Multiplex T-cell Stimulation Assay Utilizing a T-cell Activation Reporter-based Detection System

Immune tolerance and response are both largely driven by the interactions between the major histocompatibility complex (MHC) expressed by antigen presenting cells (APCs), T-cell receptors (TCRs) on T-cells, and their cognate antigens. Disordered interactions cause the pathogenesis of autoimmune diseases such as type 1 diabetes. Therefore, the identification of antigenic epitopes of autoreactive T-cells leads to important advances in therapeutics and biomarkers. Next-generation sequencing methods allow for the rapid identification of thousands of TCR clonotypes from single T-cells, and thus there is a need to determine cognate antigens for identified TCRs. This protocol describes a reporter system of T-cell activation where the fluorescent reporter protein ZsGreen-1 is driven by nuclear factor of activated T-cells (NFAT) signaling and read by flow cytometry. Reporter T-cells also constitutively express additional pairs of fluorescent proteins as identifiers, allowing for multiplexing of up to eight different reporter T-cell lines simultaneously, each expressing a different TCR of interest and distinguishable by flow cytometry. Once TCR expression cell lines are made they can be used indefinitely for making new T-cell lines with just one transduction step. This multiplexing system permits screening numbers of TCR-antigen interactions that would otherwise be impractical, can be used in a variety of contexts (i.e., screening individual antigens or antigen pools), and can be applied to study any T-cell-MHC-antigen trimolecular interaction.

Proinsulin-Reactive CD4 T Cells in the Islets of Type 1 Diabetes Organ Donors

Proinsulin is an abundant protein that is selectively expressed by pancreatic beta cells and has been a focus for development of antigen-specific immunotherapies for type 1 diabetes (T1D). In this study, we sought to comprehensively evaluate reactivity to preproinsulin by CD4 T cells originally isolated from pancreatic islets of organ donors having T1D. We analyzed 187 T cell receptor (TCR) clonotypes expressed by CD4 T cells obtained from six T1D donors and determined their response to 99 truncated preproinsulin peptide pools, in the presence of autologous B cells. We identified 14 TCR clonotypes from four out of the six donors that responded to preproinsulin peptides. Epitopes were found across all of proinsulin (insulin B-chain, C-peptide, and A-chain) including four hot spot regions containing peptides commonly targeted by TCR clonotypes derived from multiple T1D donors. Of importance, these hot spots overlap with peptide regions to which CD4 T cell responses have previously been detected in the peripheral blood of T1D patients. The 14 TCR clonotypes recognized proinsulin peptides presented by various HLA class II molecules, but there was a trend for dominant restriction with HLA-DQ, especially T1D risk alleles DQ8, DQ2, and DQ8-trans. The characteristics of the tri-molecular complex including proinsulin peptide, HLA-DQ molecule, and TCR derived from CD4 T cells in islets, provides an essential basis for developing antigen-specific biomarkers as well as immunotherapies.

Multiplex T Cell Stimulation Assay Utilizing a T Cell Activation Reporter-Based Detection System

Recent advancements in single cell sequencing technologies allow for identification of numerous immune-receptors expressed by T cells such as tumor-specific and autoimmune T cells. Determining antigen specificity of those cells holds immense therapeutic promise. Therefore, the purpose of this study was to develop a method that can efficiently test antigen reactivity of multiple T cell receptors (TCRs) with limited cost, time, and labor. Nuclear factor of activated T cells (NFAT) is a transcription factor involved in producing cytokines and is often utilized as a reporter system for T cell activation. Using a NFAT-based fluorescent reporter system, we generated T-hybridoma cell lines that express intensely fluorescent proteins in response to antigen stimulation and constitutively express additional fluorescent proteins, which serve as identifiers of each T-hybridoma expressing a unique TCR. This allows for the combination of multiple T-hybridoma lines within a single reaction. Sensitivity to stimulation is not decreased by adding fluorescent proteins or multiplexing T cells. In multiplexed reactions, response by one cell line does not induce response in others, thus preserving specificity. This multiplex assay system will be a useful tool for antigen discovery research in a variety of contexts, including using combinatorial peptide libraries to determine T cell epitopes.

Cost-benefit analysis of controlling rabies: placing economics at the heart of rabies control to focus political will

Rabies is an economically important zoonosis. This paper describes the extent of the economic impacts of the disease and some of the types of economic analyses used to understand those impacts, as well as the trade-offs between efforts to manage rabies and efforts to eliminate it. In many cases, the elimination of rabies proves more cost-effective over time than the continual administration of postexposure prophylaxis, animal testing and animal vaccination. Economic analyses are used to inform and drive policy decisions and focus political will, placing economics at the heart of rabies control.

Effects of total and regional fat loss on plasma CRP and IL-6 in overweight and obese, older adults with knee osteoarthritis

OBJECTIVE

To describe associations between total and regional body fat mass loss and reduction of systemic levels of inflammation (C-reactive protein (CRP) and interleukin-6 (IL-6)) in obese, older adults with osteoarthritis (OA), undergoing intentional weight loss.

