'When the bedbugs come, that's another problem': exploring the lived experiences of bedbug infestations among low-income older adults and service providers who support them

AIMS

Older adults in low-income housing communities are more vulnerable to bedbug infestations. Prior research, however, has predominately focused on the effectiveness of integrated pest-management strategies, with little attention given to the lived experiences of tenants struggling with infestations. We used a qualitative approach to explore what it is like to live with and treat bedbug infestations from the perspectives of low-income older adults and service providers.

METHODS

Participants included low-income older adults (n = 58) and service providers (n = 58) who offer supports directly in the buildings. Semi-structured qualitative interviews and focus groups were used to explore the challenges of preparing and treating units for bedbugs, and examine how bedbugs impact access to support services.

RESULTS

Bedbugs were a widespread issue, and underlying physical, mental, social, and financial challenges made it difficult for older tenants to prepare their units and access treatment. Tenants also faced bedbug stigma from community services, as many were unwilling to provide services in infested units. Although some service providers utilized strategies to minimize exposure, many were concerned these strategies created additional stigma.

CONCLUSION

Our findings highlight an urgent need to increase public health funding to support older adults with the costs of bedbug elimination and to enhance pest-management strategies through partnerships with health and social service agencies to improve outcomes for older adults.

Multicenter review of a tadalafil suspension formulation in infants and children with pulmonary hypertension: a north american experience

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary arterial hypertension (PAH) is a disease characterised by an increase in pulmonary vascular resistance and pulmonary artery pressure. Phosphodiesterase type 5 (PDE5) inhibitors, with sildenafil the earliest among them, are widely used in the management of pediatric PAH. There has more recently been a transition to once-daily tadalafil suspensions. Herein, we present a multicenter experience detailing safety, tolerability and haemodynamic data utilizing tadalafil suspension alone or in combination for the management of pediatric PAH.

Methods and materials

We performed a retrospective review of all infants and children at two North American paediatric PH centres between December 2013 and April 2022. We included all patients less than 9 years of age who were treated with a tadalafil suspension after an initial treatment with sildenafil. Demographic, clinical, imaging, and laboratory data were collected.

Results

Over the study period, 158 children were treated with tadalafil therapy: 41 (25.9%) had group 1 PAH, 81 (51.3%) had group 3 PH, and 33 (20.9%) had group 5 PH. The median initial dose of tadalafil was 1.0 mg/kg once daily with a median time to maximum dose of 1 day. The majority of patients required the suspension formulation due to an inability to take oral tablets or the need for nasogastric or nasojejunal feeding. We observed improvements in median echocardiographic parameters in the six months following initiation, namely, in RVFAC from 34.7% (Q1 = 31.0%, Q3 = 42.0%) to 37.0% (Q1 = 31.0%, Q3 = 44.0%) and in TAPSE from 1.0 (Q1 = 0.8, Q3 = 1.7) cm to 1.3 (Q1 = 1.0, Q3 = 1.7) cm. We observed median decreases in RVSp from 51.0 (Q1 = 35.0, Q3 = 69.0) mmHg to 37.0 (Q1 = 30.0, Q3 = 50.0) mmHg and in NT pro BNP levels from 439.0 (Q1 = 217.0, Q3 = 2051.0) ng/L to 313.0 (Q1 = 193.0, Q3 = 1110.0) ng/L. Tadalafil therapy was well tolerated over the six-month period: at baseline, only four patients (2.5%) reported gastrointestinal side effects, two (1.3%) reported adverse skin adverse effects (i.e., rash and flushing), and one (0.6%) reported adverse neurological effects. At six months, 150 patients (94.9%) reported no adverse effects.

Conclusion

Tadalafil, a long-acting PDE5 inhibitor, when administered in a suspension formulation, has a safe and tolerable adverse effect profile once patients are established on sildenafil therapy. Following 6 months of once daily tadalafil suspension, alone or in combination, showed a trend towards improvement in clinical parameters, echocardiographic measurements, and laboratory results for pediatric PAH. All patient adverse effects were managed with non pharmacological measures and there was good patient compliance.

