. Using denaturing gradient gel electrophoresis, mutations were sought in codons 3350-3466. This includes the important positively charged residues 3357-3367. DNA from 928 hyperlipidaemic individuals was studied and two hitherto unknown DNA changes were discovered, one of which resulted in an altered amino acid in the apo B. A known polymorphism Q3405E was also detected at a carrier frequency of 1.4%. Using growth of U937 cells as a measure of binding affinity of LDL to its receptor the newly discovered mutant A3371V permitted the same growth as LDL from normolipidaemic individuals of the U937 cells, however, the LDL from Q3405E individuals permitted only 77% of the normal growth (P=0.009).

Cloning of a complementary DNA encoding an Ambystoma mexicanum metallothionein, AmMT, and expression of the gene during early development

We have used a polymerase chain reaction strategy to isolate a metallothionein (MT) cDNA from the amphibian Ambystoma mexicanum (axolotl). This cDNA is 875-bp long and encodes a 60 amino acid protein, AmMT, typical for family 1 MTs. It contains 20 cysteine (Cys) residues that can be aligned with those of other vertebrate MTs. The overall structure of the protein is unique among vertebrates in having only two amino acid residues before the first Cys at the amino-terminal end. Northern analyses showed that AmMT is expressed throughout embryogenesis, giving rise to three mRNA species of 650, 750, and 1,600 nucleotides (nt). The 750 and 1,600 nt transcripts appear to result from differential use of polyadenylation signals, whereas the 650 nt RNA could arise from deadenylation of the 750-nt transcript. Both the 750- and 1,600-nt RNAs were presented in embryos before the mid-blastula transition (MBT). After the MBT, the 750-nt RNA was replaced by the 650-nt RNA which was gradually degraded to undetectable levels in post-neurulation embryos. Levels of the 1,600-nt transcript increased at gastrulation and reach a maximum in Stage 30 embryos. In adult animals, levels of the 750-nt RNA were high in liver and testes, and very low in lung, gut, skin, and oviducts, whereas levels of the 1,600-nt transcript were similar and moderately elevated in all tissues examined. In contrast, in Xenopus laevis, Northern analysis did not detect XIMT-A mRNA in embryos before late neurulation (Stage 24). XIMT-A mRNA levels then increased sharply in Stage 36 hatched embryos at levels similar to those found in adult livers. These results show that AmMT presents a unique expression pattern among metazoans being transcribed as two transcripts differing in the length of their 3' untranslated regions, the levels of which vary during embryogenesis and in adult tissues.

Expect the worse or hope for the best? Prenatal diagnosis of geleophysic dysplasia

Geleophysic dysplasia is a rare, autosomal recessive disorder which causes disproportionate short stature associated with severe physical handicaps, but is compatible with survival into adulthood. We present a case, a first-born child, where genetic counselling difficulties arose following ultrasound recognition of short-limbed dwarfism in association with polyhydramnios and an initial incorrect prenatal diagnosis of lethal chondrodysplasia. After birth of the surviving affected infant, the parents had great difficulty accepting that there had been a prenatal misdiagnosis and they were greatly disappointed by our inability to predict the postnatal survival of an infant to whom no hope of life had previously been given. The correct diagnosis was not made until the proband was nearly 1 year old, and the true prognosis then became clearer. This experience underlines the relative ease of prenatal recognition of skeletal growth abnormalities compared with the considerable difficulties experienced in reaching a precise diagnosis. Thus, following prenatal diagnosis of unspecified chondrodysplasia when parents seek definite information about the prognosis, the temptation to be either overpessimistic or overoptimistic should be avoided.

Investigation of interferometric noise in fiber-optic gas sensors with use of wavelength modulation spectroscopy

We report on interferometric noise limitation of fiber-optic gas sensors with highly coherent lasers and wavelength modulation spectroscopy. Interference between signal wave and reflected waves causes signal fluctuation in the output, which limits the performance of the sensing system. Sensor resolution limited by interferometric noise is calculated for a fiber-optic gas sensor with the Q(6) absorption line of methane gas at approximately 1650 nm. The results are useful for system designers of this particular type of gas sensor.

