[Secondary traumatization among wives of soldiers with combat stress reaction]

While the long-term effects of war-related psychic trauma on veterans have been studied extensively, the impact of the results of the trauma on wives has received only minimal attention. The implications of combat-induced stress reaction and post-traumatic stress disorder were examined in a sample of 212 wives of Israeli veterans of the 1982 Lebanon War. Both types of reaction in husbands were found to be associated with increased psychiatric and somatic symptoms in their wives.

The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials

OBJECTIVE

To develop a set of disease activity measures for use in rheumatoid arthritis (RA) clinical trials, as well as to recommend specific methods for assessing each outcome measure. This is not intended to be a restrictive list, but rather, a core set of measures that should be included in all trials.

METHODS

We evaluated disease activity measures commonly used in RA trials, to determine which measures best met each of 5 types of validity: construct, face, content, criterion, and discriminant. The evaluation consisted of an initial structured review of the literature on the validity of measures, with an analysis of data obtained from clinical trials to fill in gaps in this literature. A committee of experts in clinical trials, health services research, and biostatistics reviewed the validity data. A nominal group process method was used to reach consensus on a core set of disease activity measures. This set was then reviewed and finalized at an international conference on outcome measures for RA clinical trials. The committee also selected specific ways to assess each outcome.

RESULTS

The core set of disease activity measures consists of a tender joint count, swollen joint count, patient's assessment of pain, patient's and physician's global assessments of disease activity, patient's assessment of physical function, and laboratory evaluation of 1 acute-phase reactant. Together, these measures sample the broad range of improvement in RA (have content validity), and all are at least moderately sensitive to change (have discriminant validity). Many of them predict other important long-term outcomes in RA, including physical disability, radiographic damage, and death. Other disease activity measures frequently used in clinical trials were not chosen for any one of several reasons, including insensitivity to change or duplication of information provided by one of the core measures (e.g., tender joint score and tender joint count). The committee also proposes specific ways of measuring each outcome.

CONCLUSION

We propose a core set of outcome measures for RA clinical trials. We hope this will decrease the number of outcomes assessed and standardize outcomes assessments. Further, we hope that these measures will be found useful in long-term studies.

Infectivity, growth and distribution of preovigerous adults of Echinostoma caproni in ICR mice

All 23 6-8-week old outbred female ICR mice, each fed 100 metacercarial cysts of Echinostoma caproni, were infected on days 2, 4, 6, and 8 postinfection (PI) with a mean of 45 worms/host. To examine worm distribution in the mouse, the small intestine was divided into five equal sections (segments 1-5 beginning with the pylorus). Worms were found mainly in segments 3 and 4 and were never found in segment 1. Mean body area of worms fixed in 10% neutral buffered formalin (NBF), hot alcohol-formalin-acetic acid (AFA) and aceto-carmine increased slowly until day 4 and then rapidly until day 8 PI. There was a significant difference in the mean body area of worms fixed in hot AFA, NBF, and aceto-carmine on all days except 4 and 6. Distinction of the ovary and ootype was apparent by day 6 and uterine cooling was observed by day 8 PI. Only 2 of 50 worms showed eggs in the uterus on day 8 PI.

The expulsion of Echinostoma trivolvis: worm kinetics and intestinal cytopathology in conventional and congenitally athymic BALB/c mice

The infectivity and distribution of Echinostoma trivolvis were studied in male, conventional and congenitally athymic nude mice, each infected with 30 metacercarial cysts. In conventional mice, worm recoveries at 6 and 8 days post-exposure were 58.3 and 54.0%, respectively. Worm recovery declined to 44.0% by day 10, to 4.3% by day 13, and 0% by day 17. In athymic mice, worm recoveries at 6 and 8 days post-exposure were 61.7 and 36.3%, respectively. Worm recovery declined to 27.7% by day 10, to 0.7% by day 13, and 0% by day 17. The distribution of worms demonstrated a posteriad migration over time in both groups. Kinetic changes in the number of goblet and mucosal mast cells in the upper ileum of mice infected with E. trivolvis were examined. In conventional mice, the number of goblet cells increased rapidly to reach a peak at day 13 and then declined gradually. The number of goblet cells in athymic mice also increased to reach a peak at day 13, and then declined rapidly. However, the number of goblet cells in athymic mice was always less than that in conventional mice. The mast cell number in infected conventional mice increased rapidly to reach a peak at day 17 and then declined. There was no increase in the mast cell number of infected athymic mice throughout the experiment. Whereas common pathological changes occurred in the intestines of both mice groups infected with echinostomes some ultrastructural differences were observed in the gut epithelial cells of conventional versus athymic mice.

