Information technology improves Emergency Department patient discharge instructions completeness and performance on a national quality measure: a quasi-experimental study

OBJECTIVE

To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19).

METHODS

We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated.

RESULTS

The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats.

CONCLUSION

With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.

Isolation of thermophiles from broadleaf tobacco and effect of pure culture inoculation on cigar aroma and mildness

Thermophilic members of the genus Bacillus isolated from fermented Connecticut broadleaf tobacco included eight strains of B. subtilis, five strains of B. coagulans, four strains of B. megaterium, and three strains of B. circulans. Some of these strains in pure single or mixed culture were employed to enrich the normal thermophile flora of "sweating" tobacco. Three strains of B. subtilis and one of B. circulans, either in single or multiple enrichment, caused the more rapid appearance of a pleasing aroma in Pennsylvania "Wrapper B" filler tobacco. These conclusions are based on subjective reactions of professional testers after numerous blindfold smoking tests.

Tooth wear in children with Down syndrome

BACKGROUND

Several studies have described the impact that dental caries and periodontitis may have on the dentitions of individuals with Down syndrome, but there are few reports about the effects of tooth wear. This investigation aimed to compare the aetiology, prevalence and severity of tooth wear in 49 cytogenetically confirmed Down syndrome children with 49 non-Down syndrome controls.

METHODS

This study involved three aspects: an oral examination, including obtaining dental impressions; a dietary analysis spanning three days; and a questionnaire seeking information about habits, medical problems and medications. Tooth wear severity was scored on a 4-grade scale (none-to-little; moderate; severe; very severe), while aetiology was classified as being due to attrition mainly, erosion mainly, or a combination of both. Double determinations established scoring method reliability and chi-square tests assessed associations between samples.

RESULTS

Tooth wear was significantly more frequent (p<0.01) in the Down syndrome than the non-Down syndrome sample (67.4 per cent cf 34.7 per cent), with more of the Down syndrome children showing severe to very severe wear (59.2 per cent cf 8.2 per cent). Significantly more Down syndrome children (p<0.05) displayed a multifactorial aetiology of tooth wear, i.e., both attrition and erosion (46.7 per cent cf 28.6 per cent), although no particular dietary link was established. Gastric reflux and vomiting were reported in over 20 per cent of the Down syndrome sample.

CONCLUSIONS

Given the potential consequences of high levels of tooth wear, associated with tooth grinding and an acidic oral environment in Down syndrome children, educational programmes aimed at increasing awareness of carers and health professionals are needed urgently.

Influence of a financial incentive on cognitive services: CARE project design/implementation

OBJECTIVE

To describe the design and methods of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project, a demonstration project in which community pharmacies were paid for cognitive services (CS) provided to Medicaid patients, its evaluation objectives, and the extent to which implementation objectives were achieved.

DESIGN

Prospective randomized trial. Community pharmacies were allocated to a documentation-and-payment group, documentation-only group, and "silent" control group. CS were reported using a problem-intervention-result classification system embedded within a pseudo-National Drug Code format. Management strategies included use of area coordinators.

SETTING

Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term-care residents.

PARTICIPANTS

200 community pharmacies (110 treatment; 90 control), with another 100 randomly selected pharmacies as a silent control group.

INTERVENTIONS

A modest monthly stipend. The treatment group billed Medicaid for each documented CS associated with a drug therapy-related problem. All participants received training in documentation methods. A unique coding scheme allowed documentation of CS within the constraints of the Medicaid program. Data edit checks and feedback were used to ensure data quality and completeness. Area coordinators were used to facilitate training, compliance with study procedures, and participation.

MAIN OUTCOME MEASURES

Participation rates, documentation rates, coding scheme revision, data quality and completeness rates, and effectiveness of area coordinators.

