Coinfection with Borrelia burgdorferi and the agent of human granulocytic ehrlichiosis alters murine immune responses, pathogen burden, and severity of Lyme arthritis

Lyme disease and human granulocytic ehrlichiosis (HGE) are tick-borne illnesses caused by Borrelia burgdorferi and the agent of HGE, respectively. We investigated the influence of dual infection with B. burgdorferi and the HGE agent on the course of murine Lyme arthritis and granulocytic ehrlichiosis. Coinfection resulted in increased levels of both pathogens and more severe Lyme arthritis compared with those in mice infected with B. burgdorferi alone. The increase in bacterial burden during dual infection was associated with enhanced acquisition of both organisms by larval ticks that were allowed to engorge upon infected mice. Coinfection also resulted in diminished interleukin-12 (IL-12), gamma interferon (IFN-gamma), and tumor necrosis factor alpha levels and elevated IL-6 levels in murine sera. During dual infection, IFN-gamma receptor expression on macrophages was also reduced, implying a decrease in phagocyte activation. These results suggest that coinfection of mice with B. burgdorferi and the HGE agent modulates host immune responses, resulting in increased bacterial burden, Lyme arthritis, and pathogen transmission to the vector.

Studies on poly(propylene fumarate-co-ethylene glycol) based bone cement

Poly(propylene fumarate-co-ethylene glycol) random (PPF-1) and block (PPF-2) copolymer oligomers were prepared. Comparing the setting characteristics of PPF-1 and PPF-2 with comonomer n-vinyl pyrrolidone (n-VP) and swelling characteristics of cured PPF-1 and PPF-2, lower setting temperature and setting time was observed with the former leading to higher swelling coefficient and lower cross link density in the cured PPF-1. Due to the high swelling coefficient and low setting exothermic temperature associated with PPF-1, the bone cement was prepared from PPF-1, n-VP and hydroxyapatite (HAP). The in vitro degradation studies reveal lesser weight loss and deformation of PPF-1/n-VP/HAP based cured resin in Ringer's solution and phosphate buffered saline in comparison with that of PPF-1/n-VP cured resin. Though the bone cement composite has adequate mechanical properties with HAP, the compressive strength and modulus of the composite aged in Ringer's solution and PBS reduced appreciably which is due to extensive hydration and plasticization by the PEG unit. However, the bone-binding and bond strength of the bone cement determined as the load for separation of bones was found to be similar to that of fast setting calcium phosphate-atelocollagen (5%) bone cement. The bone cement PPF-1/n-VP/HAP could be used as scaffold for correcting the bone defects.

[Statins and stroke]

The role of cholesterol in the pathogenesis of stroke, the role of the treatment of hypercholesterolemia in the prevention of stroke have been controversed. The explanation was based on the heterogenous characteristics of stroke, on the relationship between several risk factors, and on the role of the age, in the evaluation of these 2 questions. The discovery of statins induced major therapeutic trials whose aim was the impact on coronary events. These trials demonstrated that statins were accompanied with a major reduction of cholesterol levels and stroke events similar to the one observed with coronary events. Even prospective, placebo controlled, randomized specific trials for stroke are necessary, we can state that cholesterol reduction is the most important mechanism accounting for a decrease in stroke occurrence with statins.

Studies on polyurethane potting compound based on HDI-TMP adduct for fabrication of haemodialyzer

Polyurethane potting compounds based on hexamethylene diisocyanate-trimethylol propane (HDI-TMP) adduct (Component "A") and polypropylene glycol, polyethylene glycol and castor oil (Component "B") were prepared as potential compounds for the fabrication of haemodialyzer. The setting characteristics of the potting compounds having isocyanate index 2.0 are better than those compounds having 1.35. The aging stability of PEG and PPG based potting compounds are poorer than those of castor oil based potting compounds. Appreciable hydrolytic, oxidative and chemical stability could be observed with castor oil based potting compounds of HDI-TMP adduct.

Methods of feminist family therapy supervision

Although feminist family therapy has been studied and practiced for more than 20 years, writing about feminist supervision in family therapy has been limited. Three supervision methods emerged from a qualitative study of the experiences of feminist family therapy supervisors and the therapists they supervised: The supervision contract, collaborative methods, and hierarchical methods. In addition to a description of the participants' experiences of these methods, we discuss their fit with previous theoretical descriptions of feminist supervision and offer suggestions for future research.

Necrotising fasciitis of the breast

Necrotising fasciitis is a rare condition and to the best of our knowledge has never been reported in the breast. We report the first case in the literature of necrotising fasciitis involving the breast.

