An outbreak of Salmonella typhimurium RDNC A045 at a wedding feast in South Australia

In April 1998 an outbreak of salmonellosis amongst guests at a wedding feast was investigated. Of the 58 attendees interviewed 38 (66%) subsequently developed gastrointestinal symptoms. Stool cultures from 7 cases grew Salmonella Typhimurium RDNC A045. Food samples were culture-negative for Salmonella spp. A cohort study implicated spatchcock (RR 2.5, 95% CI 1.09-5.77) and scampi (RR 2.0, 95% CI 1.05-3.89). Temperature abuse and cross-contamination within the kitchen during preparation and cooking are likely to have been the main contributing factors to this outbreak. Control measures included staff education in safe food handling and improvements in poultry processing methods to minimise carcass contamination.

Consumer attitudes and behaviours--key risk factors in an outbreak of Salmonella typhimurium phage type 12 infection sourced to chicken nuggets

OBJECTIVES

To identify the source and intervention methods for an outbreak of Salmonella Typhimurium phage type 12 in South Australia.

METHOD

Ten cases of S. Typhimurium phage type (PT) 12 infection were notified in South Australia in a four-week period from 7 May 1998. Nine cases and 27 controls were included in a case control study to test the hypothesis that illness was associated with the consumption of chicken nuggets.

RESULTS

A significant association between illness and the consumption of one brand of chicken nuggets was determined, odds ratio undefined (95% CI undefined; p = undefined). Nine of nine cases and one of 27 controls reported eating these chicken nuggets. S. Typhimurium PT 12 was isolated from an opened sample of this particular brand of nuggets which had been retrieved from the home of one case.

CONCLUSIONS AND IMPLICATIONS

The implicated nuggets were essentially a raw product which had been 'flash fried' in contrast with other brands which were fully cooked. The investigation highlighted issues of inadequate labelling and consumer responses to labelling information which affect food safety. A media release to highlight to the consumer the need to cook frozen food properly and a voluntary recall of the 'flash fried' product was instigated as a result of these conclusions. Further action is needed to eliminate the potential hazard that consumers will perceive and handle 'flash fried' nuggets as if they are a cooked chicken product.

Biocompatibility of sweetpotato and peanut in a hydroponic system

'Georgia Red' peanut (Arachis hypogaea L.) and TU-82-155 sweetpotato [Ipomoea batatas (L.) Lam] were grown in monocultured or intercropped recirculating hydroponic systems in a greenhouse using the nutrient film technique (NFT). The objective was to determine whether growth and subsequent yield would be affected by intercropping. Treatments were sweetpotato monoculture (SP), peanut monoculture (PN), and sweetpotato and peanut grown in separate NFT channels but sharing a common nutrient solution (SP-PN). Greenhouse conditions ranged from 24 to 33 degrees C, 60% to 90% relative humidity (RH), and photosynthetic photon flux (PPF) of 200 to 1700 micromoles m-2 s-1. Sweetpotato cuttings (15 cm long) and 14-day-old seedlings of peanuts were planted into growth channels (0.15 x 0.15 x 1.2 m). Plants were spaced 25 cm apart within and 25 cm apart between growing channels. A modified half-Hoagland solution with a 1 N: 2.4 K ratio was used. Solution pH was maintained between 5.5 and 6.0 for treatments involving SP and 6.4 and 6.7 for PN. Electrical conductivity (EC) ranged between 1100 and 1200 microS cm-1. The number of storage roots per sweetpotato plant was similar for both SP and SP-PN. Storage root fresh and dry mass were 29% and 36% greater, respectively, for plants in the SP-PN treatment than for plants in the SP treatment. The percent dry mass of the storage roots, dry mass of fibrous and pencil roots, and the length-to-diameter ratio of storage roots were similar for SP and SP-PN sweetpotato plants. Likewise, foliage fresh and dry mass and harvest index were not significantly influenced by treatment. Total dry mass was 37% greater for PN than for SP-PN peanut plants, and pod dry mass was 82% higher. Mature and total seed dry mass and fibrous root dry mass were significantly greater for PN than for SP-PN plants. Harvest index (HI) was similar for both treatments. Root length tended to be lower for seedlings grown in the nutrient solution from the SP-PN treatment.

Pyrimidinylimidazole inhibitors of CSBP/p38 kinase demonstrating decreased inhibition of hepatic cytochrome P450 enzymes

Pyrimidine analogs of the pyrimidinylimidazole class of CSBP/p38 kinase inhibitors were prepared in an effort to reduce the potent inhibition of hepatic cytochrome P450 observed for the pyridinyl compounds. The substitution of pyrimidin-4-yl, 2-methoxypyrimidin-4-yl, or 2-methylaminopyrimidin-4-yl for pyridin-4-yl effectively dissociates CSBP/p38 kinase from P450 inhibition for this series and furthermore achieves an increase in oral activity.

DNA-based and alphavirus-vectored immunisation with prM and E proteins elicits long-lived and protective immunity against the flavivirus, Murray Valley encephalitis virus

The immunogenicity and protective efficacy of DNA-based vaccination with plasmids encoding the membrane proteins prM and E of the flavivirus Murray Valley encephalitis virus (MVE) were investigated. Gene gun-mediated intradermal delivery of DNA encoding the prM and E proteins elicited long-lived, virus-neutralising antibody responses in three inbred strains of mice and provided protection from challenge with a high titer inoculum of MVE. Intramuscular DNA vaccination by needle injection also induced MVE-specific antibodies that conferred resistance to challenge with live virus but failed to reduce virus infectivity in vitro. The two routes of DNA-based vaccination with prM and E encoding plasmids resulted in humoral immunty with distinct IgG subtypes. MVE-specific IgG1 antibodies were always prevalent after intradermal DNA vaccination via a gene gun but not detected when mice were immunised with DNA by the intramuscular route or infected with live virus. We also tested a Semliki Forest virus replicon as vector for a flavivirus prM and E protein-based subunit vaccine. Single-cycle infections in mice vaccinated with packaged recombinant replicon particles elicited durable, MVE-specific, and virus-neutralising antibody responses.