A randomized trial of a decisional aid for mental capacity assessments

The objective of this study was to evaluate the clinical utility of a decisional aid for mental capacity assessments which was developed using a group judgment methodology. This was carried out by a randomized, controlled trial. The subjects comprised 64 University of Toronto psychiatry residents in postgraduate years 1 through 4. Residents were randomized to carry out mental capacity assessments on simulated cases with, or without, the use of the decisional aid. The main outcome measure was the extent of agreement between the mental capacity determinations of residents and those of experts. There was no difference between the intervention and control groups with respect to the overall mean level of agreement with experts (0.87 vs 0.86, p = 0.88; 95% confidence interval for the difference between the study groups, -0.07 to +0.08). A logistic regression analysis, which adjusted for imbalances between the groups, also revealed no difference between the groups in their agreement with experts. The mean time per competency assessment was significantly longer in the intervention group (19.1 vs 10.8 min; p < 0.001). It was concluded that the decisional aid did not improve the ability of the psychiatry residents to make mental capacity assessments on simulated cases. Despite relatively limited formal training, the psychiatry residents had a high level of agreement with experts.

Preparing for accreditation: an opportunity for faculty development and curriculum renewal

An approach to ACEHSA accreditation is described which turns this exercise into an occasion for faculty self reflection, development, and renewal. The carefully facilitated process examines the curriculum, its fundamental bases, processes, and products from multiple points of view including those of the faculty, current students, graduates, and employers. The process is derived from deliberative curriculum inquiry and results in curriculum specifications that are ordered by actual practice and truly understood and supported by faculty, students, and practitioners. Feedback from participants indicates that the carefully guided process of introspection turned a negative expectation surrounding the preparation for accreditation into a positive experience of faculty development and curriculum renewal. The process was improved across the two replications documented here.

Lipids in the broodsac of Leucochloridium variae (Digenea, Leucochloridiidae) and its snail host Succinea ovalis

Thin-layer chromatographic analysis was used to examine lipophilic pigments and neutral lipids in the broodsac of Leucochloridium variae and in the tissues of its snail host, Succinea ovalis. Beta-carotene and lutein were not detected in either the parasite or the host on a C-18 reversed phase layer developed in a solvent system of petroleum ether-acetonitrile-methanol (2:4:4). This chromatographic system was able to detect 10 ng of a beta-carotene standard and 100 ng of a lutein standard. The Mangold solvent system on a silica gel plate showed the presence of triacylglycerols, free sterols, and sterol esters as the major neutral lipids in both snail and parasite tissues. As seen in a previous sporocyst-snail relationship, the qualitative neutral lipid profiles of both host and parasite are similar.

Physico-chemical conditions necessary for the in vitro excystment of Zygocotyle lunata (Trematoda:Paramphistomatidae)

Various physico-chemical factors associated with the in vitro excystment of metacercariae of Zygocotyle lunata were studied. Metacercariae could excyst with or without the presence of trypsin or bile salts, although the rate of excystation was slower in the absence of both. Crude ox-bile extract promoted faster excystment than did more refined sodium taurocholate. Pretreatment of cysts with pepsin also resulted in faster excystment rates. Optimal excystation occurred at 40 degrees C and between pH 5.5 and 7.5. The broad pH and temperature ranges and the non-specific enzyme/bile salt requirements for excystation were correlated with the wide range of vertebrate hosts used by this trematode.

