Demonstration of the feasibility of emergency department immunization against influenza and pneumococcus

STUDY OBJECTIVE

To demonstrate the feasibility of systematic immunization against influenza and pneumococcus in a public emergency department.

METHODS

This was a demonstration project conducted from October 21, 1996, through December 2, 1996, at Cook County Hospital, an inner-city hospital with a 1996 adult ED census of 120,449. Seventy-eight percent of patients are uninsured; 92% are people of color; 73% deny having a primary physician. Only 15% have emergency complaints. Nurses received standing orders that all nonemergency adult patients meeting Centers for Disease Control and Prevention criteria for high risk should be offered immunization against influenza and pneumococcus at triage. Cash prizes were offered to nurses appropriately immunizing the most patients. The date of immunization was entered into the computerized patient registration system, available to all providers within the county system. From November 4 through November 18, an extra nurse was assigned to triage to test for improvement in immunization rates. A time-motion study determined the time required per immunization on the basis of a convenience sample of 8 nurses drawn from all 3 shifts.

RESULTS

Only 3% of identified high-risk patients reported previous pneumococcal immunization. Despite extreme variation in nurse performance, 2,631 patients (24% of patients triaged) were screened, and 716 high-risk patients were identified (27% of patients screened). A total of 1234 patients were immunized against influenza, and 241 patients were appropriately immunized against pneumococcus. Sixty-one percent of high-risk patients with no contraindication to influenza immunization were immunized against influenza. Thirty-five percent of high-risk patients not previously immunized against pneumococcus were immunized against pneumococcus. Immunizations per shift per triage nurse varied from 0 to 24. Median time for all activities related to immunization was 4 minutes (range, 2 to 10 minutes). There was no increase in immunization rates with the addition of an extra nurse at triage (95% confidence interval for odds ratio, .929 to 1.153).

CONCLUSION

Systematic immunization against influenza and pneumococcus is both needed and feasible in a public ED. "Buy-in" by nurses is variable. Increased staffing alone does not improve immunization rates.

Phage P22 tailspike protein: removal of head-binding domain unmasks effects of folding mutations on native-state thermal stability

A shortened, recombinant protein comprising residues 109-666 of the tailspike endorhamnosidase of Salmonella phage P22 was purified from Escherichia coli and crystallized. Like the full-length tailspike, the protein lacking the amino-terminal head-binding domain is an SDS-resistant, thermostable trimer. Its fluorescence and circular dichroism spectra indicate native structure. Oligosaccharide binding and endoglycosidase activities of both proteins are identical. A number of tailspike folding mutants have been obtained previously in a genetic approach to protein folding. Two temperature-sensitive-folding (tsf) mutations and the four known global second-site suppressor (su) mutations were introduced into the shortened protein and found to reduce or increase folding yields at high temperature. The mutational effects on folding yields and subunit folding kinetics parallel those observed with the full-length protein. They mirror the in vivo phenotypes and are consistent with the substitutions altering the stability of thermolabile folding intermediates. Because full-length and shortened tailspikes aggregate upon thermal denaturation, and their denaturant-induced unfolding displays hysteresis, kinetics of thermal unfolding were measured to assess the stability of the native proteins. Unfolding of the shortened wild-type protein in the presence of 2% SDS at 71 degrees C occurs at a rate of 9.2 x 10(-4) s(-1). It reflects the second kinetic phase of unfolding of the full-length protein. All six mutations were found to affect the thermal stability of the native protein. Both tsf mutations accelerate thermal unfolding about 10-fold. Two of the su mutations retard thermal unfolding up to 5-fold, while the remaining two mutations accelerate unfolding up to 5-fold. The mutational effects can be rationalized on the background of the recently determined crystal structure of the protein.

Spontaneous regression of a herniated disk. A case report with a four year follow-up

A 32-year-old male was seen with a "large" lumbar disk herniation on a magnetic resonance image. His pain was described as mild and he was treated nonoperatively. Four years later the disk showed almost complete spontaneous regression. No other reports of a longer follow-up MR image interval have been reported in the literature.