Limitation of absorption-based fiber optic gas sensors by coherent reflections

We report the noise limitation of fiber optic gas sensors with highly coherent laser sources. Interference between signal and reflected waves causes signal fluctuation in the output; this limits the performance of the sensing system. Sensor resolutions limited by coherent reflections are calculated and compared with experimental results.

Changes in empowerment: effects of participation in a lay health promotion program

The Camp Health Aide Program is a lay health promotion program for migrant and seasonal farmworkers. The program increases access to health care while facilitating leadership development and empowerment of individual farmworkers through training and experience as lay health promoters (camp health aides [CHAs]). This article describes a study which documents impacts on the CHAs of working as lay health promoters in terms of changes in personal empowerment. The authors developed a working definition of personal empowerment and interviewed 27 CHAs at three program sites (Arizona, New Jersey, and Florida) at three different times. CHAs are grouped in five descriptive categories reflecting varying degrees of change in empowerment over this period. Of the total group of 27 CHAs, 24 exhibited some increase in personal empowerment during the study period. These changes are described in detail, and implications are discussed.

Specialisation in nursing: implications in Australia

Specialisation in professional nursing practice requires the collaborative development of appropriate processes, systems and pathways. Orderly development ensures that the unique knowledge, skills and attributes of specialist nurses are revealed, thereby empowering nurses and adding depth and breadth to specialist nursing knowledge and clinical practice.

HIV antibodies: further questions and a plea for clarification

The existence of specific antibody/protein reactions is the crucial assumption underlying proof of HIV isolation, proof of HIV infection and the causative role of HIV in AIDS. However, since 1. antibodies which react with the 'HIV' proteins arise following allogenic stimuli in non-HIV-infected animals and humans, as well as in mice and humans with autoimmune disorders; antibodies to antigens from both mycobacteria and yeasts cross-react with HIV env and gag proteins; 2. individuals belonging to the AIDS risk groups are subjected to allogenic stimuli and have high levels of autoimmune antibodies, while the vast majority of patients in the AIDS risk groups are infected with either or both mycobacteria or yeasts; the evidence for the existence of HIV and its putative role in AIDS must be reappraised.

Comparison of biochemical markers of bone turnover in Paget disease treated with pamidronate and a proposed model for the relationships between measurements of the different forms of pyridinoline cross-links

We have compared the use of new markers of bone turnover in the assessment and treatment of Paget disease and made observations on the mechanisms of bone resorption. Urine hydroxyproline (Hyp) as a bone resorption marker and serum alkaline phosphatase (ALP) as a bone formation marker have traditionally been used to biochemically assess and monitor treatment of Paget disease. Hyp and total ALP were compared with total urine pyridinoline (Pyd) and deoxypyridinoline (Dpd), free urine Pyd and Dpd, urine type I collagen N-terminal cross-linked telopeptide (NTX), type I collagen C-terminal propeptide (PICP), serum osteocalcin, and bone ALP in Paget patients treated with pamidronate. Patients were divided into three biochemical severity-based treatment groups by their fasting urine hydroxyprolline excretion (HypE) levels (Le., group 1, HypE < 5.0 mumol/l of glomerular filtrate [GF]; group 2, HypE of 5.0-9.9 mumol/l of GF; group 3, HypE > 10 mumol/l of GF). Group 1 received one 60 mg intravenous infusion of pamidronate, and groups 2 and 3 received four and six 60 mg infusions at weekly intervals, respectively. Fasting serum and morning urine specimens were taken before and at 2, 6, 13, and 26 weeks after starting treatment. Baseline Z scores were used to compare separation of patient results from normal, and the difference in Z scores from baseline to 13 weeks was used to compare response to treatment. Baseline discrimination and response to treatment at all disease activity levels was greatest for NTX and was poor for osteocalcin, PICP, and C-terminal cross-linked telopeptide of type I collagen (ICTP). The other markers showed good discrimination and response at medium and high levels of disease activity. NTX, total Pyd and Dpd, free Pyd and Dpd, and ICTP are all pyridinoline cross-link-based markers, but discrimination and response by NTX was generally much greater than for the others. Determination of the mechanism of the difference between NTX and other cross-link measures is necessary for appropriate use of the markers and may also lead to a better understanding of the bone resorption process. It has been proposed that the greater sensitivity and discrimination of NTX is because it is more bone-specific than the other cross-link markers with significant amounts of free Pyd and Dpd coming from nonbone sources. We propose another model where the proportion of peptide-bound cross-links such as NTX may be increased in high bone turnover states partly due to a rate-limiting step in their degradation to free cross-links. Conditions with high bone resorption rates would have high levels of NTX that would decline rapidly when resorption rates fall to a level where the capacity to degrade NTX matches the rate of production.

