Pregnancy Care Utilization, Experiences, and Outcomes Among Undocumented Immigrants in the United States: A Scoping Review

BACKGROUND

Undocumented immigrants face many barriers in accessing pregnancy care, including language differences, implicit and explicit bias, limited or no insurance coverage, and fear about accessing services. With the national spotlight on maternal health inequities, the current literature on undocumented immigrants during pregnancy requires synthesis.

OBJECTIVE

We aimed to describe the literature on pregnancy care utilization, experiences, and outcomes of undocumented individuals in the United States.

METHODS

We performed a scoping review of original research studies in the United States that described the undocumented population specifically and examined pregnancy care utilization, experiences, and outcomes. Studies underwent title, abstract, and full-text review by two investigators. Data were extracted and synthesized using descriptive statistics and content analysis.

RESULTS

A total of 5,940 articles were retrieved and 3,949 remained after de-duplication. After two investigators screened and reviewed the articles, 29 studies met inclusion criteria. The definition of undocumented individuals varied widely across studies. Of the 29 articles, 24 showed that undocumented status and anti-immigrant policies and rhetoric are associated with decreased care utilization and worse pregnancy outcomes, while inclusive health care and immigration policies are associated with increased prenatal and postnatal care utilization as well as improved pregnancy outcomes.

CONCLUSIONS

The small, heterogeneous literature on undocumented immigrants and pregnancy care is fraught with inconsistent definitions, precluding comparisons across studies. Despite areas in need of further research, the signal among published studies is that undocumented individuals experience variable access to pregnancy care, heightened fear and stress regarding their status during pregnancy, and worse outcomes compared with other groups, including documented immigrants.

Establishing Academic Homes for Homelessness: A Call to Action

Although homelessness ranks as one of society's most pressing and visible health equity challenges, the academic community has not actively addressed its health impacts, root causes, and potential solutions. Few schools and programs of public health even offer a basic course for students. In the COVID-19 pandemic era, academia must demonstrate urgency to address homelessness and educate learners, motivate fledgling researchers, inform policy makers, offer community-engaged and evidence-based studies, and join in the growing national debate about best approaches. At a minimum, every public health student should understand the interdisciplinary challenges of homelessness, its implications for health equity, and opportunities to address the crisis. We call for academia, particularly schools and programs of public health, to engage more fully in national partnerships to care for members of society who are most marginalized, in terms of health and behavioral health outcomes, quality of life, and connectedness.

Investigating strategies to increase general education teachers' adherence to evidence-based social-emotional behavior practices: A meta-analysis of the single-case literature

Educational researchers have produced a variety of evidence-based practices (EBP) to address social, emotional, and behavioral (SEB) needs among students. Yet, these practices are often insufficiently adopted and implemented with fidelity by teachers to produce the beneficial outcomes associated with the EBP, leaving students at risk for developing SEB problems. If ignored, SEB problems can lead to other negative outcomes, such as academic failure. Therefore, implementation strategies (i.e., methods and procedures designed to promote implementation outcomes) are needed to improve teachers' uptake and delivery of EBPs with fidelity. This meta-analysis sought to examine the types and magnitude of effect of implementation strategies that have been designed and tested to improve teacher adherence to SEB EBPs. Included studies (a) used single case experimental designs, (b) employed at least one implementation strategy, (c) targeted general education teachers, and (d) evaluated adherence as a core dimension of fidelity related to the delivery of EBPs. In total, this study included 28 articles and evaluated 122 effect sizes. A total of 15 unique implementation strategies were categorized. Results indicated that, on average, implementation strategies were associated with increases in teacher adherence to EBPs above baseline and group-based pre-implementation trainings alone (g = 2.32, tau = 0.77). Moderator analysis also indicated that larger effects were associated with implementation strategies that used a greater number of unique behavior change techniques (p < .001). Implications and future directions for research and practice regarding use of implementation strategies for general education teachers are discussed.

