Baseline NK cell frequencies are greater in individuals with asymptomatic SARS-CoV-2 infection compared to those that develop symptomatic illness

As NK cells are critical for control of viral infections, we tested the hypothesis that individuals with asymptomatic SARS-CoV-2 infection have greater NK cell frequencies prior to infection than individuals with mild, symptomatic infection. Marine recruits who elected to participate in the COVID-19 Health Action Response for Marines (CHARM) study were prospectively followed for two months twice weekly using PCR testing for SARS-CoV-2 infection and symptom questionnaires. Peripheral blood mononuclear cells obtained prior to infection during enrollment in the study and at various time points post-infection from 47 participants diagnosed with asymptomatic infection and 49 with symptomatic infection were analyzed by flow cytometry for frequencies of total NK cells, NK cell subsets, and surface expression of activating and inhibitory receptors. Consistent with our hypothesis, frequencies of total (CD3−CD14−CD19−CD56+) NK cells were significantly greater at baseline in asymptomatic compared to symptomatic participants (10.4% vs 8.3%, p = 0.015). This difference was due to increased frequencies of mature (CD56dimCD16+) NK cells in asymptomatic individuals (76.3% vs 69.8%, p = 0.049). No differences were observed in baseline frequencies of immature (CD56brightCD16−) or adaptive (CD56dimCD16+NKG2C+CD57+) NK cells, or in surface expression of activating (NKG2C, NKG2D) or inhibitory (NKG2A, KIR2DL1, KIR2Dl2/L3/S2, KIR3DL1) receptors. Frequencies of total and mature NK cells decreased significantly post-infection, reaching a nadir at 3–4 weeks. In contrast, frequencies of immature NK cells increased by 4 weeks. These results suggest that NK cells may play a protective role against symptomatic SARS-CoV-2 infection.

This work was supported by a grant from the Defense Health Agency through the Naval Medical Research Center (work unit number 9700130).

Control of established, CNS-resident lyssavirus infection by an adaptive immune response stimulated by single-dose monoclonal antibody therapy

Rabies virus and related lyssaviruses cause uniformly fatal disease, once the infection progresses to the central nervous system. Current lyssavirus immunotherapies are directed toward peripheral neutralization of virus to prevent CNS infection during the pre-symptomatic stage of disease. In this study, using an anti-lyssavirus human monoclonal antibody (mAb), F11, we evaluated the efficacy of immunotherapy on established lyssavirus infections in mice. Remarkably, using luminescence-based longitudinal tracing of virus infection in a mouse model of lethal disease, we found that a single dose of F11 reverses clinical signs of disease and protects animals from lethality following lyssavirus infection, even when administered after initiation of virus replication in the CNS. Investigation of the mechanisms of F11 efficacy revealed that F11-dependent neutralization is insufficient to protect animals from mortality. Control of infection requires an intact adaptive immune response, particularly CD4 T cells. Additionally, in vivo analysis of the F11-N297G mutant, which has defective FcRγ binding, showed a transiently increased viral load and increased morbidity when compared to F11 treated mice. Despite long-term survival and absence of clinical signs of disease in F11-treated animals, we found that lyssavirus infection persists chronically, concomitant with elevated expression of cellular immune response genes. These findings demonstrate that single-dose mAb therapy can stimulate an adaptive, T cell-dependent response that is durable and highly effective against an established CNS infection by a lethal neurotropic virus.

Supported by grants from the National Institute of Health (U01GM109887, R01AI125552), and a USU Program Project Grant (MIC-732515) and a USU Center for Global Health Engagement grant (HU00011920118)

Quality Improvement Within a Mental Health Setting: Alcohol Detoxification

Aims We describe a clinical audit on alcohol detoxification, using NICE guidelines as a comparable standard. NICE guidelines recommend completing a thorough alcohol history, documentation of a physical examination including screening for Wernicke's encephalopathy, monitoring of vital signs and liver investigations. Breath alcohol level and standardised assessment of withdrawal should be completed in addition to documentation of chlordiazepoxide and thiamine prescriptions. The reported mental health service completed the first cycle of the audit as part of a large-scale, international audit on alcohol detoxification by the Prescribing Observatory for Mental Health, UK (POMH-UK). Two additional audit cycles were completed within the service to ensure continuous quality improvement and clinical effectiveness. Methods Retrospective chart reviews were performed for admissions within pre-defined 6-month periods. Inclusion criteria: ICD-10 F10 diagnosis; prescription of alcohol detoxification schedule. Results This mental health service demonstrated greater compliance with the NICE standards in comparison to other services in the POMH-UK audit. The second-cycle audit showed increased compliance in most areas compared to the initial results. The third-cycle audit focused on two specific areas that required improvement to optimise quality improvement - Breath Alcohol Level and Clinical Institute of Withdrawal Assessment, documentation of which improved from 79% to 85% and 39% to 91% respectively in the final audit cycle. Conclusion The results of this audit indicate that adherence to defined clinical standards within this mental health service exceeds that of the benchmark POMH-UK data. The effectiveness of electronic patient records in improving adherence to set clinical standards, specifically in relation to documentation of clinical parameters is evident. The report also confirms continued improved results with each audit cycle within the service.