Cognitive behavioural therapy in pain management for sickle cell disease

It is well established that the treatment of pain is improved by the incorporation of psychological, social and behavioural components in that treatment (Rosenthiel and Keefe), 1983). However, until very recently, the management of sickle cell disease (SCD) in British hospitals has focused exclusively on the physical dimension of pain (Thomas et al, 1998). Although pain is wrong (vaso-occlusive crisis), every individual reacts in a different way. This reaction is influenced in part by immediate role models, usually within the family, and by a person's cognition (thought patterns, beliefs and expectations) in relation to the pain. This paper presents research that has shown that cognitive behavioural therapy (CBT) in SCD is an effective aid in the treatment of chronic pain, reducing psychological distress and boosting confidence.

Is acute appendicitis another inflammatory condition associated with highly active antiretroviral therapy (HAART)?

OBJECTIVE

To report the occurrence of acute appendicitis as a possible manifestation of the immune restoration inflammatory syndrome (IRIS) following the commencement of highly active antiretroviral therapy (HAART) in HIV patients.

DESIGN

Case-note review of HIV patients on HAART with acute appendicitis.

METHODS

Review of HIV markers, antiretroviral therapy and abdominal ultrasound results of four HIV patients with acute appendicitis and the histopathology reports on the appendix in two of the patients.

RESULTS

From a population of approximately 350 HIV patients on HAART, we found four patients who developed acute appendicitis within 6 months of commencing or changing HAART.

CONCLUSION

Acute appendicitis occurring in HIV patients on HAART may represent a variant of IRIS. Further immunohistopathological and epidemiological evaluation will be needed to define this relationship fully.

A test of the Circumplex Model of Marital and Family Systems using the Clinical Rating Scale

Most studies of the Olson Circumplex Model of Marital and Family Systems have utilized a version of the Family Adaptability and Cohesion Evaluation Scales (FACES). Because FACES does not appear to operationalize the curvilinear dimension of the Circumplex Model, researchers have been pessimistic about the model's validity. However, the Clinical Rating Scale (CRS) has received some support as a curvilinear measure of the Circumplex Model. Therefore, we used the CRS rather than FACES to test the validity of the Circumplex Model hypotheses. Using a structural equation-modeling analytical approach, we found support for the hypotheses pertaining to the effects of cohesion and communication on family functioning. However, we found no support for the hypotheses pertaining to the concept of adaptability. We discuss these results in the context of previous studies of the Circumplex Model using FACES. Based on the collective findings, we propose a preliminary reformulation of the Circumplex Model.

Studies on polyurethane potting compound based on isocyanurate of aliphatic diisocyanate for fabrication of a haemodialyser

Polyurethane potting compounds based on multifunctional isocyanurate of aliphatic diisocyanate, hexamethylene diisocyanate (HDI-IC) as Component A and polypropylene glycol, polyethylene glycol and castor oil (Component B) were prepared as potential potting compounds for the fabrication of a haemodialyser. The setting characteristics of the potting compounds having isocyanate index 2.54 are better than those of the compounds having 1.77. The ageing stability of castor oil and PPG-based potting compounds having isocyanate index 2.54 is better than that of PEG oil-based potting compounds. Appreciable hydrolytic, oxidative and chemical stability could be observed with HDI-IC/PPG/2.54 potting compounds for development of haemodialyser, oxygenator, etc.

CD52 antibodies for prevention of graft-versus-host disease and graft rejection following transplantation of allogeneic peripheral blood stem cells

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity after allogeneic bone marrow transplantation, but can be avoided by removing T lymphocytes from the donor bone marrow. However, T cell depletion increases the risk of graft rejection. In this study, two strategies are used to overcome rejection: (1) use of high doses of stem cells obtained from peripheral blood (PBSC), (2) admixture with a CD52 monoclonal antibody in order to deplete both donor and residual recipient lymphocytes. Two antibodies are compared: CAMPATH-1G (rat IgG2b) and its humanized equivalent CAMPATH-1H (human IgG1). A total of 187 consecutive patients at six centers received PBSC transplants from HLA-matched siblings between 1997 and 1999. A wide spectrum of diseases, both malignant and non-malignant, was included. The recovery of CD34+ cells after antibody treatment was close to 100%. The risk of acute GVHD (grade 2 to 4) was 11% in the CAMPATH-1G group and 4% in the CAMPATH-1H group (P = NS). The risk of chronic GVHD (any grade) was 11% in the CAMPATH-1G group and 24% in the CAMPATH-1H group (P = 0.03) but the risk of extensive chronic GVHD was only 2%. The overall risk of graft failure/rejection was 2%, not significantly different between the two antibodies. Antibody treatment was equally effective at concentrations between 10 microg/ml and 120 microg/ml and it made no significant difference to the outcome whether the patients received post-transplant immunosuppression or not (87% did not). Transplant-related mortality in this heterogenous group of patients (including high-risk and advanced disease) was 22% at 12 months. It is proposed that treatment of peripheral blood stem cells with CAMPATH-1H is a simple and effective method for depleting T cells which may be applicable to both autologous and allogeneic transplants from related or unrelated donors. Special advantages of this approach are the simultaneous depletion of donor B cells (which reduces the risk of EBV-associated lymphoproliferative disease) and the concomitant infusion of CAMPATH-1H to deplete residual recipient T cells and thus prevent graft rejection.