RESULTS

Pharmacists documented more than 20,240 CS records. Approximately 89% of records passed edit checks, and 94% did so after modification. Nearly 83% could be linked to a paid drug or CS claim. The coding system was sufficient, with minor modifications, to account for all interventions documented. Area coordinators did not function as expected.

CONCLUSION

A system for documentation and payment of pharmacists' CS to Medicaid recipients was implemented successfully and relatively easily in community pharmacies.

Comparison of exposed dentinal surfaces resulting from abrasion and erosion

The aim of this study was to compare the shape of exposed dentinal surfaces caused by abrasion and erosion with a view to developing a diagnostic clinical test. The study material consisted of 80 natural teeth and 129 dental models obtained from Australian Aborigines known to display considerable dental abrasion due to their diet, and dental models of 37 Caucasians diagnosed with dental erosion through detailed history and dietary analysis. Polyvinyl siloxane impressions were obtained of all occlusal surfaces with dentinal scooping in both the 'abrasion' and 'erosion' groups. All impressions were sectioned buccolingually through the deepest point of the scooped dentine, and then the profiles were photocopied at x2 magnification. The breadth and depth of dentinal profiles were measured to an accuracy of 0.1 mm, enabling ratios of depth:breadth to be determined, and the position of the deepest part of each scooped surface was recorded. The mean depth:breadth ratio of scooped dentine was significantly greater in the Aboriginal natural teeth (0.19 +/- 0.06, mean +/- SE) than in the Aboriginal dental models (0.15 +/- 0.04). Both Aboriginal natural teeth and models with abrasion showed significantly smaller ratios (p < 0.05) than the Caucasian models showing erosion (0.33 +/- 0.07). Furthermore, in the abrasion samples, the deepest region of the scooped dentine tended to be lingually placed more often in maxillary teeth but buccally placed more often in mandibular teeth (p < 0.05). These results indicate that scooped dentine on abraded occlusal surfaces of teeth displays significant differences in shape compared with that caused mainly by erosion.

Principal findings from the Washington State cognitive services demonstration project

In addition to dispensing, pharmacists are ideally positioned to provide cognitive services that are targeted at optimizing drug therapy through identification and resolution of drug therapy problems. The Washington Cognitive Activities and Reimbursement Effectiveness project sought to determine: (1) if pharmacists would respond to a financial incentive by performing more cognitive services, and (2) the effect on drug cost of cognitive services they performed.

Replication-competent retroviral vectors for expressing genes in avian cells in vitro and in vivo

Replication-competent retroviral vectors based on Rous sarcoma virus (RSV) are becoming increasingly popular for expressing genes in both primary cell cultures and embryonic chick tissues in ovo. In this article, we review the features of RSV and its life cycle that make it suitable for use as a vector. We describe the design and use of the RCAS and RCAS (BP) series of vectors, which are currently the most widely used RSV-based vectors, illustrating both their strengths and weakness. Finally, we outline laboratory protocols suitable for the banding of these retroviral vectors.

Overexpression of BMP-2 and BMP-4 alters the size and shape of developing skeletal elements in the chick limb

Bone morphogenetic proteins are members of the transforming growth factor beta (TGF beta) superfamily which are involved in a range of developmental processes including modelling of the skeleton. We show here that Bmp-2 is expressed in mesenchyme surrounding early cartilage condensations in the developing chick limb, and that Bmp-4 is expressed in the perichondrium of developing cartilage elements. To investigate their roles during cartilage development, BMP-2 and BMP-4 were expressed ectopically in developing chick limbs using retroviral vectors. Over-expression of BMP-2 or BMP-4 led to a dramatic increase in the volume of cartilage elements, altered their shapes and led to joint fusions. This increase in volume appeared to result from an increase in the amount of matrix and in the number of chondrocytes. The latter did not appear to be due to increased proliferation of chondrocytes, suggesting that it may result from increased recruitment of precursors. BMP-2 and BMP-4 also delayed hypertrophy of chondrocytes and formation of the osteogenic periosteum. These data provide insights into how BMP-2 and BMP-4 may model and control the growth of skeletal elements during normal embryonic development, suggesting roles for both molecules in recruiting non-chondrogenic precursors to chondrogenic fate.

