Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Structural characteristics and properties of the regenerated silk fibroin prepared from formic acid

Structural characteristics and thermal and solution properties of the regenerated silk fibroin (SF) prepared from formic acid (FU) were compared with those of SF from water (AU). According to the turbidity and shear viscosity measurement, SF formic acid solution was stable and transparent, no molecular aggregations occurred. The sample FU exhibited the beta-sheet structure, while AU random coil conformation using Fourier transform infrared (FTIR), X-ray diffraction (XRD), and differential scanning calorimetry. The effects of methanol treatment on samples were also examined. According to the measurement of crystallinity (XRD) and crystallinity index (FTIR), the concept of long/short-range ordered structure formation was proposed. Long-range ordered crystallites are predominantly formed for methanol treated SF film while SF film cast from formic acid favors the formation of short-range ordered structure. The relaxation temperatures of SF films measured by dynamic thermomechanical analysis supported the above mechanism due to the sensitivity of relaxation temperature on the short-range order.

Detection of minimal disease in hematopoietic malignancies of the B-cell lineage by using third-complementarity-determining region (CDR-III)-specific probes

Approximately 80% of hematopoietic malignancies of the B-cell lineage carry only one or two immunoglobulin heavy chain gene rearrangements indicating their clonal origin. These rearrangements due to the recombination of various variable, diversity, and joining regions of the heavy-chain gene segments during B-cell commitment result in a region called complementarity-determining region III (CDR-III). This region, which encompasses the diversity region of the heavy-chain segment, because of extensive somatic mutations, provides a DNA-encoded signature specific for each B-cell clone. CDR-III sequences were obtained from DNA of pre-B-cell acute lymphoblastic leukemia by using suitable primers and the polymerase chain reaction. The sequences were used to generate diagnostic probes that hybridized only to the amplified CDR-III of leukemic cells from which the sequences were derived. With these probes, leukemic cells could be detected when diluted 1:10,000 with other cells. By cloning the amplified CDR-III into recombinant libraries residual leukemic cells were accurately quantitated in bone-marrow samples from repeated relapses and remissions in one case of acute lymphoblastic leukemia. During a clinical remission lasting greater than 7 mo, malignant cells were present in marrow at greater than 1 per 1000 cells. These findings indicate that custom-made diagnostic probes will be useful in accurate quantitation of malignant cells in acute lymphoblastic leukemia patients in clinical remission and will allow investigation of the biological significance of low or high numbers of residual leukemic cells in evolution of that disease.

Characterization of cDNA clones for human myeloperoxidase: predicted amino acid sequence and evidence for multiple mRNA species

Myeloperoxidase is a component of the microbicidal network of polymorphonuclear leukocytes. The enzyme is a tetramer consisting of two heavy and two light subunits. A large proportion of humans demonstrate genetic deficiencies in the production of myeloperoxidase. As a first step in analyzing these deficiencies in more detail, we have isolated cDNA clones for myeloperoxidase from an expression library of the HL-60 human promyelocytic leukemia cell line. Two overlapping plasmids (pMP02 and pMP062) were identified as myeloperoxidase cDNA clones based on the detection with myeloperoxidase antiserum of 70 kDa protein expressed in pMP02-containing bacteria and a 75 kDa polypeptide produced by hybridization selection and translation using pMP062 and HL-60 RNA. Formal identification of the clones was made by matching the predicted amino acid sequences with the amino terminal sequences of the heavy and light subunits. Both subunits are encoded by one mRNA in the following order: pre-pro-sequences--light subunit--heavy subunit. The molecular weight of the predicted primary translation product is 83.7 kDa. Northern blots reveal two size classes of hybridizing RNAs (approximately 3.0-3.3 and 3.5-4.0 kilobases) whose expression is restricted to cells of the granulocytic lineage and parallels the changes in enzymatic activity observed during differentiation.

