Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit

Introduction

Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population.

Methods

We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission.

Results

Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff.

Conclusions

Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

The Reliability of Activated Partial Thromboplastin Time Methods and the Relationship to Lipid Composition and Ultrastructure

Wide variations in procoagulant properties, lipid composition and ultrastructure of five commonly used APTT methods have been demonstrated. Performance of the methods with a range of coagulation abnormalities has been ranked. Most of the reagents obtained a high score with one or more defects, but a low score with others. A consistent good ranking throughout was only observed with one reagent.

The number of significant correlations between the reagents’ procoagulant activities and lipid content confirms the view that the performance of an APTT method is largely dependent upon its lipid composition. Marked differences in concentration and distribution of phospholipids, fatty acids and neutral lipids were evident. The importance of the concentration of phosphatidyl serine in regulating the procoagulant activity of an APTT method has been demonstrated. Electron microscopy provides evidence of the contrasting composition of the reagents from the more discrete uniform liposomes present in the more reliable reagents, to more ill-defined components present in those reagents which performed less well. The study highlights the need for standardisation of the APTT.

Evaluation of hibergene loop-mediated isothermal amplification assay for detection of group B streptococcus in recto-vaginal swabs: a prospective diagnostic accuracy study

OBJECTIVES

To prospectively evaluate HiberGene's loop-mediated isothermal amplification (LAMP) assay for detection of group B streptococcus (GBS) in maternal recto-vaginal swabs and compare it with enrichment culture.

METHODS

Following ethical approval and informed written consent, two low vaginal and rectal swabs were obtained from 400 pregnant women. One swab was tested for GBS using the rapid LAMP assay (index test), the second swab was tested using enrichment culture (reference standard). Antimicrobial susceptibility testing was performed according to EUCAST guidelines.

RESULTS

There were 376 concordant results, 20 discordant and four invalid LAMP results. Among discordant results, six were LAMP negative/culture positive and 14 were LAMP positive/culture negative. The sensitivity was 92.2%, specificity 95.6%, positive predictive value 83.5% and negative predictive value 98.1%. The prevalence of GBS carriage was 19.25% (77/400). Forty-eight of 77 GBS-positive women were colonized vaginally (62.3%) and 70 were colonized rectally (90.9%). Erythromycin resistance was 22.4% (17/76) and clindamycin resistance was 17.1% (13/76).

CONCLUSIONS

The LAMP assay is a rapid and simple test with results available in approximately 1 h compared with 48 h for culture. The test has good sensitivity and specificity compared with enrichment culture. This test can be used for rapid antenatal GBS screening.

Prevalence of gonococcal conjunctivitis in adults and neonates

PURPOSE

To report the prevalence of gonococcal conjunctivitis (GC) presenting to a tertiary referral maternity hospital (NMH) and a tertiary referral ophthalmic hospital (RVEEH) from 2011 to 2013 and describe the demographics, clinical presentation, and antibiotic susceptibility of Neisseria gonorrhoeae ocular infections.

METHODS

Demographic, clinical, and microbiological data were collected from patients with laboratory confirmed GC.

RESULTS

There were 27 556 live births at NMH during the study period, and no case of neonatal GC was identified. Fourteen cases of GC were identified at RVEEH in this period, representing a prevalence of 0.19 cases per 1000 eye emergency attendees. Antibiotic susceptibility data were available on nine cases, of which, all were ceftriaxone- and ciprofloxacin sensitive. 64.3% of patients were male, with a mean age of 18 years. The mean duration of symptoms was 3 days. All patients presented with unilateral conjunctival injection and purulent discharge. Eight cases had visual impairment at presentation and their mean visual acuity was 6/15. Corneal involvement was present in 25% of patients. Uveitis was not detected. On receipt of positive culture and/or PCR results, treatment was altered in two thirds of patients. All patients were referred for full STI screening and all patients showed a full clinical recovery 1 week posttreatment.

CONCLUSION

We observed that GC presented in young adults with a male predominance and was rare in neonates. In cases of unilateral purulent conjunctivitis, there should be a high clinical suspicion of GC, early swab for PCR and culture, and knowledge of current CDC-recommended antibiotic guidelines.