Identification of a Theileria annulata antigen expressed in multiple stages of the parasite life cycle

In order to identify sporozoite surface molecules which may be involved in invasion and could act as potential vaccine candidates, a number of Mabs were raised in mice against T. annulata sporozoites. These were assayed for their ability to block sporozoite invasion of bovine peripheral blood mononuclear (PBM) cells in vitro. One of these, Mab 4B11, was found to neutralize sporozoite invasion to a high degree and to recognize a group of sporozoite antigens on Western blots. A T. annulata lambdagt11 genomic expression library was screened with Mab 4B11 and a positive clone containing a 900-bp insert (KP8) analysed further. Data from Southern and Northern blotting indicated that the gene containing the KP8 sequence, termed sporozoite and macroschizont gene 2 (spm2), was expressed both in T. annulata sporozoites and in later parasite life-cycle stages, macroschizont-infected leucocytes and piroplasms. The KP8 sequence was expressed in E. coli as a fusion protein with glutathione-S-transferase (GST) using the vector pGEX1lambdaT. Bovine antiserum raised against GST-KP8 recognised a single high molecular weight molecule on Western blots corresponding to one of the antigens recognised by Mab 4B11, expressed in sporozoites, macroschizont-infected leucocytes, and piroplasms. While our evidence suggests that the spm2 molecule alone is not responsible for sporozoite neutralization, it is a multistage antigen likely to function both in T. annulata sporozoites and in subsequent parasite life-cycle stages.

The impact of rubella immunisation on the incidence of rubella, congenital rubella syndrome and rubella-related terminations of pregnancy in South Australia

OBJECTIVES

To describe the impact of rubella immunisation on the incidence of rubella, congenital rubella syndrome and rubella-related terminations of pregnancy in South Australia, and to identify factors associated with a re-emerging problem.

DESIGN AND METHODS

A population-based descriptive study using data from South Australian notifications of disease, births and terminations of pregnancy, the rubella immunisation programme, antenatal rubella antibody screening and paediatric hospital case records.

SETTING

South Australia (population 1.48 million people; 20,000 births per year).

MAIN OUTCOME MEASURES

Incidence of rubella (age-sex specific), congenital rubella syndrome and rubella-related terminations of pregnancy; antenatal rubella sero-positive rates; rubella immunisation uptake rates.

RESULTS

Rubella notification rates in 1990-1996 were significantly higher for males than females for ages 15-34 years. There were five cases of congenital rubella syndrome notified in 1980-1996 compared with at least 20 confirmed or compatible cases in 1965-1979. Rubella-related terminations of pregnancy are now rare, with the last termination for maternal rubella being in 1993. The antenatal rubella sero-positive rate in 1995 was 96.7%, but was significantly lower among Asian women born overseas (78.6% among those 30 years or older). Vaccination uptake rates in schoolgirls decreased between 1990 and 1994 (91.2% to 86.9%).

CONCLUSIONS

Since the introduction of rubella immunisation, the incidence of rubella infection among women of reproductive age, and of rubella-related terminations, has fallen. Congenital rubella syndrome has not been notified since 1990 but its risk persists with a recent increase in rubella notifications, a fall in school immunisation rates, a relatively low antenatal sero-positive rate among older Asian women born overseas and the trend towards giving birth at older ages. Effective immunisation programmes must be maintained, particularly in schools and for young children and migrant women.

Upregulation of Jun and Fos family members and permanent JNK activity lead to constitutive AP-1 activation in Theileria-transformed leukocytes

Theileria parasitises bovine leukocytes and transforms them into proliferating, metastatic tumours, where the infection resembles a leukaemia-like disease. We have studied the signal transduction pathways leading to activation of the transcription factor AP-1 in different transformed leukocytes. Parasite infection leads to an up-regulation of all members of the Jun/Fos family of proteins and surprisingly, this occurs in the absence of any detectable ERK, or p38 MAP kinase activity. In the parasitised B-sarcoma TBL3, AP-1 induction occurs in the absence of any JNK activity. In contrast, in infected macrophage and B-cell lines, AP-1 transcriptional activity is strictly associated with the parasite-induced constitutive activation of JNK and subsequent c-Jun N-terminal phosphorylation. Thus, constant AP-1 transcriptional activity involves both an upregulation in the levels of Jun and Fos proteins and constitutive JNK activation.

Principles for the safety evaluation of flavouring substances

This paper reviews efforts by various organizations to develop principles and procedures for the safety evaluation of flavouring substances. Critical factors considered in safety evaluation of these substances include their level of human intake, ease of metabolism to innocuous end-products and the margin of safety between no-observed-effect levels in animal studies and human intakes. These factors form the basis for the principles and criteria laid out in this paper.

Pertussis in South Australia 1893 to 1996

This study describes trends in reports of pertussis in South Australia. Data were analysed from three sources: mortality data since 1893 from South Australian yearbooks, notification data from 1917, and hospitalisation data for pertussis or related complications since July 1985. Crude and age-specific rates of mortality, notifications and hospitalisation were compared. Pertussis peaked in 3 to 5 yearly cycles. The mortality and notification rates have generally declined over time. However, since 1993 the notification rate has remained high. The median age for pertussis notifications increased from 4 years in 1984 to 15 years in 1996. Serological testing for pertussis was included in 15% of notifications in 1985 and 90% in 1996. The age specific hospitalisation rate for pertussis was highest in infants < or = 6 months. Since the turn of the century, mortality and notification rates due to pertussis have declined. Over the past decade the major burden of severe disease resulting in hospitalisation has been borne by infants < or = 6 months. These infants are too young to be afforded protection from three primary immunisations against pertussis. Despite no substantial increase in mortality nor hospitalisation for pertussis in South Australia, the notification rate has remained high since 1993. This increase may be attributable to the use of more sensitive tests for pertussis, such as serology.