P3770Interatrial block: a prognostic factor for atrial fibrillation in cryptogenic stroke patients

Background

Atrial fibrillation (AF) is a well-known risk factor for ischemic stroke. Interatrial block (IAB), resulting from a conduction delay in Bachmann's bundle, is an electrical abnormality that, especially in its advanced (A-IAB) form, has been associated with atrial fibrotic cardiopathy and remodeling, sharing a common pathologic substrate with AF. Therefore, IAB has been proposed as a marker of atrial electromechanical dysfunction that may predispose to the development of AF. We hypothesized that IAB could be a marker of AF in patients with cryptogenic stroke (CS).

Methods

We retrospectively screened a cohort of CS patients with no prior history of AF, and collected their demographic, cardiovascular risk factors and other co-morbidities, stroke severity and resultant functional disability (NIHSS and mRS scales), CHA2DS2-VASc score, baseline 12-lead ECG, transthoracic echocardiogram, and neuroimaging studies on admission. All patients underwent continuous ECG monitoring for at least 48h. Forty-eight (64%) patients underwent additional out-patient 24h Holter monitoring following hospital discharge. P-wave (PW) analysis of baseline ECG classified patients into three groups: normal p-wave duration (N, PW <120 ms), partial IAB (P-IAB, PW ≥120 ms) and advanced IAB (A-IAB, PW ≥120 ms and biphasic morphology in leads DII, DIII and aVF). AF episodes (defined as irregular supraventricular arrhythmias without detectable PWs lasting >30 s), frequent premature atrial contractions (PACs) (>1%) and atrial tachyarrhythmia episodes (runs of >3 consecutive PACs) were detected on 24h Holter readings. Ischemic brain lesions were classified as cortical, subcortical or lacunar in relation to their localization and maximal diameter.

Results

Out of the 80 consecutive CS patients identified, 5 were excluded due to poor quality ECG readings. A high prevalence of both P-IAB (n=30, 40%) and A-IAB (n=23, 30.7%) was found in the final analysis with 75 CS patients. No differences were found between demographics, cardiovascular risk factors and co-morbidities, NIHSS, mRS and CHA2DS2-VASc scores, left atrial size and left ventricular ejection fraction among the 3 ECG categories. Cortical ischemic brain lesions were more frequent in patients in the IAB groups than in the N ECG group. After a mean follow-up of 522 days, AF was clinically diagnosed in 13 patients (17%), with an increasing risk in accordance to the severity of the IAB (p<0.05) (Figure 1A). 24h Holter readings showed greater frequency of PACs and atrial tachyarrhythmia episodes in patients with IAB (p<0.05) (Figure 1B).

Figure 1

Conclusions

In CS, IAB is associated with a greater risk to develop AF and its presence identifies a subgroup of patients with probable atrial fibrotic cardiopathy that could potentially benefit from early oral anticoagulation in secondary prevention.

Meaningful changes in the Short Form 12 physical and mental summary scores after total knee arthroplasty

BACKGROUND

The aim of this study was to identify minimal clinically important difference (MCID), minimal important change (MIC) and minimal detectable change (MDC) for the Short Form (SF-) 12 physical and mental component summary (PCS, MCS) scores after total knee arthroplasty (TKA) using an anchor based methodology.

METHODS

During a 10-year period, 2589 TKA were performed. SF-12 PCS and MCS scores were recorded preoperatively and at one year postoperatively. At one year, patients were asked "How much did the knee replacement surgery improve the quality of your life?" Their response was recorded as: a great improvement, moderate improvement, little improvement, no improvement at all, or the quality of my life is worse. Patients recording a little (n = 211) and no (n = 115) were used to calculate the MCID and the MIC. The MDC90 was calculated using distribution based methods for the whole cohort.

RESULTS

The MCID was 1.8 (p = 0.04) for the PCS and 1.5 (p = 0.33) for the MCS score. The MIC was 2.7 (p = 0.04) for the PCS and -1.4 (p = 0.17) for the MCS score. The MDC90 was 8.9 for the PCS and 13.8 for the MCS score.

CONCLUSION

The MCID for the PCS can be used to compare the outcomes between groups, and the MIC can be used to ensure that a clinical difference has been observed for a cohort of patients. The values for the MDC90 can be used to assess whether or not an individual patient has experienced a change.

The rate and predictors of patient satisfaction after total knee arthroplasty are influenced by the focus of the question: a standard satisfaction question is required

Aims

The primary aim of this study was to assess the rate of patient satisfaction one year after total knee arthroplasty (TKA) according to the focus of the question asked. The secondary aims were to identify independent predictors of patient satisfaction according to the focus of the question.

Patients and Methods

A retrospective cohort of 2521 patients undergoing a primary unilateral TKA were identified from an established regional arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 12-Item Short-Form Health Survey (SF-12) scores were collected preoperatively and one year postoperatively. Patient satisfaction was assessed using four questions, which focused on overall outcome, activity, work, and pain. Logistic regression analysis was used to identify independent preoperative predictors of increased stiffness when adjusting for confounding variables.