DESIGN

Data come from a single-blind, 18-month, randomized controlled trial in adults (age: 65.6 ± 6.2; Body mass index (BMI): 33.6 ± 3.7) with knee OA. Participants were randomized to diet-induced weight loss plus exercise (D + E; n = 150), diet-induced weight loss-only (D; n = 149), or exercise-only (E; n = 151). Total body and region-specific (abdomen and thigh) fat mass were measured at baseline and 18 months. High-sensitivity CRP and IL-6 were measured at baseline, six and 18 months. Intervention effects were assessed using mixed models and associations between inflammation and adiposity were compared using logistic and mixed linear regression models.

RESULTS

Intentional total body fat mass reduction was associated with significant reductions in log-adjusted CRP (β = 0.06 (95% CI = 0.04, 0.08) mg/L) and IL-6 (β = 0.02 (95% CI = 0.01, 0.04) pg/mL). Loss of abdominal fat volume was also associated with reduced inflammation, independent of total body fat mass; although models containing measures of total adiposity yielded the best fit. The odds of achieving clinically desirable levels of CRP (<3.0 mg/L) and IL-6 (<2.5 pg/mL) were 3.8 (95% CI = 1.6, 8.9) and 2.2 (95% CI = 1.1, 4.6), respectively, with 5% total weight and fat mass loss.

CONCLUSIONS

Achievement of clinically desirable levels of CRP and IL-6 more than double with intentional 5% loss of total body weight and fat mass. Global, rather than regional, measures of adiposity are better predictors of change in inflammatory burden.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00381290.

Insulin resistance, beta cell dysfunction and visceral adiposity as predictors of incident diabetes: the Insulin Resistance Atherosclerosis Study (IRAS) Family study

AIMS/HYPOTHESIS

Central obesity, insulin resistance and beta cell dysfunction are independent risk factors for incident type 2 diabetes, although few studies have used detailed measures of these disorders. Our objective was to study the association of directly measured visceral and subcutaneous adipose tissue (VAT, SAT), insulin sensitivity (S (I)) and the acute insulin response (AIR) with incident type 2 diabetes.

METHODS

Participants were 1,230 Hispanic-Americans and African-Americans in the Insulin Resistance Atherosclerosis Study (IRAS) Family Study who were free of type 2 diabetes at baseline (2000-2002). S (I) and AIR were determined from frequently sampled IVGTTs with minimal model analysis. VAT and SAT were determined by computed tomography. Impaired fasting glucose and type 2 diabetes were defined according to American Diabetes Association criteria.

RESULTS

Incident type 2 diabetes was diagnosed in 90 participants after 5 years. After adjustment for age, sex, ethnicity, centre, impaired fasting glucose, triacylglycerol, HDL-cholesterol and systolic BP, both S(I) and AIR were inversely associated with type 2 diabetes (S (I), OR 0.53, 95% CI 0.39-0.73; AIR, OR 0.22, 95% CI 0.14-0.34 per SD; both p < 0.001), while both VAT and SAT were positively associated with type 2 diabetes (VAT, OR 1.68, 95% CI 1.22-2.33; SAT, OR 1.49, 95% CI 1.13-1.99; both p < 0.01). In a model including all four factors, S (I) and AIR (S (I), OR 0.55, 95% CI 0.37-0.80; AIR, OR 0.21, 95% CI 0.13-0.33; both p < 0.01) were significant predictors of type 2 diabetes, although associations with VAT and SAT were no longer significant. A significant sex x VAT interaction indicated a stronger association of VAT with type 2 diabetes in women than in men.

CONCLUSIONS/INTERPRETATION

Insulin resistance, beta cell dysfunction and VAT predicted incident type 2 diabetes, with evidence of a stronger association of VAT with type 2 diabetes among women.

Erythema nodosum leprosum in Nepal: a retrospective study of clinical features and response to treatment with prednisolone or thalidomide

INTRODUCTION

Erythema nodosum leprosum (ENL) is an inflammatory reaction, which may occur in the course of leprosy and may result in nerve function impairment and subsequent disability.

METHODS

This retrospective study explores demographic and disease specific parameters. Severity of ENL was assessed using the Reaction Severity Scale (RSS). Records of 94 patients were reviewed. The study reports also on the treatment of 76 of these patients who were treated with prednisolone alone or thalidomide in addition to prednisolone. RESULTS Thirty percent of patients presented with ENL at time of diagnosis; 41% developed ENL-reaction in the first year of MDT. Forty-eight percent of patients were treated for ENL-reaction for less than 12 months; 13% for more than 5 years. High RSS-scores correlated with a longer duration of treatment. In group A (prednisolone) 51.7% and in group B (prednisolone and thalidomide) 76.6% of patients were male. Age, leprosy classification, delay of multidrug treatment (MDT) and interval between MDT and first ENL-symptoms did not differ significantly in both groups. Median duration of ENL-treatment was 15 months in group A versus 38 months in group B (P < 0.001). At the start of treatment, ENL-reaction was less severe in group A (RSS = 12) than in group B (RSS = 18; P = 0.003).

DISCUSSION

ENL-symptoms may be of help in the early diagnosis and adequate treatment of ENL. Characterisation of (sub) groups of patients with ENL based on presence and severity of symptoms is important for future prospective studies to better evaluate the efficacy of interventions.