Exercise preconditioning reduces neuronal apoptosis in stroke by up-regulating heat shock protein-70 (heat shock protein-72) and extracellular-signal-regulated-kinase 1/2

Exercise preconditioning induces neuroprotection after stroke. We investigated the beneficial role of heat shock protein-70 (HSP-70) and phosphorylated extracellular-signal-regulated-kinase 1/2 (pERK 1/2), as they pertain to reducing apoptosis and their influence on Bcl-x(L), Bax, and apoptosis-inducing factor (AIF) in rats subjected to ischemia and reperfusion. Adult male Sprague-Dawley rats were subjected to 30 min of exercise on a treadmill for 1, 2, or 3 weeks. Stroke was induced by a 2-h middle cerebral artery (MCA) occlusion using an intraluminal filament. Protein levels of HSP-70, pERK 1/2, Bcl-x(L), Bax, and AIF were analyzed using Western blot. Neuroprotection was based on levels of apoptosis (TUNEL) and infarct volume (Nissl staining). Immunocytochemistry was used for cellular expression of HSP-70 and pERK 1/2. Significant (P<0.05) up-regulation of HSP-70 and pERK 1/2 after 3 weeks of exercise coincided with significant (P<0.05) reduction in neuronal apoptosis and brain infarct volume. Inhibition of either one of these two factors showed a significant (P<0.05) reversal in the neuroprotection. Bax and AIF were down-regulated, while levels of Bcl-x(L) were up-regulated in response to stroke after exercise. Inhibiting HSP-70 or pERK 1/2 reversed this resultant increase or decrease. Our results indicate that exercise diminishes neuronal injury in stroke by up-regulating HSP-70 and ERK 1/2.

Detection of pigeon circovirus in cloacal swabs: implications for diagnosis, epidemiology and control

Pigeon circovirus (picv) was detected in cloacal swab samples by means of a newly-developed, sensitive pcr. An initial investigation of 17 Belgian racing pigeons aged up to eight months showed that rates of detection of 88 per cent and above were achieved using samples of cloacal swab, blood and bursa of Fabricius. The sampling of 15 caged pigeons six times when they were from three to 31 weeks of age indicated that picv infections were more readily detected in cloacal swabs than in blood, and that the virus could be detected in cloacal swabs for longer periods after infection than in blood. picv infections were detected in cloacal swabs from 38 of 47 young pigeons aged from two to 31 weeks, from 12 racing lofts, which had clinical signs including diarrhoea and weight loss, regurgitation and respiratory signs. Samples from birds from two infected lofts indicated that picv could be detected in some birds for at least 27 weeks. Although nine of 14 pigeons aged from 32 to 45 weeks were virus-positive, picv was detected in only one of 18 adult pigeons that originated from four infected lofts.

New data on the transmission of pigeon circovirus

Nineteen racing pigeons aged from one to five years were examined postmortem. pcr tests showed that the spleens of 16 of them were positive for pigeon circovirus, the livers of six were positive, and blood from one of them was positive for the virus. Five of 44 embryos in embryonated eggs collected from three lofts were positive by pcr, but swabs taken from the crops of 64 adult birds which were feeding one- to 10-day-old squabs in these three lofts were negative for the viral dna.

Substrate effect on refractive index dependence of plasmon resonance for individual silver nanoparticles observed using darkfield microspectroscopy

We use optical darkfield micro-spectroscopy to characterize the plasmon resonance of individual silver nanoparticles in the presence of a substrate. The optical system permits multiple individual nanoparticles to be identified visually for simultaneous spectroscopic study. For silver particles bound to a silanated glass substrate, we observe changes in the Plasmon resonance due to induced variations in the local refractive index. The shifts in the plasmon resonance are investigated using a simple analytical theory in which the contributions from the substrate and environment are weighted with distance from the nanoparticle. The theory is compared with experimental results to determine a weighting factor which facilitates modeling of environmental refractive index changes using standard Mie code. Use of the optical system for characterizing nanoparticles attached to substrates for biosensing applications is discussed.

Trachipleistophora hominis infection in the myocardium and skeletal muscle of a patient with AIDS

OBJECTIVES

To review the literature relevant to microsporidial infection of muscle and to describe a case of human microsporidial infection involving both skeletal and cardiac muscle.

METHODS

Samples from an AIDS patient with myositis have been examined by light and electron microscopy.

RESULTS

We describe the findings at autopsy of a 47 year old Australian male with late stage AIDS, who had skeletal and cardiac muscle involvement with the microsporidian Trachipleistophora hominis. This is the third definitively identified case of human T. hominis infection and the first to describe infection of the myocardium.

CONCLUSIONS

Microsporidial infection of muscle is rare in humans, but more work is needed to elucidate both the organisms and routes of transmission of this group of parasitic protozoa.

National epidemic of Lordsdale Norovirus in the UK

BACKGROUND

In early 2002 reports of outbreaks of gastroenteritis reached unprecedented levels in the UK. Forty five Norovirus outbreaks were reported in January 2002.

OBJECTIVES

The objective of the study was to determine whether the outbreaks were Noroviral in origin and if so whether they represented a homogeneous or heterogeneous collection of Noroviruses by applying EIA and sequence analysis to representative faecal samples.

STUDY DESIGN

Faecal specimens were collected during the week of highest incidence from 21 outbreaks in a variety of health care settings including hospitals and nursing homes. The outbreaks occurred in geographically distinct regions of the UK and samples were collected by reference laboratories in Glasgow, Manchester, Bristol and Southampton.