Antibody to Coxsackie B virus in diagnosing postviral fatigue syndrome

OBJECTIVE

To study the association between coxsackie B virus infection and the postviral fatigue syndrome and to assess the immunological abnormalities associated with the syndrome.

DESIGN

Case-control study of patients with the postviral fatigue syndrome referred by local general practitioners over one year.

SETTING

General practitioner referrals in Dunbartonshire, Scotland.

PATIENTS

254 Patients referred with the postviral fatigue syndrome (exhaustion, myalgia, and other symptoms referable to postviral fatigue syndrome of fairly recent onset--that is, several months) and age and sex matched controls obtained from same general practitioner; 11 patients were rejected because of wrong diagnoses, resolution of symptoms, and refusal to participate, leaving 243 patients and matched controls.

MAIN OUTCOME MEASURES

Detailed questionnaire (patients and controls) and clinical examination (patients) and blind analysis of blood sample at entry and after six months for determination of coxsackie B virus IgM and IgG antibodies and other variables (including lymphocyte protein synthesis, lymphocyte subsets, and immune complexes).

RESULTS

Percentage positive rates for coxsackie B virus IgM at entry were 24.4% for patients and 22.6% for controls and for coxsackie B virus IgG 56.2% and 55.3% respectively; there were no significant differences between different categories of patients according to clinical likelihood of the syndrome nor any predictive value in a fourfold rise or fall in the coxsackie B virus IgG titre in patients between entry and review at six months. The rates of positive antibody test results in patients and controls showed a strong seasonal variation. Of the numerous immunological tests performed, only a few detected significant abnormalities; in particular the mean value for immune complex concentration was much higher in 35 patients and 35 controls compared with the normal range and mean value for total IgM was also raised in 227 patients and 35 controls compared with the normal range.

CONCLUSIONS

Serological tests available for detecting coxsackie B virus antibodies do not help diagnose the postviral fatigue syndrome. Percentage positive rates of the antibodies in patients simply reflect the background in the population as probably do the raised concentrations of total IgM and immune complexes.

A cumulative review of studies on travellers, their experience of illness and the implications of these findings

A cumulative review of illness experienced by 13,816 travellers returning to Scotland since 1977, shows an overall attack rate of 36%. Alimentary complaints predominated; 18% of travellers had these alone and a further 10% had other symptoms as well as their gastro-intestinal disorder. Higher attack rates were noted in those taking package holidays. Inexperience of travel, smoking, more southerly travel and younger age (particularly those between 20- and 29-years-old) were other contributing factors. A similar pattern emerged from a I year study of hospital in-patients with travel related admissions. Serological studies of 470 travellers showed that 20% had incomplete immunity to poliomyelitis; 25% of those tested (312 travellers) had serological evidence of typhoid immunisation, I.9% (of 760 travellers) had antibodies to Legionella pneumophila, 64% (5II travellers tested) had antibodies to hepatitis A, 87% (288 tested) had adequate levels of tetanus antitoxin but only 40% of the 225 travellers tested had adequate levels of diphtheria antitoxin. Amongst a subgroup of 645 travellers the travel agent was the most frequently consulted source of pre-travel health advice. This carries particular significance for the dissemination of relevant advice in view of the inadequacies found from study of the health information in travel brochures. These findings, viewed against the perspective of the continuing growth in international travel, means that travellers, the medical profession, the travel trade, health educators, global health agencies and health authorities in those countries accepting and encouraging tourists, will be required to recognise the health implications of further tourism development if this problem of illness associated with travel is to be brought under control.

Myalgic encephalomyelitis--a persistent enteroviral infection?