Remifentanil and propofol total intravenous anaesthesia for thymectomy in myasthenia gravis

We report a case of trans-sternal thymectomy for myasthenia gravis using a non relaxant, total intravenous technique with propofol and remifentanil. This afforded excellent control of heart rate and pressor responses during surgery while allowing early return of spontaneous ventilation and extubation within nine minutes of termination of anaesthesia. Advantages and disadvantages of this approach versus relaxant and volatile techniques are discussed with particular reference to preservation of neuromuscular function.

A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group

BACKGROUND

Critically ill patients who require mechanical ventilation are at increased risk for gastrointestinal bleeding from stress ulcers. There are conflicting data on the effect of histamine H2-receptor antagonists and the cytoprotective agent sucralfate on rates of gastrointestinal bleeding, ventilator-associated pneumonia, and mortality.

METHODS

In a multicenter, randomized, blinded, placebo-controlled trial, we compared sucralfate with the H2-receptor antagonist ranitidine for the prevention of upper gastrointestinal bleeding in 1200 patients who required mechanical ventilation. Patients received either nasogastric sucralfate suspension (1 g every six hours) and an intravenous placebo or intravenous ranitidine (50 mg every eight hours) and a nasogastric placebo.

RESULTS

The patients in the two groups had similar base-line characteristics. Clinically important gastrointestinal bleeding developed in 10 of 596 (1.7 percent) of the patients receiving ranitidine, as compared with 23 of 604 (3.8 percent) of those receiving sucralfate (relative risk, 0.44; 95 percent confidence interval, 0.21 to 0.92; P=0.02). In the ranitidine group, 114 of 596 patients (19.1 percent) had ventilator-associated pneumonia, as compared with 98 of 604 (16.2 percent) in the sucralfate group (relative risk, 1.18; 95 percent confidence interval, 0.92 to 1.51; P=0.19). There was no significant difference between the groups in mortality in the intensive care unit (ICU) (23.5 percent in the ranitidine group and 22.9 percent in the sucralfate group) or the duration of the stay in the ICU (median, nine days in both groups).

CONCLUSIONS

Among critically ill patients requiring mechanical ventilation, those receiving ranitidine had a significantly lower rate of clinically important gastrointestinal bleeding than those treated with sucralfate. There were no significant differences in the rates of ventilator-associated pneumonia, the duration of the stay in the ICU, or mortality.

An approach to the treatment of psychogenic parasitosis

BACKGROUND

Patients with psychogenic parasitosis typically seek help from nonpsychiatric physicians and can be difficult and time-consuming to treat. Pimozide has been promoted as the treatment of choice but is not indicated for every patient presenting with this symptom. Our purpose was to develop a realistic treatment protocol for the nonpsychiatric physician faced with these patients.

METHODS

Using what is known about this problem through review of the literature and our own experience with 20 patients, a practical treatment strategy is suggested.

RESULTS

It is proposed that dermatologists and primary care professionals seeing these patients determine (1) whether or not the patient's belief in infestation is shakable and (2) whether or not the patient is depressed, in order to chose a therapeutic plan.

CONCLUSIONS

Dermatologists and psychiatrists can work together to develop treatment protocols that minimize risk and maximize therapy for patients with psychogenic parasitosis.

The measurement of intervention effects in developmental phonological disorders

The effectiveness of speech and language therapy for developmental phonological disorders has typically been measured in terms of the diminution of the application of phonological processes. Often substantial amounts of intervention and time may be needed to show up such changes. Shorter and more clinically realistic intervention regimes can result in small but significant changes in speech production which represent positive developments in the phonological system. In order to measure progress in this sort of therapy a sensitive instrument of measurement is required. In this paper we describe a research measurement tool, the probe scoring system, which was designed to detect small changes in the child's phonological system following therapy and contrast it to some of the instruments selected for use in other efficacy studies. The potential for wider clinical application is also considered.

Calcium- and hydroxyapatite-binding properties of glucuronic acid-rich and iduronic acid-rich glycosaminoglycans and proteoglycans

This study describes the interaction of a small chondroitin sulphate proteoglycan and the glycosaminoglycans chondroitin 4-sulphate, dermatan sulphate and heparan sulphate with hydroxyapatite. All macromolecules possessed a high affinity, with the iduronic acid-rich dermatan sulphate and heparan sulphate displaying higher adsorption maxima than the glucuronic acid-rich chondroitin 4-sulphate. At similar concentrations, dermatan sulphate produced a 30% inhibition of hydroxyapatite-induced crystal growth, whilst chondroitin 4-sulphate yielded 50% inhibition. Estimation of the calcium binding capacity of these glycosaminoglycans using equilibrium dialysis indicated that chondroitin 4-sulphate bound five times more calcium than dermatan sulphate at a calcium concentration similar to that of serum. The data indicate a possible important role for chondroitin 4-sulphate in dentinogenesis where it is the dominant glycosaminoglycan, since it could act as a capture point for calcium ions during mineralisation, with the leucine-rich domain of its parent proteoglycan acting as anchor points to type I collagen.

Baseline quality of life of patients with advanced prostate cancer. European Organization for Research and Treatment of Cancer (EORTC), Genito-Urinary Tract Cancer Cooperative Group (GUT-CCG)

Quality of life (QoL) is now commonly studied in prostate cancer. However, little is known about the appropriateness of the various QoL instruments in this group of patients. The purpose of this work was to study the baseline QoL assessment of patients with prostate cancer who were randomised into three EORTC phase III studies. The three trials included locoregional prostate cancer patients, poor prognosis metastatic patients and hormone resistance patients, respectively. In the three trials, patients were asked to complete a questionnaire assessing their physical and psychosocial functioning and their symptom levels. These questionnaires included questions from the EORTC QLQ-C30 (version 1): the physical functioning, role functioning, global health/QoL scales and a single pain item. The psychometric properties of the scales were assessed and an analysis was performed to investigate if differences existed in the scale scores between the three groups of patients, 638 baseline questionnaires were available for patients entered into the three trials. The Gutman coefficients of reproducibility and scalability were 0.94 and 0.71, respectively, for the physical functioning scale and 0.97 and 0.90, respectively, for the role functioning scale. The Cronbach's alpha reliability coefficients were 0.68, 0.48 and 0.90 for the physical functioning, role functioning and global health/QoL scales, respectively. The four scales were able to distinguish clearly between the patient populations under study. The physical functioning, role functioning, global health/QoL scales and the single pain item scale from the EORTC QLQ-C30 (version 1) are valid measures when used in the setting of prostate cancer.