International links between Streptococcus pneumoniae vaccine serotype 4 sequence type (ST) 801 in Northern European shipyard outbreaks of invasive pneumococcal disease

BACKGROUND

Pneumococcal disease outbreaks of vaccine preventable serotype 4 sequence type (ST)801 in shipyards have been reported in several countries. We aimed to use genomics to establish any international links between them.

METHODS

Sequence data from ST801-related outbreak isolates from Norway (n = 17), Finland (n = 11) and Northern Ireland (n = 2) were combined with invasive pneumococcal disease surveillance from the respective countries, and ST801-related genomes from an international collection (n = 41 of > 40,000), totalling 106 genomes. Raw data were mapped and recombination excluded before phylogenetic dating.

RESULTS

Outbreak isolates were relatively diverse, with up to 100 SNPs (single nucleotide polymorphisms) and a common ancestor estimated around the year 2000. However, 19 Norwegian and Finnish isolates were nearly indistinguishable (0-2 SNPs) with the common ancestor dated around 2017.

CONCLUSION

The total diversity of ST801 within the outbreaks could not be explained by recent transmission alone, suggesting that harsh environmental and associated living conditions reported in the shipyards may facilitate invasion of colonising pneumococci. However, near identical strains in the Norwegian and Finnish outbreaks does suggest that transmission between international shipyards also contributed to those outbreaks. This indicates the need for improved preventative measures in this working population including pneumococcal vaccination.

The use of next-generation sequencing for the determination of rare blood group genotypes

OBJECTIVES

Next-generation sequencing (NGS) for the determination of rare blood group genotypes was tested in 72 individuals from different ethnicities.

BACKGROUND

Traditional serological-based antigen detection methods, as well as genotyping based on specific single nucleotide polymorphisms (SNPs) or single nucleotide variants (SNVs), are limited to detecting only a limited number of known antigens or alleles. NGS methods do not have this limitation.

METHODS

NGS using Ion torrent Personal Genome Machine (PGM) was performed with a customised Ampliseq panel targeting 15 different blood group systems on 72 blood donors of various ethnicities (Caucasian, Hispanic, Asian, Middle Eastern and Black).

RESULTS

Blood group genotypes for 70 of 72 samples could be obtained for 15 blood group systems in one step using the NGS assay and, for common SNPs, are consistent with previously determined genotypes using commercial SNP assays. However, particularly for the Kidd, Duffy and Lutheran blood group systems, several SNVs were detected by the NGS assay that revealed additional coding information compared to other methods. Furthermore, the NGS assay allowed for the detection of genotypes related to VEL, Knops, Gerbich, Globoside, P1PK and Landsteiner-Wiener blood group systems.

CONCLUSIONS

The NGS assay enables a comprehensive genotype analysis of many blood group systems and is capable of detecting common and rare alleles, including alleles not currently detected by commercial assays.

Dysregulation of methionine metabolism in multiple sclerosis

We report a significant reduction in plasma methionine concentrations in relapse remitting multiple sclerosis (MS) patients compared to controls. In vivo studies demonstrate that changes in peripheral methionine levels in mice can regulate histone H3 methylation and expression of DNA methyltransferase 3A (DNMT3A) centrally, in the cerebral cortex. Therefore, we propose that decreases in circulating methionine represent one of the earliest manifestations of dysregulated methionine metabolism in MS with potential impacts on both histone H3 and DNA methylation in the central nervous system.

Search Strategies Used by Process Operatives in Continuous-Flow Technology: Performance and Learning

Observation was made of 12 process operatives during 96 hr. on a continuous process for electrolytic treatment of steel. Results allowed decision points to be specified and flow charts to be devised for operatives' tasks. The content analysis was accompanied by an examination of the frequency distribution of job activities, giving a comparison of numbers of interpersonal, intra-team activities to man-machine activities and testing the possibility of consistent patterns. The findings suggest an approach to training, with emphasis on the similarity between maintenance, repair and process monitoring tasks.

Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

BACKGROUND

Socioeconomic deprivation is known to influence the presentation of patients with breast cancer and their subsequent treatments, but its relationship with surgical outcomes has not been investigated. A national prospective cohort study was undertaken to examine the effect of deprivation on the outcomes of mastectomy with or without immediate breast reconstruction.