Human astrocytes proliferate in response to tumor necrosis factor alpha

Two different human astrocytic cell lines derived from adult epilepsy surgical specimens were exposed in vitro to concentrations of 1-100 ng/ml recombinant tumor necrosis factor alpha (TNF alpha). Results indicated dose-dependent stimulation of DNA synthesis and proliferation. Both of these effects were abrogated by treatment with monoclonal antibody specific for TNF alpha but not by irrelevant murine IgG. Immunocytochemical characterization of TNF alpha-treated and control cultures indicated that greater than 98% of proliferating cells contained cytoplasmic glial fibrillary acidic protein (GFAP), and were therefore astrocytic in nature. These studies demonstrate that growth of adult human non-neoplastic astrocytes is stimulated by TNF alpha, an inflammatory cytokine produced primarily by macrophages but also by astrocytes.

Time-resolved fluorescence anisotropy for systems with lifetime and dynamic heterogeneity

The time dependence of the fluorescence anisotropy expected when a fluorophore exists in distinct environments having different fluorescence decay and motional behavior is illustrated by simulation calculations. A wide range of behavior is observed. The analysis of such decays in terms of the underlying physical parameters is also illustrated and discussed. In particular, the analysis of 'associated' heterogeneous behavior using a homogeneous environment model with complex motional behavior is evaluated. It is argued that anisotropy decays that exhibit a high initial anisotropy and that rise at long times must be due to a heterogeneous environment. Anisotropic rotor diffusion cannot give rise to behavior of this type. A similar conclusion is reached for anisotropies that exhibit downward curvature. On the other hand, anisotropy decays that are monotonically decreasing and have a positive second derivative at all times cannot be analyzed in a unique fashion and therefore an ambiguity exists in the interpretation of such data in terms of motional behavior.

The safety and efficacy of a two-dose daclizumab (zenapax) induction therapy in liver transplant recipients

BACKGROUND

Induction therapy with daclizumab has been shown to be efficacious in the prevention of acute rejection in kidney transplant patients. The routine use of antibody induction therapy in liver transplantation has not gained widespread acceptance, except in the cases of renal insufficiency. The recent approval of daclizumab prompted us to initiate this pilot study using induction therapy in those patients at risk for developing posttransplant renal insufficiency.

METHODS

This nonrandomized study examined the use of daclizumab in 39 of the last 97 liver transplants performed at the University of Alabama in Birmingham. The daclizumab group received 2 mg/kg intravenously before organ engraftment, and 38 of the 39 received 1 mg/kg intravenously on postoperative day 5. The control group consisted of the remaining 58 contemporary patients. Additional immunosuppression consisted of steroids, tacrolimus, or microemulsion cyclosporine in all patients and mycophenolate mofetil in selected patients.

RESULTS

Pretransplant demographics were not significantly different between the groups. In the induction group there were significantly fewer males, 14 (36%) vs. 34 (59%) (P=0.03). They had greater renal insufficiency at the time of transplant, serum creatine 1.9+/-0.37 mg/dl vs. 0.8+/-0.5; P=0.0009, and more patients were at higher acuity (status 1 and 2A): 12 (31%) vs. 3 (5%) P=0.0006 than in the noninduction group. By postoperative day 7, renal function improved in the induction group such that it was not significantly different from the noninduction group and remained similar throughout the rest of the follow-up. The induction group also experienced significantly less acute rejection, 7 (18%) vs. 23 (40%) (P=0.02) than in the noninduction group in the first 6 months. The 1-, 3-, and 6-month patient survival rates were similar in the induction group, 97.4%, 97.4%, and 97.4%, vs. non-induction 94.8%, 93.0%, and 93% (P=NS). The incidence of cytomegalovirus, in the first 6 months, in the induction group was four (10%) vs. five (9%) (P=NS) in the noninduction group.

CONCLUSION

In the pilot study, induction therapy with daclizumab was safe, facilitated improvement in renal function, and appeared to reduce the incidence of acute rejection. Combination therapy with daclizumab may be an important adjunct in immunosuppressive strategies for liver transplant recipients.

