Considering uncertainty in comparing the burden of illness due to foodborne microbial pathogens

The uncertainty attendant to burden-of-illness estimates should be taken into account in comparing the public health impact of different foodborne pathogens. In this paper, decision analysis concepts are applied to the comparisons of pathogen-specific burden-of-illness estimates. In situations wherein the magnitude of uncertainty varies, the rank order of pathogen-specific burden-of-illness estimates is sensitive to the decisional criteria applied. To illustrate the magnitude of attendant uncertainty in pathogen-specific foodborne-illness estimates, probabilistic risk assessment methods are used to characterize the uncertainty regarding the burden of illness due to Escherichia coli O157:H7. The magnitude of uncertainty about the burden of food-related illness due to E. coli O157:H7 is substantial, ranging from less than 50,000 to more than 120,000 cases/year. This example underscores the importance of considering the uncertainty attendant to burden-of-illness estimates in comparing the public health impacts of different pathogens. Although some would argue that the expected value of the number of illnesses provides the "best estimate" for decision-making, this merely reflects a decision-making rule of convention and not a scientific truism.

Apoptotic effects in primary human umbilical vein endothelial cell cultures caused by exposure to virion-associated and cell membrane-associated HIV-1 gp120

During the course of HIV-1 infection, free virus, infected cells, and free HIV-1 proteins circulate within the host, exposing the host endothelium to these viral factors. We have previously presented evidence showing that soluble HIV-1 gp120 protein interacts with chemokine receptors on primary human endothelium and (through those interactions) induces apoptosis as well as other intracellular effects. The current study examines the effect of exposure of vascular endothelium to gp120 IIIb expressed on the surface of Jurkat cells and in the context of viral particles. Apoptosis was observed in human umbilical vein endothelial cell (HUVEC) cultures exposed to gp160-transfected Jurkat cells as well as to virion particles with gp120 on their surface. Additional experiments show that this apoptotic effect was caused by gp120 protein acting through chemokine receptors on the HUVEC surface, primarily the CXCR4 receptor. At higher concentrations of gp120, this lymphotrophic variant, which has been shown to interact predominantly with CXCR4, seems to interact with and induce apoptosis through the CCR5 receptor. Finally, this apoptotic effect in HUVEC cultures occurs at low levels of the inducing agent, gp120, on cell membranes or on virion particles. These results demonstrate that HIV-1 gp120 is capable of interacting with and killing vascular endothelial cells in multiple in vivo contexts.

Postpartum pituitary hypophysitis

The case of a young woman who developed lymphocytic hypophysitis 2 weeks after delivery of a healthy baby is reported. The patient presented with clinical features suggestive of a pituitary mass lesion, but surgery was avoided when other clinical and radiologic features were considered. The patient recovered with steroid treatment only. We review the literature on this increasingly recognized condition and argue that medical management may be more suitable than previously thought.

The midface degloving approach for intracranial tumours

Although many approaches to the anterior clivus and parasellar region have been described, safe access to this area remains difficult. The authors describe the use of the midface degloving approach as a route for resection of intracranial lesions of the anterior skull base. Six cases are presented: two sellar meningiomas, a trigeminal neuroma, a pituitary adenoma, fibrous dysplasia and fibrosis of the trigeminal nerve within Meckel's cave. The midface degloving approach has allowed excellent exposure, avoids any visible scarring and obviates the need for craniotomy. The approach is a useful adjunct to the armamentarium of the surgeon operating in this area and indeed may allow removal of lesions that could not safely be removed transcranially.

On a hiding to nothing? Assessing the corporate governance of hospital and health services in New Zealand 1993-1998

In New Zealand the governance of public sector hospital and health services has changed significantly over the past decade. For most of the century hospitals had been funded by central government grants but run by locally elected boards. In 1989 a reforming Labour government restructured health services along managerialist lines, including changing governance structures so that some area health board members were government appointments, with the balance elected by the community. More market oriented reform under a new National government abolished this arrangement and introduced (1993) a corporate approach to the management of hospitals and related services. The hospitals were established as limited liability companies under the Companies Act. This was an explicitly corporate model and, although there was some modification of arrangements following the election of a more politically moderate centre-right coalition government in 1996, the corporate model was largely retained. Although significant changes occurred again after the election of a Labour government in 1999, the corporate governance experience in New Zealand health services is one from which lessons can, nevertheless, be learnt. This paper examines aspects of the performance and process of corporate governance arrangements for public sector health services in New Zealand, 1993-1998.