A biomechanical analysis of anterior load carriage

Front load carriage is a common occupational task in some industries (e.g. agriculture, construction), but, as compared to lifting tasks, relatively little research has been conducted on the biomechanical loading during these activities. The focus of this study was to explore the low back biomechanics during these activities and, specifically, to examine the effects of load height and walking speed on trunk muscle activity and trunk posture. Eleven male participants participated in two separate front load-carriage experiments. The first experiment called for carrying a barbell (with weight corresponding to 20% of elbow flexion strength) at three heights (knuckle height, elbow height and shoulder height) at a constant horizontal distance from the spine. The second experiment called for participants to carry a bucket of potatoes weighing 14 kg at the same three heights, but with no further restrictions in technique. In both experiments, the participants performed this task while either standing still or walking at a self-selected speed. As they performed these tasks, the activity levels of the right-side muscle of the rectus abdominis, external oblique, biceps brachii, anterior deltoid and three levels (T9, T12 and L3) of the erector spinae were sampled. Mid-sagittal plane trunk posture was also quantified using three magnetic field-based motion sensors at T9, T12 and L3. The results showed a significant effect of both walking speed and load height on trunk posture and trunk muscle activity levels in both the barbell and bucket experiments. In the barbell experiment, the walking trials generated 43% more trunk muscle activity than the standing trials. Trials at shoulder height produced 11% more muscle activity than trials at elbow height in the T9 erector spinae muscles and 71% more muscle activity in the anterior deltoid. In the bucket experiment, trunk muscle activity responded in a similar fashion, but the key result here was the quantification of the natural hyperextension posture of the spine used to balance the bucket of potatoes. These results provide insight into muscle activation patterns in dynamic settings, especially (load) carrying biomechanics, and have implications in industrial settings that require workers to carry loads in front of their bodies.

Transformation of a leprosy hospital in Nepal into a rehabilitation centre: the Green Pastures Hospital experience

Green Pastures Hospital for leprosy patients in Pokhara Nepal, was established in 1957 by the International Nepal Fellowship (INF) in a decade which saw the establishment of many similar hospitals in other leprosy endemic countries. In recent years, mainly due to significant improvements in leprosy control services and the wide implementation of multiple drug therapy (MDT) for all patients, many of these specialist hospitals have encountered 1) a decline in prevalence rate, 2) a large decline in the percentage of patients presenting with WHO grade 2 disability, 3) a decline in the previous indications for hospital admission, e.g. immunologically mediated reactions, and 4) a need to develop financial independence making them less dependent on donor agencies. In addition, the decision to change from specialist to general services opened up the possibility of using facilities and expertise for the rehabilitation of non-leprosy affected persons, whilst also moving towards the reduction of stigma and prejudice against patients with leprosy. This paper describes the process of 'transformation' of an established and well known leprosy hospital in Western Nepal from 1997 onwards into a general rehabilitation hospital. Careful preparation, with full involvement of existing staff and co-operation with other agencies in the hospital catchment area were key factors in what has now become a successful venture. Surgical procedures and orthopaedic appliance services for non-leprosy affected persons have increased in recent years and the introduction of a dermatology service has resulted in out-patient attendance rising from about 1000 in 1999 to 4500 in 2003. No evidence of reluctance to attend and use the facilities offered by this hospital because of stigma against leprosy has been encountered. Many of the changes described have been made in order to reduce financial dependence on donor sources of support, but the underlying reason for transformation is still based on the vision of the INF mission to work for and improve the condition of the marginalized in society.

Reliability of thumb web measurements

Two new methods of thumb web space measurement, the intermetacarpal distance (IMD) and the derived intermetacarpal angle (DIMA), were proposed and compared with a conventional method for interrater reliability. Forty subjects (22 normal hands, 18 impaired hands) were measured. Reliability of the measurement was estimated using the intraclass correlation coefficient (ICC) and the Bland and Altman method of 95% limits of agreement. Overall, the IMD method showed an ICC of 0.88 with 95% limits of agreement of -6.9 to 5.6 mm (approximately +/-6.2 mm). Similarly, for the DIMA method, the ICC was 0.47 with 95% limits of agreement of -11.9 to 5.1 degrees (approximately +/-8.5 degrees ). The IMD method appears more reliable than the conventional method, which had an ICC of 0.26 and 95% limits of agreement of -17.5 to 9.2 degrees (approximately +/-13.3 degrees ). The IMD method is recommended as a reliable method of measuring the thumb web space.

