Contribution of ovarian steroid production to urinary estrone conjugate concentrations in Macaca mulatta

This study was designed to test the hypothesis that basal estrone conjugate (E1C) profiles do not accurately detect ovarian function when ovarian estrogen production is low or absent. We employed surgical removal of active ovaries from laboratory rhesus macaques to simulate an acute decline in ovarian estrogen production. In the first experiment, urine samples collected prior to and following ovariectomy (Ovx) were subjected to high-performance liquid chromatography (HPLC) separation. Eluates were then assayed for E1C immunoreactive components. The results indicated a modest decrease in total immunoreactive polar conjugates following ovariectomy, with no substantial change in the overall retention profile. In the second experiment, estradiol (E2) cypionate injections were used to replace the E2 component of ovarian estrogen production in the treated (Tx) group, while the control group (C) received only vehicle. Urine samples were hydrolyzed and individual estrogens were separated by celite chromatography prior to immuno-assay. Both the Tx and C groups exhibited similar urinary excretion levels of estrone (E1), E2, and E1C prior to Ovx (Pre-Ovx) and after Ovx (Post-Ovx), but there were significant differences between groups after treatment (Post-Tx). Significant differences were observed in the Tx group's excretion of E1, E2, and E1C in the Pre- vs. Post-Ovx samples and in the Post-Ovx and Post-Tx samples. The C group also showed the expected significant differences in the Pre- vs. Post-Ovx samples, as well as in the Pre-Ovx and Post-Tx samples. The results indicate that the use of E1C measurements is clearly a suitable method for monitoring ovarian function in intact, cycling animals, but urinary E2 measurements are required to verify loss of follicular activity.

Systematic review of isolation policies in the hospital management of methicillin-resistant Staphylococcus aureus: a review of the literature with epidemiological and economic modelling

OBJECTIVE

To review the evidence for the effectiveness of different isolation policies and screening practices in reducing the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital in-patients. To develop transmission models to study the effectiveness and cost-effectiveness of isolation policies in controlling MRSA.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, The Cochrane Library and SIGLE (1966-2000). Hand-searching key journals. No language restrictions.

REVIEW METHODS

Key data were extracted from articles reporting MRSA-related outcomes and describing an isolation policy in a hospital with epidemic or endemic MRSA. No quality restrictions were imposed on studies using isolation wards (IW) or nurse cohorting (NC). Other studies were included if they were prospective or employed planned comparisons of retrospective data. Stochastic and deterministic models investigated long-term transmission dynamics, studying the effect of a fixed capacity IW, producing economic evaluations using local cost data.

RESULTS

A total of 46 studies were accepted: 18 IWs, 9 NC, 19 other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures which included patient isolation were effective in controlling MRSA. In two others IW use failed to prevent endemic MRSA. There was no robust economic evaluation. Models showed that improving the detection rate or ensuring adequate isolation capacity reduced endemic levels, with substantial savings achievable.

CONCLUSIONS

Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well-designed studies allow the role of isolation measures alone to be assessed. Nonetheless, there is evidence that concerted efforts that include isolation can reduce MRSA even when endemic. Little evidence was found to suggest that current isolation measures recommended in the UK are ineffective, and these should continue to be applied until further research establishes otherwise. The studies with the strongest evidence, together with the results of the modelling, provide testable hypotheses for future research. Guidelines to facilitate design of future research are produced.

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

The infectious intestinal disease study of England: a prospective evaluation of symptoms and health care use after an acute episode

The sequelae of Infectious Intestinal Disease (IID) in a population-based sample of cases and matched controls were investigated for a period of 3 months following the initial infection. Incident cases of IID presenting to GPs or occurring in the community and controls were studied at 3 weeks and over a 3-month follow-up period. Cases were six times more likely than controls to have gastrointestinal symptoms, particularly diarrhoea, at 3 weeks. Ten per cent of cases consulted their GP in the 3 months after episode and 2.3% were referred to hospital. GP presentation rates were twice as high in cases. Gastrointestinal symptoms persist after IID, leading to an increased likelihood of GP consultation and hospital referral. Diagnosis of irritable bowel syndrome may be more likely following IID. The burden of IID is likely to be considerable given its high incidence and the frequency of such sequelae.