Aggregative adherence fimbria II, a second fimbrial antigen mediating aggregative adherence in enteroaggregative Escherichia coli

Enteroaggregative Escherichia coli (EAEC) has been implicated as an agent of pediatric diarrhea in the developing world. We have shown previously that EAEC adheres to HEp-2 cells by virtue of a plasmid-encoded fimbrial adhesin designated aggregative adherence fimbria I (AAF/I), the genes for which have been cloned and sequenced. However, not all EAEC strains express AAF/I. Using TnphoA mutagenesis, we have characterized a novel fimbria (designated AAF/II) which mediates HEp-2 adherence of the human-pathogenic strain 042. AAF/II is 5 nm in diameter and does not bind AAF/I antiserum, as determined by immunogold transmission electron microscopy. TnphoA identified a gene (designated aafA) which bears significant homology to aggA, the fimbrial subunit of AAF/I (25% identity and 47% similarity at the amino acid level). When hyperexpressed and purified by polyhistidine tagging, the AafA protein assembled into 5-nm-diameter filaments which bound anti-AAF/II antiserum. The cloned aafA gene complemented a mutation in the aggA gene to confer fimbrial expression from the AAF/I gene cluster, manifesting phenotypes characteristic of AAF/II but not AAF/I. The aafA mutant did not adhere to human intestinal tissue in culture, suggesting a role for AAF/II in intestinal colonization. By using DNA probes for AAF/I and AAF/II derived from fimbrial biosynthesis genes, we show that AAF/I and AAF/II are each found in only a minority of EAEC strains, suggesting that still more EAEC adhesins exist. Our data suggest that AAF adhesins represent a new family of fimbrial adhesins which mediate aggregative adherence in EAEC.

Systolic and diastolic effects of variable atrioventricular delay in patients with complete heart block and normal ventricular function

This study was designed to demonstrate the effects of varying the atrioventricular delay (AVD) on ventricular diastolic filling dynamics and the resultant stroke volume in patients with complete heart block and normal cardiac function. We studied 7 patients with normal cardiac function in whom a dual chamber pacemaker had been implanted because of complete heart block. Doppler and M-mode echocardiography was performed at 70, 100, 140, 180, and 220 ms, AVD with the device in DDD mode at a rate of 80 beats/min. The effects of these variable intervals on the contribution of the E and A waveform to the diastolic filling, on the stroke volume, and on the systolic intervals were evaluated. Optimization of this interval, with a 19% increase in stroke volume was achieved in the group of patients at an AVD of 140 ms. When considered individually, the AVD associated with the largest stroke volume, was 100 ms in 2 patients and 140 ms in the remaining 5. At this individual optimal AVD the ventricular septal contraction occurred 31 +/- 14 ms, before the end of the transmitral flow. The optimal AVD is, therefore, the one which synchronizes the ventricular and atrial systole so that the first ventricular septal contraction occurs after the peak of the A wave, just before the end of the transmitral flow. Because of the different functional cardiovascular status of the single patient, this parameter should be individualized; this can be clinically important as it may lead, in this patient population, to an improvement of the stroke volume up to 42%.

Postoperative elevation of creatine kinase (CK-MB): does it contribute to diagnosis of myocardial infarction?

PURPOSE

This retrospective study sought to determine the benefit of measurement of changes in plasma creatine kinase-myocardial band (CK-MB) levels in elective postoperative high risk surgical patients beyond that obtained from the surface 12 lead ECG.

METHODS

The charts of 111 patients admitted to the surgical intensive care unit (SICU) of a tertiary level university teaching hospital were reviewed. They were screened using predetermined definitions of myocardial infarction (MI) (as reflected by changes in the 12 lead surface ECG (Minnesota code) or elevations in CK-MB) for complications such as pulmonary oedema, congestive heart failure, arrhythmias, or cardiogenic shock. Four groups were identified based on changes in the ECG indicative of MI (Present-ECG+ or Absent-ECG-) and elevations of CK-MB (Present-CKMB+ or Absent-CKMB-) and compared for the incidence of complications.

RESULTS

No patient with ECG- findings had a complication. Fifteen patients with ECG+ findings were identified and all had complications. Fourteen of these patients had CKMB+ results. In contrast, 29 patients with CKMB+ results alone (i.e., ECG-) had no complications.

CONCLUSION

Clinically important (i.e., requiring therapeutic intervention) postoperative myocardial infarction was detected by ECG changes. The benefit of determining changes in CK-MB was minimal from a therapeutic perspective.

Comparison of the Bard BTA test with voided urine and bladder wash cytology in the diagnosis and management of cancer of the bladder

OBJECTIVES

To compare the Bard BTA test, a simple latex-agglutination test for cancer of the bladder (BC) that can be performed in less than 3 minutes in the urologist's office, with voided urine or bladder wash cytology in the diagnosis of subjects suspected of having BC on the basis of symptoms or recent abnormal cystoscopy or intravenous urography.

METHODS

The study was performed at three medical centers in 414 subjects (147 female and 267 male; mean age 60 years), 345 of whom (83%) had no prior history of BC. The cytologic examinations were performed by pathologists unaware of the results of the BTA test.

RESULTS

Cystoscopy or cystoscopy and biopsy revealed BC in 71 subjects (17%). The overall sensitivities of the BTA test and cytology were 70% and 25%, respectively. The specificities of the BTA test and cytology in the 337 subjects without BC were 90% and 100%, respectively. The sensitivities of the BTA test by tumor grade were 17%, 64%, and 92% for grades 1, 2, and 3, respectively; those of cytology were 17%, 14%, and 44%. Regression analysis suggests that tumor grade but no other study variable explains the sensitivity of the BTA test.