METHODS

Data were collected on patient case mix, operative procedures and inpatient complications following mastectomy with or without immediate breast reconstruction in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between patients' level of (regional) deprivation and the likelihood of local (mastectomy site, flap, flap donor and implant) and distant or systemic complications, after adjusting for potential confounding factors.

RESULTS

Of 13,689 patients who had a mastectomy, 2849 (20.8 per cent) underwent immediate reconstruction. In total, 1819 women (13.3 per cent) experienced inpatient complications. The proportion with complications increased from 11.2 per cent among the least deprived quintile (Q1) to 16.1 per cent in the most deprived (Q5). Complication rates were higher among smokers, the obese and those with poorer performance status, but were not affected by age, tumour type or Nottingham Prognostic Index. Adjustment for patient-related factors only marginally reduced the association between deprivation and complication incidence, to 11.4 per cent in Q1 and 15.4 per cent in Q5. Further adjustment for length of hospital stay, hospital case volume and immediate reconstruction rate had minimal effect.

CONCLUSION

Rates of postoperative complications after mastectomy and breast reconstruction surgery were higher among women from more deprived backgrounds.

Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics

OBJECTIVES

To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts.

DESIGN

Cohort study using patient level data from hospital episode statistics.

SETTING

English NHS trusts.

PARTICIPANTS

Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008.

MAIN OUTCOME MEASURE

Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery.

RESULTS

55,297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11,032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10,212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45,793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%).

CONCLUSION

One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

Family health services authorities and community pharmacists at the purchaser-provider interface

The views of both purchasers (family health services authorities [FHSAs]) and providers (community pharmacists) were sought on the development of community pharmaceutical services in the light of the 1992 pharmaceutical care report. Questionnaires were posted to the 480 pharmacists in charge of all community pharmacies in Wessex and to the 98 general managers of FHSAs in England and Wales. The questionnaires focused on reactions to those recommendations of the pharmaceutical care report which, if implemented, would have significant implications for the community pharmacist's workload. Both the FHSAs and community pharmacists indicated that, in their view, the skills of the community pharmacist are currently underutilised. Both groups expressed enthusiasm for the pharmaceutical care report recommendations that the following services should be provided: domiciliary services, disposal of unwanted medicines, supply of aids for disabled people, supply of compliance aids and adverse drug reaction reporting. Neither group was enthusiastic about pharmacists providing a therapeutic drug monitoring service from community pharmacies. On other areas, pharmacists were more enthusiastic about the provision of health advice, diagnostic/screening services and treatment protocols, while FHSAs favoured distribution of welfare foods, needle exchange, instalment dispensing and referral forms.

Overall, both the FHSAs and community pharmacists were receptive to the principle of the development of the role of the community pharmacist within the primary health care team but expressed concerns regarding the training and workload implications.

Tolerability and safety of novel half milliliter formulation of glatiramer acetate for subcutaneous injection: an open-label, multicenter, randomized comparative study

Daily glatiramer acetate (GA) 20 mg/1.0 mL is a first-line treatment for relapsing-remitting multiple sclerosis (RRMS). To reduce the occurrence of injection pain and local injection site reactions (LISRs), a reduced volume formulation of GA was developed. This study compared pain and LISRs after injecting the marketed and the novel formulations. RRMS patients currently injecting GA participated in this multicenter, randomized, crossover comparative study. All patients administered once-daily subcutaneous injections of GA 20 mg/1.0 mL (marketed formulation) or GA 20 mg/0.5 mL (reduced volume formulation) for 14 days. Patients were crossed-over to the alternate treatment for an additional 14 days. Using a Visual Analog Scale (VAS), patients recorded in daily diaries the severity of injection pain immediately and 5 min post-injection, and the presence and severity of LISRs (swelling, redness, itching, lump) within 5 min and 24 h post-injection. VAS pain scores were ranked significantly lower immediately and 5 min after GA 20 mg/0.5 mL injections (p < 0.0001). Although LISRs were rare for both preparations, the severity of reactions ranked significantly lower and fewer symptoms occurred within 5 min and 24 h of using the reduced volume formulation (p < 0.0001). GA injected subcutaneously in a reduced volume formulation is a more tolerable option.

Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England

AIMS

English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment.

METHODS

We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation.

RESULTS

Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p<0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p<0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction.

CONCLUSIONS

There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.