RESULTS

The samples were all positive for Noroviruses by negative stain electron microscopy (EM) and Lordsdale virus (LV) EIA, therefore reverse transcriptase polymerase chain reaction (RT-PCR) amplification and nucleotide sequencing of the Norovirus RNA polymerase gene was performed on amplicons from samples of each of the 21 outbreaks to investigate the nature and extent of diversity. All samples were very closely related to the reference Lordsdale virus genome sequence. LV was first discovered during an hospital outbreak of gastroenteritis in Southampton General Hospital in March 1993.

CONCLUSIONS

Noroviruses are a major cause of outbreaks of gastroenteritis in health care settings. LV is the predominant Norovirus in the UK and was detected in outbreaks that occurred during the national peak of gastroenteritis reports in January 2002.

Emerging human protozoan infections in the temperate European climate

There has been a resurgence of interest in medical protozoology in the last twenty years or so mainly as a result of the recognition of HIV infection and the opportunistic protozoan infections associated with it. Many new species of microsporidia have been recognised as parasites causing human disease and several rare infections, such as isosporiasis, have become more commonly recognised, even in temperate climates. Some of the infections seen in temperate regions have arrived through foreign travel (tourism, work or immigration), sometimes exacerbated by immunosuppression (due to HIV, organ transplantation or malignancy). Importation of food from around the world and climate change (global warming) may also be contributing to the increase in previously rare protozoan infections now being seen in temperate regions. This article reviews the current status of these new and re-emerging human protozoan infections in temperate, rather than tropical locations.

Actin filaments in human renal tubulo-interstitial fibrosis: significance for the concept of epithelial-myofibroblast transformation

Epithelial-myofibroblast transformation has been argued as playing a role in tubulo-interstitial fibrosis. To investigate this hypothesis, we examined 9 renal biopsy specimens from patients with chronic renal disease by light and electron microscopy. In all cases, electron microscopy confirmed light microscope observations in relation to tubulo-interstitial fibrosis-tubular atrophy, accumulation of extracellular matrix and of mesenchymal interstitial cells, and infiltration by inflammatory cells. Tubular epithelial cells (TECs) contained bundles of actin filaments: mostly lacking the focal densities typical of smooth-muscle myofilaments. The interstitium contained collagen and inflammatory cells. Some endothelial cells showed bundles of myofilaments. Free mesenchymal cells in the matrix were spindled and had sparse rough endoplasmic reticulum (rER), small attachment plaques, few actin filaments and no lamina. In one case, myofibroblasts (defined by abundant rER, myofilaments and fibronexuses) were present. Most of the mesenchymal cells, therefore, did not correspond to myofibroblasts, nor to classical fibroblasts because of the sparse rER and the presence of actin filaments. We therefore called these cells myoid stromal cells, regarding them as stromal mesenchymal elements showing partial activation towards a smooth-muscle phenotype. This paper demonstrates a greater phenotypic complexity of actin-containing stromal cells in the interstitium than previously appreciated, with only a minority conforming to true or fully differentiated myofibroblasts. The widespread presence of actin (as filaments or immunoreactivity) in both TECs and interstitial cells, combined with the absence of evidence of intermediate forms or of migration from epithelium into interstitium, may point to epithelium and interstitium as separate targets for actin upregulation as an alternative hypothesis to epithelial-myofibroblast transformation.

Glutamine deprivation facilitates tumour necrosis factor induced bacterial translocation in Caco-2 cells by depletion of enterocyte fuel substrate

BACKGROUND AND AIMS

Factors that induce luminal bacteria to cross the intestinal epithelium following injury remain poorly defined. The aim of this study was to investigate the interaction between glutamine metabolism, energy supply, and inflammatory mediators in determining the translocation of non-pathogenic bacteria across cultured enterocytes.

METHODS

The effect of tumour necrosis factor alpha (TNF-alpha) on translocation of Escherichia coli C25 across Caco-2 epithelial monolayers was studied in the presence of products and inhibitors of glutamine metabolism. Simultaneous measurements of transepithelial electrical resistance (TEER) and flux of lucifer yellow were used to assess effects on the paracellular pathway. Lactate dehydrogenase release was used to monitor enterocyte integrity. Imaging of monolayers in these experimental conditions was undertaken with transmission electron microscopy.

RESULTS

Exposure to basolateral TNF-alpha (20 ng/ml) for six hours induced translocation of E coli across Caco-2 but only if accompanied by simultaneous glutamine depletion (p<0.01). Translocation was inhibited by addition of glutamine for two hours (p<0.01) but not by an isonitrogenous mixture of non-glutamine containing amino acids. Inhibition of glutamine conversion to alpha-ketoglutarate, but not blockade of glutathione or polyamine synthesis, also induced translocation in the presence of TNF-alpha. Manipulations that induced bacterial translocation were associated with a marked reduction in enterocyte ATP levels. No effect of these treatments on paracellular permeability or lactate dehydrogenase release was observed. Conditions in which translocation occurred were associated with the presence of bacteria within enterocyte vacuoles but not the paracellular space.