Myalgic encephalomyelitis is a common disability but frequently misinterpreted. Amongst 6,000 patients referred for general microbiological diagnosis between 1975 and 1987, 420 cases were recognized. Coxsackie B neutralization tests, in 205 of these, demonstrated significant titres in 103/205 (50%), while of 124 additionally investigated for enteroviral IgM, 38/124 (31%) were positive. This illness is distinguished from a variety of other post-viral states by an unique clinical and epidemiological pattern characteristic of enteroviral infection. Prompt recognition and advice to avoid over-exertion is mandatory. Routine diagnosis, specific therapy and prevention, await further technical advances.

Features of Coxsackie B virus (CBV) infection in children with prolonged physical and psychological morbidity

A retrospective study of the clinical features in 39 children who were investigated for evidence of Coxsackie B virus (CBV) infection is reported. Eighteen children were found to have serological evidence of infection. An extensive range of features was elicited in both seropositive and seronegative patients, most children complaining of abnormalities referable to muscle and, in particular, of weakness and easy fatiguability. Children with evidence of CBV infection were significantly more likely to belong to social classes I and II, to have relatives with serological evidence of CBV infection, and to show certain dysphoric features as well as to complain of sore throats. The relationship between CBV infection and 'myalgic encephalomyelitis' or 'post-viral syndrome' is discussed, and it is suggested that these descriptions are inappropriate given our current knowledge, and inadequately describe the clinical features seen in the children under study. An alternative description, 'fatigue-dysphoria syndrome' is proposed.

Fatal outcome of echovirus 7 infection

A 9-month-old boy died of a disseminated echovirus 7 (E7) infection with virus being cultured from his liver and spleen. His hepatic failure was complicated by candidiasis and marrow hypoplasia and aggravated by a possible immune deficiency.

Vaccine-induced polioencephalomyelitis in Scotland

A six-month-old British female, living in Glasgow was admitted in June 1986 with a four-day history of fever and lower limb weakness following immunisation with oral polio and triple (DTP) vaccines. Examination revealed paralysis of all limbs, facial muscles and right diaphragm, scoliosis, opsoclonus and ocular flutter. Poliovirus types 1, 2 and 3, isolated from her stool specimens were all vaccine-like strains. Her serial serum IgA levels were persistently low and salivary IgA was undetectable. This appears to be the first fully authenticated case of poliovaccine damage in Scotland. It is unclear whether the selective IgA deficiency contributed to her vulnerability. It is essential to investigate elaborately and process viral isolates in every suspected case of acute poliomyelitis so as to determine the dimension and ramifications of poliovaccine damage in the UK population which is known to be rather apprehensive about vaccine dangers.

Postviral fatigue syndrome: persistence of enterovirus RNA in muscle and elevated creatine kinase

Enterovirus-specific probes have been prepared by reverse transcription of conserved sequences in purified Coxsackie B2 virus genomic RNA and molecular cloning techniques. These probes were used in quantitative slot blot hybridizations to test for the presence of enterovirus-specific RNA in skeletal muscle biopsy specimens from 96 patients who had suffered from the postviral fatigue syndrome myalgic encephalomyelitis for up to 20 years. Biopsy specimens from 20 patients were positive for the presence of virus-specific RNA with hybridization signals more than three standard deviations greater than the mean of the normal muscle controls. Biopsies from the remaining 76 patients were indistinguishable from the controls. These data show that enterovirus RNA is present in skeletal muscle of some patients with postviral fatigue syndrome up to 20 years after onset of disease and suggest that a persistent virus infection has an aetiological role.