Language learning impairment: integrating research and remediation

Timing cues present in the acoustic waveform of speech provide critical information for the recognition and segmentation of the ongoing speech signal. Research has demonstrated that deficient temporal perception rates, that have been shown to specifically disrupt acoustic processing of speech, are related to specific language-based learning impairments (LLI). Temporal processing deficits correlate highly with the phonological discrimination and processing deficits of these children. Electrophysiological single cell mapping studies of sensory cortex in brains of primates have shown that neural circuitry can be remapped after specific, temporally cohesive training regimens, demonstrating the dynamic plasticity of the brain. Recently, we combined these two lines of research in a series of studies that addressed whether the temporal processing deficits seen in LLIs can be significantly modified through adaptive training aimed at reducing temporal integration thresholds. Simultaneously, we developed a computer algorithm that expanded and enhanced the brief, rapidly changing acoustic segments within ongoing speech and used this to provide intensive speech and language training exercises to these children. Results to date from two independent laboratory experiments, as well as a large national clinical efficacy trial, demonstrate that dramatic improvements in temporal integration thresholds, together with speech and language comprehension abilities of LLI children, results from training with these new computer-based training procedures.

Spastic paraplegia, optic atrophy, microcephaly with normal intelligence, and XY sex reversal: a new autosomal recessive syndrome?

Two female sibs of first cousin Iranian parents were found to have the syndrome of spastic paraplegia, optic atrophy with poor vision, microcephaly, and normal cognitive development. Karyotype analysis showed a normal female constitution in one and a male constitution (46,XY) in the other. The XY female showed normal female external genitalia, normal uterus and tubes, and streak gonads. SRY gene sequencing was normal. We conclude that the present family probably represents a new autosomal recessive trait of pleiotropic effects including XY sex reversal and adds further evidence for the heterogeneity of spastic paraplegia syndromes as well as sex reversal syndromes.

A family with three germline mutations in BRCA1 and BRCA2

Several cancer genetics centres offer testing for specific BRCA1 and BRCA2 mutations to Ashkenazi Jewish individuals with a family history of breast and ovarian cancers. Testing involves screening for three common mutations found in this population, namely BRCA1 185delAG, 5382insC and BRCA2 6174delT (Struewing et al., Nat Genet 1995: 11: 198-200; Roa et al., Nat Genet 1996: 14: 185-187; Oddoux et al., Nat Genet 1996: 14: 188-190). We have identified a large Ashkenazi Jewish kindred (W9170) with ten cases of breast cancer and four cases of ovarian carcinoma. Initially, mutation analysis for this family identified a BRCA1 185delAG mutation in the proband diagnosed with three separate primary cancers of the breast, ovary and colon. Another individual in this family diagnosed with two primary cancers of the ovary and breast, was identified as having a second mutation, BRCA1 5382insC. Subsequent work found that two sisters (cousins of the proband), both diagnosed with carcinoma of the breast, had a third mutation, BRCA2 6174delT. These three mutations have previously been found to be more common in the Ashkenazi Jewish population (References as above). The identification of all three mutations in one family, raised new implications for the manner in which testing and counselling should be offered. In our opinion, Ashkenazi Jewish individuals in breast-ovarian cancer families should be offered complete testing for the three common Ashkenazi Jewish mutations regardless of previous identification of one of these mutations in the family.

Speech modifications algorithms used for training language learning-impaired children

In this paper, the details of processing algorithms used in a training program with language learning-impaired children (LLI's) are described. The training program utilized computer games, speech/language training exercises, books-on-tape and educational CD-ROM's. Speech tracks in these materials were processed using these algorithms. During a four week training period, recognition of both processed and normal speech in these children continually increased to near age-appropriate levels. We conclude that this form of processed speech is subject to profound perceptual learning effects and exhibits widespread generalization to normal speech. This form of learning and generalization contributes to the rehabilitation of temporal processing deficits and language comprehension in this subject population.

Bowling related injuries of the hand and upper extremity; a review

Bowling is one of the oldest and most popular indoor sports. The earliest evidence of bowling dates back to ancient Egypt. Archaeologists discovered equipment for a game resembling bowling. Modern forms of bowling appeared in England as early as the 1100s. Bowling can cause a variety of hand and upper extremity injuries either due to acute or reparative forces. Greater number of such injuries is being encountered as the popularity of the game has increased. The goal of this article is to present an overview of bowling related injuries, their mechanisms along with preventive and treatment measures.