Patient outcomes after reoperation on the lumbar spine

A consecutive series of thirty-nine patients who had had a reoperation of the lumbar spine was followed up for an average of forty-eight months (range, twenty-four to eighty-six months). The patients were evaluated with regard to pain, functional status, and work status. Twenty-eight patients (72 percent) had a successful outcome, as determined by their ability to return to work, their lack of a need for narcotic analgesics, and their satisfaction with the operative results. Factors that were significantly associated with a successful outcome included a younger age (p < 0.02), working outside the home (p < 0.05), an initial period of improvement after the previous (index) operation (p < 0.01), fewer spinal levels operated on previously (p < 0.05), and a revision procedure incorporating anterior interbody arthrodesis (p < 0.02).

Resistance to Onchocerca volvulus: differential cellular and humoral responses to a recombinant antigen, OvMBP20/11

Persons putatively immune (PI) to Onchocerca volvulus (Ov) infection were identified in Ecuador on the basis of epidemiologic, clinical, and parasitologic findings. Immune responses of PI subjects to a recombinant onchocercal protein, OvMBP20/11, were determined and compared with those of a comparable infected (INF) group from the same Ov-endemic area. PI subjects had significantly less antibody reactivity to this molecule; however, not all INF subjects had an antibody response. IgG1 and IgG4 were the predominant IgG subclasses induced to this molecule, and the amount of IgG1 produced was the only significant difference between the PI and INF groups. In contrast to the antibody responses, proliferative responses to OvMBP20/11 were significantly higher in PI than in INF subjects. Cytokine analysis of peripheral blood mononuclear cell culture supernatants revealed that INF subjects produced significantly more interleukin-10 in response to OvMBP20/11 than did PI subjects. This antigen induced few other cytokines, and there were no differences between study groups.

Soft tissue swelling with fractures: abuse versus nonintentional

The objectives were to 1) define the amount of postfracture swelling at presentation in long bone fractures, and 2) to study the relationship between suspected abuse and/or neglect (A/N) and degree of postfracture swelling at presentation. This was a prospective study of 37 patients less than 11 years of age presenting with long bone fractures to the emergency department (ED) of the Children's Hospital of Michigan between August 1992 and December 1992. Data were recorded at the time of the ED visit and from medical records which were reviewed four to six months later. Of the patients enrolled in the study, eight were categorized as A/N and 29 as nonintentional. There was no difference in reported injury age between the two groups (15.5 +/- 24.5 hours vs 14.0 +/- 17.7, P = 0.8). At presentation the mean increase in circumference from post-fracture swelling was 9.6 +/- 7.1%, using the uninjured extremity as the control. The abuse group had a lesser increase in circumference compared to the nonintentional group, even after adjusting for injury age (3.8 +/- 3.6% vs 11.2 +/- 7.0%, P < 0.006). We concluded that patients with long bone fractures had a mean swelling of 9.6 +/- 7.1% at presentation. Injuries induced by A/N present with less swelling than similar injuries sustained nonintentionally, and we speculate that this difference indicates that the history and/or time of injury may not be reliable.