Coxsackie B viruses and myalgic encephalomyelitis

Data collected over the past 6 years suggest that Coxsackie B viruses (CBV) play an important role in myalgic encephalomyelitis (ME). Since psychological upset is a feature of this illness, 247 patients, recently admitted to a psychiatric hospital, were tested for neutralizing antibodies to CBV. A total of 12.5% had significantly raised CBV titres compared with 4-5% of 'well' control groups; the percentage positive was greatest (21%) in those aged 30-39 years. During 1985 and 1986 sera from 290 adults with ME were tested using the newly developed CBV IgM ELISA test; 37% were CBV IgM positive compared with 9% of 500 'well' adult controls. Forty-seven children, with ME were similarly tested during this period; 38% were positive, implying recent or active CBV infection. The combined use of this ELISA test and the virus probe techniques now available should further help to elucidate the exact role of CBV in this disabling illness.

Non-polio enteroviruses and motor neurone disease

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Chronic enterovirus infection in patients with postviral fatigue syndrome

76 patients with the postviral fatigue syndrome (PVFS) and 30 matched controls were investigated. Virus isolation was attempted from concentrated faecal samples by direct culture and after acid dissociation of virus from antibody. Positive cultures of enteroviruses were obtained from 17 (22%) patients and 2 (7%) controls. An enterovirus-group-specific monoclonal antibody, 5-D8/1, directed against the VP1 polypeptide, was used to detect enteroviral antigen in the circulation, either free or complexed with antibody. VP1 antigen was detected in the serum of 44 (51%) of a further group of 87 PVFS patients. The number of patients positive for VP1 antigen was greater (42/44) when IgM complexes were detectable than when they were not (2/23). 1 year later, the 17 patients of the first group of 76 with positive cultures were again studied. The same virus was again isolated from 5 (29%), 13 (76%) had detectable IgM responses to enteroviruses, and 9 (53%) were positive for VP1 antigen in the serum. These results show that chronic infection with enteroviruses occurs in many PVFS patients and that detection of enterovirus antigen in the serum is a sensitive and satisfactory method for investigating infection in these patients.

Coxsackie B viruses and the post-viral syndrome: a prospective study in general practice

In a prospective study sera from 140 patients with symptoms suggesting a post-viral syndrome and sera from 100 controls were tested for neutralizing antibodies to Coxsackie B viruses. Sixty-five of the patients (46%) and 25 of the controls (25%) had significant antibody titres. The 65 positive cases who had presented with symptoms were followed up and retested six months later and again after one year. Of these 65 patients 36 (55%) were still unwell after one year and high antibody titres persisted in all but two of the patients. Recovery was not found to correlate with a fall in antibody level, but was more rapid in patients whose presenting symptoms were paraesthesiae, anorexia or dyspnoea. The importance of correctly identifying patients with the post-viral syndrome, who may otherwise be labelled neurotic, is emphasized.

Routine use of mu-antibody-capture ELISA for the serological diagnosis of Coxsackie B virus infections

The role of coxsackie B viruses (CBV) in myo/pericarditis has been well documented; however, interpretation of static high neutralising antibody titres in individual patients has always been difficult. In introducing the mu-antibody capture ELISA test for the detection of CBV-specific IgM, we hoped to overcome this problem. A regimen for the routine serological diagnosis of CBV infections was introduced, using the CBV IgM ELISA as a screening test, followed by neutralisation tests (NT) to confirm the positive results. Seven hundred and sixty patients and 304 healthy adult controls were tested. The percentage CBV IgM positive in each of the clinical categories myo/pericarditis (33%) chest pain (22%), myalgic encephalomyelitis (31%), myalgia/Bornholm (19%) and controls (9%) was similar to those found in previous studies using NT alone. Cross-reactions with other enteroviruses, including hepatitis A (Enterovirus 72), were observed but did not prove to be a problem in the illness studied, since most involved adults. Both homotypic and heterotypic CBV IgM responses were found. Matching IgM and NT indicated a recent CBV infection. Positive IgM with negative NT titres suggested a recent infection with an enterovirus other than a CBV.