Results

Using patient satisfaction with the overall outcome (n = 2265, 89.8%) as the standard, there was no difference in the rate of satisfaction for pain relief (n = 2277, odds ratio (OR) 0.95, 95% confident intervals (CI) 0.79 to 1.14, p = 0.60), but patients were more likely to be dissatisfied with activities (79.3%, n = 2000/2521, OR 2.22, 95% CI 1.96 to 2.70, p < 0.001) and work (85.8%, n = 2163/2521, OR 1.47, 95% CI 1.23 to 1.75, p < 0.001). Logistic regression analysis identified different predictors of satisfaction for each of the focused satisfaction questions. Overall satisfaction was influenced by diabetes (p = 0.03), depression (p = 0.004), back pain (p < 0.001), and SF-12 physical (p = 0.008) and mental (p = 0.01) components. Satisfaction with activities was influenced by depression (p = 0.001), back pain (p < 0.001), WOMAC stiffness score (p = 0.03), and SF-12 physical (p < 0.001) and mental (p < 0.001) components. Satisfaction with work was influenced by depression (p = 0.007), back pain (p < 0.001), WOMAC function (p = 0.04) and stiffness (p = 0.05) scores, and SF-12 physical (p < 0.001) and mental (p < 0.001) components. Satisfaction with pain relief was influenced by diabetes (p < 0.001), back pain (p < 0.001), and SF-12 mental component (p = 0.04).

Conclusion

The focus of the satisfaction question significantly influences the rate and the predictors of patient satisfaction after TKA. Cite this article: Bone Joint J 2018;100-B:740-8.

Three groups of dissatisfied patients exist after total knee arthroplasty: early, persistent, and late

AIMS

The primary aim of this study was to assess whether patient satisfaction one year after total knee arthroplasty (TKA) changed with longer follow-up. The secondary aims were to identify predictors of satisfaction at one year, persistence of patient dissatisfaction, and late onset dissatisfaction in patients that were originally satisfied at one year.

PATIENTS AND METHODS

A retrospective cohort consisting of 1369 patients undergoing a primary TKA for osteoarthritis that had not undergone revision were identified from an established arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Short Form 12 (SF-12) questionnaire scores were collected preoperatively, and one and five years postoperatively. In addition, patient satisfaction was assessed at one and five years postoperatively. Logistic regression analysis was used to identify independent predictors of satisfaction at one and five years.

RESULTS

The overall rate of satisfaction did not change from one (91.7%, n = 1255) to five (90.1%, n = 1234) years (p = 0.16). Approximately half (n = 53/114) of the patients who were dissatisfied at one year became satisfied with their TKA at five years, whereas 6% (n = 74/1255) of those who were satisfied at one year became dissatisfied at five years. At one year, patients with lung disease (p = 0.04), with depression (p = 0.001), with back pain (p < 0.001), undergoing unilateral TKA (p = 0.001), or with a worse preoperative WOMAC pain score (p = 0.04) were more likely to be dissatisfied. Patients with gastric ulceration (p = 0.04) and a worse WOMAC stiffness score (p = 0.047) were at increased risk of persistent dissatisfaction at five years. In contrast, a worse WOMAC pain score (p = 0.01) at one year was a predictor of dissatisfaction in previously satisfied patients at five years.

CONCLUSION

Three groups of dissatisfied patients exist after TKA: 'early' dissatisfaction at one year, 'persistent' dissatisfaction with longer follow-up, and 'late' dissatisfaction developing in previously satisfied patients at one year. All three groups have different independent predictors of satisfaction, and potentially addressing risk factors specific to these groups may improve patient outcome and their satisfaction. Cite this article: Bone Joint J 2018;100-B:161-9.

UNILATERAL INHIBITION OF THE RENAL SHWARTZMAN PHENOMENON FOLLOWING INJECTION OF BACTERIAL FILTRATE INTO THE RENAL ARTERY

A positive Shwartzman reaction, as indicated by thrombosis and focal hemorrhage in one or more organs, was elicited in 19 of 34 rabbits in which the preparatory injection of bacterial filtrate was made into the left renal artery and the reacting injection was made in the ear vein 24 hours later. In 24 of the 34 rabbits the kidneys were undisturbed throughout the duration of the experiment except for the intra-arterial injection of the left. In 12 of these 24 a positive Shwartzman reaction was observed in the uninjected right kidneys. In only 1 of the 24 injected left kidneys were there changes that might be construed as representing a positive Shwartzman reaction. The changes in this kidney consisted of glomerular thrombosis, not associated with hemorrhage or necrosis. The positive renal Shwartzman reactions seen in the right kidneys were similar to those reported by Apitz and Gerber as representing the renal changes occurring as part of a generalized Shwartzman reaction. The retention of the bacterial filtrate of the preparatory injection in the left kidney, by obstructing both vein and artery for 15 minutes, did not lessen the refractory state. The removal of the right kidney prior to the experiment, with the subsequent demonstration that circulation through the remaining left kidney was not impaired by the intra-arterial injection of filtrate, indicated that the refractory state of the injected kidney was not the result of failure of the reacting dose of filtrate to reach the kidney. In the unilaterally nephrectomized rabbits the development of a positive reaction in other organs indicated that the lack of reaction in the kidney represented a local refractory state. No explanation of the phenomenon was disclosed by these experiments.

Reversible cytotoxic cerebral edema in cerebral fat embolism

We present a case of cerebral fat embolism (CFE) that demonstrated evidence of diffuse white matter cytotoxic edema on diffusion-weighted magnetic resonance imaging, in addition to punctate hyperintensities on T2-weighted and diffusion-weighted imaging. The case suggests that CFE represents a combination of occlusive arteriolar disease and secondary neurotoxicity.