The funding and organization of infection control in NHS hospital trusts: a study of infection control professionals' views

The problems associated with hospital-acquired infection have been causing increasing concern in England in recent years. This paper reports the results of a nationwide survey of hospital infection control professionals' views concerning the organizational structures used to manage and obtain funding for control of infection. A complex picture with significant variation between hospitals emerges. Although government policy dictates that specific funding for hospital infection control is formally made available, it is not always the case that infection control professionals have adequate resources to undertake their roles. In some cases this reflects the failure of hospitals' infection control budgetary mechanisms; in others it reflects the effects of decentralizing budgets to directorate or ward level. Some use was made of informal mechanisms either to supplement or to substitute for the formal ones. But almost all infection control professionals still believed they were constrained in their ability to protect the hospital population from the risk of infectious disease. It is clear that recent government announcements that increased effort will be made to support local structures and thereby improve the control of hospital acquired infection are to be welcomed.

An archaeal XPF repair endonuclease dependent on a heterotrimeric PCNA

Archaea share many similarities with eukarya in their information processing pathways and have proven to be a useful model for studies of DNA replication and transcription, but DNA repair pathways are not well understood in archaea. Nucleotide Excision Repair (NER) deals with many bulky DNA lesions and involves over 30 proteins in eukarya. Archaeal NER has not been characterized biochemically, but homologues of the human repair nucleases XPF and XPG have been identified by homology searches. Crenarchaeal XPF proteins have a simplified domain structure, consisting of the C-terminal nuclease domain conserved in XPF and Mus81 but lacking the N-terminal 'helicase' domain that is found in eukaryal and euryarchaeal sequences. Unexpectedly, Sulfolobus XPF is only active in the presence of the sliding clamp PCNA, which is a heterotrimer in this organism. Interactions with two of the three subunits of PCNA are mediated via a C-terminal interaction motif. The PCNA-XPF complex acts as a structure-specific nuclease on a similar range of DNA flap, bubble and junction substrates as the human protein, suggesting a fundamental conservation through billions of years of evolution.

The study of infectious intestinal disease in England: socio-economic impact

To assess the socio-economic impact of infectious intestinal disease (IID) on the health care sector, cases and their families, cases of IID ascertained from a population cohort component and those presenting to general practices were sent a socio-economic questionnaire 3 weeks after the acute episode. The impact of the illness was measured and the resources used were identified and costed. The duration, severity and costs of illness linked to viruses were less than those linked to bacteria. The average cost per case of IID presenting to the GP was Pound Sterling253 and the costs of those not seeing a GP were Pound Sterling34. The average cost per case was Pound Sterling606 for a case with salmonella, Pound Sterling315 for campylobacter, Pound Sterling164 for rotavirus and Pound Sterling176 for SRSV. The estimated cost of IID in England was Pound Sterling743m expressed in 1994/5 prices. The costs of IID are considerable and the duration of the illness was found to be longer than previous reports have suggested.

Spontaneous rat bite fever in non-human primates: a review of two cases

Rat bite fever is a worldwide zoonotic, non-reportable disease. This entity encompasses similar, yet distinct, disease syndromes caused by Streptobacillus moniliformis or Spirillum minus. Naturally occurring rat bite fever has not been previously described in non-human primates. This report describes two cases of non-human primate rat bite fever caused by S. moniliformis; a rhesus macaque (Macaca mullata) with valvular endocarditis, and a titi monkey (Callicebus sp.) with septic arthritis. Potential sources of infection included direct contact, and ingestion of surface water or feed contaminated with rodent feces.

Genetic diversity in bambara groundnut (Vigna subterranea (L.) Verdc) landraces revealed by AFLP markers

Bambara groundnut (Vigna subterranea (L.) Verdc), an African indigenous legume, is popular in most parts of Africa. The present study was undertaken to establish genetic relationships among 16 cultivated bambara groundnut landraces using fluorescence-based amplified fragment length polymorphism (AFLP) markers. Seven selective primer combinations generated 504 amplification products, ranging from 50 to 400 bp. Several landrace-specific products were identified that could be effectively used to produce landrace-specific markers for identification purposes. On average, each primer combination generated 72 amplified products that were detectable by an ABI Prism 310 DNA sequencer. The polymorphisms obtained ranged from 68.0 to 98.0%, with an average of 84.0%. The primer pairs M-ACA + P-GCC and M-ACA + P-GGA produced more polymorphic fragments than any other primer pairs and were better at differentiating landraces. The dendrogram generated by the UPGMA (unweighted pair-group method with arithmetic averaging) grouped 16 landraces into 3 clusters, mainly according to their place of collection or geographic origin. DipC1995 and Malawi5 were the most genetically related landraces. AFLP analysis provided sufficient polymorphism to determine the amount of genetic diversity and to establish genetic relationships in bambara groundnut landraces. The results will help in the formulation of marker-assisted breeding in bambara groundnut.