Functional significance of variation in bryophyte canopy structure

In most bryophytes, the thickness of boundary layers (i.e., unstirred layers) that surrounds plant surfaces governs rates of water loss. Architectural features of canopies that influence boundary layer thickness affect the water balance of bryophytes. Using field samples (9.3 cm diameter cushions) from 12 populations (11 species) of mosses and liverworts, we evaluated the relationship between canopy structure and boundary layer properties. Canopy structure was characterized using a contact surface probe to measure canopy depth along perpendicular transects at spatial scales ranging from 0.8 to 30 mm on 186 points per sample. Semivariance in depth measurements at different spatial scales was used to estimate three architectural properties: surface roughness (L(r)), the scale of roughness elements (S(r)), and fine-scale surface texture, the latter characterized by the fractal dimension (D) of the canopy profile. Boundary layer properties were assessed by evaporation of ethanol from samples in a wind-tunnel at wind speeds from 0.6 to 4.2 m/s and applied to characterize mass transfer using principles of dynamic similarity (i.e., using dimensionless representations of conductance and flow). In addition, particle image velocimetry (PIV) was used to visualize and quantify flow over two species. All cushions exhibited the characteristics of turbulent as opposed to laminar boundary layers, and conductance increased with surface roughness. Bryophyte canopies with higher L(r) had greater conductances at all wind speeds. Particle image velocimetry analysis verified that roughness elements interacted with flow and caused turbulent eddies to enter canopies, enhancing evaporation. All three morphological features were significantly associated with evaporation. When L(r), S(r), and D were incorporated with a flow parameter into a conductance model using multiple linear regression, the model accounted for 91% of the variation in mass transfer.

Disruption of lactogenesis by retained placental fragments

This case report describes a situation in which lack of milk production led the mother to seek help from a lactation consultant in private practice. Despite extensive breast stimulation with the baby at breast and mechanical breast expression, no milk was produced. Retained placenta was suspected by the lactation consultant. The mother was later diagnosed with placenta increta. Only when this condition was diagnosed and resolved did milk onset occur. It is important to evaluate for retained placental fragments when lactation appears to be delayed.

Towards an understanding of non-compliance. An assessment of risk factors for defaulting from leprosy treatment

Within the Eastern Leprosy Control Project of Nepal, a retrospective case control study looked for simple factors that might be used operationally to predict non-compliant behaviour in patients. Patients with these factors would then become the targets of measures such as intensified health education messages and home visits in order to reduce the risk of defaulting. A study of 1442 patient cards (half defaulters, half treatment completed) revealed occasional small but significant demographic and clinical differences, but none was of a sufficient magnitude to be operationally useful. Review of the attendance of patients in the first few months of treatment suggested that eventual defaulting was strongly associated with irregularity from the commencement of treatment. It is possible that an early indicator based on attendance over the first months can be used to target patients who are in danger of non-completion of treatment.

Echogenic intracardiac focus in 2nd-trimester fetuses with trisomy 21: usefulness as a US marker

PURPOSE

To determine whether there is a relationship between the presence of an echogenic intracardiac focus in 2nd-trimester fetuses and trisomy 21 (Down syndrome).

MATERIALS AND METHODS

A complete genetic ultrasonographic (US) scan was obtained in 3,303 consecutive fetuses with an estimated gestational age of 14.0-24.0 weeks (mean +/- SD, 17.1 weeks +/- 1.75). US was performed in a prospective fashion without any knowledge of karyotype and included assessment of any potential echogenic intracardiac focus (ie, calcified papillary muscle). Karyotypes were obtained in all fetuses. Maternal ages ranged from 13.0 to 47.4 years (mean, 35.1 years +/- 5.1). The prevalence of Down syndrome in this population was 1.6% (53 of 3,303 fetuses).

RESULTS

An echogenic intracardiac focus was seen in 147 of the 3,192 karyotypically normal fetuses (4.6%) and 16 of the 53 fetuses with trisomy 21 (30%). The positive predictive value (PPV) of an echogenic intracardiac focus in this high-risk population was 9.8%; sensitivity, 30%; specificity, 95%; likelihood ratio, 6.6; and relative risk (RR), 8.2 (P <.001). For a sonographically isolated echogenic intracardiac focus, the PPV was 3.7%; sensitivity, 19%; specificity, 95%; likelihood ratio, 4.2; and RR, 4.8 (P =.002).

CONCLUSION

A sonographically isolated echogenic intracardiac focus (no other anomalies or markers noted on a complete genetic sonogram) was associated in our high-risk population with a 4.8-fold (95% CI: 1.8, 12.5) increase in RR for trisomy 21 (P =.002).

Substrate oxidation and availability during acute exercise in non-obese, obese, and post-obese sedentary females

OBJECTIVE

This study compared fat oxidation rates during an acute bout of cycle ergometry exercise (E) typical of progressive fat oxidation in healthy, but sedentary, women of different obesity histories.

DESIGN

Five never-obese (NO) (mean age=25+/-3 (s.e.)y, mean body fat=25.0+/-2.8 (s.e.)%), five obese (O) (26+/-3 y, 44. 4+/-1.7%), and five post-obese (PO) (22+/-1 y, 32.2+/-3.0%) women cycled for 60 min at 60-65% peak VO2. To identify the specific effects of E, a control trial consisting of 60 min of seated rest (R) was also performed. E and R trials were counterbalanced one month apart in the follicular phase and conducted following a 3 d normalized, eucaloric diet.

MEASUREMENTS

Dual energy X-ray absorptiometry (DEXA) was used to determine body composition, and all were weight stable for at least eight weeks prior to experimentation. During both trials breath by breath measurements of VO2 and RER were used to determine substrate oxidation and energy expenditure. Blood samples were collected for hormone and metabolite analysis before, and every 15 min during exercise or rest.