Validation and Use of the Measure of Effective Attributes of Trainers in School-Based Implementation of Proactive Classroom Management Strategies

In-service training is a critical and frequently utilized implementation strategy to support the adoption and delivery of evidence-based practice (EBP) across service settings, but is characteristically ineffective in producing provider behavior changes, particularly when delivered in single exposure didactic events. EBP trainers are in a strategic position to leverage their trainee-perceived characteristics to influence trainees' attitudes, motivation, and intentions to implement, and ultimately increase the likelihood of successful uptake of skills. The purpose of this study was to extend research on the measure of effective attributes of trainers (MEAT) by examining its underlying factor structure and reliability in the context of in-service EBP training for teachers (i.e., structural validity). This study also examined the predictive validity of the MEAT by examining relationships with a measure of teacher intentions to implement EBPs following a standardized training experience (i.e., predictive validity). An exploratory factor analysis (EFA) was employed to determine the latent factors (i.e., subscales of characteristics) that underlie the data. Additionally, a forward selection, stepwise regression was conducted to determine the extent to which trainer attributes could explain variance in intentions to implement. Results indicated that the MEAT was a valid and reliable measure to examine trainer attributes in school settings. Moreover, findings suggested that trainer attributes, particularly those related to trainee perceptions of the trainers' welcoming disposition (i.e., related to trainers' warm, positive temperament and internal character traits), were significantly associated with trainees' intentions to implement the trained upon EBP.

Training Clinicians to Care for Patients Where They Are

Homelessness remains a pervasive, long-standing problem in the United States and is poised to increase as a result of the COVID-19 pandemic. Individuals experiencing homelessness bear a higher burden of complex medical and mental health illnesses and often struggle to obtain quality and timely health care. The United States desperately needs to train a workforce to confront this large and growing crisis, but few health professional schools currently devote curricula to the clinical needs of people experiencing homelessness. This article discusses educational and curricular strategies for health professional students. Understanding the health needs of-and the social influences on the lives of-people experiencing homelessness is crucial for addressing this health equity challenge.

Improving the Delivery of Chronic Opioid Therapy Among People Living With Human Immunodeficiency Virus: A Cluster Randomized Clinical Trial

BACKGROUND

Chronic pain is prevalent among people living with human immunodeficiency virus (PLWH); managing pain with chronic opioid therapy (COT) is common. Human immunodeficiency virus (HIV) providers often diverge from prescribing guidelines.

METHODS

This 2-arm, unblinded, cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015 to 2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing, and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences.

RESULTS

At 12 months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs 20%; adjusted odds ratio [AOR], 13.38 [95% confidence interval {CI}, 5.85-30.60]; P < .0001). We did not detect a statistically significant difference in early refills (22% vs 30%; AOR, 0.55 [95% CI, .26-1.15]; P = .11), pain severity (6.30 vs 5.76; adjusted mean difference, 0.10 [95% CI, -1.56 to 1.75]; P = .91), or HIV viral load suppression (86.9% vs 82.1%; AOR, 1.21 [95% CI, .47-3.09]; P = .69).

CONCLUSIONS

TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.

Abstract B124: Breast cancer treatment delays at an urban safety net hospital among women experiencing homelessness

Abstract Disparities in outcomes for vulnerable women is a persistent, ongoing problem. Timely treatment improves breast cancer outcomes and efforts to improve delays among underserved patients is needed. Specifically, homelessness and breast cancer treatment outcomes are understudied. This is a novel and descriptive study exploring types of homelessness and treatment delays at an urban safety net hospital providing care to a vulnerable patient population. Experimental Procedures This study is a retrospective chart review of homeless female patients diagnosed with breast cancer between January 1, 2000 and December 31, 2014. Data for this study were acquired from the hospital cancer registry and electronic medical record. Homelessness was categorized as transitionally, episodically or chronically homeless. Other variables collected included demographic characteristics and time to treatment. A detailed chart review was conducted to identify delays to breast cancer treatment and the potential reasons for delay between diagnosis and first treatment. All demographic characteristics, time to treatment and factors related to delays to treatment were analyzed descriptively, reporting frequencies and proportions. Delay to treatment was calculated as date of pathologically confirmed biopsy of breast cancer to date of first treatment (surgery or chemotherapy). Summary of Data The total number of individuals analyzed was 24. All except two subjects were delayed to treatment (&gt; 30 days from diagnosis to treatment). Most women in this cohort were categorized as chronically homeless (46%) with the rest categorized as transitionally (29%) or episodically (12%) homeless. The majority of subjects (70%) were Black, non-Hispanic. Most women identified as single (58%) or divorced (21%) at the time of breast cancer diagnosis. All except one subject were publicly insured (71% Medicaid; 12% Medicare) or uninsured (8%). Regardless of type of homelessness, most subjects were either 30-60 or 60-90 days delayed. Those who were chronically homeless experienced significantly more delays to first treatment (56% of those who were delayed 30-60 days and 57% of those who were delayed 60-90 days; p-value 0.006) than those who were episodically or transitionally homeless. Conclusions Significant delays and barriers to breast cancer treatment exist among women experiencing homelessness. Further studies and focused efforts to improve timely breast cancer care for homeless women is warranted.