CONCLUSIONS

The BTA test is considerably more sensitive than cytology in the detection of BC. For urologists who use cytology in the diagnosis and follow-up of patients with BC, the BTA test may replace cytology.

The pattern and structure of one-person households in England and Wales and France

"This paper examines the increase of one-person households during the 1980s in England and Wales and France set within the broader context of household change in Europe as a whole....One-person households vary geographically by age, with younger one-person households found especially in larger urban areas; older one-person households have a more varied distribution, although rural and traditional retirement areas have particular concentrations. Increases in numbers are a result of both compositional changes in the population (increasing numbers of divorced and never-marrieds as well as increasing numbers of elderly) and also an increasing propensity to live alone, especially among younger age groups."

Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.

Evaluation and follow-up of patients with N1-3 M0 or NXM1 prostate cancer in phase III trials

OBJECTIVES

The aim of this discussion is to review the design and conduct of phase III trials in metastatic prostate cancer, to seek ways of improving their study design, accuracy, relevance to clinical practice, acceptability to patients, and ease of participation by clinicians. We also aim to try to set uniform definitions for the evaluation of the different endpoints used in clinical trials on metastasized prostate cancer.

METHODS

The work was started by correspondence between the participants in the group for the year before the consensus meeting. Two comprehensive questionnaires were circulated and the answers were distributed to all the members of the group. The statements were finalized during the consensus meeting.

RESULTS

There were some differing opinions concerning the methods of evaluation of endpoints for follow-up, such as time to tumor progression and time to treatment failure. After the consensus conference, there were no major disagreements within the group.

CONCLUSIONS

The aim of phase III trials is to influence clinical management. To obtain a credible result they require a sound statistical basis with appropriate power and encompassing patients from small urologic practices as well as large or academic institutions. However, deviation from routine practice may affect the accrual rate, and the trial procedure should therefore be as similar as possible to routine management. Trials inevitably involve extra work and cost. Both should be kept to a minimum to encourage participation and hasten a timely conclusion. It is mandatory to create uniform ways of designing and evaluating clinical trials in prostate cancer.

Concurrent outbreaks of Salmonella Typhimurium in South Australia

The Communicable Disease Control Branch of the South Australian Health Commission received 45 laboratory notifications of Salmonella between 23 December 1996 and 17 January 1997. A rapid screening test, undertaken by the Institute of Medical and Veterinary Sciences, Adelaide, was the first indication that this was more than one outbreak, prompting the establishment of separate investigations. Three Salmonella Typhimurium (S. Typhimurium) phage types were subsequently identified. Investigations are continuing into an outbreak of S. Typhimurium phage type (PT) 64, while investigations failed to identify any association between four cases of PT 44. As of 12 February 1997, 71 notifications had been confirmed as S. Typhimurium PT 135. Epidemiological investigations found this outbreak was associated with consumption of bread rolls with a meat filling distributed through local Asian grocery stores from a home-based manufacturer. The product was voluntarily withdrawn and there have been no new cases of PT 135.

Headaches and neck pain in farmers

The prevalence of headache and neck pain in farmers was determined by use of a questionnaire. Information about activities which increased the symptoms and about the treatments sought was also recorded. Results showed that 77.7% of farmers experienced neck pain and 79.2% experienced headache. Driving a tractor was the activity which was most frequently described as increasing symptoms in both conditions. While driving a tractor, farmers are exposed to whole-body vibration and assume a rotated neck posture. The contribution of these factors to the development of headache and neck pain is discussed.

Preventing epidemics in a community of households

The occurrence of epidemics of vaccine-preventable diseases, and the immunization coverage required to prevent them, is affected by the presence of households and heterogeneity in the community. We consider a community where individuals live in households and are of different types, according to infectivity and/or susceptibility to infection. We describe a method for computing the critical immunization coverage to prevent epidemics in such communities and discuss the effectiveness of immunization strategies. In a heterogeneous community where individuals live in households several immunization strategies are possible and we examine strategies targeting households, randomly selected individuals, or groups with highly intense transmission, such as school children. We compare estimates of the critical immunization coverage if we assume that disease is spread solely by random mixing with estimates which result if we assume the effects of the household structure. Estimates made under these two sets of assumptions differ. The results provide insights into the community effects of vaccination, and the household structure of the community should be taken into account when designing immunization policies.

Finger duplication in Apert's syndrome

Three cases of unilateral duplication of the little finger in children with Apert's syndrome are presented. They provide additional evidence that the hands in Apert's syndrome are not always symmetrically affected.

Effectiveness of a consultation intervention to promote tobacco control policies in Northwest Indian tribes: integrating experimental evaluation and service delivery

A quasi-experimental replication of an intervention for promoting tobacco control policies in Northwest Indian tribes is described and the process of intervention including issues of collaboration among research institutions and Indian organizations is discussed. The policy intervention was evaluated using a pretest-posttest design wherein 20 tribes that had served as wait-list controls now received the intervention. The intervention comprised a tribal representative attending a kickoff orientation; follow-up visits to the tribes; distribution of tobacco policy workbooks; and phone call consultations. Policy status and stringency were assessed by means of telephone interviews with two key contacts per tribe, and by a count of enacted policies. There were significant pre-post changes in the primary outcome measure, a composite summary score of tobacco policy stringency, and changes were also reflected in enacted policies. The intervention effects observed were similar to those found in the prior randomized trial and suggest a robust, disseminable intervention. Much of the success achieved was attributed to the role of an Indian organization in planning the project and implementing the intervention and evaluation protocols.

Underdetection of clinical benign prostatic hyperplasia in a general medical practice

OBJECTIVE

To measure detection of clinical benign prostatic hyperplasia (BPH) in a general medicine practice.

DESIGN

Self-administered questionnaire and retrospective ambulatory medical record review.