RESULTS

All three groups showed a similar and progressive shift toward fat oxidation as exercise progressed. No group differences were observed for E energy expenditure or fat oxidation. Glycerol (P<0.0001) and free fatty acids (P<0.0001) increased similarly in all three groups, but PO maintained the highest free fatty acid level during exercise (group effect; P<0.01). E and R decreased (P<0.001 for both) insulin levels across groups, with lowest levels noted in PO and highest in O. Plasma epinephrine (P<0.0001) and norepinephrine (P<0.001) increased similarly during E in all three groups. Plasma growth hormone (GH) levels rose (P<0.05) during E, with a pronounced increase observed in PO.

CONCLUSION

We conclude that exercise of equal relative intensity elicited similar fat oxidation rates among NO, O, and PO women, despite group differences in free fatty acid availability. The PO women's persistently lower insulin and higher plasma GH levels may have enhanced free fatty acid availability.

A scale to assess activities of daily living in persons affected by leprosy

The aim of this study was to develop a scale for identifying disability among people in the rural areas of developing countries. The studies were carried out in the Green Pastures Hospital and the leprosy field programme of the Western Region of Nepal. With the help of staff experienced in working with people with disability, a 68-question questionnaire was made, based on the International Classification of Impairments, Activities and Participation (ICIDH-2). A survey was carried out of 269 people affected by leprosy who had impairments, as well as a sample of those who were unimpaired. The survey results were used to develop the questionnaire into a scale, using standard scale development methods. This included checking of criterion validity, discrimination and reliability and stability using weighted kappa statistics. Of the 68 questions, 38 were included in the second draft of the instrument. Eight questions were added to identify difficulty in relationships, about the use of aids and about occupation and employment. The sum score of the scale against the expert score gave a Spearman correlation coefficient of 0.72. Intra- and inter-interviewer reliability coefficients were 0.77 (95% CI 0.73-0.81) and 0.61 (95% CI 0.56-0.67), respectively. The stability test gave an overall kappa of 0.76 (95% CI 0.70-0.82). Four questions with particularly poor results were omitted from the final draft of the instrument. An interview-based instrument was developed for identifying limitations in activities of daily living (disability) in people living in a rural setting in a developing country--the Green Pastures Activity Scale (GPAS). The scale performed well during validity and reliability testing. It consists of 34 activity questions, five relationship questions, and three questions on the use of aids, occupation and employment.

Reliability of Semmes Weinstein monofilament and ballpoint sensory testing, and voluntary muscle testing in Bangladesh

The reliability of methods of testing nerve function is important, since diagnostic decision making is a direct function of the quality of the test. Three methods of nerve function testing were investigated at the Danish Bangladesh Leprosy Mission (DBLM) in north Bangladesh, and assessed for inter-observer reliability. The three methods were 1) ballpoint pen test (BPT) for sensory function; 2) graded Semmes Weinstein monofilament test (SWM) for sensory function and 3) voluntary muscle testing (VMT) for motor function. The weighted kappa (kappa w) statistic was used to express inter-observer reliability. Using this statistic, 0 represents agreement no better than random, and 1.0 complete agreement. kappa w values of > or = 0.80 are reckoned to be adequate for monitoring and research. Fifty-three patients were tested, a Senior physiotechnician acting as 'gold standard' against whom four other staff physiotechnicians were assessed. All three testing methods were found to have minimal inter-observer variation, with the kappa w for inter-observer agreement using BPT being 0.86, the SWM 0.92, and VMT 0.94. It is concluded that in trained and experienced hands, all three methods are reliable and repeatable to a level allowing confident use of results obtained in monitoring and research.

Verbal retelling abilities in adolescents with and without language-learning disabilities for social studies lectures

Verbal retelling abilities for social studies lectures were examined and compared in 20 adolescent boys, ages 12-5 to 14-7, with language-learning disabilities (LLD) and 29 with normal language abilities (NL). Participants viewed one videotaped social studies lecture with a comparison expository discourse structure and one with a causation discourse structure. Following each lecture presentation, participants verbally retold the lecture. Results of several repeated-measures analyses of variance indicated that the group with LLD produced a significantly smaller number of T-units, subordinate clauses, subordinate clauses per T-unit, T-units per second, lecture components per second, and percentage of lecture components in their retellings, compared with the group with NL, regardless of lecture type. Both groups produced a significantly greater number of T-units and subordinate clauses for the comparison lecture. By contrast, both groups recalled a significantly greater number of lecture components per T-unit and per second for the causation lecture. Results indicated that the comparison discourse structure facilitated more substantive and elaborate retellings, whereas the causation discourse structure facilitated more efficient, concise retellings in both groups. Research and instructional implications are discussed.