Expulsion of Echinostoma trivolvis (Cort, 1914) Kanev, 1985 and retention of E. caproni Richard, 1964 (Trematoda: Echinostomatidae) in C3H mice: pathological, ultrastructural, and cytochemical effects on the host intestine

C3H mice were infected with 30 metacercarial cysts of either echinostome to study the pathological, ultrastructural, and cytochemical effects of the infection on the mouse small intestine. In mice infected with Echinostoma caproni, the intestine showed villous atrophy with fused or eroded villi. The microvilli of the enterocytes were sparse and distorted and showed reduced alkaline phosphatase activity. The crypts of Lieberkuhn were hyperplastic and showed a marked reduction in goblet and Paneth cells. As compared with uninfected controls, there was a marked reduction in glucose-6-phosphatase activity in the enterocytes of the infected gut. Collagen fibers and the number of fibroblasts were increased under the epithelium. In mice infected with E. trivolvis, the tips of the intestinal villi were bent and blunted. The microvilli of the enterocytes were less tightly packed than those of uninfected controls. The mitochondria in the enterocytes were irregularly shaped, contained intracristal bodies, and showed increased cytochrome oxidase activity as compared with those of uninfected controls. The crypts were hyperplastic but showed an increase in the numbers of goblet and Paneth cells. The fibroblasts and collagen fibers showed abnormal development. The ultrastructural and cytochemical differences seen in this study reflect the uniqueness of the host-parasite relationship of each of these echinostome species in the gut of the C3H mouse.

Fatty acid composition of Echinostoma trivolvis (Trematoda) rediae and adults and of the digestive gland-gonad complex of Helisoma trivolvis (Gastropoda) infected with the intramolluscan stages of this echinostome

Gas-liquid chromatographic studies were done to determine the fatty acid composition of the digestive gland-gonad (DGG) complex of Helisoma trivolvis snails infected with the intramolluscan stages of Echinostoma trivolvis, of rediae freed from the DGG, of uninfected DGG, and of 41-day-old adult worms grown in golden hamsters. The DGG of infected snails showed significantly higher levels of stearic acid (18:0), hexatrienoic acid (16:3n-4), and docosahexanoic acid (22:6n-3) than that of uninfected snails. However, the DGG of uninfected snails showed significantly higher levels of 20:2 non-methylene-interrupted diene (NMID) and adrenic acid (22:4n-6) than that of infected snails. The profiles of other fatty acids were remarkably similar in both infected and uninfected snails. Adult worms showed significantly higher amounts of numerous saturated fatty acids and dienes as compared with the rediae. However, the rediae showed significantly higher amounts of certain monoenes and trienes as compared with the adults. Fatty acid differences between rediae and adults probably reflect differences in either the available lipid pools in the immediate host sites or the metabolic activity of each stage of this echinostome.

Cultivation of excysted metacercariae of Echinostoma caproni to ovigerous adults in the allantois of the chick embryo

Chemically excysted metacercariae of Echinostoma caproni inoculated into the allantois of domestic chick embryos became ovigerous in that site within 9 days postinoculation. The egg preparation technique of Saville and Irwin was markedly better than that of a modified Zwilling procedure for obtaining large numbers of postinoculation embryos with worm infections. Adults of E. caproni from the allantois were larger and became ovigerous sooner than worms grown on the chorioallantois. Only worms from the allantois produced eggs with fully developed miracidia. Miracidia were released from these eggs, but an insufficient number was available to attempt infections in Biomphalaria glabrata snails.

Use of an aceto-carmine procedure to examine the excysted metacercariae of Echinostoma caproni and E. trivolvis

A simple aceto-carmine procedure was developed to relax, fix, stain, and clear excysted metacercariae of Echinostoma caproni and E. trivolvis. This procedure allowed for morphologic details on whole metacercariae comparable to those seen with more elaborate staining procedures. Differences in dimensions and staining intensities between the two species of metacercariae are described.

From front line to home front: a study of secondary traumatization

While the long-term effects of combat trauma on veterans have been studied extensively, its impact on veterans' wives has yet to be investigated. This study examined the implications of combat-induced psychopathology--wartime combat stress reaction (CSR) and current posttraumatic stress disorder (PTSD)--in a sample of 205 wives of Israeli combat veterans of the 1982 Lebanon war. Results show that both CSR and PTSD were associated with increased psychiatric symptoms in the wives. In addition, current PTSD was particularly found to contribute to impaired social relations among veterans' wives in a broad range of contexts, from inner feelings of loneliness, through impaired marital and family relations, and extending to the wider social network. Implications of these findings for treatment and further research are discussed.

Regulatory intensity, hospital size and the formalization of medical staff organization in hospitals

Using a theory of organizational response to regulation, this study examined the effects of regulatory intensity and hospital size on the formalization of medical staff organization in Canadian hospitals. The general hypothesis was that, in provinces with greater regulatory intensity, hospitals would exhibit greater formalization of medical staff, and greater involvement of physicians in hospital governance and management; larger hospitals would have greater formalization of medical staff than smaller hospitals. Data from 574 hospitals indicated that both hospital size and provincial regulatory intensity were important factors predictive of the overall formalization of medical staff organization. Depending upon the provincial location, hospitals have developed different patterns of formalizing their medical staff structures.