An in situ and in vitro investigation for the transglutaminase potential in tissue engineering

Transglutaminases (TGases) constitute a family of enzymes that stabilize protein assemblies by gamma-glutamyl-epsilon-lysine crosslinks. The role of tissue transglutaminase (TGase 2) in several pathophysiologies, wound healing applications, biomaterials functionalization, and drug delivery systems provides grounds for its use in tissue engineering. Herein, we initially studied the endogenous TGase activity and expression under normal (skin, duodenum, colon, and small bowel) and pathophysiological (keloid scar) conditions on cadaveric human tissues. Successful inhibition was achieved using low concentrations of BOC-DON-QIV-OMe (0.1 mM and 1 mM for normal skin and keloid scar, respectively), iodoacetamide (0.1 mM and 1 mM for normal skin and keloid scar, respectively), and cystamine dihydrochloride (1 mM and 10 mM for normal skin and keloid scar, respectively), whilst di-BOC-cystamine was found ineffective even at 100 mM concentration. Secondly, the addition of exogenous guinea pig liver transglutaminase (gpTGase) onto the inhibited tissues and collagen scaffolds was studied, and results presented advocate its use as potential tissue adhesive and drug delivery tool. However, the investigation of its crosslinking extent using second harmonic generation microscopy and differentially scanning calorimetry revealed rather poor stabilization function. Overall, our study indicates that TGase 2 has a role as a biological glue to consolidate various micro-structural components of tissues and biomaterials.

The clinical and public health value of non-culture methods in the investigation of a cluster of unexplained pneumonia cases

During 2003, a cluster of initially unexplained pneumonia cases (two fatal) occurred in patients aged <50 years in a British city. Routine culture tests were inconclusive, however, pneumococcal infection was suspected and the putative outbreak was investigated using non-culture methods. Clinical samples from ten patients were tested by pneumococcal polymerase chain reaction (PCR) and multi-locus sequence typing (MLST), or Binax NOW pneumococcal urine antigen test and serotype-specific enzyme-linked immunosorbent assay (ELISA). Lung samples from the deceased patients were PCR positive and yielded different MLST types. Two patients in one family group were serotype 1 pneumococcal antigen positive. Two further patients were serotype 1 antigen positive, and one serotype 4 positive. Two antigen-positive cases were also serum PCR positive. Non-culture methods confirmed the disease aetiology in six cases. Serotype and MLST results showed no single outbreak, but a family cluster of cases in a high background of pneumococcal pneumonia, providing important epidemiological data that would not otherwise have been available.

Emergence of a fluoroquinolone-resistant strain of Streptococcus pneumoniae in England

OBJECTIVE

To determine the epidemiological relationship between pneumococci of serotype 9V, with reduced susceptibility to ciprofloxacin, penicillin and erythromycin, referred to the Reference Laboratory during 1997-2001.

METHODS

Isolates were characterized by multilocus sequence typing (MLST), PFGE, and sequencing of parC and gyrA. Relevant clinical data were sought.

RESULTS

Forty-eight isolates were received from nine laboratories in England, but 35 (73%) were from one laboratory in Birmingham, and were mostly from elderly patients receiving ofloxacin or ciprofloxacin for respiratory infections. There were two quinolone resistance phenotypes, with ciprofloxacin, moxifloxacin and gemifloxacin MICs of 8-32, 0.5-1 and 0.125-0.25 mg/L, and 64-256, 4-16 and 1-4 mg/L, respectively. Each of three isolates from the former group had mutations in parC, whereas each of nine isolates from the more resistant group had mutations in both parC and gyrA. Several also had increased quinolone efflux. Typing of 27 quinolone-resistant isolates showed that eight were indistinguishable from the epidemic Spain9V-3 (ST156) clone, while the remainder belonged to a novel but related type (ST609), that differed from Spain9V-3 at 2/7 alleles (2 bp changes in aroE and 1 bp change in gdh). Both MLST types were represented among isolates with high- and low-level quinolone resistance. Three of five serotype 9V isolates from Birmingham, with reduced susceptibility to penicillin and erythromycin, and ciprofloxacin MICs of 1-2 mg/L, belonged to MLST type ST609, while another was indistinguishable from the Spain9V-3 clone. Review of records of 32 patients from Birmingham indicated that some isolates were nosocomial, whereas others were acquired in the community.