The prognostic importance of the ossific nucleus in the treatment of congenital dysplasia of the hip

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. Some investigators have suggested that the presence of the ossific nucleus of the femoral head at the time of closed or open reduction is associated with a lower rate of ischemic necrosis. This finding, if verified, could lead to a delay in the treatment of a dislocated hip until ossification of the femoral head has begun, which may be well after the age when the patient has started to walk. We conducted a computerized search of the medical records at our two tertiary-care children's hospitals to identify all patients with congenital dysplasia of the hip who had had a closed or open reduction between January 1, 1979, and December 31, 1993. One hundred and twenty-four patients (153 hips) who satisfied the criteria for inclusion were identified. The ossific nucleus was present in ninety hips and absent in sixty-three. Closed reduction was used in 112 hips and open reduction, in forty-one. Ischemic necrosis was identified in five hips (3 percent): four (6 percent) of the sixty-three hips that did not have an ossific nucleus and one (1 percent) of the ninety hips that had an ossific nucleus at the time of the reduction. With the numbers available for study, we could not detect a difference between these two groups. The age at reduction (p > 0.99), the method of reduction (p = 0.611), previous treatment with a Pavlik harness (p = 0.592), the use of preliminary traction (p = 0.602), concomitant procedures (p > 0.99), and a failure of the primary closed reduction (p = 0.579) were not associated with the development of ischemic necrosis after reduction. In our analysis of patients who were managed over a fifteen-year period, the data did not support the hypothesis that the presence of an ossific nucleus at the time of reduction of a congenitally dislocated hip is associated with a lower prevalence of ischemic necrosis of the femoral head. Sound operative principles dictate that operative reduction of a congenitally displaced hip should be performed when the child can be safely placed under anesthesia and without regard to the presence or absence of the ossific nucleus.

Intertester reliability of manual muscle strength testing in leprosy patients

This study reports the results of a study on the intertester reliability of manual muscle strength testing in leprosy patients with confirmed motor function loss of at least one nerve. Three testers graded the muscle strength of 72 patients in random order. Both hands and feet were graded. Strength was graded on a modified Medical Research Council Scale (9 points, 5, 4+, 4, 3+, 3, 2+, 2, 1, 0). The following movements were tested for strength: little finger and index finger abduction, intrinsic position of all four fingers, thumb abduction and opposition, foot dorsiflexion and eversion and extension of the big toe. The weighted kappa statistic was used to calculate the chance-corrected percentage of agreement between observers. Overall agreement for each of the 11 tests appeared to be good or very good (0.61-1.00). However, when data for hands or feet with normal strength or complete paralysis were excluded from the analysis, the reliability of the remaining mid-range scale was not acceptable (kappa 0.55-0.88, direct agreement range 11-41%). While the reliability of this scale could possibly be improved by special training, we feel that, for the evaluation of nerve function for leprosy patients with (suspected) nerve function loss, the extended 9-point VMT scale should only be used when direct intra- or intertester agreement is more than 80%.

Reliability and validity of a macronutrient self-selection paradigm and a food preference questionnaire

Our laboratory has developed a macronutrient self-selection paradigm (MSSP) designed to vary fat content significantly and systematically with sugar, complex carbohydrates, and protein content in a battery of foods in which fat is commonly consumed in the American diet. We have also developed a food preference questionnaire (FPQ) according to an identical design but using a list of foods mutually exclusive of those presented for selection and intake in the MSSP. Men were tested twice on both instruments, with a 4-week interval between tests. It was determined that the MSSP has strong test-retest reliability for overall fat (r = 0.91) and other macronutrient intake and total caloric intake. In addition, hunger and fullness ratings were reproducible, and fat preferences (r = 0.99) and hedonic responses to foods listed on the FPQ were highly consistent across trials. This study also demonstrated that the MSSP is a valid instrument with respect to the men's reports of habitual intake of fat (r = 0.80) and total carbohydrates on the Block food questionnaire (FQ). In addition, men's fat preferences on the FPQ were validated with respect to overall fat (r = 0.86) and total caloric intake in the MSSP and fat intake (r = 0.83) reported on the Block FQ. The MSSP also has the capability to detect a wide range of fat intake (3.06-50.35% among the present subjects), indicating that this instrument can identify individuals who differ markedly in fat intake or could detect changes in fat preference within subjects. In addition, this paradigm detected a large range of sugar and total caloric intake. It is anticipated that the use of these laboratory tools can enhance our understanding of the relationship between dietary fat intake and obesity.

Responses of captive and free-ranging coyotes to simulated oral rabies vaccine baits

The objective of this study was to develop a bait for delivering an oral rabies vaccine to free-ranging coyotes (Canis latrans) in southern Texas. Captive trials were conducted from January to April, 1994, to determine bait preferences and behavioral responses of coyotes (n = 42) to selected baits and attractants. Baits were hollow rectangular cubes made of polymer dog food or fish meal. Attractants had sweet (watermelon), fruity (raspberry), sulfurous (synthetic WU), and lard (beef lard) fragrances. Captive coyotes did not exhibit a preference for either bait bases or attractants; however, coyotes chewed dog food baits 1.6 times more than fish meal baits. Average proximity of coyotes eliciting a response to baits was 2.2 +/- 1.3 m (mean +/- SE). Captive coyotes readily accepted dog food baits containing 2 ml of liquid rhodamine B, a biological marker. Rhodamine B staining of the oropharyngeal region was evident in each captive coyote. Results from the field evaluation of baits and attractants were consistent with that of the captive trials. Of 2,070 bait station-nights conducted from February to April, 1994, coyotes comprised the greatest single species visitation and uptake rates with 31% and 28%, respectively. Bait uptake rates of free-ranging coyotes did not differ among bait-attractant combinations. Coyotes took baits 93% of the time they encountered a bait, regardless of bait type.