Application of standardized mistletoe extracts augment immune response and down regulates metastatic organ colonization in murine models

The immunomodulatory and antimetastatic activity of standardized aqueous mistletoe extracts from plants grown on fir trees (ME-A) and pine trees (ME-P) were evaluated in BALB/c-mice. Regular subcutaneous (s.c.) and intraperitoneal (i.p.) applications (three times per week for 14 consecutive days; 5 and 50 microg per injection and mouse) upregulated thymus weight and peripheral blood leukocyte counts in tumor bearing mice. To check the influence of ME-A and ME-P treatment on growth of experimental metastases, RAW 117 H 10 lymphosarcoma cells and L-1 sarcoma cells were intravenously inoculated into BALB/c-mice to establish liver and lung colonization. ME-A and ME-P were regularly administered starting 24 h after tumor cell challenge. Organ colonization was investigated on day 14 after tumor cell inoculation and demonstrated statistically significant (P<0.05) reductions of experimental liver and lung metastases for ME-A and ME-P treated mice.

Flow-cytometric detection of lactase expression in normal and coeliac intestinal epithelium

OBJECTIVE

Enterocyte lactase expression is a useful marker of gluten toxicity. In this study, the technique of flow cytometry was evaluated to quantify lactase expression in coeliac disease (CD).

METHODS

Duodenal enterocyte suspensions were obtained from 23 patients with CD, four patients with dermatitis herpetiformis (DH), and 33 control subjects. The percentage of enterocytes that reacted with anti-lactase monoclonal antibody was determined by flow cytometry. In some subjects, organ culture of duodenal biopsies in the presence of various stimuli (including gluten fractions) was performed before enterocyte analysis.

RESULTS

This study demonstrated that lactase expression can be readily investigated semi-quantitatively using flow cytometry. Moreover, the level of expression correlated with the extent of mucosal damage in gluten-sensitive individuals. However, in organ culture experiments, lactase expression did not change in the presence of gluten or after marked T-cell activation for 48 h.

CONCLUSIONS

Measurement of enterocyte lactase expression by flow cytometry is a useful adjunctive test in the diagnosis and monitoring of gluten-sensitive enteropathy. However, lactase expression is not a suitable marker of gluten-induced toxicity in organ culture.

Randomized trial of folic acid supplementation and serum homocysteine levels

BACKGROUND

Lowering serum homocysteine levels with folic acid is expected to reduce mortality from ischemic heart disease. Homocysteine reduction is known to be maximal at a folic acid dosage of 1 mg/d, but the effect of lower doses (relevant to food fortification) is unclear.

METHODS

We randomized 151 patients with ischemic heart disease to 1 of 5 dosages of folic acid (0.2, 0.4, 0.6, 0.8, and 1.0 mg/d) or placebo. Fasting blood samples for serum homocysteine and serum folate analysis were taken initially, after 3 months of supplementation, and 3 months after folic acid use was discontinued.

RESULTS

Median serum homocysteine level decreased with increasing folic acid dosage, to a maximum at 0.8 mg of folic acid per day, when the homocysteine reduction (placebo adjusted) was 2.7 micromol/L (23%), similar to the known effect of folic acid dosages of 1 mg/d and above. The higher a person's initial serum homocysteine level, the greater was the response to folic acid, but there were statistically significant reductions regardless of the initial level. Serum folate level increased approximately linearly (5.5 nmol/L for every 0.1 mg of folic acid). Within-person fluctuations over time in serum homocysteine levels, measured in the placebo group, were large compared with the effect of folic acid, indicating that monitoring of the reduction in an individual is impractical.

CONCLUSIONS

A dosage of folic acid of 0.8 mg/d appears necessary to achieve the maximum reduction in serum homocysteine level across the range of homocysteine levels in the population. Current US food fortification levels will achieve only a small proportion of the achievable homocysteine reduction.

Genome sequence of Halobacterium species NRC-1

We report the complete sequence of an extreme halophile, Halobacterium sp. NRC-1, harboring a dynamic 2,571,010-bp genome containing 91 insertion sequences representing 12 families and organized into a large chromosome and 2 related minichromosomes. The Halobacterium NRC-1 genome codes for 2,630 predicted proteins, 36% of which are unrelated to any previously reported. Analysis of the genome sequence shows the presence of pathways for uptake and utilization of amino acids, active sodium-proton antiporter and potassium uptake systems, sophisticated photosensory and signal transduction pathways, and DNA replication, transcription, and translation systems resembling more complex eukaryotic organisms. Whole proteome comparisons show the definite archaeal nature of this halophile with additional similarities to the Gram-positive Bacillus subtilis and other bacteria. The ease of culturing Halobacterium and the availability of methods for its genetic manipulation in the laboratory, including construction of gene knockouts and replacements, indicate this halophile can serve as an excellent model system among the archaea.

Increased HLA-DR and CD44 antigen expression in the gut: evidence of extraarticular immunological activity in rheumatoid arthritis

OBJECTIVE

To examine the gastrointestinal (GI) immune system in rheumatoid arthritis (RA) for evidence of activation.