Growth, development, pathogenicity, and transplantation of Echinostoma caproni (Trematoda) on the chick chorioallantois

Excysted metacercariae of Echinostoma caproni were cultivated on the chorioallantoic membrane (CAM) of 6-day-old domestic chick embryos for 2-13 days postinoculation. There was no significant difference in the body area of fixed and stained preovigerous worms from the CAM versus those grown in domestic chicks. However, ovigerous worms from the CAM were significantly smaller than those from chicks. Worm development, i.e., gonadal differentiation, uterine curling, vitellinogenesis, ovigerousness, and oviposition, took 1 day longer on the CAM than in the chick. Histopathologic studies of worms attached to the CAM were done on cryostat and paraffin sections stained with hematoxylin and eosin. Some worms attached to the CAM by their collar spines and acetabulum, whereas others penetrated the chorionic epithelium and encapsulated in the mesenchyme. Pathogenicity to the CAM included hyperplasia of the chorionic epithelium, hemorrhagia, reduced fibrocytes and blood vessels, but increased lymphocytes and eosinophils in the mesenchyme. Attempts to transplant 11-day-old CAM worms to new CAMs were unsuccessful.

The expulsion of Echinostoma trivolvis (Trematoda) from ICR mice: scanning electron microscopy of the worms

Echinostoma trivolvis adults are rejected from ICR mice within 3 weeks postinfection (p.i.) but are retained in golden hamsters for greater than 15 weeks. The present study used scanning electron microscopy (SEM) to examine worm topography in ICR mice, particularly that of the collar spines, and to correlate worm loss with tegumentary changes. The topography of the worm in ICR mice was similar to that observed in previous studies on this echinostome in domestic chick embryos, chickens, and golden hamsters. Observations were made on the pattern of collar spines in 115 worms from ICR mice at 3-14 days p.i. All worms examined at 3 days exhibited extended spines, whereas about 70% of the worms examined at 14 days displayed retracted or missing spines. Eight worms from golden hamsters examined at 14 days p.i. showed extended collar spines. The retraction or loss of collar spines may play a role in the expulsion of E. trivolvis from ICR mice.

The effects of crowding on adults of Echinostoma caproni in experimentally infected golden hamsters

Fifty-nine of 60 (98%), 6-month-old male golden hamsters, Mesocricetus auratus, fed 15 (group A), 50 (group B), or 200 (group C) metacercarial cysts of Echinostoma caproni (Digenea: Echinostomatidae) were infected 7-34 days postexposure. The mean number of worms recovered in groups A, B and C were 9, 10, and 50, respectively. The percentage recovery was significantly different between group A (63%) and groups B (21%) and C (23%). The intestine was divided into three equal regions (I, II, III). Worms from group A were located in segments II and III of the small intestine whereas worms from groups B and C were distributed in all three segments. The body area, ovarian and testicular areas of worms from group A were greatest, followed in decreasing order by body and gonadal areas of worms from groups B and C. Echinostoma caproni eggs were found in the faeces of all the hamsters examined from groups A, B and C by days 9, 10 and 11, respectively. Physical damage occurred at the site of attachment of the echinostome. Pathological observations indicated the presence of enlarged lymphatic nodules with lymphocytes being the primary cellular infiltrate at the site of parasite attachment.

Scanning and transmission electron microscopical observations on the tegument of excysted metacercariae and adults of Zygocotyle lunata

Scanning and transmission electron microscopical observations were made on the tegument of excysted metacercariae and adults of the paramphistome, Zygocotyle lunata (Digenea: Trematoda). In accord with other paramphistomes studied, this species lacks spines and mitochondria in the tegumentary syncytium and associated cytons. The newly excysted metacercarie, which possessed relatively few tegumental papillae, were cylindrical in comparison to adults which were distinctly flat. The adults had large numbers of tegumental papillae in the region of the oral sucker and acetabulum.