Ocular impairments in an impairment survey of leprosy-affected persons in Nepal

An impairment survey was carried out in Nepal. The study subjects (n = 318) were a mixture of out-patients and patients admitted less than one month before the survey. Of the subjects, 101 were attending the hospital out-patients clinic or were admitted and the rest were examined in the field. The patients studied included those on MDT and care-after-cure cases. Ocular impairments were found in 25% of these cases. The most common ocular impairment was poor vision followed by lagophthalmos and insensitive cornea.

Listening comprehension and recall abilities in adolescents with language-learning disabilities and without disabilities for social studies lectures

Listening comprehension and recall abilities for social studies lectures were examined and compared in 20 adolescent males with language-learning disabilities (LLD) and 29 without disabilities (WD). Subjects viewed two social studies lectures with comparison and causation expository discourse structures and verbally responded to literal and inferential comprehension questions. Regardless of lecture type or question type, the group with LLD performed significantly more poorly than did the group WD. Both groups responded accurately to significantly more inferential questions for the causation lecture over the comparison lecture. Neither group demonstrated a significant difference with respect to their response accuracy for the literal questions across lecture types.

Impairment and disability in leprosy: in search of the missing link

This paper describes the results of a survey aimed at studying the relationship between impairment and disability in leprosy. Persons affected by leprosy attending the Green Pastures Hospital, Pokhara, or one of the field clinics in the Western Region of Nepal visited during the study period were interviewed using a standardized questionnaire. Two hundred and sixty-nine subjects were included in the study. For the analysis, 'disability', was defined as activities being done with 'much difficulty', 'only with help' or being 'impossible'. The most commonly affected indoor activities were cutting nails (22%), washing clothes (16%), using scissors (17%) and tying a knot (18%). Among the outdoor activities, cutting grass, digging, harvesting, threshing and milking a cow or buffalo were the most commonly affected (22%-26%). Sensory impairment of the thumb and/or index finger at the 2 g level was a very significant risk factor for disability activities involving the hand(s). Muscle weakness of the thumb and mobile clawing of the fingers had a strong association with disability in several activities. Sensory impairment of the sole was the strongest determinant of disability in activities involving the lower limb. We recommend that efforts should be made to include disability as a standard activity for monitoring and evaluation of rehabilitation, both for individuals and on programme level.

Nutrient intake patterns, body mass index, and vitamin levels in patients with rheumatoid arthritis

OBJECTIVE

To assess nutrient intakes and vitamin levels in 79 patients with rheumatoid arthritis participating in a trial and to determine whether changes in body mass index were associated with changes in disease activity.

METHODS

This study evaluated baseline vitamin levels, 1-day dietary intakes, and weight every 3 months for 1 year. Linear regression analysis was used to evaluate the relationship of time to body mass index. Analysis of covariance was used to determine if body mass index, time, or treatment had an effect on disease activity.

RESULTS

Deficient vitamin levels and poor nutrient intake patterns were prevalent in the study population. Changes in body mass index over time did not correlate with changes in disease activity.

CONCLUSIONS

Rheumatoid arthritis patients are at high risk of obesity, abnormal vitamin levels, and poor nutrient intakes. Changes in body mass index failed to correlate with changes in disease activity.

Disqualifying family communication and childhood social competence as predictors of offspring's mental health and hospitalization. A 10- to 14-year longitudinal study of children at risk of psychopathology

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents had been hospitalized for a functional psychiatric disorder before initial assessment and, second, the male index offspring should be 18 years or older at follow-up. Initial measures included observationally based coding of the family's level of disqualifying communication toward the index offspring, index child's scores on the Child Manifest Anxiety Scale, and ratings of the index child's social competence carried out by peers, teachers, and parents. Offspring outcome was measured by the Mental Health Inventory, Global Assessment Scale (GAS), and hospitalization for psychiatric disorder. The results showed that every measure of offspring outcome was predicted by the amount of disqualification directed to the offspring from the other family members. In addition, GAS score and mental health were predicted by the offspring's competence as a child. Family disqualification, childhood competence, and socioeconomic status accounted for 63% of the variance in adult GAS scores.

The father-infant relationship: becoming connected

PURPOSE

To explore fathers' experiences of developing a relationship with their infants during the infant's first 2 months of life

DESIGN

Grounded theory approach

SETTING

Fathers' homes or other mutually agreed-upon site

PARTICIPANTS

First-time fathers (N = 14), ages 28-44, Caucasian, middle class

MAIN OUTCOME MEASURES

Tape-recorded semistructured interviews to elicit fathers' perceptions of their fathering selves, their infants, and the father-infant relationship.

RESULTS

Using constant comparative method for analysis, three major categories were identified as operative in the initial development of the father-infant relationship: (a) making a commitment, (b) becoming connected, and (c) making room for the baby

CONCLUSIONS

With an increased understanding of the father-infant relationship, nurses can provide humanistic, thoughtful care to assist fathers in developing this significant relationship.