Prior BCG vaccination improves survival of Gambian patients treated for pulmonary tuberculosis

The protection provided by BCG against pulmonary tuberculosis ranges from nil to over 90%. While BCG protects against the more serious forms of tuberculosis, it is not known whether or not it protects patients with pulmonary tuberculosis from death. In a study designed to look at the effects of immunotherapy with M. vaccae as an adjunct to chemotherapy in 285 adult Gambian patients treated for proven pulmonary tuberculosis, we examined the association between the presence or absence of a BCG scar and mortality. The data showed that subjects who had a BCG scar were significantly younger than those who did not, and were less likely to have nutritional oedema. During the course of treatment, none of the 85 patients who had a BCG scar died compared to 35 of 200 patients (17.5%) who did not (P < 0.001). In these Gambian patients with pulmonary tuberculosis, prior vaccination with BCG may have provided substantial protection against death. However, there is the possibility that this finding is the result of confounding by other factors or has arisen from bias. Researchers with similar data need to investigate this question as this association, if true, could have major implications for BCG vaccination.

Immune reconstitution after allogeneic bone marrow transplantation depleted of T cells

BACKGROUND

Immune reconstitution following transplantation in individuals who had received T-cell-depleted marrow from HLA identical siblings was serially documented and correlated with the clinical recovery.

METHODS

Patients were preconditioned with radiation containing programs. GvHD prophylaxis was by T-cell depletion with CAMPATH 1G (ex vivo; median dose 20 mg). After transplantation lymphoid development was studied by flow cytometry and serum Ig concentrations were determined. Charts were reviewed to determine the effects of the immune reconstitution on the clinical performance.

RESULTS

The mean donor mononuclear cell number infused was 0.89x10(8)/kg. Within 6 months all the patients recovered their blood parameters and only one required therapy for GvHD. However, despite normal blood counts, 15 suffered life-threatening opportunistic infections, developing at a median of 24 weeks post grafting, but occurring even after 11 months. At 8 weeks from marrow infusion when leukocyte values had normalized in 15/20, compared to normal, immunophenotyping of blood cells from BMT revealed a significantly reduced mean lymphocyte count (1.06, SD 0.83x10(9)/l; P = 0.01), cells expressing CD3 (0.7x10(9)/l, SD 0.68; P = 0.05), CD4 (0.13x10(9)/l, SD 0.21; P = 0.0001) and CD19 (0.04x10(9)/l, SD 0.05; P = 0.001). Populations expressing CD8 and CD56 remained within normal range throughout the study. Normalization of cell numbers displaying CD2, CD3 and CD19 was delayed until 52, 52 and 24 weeks respectively, while CD4 counts persisted subnormal even at 72 weeks. Serum IgA levels were significantly decreased for the entire study period.

CONCLUSIONS

T-cell depletion with CAMPATH 1G while effectively preventing GvHD, also causes clinically significant and prolonged immunosuppression with apparently important clinical implications.

The efficacy of bilingual health advocacy in ethnic minority patients with cancer

AIM

This research aims to establish the efficacy of introducing trained bilingual health advocates to non-English speaking cancer patients.

METHOD

Male and female Bengali advocates received appropriate training. They were then given a group of patients to manage, while a control group received no such intervention. Outcomes were determined at the baseline and after three months. The study finally concludes in April 2000.

RESULTS

The progress so far shows that the advocates had only recruited half of the expected number of Bengali cancer patients. Focus groups showed, however, that healthcare professionals felt that their training was inadequate to overcome the language and cultural barriers, and many were distressed that they were not meeting the needs of minority ethnic patients.

CONCLUSION

The authors anticipate that this study will concur with research in other health sectors where bilingual health advocacy has been beneficial, and that future care will be better informed as a result.