CONCLUSIONS

In inflammatory conditions, the availability of glutamine as an enterocyte fuel substrate is essential for the preservation of a functional barrier to microorganisms. In conditions of acute glutamine depletion, cytokine mediated bacterial translocation appears to be primarily a transcellular process.

Evaluation of a commercial ELISA for detecting Norwalk-like virus antigen in faeces

A commercially available enzyme immunoassay, the IDEIA Norwalk-like virus (NLV) enzyme linked immunosorbent assay (ELISA; Dako Cytomation, Ely, UK) for detecting NLV antigen in faecal samples and determining the NLV genogroup was evaluated. The performance of the ELISA was compared with that of electron microscopy and the reverse transcription polymerase chain reaction by testing a panel of faecal samples collected from patients involved in outbreaks of gastroenteritis. When compared with reverse transcription-polymerase chain reaction (RT-PCR), the ELISA had a sensitivity and specificity of 55.5 and 98.3%, respectively. This compares with a sensitivity and specificity for EM of 23.9 and 99.2%, respectively. The sensitivity and specificity of the ELISA for determining the aetiology of a Norwalk virus-like outbreak, based on two or more positive samples within an outbreak, were 52.2 and 100% when two samples were collected from an outbreak and 71.4 and 100% when six or more samples were collected. The ELISA correctly identified the NLV genogroups of viruses previously characterised by partial DNA sequencing. The ELISA is a suitable alternative to the preliminary screening by EM for investigating outbreaks of gastroenteritis. Outbreaks, negative by ELISA should be examined by RT-PCR in order to detect strains non-reactive in the assay and virus strains from representative ELISA positive outbreaks should be characterised fully to allow the genetic diversity of NLVs co-circulating in the population to be described.

Protozoan enteric infection in AIDS related diarrhea in Thailand

The aim of this study was to determine the prevalence of enteric protozoa and other pathogens in AIDS patients with diarrhea in Bangkok, Thailand. Of 288 consecutive patients screened in the 10 month period between November 1999-August 2000 inclusive, 55 (19.2%) had Cryptosporidium spp, 13 (4.5%) had Isospora oocyst, 11 (3.8%) had Giardia lamblia, 3 (0.9%) had Entamoeba histolytica, and 1 (0.3%) had Iodamoeba butschlii infection. The prevalence of microsporidia was 11% in this study. Of 251 patients for whom stool culture for bacteria was performed, enteric bacterial pathogens isolated were Campylobacter spp in 18 (7.1%), Salmonella spp in 11 (4.3%), and Shigella spp in 1 (0.5%). Other pathogens found in these patients were Clostridium difficile in 16/102 (15.6%). Mycobacterium spp in 18/287 (6.2%), and Strongyloides stercoralis in 23/288 (8.0%). Overall, parasitic and bacterial pathogens were identified in 140 (48.6%) patients. These pathogens were identified by the routine simple wet smear technique in 32, formalin-ether concentration method in 46, culture for S. stercoralis in 5, and culture for bacteria in 30. Additional test, using modified Ziehl-Neelsen staining, identified cryptosporidial oocyst, isospora oocyst, and Mycobacterium spp in 72. The microsporidia, initially identified by modified trichrome blue staining, all were then determined to be Enterocytozoon bieneusi by thin sectioning electron microscopy. Protozoan and bacterial pathogens were confirmed to be important etiologic agents in diarrhea in AIDS in Thailand. They were all associated with increased mortality. Routine stool examination by simple wet smear detected only one-fourth of these pathogens. Therefore all diagnostic techniques for these organisms should be made more widely available in Thailand.

Growth of Trachipleistophora hominis (Microsporidia: Pleistophoridae) in C2,C12 mouse myoblast cells and response to treatment with albendazole

The microsporidium Trachipleistophora hominis Hollister, Canning, Weidner, Field, Kench et Marriott, 1996, originally isolated from human skeletal muscle cells, inhibited myotube formation from myoblasts when grown in a mouse myoblast cell line C2,C12. Uninfected cultures readily converted to myotubes. Albendazole, a drug with known antimicrosporidial activity, was tested against T. hominis in C2,C12 cells. The drug was added when infection had reached 75% of C2,C12 cells, a level comparable to that obtained in heavily infected muscle in vivo. Doses of 1 ng/ml and 10 ng/ml had no effect on merogony or sporogony. In cultures exposed to 100 ng/ml albendazole, the C2,C12 cells remained in good condition while infection levels dropped to 25% over 7 weeks. Drug doses of 500 ng/ml and 1,000 ng/ml were deleterious to the host cells but some spores retained viability and were able to establish new infections once albendazole pressure was removed. T. hominis meronts exposed to 100 ng/ml albendazole mostly lacked the normally thick surface coat and its reticulate extensions. Meronts were not seen in cultures exposed to higher drug doses. Albendazole at a concentration of 100 ng/ml and higher had a profound effect on spore morphogenesis. There was erratic coiling of the polar tube, often involving the formation of double tubes, and chaotic disposition of membranes which could have been those of polaroplast. The in vitro susceptibility of T. hominis to albendazole was low in comparison with in vitro susceptibility of other microsporidia of human origin.