CONCLUSIONS

In the late 1990s, a quinolone-resistant strain, clonally related to Spain9V-3, emerged in England, principally in Birmingham.

Diagnosis of invasive pneumococcal infection by PCR amplification of Streptococcus pneumoniae genomic fragments in blood: a multi-centre comparative study

The increasing interest in the prevention of pneumococcal disease by immunisation necessitates improved organism-specific surveillance. This is particularly the case with regard to the contribution of Streptococcus pneumoniae infection to community-acquired pneumonia where blood cultures are often negative and sputum culture results ambiguous. Examination by PCR of blood samples taken at hospital admission offers one possibility for such improvement. The sensitivity, specificity and convenience of three pneumolysin gene PCR assays were compared in a large study, using EDTA blood from 175 patients (95 with proven pneumococcal bacteraemia, 80 with bacteraemia due to other organisms). The assays used were a PCR-enzyme immunoassay, a hybridisation probe assay run on the Roche LightCycler and a hydrolysis probe (TaqMan) assay run on an ABI 7700. Overall samples from only 57% of patients with bacteraemic pneumococcal infection yielded a positive result in at least one assay. Individual sensitivities ranged from 45% (TaqMan/ABI) through 35% (PCR-EIA) to 21% (Hybridisation/LightCycler). Specificity (PCR negative in the 80 control patients) ranged from 97-100%. The TaqMan/ABI assay was run in two centres and concordance between results was 91.4%, discrepancies being associated with very weakly positive samples. Overall, the TaqMan/ABI was the most sensitive and convenient assay; however, this method does not appear to offer any significant improvement over conventional blood cultures and is unlikely to be sufficiently sensitive to confirm a pneumococcal aetiology for non-bacteraemic pneumococcal pneumonia. For the present, therefore, blood culture is the preferred option.

The main issues affecting coasts of the Indian and western Pacific Oceans: a meta-analysis from Seas at the Millennium

A review of the world oceans in three volumes by 365 scientists, provides scope for several 'meta-analyses' of the main problems affecting over 100 areas in the year 2000. This article summarises the main issues affecting a sub-set of the reviewed areas, covering Asian, African and Arabian countries dealt with in Volume 2, which included over 50 articles. From all issues raised, assessment is made of the nature of the major ones, including evaluation of reasons why so many of them remain important issues after so much attention to them. These include long standing problems, several problems more newly flagged as becoming particularly important, the issue of global warming and no less than three related issues connected with fishing and over exploitation. One or two issues such as industrial pollution and sewage, previously considered of almost universal concern, almost traditional pollution issues even, continue to feature strongly for some countries, but while these were almost always referred to in Seas chapters, by and large these categories appear not to be the most pressing of issues today, except in localized areas (albeit areas where huge numbers of people live). Perhaps other issues have simply taken over. They are excluded from this article.

Endothelium-derived nitric oxide synthase protein expression in ovine placental arteries

During the third trimester, fetoplacental and uterine blood flows increase dramatically to meet the high metabolic demands of the growing fetus. We hypothesized that the expression of endothelial nitric oxide synthase (eNOS) in fetoplacental artery endothelium and the concentrations of nitric oxide (NO) and cyclic GMP (cGMP) in amniotic fluid (AF) are increased during the third trimester of ovine gestation. Placental arteries and AF were collected from ewes at 110, 120, 130, and 142 days of gestation (n = 24; mean +/- SEM term = 145 +/- 3 days). Expression of eNOS protein was measured in intact and denuded placental arteries and in endothelium-derived protein by Western analysis and confirmed by immunohistochemistry. Concentrations of NO (nitrates plus nitrites) and cGMP were determined in AF. Placental artery eNOS protein expression was localized to the endothelium, where it was markedly greater than in vascular smooth muscle. Placental artery endothelium-derived eNOS expression and AF cGMP concentrations were similar at 110 and 120 days of gestation; however, both peaked at 130 days at levels two- to threefold above baseline (P < 0.05) before returning to baseline at 142 days of pregnancy. The AF NO (nitrates plus nitrites) levels, however, increased progressively between 120 days of gestation and term (P < 0.05). We concluded that endothelium-derived placental artery eNOS levels, AF NO (nitrates plus nitrites), and AF cGMP were markedly increased during the third trimester, thus supporting a role for NO-mediated elevations in cGMP in the control of fetoplacental blood flow.