Concurrent infections of Echinostoma caproni and Echinostoma trivolvis in ICR mice

ICR female mice, 6- to 8-weeks old, were exposed concurrently to 25 metacercarial cysts of Echinostoma caproni and 25 metacercarial cysts of Echinostoma trivolvis and necropsied 10 and 14 days post-infection. Controls consisted of mice exposed singly to either 25 or 50 E. caproni or E. trivolvis cysts. All 23 mice exposed to E. caproni cysts were infected with a total of 331 worms (37.8%), whereas only 11 (37.9%) of 29 mice exposed to E. trivolvis cysts were infected with a total of 77 (6.4%) worms. In the concurrent infections, 13 (59.1%) of 22 mice were infected with both species and the percentage of worm recovery was 72.6% for E. caproni and 14.2% for E. trivolvis. There was no difference in worm distribution of either species in single vs concurrent infections. In concurrent infections at 14 days PI, there was a significant decrease in the body area of worms of both species, when compared to single worm species.

Infectivity, growth, and distribution of Echinostoma caproni (Trematoda) in the ICR mouse

Host-parasite interactions of the intestinal trematode Echinostoma caproni were studied in ICR laboratory mice. All of 40 mice, each fed 25 metacercarial cysts of Echinostoma caproni, were infected 1-20 wk postinfection (PI) with a mean of 17.2 worms/host. At 24 and 29 wk PI only 2 of 6 mice (33%) were infected, with a mean of 4.2 worms/host. Mean body area of worms increased rapidly to about 5 mm2 by week 2, increased less rapidly to 8.8 mm2 by week 12, plateaued until week 24, and then declined. Mean dry weight of worms increased rapidly to about 0.5 mg by week 2, less rapidly to 1.4 mg by week 12, and then plateaued until week 24 PI. From 1 to 8 wk PI most worms localized in the jejunum and ileum; later most worms were in the jejunum and duodenum. Considerable differences were seen in the growth and distribution of E. caproni in the ICR mouse compared with previous studies on this echinostome species in the NMRI mouse.

Cultivation of excysted metacercariae of Echinostoma caproni (Trematoda) to ovigerous adults on the chick chorioallantois

Excysted metacercariae of Echinostoma caproni were cultivated on the chick chorioallantoic membrane (CAM) maintained at 38.5 +/- 1 C and a relative humidity of 60-65%. Of 59 6-day-old embryos, each inoculated with 25 metacercariae, 29 (49.2%) were infected 2-12 days postinoculation. The total number of worms recovered from the infected eggs was 163 or 22.5% of the 725 inoculated metacercariae. Eggs contained from 1 to 12 (average 5.6) worms per CAM. Worm length increased rapidly from an average of 0.5 mm at 2 days to about 3.0 mm at 6 days postinoculation. Ovigerous worms first were seen on day 8 PI, but fluke eggs did not develop embryos. Worm development in ovo lagged about 1 day behind that of in vivo worms. One worm maintained for 17 days on 2 successive CAMs reached 6 mm in length, contained about 100 eggs in its uterus, and laid an additional 100 eggs on the CAM surface.

Schistosoma japonicum: changes in lipase activity in adults maintained in vitro

Schistosoma japonicum (Chinese strain) adult worm pairs (10-12 weeks old) were fixed in 4 degrees C absolute acetone or neutral buffered formalin either immediately after recovery from mice, or following incubation for 0.5 or 1.0 h. Males and females were incubated individually in Earle's balanced salt solution at 37 degrees C. Lipase activity was determined in frozen sections by Gomori's method using Tween 80 as substrate. In unincubated males, lipase activity was localized only in the parenchyma; in females it was present in the vitellaria and parenchyma subjacent to the tegument. After 0.5 h incubation, males showed less lipase activity in the parenchyma than unincubated males, and females showed increased activity in the parenchyma subjacent to the tegument, but not in the vitellaria. Following 1.0 h incubation, males showed less lipase activity than previously, and females showed a marked increase in activity, particularly in the parenchyma subjacent to the tegument.

A comparison of Echinostoma caproni and Echinostoma trivolvis (Trematoda: Echinostomatidae) adults using isoelectrofocusing

An isoenzymatic analysis using thin-layer agarose gel isoelectrofocusing on laboratory strains of Echinostoma trivolvis and Echinostoma caproni adults showed characteristic monomorphic phenotypes for phosphoglucomutase and glucose phosphate isomerase. The fixed allelic variation observed between these 2 taxa is consistent with their current classification as distinct species.