SETTING

Hospital-based general medicine practice.

PATIENTS

Two hundred and four men aged 50 years and older.

MEASUREMENTS AND MAIN RESULTS

Clinical information was obtained from a self-administered questionnaire containing the American Urological Association symptom index and the BPH Impact Index bother scale, and from retrospective review of ambulatory medical records for the previous 24 months. Thirty percent of patients had moderate to severe urinary tract symptoms, and 67% of these individuals were bothered by the symptoms. Only 52% with moderate to severe symptoms recalled any discussion with their primary care physician about their symptoms. There was medical record documentation of a review of urinary tract symptoms in only 18% and a prostate examination in only 64%. Patients with more symptoms and bother tended to recall a discussion of urinary tract symptoms with their physician. However, moderate to severe symptoms and bother were not associated with increased documentation of a history of urinary tract symptoms or prostate examination.

CONCLUSIONS

Clinical BPH was underdetected in a general medicine practice. Because many men do not complain to their physicians about urinary tract symptoms and reduced quality of life, perhaps primary care physicians should pay more attention to recognizing this common condition of older men.

The clinical spectrum of postpartum thyroid disease

The clinical and biochemical features of postpartum thyroid disease were analysed in 152 antithyroid peroxidase antibody-positive (anti-TPO+ve) women and compared with 239 anti-TPO-ve age-matched control postpartum women. All were assessed monthly for up to 12 months postpartum. Seventy three anti-TPO+ve women developed postpartum thyroiditis (PPT): 19.2% hyperthyroid alone, 49.3% hypothyroid alone, and 31.5% characterized by hyper- followed by hypothyroidism. None of the antibody-negative women developed any thyroid dysfunction. A significant increase in many of eleven symptoms of hypothyroidism and some of eight symptoms of hyperthyroidism compared to control women was observed in all anti-TPO+ve women, independent of thyroid status. This was particularly seen in women who later developed PPT when they were euthyroid, but was also observed in euthyroid anti-TPO+ve women who showed no decline of thyroid function during the postpartum period. Although PPT is usually transient, this condition, and the euthyroid antibody-positive state, may be associated with significant symptomatology, including an increased incidence of minor to moderate depression. Early recognition of this syndrome by antenatal screening of thyroid antibodies may contribute to improved management of women during the postpartum period.

The role of complement in the pathogenesis of postpartum thyroiditis: ultrasound echogenicity and the degree of complement-induced thyroid damage

Postpartum thyroiditis (PPT) is a transient autoimmune thyroiditis occurring during the postpartum year that is characterized by circulating antithyroid antibodies, abnormal thyroid ultrasound echotexture, and episodes of hyperthyroidism, hypothyroidism, or both. In this study we examined the relationship between lymphocytic thyroiditis, as indicated by echotexture changes, and complement-activating thyroid autoantibodies. Thyroid ultrasound echotexture, thyroid function, and bioactive (complement-activating) thyroid peroxidase (TPO) antibodies have been measured in a group of 63 TPO antibody-positive women during the postpartum year. When the maximum bioactive TPO antibody activity recorded was compared with echogenicity and thyroid status, there was a correlation between hypoechogenicity, elevated antibody activity, and abnormal thyroid status (r = 0.72, p < 0.001). However, 7 cases showed severe ultrasound changes in the absence of any thyroid dysfunction (3 of these cases showed normal bioactive antibody activity), while 4 (all hyperthyroid PPT) showed thyroid dysfunction in the absence of any ultrasound changes. Within the euthyroid ultrasound normal group, bioactive TPO antibody activity remained low throughout the postpartum year. Antibody activity in the hypoechogenic euthyroid women was significantly elevated (p < 0.001) compared with the echo normal group, but was indistinguishable from the activity curve obtained in women whose PPT included a hypothyroid phase. The determination of echotexture by thyroid ultrasonography gives a useful, noninvasive measure of the degree of thyroiditis in these women. However, as a significant number of cases with severe changes in echotexture remained euthyroid, we conclude that the development of thyroid dysfunction is not an inevitable consequence of lymphocytic thyroiditis during the postpartum and suggests that other factors must also be involved in progression to overt thyroid dysfunction.

As mammography use increases, are some providers omitting clinical breast examination?

OBJECTIVE

To explore use of clinical breast examination (CBE) among women receiving mammography.

METHODS

A retrospective cohort analysis of 100 women aged 50 years or older with at least one bilateral mammogram. Chart review documented demographic information, severity of illness, and performance of CBE (from 1 year prior to 18 months after the mammogram).

RESULTS

The mean age of the 100 women was 63 years. They were predominantly unmarried (60%), nonwhite (58%), and not currently employed (57%). Three quarters (76%) had mammography and CBE (comprehensive screening), while the remaining 24% had mammography only. Sociodemographic factors did not differ for women with and without comprehensive screening (P>.1). However, patients of female providers were more likely to receive comprehensive screening than patients of male providers. Specifically, 95% of women seen by female attending physicians or fellows had comprehensive screening vs 67% for male attending physicians or fellows and 61% for residents (P=.008).

CONCLUSIONS

Mammography may be replacing CBE especially among patients of male providers. Interventions targeted to these providers could help improve the use of CBE and mammography.

Conservation of neutralizing determinants between the sporozoite surface antigens of Theileria annulata and Theileria parva

The sporozoite surface antigens SPAG-1 of Theileria annulata and p67 of Theileria parva are postulated to contain determinants necessary for host cell invasion and/or recognition and are both being considered as candidates for inclusion in subunit vaccines. Preliminary data suggest that these are related molecules. In this paper we describe the investigation of the relationship between these sporozoite antigens further by analysis of the immunological cross-reactivity using Mabs and sera raised against each antigen. The cross-reactions were examined by carrying out Western blots, IFA tests, and in vitro sporozoite neutralization assays. In addition, sequence comparison data which clearly establish that these surface antigens are encoded by related genes are presented. The regions of SPAG-1 identified as containing cross-reactive epitopes recognized by p67 antiserum correlated to regions of high predicted homology between p67 and SPAG-1, which are located at their respective N- and C-termini. Furthermore, p67 and SPAG-1 were found to contain cross-reactive determinants responsible for neutralization of sporozoite infectivity in vitro, and at least some of these were located in the C-termini of both molecules. The relevance of these findings to the possible roles for these molecules in host cell invasion is discussed.