Delayed seizure-like activity following analytically confirmed use of previously unreported synthetic cannabinoid analogues

Synthetic cannabinoid use has become widespread, leading to increased burdens on health care providers. Symptoms range from agitation and psychosis to seizures and acute kidney injury. We report a case where a patient was assessed and treated twice within 12 h for seizures following synthetic cannabinoid intoxication. Blood sample determinations showed low concentrations of analogues not previously reported, some of which are legal. Clinicians should be aware that synthetic cannabinoids may cause an array of severe health consequences. Given the ever evolving structure of available analogues, clinicians must also be prepared for other unexpected adverse effects.

Ethnicity and cancer outcomes: behavioral and psychosocial considerations

Cancer has been the subject of thousands of behavioral and psychosocial studies. The literature has focused largely on non-Hispanic Whites, despite the fact that cancer outcomes vary by ethnicity. This article provides a review of those studies that do consider the relations between ethnicity and cancer-related adherence behaviors, survival, and quality of life. The authors propose a mediational framework that links ethnicity and cancer outcomes through socioeconomic status, knowledge and attitudes, and access to medical care. They use this framework to organize the literature and to develop recommendations for future research.

Operative treatment of tertiary hyperparathyroidism: a single-center experience

OBJECTIVE

To review the experience with the operative treatment of tertiary hyperparathyroidism (TH) from a single renal transplant center.

SUMMARY BACKGROUND DATA

Most patients with chronic renal failure show evidence of secondary hyperparathyroidism by the time maintenance hemodialysis begins. Persistent secondary hyperparathyroidism (i.e., TH) requiring surgical intervention is uncommon in the authors' experience.

METHODS

Charts of patients who underwent parathyroidectomy for TH were reviewed retrospectively. Information obtained included demographics, laboratory data, symptoms, operative procedure (including morbidity and mortality rates), and pathology. Comparisons of demographic data and allograft survival were made between the transplant population as a whole and a matched cohort group of patients.

RESULTS

Thirty-eight patients from 4344 renal transplant procedures during a 29-year period required parathyroidectomy for TH. All patients had hypercalcemia; 20 were asymptomatic and 18 had varying symptoms. Mean time from renal transplantation to parathyroidectomy was 997 +/- 184 days, with a mean preoperative calcium level of 12.2 +/- 0.14 mg/dl. Total parathyroidectomy with parathyroid autograft was performed in 26 of 34 primary procedures. There were no deaths. The operative morbidity rate was 6% (wound separation and vocal cord hemiparesis, one each). Pathology was reported in all patients and recently reviewed in 28 patients. Twenty-four had diffuse hyperplasia and nine had nodular hyperplasia; one had an adenoma. Parathyroid glands diagnosed as nodular hyperplasia were significantly larger by total mass than those with diffuse hyperplasia. Comparison of allograft survival between the study group and a matched cohort group of patients revealed no difference in long-term graft survival.

CONCLUSIONS

Operative intervention is recommended in patients with an asymptomatic increase in serum calcium to >12.0 mg/dl persisting for >1 year after the transplant, acute hypercalcemia (calcium >12.5 mg/dl) in the immediate posttransplant period, and symptomatic hypercalcemia.

Evaluation of right ventricular volume and ejection fraction in children by two-dimensional echocardiography