Cost-effectiveness of different MRSA screening methods

We describe a model to examine the cost-effectiveness of various laboratory-screening approaches to detect methicillin-resistant Staphylococcus aureus (MRSA). A critical literature review was used to derive relevant data on the sensitivity (X), specificity (S) and time to result (T) of different tests. Additional cost information was provided by a hospital. Tests were considered in four interactive groups based on a hierarchy of procedures used in laboratories. X, S and Ts of screening tests were then used in formulae to calculate effectiveness for the various tests. The model was developed to explore the effects on MRSA infection acquisition of differing X, S and T for the different tests in detecting MRSA colonized patients admitted to a high-risk unit such as an intensive care unit. It was concluded that taking a sample from the nose alone and inoculating directly on to Ciprofloxacin Baird-Parker agar without broth incubation and confirmation by a Pastorex Staph-Plus test without any methicillin resistance confirmation test was the most cost-effective approach. The complexity of designing this apparently simple scenario is apparent, and we describe many other factors that would need to be considered to refine this model further. However, this and other models should aid the debate and development of more cost-effective screening strategies given the lack of standardization or agreement concerning so many of the variables within the UK and elsewhere.

Postnatal depression: use of health services and satisfaction with health-care providers

The objective of this study was to compare health-care use and satisfaction with health-care providers between depressed and non-depressed women in the first 4 months after childbirth. Sixteen weeks after delivery a questionnaire, which included the Edinburgh Postnatal Depression Scale (EPDS) and items about health-care use and satisfaction, was mailed to women who attended the antenatal clinic, Royal Women's Hospital, Brisbane. Completed questionnaires were returned by 574 (86.4%) of the 664 women surveyed. During the study period most women (91%) visited a general practitioner at least once and 117 (12%) saw their doctor on five or more occasions. A total of 118 (20.7%) scored above 12 on the EPDS. Depressed women were more likely to visit a psychiatrist (OR, 9.2; 95% CI, 4.3-19.6), social worker (OR, 6.1; 95% CI, 3.3-11.1), postnatal depression group (OR, 4.0; 95% CI, 1.3-12.6), paediatrician (OR, 2.5; 95% CI, 1.6-3.9), or a general practitioner (OR, 2.1; 95% CI, 1.4-3.2) than non-depressed women. Twenty-two (18.5%) of the depressed women had contact with a psychiatrist. Compared with non-depressed women, those scoring above 12 on the EPDS were less satisfied with the services of general practitioners (P=< 0.000), paediatricians (P=0.002), Nursing Mothers' Associations of Australia (P=0.043) and obstetricians (P=0.045). Postpartum depression leads to an increase use of health-care services and has a negative effect on satisfaction with some services.

The study of infectious intestinal disease in England: risk factors for cases of infectious intestinal disease with Campylobacter jejuni infection

This is a case-control study aimed at identifying risk factors for intestinal infection with Campylobacter jejuni. Cases were defined as subjects with diarrhoea occurring in community cohorts or presenting to General Practitioners (GPs) with Campylobacter jejuni in stools. Controls were selected from GP lists or cohorts, matched by age, sex, and GP practice. Travel abroad and consumption of chicken in a restaurant were statistically significantly associated with being a case. There was no statistically significant risk associated with consumption of chicken other than in restaurants nor with reported domestic kitchen hygiene practices. Consumption of some foods was associated with a lower risk of being a case. Most cases remained unexplained. We suggest that infection with low numbers of micro-organisms, and individual susceptibility may play a greater role in the causation of campylobacter infection than previously thought. It is possible that in mild, sporadic cases infection may result from cross contamination from kitchen hygiene practices usually regarded as acceptable. Chicken may be a less important vehicle of infection for sporadic cases than for outbreaks, although its role as a source of infection in both settings requires further clarification in particular in relation to the effect of domestic hygiene practices. The potential effect of diet in reducing the risk of campylobacteriosis requires exploration.