Mu-antibody capture ELISA for the rapid diagnosis of enterovirus infections in patients with aseptic meningitis

Between August and November 1985, 45 patients with suspected aseptic meningitis were investigated using conventional virus isolation procedures and the mu-antibody capture Coxsackie B IgM enzyme-linked immunoabsorbent assay (ELISA) test, which is well known to cross-react with other members of the enterovirus group. An enterovirus was isolated from 22% of patients compared with 67% who were positive in the ELISA test. Not only was the rate of enterovirus detection increased by using this ELISA method, the clinician received a result within 2 days of submission of serum to the laboratory. A positive result was reassuring to the patient and helpful in clinical management. The main disadvantage of this test was its cost since Coxsackie B1-5 virus antigens were essential. Development of a single inexpensive enterovirus-specific antigen is thus desirable.

Illness associated with a package holiday in Romania

A study of 370 holidaymakers returning from Romania revealed that 279 (75%) reported illness. Alimentary symptoms predominated and were recorded either alone or along with other symptoms by 71 per cent of the tourists. The highest illness rate (82%) occurred in those under 39 years of age and those over 60 years had least illness (38%). Most of the tourists attributed their illnesses to the supply, handling or preparation of food and drink. Twenty-six (21%) tourists had serological evidence of typhoid immunisation out of 121 from whom blood samples were obtained. Most of the tourists studied (85%) were immune to poliomyelitis.

Poliomyelitis in an adult male

Paralytic poliomyelitis is now unusual in developed countries following the success of vaccination programmes. This paper reports a case of poliomyelitis in a patient with incomplete vaccination where the source of infection is unclear.

The postviral fatigue syndrome--an analysis of the findings in 50 cases

The clinical, pathological, electrophysiological, immunological and virological abnormalities in 50 patients with the postviral fatigue syndrome are recorded. These findings confirm the organic nature of the disease. A metabolic disorder, caused by persistent virus infection and associated with defective immunoregulation, is suggested as the pathogenetic mechanism.

A study of Coxsackie B virus infections, 1972-1983

The results of a twelve-year study of Coxsackie B virus (CBV) infections in patients with a variety of acute and chronic illnesses are reported. CBVs were isolated from only 123 patients most of whom were children with respiratory illness. Virus diagnosis in adults was based mainly on the detection of significant rising or static high neutralizing antibody titres. Between 1972 and 1979 most investigations centred on patients with suspected viral heart disease, 12% of whom were found to have diagnostically significant CBV titres. In studies on patients with definite myo-pericarditis the number positive increased to 33%. In 1980 clinical interest switched to the possible role of CBV in myalgic encephalomyelitis (ME), an illness of diverse symptomatology. Investigation of suspected cases of ME in 1983 showed that 16% were serologically positive compared to 4% of normal adults in the West of Scotland. In patients with well-documented ME this figure rose to 41%. The demand by clinicians for CBV neutralizing antibody tests has increased over the past twelve years and continues to escalate annually, especially in patients with chronic relapsing illness.

Fetal damage after accidental polio vaccination of an immune mother

Irreparable damage to the anterior horn cells of the cervical and thoracic cord was found in a 20-week-old fetus whose mother was immune to poliomyelitis before conceiving but who was inadvertently given oral polio vaccine at 18 weeks gestation. Polio neutralizing antibody titres in sera, taken before and after pregnancy, were identical and were at levels normally regarded as providing protection. Unsuccessful attempts were made to isolate poliovirus from extracts of fetal brain, lung, liver and placenta. Fluorescent antibody tests were performed on various levels of the central nervous system and on the left and right extensor forearm muscles. Specific positive fluorescence to poliovirus 2 and 3 antigens was detected at dorsal spinal cord level only. One positive result was seen with Coxsackie A9 antiserum and fresh guinea-pig complement in the inflammatory cells in the right extensor forearm muscles.This experience, as yet unexplained, underlines the importance of ensuring that women are not pregnant prior to oral polio vaccination.