We estimated right ventricular volume and ejection by two-dimensional echocardiography (2DE) and compared the measurements with those obtained by right ventricular cineangiography (ANGIO) in 20 children whose ages ranged from 1 month to 10 years and who had a variety of congenital defects. The two echocardiographic planes used for calculating volume were the apical four-chamber (A4C) and parasternal short-axis (SA) planes. End diastolic volume (EDV) and end systolic volume (ESV) were calculated from these planes by single-plane area-length methods. The EDV and ESV were uniformly underestimated, but the estimate of ejection fraction (EF) was satisfactory. For EF, r = 0.83 from the apical four-chamber view and r = 0.78 from the short-axis view. The axes of the two echocardiographic planes passed through different segments of the right ventricle (RV) and we found that the value given by adding the volumes obtained from the two single-plane segments correlated quite well with the value obtained by angiography: for EDV, 2DE = 0.62 ANGIO + 7.0, r = 0.81, standard error of the estimate (s.e.e.) = 15.4 ml; for ESV, 2DE = 0.82 ANGIO + 1.4, r = 0.85, s.e.e. = 6.5 ml; and for EF, 2DE = 0.66 ANGIO + 17.8, r = 0.82, s.e.e. = 7.4 ml. Two-dimensional echocardiography can be used to evaluate right ventricular EF derived from volume measurements or from each of the echocardiographic planes of which, in our series, the apical four-chamber EF provided the better correlation.

Peripheral blood chimerism in renal allograft recipients transfused with donor bone marrow

Experimental studies have shown that administration of antilymphocyte serum combined with donor bone marrow cells can induce tolerance to allograft tissue. We have initially reported application of these protocols in clinical studies of cadaveric renal allograft recipients who were treated with MALG and donor-specific bone marrow cells. To evaluate the effectiveness of the donor marrow cells in the production of chimerism, a detection method based on 32P-incorporated PCR was established. The 32P PCR was utilized with primers specific for the HLA class II, VNTR (D17S5 and D1S111), and/or Y-chromosome genes to detect the presence of allogeneic chimerism in the recipients. Immediately posttransplant, 26.4% of marrow recipients demonstrated the presence of allogeneic chimerism prior to the marrow transfusion as did 18% in the untransfused controls. In transfused patients, chimerism was detected most frequently during the 1-3-month interval after marrow transfusion (65%), and then diminished to 50-56% at 3-12 months posttransfusion. In the control group the frequency of allogeneic chimerism was gradually decreased and was undetectable in the majority of the patients beyond 3 months posttransplant while marrow-transfused recipients were more likely to have chimeric cells detected consistently beyond 3 months. Rejection episodes were significantly effected by the presence of chimerism in the recipients. Of the transfused patients, 91.3% who demonstrated allogeneic chimerism were rejection-free as compared with 8.7% who experienced at least one rejection episode (P = 0.01). While the presence of allogeneic chimerism in the control group was correlated with rejection-free graft survival, this difference did not reach statistical significance.

Alcohol and drug use in the context of anal sex and other factors associated with sexually transmitted infections: results from a multi-city study of high-risk men who have sex with men in the USA

Men who have sex with men (MSM) who use alcohol and drugs are at especially high risk for sexually transmitted infections (STIs); more information is needed about associated factors to improve risk reduction. We assessed reported STIs and demographic and event-level alcohol and drug use characteristics associated with STIs in a diverse, multi-city study in the USA of MSM who use substances. Improved risk reduction efforts are needed for this group as well as some initiatives tailored to men who are HIV positive, younger and use drugs (not alcohol) in the context of anal sex.

An association between the heat-humidity index and preterm labor and delivery: a preliminary analysis

OBJECTIVES

The goal of this study was to determine whether a relationship exists between heat-humidity indexes and rates of preterm labor and preterm delivery.

METHODS

Preterm labor and delivery rates were compared during the 2 summer and 2 winter weeks with the highest and lowest heat-humidity indexes for each season.

RESULTS

The rate of preterm labor increased consistently from 1.23% to 3.00% as the heat-humidity index rose. When preterm births were examined, the trend was similar but not statistically significant.

CONCLUSIONS

Given the public health import of preterm labor and the frequency with which pregnant women may be exposed to extremes of heat, studies designed to confirm or refuse our preliminary observations are warranted.