The role of the haemoglobinopathy nurse counsellor: an exploratory study

The haemoglobin disorders are among the most common genetically inherited conditions within the United Kingdom. Individuals who are fully affected have severely impaired health while carriers may be faced with difficult reproductive decisions although generally they are well. Policy makers agree that counselling for families at risk should be undertaken in primary care settings and since the early 1980s this service has been undertaken mainly by specialist haemoglobinopathy nurse counsellors. Despite a number of government reports and recommendations for best practice, problems with service provision continue to be highlighted. However, there is little documented information about the work undertaken by the counsellors or how they perceive their role. A descriptive study was therefore conducted to fill this gap. It took the form of a questionnaire survey undertaken with 26 counsellors. The results were analysed by content and used to develop an interview schedule which was employed to obtain more detailed information from staff in four centres. The counsellors suggested that most of their time was spent in client-centred activities and most clients were first seen antenatally. However, there were significant barriers which prevented optimal service provision. These included: problems of communication with other health professionals, obtaining laboratory results crucial to the early identification of couples at risk, late referral from general practitioners and poor facilities for administration, especially maintaining computer databases essential for record keeping. Developing and obtaining written information suitable for families was particularly time-consuming.

How to organize a study day: a practical account

Organizing a memorable study day is a great challenge. A good study day has the potential to stimulate innovative ideas and improve nursing practice. It is therefore imperative that study days are of high quality, are relevant and well organized. This article highlights some valuable lessons that were learnt from the experience of organizing a study day at a London hospital. It discusses the processes involved including brainstorming, programme preparation, advertising and the provision of care for delegates. The areas that could have been improved are also highlighted.

A computerized method of identifying potentially preventable heart failure admissions

Heart failure (HF) is both highly prevalent and costly to society. Successful self-care is essential to effective HF management. This study sought to develop a method to identify, via medical records (International Classification of Diseases, 9th Revision, Clinical Modification) coding, HF admissions attributable to ineffective self-care. Expert panels completed an iterative series of mailed surveys to generate and validate a list of coded diagnoses that represent HF sequelae modifiable through self-care. Sixteen diagnoses resulted. Chart review at one hospital revealed that these modifiable sequelae were frequently present but not coded. A computerized method of identifying self-care deficits would allow nurses to identify patients in need of patient education.

Beyond the clinic: in-home therapy with Head Start families

Social workers and case managers have provided in-home services to families for some time. The field of Marriage and Family Therapy, however, has begun to do in-home work only recently. This paper describes the experiences of MFT interns who worked with families in their homes. Two university graduate MFT training programs conceptualized and practiced in-home therapy with families who had at least one child enrolled in the local Head Start program. This collaborative effort was part of the AAMFT-Head Start Training Partnership Project that had the goal of funding projects that demonstrated successful partnerships between MFT and Head Start. Six interns worked with 27 Head Start families in their homes. A model of the interns' transition from clinic-based to home-based therapy is discussed and applied to working with Head Start families. The framework of in-home therapy is expanded to conceptualizing larger systems and community-based interventions, and recommendations for family therapists in private practice and agency settings are made.

The AAMFT-Head Start Training Partnership Project: enhancing MFT capacities beyond the family system

This paper summarizes the experience of a two-year project to promote partnerships between 12 graduate Marriage and Family Therapy (MFT) training programs and their 12 local Head Start partners. The American Association for Marriage and Family Therapy (AAMFT) awarded 9 grants to MFT-Head Start partnerships that had established relationships with each other prior to the project. Three MFT-Head Start pairs that had no preexisting relationship but wanted to develop one received planning grants. The partnership project provided an exciting opportunity for MFT faculty and interns to integrate family systems theory into larger organizational settings and to enhance the capacity of MFTs to serve disadvantaged, low-income, culturally diverse families and the community agencies that work with them. Preparing MFT students to intervene and respond systemically both in organizations and with the families they serve represents a viable alternative to more traditional approaches to MFT that limit the focus to the family system. Survey results and interview data reflect the rich experiences of MFT faculty and supervisors, MFT interns, and Head Start staff. Implementation issues are discussed and recommendations are made to improve the collaboration between MFTs and community-based agencies such as Head Start.

Ex vivo depletion of T cells from bone marrow grafts with CAMPATH-1 in acute leukemia: graft-versus-host disease and graft-versus-leukemia effect

BACKGROUND

Preventing graft-versus-host disease (GVHD) by depletion of T lymphocytes from the stem cell graft for transplantation remains controversial, mainly because of the perceived increase in disease recurrence.