Citation Format: Kate Festa, Ariel E Hirsch, Michael R Cassidy, Lauren Oshry, Kathryn Quinn, Margaret M Sullivan, Naomi Y Ko. Breast cancer treatment delays at an urban safety net hospital among women experiencing homelessness [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B124.

Provider opioid prescribing practices and the belief that opioids keep people living with HIV engaged in care: a cross-sectional study

We describe HIV providers' opioid prescribing practices and assess whether belief that chronic opioid therapy (COT) keeps people living with HIV (PLWH) engaged in care is associated with differences in these practices among providers from two HIV clinics. We conducted logistic regression to evaluate the association between the belief that COT keeps PLWH engaged in care and at least one component of guideline-recommended care (i.e., urine drug tests, treatment agreements, and/or prescription monitoring program use). The sample included 41 providers with a median age of 42 years, 63% female, 37% non-white. Routine adherence to guideline-recommended practices was: 34% urine drug tests, 27% treatment agreements, and 17% prescription monitoring program. Over half [54%] agreed that COT keeps PLWH engaged in care. There was no significant association between belief that COT keeps PLWH engaged in care and routinely providing any recommended COT care component (aOR 2.38; 95% CI 0.65-8.73). Most HIV providers do not routinely follow guidelines for opioid prescribing. We observed a positive association between belief that COT keeps PLWH engaged in care and following any guideline-recommended prescribing practices, although the result was not statistically significant. Interventions are needed to improve guideline-concordant care for COT by HIV providers.

A Community-Based Approach to Cervical Cancer Prevention: Lessons Learned in Rural Guatemala

BACKGROUND

One international and three local organizations developed the Santa Ana Women's Health Partnership (SAWHP) to address cervical cancer in Santa Ana Huista, Huehuetenango, Guatemala. This paper describes the structure, outcomes, and lessons learned from our community partnership and program.

METHODS

The community partnership developed a singlevisit approach (SVA) program that guided medically underserved women through screening and treatment of cervical cancer.

LESSONS LEARNED

The program promoted acceptability of SVA among rural women by engaging local female leaders and improving access to screening services. The program's approach focused on maximizing access and generated interest beyond the coverage area. Distrust among the community partners and weak financial management contributed to the program's cessation after 4 years.

CONCLUSIONS

The SAWHP design may guide future implementation of cervical cancer screening programs to reach medically underserved women. Open, ongoing dialogue among leaders in each partner institution is paramount to success.

Screening for Colorectal Cancer at the Worksite

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. To increase statewide CRC screening rates, the Alabama Department of Public Health (through a Centers for Disease Control and Prevention [CDC] Colorectal Cancer Control Program grant) partnered with The University of Alabama in Huntsville (UAH) and The University of South Alabama (USA) to provide free CRC screening opportunities to eligible University employees and dependents. Resources were invested at both universities to ensure participant education, tracking, and monitoring. In total, 86 fecal immunochemical tests (FITs) were distributed at the UAH campus and 62 were returned for testing; 146 FITs were distributed on the USA campus with 111 returned. Fecal immunochemical test return rates were over 70% at each site. Most notably, 21 positive FITs were identified among UAH participants and 25 at USA. Findings from both efforts suggest that employer-based screening initiatives are a systematic and replicable means of improving CRC screening.

Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models?

PURPOSE

The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients.

METHODS

This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service.

RESULTS

Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending.

CONCLUSION

Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.

Colorectal cancer screening practices in Alabama: a survey of primary care physicians

In order to inform efforts to increase screening rates for colorectal cancer (CRC), we conducted a survey of Alabama primary care physicians regarding CRC screening practices, educational preferences, and perceptions of obstacles to screening. A mail survey of 2,378 Alabama physicians in Family Medicine, Internal Medicine, and Obstetrics & Gynecology was conducted. Many physicians are not fully up-to-date with current CRC screening practices that could improve patient compliance with screening guidelines. One example is the potential use of high-sensitivity stool tests, such as the fecal immunochemical test, instead of the no longer recommended low-sensitivity guaiac fecal occult blood tests. In addition, enhanced multimedia and web-based approaches to educating physicians and patients could be more fully utilized. Further, greater use of health information technologies could increase screening rates. Enhancing primary care physicians' knowledge of screening modalities and increasing their use of electronic technology could significantly improve colorectal cancer screening outcomes.

Comparison of the Biobullet versus traditional pharmaceutical injection techniques on injection-site tissue damage and tenderness in beef subprimals

The incidence and severity of injection-site lesions has decreased since the development of the Beef Quality Assurance program. The objective was to evaluate the route of administration and the pharmaceutical product on the impact on tenderness, collagen concentration, and lesion occurrence in muscles of chucks and rounds. A total of 144 yearling steers (initial BW = 383 +/- 29.4 kg) were selected and transported to Oklahoma State University. Steers were blocked into 2 groups of 72 based on initial BW and were randomly allocated, within block, into pens of 6 head per pen (12 pens per block). Each pen was randomly assigned an injection protocol. On May 19, 2006 (d 0), steers were administered one of the following treatment injections: a standard Biobullet containing 100 mg of ceftiofur sodium (Naxel, Pfizer Inc., New York, NY); a traditional needle and syringe dose of ceftiofur sodium; a standard Biobullet containing BallistiVac infectious bovine rhinotracheitis (IBR; Titanium 5, SolidTech Animal Health, Newcastle, OK); a traditional needle and syringe dose of IBR; a traditional needle and syringe dose of Vira Shield 5 (Grand Laboratories Inc., Freeman, SD); a standard placebo Biobullet; or a traditional needle and syringe dose of sterile water. Percentage of samples with an identifiable lesion did not differ by drug administered or injection method. Warner-Bratzler shear force values of lesion center cores in chucks tended to be different (P = 0.07) from cores from the control steaks and at 2.54 and 5.08 cm away from the lesion center. Lesion centers from the Biobullet-BallistiVac IBR had a Warner-Bratzler shear force value of 7.01 kg, which was greater (P < 0.05) than values for lesion centers from chucks injected with a Biobullet-placebo (6.27 kg) or needle-ceftiofur sodium (5.08 kg). No significant differences (P > 0.10) were observed in the total collagenous connective tissue in samples extracted from the chuck or round. The comparison of lesion site and control (nonlesion site) samples for lipid concentration showed no significant difference (P > 0.10) among treatments in the round. It was concluded the Biobullet did not create a greater occurrence of lesions in the muscles of the chuck and round. The Biobullet is not an appropriate injection method for the round of beef cattle because it caused tissue damage similar to a needle injection. However, the Biobullet can be used effectively in neck (chuck) applications without additional negative effects on tenderness.

Mental health of undocumented Mexican immigrants: a review of the literature

The Latino population in the United States, the majority of whom are Mexican, is one of the fastest growing. Similarly, the number of undocumented Mexican immigrants (UMIs) continues to swell. However, little is known about UMIs living in the United States, and much less is known about their mental health status. This interdisciplinary review of the literature aims to outline the current state of knowledge regarding the mental health of UMIs in the United States. Themes isolated from the literature include failure to succeed in the country of origin; dangerous border crossings; limited resources; restricted mobility; marginalization/isolation; blame/stigmatization and guilt/shame; vulnerability/exploitability; fear/fear-based behaviors; and stress, depression, and health implications.