Bovine plasma corticoids during parturition

Concentrations of adrenal corticoids in plasma were determined by a competitive protein-binding technique using jugular blood samples taken three times daily and more frequently during labor from 21 cows before and after parturition. The prepartum value was 6 ng/ml with a sharp rise during the last 16 h before calving. The average value at the time of calving was 19.2 ng/ml with a significant drop 1 h after calving to 11.2 ng/ml and a return to basal concentrations by 3 days postpartum. Evidence that labor is responsible for the increased corticoid is given. Maternal cortisol at calving was correlated with the time taken to calve .23, calf cortisol .04, cow:calf weight ratio -.07, and calf weight .14.

Relationship of the antispasticity effect of tizanidine to plasma concentration in patients with multiple sclerosis

BACKGROUND

Spasticity is a serious problem in multiple sclerosis (MS) and many patients do not achieve a satisfactory response to currently available oral antispasticity drugs. Tizanidine hydrochloride, an alpha 2-noradrenergic agonist, has been shown to have an antispasticity effect in single center trials of patients with MS.

OBJECTIVE

To compare plasma concentrations of tizanidine with objective measures of muscle tone in patients with MS with moderate to severe spasticity.

SETTING

Ten centers, all tertiary referral centers for the specialized treatment of patients with MS, in the United States and Canada.

DESIGN

A randomized, double-blind, placebo-controlled, dose-response study of tizanidine hydrochloride (8 or 16 mg).

PATIENTS

One hundred forty-two patients with spastic MS who were not taking any interfering medication, such as an antispasticity drug or other alpha-noradrenergic agonist, entered the trial.

RESULTS

Tizanidine treatment reduced muscle tone significantly, as shown by improved Ashworth scores and increased knee swing amplitude recorded by the pendulum test, both of which correlated significantly with plasma concentration. Placebo had no significant effect on muscle tone. Dizziness, drowsiness, dry mouth, and fatigue were reported most often in the group treated with tizanidine at peak plasma concentration.

CONCLUSIONS

Tizanidine reduces spasticity in MS, and both therapeutic effects and side effects are related to the plasma drug levels.

Thermoregulatory responses to hyperthermia during isoflurane anesthesia in humans

The authors tested the hypotheses that isoflurane anesthesia increases the threshold for sweating but minimally decreases the gain (sensitivity) or maximum intensity of this response and that thermoregulatory responses to hyperthermia are similar in anesthetized men and women. Sweating in response to core hyperthermia was studied in five men and five women during 0, 0.8, and 1.2% end-tidal isoflurane anesthesia. Thigh sweating was quantified by measuring gas flow, relative humidity, and temperature passing over a known surface area. The distal esophageal temperature triggering sweating was considered the sweating threshold, and gain was defined as the core temperature increment required to increase sweating rate from 25 to 75% of maximum observed intensity. The sweating threshold increased linearly with isoflurane concentration from 36.6 +/- 0.1 to 38.1 +/- 0.1 degrees C in the men and from 37.1 +/- 0.3 to 38.3 +/- 0.2 degrees C in the women. The thresholds were significantly higher in women than in men. Gain and maximum sweating intensities were similar at each anesthetic concentration and in men and women. These data indicate that isoflurane anesthesia significantly increases the threshold triggering thermoregulatory sweating but that gain and maximum sweating rate are relatively well preserved.

Analysis of anonymous pooled urine from portable urinals in central London confirms the significant use of novel psychoactive substances

AIM

Analysis of urine samples collected across a city centre, for the detection of novel psychoactive substances (NPS).

DESIGN

Cross-sectional study of anonymized urine samples used for the analysis of classical recreational drugs, NPS and metabolites.

METHODS

Pooled urine samples collected from portable stand-alone four-person urinals across a city centre were analysed using full-scan accurate-mass high-resolution liquid chromatography coupled to tandem mass spectrometry. Data were processed against compound databases containing >1700 drug compounds and metabolites.