Coral reefs: beyond mortality?

The scale of the collapse of coral reef communities in 1998 following a warming episode (Wilkinson, 2000) was unprecedented, and took many people by surprise. The Indian Ocean was the worst affected with a coral mortality over 75% in many areas such as the Chagos Archipelago (Sheppard, 1999), Seychelles (Spencer et al., 2000) and Maldives (McClanahan, 2000). Several other locations were affected at least as much, with mortality reaching 100% (to the nearest whole number); this is being compiled by various authors (e.g., CORDIO, in press). For example, in the Arabian Gulf, coral mortality is almost total across many large areas of shallow water (Sheppard, unpublished; D. George and D. John, personal communication). The mortality is patchy of course, depending on currents, location inside or outside lagoons, etc., but it is now possible to swim for over 200 m and see not one remaining living coral or soft coral on some previously rich reefs.

Development and evaluation of an antibody capture ELISA for detection of IgG to Epstein-Barr virus in oral fluid samples

The development of an EBV IgG antibody capture ELISA (GACELISA) for detection of EBV viral capsid antigen specific IgG in oral fluids is described. The assay was optimised and evaluated using paired serum and oral fluid samples from healthy laboratory staff (n=82) and oral fluids collected either for routine measles, mumps, and rubella testing (n=629) or for an epidemiological study of atopic dermatitis (n=252). Statistical analysis by mixture modelling was used to determine the GACELISA cut-off and to estimate the sensitivity and specificity of the assay. Sensitivity and specificity was also assessed by comparing the results of immunofluorescence assay for EBV specific IgG in serum with those of GACELISA in 82 matching oral fluids. Compared to serum immunofluorescence assay, oral fluid GACELISA was found to have a sensitivity of 82.2 and 88.9% specificity with these samples. Mixture modelling, predicted the GACELISA to be 88.4% sensitive and of 99.4% specific. The prevalence of antibody to EBV in oral fluids was found to be 73.8% in laboratory staff, 34.4--73.9% in measles, mumps, and rubella patients and 22.2% in atopic dermatitis study participants. A robust, reliable and reproducible EBV GACELISA has been developed which will be a useful tool for epidemiological investigations.

Ultrasonography for the diagnosis of diseases of the tendon and tendon sheath of the biceps brachii muscle

OBJECTIVE

To describe the ultrasonographic appearance of the normal and diseased biceps brachii tendon and its tendon sheath in dogs.

STUDY DESIGN

A prospective clinical study.

ANIMALS

One hundred twenty client-owned dogs.

METHODS

In the first part of the study, the ultrasonographic appearance of the normal biceps brachii muscle and the surrounding soft tissue was determined in 27 healthy dogs. Standard views were described and established. In the second part, 120 dogs with suspected pathology of the biceps brachii muscle were examined ultrasonographically. Fifty-five of these dogs had no sonographic changes, and 65 dogs had sonographically detectable pathologic changes of the tendon or the tendon sheath or both. The mean age of the affected dogs was 3.7 years. The ratio of males to females was 1.95:1. Sedation or anesthesia of the dogs was required because of the extreme movements of the leg necessary for the examination. To achieve a perpendicular view of the tendon and the tendon sheath, the area of the shoulder joint was rotated outward and abducted as far as possible. Examination of the muscle-tendon apparatus of the biceps brachii muscle was divided into 4 main sections.

RESULTS

Linear transducers (7.5-10 MHz) allowed the soft tissue structures to be easily visualized with ultrasonography. Pathologic changes of the tendon and tendon sheath were visualized sonographically by using high-frequency linear probes. Partial or complete tendon rupture, medial luxation of the tendon, corpora libera in the tendon sheath, and tenosynovitis were clearly shown.

CONCLUSIONS

High-frequency ultrasonography using linear transducers allows the examiner to accurately define the pathologic changes in the region of the biceps brachii tendon in dogs.

CLINICAL RELEVANCE

The use of sonography for diagnosis of disease processes of the tendon and tendon sheath of the biceps brachii muscle complements clinical and radiographic examination findings.