Confirmatory and disconfirmatory family communication as predictor of offspring socio-emotional functioning. A 10 to 14 year follow-up of children at risk

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents should have been hospitalized for a functional psychiatric disorder before initial assessment and the male index offspring should be 18 years or older at follow-up. Family communication was observed by the Consensus Rorschach procedure and coded with the Confirmation-Disconfirmation Coding System. Offspring childhood social competence was rated by peers, teachers and parents. Outcome measures included the Denver Community Mental Health Questionnaire, the Global Assessment Scale and hospitalization for a psychiatric disorder. Results showed that the family's level of confirmation and disconfirmation communication during Consensus Rorschach at initial testing predicted offspring interpersonal functioning and hospitalization for psychiatric disorders. These findings were not due to the initial social competence or IQ of the child, the level of functional impairment in parents or their social class.

A novel sustained-release formulation of ibuprofen provides effective once-daily therapy in the treatment of rheumatoid arthritis and osteoarthritis

The efficacy and safety of a novel sustained-release formulation of ibuprofen given once-daily was compared with conventional-release ibuprofen tablets 400 mg given four times daily, in a single-blind, parallel-group study. This study was conducted at 84 general practice centres throughout the UK among patients with osteoarthritis or rheumatoid arthritis. An unequal randomisation in the ratio of 4:1 was carried out, with 463 patients who received sustained-release and 115 who received conventional-release ibuprofen providing evaluable data. In this study sustained-release ibuprofen was shown to be a more effective alternative to conventional ibuprofen therapy for the treatment of arthritic diseases in general practice, offering the convenience of once-daily dosing and the associated potential benefit of improved patient compliance.

A CHO cell line resistant to deoxycholic acid

Spontaneous mutants resistant to deoxycholic acid (DCA) have been selected from a CHO cell line AuxBl. One of the colonies or 'lines' selected was subsequently mutagenized by ethylmethanesulfonate (250 micrograms/ml) and a more resistant cell, named alpha 3, has been selected. When AuxBl and alpha 3 were exposed to graded concentrations of DCA for 1 h, the LD50 for the mutant strain alpha 3 was 0.66 mM compared to 0.26 mM for the parental line. AuxBl. alpha 3 showed a cross-resistance compared to AuxBl with respect to cholic acid and chenodeoxycholic acid and to other acidic lipids such as linoleic and oleic acids. As an initial step in characterization of the cell lines, the amounts of different phospholipids from whole cell extracts of the parental and mutant strains have been measured after thin-layer chromatography (TLC) separation. The results obtained demonstrated that the fraction of sphingomyelin and phosphatidylcholine over the total phospholipids was slightly increased in the resistant cell line, alpha 3, compared to the parental line, AuxBl (54.9% +/- 1.04 compared to 51.2% +/- 0.3, P = 0.01). Further characterization of cell lines resistant to bile acids could lead to the identification of the cellular target of bile acid action.

A two-year analysis of DRG #288, procedures for obesity

DRG #288 is composed of operative procedures performed for obesity, both gastric and plastic. A two-year cost analysis of 103 consecutive gastric reduction operations performed for morbid obesity was conducted at Robert Wood Johnson University Hospital. It showed a net loss to the hospital of $18,033 in 1984 and $24,126 in 1985. Although the mean length of stay was 1.43 days less in 1985 than in 1984, DRG #288 was still a money loser. A detailed cost breakdown of nine active cost-center categories showed large financial disincentives (losses) in surgical supplies, OR/recovery room time and X ray utilization during both years of the study. These losses were not offset by substantial profits in the room-and-board category, which is directly related to length of stay. It is intuitively obvious that plastic surgical procedures for obesity require less expensive surgical supplies, fewer X rays, and shorter OR/recovery room times than gastrointestinal operations performed for morbid obesity. We conclude that DRG #288 is improperly constructed because it contains a clinically incoherent, heterogeneous mixture of operations that cannot be expected to consume similar amounts of resources and incur similar costs. Hospitals in which the preponderance of operations performed for obesity are gastrointestinal as opposed to plastic are inherently penalized by the current aggregation of DRG #288.

Cellular toxicity of fecal water depends on diet

To determine whether concentrations of potentially toxic lipids in the aqueous phase of human stool are responsive to changes in dietary fat, calcium, and fiber, 20 male volunteers were placed on a high-fat, low-calcium, low-fiber or a low-fat, high-calcium, high-fiber diet for 4 days. To assess toxicity of the fecal fractions, we examined the ability of fecal supernatants to lyse human erythrocytes. Bile acid concentrations in fecal water from the low-fat group were reduced significantly from 180 +/- 60 microM to 100 +/- 70 microM; in the high-fat group, increased from 190 +/- 60 microM to 250 +/- 100 microM. Erythrocyte lysis was 76% for the high-fat group, 37% for the low-fat group. There was a significant weak correlation between aqueous bile acid concentration and cell lysis. Results suggest that diet can influence concentrations of detergents in the aqueous phase of human stool and the potential toxicity of this fraction to cell membranes.

Collagen types present at human fracture sites--a preliminary report

Collagen has been examined from normally and abnormally healing fractures. A higher proportion of type III collagen than was expected was found in abnormally healing fractures. Very little is known about collagen synthesis in healing fractures and how it is altered in abnormal healing states such as delayed and non-union.