RESULTS

Seven established recreational drugs (3,4-methylenedioxyamphetamine, cocaine, cannabis, ketamine, 3,4-methylenedioxy-N-methylamphetamine, methamphetamine and amphetamine) and six potential NPS [hordenine (all 12 urinals), cathine (11), methylhexaneamine (9), 4-methylmethcathinone (6), methiopropamine and metabolites (2) and methoxetamine and metabolites (1)] were detected. Methylhexaneamine, methiopropamine and hordenine are currently uncontrolled in the UK, whereas methoxetamine is currently subject to a Temporary Class Drug Order. Metabolites of the anabolic steroid nandrolone were found in two urinals and trenbolone metabolites and clenbuterol in one urinal.

CONCLUSION

Analysis of pooled urine samples collected anonymously from stand-alone urinals in a large inner city can detect the use of recreational drugs, NPS and anabolic steroids. Metabolite detection indicates actual drug use, metabolism and elimination rather than simply discarded drugs in the urinals. This technique by confirming the actual drug(s) used has the potential to be additive to currently used datasets/key indicators providing more robust information for healthcare authorities, legislative and law enforcement on the drugs actually being used.

A Randomized Controlled Trial of the Effect of Early Upper-Limb Training on Stroke Recovery and Brain Activation

Background. Upper-limb (UL) dysfunction is experienced by up to 75% of patients poststroke. The greatest potential for functional improvement is in the first month. Following reperfusion, evidence indicates that neuroplasticity is the mechanism that supports this recovery. Objective. This preliminary study hypothesized increased activation of putative motor areas in those receiving intensive, task-specific UL training in the first month poststroke compared with those receiving standard care. Methods. This was a single-blinded, longitudinal, randomized controlled trial in adult patients with an acute, first-ever ischemic stroke; 23 participants were randomized to standard care (n = 12) or an additional 30 hours of task-specific UL training in the first month poststroke beginning week 1. Patients were assessed at 1 week, 1 month, and 3 months poststroke. The primary outcome was change in brain activation as measured by functional magnetic resonance imaging. Results. When compared with the standard-care group, the intensive-training group had increased brain activation in the anterior cingulate and ipsilesional supplementary motor areas and a greater reduction in the extent of activation ( P = .02) in the contralesional cerebellum. Intensive training was associated with a smaller deviation from mean recovery at 1 month (Pr>F0 = 0.017) and 3 months (Pr>F = 0.006), indicating more consistent and predictable improvement in motor outcomes. Conclusion. Early, more-intensive, UL training was associated with greater changes in activation in putative motor (supplementary motor area and cerebellum) and attention (anterior cingulate) regions, providing support for the role of these regions and functions in early recovery poststroke.

Heat loss during surgical skin preparation

BACKGROUND

Hypothermia develops rapidly during the 1st h of anesthesia and results in part from evaporative heat loss during surgical skin preparation. The authors tested the hypothesis that evaporation of skin preparation solution contributes significantly to hypothermia.

METHODS

Five healthy, unanesthetized volunteers were studied in a 22 +/- 0.4 degrees C environment. One thigh of each volunteer was washed for 10 min, using each of the following representative solutions: (1) water; (2) 50% ethanol in water (EtOH/H2O; similar to tincture of iodine); and (3) povidone-iodine gel. Water and EtOH/H2O each were tested at ambient temperature (cold), warmed to 40 degrees C before application (warm), and with radiant heating of the skin, and gel only at ambient temperatures, resulting in seven study states. Heat loss and skin temperatures on the washed thighs were measured using thermal flux transducers, and values compared with the data obtained from the contralateral unwashed thighs. Change in mean body temperature (per 70 kg) due to washing was calculated by integrating measured heat loss over time and multiplying by the specific heat of human tissue. A mathematical model was developed to predict cutaneous heat loss using only skin temperature, independent of the type and temperature of skin-preparation solution or the use of radiant heating during preparation.