METHODS

Duodenal biopsies from 25 patients with RA were obtained by endoscopy. Single cell suspensions from the epithelial layer and lamina propria were prepared. Flow cytometry was used to examine the expression of CD4, CD8, T cell receptor-gammadelta (TCR-gammadelta), TCR-alphabeta, HLA-DR, CD44, and interleukin 2 receptor on gut T lymphocytes. Fifteen disease control (DC) individuals and 6 patients with osteoarthritis (OA) taking longterm nonsteroidal antiinflammatory drug (NSAID) therapy were also investigated. Peripheral blood T lymphocytes from all individuals were examined for the expression of these surface molecules.

RESULTS

HLA-DR expression was significantly increased on intraepithelial lymphocytes (IEL) and enterocytes from patients with RA (n = 13) compared with the 2 control groups (p<0.01). Immunohistochemistry also revealed increased expression of HLA-DR on enterocytes from patients with RA. RA IEL (n = 6) expressed significantly higher levels of CD44 (p<0.02). In the lamina propria, a small but significant gammadelta T lymphocyte population (mean 5.5%, range 2-12%) was detected in rheumatoid factor positive RA patients (n = 8) compared with RF negative RA patients (n = 8, mean 2%, range 0.4-6%; p<0.01) and the disease control group (n = 15, mean 2%, range 0.5-5%; p<0.01). None of these changes were detectable in peripheral blood lymphocytes from patients with RA.

CONCLUSION

This study demonstrates evidence of activation of specific components of the GI immune system in RA. Peripheral blood T lymphocytes from patients with RA did not show increased expression of activation markers, suggesting that changes in the RA GI tract are not systemic but localized. Moreover, these changes appear to be independent of NSAID therapy.

Lansoprazole is superior to ranitidine as maintenance treatment for the prevention of duodenal ulcer relapse

AIM

To compare lansoprazole 30 mg once daily, lansoprazole 15 mg once daily and ranitidine 150 mg once nightly in the prevention of duodenal ulcer relapse in patients whose duodenal ulcers had been previously healed with lansoprazole 30 mg once daily or ranitidine 300 mg nightly.

METHODS

A double-blind, parallel group, randomized multicentre study conducted in 33 centres in the UK, Eire, Sweden and Australia. Two hundred and nineteen patients with a duodenal ulcer were randomized to receive lansoprazole 30 mg and 217 to receive ranitidine 300 mg for 8 weeks. Patients were then re-randomized to receive lansoprazole 30 mg (122 patients), lansoprazole 15 mg (121 patients) or ranitidine 150 mg (116 patients) for 12 months. All patients had an endoscopically-proven duodenal ulcer at baseline and were considered suitable for long-term maintenance therapy to prevent relapse.

RESULTS

Significantly more patients were healed on lansoprazole (98%) compared to ranitidine (89%) (P < 0.001, Fisher's exact test). Lansoprazole provided more rapid symptom relief than ranitidine. Lansoprazole 30 mg and lansoprazole 15 mg increased the probability of not relapsing in comparison to ranitidine (P = 0.001 and 0.06, respectively, life-table analysis). Relapse rates over the 12 months were lower in the lansoprazole treatment groups (lansoprazole 30 mg, 5%; lansoprazole 15 mg, 12%; and ranitidine, 21%; lansoprazole 30 mg vs. ranitidine 150 mg, P = 0.002). Symptoms were well controlled in both groups during the maintenance phase. All treatments were well tolerated with no major differences seen in adverse event profiles between treatment groups.

CONCLUSIONS

Both doses of lansoprazole (30 mg and 15 mg) were superior to ranitidine 150 mg in the prevention of duodenal ulcer relapse. Lansoprazole was superior to ranitidine in terms of symptom control and duodenal ulcer healing. Both treatments were well tolerated.

Carriage of Neisseria meningitidis and Neisseria lactamica among ethnic Greek school children from Russian immigrant families in Athens

During February and March 1995, a survey of meningococcal carriage in 625 school children was carried out in a suburb of Athens in which there was a large number of ethnic Greeks who had immigrated from Russia beginning in the early 1990s. The objectives of the study were: (1) to determine if factors associated with carriage of meningococci observed in a previous study of Greek school children were similar for the immigrant population; (2) to compare phenotypic characteristics of meningococci from the immigrant population with those isolated from children in Athens. Overall isolation rate for meningococci was 82/625 (13.1%), significantly higher than that found for school children in Athens (5.8%) during the winter of 1990 1991 (5.8%) (chi=25.98, P=0.0000003). By univariate analysis, carriage was not associated with sex, number of individuals per household, blood group, secretor status, socioeconomic level or maternal smoking; however, it was associated with fathers' smoking. The high proportion of men who smoked compared with the low proportion of women smokers might contribute to this finding. The main serogroup of meningococci isolated from this population was A (28%). While serogroup A appears to be more prevalent among Russian and Kurdish immigrants (14%) than among Greek school children or military recruits (4%), there has not been an increase in group A meningococcal disease in Greece. The isolation rate for N. lactamica was high 105/625 (17.3%). A few of these strains bound some of the monoclonal antibodies used for meningococcal serotyping and subtyping, and they are being examined in greater detail.