Major histocompatibility complex class II and complement polymorphisms in postpartum thyroiditis

The objective was to re-evaluate the association between class II HLA-DR and DQ MIIC antigens and postpartum thyroiditis (PPT) and to determine the prevalence of the class III complement allotypes of Properdin factor B (Bf), C4A and C4B in this condition. Two hundred and sixty-five (of 2897) pregnant women screened positive for thyroid autoantibody activity took part. Further blood samples were obtained for HLA class II (185) and complement (193) typing. The severity of the ensuing PPT was assessed by measuring thyroid function during the postpartum year. The HLA-DR and DQ phenotypes were assigned from restriction fragment length polymorphism analysis, and Bf, C4A and C4B allotypes were determined by immunofixation with anti-Bf or anti-C4 antibodies after electrophoresis. A weak association between the HLA class II antigens and PPT, as indicated by a reduced frequency of DR15 and DQ6 together with an increased frequency of-DR5 and DQ7, was confirmed. However, only the change in DR5 frequency remained significant after correction (corrected p < 0.05). Postpartum thyroiditis was also associated with frequency disturbances in BI and C4A allotypes but not C4B allotypes. Whilst this study has not provided evidence of a strong marker gene for PPT, it does not preclude the involvement of the MIIC in this condition. These data show disturbances in complement allotype frequencies, suggesting that the class III region may provide a useful focus for further study of this pathology.

Immunization levels for preventing epidemics in a community of households made up of individuals of various types

A method is proposed for computing an epidemic threshold parameter for the spread of a communicable disease in a community of households in which individuals are of p different types. The threshold parameter is the largest eigenvalue of a p x p matrix whose elements depend on the rates of disease transmission between types and the distribution of the household size. More explicit expressions are given for diseases that are highly infectious within households, to the point that the infection of any member of a household results in the infection of all susceptible members of that household. For a variety of vaccination strategies it is described how this approach can be used to determine the level of immunity required to prevent epidemics. A numerical example illustrates the results.

The comparative effects of sevoflurane versus propofol in the induction and maintenance of anesthesia in adult patients

A randomized, prospective study was performed at four institutions to compare anesthetic induction, maintenance, and recovery characteristics between sevoflurane- and propofol-based anesthesia in 186 ASA physical status I and 11 patients undergoing elective surgical procedures of 1-3 h. Group 1 (n = 93) patients received sevoflurane-nitrous oxide for both induction and maintenance of anesthesia while Group 2 (n = 93) received propofol-nitrous oxide anesthesia. Induction of anesthesia and tracheal intubation times were significantly shorter with propofol (2.21 +/- 0.2 min, 5.11 +/- 0.3 min, respectively) than with sevoflurane (3.11 +/- 0.2 min, 7.21 +/- 0.3 min, respectively). Emergence times after sevoflurane (8.81 +/- 1.2 min) were significantly shorter than with propofol (13.21 +/- 1.2 min). Overall frequency of complication-free induction, maintenance, and emergence did not differ between the two anesthetic groups. However, side effects involving airway excitement were more prevalent during mask induction with sevoflurane as compared to propofol. Patients in the sevoflurane group were oriented and required postoperative analgesia much earlier than those who received propofol. Both groups were hemodynamically stable throughout the study period. The incidence of postoperative nausea, vomiting, and pain-discomfort scores were similar between the two groups. Urinary specific gravity decreased in the sevoflurane-treated group while serum creatinine and urinary pH were unchanged from preoperative values in both groups. Sevoflurane compared favorably with propofol when used for anesthesia for elective procedures of 1-3 h duration.

Perioperative management of drug therapy, clinical considerations

The objectives for the provision of a safe anaesthetic include rendering the patient analgesic for the procedure (amnesic if appropriate), with control of adverse haemodynamic perturbations, and muscle relaxation to facilitate surgery as necessary. This must be done with an understanding of the patient's pre-existing pathophysiology and drug therapy. This article focuses on the management of medications in the perioperative period from the practitioner's perspective. Areas of drug therapy examined include drugs affecting the cardiovascular, central nervous, haemostatic and endocrine systems. Review of the limited data available suggests that the safest course of action for the preoperative management of the vast majority of drug therapy is to continue such therapy until the time of surgery, particularly agents in which a withdrawal syndrome has been described, e.g. beta-adrenoceptor blocking agents, alpha 2-adrenoceptor agonists. Exceptions to this generalisation might include discontinuing ACE inhibitors prior to surgery as these agents may be associated with adverse haemodynamic changes during surgery. The management of drug therapy for patients receiving monoamine oxidase inhibitors (MAOIs) continues to be challenging due to the potential for drug interactions, e.g. severe hypertension with use of indirect-acting vasopressors and excitatory/depressive reactions with administration of pethidine (meperidine) or dextromethorphan. However, recent clinical experience has demonstrated the relative safety of continuing MAOIs prior to surgery by use of specific 'MAOI safe' anaesthetic techniques and/or substitution of short-acting MAOIs which do not irreversibly inhibit the enzyme. For drugs affecting the coagulation system, such as heparin and warfarin, prudence dictates discontinuing these agents whenever possible prior to surgery where it can be anticipated that haemorrhage will occur, e.g. vascular surgery, or where the consequences of even minor bleeding could be catastrophic, e.g. eye surgery. Controversy exists as to the management of patients receiving prophylactic low dose heparin for deep vein thrombosis prophylaxis or in whom intraoperative or postoperative anticoagulation is planned, e.g. aortic surgery, and in whom a regional anaesthetic technique is planned as part of the anaesthetic management. The data available suggest that, where prophylactic use of heparin is concerned, and provided the administration of the last dose of heparin and the institution of a regional anaesthetic nerve block does not occur at the same time, use of regional anaesthesia is not contraindicated in such circumstances. Where therapeutic anticoagulation is planned as part of the surgical management, there is a very small risk of the development of epidural or spinal haematoma when major central conduction nerve block is employed for anaesthesia, with resultant spinal cord compression and paralysis. These precautions do not apply to patients receiving aspirin or other nonsteroidal anti-inflammatory agents as there is a large clinical and published experience of the safety of regional anaesthesia in this group of patients. Patients treated with fibrinolytic agents are at increased risk for bleeding should surgery be required. For these patients, pre- and intraoperative use of agents with antifibrinolytic activity, e.g. aprotinin, has been demonstrated in case reports to be beneficial. Finally, recommendations for the management of patients who have received or are receiving glucocorticoids are given. Throughout the review, areas of uncertainty where further research is required are identified.