Hepatitis and death following vaccination with 17D-204 yellow fever vaccine

We describe a man vaccinated with the 17D204 strain of yellow fever virus, who subsequently died of yellow fever. Sequencing of the NS5-39 untranslated region showed that the virus isolated from the patient was identical to the vaccine strain of the same batch, and different from wild-type virus. Both viruses contained a mutation, although the association of this mutation with virulence is unknown. Severe, rapidly progressive, and ultimately fatal disease can follow use of the 17D204 vaccine strain. There is need for renewed discussion as to the safety of the vaccine and the indications for its use.

An economic model to assess the cost and benefits of the routine use of silver alloycoated urinary catheters to reduce the risk of urinary tract infections in catheterized patients

Prevalence studies generally find nosocomial urinary tract infections to be the most common type of nosocomial infection, accounting for between 21% and 45% of all HAIs. The main risk factor appears to be the presence of a urinary catheter, with an estimated 80% of these infections being associated with their use. This paper describes a model which quantifies the extent of the burden of these infections in terms of the number of patients affected and the costs incurred by the hospital sector; and identifies the potential benefits of the routine use of silver alloy coated catheters, as a means of reducing the incidence of this type of infection. An illustrative model of the annual costs and benefits associated with the routine use of this intervention in adult, non-day case patients admitted to the medical and surgical specialties of NHS hospitals throughout England is presented. The results suggest that a 14.6% reduction in the incidence of urinary tract infections in catheterized medical patients, and a 11.4% reduction in catheterized surgical patients, would cover the cost of the intervention. Any further reduction in incidence would result in net positive benefits.

The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed

Between April 1994 and May 1995 4000 adult patients admitted to selected specialties of a district general hospital were recruited to this study. Hospital-acquired infections presenting during the in-patient stay were identified using previously validated methods of surveillance, and information on daily resource use by both infected and uninfected patients was recorded and estimates of their cost derived. Linear regression modelling techniques were used to estimate how much of the observed variation in resource use and costs could be explained by the presence of an infection. Complete in-patient data sets were obtained for 3980 patients. Of these, 309 patients (7.8%; 95% CI; 7.0, 8.6) presented with one or more hospital-acquired infections during the in-patient period. Infected patients, on average, incurred hospital costs 2.9 (regression model estimate: 2.8; 95% CI; 2.6, 3.0) times higher than uninfected patients, equivalent to an additional pound3154 (regression model estimate pound2917). Both the incidence and the economic impact varied with site of infection and with admission specialty. Estimates of the burden of hospital-acquired infections occurring in adult patients admitted to similar specialties at NHS hospitals in England were derived from the results of this study. An estimated 320 994 (95% CI; 288 071, 353 916) patients per annum acquire one or more infections which present during the in-patient period, and these infections cost the hospital sector an estimated 930.62 million pounds (95% CI; 780.26 pounds; 1080.97 million pounds) per annum. The results presented represent the gross economic benefits that might accrue if these infections are prevented. Further research is required to establish the net benefits of prevention.

Treatment of unstable fractures of the forearm in children. Is plating of a single bone adequate?

Unstable fractures of the forearm in children present problems in management and in the indications for operative treatment. In children, unlike adults, the fractures nearly always unite, and up to 10 degrees of angulation is usually considered to be acceptable. If surgical intervention is required the usual practice in the UK is to plate both bones as in an adult. We studied, retrospectively, 32 unstable fractures of the forearm in children treated by compression plating. Group A (20 children) had conventional plating of both forearm bones and group B (12 children) had plating of the ulna only. The mean age was 11 years in both groups and 23 (71%) of the fractures were in the midshaft. In group B an acceptable position of the radius was regarded as less than 10 degrees of angulation in both anteroposterior (AP) and lateral planes, and with the bone ends hitched. This was achieved by closed means in all except two cases, which were therefore included in group A. Union was achieved in all patients, the mean time being 9.8 weeks in group A and 11.5 weeks in B. After a mean interval of at least 12 months, 14 children in group A and nine in group B had their fixation devices removed. We analysed the results after the initial operation in all 32 children. The 23 who had the plate removed were assessed at final review. The results were graded on the ability to undertake physical activities and an objective assessment of loss of rotation of the forearm. In group A, complications were noted in eight patients (40%) after fixation and in six (42%) in relation to removal of the radial plate. No complications occurred in group B. The final range of movement and radiological appearance were compared in the two groups. There was a greater loss of pronation than supination in both. There was, however, no limitation of function in any patient and no difference in the degree of rotational loss between the two groups. The mean radiological angulation in both was less than 10 degrees in both AP and lateral views, which was consistent with satisfactory function. The final outcome for 23 patients was excellent or good in 12 of 14 (90%) in group A, despite the complications, and in eight of nine in group B (90%). If reduction and fixation of the fracture of the ulna alone restores acceptable alignment of the radius in unstable fractures of the forearm, operation on the radius can be avoided.