Ultrastructure of Buddenbrockia identifies it as a myxozoan and verifies the bilaterian origin of the Myxozoa

The phylogenetic affinities of Buddenbrockia, a nematode-like parasite of freshwater bryozoans, have remained unknown since it was first reported in the nineteenth century. The discovery of Buddenbrockia parasitic in Hyalinella punctata in Ohio and Plumatella repens in France has provided material for the first ultrastructural study of this animal. This has revealed the presence of polar capsules, diagnostic myxozoan features, in the body wall. Other features, which place Buddenbrockia firmly among tetracapsulid myxozoans in the Class Malacosporea, are the unusual morphology of the polar capsules, the absence of the external tube in capsulogenesis, the body wall with its unusual cell junctions and utilization of freshwater bryozoans as hosts. The ultrastructural study has established the triploblastic organization of Buddenbrockia by confirmation of the presence of an inner layer of cells and 4 sets of longitudinal muscles. Our studies have, thus, simultaneously revealed that Buddenbrockia is a myxozoan and that the myxozoans are derived from bilaterians. The latter conclusion resolves the ongoing controversy over the triploblastic versus diploblastic nature of the Myxozoa. Our studies also provide evidence that bryozoans are ancestral hosts for the myxozoans and that loss of triploblast features has characterized the major radiation of the better known endoparasites of fish and worms in the Class Myxosporea.

Genotyping of Enterocytozoon bieneusi in AIDS patients from the north west of England

OBJECTIVES

In this study Enterocytozoon bieneusi -positive faeces samples from AIDS patients in the north west of England were investigated by polymerase chain reaction (PCR) and DNA sequencing for potential zoonotic origins.

METHODS

The ITS and flanking regions of the rDNA was amplified by PCR and product sequenced. Sequences were compared with those held on GenBank to ascribe known genotypes.

RESULTS

Of 13 E. bieneusi -positive samples tested, all gave a 508 bp amplification product by PCR. The samples yielded the following: genotypes B (n=11; so far only been found in humans), D (n=1; has been reported from humans and a laboratory macaque) and K (n=1; previously identified only from a cat).

CONCLUSIONS

A possible zoonotic link with cats has been demonstrated for one human case. The origin of the majority of cases in the north west of England is unknown and may indicate that genotype B is solely a human pathogen.

Interleukin 6 and C-reactive protein levels in patients with acute allergic reactions: an emergency department-based study

BACKGROUND

Elevations of interleukin 6 (IL-6) have been described in drug-induced anaphylaxis. Although IL-6 is well known to stimulate an acute phase response, profiling acute phase protein levels, such as C-reactive protein (CRP), has, to our knowledge, never been performed in patients with acute allergic reactions.

OBJECTIVE

To examine the pattern of IL-6 and CRP levels in patients with acute allergic reactions and to relate these to relevant clinical and laboratory parameters.

METHODS

Plasma CRP and serum IL-6 levels were determined in 85 adult emergency department patients. These patients had been previously studied with questionnaires, physical examinations, and histamine/tryptase levels. Clinical and historical features were related to CRP and IL-6 levels. CRP and IL-6 levels were also examined for relationships with histamine and tryptase levels.

RESULTS

CRP and IL-6 levels were significantly correlated with one another in the study patients (Spearman p = 0.36, P = 0.0008). Similar to histamine levels, IL-6 levels were significantly correlated with the extent of erythema manifested by the study patients. The extent of erythema was independently predicted by both IL-6 and histamine levels. Histamine levels were negatively correlated with CRP levels (Spearman p = -0.32, P = 0.003). Unlike histamine levels, IL-6 and CRP did not show significant relationships with the extent or presence of urticaria/angioedema or the presence of wheezing. IL-6 levels were correlated with the duration of symptoms before serologic sampling. An inverse correlation was observed between IL-6 levels and mean arterial blood pressure. Multivariate modeling showed significant independent effects from mean arterial pressure, duration of symptoms, erythema extent, and age in predicting IL-6 levels. Tryptase levels were higher in patients whose IL-6 levels were >20 pg/mL.

CONCLUSIONS

CRP and IL-6 levels are not simple surrogate markers for histamine or tryptase release by mast cells or basophils in acute allergic reactions. Increasing IL-6 levels relate to greater erythema extent, lower mean arterial blood pressure, and a longer duration of symptoms. It would be interesting to speculate that CRP and IL-6 increases characterize a late-phase response in immediate hypersensitivity reactions. In this perspective, the inverse relationship between CRP and histamine levels could be explained. As histamine levels are waning, CRP levels are increasing. Timed studies for histamine and CRP/IL-6 levels in allergic reactions are necessary to confirm this hypothesis.