QS-21 promotes an adjuvant effect allowing for reduced antigen dose during HIV-1 envelope subunit immunization in humans

Three separate studies were undertaken in HIV-1 uninfected persons to determine if the adjuvant QS-21 improves the magnitude or kinetics of immune responses induced by recombinant soluble gp120 HIV-1(MN) protein (rsgp120) immunization. The QS-21 was administered at two doses (50 and 100 microg), either alone or in combination with aluminum hydroxide (600 microg). At the highest doses of rsgp120 (100, 300, and 600 microg), QS-21 exerted no significant effect on either binding or neutralizing antibody titers. Antibody binding and neutralizing responses fell dramatically when rsgp120, formulated with alum alone, was given at low doses (3 and 30 microg). In contrast, antibody responses similar in titer to those in the high dose antigen groups were induced with the low dose rsgp120 formulated with QS-21. In addition, the lymphocyte proliferation and delayed type hypersensitivity skin testing were superior in the QS-21 recipients compared with the alum recipients at the low antigen doses. Moderate to severe pain was observed in majority of the volunteers receiving QS-21 formulations, and vasovagal episodes and hypertension were not infrequent. Thus, the use of QS-21 may provide a means to reduce the dose of a soluble protein immunogen.

Microflow-based automated chemistries: application to protein sequencing

We describe a microflow-based instrument, consisting of multiple rotary valves, capillary tubing, and miniaturized reaction vessels, for the purpose of performing automated chemical and biochemical reations on a very small scale (i.e. submicroliter volumes). The novelty is that close to 100% of the reaction end products are available in a minimal volume (< or = 5 microL) inside a pressurized microvial for subsequent analysis. This makes the system compatible with capillary HPLC and, in principle, with continuous-flow nanoelectrospray mass spectrometry. Total control of flow path combinations and directions, temperatures, and gas pressures enables precise execution of complex biochemical laboratory procedures. Instrument performance was convincingly demonstrated by partially sequencing 100 fmol of an intact protein using classical Edman chemistry in combination with capillary-bore liquid chromatography. To our knowledge, this is the smallest amount of protein ever reported to be successfully analyzed in this way. Additional applications that merge enzymatic and chemical procedures with high-sensitivity analytical devices can be envisioned in the future.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE

The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay.

METHODS

This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis.

RESULTS

The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47).

CONCLUSION

Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Antibodies to tissue transglutaminase: comparison of ELISA and immunoprecipitation assay in the presence and in the absence of calcium ions

Endomysial antibodies are characteristic of coeliac disease and tissue transglutaminase (tTG) has been identified as a major component of the endomysial antigen. tTG autoantibodies were measured in sera from patients with coeliac disease using ELISA based on guinea pig tTG and immunoprecipitation assay (IPA) based on 35S-labelled human tTG produced in an in vitro transcription/translation system. In addition, the effect of calcium ions on the interaction between tTG autoantibodies in the two assays was studied. Under standard (i.e. Ca2+-free) conditions, 36/39 (92%) coeliac sera were positive for IgA tTG antibodies by ELISA and 34/39 (87%) sera were positive by IPA. Comparison of ELISA and IPA results showed three sera positive by ELISA but negative by IPA and one serum which was positive by IPA but negative by ELISA. Bland and Altman analysis of the correlation between the ELISA and IPA showed that the results for 37 out of 39 samples were in the agreement. The results by ELISA carried out without and with Ca2+ were in good agreement (r=0.99; n=39). IPA using Ca2+ containing buffer detected fewer samples compared to IPA using standard assay buffer however the results of the two assays also showed a good agreement (r=0.93; n=39). Our studies confirm that antibodies to tTG are good markers of coeliac disease and indicate that the autoantibody binding sites on tTG are formed in a way which is essentially independent of Ca2+.