Protein and energy value of pearl millet grain for mature goats

We conducted two studies to assess the protein and energy value of pearl millet grain (Pennisetum glaucum [L.] R. Br.) for mature goats. In Exp. 1, 15 2-yr-old male castrated goats were gradually introduced over a 4-mo period to three all-grain diets consisting of 100% corn (Zea mays L.), 50:50 corn:pearl millet, and 100% pearl millet. After the adjustment to all-grain feeds, the goats were fed the diets in metabolism crates for 2-d adjustment and 7-d total collection periods. For Exp. 2, complete diets containing the three grain treatments (corn, 50:50 corn:pearl millet, and pearl millet) as 40% of the total DM as fed (the remainder was mainly alfalfa meal and mineral supplement) were balanced to contain 16% crude protein (CP) and 2.24 Mcal digestible energy (DE)/kg on an air-dry basis. Twelve mature (4- to 6-yr-old) buck goats were randomly assigned to diets and fed in pens for 14 d and then moved to metabolism crates for 10-d adjustment and 10-d total collection periods. In Exp. 1, DM intake was unaffected by dietary treatment, but digestibility of DM and organic matter was lowest (P < .10) in goats fed 100% pearl millet. Digestibility of complete diets also decreased (P < .10) as corn was replaced by 50 or 100% pearl millet, but DM intake increased (P < .10) on the 100% millet diet. In both experiments, substituting pearl millet for corn had no effect on nitrogen retained by the goats. Metabolizable energy of pearl millet was only 92% that of corn, but ME intake was similar when the grains were fed as 40% of the dietary DM. Pearl millet has potential as a major energy feed for goats in areas where it can be economically produced.

Lead absorption and renal dysfunction in a South African battery factory

OBJECTIVES

To test the association between inorganic lead (Pb) exposure, blood pressure, and renal function in South African battery factory workers, with both conventional and newer measures of renal function and integrity.

METHODS

Renal function measures included serum creatinine, urea, and urate (n = 382). Urinary markers (n = 199) included urinary N-acetyl-beta-D-glucosaminidase (NAG), retinol binding protein, intestinal alkaline phosphatase, tissue non-specific alkaline phosphatase, Tamm-Horsfall glycoprotein, epidermal growth factor, and microalbuminuria.

RESULTS

Mean current blood Pb was 53.5 micrograms/dl (range 23 to 110), median zinc protoporphyrin 10.9 micrograms/g haemoglobin (range 1.9 to 104), and mean exposure duration 11.6 years (range 0.5 to 44.5). Mean historical blood Pb, available on 246 workers, was 57.3 micrograms/dl (range 14 to 96.3). After adjustment for age, weight and height, positive exposure response relations were found between current blood Pb, historical blood Pb, zinc protoporphyrin (ZPP), and serum creatinine and urate. Blood pressure was not associated with Pb exposure. Among the urinary markers, only NAG showed a positive association with current and historical blood Pb.

CONCLUSION

An exposure-response relation between Pb and renal dysfunction across the range from < 40 to > 70 micrograms/dl blood Pb was found in this workforce, with conventional measures of short and long term Pb exposure and of renal function. This could not be explained by an effect on blood pressure, which was not associated with Pb exposure. The findings probably reflect a higher cumulative renal burden of Pb absorption in this workforce in comparison with those in recent negative studies. The results also confirm the need for strategies to reduce Pb exposure among industrial workers in South Africa.

A reversibly unfolding fragment of P22 tailspike protein with native structure: the isolated beta-helix domain

The homotrimeric tailspike endorhamnosidase of phage P22 has been used to compare in vivo and in vitro folding pathways and the influence of single amino acid substitutions thereon. Its main structural motif, which contains the known folding mutation sites, consists of three large right-handed parallel beta-helices. A thermodynamic analysis of the stability of tailspike is prevented by the irreversibility of unfolding at high temperatures or high concentrations of denaturant, probably due to interdigitation of the domains neighboring the beta-helix. We therefore expressed and isolated a tailspike fragment comprising only its central beta-helix domain (residues 109-544). As shown by equilibrium ultracentrifugation, the isolated beta-helix is a monomer at concentrations below 1 microM and trimerizes reversibly at higher protein concentrations. Both the similarity of fluorescence and CD spectra, compared to the complete protein, and the specific binding and hydrolysis of substrate suggest a nativelike structure. Moreover, urea denaturation transitions of the beta-helix domain are freely reversible, providing the basis for a future quantitative analysis of the effects of the folding mutations on the thermodynamic stability of the domain and of structural features responsible for folding and stability of the parallel beta-helix motif in general.