Perceived social support and community adaptation in schizophrenia

Prompted by the continuing transition to community care, mental health nurses are considering the role of social support in community adaptation. This article demonstrates the importance of distinguishing between kinds of social support and presents findings from the first round data of a longitudinal study of community adaptation in 156 people with schizophrenia conducted in Brisbane, Australia. All clients were interviewed using the relevant subscales of the Diagnostic Interview Schedule to confirm a primary diagnosis of schizophrenia. The study set out to investigate the relationship between community adaptation and social support. Community adaptation was measured with the Brief Psychiatric Rating Scale (BPRS), the Life Skills Profile (LSP) and measures of dissatisfaction with life and problems in daily living developed by the authors. Social support was measured with the Arizona Social Support Interview Schedule (ASSIS). The BPRS and ASSIS were incorporated into a client interview conducted by trained interviewers. The LSP was completed on each client by an informal carer (parent, relative or friend) or a professional carer (case manager or other health professional) nominated by the client. Hierarchical regression analysis was used to examine the relationship between community adaptation and four sets of social support variables. Given the order in which variables were entered in regression equations, a set of perceived social support variables was found to account for the largest unique variance of four measures of community adaptation in 96 people with schizophrenia for whom complete data are available from the first round of the three-wave longitudinal study. A set of the subjective experiences of the clients accounted for the largest unique variance in measures of symptomatology, life skills, dissatisfaction with life, and problems in daily living. Sets of community support, household support and functional variables accounted for less variance. Implications for mental health nursing practice are considered.

Quality of life during acute and intermittent treatment of gastro-oesophageal reflux disease with omeprazole compared with ranitidine. Results from a multicentre clinical trial. The European Study Group

AIMS

To investigate quality of life in patients with gastro-oesophageal reflux disease.

PATIENTS

A series of 704 patients were randomised to treatment with ranitidine 150 mg bd, omeprazole 10 mg om or omeprazole 20 mg om for 2 weeks. Asymptomatic/mildly symptomatic patients were followed for 12 months.

METHODS

The Psychological General Well-Being index and the Gastrointestinal Symptom Rating Scale were completed before and during short-term and intermittent treatment.

RESULTS

The quality of life response rate was > 80%. The majority of the patients receiving omeprazole 20 mg om (55%) had symptom relief after 2 weeks despite the fact that more patients on ranitidine required 4 weeks' treatment and an increased dose. There was no difference in the reflux dimension of Gastrointestinal Symptom Rating Scale between treatments in the initial treatment phase, but the total Gastrointestinal Symptom Rating Scale score improved significantly more on omeprazole 10 mg om than on ranitidine 150 mg bd (p = 0.006). Both doses of omeprazole improved the total Psychological General Well-Being score more than ranitidine (omeprazole 10 mg om versus ranitidine 150 mg bd, p = 0.005, omeprazole 20 mg om versus ranitidine 150 mg bd, p = 0.031). During follow-up, relapsing patients returned to pre-treatment symptom and well-being scores, but these dimensions were restored after treatment.

CONCLUSION

The quality of life is impaired in patients presenting with reflux symptoms. Irrespective of whether the patients presented with endoscopy positive or endoscopy negative reflux disease, treatment on demand improved the quality of life.

Recommendations for using reverse staging to complete the MDS-2

The use of the Minimum Data Set (MDS) for documentation in long term care has resulted in the widespread reliance on reverse staging to document the healing of pressure and venous ulcers. This article presents a pragmatic approach for defining the healing process in a staging nomenclature so that it is physiologically accurate.

Human umbilical vein endothelial cells: a new easily available source of endomysial antigens

OBJECTIVE

To evaluate human umbilical vein endothelial cells (HUVEC) as an alternative source of endomysial antigen (EmAg) and to assess their suitability for the detection of endomysial antibodies (EmA) in coeliac disease (CD).

METHODS

HUVEC were reacted on glass slides with patient sera and examined by fluorescent microscopy. Flow cytometry was used to determine whether the EmAg was expressed on the surface of the cells or was intracellular. Absorption studies were used to confirm the specificity of results.

RESULTS

The data presented here show that HUVEC contain an intracellular antigen that binds to immunoglobulin A (IgA) from patients with active CD. Correlation studies showed that HUVEC antibodies were present in the sera of all patients that contained EmA and reticulin IgA antibodies whereas reticulin antibodies were only present in 24 of the 31 patients who were either EmA or HUVEC positive. All of the sera tested which were negative for EmA were also negative for HUVEC antibodies. Ten patients with Crohn's disease and 10 patients with ulcerative colitis were negative for HUVEC or EmA reactivity, as were 16 control subjects attending the gastroenterology clinic with non-specific symptoms and normal small intestinal biopsies.

CONCLUSIONS

These findings suggest that the antigen found in HUVEC is antigenically similar to that found in reticulin and endomysium and that all three antigens may be the same. In contrast to the monkey oesophagus, HUVEC offer an easily available antigen for the serological diagnosis of coeliac disease.

Chemotherapy with vincristine/ifosfamide/carboplatin/etoposide in small cell lung cancer

Although chemotherapy is considered the cornerstone of treatment for small cell lung cancer (SCLC), the majority of SCLC patients relapse and die of their disease within 2 years of diagnosis. Until newer, more effective drugs are developed, both optimization of available chemotherapeutic regimens and the use of combined chemotherapy/radiotherapy will be required to improve the survival of SCLC patients. Combining ifosfamide, carboplatin, and etoposide, among the most active single agents against SCLC, into the ICE regimen was a logical move that has resulted in improved response and survival rates. In limited and extensive SCLC, respectively, ICE and ICE administered with vincristine (VICE) have achieved overall response rates of 79% to 94% and 77% to 100% and 2-year survival rates of 24% to 33% and 9% to 25%, respectively. Treatment-related toxicities, especially myelosuppression, have hindered efforts to accelerate the administration of ICE and VICE regimens and to incorporate them into combined-modality treatments. However, the use of hematologic support measures, including growth factors and peripheral blood progenitor cells, may pave the way for maximizing the effectiveness of these regimens.