Health Action Zones: the "third way" of a new area-based policy?

The notion of the action zone has emerged as a key feature of New Labour's approach to social policy. There is some debate about whether Labour's area-based policies reflect the Old Left, the New Right or the "third way". This paper critically examines these issues for Health Action Zones (HAZs). First, it outlines the development of HAZs and their main features. It then examines the themes that may have underpinned the HAZ strategy. Finally it examines critiques of HAZs in the light of wider debates about area-based strategies. It is concluded that HAZs fit well with some of New Labour's key themes, and may have some characteristics of a third way in that they incorporate features of both the "Old Left" of the Black Report and the New Right of competitive, bidding exercises. Moreover, they have addressed some of the main criticisms of earlier area-based policies, arguably being based on place rather than people poverty. However, some of the issues regarding their designation illustrate unresolved problems.

The treatment of 'acquired tonsillar herniation' in pseudotumour cerebri

Acquired tonsillar herniation and syrinx formation are recognized complications of a lumboperitoneal shunt used to treat conditions of increased CSF volume. Treatment of this complication is by ventriculoperitoneal shunt or foramen magnum decompression. We describe the first case of acquired tonsillar herniation in a pseudotumour cerebri (following lumboperitoneal shunt insertion) that responded partly to ventriculoperitoneal shunt insertion and more completely to foramen magnum decompression. Our case demonstrates that a ventriculoperitoneal shunt is not always sufficient in treating this complication and reversing visual deterioration. Foramen magnum decompression may therefore be a sight saving procedure in pseudotumour cerebri with acquired tonsillar herniation and may be important in understanding the pathogenesis of conditions of increased CSF volume.

Licensing new antibacterial agents - a European perspective

There are two procedures by which new antibacterial agents may be granted marketing authorisation in the EU. The Centralised Procedure involves a single application through the European Agency for the Evaluation of Medicinal Products (EMEA). If a positive opinion is advised by the Committee on Proprietary Medicinal Products (CPMP), the European Commission grants a marketing authorisation in all EU Member States (MS). In the Mutual Recognition Procedure, the first EU country to license the drug becomes the Reference MS (RMS) and the company then requests some or all of the other MS to recognise this first authorisation. Both Centralised and Decentralised Procedures result in a Summary of Product Characteristics (SPC) which is identical in all EU MS. These EU-wide procedures have made possible the development of CPMP guidance regarding the clinical development of antibacterial agents, the presentation of data on in-vitro activity in SPCs, and the exploration of the pharmacokinetic-pharmacodynamic relationship. In addition, many CPMP guidelines that are applicable to a wide range of drugs, such as that regarding drug development in children, are pertinent to antibacterial agents.

Corporate governance of public health services: lessons from New Zealand for the state sector

New Zealand public hospitals and related services were grouped into 23 Crown Health Enterprises and registered as companies in 1993. Integral to this change was the introduction of corporate governance. New directors, largely from the business sector, were appointed to govern these organisations as efficient and effective businesses. This article presents the results of a survey of directors of New Zealand publicly-owned health provider organisations. Although directors thought they performed well in business systems development, they acknowledged their shortcomings in meeting government expectations in respect to financial performance and social responsibility. Changes in public health sector provider performance indicators have resulted in a mixed report card for the sector six years after corporate governance was instituted.

Management of bowel dysfunction: evacuation difficulties

Bowel dysfunction affects many people and encompasses a variety of problems. This article examines the different forms of bowel dysfunction and considers the nurse's role in caring for patients with this disorder, including manual evacuation.