RESULTS

Heat loss from the unwashed thigh was approximately 14 kcal/m2 during radiant warming and approximately 39 kcal/m2 without warming. Net heat loss (increment produced by washing) was approximately 30 kcal/m2 with water and gel without radiant warming, but loss was larger with EtOH/H2O than with water under all study conditions. Radiant warming reduced total heat loss (increment produced by washing and environment) during both the EtOH/H2O and water trials, compared with warm or cold EtOH/H2O and water alone. The calculated decreases in mean body temperature per 70 kg ranged from -0.2 to -0.7 degree C/m2. The smallest decrease occurred during radiant warming and washing with water, and the largest decreases during warm or cold EtOH/H2O.

CONCLUSIONS

Heat loss was significantly less with water-based than with alcohol-based solutions. Though heating the solutions and radiant warming decreased heat loss, such loss under each tested condition, even per square meter of washed surface, was small compared to other causes of perioperative hypothermia. Consequently, the authors recommend that efforts to maintain intraoperative normothermia be directed elsewhere.

Spotted fever group rickettsial infection in south-eastern Australia: isolation of rickettsiae

Flinders Island spotted fever (FISF), a spotted fever group (SFG) rickettsial disease first described in 1991, occurs in south-eastern Australia. The isolation of the aetiological agent is described for the first time having been obtained from the blood of two patients. An additional 22 cases are also reported. Of these patients four had positive initial serology, and 20 showed seroconversion (using Rickettsia australis as antigen). Acute phase blood specimens taken from seven patients caused neonatal mice to seroconvert to R. australis and a blood specimen from one of these patients (and one other) yielded rickettsiae. A field survey for possible reservoir and vector animals on Flinders Island, Tasmania and in Gippsland, Victoria (both in south-eastern Australia) yielded 217 vertebrates and 1445 invertebrate ectoparasites, mostly ticks. Ixodes cornuatus from humans and dogs in Gippsland produced seroconversion to SFG rickettsia when inoculated into mice but no invertebrate pools from Flinders Island produced seroconversion in mice. Haemolymph from an individual I. cornuatus removed from a human in Gippsland, yielded a SFG rickettsia on tissue culture. Sera from several species of native vertebrates, especially the bush rat, Rattus fuscipes, were positive for antibodies to SFG rickettsia.

A descriptive analysis of children's playground injuries in the United States 1990-4

OBJECTIVES

To review playground injury statistics over a five year period in order to develop an awareness of how and where children in the United States are being injured.

METHODS

All data are based on the United States Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) for playground related injuries during 1990-4. The surveillance data includes injuries recorded in more than 90 hospital emergency departments located throughout the United States.

RESULTS

Each year there are roughly 211,000 preschool or elementary school-children in the United States who receive emergency department care for injuries associated with playground equipment. On average, 17 of these cases result in death. 70% of all injuries occur on public playgrounds, with nearly one third classified as severe. Swings, climbers, and slides are the pieces of playground equipment associated with 88% of all NEISS reported injuries. Falls to the surface are responsible for 70%.

CONCLUSIONS

NEISS playground injury statistics contribute to our understanding of playground injuries. By identifying where and how children are injured, suggestions can be made in an attempt to make playgrounds safer.

Carcinoembryonic antigen in carcinoma of the uterine cervix. 2. Tissue localization and correlation with plasma antigen concentration

Immunoperoxidase staining for carcinoembryonic antigen (CEA) was performed on the tumors of 241 patients with invasive carcinoma of the cervix. Positive tissue staining indicative of a CEA concentration of at least 3 microgram/gm was present in 154 tumors (63%) as opposed to 0 of 30 specimens of normal cervix (p less than .001). Plasma CEA values were obtained at the time of tissue staining on all patients. Plasma CEA concentration was related more directly to total tumor burden (tumor CEA content x extent of disease) than to tumor CEA concentration alone. Progressively rising plasma CEA levels predicted recurrent disease in over 80% of patients whose tumors stained positively for CEA. In contrast, serial plasma CEA values correlated positively with clinical disease status in only 28% of patients whose tumors were devoid of CEA. Immunoperoxidase staining of tissue specimens identifies those patients whose tumors contain high levels of CEA and who therefore should benefit most from subsequent plasma antigen determinations.