Epidemic acute haemorrhagic conjunctivitis in Lagos, Nigeria

Enterovirus 70 has recently emerged as a causative agent of epidemic acute haemorrhagic conjunctivitis ( AHC ). This paper is a report of the first association of enterovirus 70 with epidemic AHC in Nigeria. Despite numerous symptoms, including reduction in visual acuity, eventual recovery in 2 to 3 weeks with no functional loss was the rule except in 11 patients. Five of these patients ended up with superficial corneal scarring. Two had evisceration for unresolving panophthalmitis, while 4 went blind from ruptured corneal abscesses or ulcers. All the 11 patients had treated themselves or used traditional medications. None of the patients had signs of involvement of the central nervous system.

Paralytic poliomyelitis and nonpolio enteroviruses: studies in Scotland

Poliomyelitis has been well controlled in Scotland by vaccination. Occasional cases of paralysis still occur in association with enteroviruses, especially coxsackieviruses. Most cases were attributable to coxsackievirus A7, which was identified in 77 cases, 12 of them paralytic (one fatal), from 1956 to 1973 (including outbreaks in 1959 and 1963) but not since then. Serologic findings suggesting poliovirus infection have been obtained in several paralytic illnesses at a late stage, months after acute illnesses in which the possibility of poliomyelitis was not considered by physicians, who no longer expect to encounter cases of poliomyelitis.

Sporadic myalgic encephalomyelitis in a rural practice

Twenty patients presenting with chronic ill-defined illnesses in a rural practice were investigated virologically. The only positive finding was the detection of elevated Coxsackie B titres in 16 of these patients. Three had experienced mainly cardiovascular symptoms; the remaining 13 are thought to have suffered from myalgic encephalomyelitis. This is a distressing and often prolonged illness, the cause of which is as yet unknown but is suspected of having a viral aetiology.

Myalgic encephalomyelitis--report of an epidemic

The relationship between the group B Coxsackieviruses and a wide variety of illnesses, particularly pleurodynia and myo/pericarditis, is already well established. The detection of raised levels of neutralizing antibody to these viruses in a group of patients in a rural practice presenting with an illness resembling myalgic encephalomyelitis (ME) was therefore unexpected. This is a most distressing and debilitating illness for the patient and the affected family. What is the immunological failure in these patients which apparently allows this virus to persist causing such unusual and bizarre illness? At present ME is probably much commoner than is realized, the majority of patients being given the dismissive diagnosis of psychoneurosis.

Coxsackie B infection in a general medical unit

From January 1979 until December 1980, neutralizing antibody titres to Coxsackie B1-6 viruses were measured in sera from 220 patients presenting to a general medical unit, the majority of whom had chest pain. No four-fold or greater rises in antibody titre were detected in these hospital patients. However, 49 per cent had titres of greater than or equal to 256 to one or more Coxsackie B virus types compared with 10 per cent of the 950 persons studied during a 'normal population' survey in the West of Scotland. When a more rigorous threshold was adopted, titres greater than or equal to 512 were found in 33 per cent and 4 per cent respectively. We conclude that Coxsackie B infections are not uncommon in the practice of a general medical unit and that they may account for more cases of both acute and subacute left chest pain than is usually realised.

Susceptibility of itinerants ("travelling people") in Scotland to poliomyelitis

A total of 109 travelling people (people with a nomadic lifestyle), living on 8 separate sites in central and south Scotland, were examined for neutralizing antibodies to poliovirus types 1, 2, and 3. Of those studied, 10% had no detectable antibody to poliovirus type 3 while 7% had no antibody to type 1, the types most commonly associated with outbreaks of paralytic poliomyelitis. Only one subject, a child aged 9 years, had no detectable poliomyelitis antibody; he had no history of poliomyelitis immunization. The best protected groups of travellers were those located on sites with good facilities.As far as poliomyelitis is concerned, we conclude that travelling people in Scotland who live on well equipped sites do not pose a hazard to nearby settled populations and, indeed, are no more vulnerable to infection than members of those communities.