Analysing the 'new' British National Health Service

The British National Health Service (NHS) has seen a proliferation of confusing and sometimes conflicting labels in recent years. It has been claimed that during the Conservative Government's period of office the 'classic' NHS was 'restructured' and then turned into the 'new' NHS. The New Labour Government of 1997 has claimed that it will deliver a 'new' NHS. If all these claims are correct, it should be possible to identify four distinct periods, with three clear 'breaks of slope' with significant changes in important indices on moving from one label to another. This paper attempts to look behind these labels by critically examining what has changed in the NHS since 1979. In simple terms, what has been 'restructured'? What is new about the 'new' NHS? Why are these changes important? It is concluded that while the NHS has certainly undergone significant changes in the past 20 years or so, the appearance of a 'new' NHS may be premature as in many areas it is possible to see the marks of continuity as well as change, and policy impact is characterised by greater incrementalism than policy rhetoric.

Autoantibodies to IA-2 in insulin-dependent diabetes mellitus. Measurements with a new immunoprecipitation assay

An immunoprecipitation assay for autoantibodies (Abs) to the human islet cell antigen IA-2 has been developed using 125I-labelled recombinant IA-2 expressed in E. coli. With this assay IA-2 Abs were detected in 103/217 (47%) of IDDM patients of different ages and with different disease duration. IA-2 Ab prevalence was higher in younger patients (at the age of 15 years or below) with the recent onset IDDM (64/113; 57%) compared to patients above the age of 15 years (11/25; 44%). One of 40 (2.5%) Graves' disease patients and five of 204 (2.5%) of NIDDM patients were also positive. IA-2 Abs were not detected in sera from patients with Hashimoto's thyroiditis (n=32), myasthenia gravis (n=20) or systemic lupus erythematosus (n=10). IA-2 Ab measurements based on 125I-labelled IA-2 showed a good correlation with the results of an immunoprecipitation assay based on 35S-labelled IA-2 produced in the in vitro transcription/translation system (r=0.78; n=113; p<0.001). Out of 217 IDDM sera which were tested for IA-2 Abs, 140 (65%) were positive for Abs to glutamic acid decarboxylase (GAD) and 166 (76%) were positive for Abs to IA-2 and/or Abs to GAD. In addition, Abs to IA-2, to GAD and to insulin were analysed in sera from recent onset IDDM patients who had not been treated with insulin (n=117). In all, 76/117 (65%) of these sera were positive for GAD Abs, 66/117 (56%) for IA-2 Abs, 45/117 (38%) for insulin Abs. However, 98/117 (84%) were positive for at least one of the three Abs confirming earlier observations on the complementarity of Ab testing in IDDM. Overall, the IA-2 Ab assay based on 125I-labelled recombinant IA-2 showed good sensitivity, precision and specificity which, combined with an easy and convenient protocol, makes it attractive for routine use.

Duplex ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission

OBJECTIVE

To determine the rate of deep vein thrombosis (DVT) newly diagnosed by duplex ultrasound in patients with acute spinal cord injury (SCI) at admission for rehabilitation.

DESIGN

Retrospective case-control study.

SETTING

Independent specialized spinal cord rehabilitation hospital.

PATIENTS

Data were collected from records of 189 SCI patients admitted for rehabilitation over a 1-year period who underwent a duplex scan and were not admitted with a known diagnosis of DVT.

MAIN OUTCOME MEASURES

A DVT newly diagnosed by duplex ultrasound at rehabilitation admission.

RESULTS

Twenty-two patients (11.6%) had a newly diagnosed DVT at time of admission. Chi-square analysis found no statistically significant relationship between level of injury (tetraplegia vs paraplegia), motor complete (ASIA A and B) versus incomplete status (ASIA C and D), or cause of SCI (traumatic vs nontraumatic injury) in determining a positive or negative duplex result (chi2 = 1.709, p = .191; chi2 = 1.314, p = .252; chi2 = 3.155, p = .076; respectively). Prophylaxis for DVT decreased the risk of developing a DVT: 4.1% of patients administered prophylaxis as compared to 16.4% of patients not given prophylaxis (chi2 = 6.558, p = .01). Only 38.6% of patients transferred to rehabilitation were undergoing DVT prophylaxis.

CONCLUSIONS

The prevalence of DVT in acute SCI patients at admission to rehabilitation is significant. A duplex ultrasound is an important noninvasive technique to screen patients with acute and subacute SCI for DVT on admission to the rehabilitation setting regardless of the completeness, level, or cause of the patients' injury.