Perceptions of stressors and reported coping strategies in nurses caring for residents with Alzheimer's disease in a dementia unit

A study was undertaken on the perceptions of stressors and coping behaviours in a group of nurses caring for residents with Alzheimer's disease in a dementia unit. The purpose of this paper is to report on the preliminary findings of the study. Repertory grid data were used to explore how nurses perceive residents, the stressors nurses experience in their work, and the coping strategies nurses use when caring for residents. The nurses identified 92 sources of stress, 683 coping behaviours and 708 coping strategies. Analyses of selected repertory grid data are presented and the stressors reported by the nurses are summarized. The coping strategies the nurses report using are classified into categories of adaptive and maladaptive responses to stress. In addition, the nursing implications of the coping strategies used by the nurses are also considered.

Retrospective analysis of healing in wounds cared for by ET nurses versus staff nurses in a home setting

The continually growing home car market is seeing a higher percentage of patients with wounds. The findings of this investigation may assist the industry in determining whether the higher cost of employing ET nurses is justified. This study compared the outcome of wound care in the home setting provided by ET nurses with outcomes of wound care provided by staff nurses in the same setting. The investigation was a retrospective study of the total population of patients with wounds (n = 519) admitted to five home care agencies in central and south Florida over an 18-month period. The sample consisted of 344 wounds cared for by ET nurses and 464 wounds cared for by staff nurses. The following data were collected through retrospective review of the records: stage of wounds, descriptions of the wounds, types of wounds, number of nursing visits, number of healed wounds, and time to heal each wound. Only 36.3% of the wounds not cared for by ET nurses healed in the time the patients were seen for skilled-nursing services by the home health care agencies. Of the ET-nursed wounds, 78.5% healed. The average number of skilled-nursing visits for patients not nursed by ET nurses was less than 17. ET-nursed patients were seen an average of 31.6 visits.

Parental smoking and carriage of Neisseria meningitidis among Greek schoolchildren

In December 1990 and January 1991, primary (320) and secondary (697) pupils in 2 areas of Athens were screened to determine the rate of carriage of Neisseria meningitidis and to determine if the genetic and environmental factors associated with carriage of meningococci in Greece were similar to those observed for northern European populations. In 1 area, socioeconomic indicators were significantly lower than in the other (p < 0.0005), but the isolation rates from pupils in the areas were similar, 5.3% and 6.3%. In contrast to studies in northwest Europe, carriage was not associated with lower socioeconomic conditions, sex, numbers of individuals per household, upper respiratory tract infection, or secretor status. By univariate analysis, carriage was associated with age (15-18 years) (p < 0.05) and mother's or other carer's smoking habits (p < 0.05)--but not father's smoking. Although the proportion of fathers who smoked was greater in the area where socioeconomic indicators were lower (61%) vs. (47%) (p < 0.0005), the proportions of women smokers were similar (33% vs. 38%). By multiple regression analysis, the only significant factors were age (p < 0.01) and carer's smoking (p < 0.05).

Reversed-phase high-performance liquid chromatographic method for the quantitation of endogenous folate catabolites in rat urine

We describe a reversed-phase high-performance liquid chromatographic procedure for the analysis of rat urine for p-aminobenzoylglutamate (pABGlu) and its acetamido derivative (p-acetamidobenzoylglutamate, apABGlu). These two catabolites arise following the in vivo cleavage of the folate molecule at the C-9-N-10 bond. Known quantities of high-specific-activity tritiated forms of the catabolites are added as internal standards to aliquots of rat urine. Following preliminary sample clean-up on C18 Sep-Pak cartridges, including derivatisation in the case of pABGlu, the urinary extracts are quantitated by HPLC. The present assay makes possible for the first time the determination of endogenous folate breakdown in the rat.

Flow cytometric analysis of surface major histocompatibility complex class II expression on human epithelial cells prepared from small intestinal biopsies

A technique for preparing viable, single cell suspensions of the epithelial layer of small intestinal tissue obtained endoscopically is described. Constant agitation of four biopsies for 60 min in the presence of chelating and reducing agents gave yields of 1.2-6.7 x 10(6) cells, of which 11-30% were intraepithelial lymphocytes (IEL). Passage through a nylon wool column removed dead cells. This preparation was suitable for flow cytometric analysis. Using this technique, surface MHC class II molecule expression was studied in 14 patients with normal small intestinal mucosa. Fluorescence labelling of these cells showed strong HLA-DR expression by epithelial cells (EC), DP was expressed less strongly, while little DQ expression could be detected. This technique demonstrates that small intestinal biopsies taken during routine endoscopy can yield adequate numbers of viable epithelial cells to perform flow cytometric analysis.