Routine enterovirus diagnosis in a human rhabdomyosarcoma cell line

For many years a substitute cell line has been sought to replace monkey kidney cell cultures for the diagnosis of enterovirus infections. Reports by various workers have shown that the RD cell line, derived from a human rhabdomyosarcoma, will support the replication of most of the prototype strains of enterovirus. The present study shows that, with the exception of the group B coxsackieviruses, RD cells are more sensitive than cynomolgus monkey kidney cultures for the isolation of a wide variety of enteroviruses from clinical specimens. Since regular access by many diagnostic laboratories to supplies of primary cell cultures is often difficult because of distance from source or cost factors, a simple cell culture system is proposed which should prove useful for the diagnosis of most of the important enterovirus infections.

Stool viruses in babies in Glasgow 2. Investigation of normal newborns in hospital

The stools of 37 newborn babies born in hospital were examined for the presence of virus. An extract of every stool passed by each baby was examined in the electron microscopy and inoculated into cell cultures. The babies were delivered in four separate maternity units (A-D). All the babies from unit A and C(9 babies) were found to be excreting rotavirus though none showed any evidence of diarrhoea. Two of the babies also excreted astrovirus. Subsequently unit A was closed for cleaning and, on reopening with more restrictions on visitors, a further 19 babies were examined. No virus was found in any of their stools, nor was virus observed in the stools of babies from units B and D, where visiting was also more restricted. Visiting restrictions in these units excluded older siblings of the babies. No virus was cultured from any stools in this study.

Role of Coxsackie B viruses in myocardial infarction

Serological evidence of Coxsackie B virus infection was found in 13.5 per cent of 52 patients with acute myocardial infarction and in 19 per cent of 52 controls with chest pain but normal electrocardiograms. In contrast to an Australian report, but in agreement with previous findings in Glasgow, it seems unlikely that Coxsackie B viruses contribute significantly to the causation of myocardial infarction.

Immune status of children of immigrants to poliomyelitis

Four ethnic groups of children from the Glasgow area--155 Asians, 85 Africans, 85 Chinese, and 93 Scots--were examined for neutralising to poliovirus types 1, 2, and 3. Only seven of the 418 children had no detectable antibody, and of these, four were aged less than 7 months; none had received polio vaccine. The best-protected children were the Chinese (93% with antibody to all three poliovirus types), followed by the African (81%), Scottish (78%), and Asian children (77%). We conclude that children of immigrants are no more vulnerable to poliovirus infection than their Scottish counterparts.

Stool viruses in babies in Glasgow. I. Hospital admissions with diarrhoea

Stools from 183 babies under 2 years of age admitted to Ruchill Hospital with diarrhoea were examined by electron microscopy, virus culture, bacterial culture and light microscopy. As far as possible, several stools were examined from each patient and the results showed rotaviruses, astroviruses and other viruses in association with symptoms, as well as the expected bacterial pathogens. Examination of several stools from the same patient also showed that in this age group the viral flora of the gut changes rapidly and that the viruses seen by electron microscopy were only rarely grown in cell culture and vice versa. This phenomenon was particularly noted with adenoviruses. In 30% of cases no microbial pathogen was identified and in the remainder the presence of the infecting organism did not always coincide with the symptoms. It is concluded that, with viruses at least, presence of the organism does not constitute proof of causation.

Echovirus type 4 infections in Scotland, 1971-72

An outbreak of infection due to echovirus 4 in Scotland involving 194 cases during 1971-72 is described. Clinical and epidemiological information was obtained and analysed for 181 patients, of whom 149 (82%) developed aseptic meningitis. The majority of cases were older children (39%) and young adults (40%), although the highest attack rate was in infants (10.5 per 100,000 population). An unusual feature of the outbreak was its biphasic nature with cases occurring largely in the same geographic areas in successive years.