Metabotropic glutamate receptor agonists potentiate cyclic AMP formation induced by forskolin or beta-adrenergic receptor activation in cerebral cortical astrocytes in culture

The metabotropic glutamate receptor (mGluR) agonist 1-aminocyclopentane-1S,3R-dicarboxylic acid (ACPD) potentiated the accumulation of cyclic AMP induced by either beta-adrenergic receptor stimulation (isoproterenol) or direct activation of adenylyl cyclase (AC) with forskolin in rat cerebral cortical astrocytes grown in a defined medium. In contrast, ACPD inhibits the cyclic AMP response in astrocytes cultured in a serum-containing medium. Pharmacological characterization indicated that a group I mGluR, of which only mGluR5 is detectable in these cells, is involved in the potentiation of cyclic AMP accumulation. Potentiation was elicited by mGluR I agonists [e.g., (R,S)-3,5-dihydroxyphenylglycine (DHPG)], but not by mGluR II or III agonists; it was pertussis toxin resistant and abolished by procedures suppressing mGluR5 function (phorbol ester pretreatment or DHPG-induced receptor down-regulation). Nevertheless, it appears that products generated through the mGluR5 transduction pathway, such as elevated [Ca2+]i or activated protein kinase C (PKC), are not involved in the potentiation as it was not influenced by either the intracellular calcium chelator BAPTA-AM or the PKC inhibitor Ro 31-8220. An inhibitor of phospholipase C, U-73122, markedly attenuated mGluR5-activated phosphoinositide hydrolysis but did not significantly affect the DHPG potentiation of the cyclic AMP response. A mechanism is proposed in which the potentiating effect on AC could be mediated by free betagamma complex that is liberated after the agonist-bound mGluR5 interacts with its coupled G protein.

The G protein-coupled receptor kinase 2 is a microtubule-associated protein kinase that phosphorylates tubulin

The G protein-coupled receptor kinase 2 (GRK2) is a serine/threonine kinase that phosphorylates and desensitizes agonist-occupied G protein-coupled receptors (GPCRs). Here we demonstrate that GRK2 is a microtubule-associated protein and identify tubulin as a novel GRK2 substrate. GRK2 is associated with microtubules purified from bovine brain, forms a complex with tubulin in cell extracts, and colocalizes with tubulin in living cells. Furthermore, an endogenous tubulin kinase activity that copurifies with microtubules has properties similar to GRK2 and is inhibited by anti-GRK2 monoclonal antibodies. Indeed, GRK2 phosphorylates tubulin in vitro with kinetic parameters very similar to those for phosphorylation of the agonist-occupied beta2-adrenergic receptor, suggesting a functionally relevant role for this phosphorylation event. In a cellular environment, agonist occupancy of GPCRs, which leads to recruitment of GRK2 to the plasma membrane and its subsequent activation, promotes GRK2-tubulin complex formation and tubulin phosphorylation. These findings suggest a novel role for GRK2 as a GPCR signal transducer mediating the effects of GPCR activation on the cytoskeleton.

Receptor-coupled phospholipase C and adenylyl cyclase function with different calcium pools in astrocytes

Astrocytes express phospholipase C (PLC)-coupled metabotropic glutamate receptors (only mGluR5 is detectable) and adenylyl cyclase (AC)-linked beta-adrenergic receptors. Calcium-sensitive effector enzymes are associated with these signal transduction pathways, but the relevant calcium compartments involved were found to be different. mGluR5-linked PLC responded primarily to extracellular Ca2+, suggesting a close spatial relation between the enzyme and Ca2+ entry channels. On the other hand, the calcium-inhibited AC associated with beta-adrenergic receptors was sensitive to intracellular Ca2+ selectively accessible to intracellular Ca2+ chelation. Furthermore, cAMP formation induced by direct activation of AC by forskolin was less responsive to intracellular Ca2+ chelation than that evoked by the receptor-activated AC, raising the possibility of selective access of the receptor to a pool of calcium-inhibited AC and/or the calcium modulation of some components of the coupling pathway.

A close look at family practice in Louisiana: manpower '97. Louisiana family practice residency program needs

There is a shortage of family physicians in Louisiana. This manuscript reports on the current status of primary care in Louisiana. It compares these data with national averages and assesses current needs. Finally, it proposes necessary steps by which this shortage can be decreased. Medical schools, residency programs, and practicing physicians will need to be involved in the solution to this problem. Louisiana can have a bright future in family medicine if the recommendations in this paper are thoroughly addressed. With ever increasing costs of quality medical care, well-placed funding and emphasis on family practice appear to be the right direction.