Bacterial contamination of blenderized whole food and commercial enteral tube feedings in the Philippines

Hospital-prepared tube feedings from four Philippine acute-care hospitals were analysed for microbial contamination. Two feedings were prepared on three separate days at each hospital. The tube feedings were either blended natural whole foods or a reconstituted commercial powdered nutritional product. Samples of each feeding were collected for coliform count and standard plate count at the time of preparation and at 1, 2 and 4 h after preparation after maintenance at room temperature (26-31 degrees C). At the time of preparation, mean coliform and standard plate counts for all samples were 10.3 most probable number per gram (MPN/g) and 7.4x10(4)colony-forming units per gram (cfu/g), respectively. Nine of 24 samples (38%) had coliform counts greater than 10 MPN/g, and 22/24 (92%) samples had standard plate counts greater than 10(3) cfu/g. There were significant increases in mean coliform and standard plate counts over 4 h (P=0.0005 and P=0.008, respectively). At 4 h after preparation, the mean coliform and standard plate counts were 18.2 MPN/g and 2.1x10(5) cfu/g, respectively. At this time, 18/24 (75%) samples had coliform counts greater than 10 MPN/g and 20/24 (83%) samples had standard plate counts greater than 10(5) cfu/g. The results of this study show that the microbial quality of the majority of the hospital-prepared enteral tube feedings analysed were not within published guidelines for safety.

Effect of high ambient temperature on contamination and physical stability of one-liter ready-to-hang enteral delivery systems

The effect of high ambient temperature on the physical stability and bacterial contamination of 1-L, prefilled, closed enteral feeding systems was examined under simulated clinical conditions. One hundred Jevity Ready-to-Hang enteral feeding systems (Abbott Park, IL, USA) were placed in a 37 degrees C incubator for 24 h. The Ready-to-Hang formula containers were visually inspected at 0 and 24 h. Formula samples were collected from the containers at 24 h and plated on trypticase soy agar. Two samples had insignificant bacterial growth of one colony-forming unit per milliliter that was not demonstrated in repeat culture. No growth was observed for any other sample. Additional samples collected from the two apparently contaminated delivery sets showed no growth. No set showed signs of formula instability, such as coagulation, clumping, or curdling. These findings suggest that, even at a high ambient temperature of 37 degrees C, the risk of bacterial contamination or compromised physical integrity is very low with the use of 1-L, prefilled, closed enteral feeding systems.

Kidney transplantation: a therapy option

The growing number of patients with end stage renal disease (ESRD) choosing kidney transplantation as a therapy option has increased critical care nurses' exposure to this patient population. Critical care nurses have a crucial involvement when caring for the patient in the postoperative period or when serious complications develop. A knowledge base of immunosuppressive therapy and the body's response to it is helpful in assessing and identifying rejection, infection, and technical complications.

Diabetic microangiopathy in patients with cystic fibrosis

Individuals with cystic fibrosis have a 1% to 7% incidence of insulin-dependent diabetes mellitus. The occurrence of diabetic microangiopathy in patients with cystic fibrosis has been reported recently. From 1978 to 1987, 19 patients with cystic fibrosis and diabetes mellitus were followed up. Four patients (21%) had evidence of diabetic microangiopathy. In one, peripheral neuropathy developed 5 years after the onset of diabetes mellitus, and the other 3 patients each had complications of retinopathy, nephropathy, and neuropathy which developed 10 years after the onset of diabetes mellitus. All were poorly compliant in their medical care. Significant morbidity was seen in the 3 patients with multisystem involvement--blindness, glaucoma, hypertension, and renal failure. The combination of long-standing diabetes mellitus, poor glycemic control, plus pathophysiologic features associated with cystic fibrosis may have contributed to the development of microangiopathy. The use of steroids in 4 other patients and dextrose infusions (as part of hyperalimentation) in another 4 patients precipitated or exacerbated diabetes. The data indicate that diabetic microangiopathy can occur in the individual with cystic fibrosis. Routine screening for diabetes and its complications in the population with cystic fibrosis, as well as optimal control of hyperglycemia, is warranted.