Quality of service in nursing homes

This paper illustrates the relevance of using the Servqual instrument as a service quality measurement tool in the healthcare context. The expectations and perceptions of nursing home residents and their relatives are compared and contrasted to determine the priorities and satisfaction levels of both groups with respect to the services provided. Some interesting differences emerged between the two respondent groups, which gave more accurate and relevant pointers as to potential areas of future improvement. Because a number of nursing homes were surveyed, it was also possible to ascertain which homes might serve as useful examples of the best practice and which were in need of improvement action. In frail, elderly respondent groups it is not especially easy to elicit views as to quality of service. Servqual, carefully and sympathetically designed and applied, proved appropriate for this task.

Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists

STUDY OBJECTIVE

Although the addition of H(2) blockers to H(1) antagonists has been promoted for use in anaphylaxis, there have been no large studies establishing the advantage of this approach in treating acute allergic syndromes. In this study we tested the hypothesis that combined H(1) and H(2) blockage results in improved outcomes in patients treated for acute allergic syndromes compared with treatment with H(1) blockade alone.

METHODS

In a randomized, double-blind, placebo-controlled trial, 91 adult patients with acute allergic syndromes were treated with either 50 mg of diphenhydramine and saline solution (control group) or with 50 mg of diphenhydramine and 50 mg of ranitidine (active group). These patients were treated with parenteral administration. Patients were recruited from an emergency department at an urban academic medical center. The primary endpoints were resolution of urticaria, angioedema, or erythema at 2 hours after protocol treatment. Areas of cutaneous involvement, heart rates, blood pressures, respiratory findings, and symptom scores were also assessed at baseline, 1 hour, and 2 hours.

RESULTS

There were significantly more patients without urticaria at 2 hours among the patients in the active group compared with those in the control group. Both groups had similar proportions of urticaria at baseline. Logistic regression models to predict resolution of urticaria, which accounted for baseline urticarial involvement, showed odds ratios in favor of the active group treatment. Similar findings were observed when the absence of both urticaria and angioedema was considered as the dependent variable. There was not a significant difference between the 2 groups with regard to the absence of erythema or angioedema (irrespective of the presence of urticaria) at 2 hours. Blood pressure and symptoms did not show differences between the 2 groups over time. Lower heart rates were observed 1 hour after treatment in the active treatment group (mean reduction 10 beats/min) compared with those found in the placebo group (mean reduction 6 beats/min).

CONCLUSION

These data show that adding H(2) blockers to H(1) antagonists results in additional improvement of certain cutaneous outcomes for patients presenting with acute allergic syndromes. These findings favor the recommendation for using combined H(1) and H(2) antihistamines in acute allergic syndromes.

A new class and order of myxozoans to accommodate parasites of bryozoans with ultrastructural observations on Tetracapsula bryosalmonae (PKX organism)

Tetracapsula bryosalmonae, formerly PKX organism, is a myxozoan parasite that causes proliferative kidney disease in salmonid fish. Its primary hosts, in which it undergoes a sexual phase, are phylactolaemate bryozoans. It develops in the bryozoan coelomic cavity as freely floating sacs which contain two types of cells, stellate cells and sporoplasmogenic cells, which become organised as spores. Eight stellate cells differentiate as four capsulogenic cells and four valve cells which surround a single sporoplasmogenic cell. The sporoplasmogenic cell undergoes meiosis and cytoplasmic fission to produce two sporoplasms with haploid nuclei. Sporoplasms contain secondary cells. The unusual development supports previously obtained data from 18S rDNA sequences, indicating that species of Tetracapsula form a clade. It diverged early in the evolution of the Myxozoa, before the radiation that gave rise to the better known genera belonging to the two orders in the single class Myxosporea. The genus Tetracapsula as seen in bryozoans shares some of the characters unique to the myxosporean phase and others typical of the actinosporean phase of genera belonging to the class Myxosporea. However, it exhibits other features which are not found in either phase. A new class Malacosporea and order Malacovalvulida are proposed to accommodate the family Saccosporidae and genus Tetracapsula. Special features of the new class are the sac-like proliferative body, valve cells not covering the exit point of the polar filament, lack of a stopper-like structure sealing the exit, maintenance of valve cell integrity even at spore maturity, absence of hardened spore walls and unique structure of sporoplasmosomes in the sporoplasms.

Histamine and tryptase levels in patients with acute allergic reactions: An emergency department-based study

BACKGROUND

Emergency department visits for acute allergic reactions are common. Although the diagnosis and classification of these allergic reactions is primarily empiric, it is not always clear whether certain signs and symptoms constitute systemic mediator release syndromes, such as anaphylaxis, and thus may warrant more aggressive therapy or follow-up.