Sonography of the canine stifle

When diagnosing disease of the stifle in dogs ultrasonography is a good addition to clinical and radiological examination. Radiology can evaluate the bony aspects of the joint and their relationship to each other. In contrast, sonography allows visualization of the soft tissue. For most evaluations the 7.5 MHz linear scanner is suited best. Normal stifles of 58 dogs of different breeds were evaluated using a standardized examination procedure. This procedure had been derived from that used in humans. The stifle is divided into several regions which are examined and evaluated. These are the suprapatellar, infrapatellar, lateral, caudal and medial region. One hundred twenty seven patients which had problems associated with the stifle joint were examined sonographically after a clinical and radiographic exam. Osteochondrosis dissecans, ruptured cranial cruciate ligament, meniscal damage, arthritis, tumor, post surgical conditions, injuries of the patella, patellar ligament or tibial tuberosity and luxating patella were examined sonographically and the findings recorded.

Effects of angiogenic growth factors on endothelium-derived prostacyclin production by ovine uterine and placental arteries

Uteroplacental and fetoplacental arteries produce substantial amounts of prostacyclin (PGI2). Because angiogenic growth factors such as basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF) are increased in pregnancy, we hypothesized that treatment of uterine and fetoplacental arteries with bFGF, VEGF, and EGF would further enhance the pregnancy-induced increase in PGI2 production. Duplicate uterine (UA) and fetoplacental (PA) artery (primary branch off of the umbilical cord = pPA; cotyledonary or tertiary = tPA) explants from seven late gestation sheep were placed in tissue culture (RPMI; 37 degrees C) for 24 h alone or with (1-100 ng/mL) bFGF, VEGF, or EGF. To evaluate the endothelial contribution to basal and stimulated PGI2 production and to determine whether it is de novo, arteries with and without endothelium from three additional late gestation ewes, tissues were incubated in the absence or presence of growth factors with or without meclofenamate (1 microM). The stable metabolite of PGI2, 6-keto-PGF1 alpha, was measured in culture media and expressed as ng/mg wet wt 24 h. PGI2 production by UA increased (p < 0.05) from 5.43 +/- 0.26 at control to 8.93 +/- 0.99 with 100 ng/mL bFGF. Although VEGF produced a similar response, EGF did not increase PGI2 production in UA. In pPA, 100 ng/mL bFGF induced a 2.2-fold increase (p < 0.01) in PGI2 production from 1.94 +/- 0.14 to 4.20 +/- 0.31; VEGF and EGF were without effect. In tPA, 50 and 100 ng/mL bFGF increased PGI2 production from 1.98 +/- 0.14 to 3.5 +/- 1.05 and 3.96 +/- 0.46 (p < 0.02). In tPA, VEGF did not increase PGI2 production; however, 10, 50, and 100 ng/mL EGF, enhanced (p < 0.03) PGI2 production from 1.98 +/- 0.14 to 3.39 +/- 0.62, 3.62 +/- 0.26, and 2.93 +/- 0.20. Endothelium removal and meclofenamate treatment caused a 90% and 100% decrease, respectively, in basal PGI2 production, with no recovery after treatment with growth factors. We conclude that PGI2 production is augmented by bFGF in UA, pPA and tPA, by VEGF in UA, and by EGF in tPA during ovine pregnancy. Basal and stimulated PGI2 secretion is endothelium-derived via de novo synthesis. bFGF, VEGF, and EGF, in addition to angiogenesis, may modulate PGI2 production, further enhancing blood flow to the growing uteroplacental bed.

Methylenetetrahydrofolate reductase and methionine synthase: biochemistry and molecular biology

Methylenetetrahydrofolate reductase and cobalamin-dependent methionine synthase catalyze the penultimate and ultimate steps in the biosynthesis of methionine in prokaryotes, and are required for the regeneration of the methyl group of methionine in mammals. Defects in either of these enzymes can lead to hyperhomocysteinemia. The sequences of the human methylenetetrahydrofolate reductase and methionine synthase are now known, and show clear homology with their bacterial analogues. Mutations in both enzymes that are known to occur in humans and to be associated with hyperhomocysteinemia affect residues that are conserved in the bacterial enzymes. Structure/function studies on the bacterial proteins, summarized in this review, are therefore relevant to the function of the human enzymes; in particular studies on the effects of bacterial mutations analogous to those causing hyperhomocysteinemia in human may shed light on the defects associated with these mutations.