The cytodiagnosis of well-differentiated neuroendocrine carcinoma. A distinct clinicopathologic entity

Well-differentiated neuroendocrine carcinoma (WDNE) has been recognized as a distinct variant of pulmonary neuroendocrine carcinoma, with characteristic histopathologic and clinical features that separate it from both carcinoid and small-cell carcinoma (SCC). Histologic review of tumors in long-term survivors (greater than two years) with an initial diagnosis of SCC has shown that the majority of these cases are, in fact, better classified as WDNE; the distinction of WDNE from SCC has, therefore, important prognostic and therapeutic implications. A retrospective review of 200 cytologies originally diagnosed as SCC was undertaken in an attempt to characterize the cytomorphologic features of WDNE. The cytologic criteria that distinguished cases of WDNE included polygonal-to-fusiform cells with a variable amount of lacy cytoplasm, oval nuclei with coarsely dispersed chromatin and frequent chromocenters, and mild nuclear and cytoplasmic anisomorphism. The majority of malignant cells were arranged either in acinarlike clusters or in epithelial sheets with evidence of palisading. Twenty-two cases were reclassified cytologically as WDNE and were accurately distinguished from all other neoplastic and SCC cases on repeated double-blind review. Clinical and histologic data confirmed the diagnosis of WDNE in all cases; it can be concluded that SCC and SDNE are cytologically distinct entities.

Isotypic and antigenic restriction of the blocking antibody response to ryegrass pollen: correlation of rye group I antigen-specific IgG1 with clinical response

To investigate the role of blocking antibodies in allergen immunotherapy (IT), we analyzed IgE, IgG, and IgG subclass 1 to 4 antibody responses to ryegrass group I antigen (RGGI) in a prospective double-blind, heterologous allergen, allergen-controlled trial of grass-pollen IT in 18 adults with seasonal rhinitis and asthma. Serum was assayed preseasonally before starting IT and again in midseason at time of documented highest natural exposure. Antibodies were measured by ELISA, and immunogenic specificities of ryegrass extract were examined by Western immunoblots. Nine subjects receiving grass-pollen IT and nine control subjects had similar clinical and immunologic status before IT. RGGI-specific IgE antibodies (sIgE) did not change from pretreatment levels in actively treated subjects but increased in control subjects (p less than 0.002). RGGI sIgG increased approximately thirteen-fold with active IT versus threefold during natural seasonal exposure (p less than 0.0005). The IgG-blocking response to RGGI was restricted to IgG1 and IgG4. Ten nonatopic subjects had similar RGGI sIgG1 but lower or undetectable sIgE and sIgG4 than the 18 atopic study subjects. Active IT dramatically increased RGGI sIgG4 (p less than 0.001) and to a lesser extent RGGI sIgG1 (p less than 0.01). Immunoblots demonstrated eight IgE-binding ryegrass-polypeptide allergens, with RGGI ubiquitous, and 11 IgG-binding polypeptides, including all eight allergens. A negative correlation between seasonal rhinitis symptom-medication scores and RGGI sIgG1 levels was found (r = -0.62, p less than 0.01), but no other immunologic parameters assayed were related to clinical improvement. Although RGGI sIgG4 predominates in the blocking response and is a useful marker of effective IT, early beneficial biologic effects may involve IgG1 antibodies.

Supraventricular tachycardia in patients with cystic fibrosis

Reports on arrhythmias in cystic fibrosis (CF) patients are limited. Four CF patients treated at our center had recurrent supraventricular tachycardia (SVT). Three had cor pulmonale, as evidenced by echocardiogram, and all had baseline tachycardia. Twenty-four hour Holter monitoring in three patients showed ectopic atrial pacing and premature atrial and ventricular contractions in one patient, rare PVCs in another, and SVT in all three. All patients had significant bronchospasm requiring the use of theophylline, prednisone, and frequent daily doses of beta-2 adrenergic agonists; two also used nebulized atropine. Average theophylline level for the group was 13.4 micrograms/ml during SVT. There was no correlation between pulmonary obstruction and the frequency of SVT. Factors such as cor pulmonale, ectopy, hypoxia, infection, intensive combination bronchodilator therapy, and corticosteroids probably interacted to precipitate SVT. Altered autonomic responses and a myocardial infiltrative process noted in some patients with CF may also play a role in causing arrhythmias.