Gender and estrous cycle effects of the 5-HT1A agonist, 8-OH-DPAT, on hypothalamic serotonin

Effects of the 5-HT1A agonist, 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT; 0.04, 0.25, or 1.0 mg/kg), on hypothalamic serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), and their ratio were determined in adult male rats and in diestrous, proestrous, and estrous female rats. Consistent with its action at the somatodendritic 5-HT1A autoreceptor, 8-OH-DPAT decreased the 5-HIAA/5-HT ratio, but the decrease was least evident in proestrous females and in males. Similar to hypothalamic tissue, there was also a decline in the 5-HIAA/5-HT ratio in the hippocampus after treatment with 0.25 mg/kg 8-OH-DPAT. When ovariectomized rats were treated with oil or estradiol benzoate followed 48 h later by oil or progesterone, 0.25 mg/kg 8-OH-DPAT produced a decrease in the hypothalamic 5-HIAA/5-HT ratio in every group except those rats treated with progesterone without estrogen priming. Treatment with estradiol benzoate increased hypothalamic 5-HIAA, and both progesterone and 8-OH-DPAT reduced the metabolite to the level of the ovariectomized control. These results suggest that both estrogen and progesterone contribute to an estrous cycle modulation of the 5-HT1A somatodendritic autoreceptor.

Use of dexamethasone in the outpatient management of acute laryngotracheitis

OBJECTIVE

Recent studies have demonstrated that a single intramuscular injection of dexamethasone (0.6 mg/kg) shortens the duration and severity of illness in hospitalized patients with acute viral laryngotracheitis (croup). Our objective was to determine if dexamethasone has a role in the outpatient management of patients with acute viral croup of moderate severity.

METHODS

Patients, 6 months to 5 years of age, who came to the emergency department (ED) with acute viral croup, a croup score of at least 2 (range 0 to 17), and a disposition of discharge were randomized in a double-blind fashion to receive a single intramuscular injection of dexamethasone, 0.6 mg/kg, or an equal volume of normal saline before discharge from the ED. Patients were excluded if they had any structural abnormalities, had received any steroids in the preceding 24 hours, or if they required beta-agonist therapy, more than one racemic epinephrine treatment, or hospitalization. Patients were followed up by telephone 24 hours and 7 to 10 days after discharge to determine whether additional medical attention was sought for perceived lack of improvement or worsening of symptoms. Secondary outcome included the parents' perception of how the child was doing at 24 hours, based on a 4-point ordinal scale: worse (1), same (2), improved (3), symptoms resolved (4), and the number of days it took for complete recovery.

RESULTS

Of the 38 patients comprising the study group, 19 received dexamethasone. The median age was 19 months (range 6 to 66 months), and median pretreatment croup score was 3 (range 2 to 5) for both groups. The number of patients requiring racemic epinephrine was similar in both groups. Five patients sought additional medical attention within 48 hours. Four of the five patients had received placebo (21% of the placebo group) and one had received dexamethasone (5% of the steroid group) (not statistically significant). At the 24-hour telephone follow-up, significantly more patients in the dexamethasone group had a score consistent with improvement compared with placebo (84% vs 42%, P = .003). There was no difference in the number of days for symptoms to completely resolve between the two groups.

CONCLUSION

The use of dexamethasone in the outpatient management of viral croup was associated with a reduction in severity of illness within 24 hours after treatment. Patients with viral croup of moderate severity should be considered as candidates for the use of dexamethasone before discharge from the ED.