METHODS

We retrospectively analyzed the outcome of 50 consecutive individuals in remission of acute lymphoblastic leukemia (n=13; 8 in complete remission [CR]1) or acute myeloblastic leukemia (n=37; 33 in CR1), who had received marrow grafts from HLA-identical siblings. The conditioning regimen included six 2-Gy fractions of total body irradiation, succeeded by cyclophosphamide at 120 mg/kg (with mesna) followed by four fractions of 1.5 Gy to lymphoid areas. Bone marrow (n=38) or peripheral blood mobilized donor mononuclear cells (n=12) were exposed ex vivo to CAMPATH-1 (IgM and complement, or IgG; antiCD52) antibodies, without any further posttransplantation immunosuppression.

RESULTS

Median patient age was 31 (range 14-51) years; 12 patients were 40 or older. Thirty-two patients were male. One patient died of pulmonary hemorrhage on day 10; another died on day 29 of interstitial pneumonitis. Except for one early death, all patients engrafted. Ten (21%) of the remaining 48 who were at risk, developed GVHD. In none was it greater than grade II. Eight patients developed serious viral infections. Four died of cytomegalovirus pneumonia, adenovirus hepatitis, and human immunodeficiency. Overall, 11 patients (22%) relapsed (4 of 33 acute myeloblastic leukemia in CR1) at a median of 235 (range 46-528) days. Mean posttransplantation follow-up was 1062 (median 560; range 10-4177) days. Thirty-three patients (66%) remained disease free at a mean of 1,118 (median 1439; range 159-4,177) days. For all patients, the performance status was between 82% and 100% (median 100).

CONCLUSION

T-cell depletion with CAMPATH-1 effectively prevents GVHD, particularly the severe acute forms, without leading to excessive risk of relapse in acute leukemia.

Apolipoprotein E genotype does not affect the age of onset of dementia in families with defined tau mutations

We have assessed whether apolipoprotein E (ApoE) genotype influences the age of onset of dementia in a series of families with frontal temporal dementia with defined mutations in the tau gene. In contrast to the situation in Alzheimer's disease (AD), we could find no evidence that the age of onset of disease was influenced by the ApoE genotype.

Influences on the inclusion of children in family therapy

This study examined factors that influence family therapists to include children in or exclude them from therapy sessions. We hypothesized that therapist comfort, child problem type (internalizing vs. externalizing), family composition (one- vs. two-parent families), and presenting problem (child-oriented problem vs. adult-oriented problem) affect therapists' inclusion of children. A survey of clinical members of AAMFT found that half of the therapists excluded children on the basis of their comfort and that those who felt more comfortable were more likely to include children in sessions. Therapists included children more frequently in cases of an internalizing vs. an externalizing child, more with single-parent than two-parent families, and more often when the presenting problem focused on a child than on an adult. Implications of the findings are discussed.

Ultrasonographically-guided fine-needle aspiration cytology in the diagnosis of colonic lesions

BACKGROUND

The use of fine-needle aspiration cytology (FNAC) in the diagnosis of colonic lesions was investigated.

METHODS

Some 22 patients (median age 71 years) with a colonic lesion identified on abdominal ultrasonography underwent ultrasonographically-guided FNAC using a 21-G needle. The sample was checked immediately by a cytopathologist for adequacy.

RESULTS

Eighteen patients had colonic carcinoma; aspiration cytology detected malignant epithelial cells consistent with colonic carcinoma in 17 patients and severely dysplastic cells in one patient. The sensitivity and specificity of ultrasonographically-guided FNAC in the diagnosis of colonic carcinoma was 94 and 100 per cent respectively. The remaining four patients had a diagnosis of ileocaecal tuberculosis, ileocaecal Crohn's disease, and metastatic adenocarcinoma in the liver with no identifiable primary (two patients). One demonstrated granulomata, grew acid-fast bacilli and the patient was treated for tuberculosis. One had inflammatory cells and the patient was found to have Crohn's disease on histology. The remaining two patients had confirmed metastatic adenocarcinoma in the liver on aspiration cytology but suspected colonic lesions were found to be benign on cytological examination and no primary lesion was subsequently demonstrated. There were no complications of FNAC and patients complained of minimal discomfort. There has been no evidence of tumour recurrence with a median follow-up of 12 (range 1-25) months.

CONCLUSION

Ultrasonographically-guided FNAC is a valid method for the diagnosis of colonic tumours.

Cutaneous meningioma of the scalp: a case report and review of literature

Ectopic meningioma outside the skull and spinal column is uncommon. We report a cutaneous meningioma of the scalp in a 77-year-old man. A review of types and their management options are discussed. We also highlight that in certain carefully selected cases, these lesions can be treated conservatively.