Altered antibody isotype in cystic fibrosis: possible role in opsonic deficiency

Patients with cystic fibrosis (CF) whose respiratory tracts are colonized with Pseudomonas aeruginosa (PA) may develop a specific opsonic deficiency for alveolar macrophage phagocytosis of PA. We examined the possible role of altered antibody (Ab) isotype in this phenomenon by measuring serum levels and distribution of IgG and IgG subclass Ab (IgG1, IgG2, IgG3, and IgG4) to the major opsonic immunodeterminant, serotype-specific lipopolysaccharide (LPS), by means of enzyme-linked immunosorbent assays employing monoclonal secondary antibodies, and comparing these results to the serum opsonic capacity in an in vitro murine alveolar macrophage phagocytic assay. Twenty-one patients with CF who were colonized with PA had approximately a 30-fold elevation of PA LPS IgG Ab levels and higher IgG subclass 1-4 Ab compared to 10 uncolonized patients with CF and 11 healthy controls (p less than 0.05-0.0005 depending on the isotype). Colonized patients with CF had a shift in PA LPS Ab distribution toward IgG3 compared to uncolonized patients with CF (p less than 0.02). A surprising finding was that uncolonized patients with CF had lower levels (p less than 0.05) and proportion (p less than 0.002) of PA LPS IgG2 Ab than controls, with an apparent shift to higher levels and proportion of PA LPS IgG4 (p less than 0.01). Serum from colonized patients with CF showed diminished opsonic capacity for phagocytosis of PA compared to uncolonized patients and controls (p less than 0.005), with 42% showing inhibitory activity. Functional Ab was also found to be inhibitory at high (greater than 500 ng/ml) concentrations. Serum opsonic capacity appeared to include a noncomplement cofactor for optimal activity.(ABSTRACT TRUNCATED AT 250 WORDS)

CT-guided stereotactic biopsy of intracranial lesions: correlation between core biopsy and aspiration smear

Computerized tomography (CT)-guided stereotactic biopsies of intracranial lesions in 29 patients were analyzed, paying particular attention to the correlation between core biopsies and aspiration smears. Seven percent were nondiagnostic due to sampling error. Discrepancies occurred between core biopsies and aspiration smears in 10% of the cases. In two instances of such discrepancies, cytologic findings on the aspiration smear yielded the diagnosis of metastatic tumor. One patient, with herpetic encephalitis, was diagnosed by electron microscopic review of the core biopsy only. One patient died of an intraoperative hemorrhage, a complication of the fine-needle technique.

Limitations and value of aspiration cytology

The successes of aspiration cytology have enhanced its popularity over the past few years. Now the limitations of the technique are becoming apparent. This article reviews the uses and contraindications for the detection of benign and malignant lesions in various body sites.

Investigation with tritiated thymidine of the relationship between the sex chromosomes, sex chromatin, and the drumstick in the cells of the female nine-banded armadillo, Dasypus novemcinctus

The functional analogies between the sex chromosomes, sex chromatin, and the drumstick in the cells of the female nine-banded armadillo (<i>Dasypus no&#965;emcinctus</i>) were investigated utilizing tritium labelled thymidine both <i>in vitro </i>and <i>in vivo</i>. Tissue culture studies demonstrated that one of the female X chromosomes is asynchronous and synthesizes DNA later than the other X and most of the autosomal complement. In interphase nuclei a peripheral focus of heavier labelling was found overlying the Barr body, indicating that the sex chromatin is formed by a great part or all of the late replicating X chromosome. Localized labelling was also observed over several drumsticks in studies performed <i>in vivo </i>supporting the view that a relationship exists between the drumstick and the asynchronous X chromosome.