OBJECTIVE

We sought to determine associations between various clinical signs and symptoms with both plasma histamine levels and serum tryptase levels in adult patients presenting to an emergency department with acute allergic syndromes. The clinical correlates of raised beta-tryptase levels were also investigated.

METHODS

Ninety-seven adult emergency department patients were prospectively studied by using a questionnaire, physical examination, and serum-plasma sampling. Plasma histamine and serum total and beta-tryptase levels were determined. Clinical groupings were compared for mediator levels by using simple and multivariate analysis.

RESULTS

Elevated levels of plasma histamine (>10 nmol/L) and serum total tryptase (>15 ng/mL) were observed in 42 and 20 patients, respectively. Detectable beta-tryptase (>/=1 ng/mL) was observed in 23 patients, including 15 of the patients with elevated total tryptase levels. Suspected food allergy incidences and the duration of reaction were similar in patients with increased histamine levels and in patients with increased tryptase levels. Increased total tryptase levels, histamine levels, or both were observed in some patients who did not have airway, cardiovascular, or abdominal signs. Histamine levels correlated better with clinical signs than tryptase levels. Histamine elevations (>10 nmol/L) were observed more frequently in patients characterized by the following clinical signs in univariate analysis: the presence of urticaria, more extensive erythema, abnormal abdominal findings, and wheezing. Total tryptase increases were observed more frequently only in patients with urticaria. Histamine levels correlated with initial heart rates. In multivariate analysis the extent of urticaria was the best single predictor of plasma histamine levels and of either an elevated histamine or tryptase level. Detectable beta-tryptase levels were observed in some patients who had neither elevated total tryptase nor elevated histamine levels. Unlike patients without detectable beta-tryptase levels, patients who had detectable beta-tryptase levels had a significant correlation between total tryptase and histamine levels (P <.05).

CONCLUSIONS

Raised histamine and, less commonly, raised tryptase levels are observed in almost 50% of patients presenting to emergency departments with acute allergic reactions. Some cases associated with systemic mediator release do not have classical features of severe anaphylaxis, such as hypotension or tachycardia. The lack of total tryptase elevations in many patients with elevated plasma histamine levels suggests basophil involvement. The clinical utility of beta-tryptase determinations in the evaluation of acute allergic reactions needs further study.

Management of hospital outbreaks of gastro-enteritis due to small roundstructured viruses

Small round structured viruses (SRSVs, Norwalk-like viruses, NLVs) are the most common cause of outbreaks of gastro-enteritis in hospitals and also cause outbreaks in other settings such as schools, hotels, nursing homes and cruise ships. Hospital outbreaks often lead to ward closure and major disruption in hospital activity. Outbreaks usually affect both patients and staff, sometimes with attack rates in excess of 50%. For this reason, staff shortages can be severe, particularly if several wards are involved at the same time. SRSVs may be spread by several routes: faecal-oral; vomiting/aerosols; food and water. Viruses may be introduced into the ward environment by any of these routes and then propagated by person-to-person spread. In an outbreak setting, the diagnosis can usually be made rapidly and confidently on clinical and epidemiological grounds, particularly if vomiting is a prominent symptom. By the time an SRSV outbreak has been recognized at ward level, most susceptible individuals will have been exposed to the virus and infection control efforts must prioritize the prevention of spread of infection to other clinical areas bycontainment of infected/exposed individuals (especially the prevention of patient and staff movements to other areas), hand-hygiene and effective environmental decontamination. This report of the Public Health Laboratory Service Viral Gastro-enteritis Working Group reviews the epidemiology of outbreaks of infection due to SRSVs and makes recommendations for their management in the hospital setting. The basic principles which underpin these recommendations will also be applicable to the management of some community-based institutional outbreaks.

Emerging pathogens: Isospora, Cyclospora and microsporidia

Isospora belli, Cyclospora cayetanensis as well as several species of microsporidia are recognized as emerging protozoan pathogens of humans. All are obligate intracellular parasites, with Isospora and the microsporidia being primarily associated with immunocompromised hosts. Cyclospora is a cause of traveller's diarrhoea, and is responsible for water-borne and food-borne outbreaks of disease. Drug treatment is available for these infections. Improved diagnostic methods including the autofluorescence of I. belli and C. cayetanensis oocysts have assisted in the routine detection of these pathogens. Since the recognition of immunosuppression due to HIV infection, microsporidia have become recognized as important human pathogens with a continuing expansion of the parasite-associated clinico-pathological spectrum. The small size, intracellular nature and poor staining properties with many histological stains result in under-reporting of microsporidial infections. Trichrome stain and optical brighteners are used to detect spores in faeces, urines, respiratory secretions and other aspirates. Electron microscopy remains an important diagnostic method but its sensitivity is relatively poor. Molecular techniques should overcome current diagnostic limitations. The ability to extract DNA and amplify by PCR directly from clinical samples has increased the usefulness of molecular methods. Restriction fragment length polymorphism analysis of amplicons can be used to determine genus, species and strain types of various microsporidia. Increased specificity is required in primer design because current primers used for amplifying non-microsporidian DNA also amplify microsporidian DNA. Diagnosis and pathogen characterisation rely increasingly on PCR-based approaches, and the sequence analysis approach becomes increasingly feasible and affordable. However, robust, reliable and sensitive methods are still required for dissecting pathogenesis, epidemiology, transmission routes and sources of infections.