Fetal heart rate changes after intrathecal sufentanil or epidural bupivacaine for labor analgesia: incidence and clinical significance

The objective of this study was to compare the incidence of intrapartum fetal heart tracing (FHT) abnormalities and the obstetric outcome after intrathecal sufentanil (ITS) versus epidural bupivacaine (EB). During the period from April to September 1994, 129 patients who met inclusion criteria were prospectively identified during labor at a single university-affiliated hospital. Inclusion criteria included: singleton, gestational age > or = 36 wk, and cephalic presentation. In the ITS group, epidural anesthesia was not administered before 60 min after ITS. Sixty-five consecutive ITS patients were compared to 64 consecutive EB patients. Each FHT was reviewed independently by two obstetricians blinded to the type of analgesia. The FHT characteristics evaluated included baseline rate, variability, and periodic changes. No differences in the incidence of clinically significant FHT abnormalities (recurrent late decelerations and/or bradycardia) were observed between the two groups (ITS 21.5% versus EB 23.4%). The rates of clinically significant FHT abnormalities in both groups was not different when patients with hypotension and medical complications were excluded (16.9% vs 17.1%). In addition, equal rates of hypotension (18.5% vs 17.2%) were noted between the groups. In both groups there was a significantly higher risk of cesarean section in patients whose previously normal FHT became abnormal postanalgesia when compared to patients without a new onset FHT abnormality (ITS 28.6% [4/14] versus 2.0% [1/51], P < 0.01; EB 33.3% [5/15] versus 8.2% [4/49], P < 0.05). This increased risk was associated with an increase in cesarean section for nonreassuring FHT in both groups (ITS 14.3% [2/14] versus 0% [0/51], P = 0.04; EB 13.3% [2/15] versus 0% [0/49], P = 0.05). These results support the conclusion that the incidence of clinically significant FHT abnormalities and hypotension is equivalent in patients receiving ITS when compared to EB within the first hour of administration. During this period, patients should have continuous FHT monitoring since a new onset FHT abnormality unveils and alerts the physicians to a possible compromised fetal condition and a corresponding increased risk of cesarean section.

Coronary care in New York City hospitals

New York City, with six medical schools and an elaborate emergency medical system, would appear to be a locale with optimal resources for coronary care. To assess coronary care facilities and practices, a comprehensive questionnaire was prepared by a multidisciplinary committee and submitted to 72 hospitals. Seventy-nine percent (57/72) responded, including all medical school affiliated hospitals and 41 of the 45 with more than 300 beds. Twenty-nine percent (16/55) did not have a coronary care unit separate from a general intensive care unit. Thirty-three percent (18/55) of coronary care units were designed before 1970. Although 85% (46/54) of the coronary care units had a 1:2 registered nurse per patient ratio during days, only 43% (23/54) maintained this ratio at night. Central monitoring was available in all hospitals, but only 40% (21/52) indicated 24-hour continuous monitor observation. Forty-five percent (25/55) had cardiac catheterization facilities, and 43% (24/56) had an intra-aortic balloon available. Forty-six percent (26/57) of coronary care units transferred post-myocardial infarction patients to non-monitored general beds. Fifty-eight percent (31/53) offered dietary counseling to patients, and 33% (18/54) had an inpatient cardiac rehabilitation program. Thus, New York City hospitals demonstrate a marked variability in coronary care unit facilities and practices and a substantial number of hospitals deviate from published recommendations for coronary care units.

Variations in management of adnexal tumours

Three interesting cases in which unconventional treatment has been very successful are presented. The first was a fibrous histiocytoma of the conjunctiva which recurred twice after apparently complete surgical excision, but which responded to immunotherapy using dinitrochlorobenzene. The second was a squamous cell carcinoma of the lower eyelid treated by total surgical excision of the lid; the wound was allowed to heal by granulation with an excellent cosmetic result. The third was a squamous cell carcinoma of the limbus treated by lamellar excision with the Crock Contact-lens Corneal Cutter; the wound was allowed to granulate, and in so doing, caused negligible astigmatism.