The assessment of handicap: an evaluation of the Environmental Status Scale

The assessment and measurement of disability and handicap are of particular relevance in rehabilitation, as these are the main foci of therapeutic intervention. The area of handicap is the least developed with few measuring tools to provide an objective assessment of status. The Environmental Status Scale (ESS) is now becoming increasingly utilized to measure handicap. It was used in a study of 50 patients on admission and discharge in a neurorehabilitation unit, to analyse its validity and usefulness as an outcome measure of the rehabilitation process. The results suggest it has limited validity, mixes disability and handicap issues and in some sections has a misleading scoring system. It requires modification to overcome these difficulties.

Source-noise limitation of fiber-optic methane sensors

The effect of source (LED) noise on the sensitivity of fiber-optic methane sensors is discussed. Once the source is dominant, the system sensitivity cannot be improved by increasing the source power further.

Transient global amnesia and cortical blindness after vertebral angiography: further evidence for the role of arterial spasm

We describe a series of six patients who experienced severe retrograde amnesia (five cases) or cortical blindness (one case) during selective vertebral angiography. All angiograms were obtained with the same nonionic contrast medium. Analysis of the contrast batch demonstrated no abnormalities, but investigation of the angiographic suite revealed a faulty contrast warming cabinet resulting in injection of contrast material above body temperature. The warming cabinet was withdrawn, and the complication has not recurred. We believe that these symptoms reflect ischemia caused by vertebral arterial spasm.

The Functional Independence Measure: a comparative validity and reliability study

The majority of measurement scales used to evaluate outcome in rehabilitation are ordinal in nature and consequently statistically valid assessments of change are difficult to make. The Functional Independence Measure (FIM) can be weighted to possess interval properties, potentially allowing more accurate analysis of change. In this study the FIM was compared to the Barthel Index (BI) to determine its validity, reliability and ease of use in two groups of 25 patients undergoing neurorehabilitation. The FIM was considered to be more valid than the BI, and equally reliable in the assessment of disability. When the two disability scores were compared using subjective and objective assessment the agreement between them was comparable, although neither was high.

HIV infection in recipients of blood products from donors with known duration of infection

From a registry of people with transfusion-acquired HIV infection, 25 recipients were identified for whom the dates of HIV infection in the 8 corresponding donors could be established. Longer times to AIDS and to death in recipients were independently associated (p < 0.01) with the receipt of blood from donors who developed AIDS more than 10 years after HIV infection, as well as with older age and fewer transfusions. Sex, zidovudine treatment, and severity of illness at transfusion were not significantly associated with survival.

Fine-needle aspiration cytology in locally advanced breast adenocarcinoma: a case with complete response to preoperative chemotherapy in association with granulomatous inflammatory reaction

Preoperative chemotherapy for locally advanced breast carcinoma (stage IIIA,B) is increasingly utilized demonstrating a 70 to 95% objective response and 15 to 35% complete response. A 70-yr-old woman presented with a 9 cm left upper outer quadrant breast mass associated with overlying skin redness and a 2.5 cm left axillary mass. Fine-needle aspiration cytology (FNA) showed a pleomorphic adenocarcinoma in both the breast and axilla. Following three courses of chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), the patient had a dramatic clinical reduction of tumor, reduction of serum CA 15-3 from 161 to 64 U/ml, and underwent a modified radical mastectomy and axillary dissection. The specimen showed no viable tumor in association with an extensive granulomatous response in both the breast and axillary lymph nodes. This case illustrates two points concerning preoperative chemotherapy for locally advanced breast cancer: (1) The role of FNA v. tissue biopsy is examined. Positive cytology must be conclusive since, as in this case, no viable carcinoma may be present after therapy. (2) Chemotherapy induced host tissue reaction has not been extensively studied. This case showed a remarkable granulomatous reaction in association with tumor elimination. Since this reaction was not present on the original aspiration cytology slides, the chemotherapy treatment must have induced this reaction. Mechanisms for creating this effective host response need further investigation.