Electron microscopy as a tool for identifying new pathogens

Electron microscopy (EM) is still an important tool for the investigation of infectious diseases, despite the introduction of powerful new methods, mainly involving the polymerase chain reaction. Particularly in the field of parasitic protozoology associated with AIDS, where many new species of human pathogens have been recognized in tissue biopsies, EM remains an essential 'catch-all' diagnostic method. The resolved ultrastructural details of these newly recognized parasites allows a unique insight into the biology of these organisms. The information produced by EM is different, but complementary, to that provided by alternative methods.

Ultrastructure of Myxidium trachinorum sp. nov. from the gallbladder of the lesser weever fish Echiichthys vipera

Myxidium trachinorum sp. nov. is described from the gallbladder of the lesser weever fish Echiichthys vipera. Pseudoplasmodia attach themselves to the gallbladder epithelium by filose processes, which are inserted between host cells. Pseudoplasmodia undergo endogenous cell formation at the secondary and tertiary levels. In the proliferative cycle, primary and endogenous cells are packed with digestive vacuoles formed by phagocytosis. In the sporogonic cycle the pseudoplasmodium becomes a pericyte enclosing two secondary cells (lacking digestive vacuoles) in a vacuole. These give rise to five cells each two valvogenic, two capsulogenic and a binucleate sporoplasm, which mature into spores. Comparison of the disporic M. trachinorum with polysporic species of Myxidium revealed significant differences in plasmodial ultrastructure, especially their attachments to host cells, surface characteristics and mode of nutrition, and in formation of generative cells. These suggest that the genus Myxidium may require revision.

Human microsporidial infection and possible animal sources

Sources of human microsporidial infection remain speculative, but possible animal reservoirs are emerging. Of the common human microsporidial infections, Enterocytozoon bieneusi has now been identified in non-human primates, pigs, dogs and a cat; Encephalitozoon intestinalis in dogs, pigs, cows, goats and donkeys and Encephalitozoon hellem in budgerigars and parrots. Evidence of species heterogeneity is also emerging suggesting that some animal isolates may be distinctive. Further molecular epidemiological studies need to be undertaken to clarify which animal genotypes can also infect humans. Some of the less common microsporidial infections found in humans, such as those involving Pleistophora-like species, may be the result of infrequent accidental exposure (for example, inadequately cooked infected fish muscle) and establishment, particularly if the individual is severely immunocompromised.

Intraoperative bacterial contamination in operations for joint replacement

All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.

Intraoperative bacterial contamination in operations for joint replacement

All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty.

Vairimorpha imperfecta n.sp., a microsporidian exhibiting an abortive octosporous sporogony in Plutella xylostella L. (Lepidoptera: Yponomeutidae)

The microsporidian genus Nosema is characterized by development in direct control with host cell cytoplasm, diplokaryotic nuclei throughout development and disporous sporogony. The genus Vairimorpha exhibits the same features plus an octoporous sporogony producing uninucleate spores in a sporophorous vesicle. A microsporidium from diamondback moth, Plutella xylostella, falls between Nosema and Vairimorpha in that it initiates but fails to complete the octosporous sequence in this host. The name Vairimorpha imperfecta n.sp. is proposed. Merogony is mainly by formation of buds from multinucleate meronts, the buds remaining attached in chains. Diplokaryotic spores measure 4.3 x 2.0 microns (fresh) and have 15.5 coils of the polar tube in 1 rank. The octosporous sporogony is aborted owing to irregular formation of nuclear spindles, incomplete cytoplasmic fission and bizarre deposition of electron-dense episporontal secretions. Phylogenetic analyses of the sequences of the small subunit rRNA genes of V. imperfecta and of several Nosema and Vairimorpha spp. place V. imperfecta in a clade with Nosema spp. from Lepidoptera rather than in the clade containing the more typical species of Vairimorpha. It is suggested that the ancestors of the Vairimorpha/Nosema complex of species exhibited both disporous and octosporous sporogonies, as does the type species of Vairimorpha, Vairimorpha necatrix. It would follow that true Nosema spp. have lost the ability to express an octosporous sequence and that V. imperfecta is in the process of losing it. It is proposed that the genera Nosema and Vairimorpha be placed in the same family Nosematidae Labbé 1899, rather than in separate families and orders as at present.