A study of infectious intestinal disease in England: risk factors associated with group A rotavirus in children

OBJECTIVE

To identify risk factors for infectious intestinal disease (IID) due to rotavirus group A in children aged under 16 years.

METHODS

Case-control study of cases of IID with rotavirus infection presenting to general practitioners (GPs) or occurring in community cohorts, and matched controls.

RESULTS

There were 139 matched pairs. In children under 16 years the following risk factors were significantly associated with rotavirus IID: living in rented council housing (adjusted OR = 3.78, P = 0.022), accommodation with more than five rooms (OR = 0.72, P = 0.002), contact with someone ill with IID (OR = 3.45, P < 0.001). Some foods were associated with decreased risk. In infants, bottle feeding with or without breast feeding was associated with increased risk (OR = 9.06, P < 0.05).

CONCLUSIONS

Contact with persons with IID, living in rented council housing and accommodation with fewer rooms, were significant risk factors for sporadic rotavirus IID in children whereas breast feeding is protective in infants.

Spontaneous intestinal adenocarcinoma in geriatric macaques (Macaca sp.)

BACKGROUND AND PURPOSE

Intestinal adenocarcinoma appears to be the most common malignant neoplasm in macaques, and is a substantial cause of morbidity and mortality in the elderly.

METHODS

A retrospective review of 32 cases was done.

RESULTS

Thirty-two cases were reviewed. Clinical examination had revealed severe weight loss, anorexia, and palpable abdominal mass. Microcytic hypochromic anemia, intermittent fecal occult blood positive test results, hypoproteinemia, and hypoalbuminemia were the predominant clinical laboratory findings. Carcinoembryogenic antigen serologic testing and single-strand conformational polymorphism analysis were performed in selected cases. The most common sites of the intestinal adenocarcinoma were ileocecal junction, colon, ileum, jejunum, and cecum. Metastases were evident in 34% of the cases and involved peripheral nodes, liver, lungs, pancreas, and adrenal gland. Overall survival of 12 macaques that underwent surgical excision was 83% at 6 months, 58% at 1 year, 50% at 1.5 years, 33% at 2 years, and 8% at 4 years. The overall mean survival rate (MSR) was > 483 postoperative days.

CONCLUSION

Intestinal adenocarcinomas should be amenable to surgical resection. Early detection of localized, non-invasive neoplasms will increase surgical cure rate. Survivability could be potentially improved by use of adjuvant therapies.

Relationship of childhood sexual abuse and eating disturbance in children

OBJECTIVE

To test the hypothesis that childhood sexual abuse increases the risk of eating disturbance in children.

METHOD

Data obtained from 20 sexually abused children were compared with data obtained from 20 nonabused control children. All subjects were female and between the ages of 10 and 15 years. Subjects completed a battery of tests assessing eating disorder behaviors, body image concern, and childhood trauma history.

RESULTS

Comparison of the 2 groups revealed that the abused children had higher levels of weight dissatisfaction and purging and dieting behavior. Furthermore, abused children reported eating less than control children when they felt emotionally upset. Abused children were less likely than control children to exhibit perfectionistic tendencies, but more likely to desire thinner body types.

CONCLUSIONS

This is the first controlled study to examine the relationship between childhood sexual abuse and eating disturbance which relied on children as subjects. The results support previous findings with adult subjects which indicate that a history of childhood sexual abuse is associated with weight and body dissatisfaction, along with purging and dietary restriction.

Intensity correction by subtraction for phased-array MRA images

A method of intensity correction is described that is particularly useful for magnetic resonance angiography images acquired with phased-array coils. In this method a low-pass filtered version of the image is subtracted from the original image to remove signal variations due to the phased-array coil. This avoids the noise amplification caused by division correction and enhances the signal-to-noise ratio of small arteries in maximum intensity projections. J. Magn. Reson. Imaging 2000;12:501-504.