The diagnostic yield of the nerve-muscle skin biopsy in paediatric neurology practice. The Montreal Children's Hospital Neuromuscular Group

OBJECTIVE

To determine the diagnostic yield of the nerve-muscle-skin (NMS) biopsy in paediatric neurology practice.

STUDY DESIGN

A consecutive series of 98 paediatric NMS biopsies done 1989-1994 retrospectively reviewed in the context of pre-biopsy clinical and laboratory parameters. Bivariate associations based on chi-square test. Unconfounded associations between pre-biopsy variables and positive diagnostic yield (PDY) assessed by multiple logistic regression.

RESULTS

Fifty seven out of 98 patients central (global delay, seizures, abnormal CNS imaging) process; 41/98 patients peripheral (motor delay, weakness) process, electromyography-nerve conduction studies (EMG-NCS) 87/98 cases; abnormal 43/87. Positive diagnostic yield (PDY) in 42/98 (43%) biopsies. Statistically significant bivariate associations between PDY and pre-biopsy; age, presenting symptom, developmental delay, weakness, reflexes, CPK, lactate, EMG-NCS and process. Unconfounded associations demonstrated with PDY and age, reflexes and process. The presence of a peripheral process or an abnormal EMG-NCS strongly predictive of PDY: 34/41 (83%) peripheral process cases had PDY, 32/40 (80%) abnormal EMG-NCS cases had PDY, and 29/31 (93.5%) peripheral process and abnormal EMG-NCS cases had PDY. Abnormal EMG-NCS with central process improved PDY to 3/9 (33%) from 4/37 (11%) for normal EMG-NCS.

CONCLUSION

NMS biopsy is a valuable diagnostic tool, particularly in the context of a suspected peripheral process or a central processes with an abnormal EMG-NCS.

Heat-induced thermal tolerance and radiation resistance to apoptosis in human lymphocytes

We have investigated heat- and radiation-induced apoptosis in human lymphocytes in vitro. We have previously shown that apoptosis was induced by radiation at doses as low as 0.05 Gy. Here we report that heat induced apoptosis in human lymphocytes in a temperature- and time-dependent manner. Temperatures at or below 42 degrees C, for up to 90 min, did not cause lymphocytes to undergo apoptosis, whereas temperatures at or above 43 degrees C, for 30 min and longer, did induce apoptosis. Lymphocytes were protected against apoptosis induced by 44 degrees C heat by a prior heat shock of 42 degrees C for 30 min. Heat-induced thermal tolerance developed immediately following the inducing heat shock, was greater after 4 h, and persisted for at least 24 h. While heat also induced radiation resistance, this change was minor and not apparent until about 24 h after the heat shock. Prior to the development of radiation resistance, heat shock sensitized lymphocytes to radiation-induced apoptosis. We have previously shown that radiation-induced apoptosis in lymphocytes varies between donors and therefore may be useful in assessing individual radiosensitivity. We report here that heat also induced variable levels of apoptosis in lymphocytes from different donors, although the range of responses was not as large as those observed with radiation-induced apoptosis. In summary, heat shock induces tolerance to heat-induced apoptosis and results first in sensitization and then protection of lymphocytes against radiation-induced apoptosis.

Human immunodeficiency virus sexual risk reduction in homeless men with mental illness

BACKGROUND

The spread of human immunodeficiency virus infection to impaired groups has intensified the challenge for its prevention; control of the epidemic now requires behavioral change among persons with limited ability to sustain attention and learn. In this randomized clinical trial, we tested an intervention to reduce sexual risk behaviors among homeless men with severe mental illness.

METHODS

Men were recruited from a psychiatric program in a homeless shelter. Of 116 eligible men, 97 (83.6%) participated. Most were African American and had a chronic psychotic disorder and a comorbid substance use disorder. Participants were assigned to a 15-session experimental group intervention or to a 2-session control intervention and observed for 18 months. The 59 participants sexually active before the trial were the main target of the intervention. Sexual risk behavior was the primary outcome.

RESULTS

Among the 59 sexually active men, follow-up data were obtained on 59 (100%) for the initial 6-month follow-up and on 56 (95%) for the remainder of the 18-month follow-up. The mean score on a sexual risk index for the experimental group was 3 times lower than for the control group (1.0 vs 3.1; P=.01) during the initial 6-month follow-up and 2 times lower during the remainder of the 18-month follow-up.

CONCLUSIONS

This intervention successfully reduced sexual risk behaviors of homeless men with mental illness. The effect diminished over 18 months but did not disappear. Similar approaches may be effective in other impaired high-risk groups.