The quantitative analysis of endogenous folate catabolites in human urine

In man folates are catabolized and excreted as inactive cleaved degradation products, a mixture of pteridines and p-aminobenzoylglutamate (pABGlu) or its acetamido derivative (apABGlu). The daily rate of excretion represents the inescapable use of the vitamin in metabolic activity and thus has implications for determining the recommended dietary allowance for the vitamin. Furthermore, the rate of catabolism has been suggested to rise during pregnancy and in certain disease states. A method is described for the quantitative extraction and assay of the folate catabolites pABGlu and apABGlu in human urine. Aliquots of 24-h urine collections are acidified and applied to columns of Dowex 50W cation-exchange resin. The catabolites are selectively batch-eluted with increasing concentrations of HCl. The fraction containing pABGlu is diazotized and then applied to a C18 Sep Pak column for further purification and concentration. The fraction containing apABGlu was deacetylated and reapplied to the Dowex column and then treated identically to the pABGlu fraction. The methanolic concentrates of both extracts were evaporated to dryness and reconstituted with water and pABGlu was regenerated by reductive cleavage of the diazotized material with Zn/HCl. The extracts of the two catabolites were separated by reverse-phase HPLC using a Radial Pak C18 column. Recovery of isolated material was monitored by the addition of high specific activity tritiated labels of both compounds added as internal standards to all urine aliquots prior to purification and analysis.

The effect of Mycoplasma arthritidis infection on the phagocytic activity of macrophages in rats and mice

The phagocytic activity of mononuclear phagocytes of A/J mice and Wistar rats was estimated by the carbon clearance test following injection of Mycoplasma arthritidis. In mice, the overall phagocytic activity was significantly increased at the end of the first week (P less than 0.0001), but the increase was marginal by the third and fourth weeks after injection. A significant increase in the relative weight of liver and spleen was observed even when phagocytic activity had returned to levels similar to those of controls (P less than 0.001). In rats, the overall phagocytic activity was significantly increased until the fourth week (P less than 0.00001). There was not, however, an increase in the relative weight of liver and spleen as observed for the mice. The results are discussed in the context of factors contributing to the pathogenic mechanisms responsible for differences in the patterns of arthritis due to mycoplasma observed in mice and rats.

HLA-DP and coeliac disease: family and population studies

We investigated polymorphism of HLA-DP genes in three DR3 related diseases, confirming an association of coeliac disease with a Bgl II DP alpha polymorphism (a restriction fragment sized 3.5 kb present in 75% of patients compared to 34% of control subjects, p less than 0.001), and finding a weaker association with dermatitis herpetiformis (57% v 34%, p = 0.01) and no association with insulin dependent diabetes mellitus. The association with coeliac disease was further investigated. Msp I DP beta polymorphism was studied in 52 healthy subjects and 59 patients: a 4.9 kb fragment was present in 51% of patients with coeliac disease compared to 11.5% of control subjects (p less than 0.001). Furthermore, nearly all subjects with the DP alpha 3.5 kb fragment also had the DP beta 4.9 kb fragment. However, disease frequency was still increased in the DP alpha 3.5 positive/DP beta 4.9 negative group. In seven families, each with at least two affected members, while the DP alpha 3.5 fragment was frequently present in patients it did not preferentially segregate with any particular HLA haplotype--for example, those associated with DR3 or DR7--and therefore is not part of an extended haplotype associated with coeliac disease. We therefore conclude that a gene(s) in the HLA-DP region predisposes to coeliac disease independently of the HLA-DR/DQ regions.

Intrazeolite photochemistry. VI. Diffuse reflectance laser flash photolysis and product studies of diphenylmethyl radicals on solid supports

Diphenylmethyl radicals have been generated by 266 nm laser excitation of 1,1,3,3-tetraphenylacetone adsorbed on silica gel and included in NaX and Silicalite zeolites and have been studied using diffuse reflectance laser flash photolysis techniques. The spectrum for the radical shows λmax at ~335 nm in all three supports and is similar to that in solution. The radicals decay over time scales that vary from hundreds of nanoseconds to minutes and there are indications that some radicals may be decaying on shorter time scales than we can monitor. The efficiency of oxygen quenching increases in going from Silicalite to NaX to silica gel, consistent with the greater accessibility of oxygen to silica gel pores as compared to the narrow channels in Silicalite. Laser dose and ketone loading effects were also examined for the various supports. Potential applications of a kinetic treatment of the data based on dispersive reaction kinetics are also discussed as a means of dealing with the problem of decay kinetics that occur over a wide range of time scales. Keywords: zeolites, kinetics, diphenylmethyl radicals, laser photolysis.

Severity of cirrhosis and the relationship of alpha 1-acid glycoprotein concentration to plasma protein binding of lidocaine

The concentration of alpha 1-acid glycoprotein, the major determinant of the plasma protein binding of basic drugs, and the extent of lidocaine protein binding was related to the severity of liver disease in 30 cirrhotic patients. In comparison with matched control subjects, alpha 1-acid glycoprotein concentration (77 +/- 7 versus 37 +/- 3 mg/dl; mean +/- SEM; p less than 0.01) and lidocaine binding (69% +/- 2% versus 35% +/- 2%; p less than 0.01) was markedly reduced. There was a significant negative correlation (r = 0.78; p less than 0.01) between free lidocaine and alpha 1-acid glycoprotein concentration. Furthermore, both were significantly related to the severity of liver disease, as assessed by use of the Child Turcotte classification.