Legionnaires' disease outbreak, Fairfield 1992: public health aspects

An investigation of an outbreak of Legionnaires' disease in 1992 in Fairfield, a municipality of Sydney, was carried out to determine the source of the outbreak. Cases of Legionnaires' disease with onset of symptoms between 11 and 20 April 1992 were included. Definite cases were individuals with a history consistent with Legionnaires' disease, confirmed by direct fluorescent antibody testing plus serology or culture. There were two control groups: patients admitted to the same hospital as the cases, matched for age and sex, and patients admitted to hospital with a presumptive diagnosis of legionnaires' disease, in whom the diagnosis was subsequently excluded. There were 26 definite cases with onset of symptoms between 11 and 20 April 1992. Six (23 per cent) died. Twenty-two cases (85 per cent) reported visiting the Fairfield business district during the ten days prior to the onset of symptoms. They were 20 times more likely to have visited Fairfield than were matched controls. Matching of Legionella pneumophila serogroup 1 from environmental and clinical samples was achieved by cytogenetic fingerprinting. Fourteen cases were linked to a single environmental sample. The epidemiological findings were consistent with a point source of Legionella in the Fairfield business district. It is most likely that the exposure occurred on 10 April 1992.

Pediatric emergency department walk-outs

The objectives of this study were to determine reasons for leaving a pediatric emergency department before physician evaluation, any adverse outcomes of those leaving, and to assess whether the presence of an ombudsman altered the pattern. This was a prospective follow-up study of all patients who left the pediatric emergency department of the Children's Hospital of Michigan before physician evaluation between October 24, 1991 and January 30, 1992. Information was obtained from medical records and a telephone questionnaire with the parent or guardian one week later. A control group of patients (n = 150) evaluated in the same period were randomly selected for comparison and matched for triage acuity score, shift, and weekday/weekend visit. Five hundred and twelve patients left during this period. Contact was made with 82% (419). Forty-three percent of patients left only because of a long wait, and an additional 19% included a long wait as one of the reasons for leaving. There was a significantly longer waiting time for walk-outs compared with controls (188 +/- 76.4 vs 93.6 +/- 64.9 minutes, P < 0.0001). Of the 419 patients followed, 256 (61%) were seen by a physician within seven days, and seven (1.7%) were hospitalized. Three hundred one (72%) were reported to be well; 108 (26%) were better. No deaths occurred. Hospitalization rates were significantly lower for patients who left compared with patients who stayed over the same period of time (7/419 vs 1931/16,990, P < 0.0001). The presence of an ombudsman was associated with an increase in walk-outs.(ABSTRACT TRUNCATED AT 250 WORDS)

Mutations in the zinc-finger region of the yeast regulatory protein ADR1 affect both DNA binding and transcriptional activation

The expression of the yeast ADH2 gene is controlled by the transcriptional activator ADR1, a zinc-finger protein that binds to an upstream activating sequence (UAS1) in the ADH2 promoter. We report here the isolation of seven mutations in the ADR1-5c allele, defining five different amino acid changes, that suppress the enhanced ADH2 expression caused by the ADR1-5c allele. Each of the mutations was shown to reduce the activation of ADH2 by a wild-type ADR1 gene, suggesting the mutations disrupt a domain important to the function of both the ADR1 and ADR1-5c proteins. All five amino acid changes occurred within the DNA-binding domain of ADR1 and were shown to severely inhibit the ability of ADR1 to bind UAS1 in vitro. These mutations were found, however, to also affect the ability of ADR1 to activate transcription independent of its ability to bind DNA. These results indicate that the DNA-binding region of ADR1 is involved in both transactivation and DNA binding.

Developmental outcome after intravascular intrauterine transfusion for rhesus haemolytic disease

The development outcome of 16 infants who had rhesus disease was assessed at 18 months. Eight had received intravascular intrauterine transfusion and eight postnatal exchange transfusions. There was no difference in developmental outcome and neither group was different from the population as a whole.