Acute hydrocephalus following aneurysmal subarachnoid hemorrhage

BACKGROUND

Acute hydrocephalus is a potentially treatable cause of early neurological deterioration after aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A retrospective study of 105 consecutive cases of aneurysmal SAH was undertaken to determine those factors significantly related to the development of acute hydrocephalus. Acute hydrocephalus was diagnosed when the bicaudate index was greater than the 95th percentile for age on a CT scan within 72 hours of the ictus.

RESULTS

Thirty-one percent of the patients developed acute hydrocephalus. Grade of SAH was a significant factor for the development of acute hydrocephalus on univariate analysis as 87% of patients with acute hydrocephalus (29/32) presented with at least grade 3 (Hunt-Hess) SAH (P < 0.05). In addition, posterior circulation aneurysms on univariate analysis were associated with acute hydrocephalus (p < 0.05). Both premorbid hypertension and intraventricular blood (p < 0.05) were predictors for acute hydrocephalus, whereas intracisternal blood, age and sex were not. On multivariate linear regression analysis, factors found to be significantly associated with acute hydrocephalus were premorbid hypertension, intraventricular blood, CSF diversion and definitive shunt procedures. External ventricular drainage was not associated with any instances of rebleeding. Thirty-seven percent (10/27) of patients with acute hydrocephalus who survived were improved by pre-operative external ventricular drainage.

CONCLUSIONS

Patients with acute hydrocephalus following SAH can be safely treated with external ventricular drainage. Multiple factors can be identified to predict those patients who will develop acute hydrocephalus post aneurysmal rupture. Approximately 30% of those patients with acute hydrocephalus will require definitive shunt placement. Acute hydrocephalus occurred in 31% of aneurysmal SAH patients in this series.

Harmonization of animal clinical pathology testing in toxicity and safety studies. The Joint Scientific Committee for International Harmonization of Clinical Pathology Testing

Ten scientific organizations formed a joint international committee to provide expert recommendations for clinical pathology testing of laboratory animal species used in regulated toxicity and safety studies. For repeated-dose studies in rodent species, clinical pathology testing is necessary at study termination. Interim study testing may not be necessary in long-duration studies provided that it has been done in short-duration studies using dose levels not substantially lower than those used in the long-duration studies. For repeated-dose studies in nonrodent species, clinical pathology testing is recommended at study termination and at least once at an earlier interval. For studies of 2 to 6 weeks in duration in nonrodent species, testing is also recommended within 7 days of initiation of dosing, unless it compromises the health of the animals. If a study contains recovery groups, clinical pathology testing at study termination is recommended. The core hematology tests recommended are total leukocyte (white blood cell) count, absolute differential leukocyte count, erythrocyte (red blood cell) count, evaluation of red blood cell morphology, platelet (thrombocyte) count, hemoglobin concentration, hematocrit (or packed cell volume), mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration. In the absence of automated reticulocyte counting capabilities, blood smears from each animal should be prepared for reticulocyte counts. Bone marrow cytology slides should be prepared from each animal at termination. Prothrombin time and activated partial thromboplastin time (or appropriate alternatives) and platelet count are the minimum recommended laboratory tests of hemostasis. The core clinical chemistry tests recommended are glucose, urea nitrogen, creatinine, total protein, albumin, calculated globulin, calcium, sodium, potassium, total cholesterol, and appropriate hepatocellular and hepatobiliary tests. For hepatocellular evaluation, measurement of a minimum of two scientifically appropriate blood tests is recommended, e.g., alanine aminotransferase, aspartate aminotransferase, sorbitol dehydrogenase, glutamate dehydrogenase, or total bile acids. For hepatobiliary evaluation, measurement of a minimum of two scientifically appropriate blood tests is recommended, e.g., alkaline phosphatase, gamma glutamyltransferase, 5' -nucleotidase, total bilirubin, or total bile acids. Urinalysis should be conducted at least once during a study. For routine urinalysis, an overnight collection (approximately 16 hr) is recommended. It is recommended that the core tests should include an assessment of urine appearance (color and turbidity), volume, specific gravity or osmolality, pH, and either the quantitative or semiquantitative determination of total protein and glucose. For carcinogenicity studies, only blood smears should be made from unscheduled sacrifices (decedents) and at study termination to aid in the identification and differentiation of hematopoietic neoplasia.

Randomized trial comparing intermittent antegrade warm blood cardioplegia with multidose cold blood cardioplegia for coronary artery bypass

Forty patients were randomized to receive antegrade multidose warm (WBC) or cold blood cardioplegia (CBC) during coronary artery bypass. Cardioplegia was infused at a predetermined dose every 10 min during cardioplegia arrest and core temperature was maintained at 37 degrees C in both groups during extracorporeal circulation. Patient profiles were similar in the two groups. Cardiac index, left ventricular stroke work index, and myocardial oxygen consumption were measured before bypass and during the first 7 h of reperfusion. There was no significant difference in myocardial metabolic and function recovery, the incidence of myocardial infarction, low cardiac output or death. Our data suggests that similar protection is provided with the two techniques of myocardial protection.