Elevated levels of serum immunoglobulins in asymptomatic carriers of Clostridium difficile

Serum levels of IgA, IgM, and polyvalent immunoglobulins reactive with Clostridium difficile were determined by ELISA for asymptomatic carriers (n = 5), symptomatic individuals (n = 21), and a pool of 30 "normal" individuals. Mean IgA concentrations expressed as optical density (OD +/- SD) were significantly higher (P < .001) for asymptomatic carriers (1.252 +/- 0.516) than for symptomatic patients (0.374 +/- 0.145). Mean serum IgM levels also were significantly higher (P < .001) for carriers (1.456 +/- 0.582) than for symptomatic patients (0.727 +/- 0.331), as were mean values for polyvalent immunoglobulins (2.25 +/- 0.718 for carriers vs. 1.457 +/- 0.574 for symptomatic patients; P < .05). Although the patient populations were small, the levels of immunoglobulins reactive with C. difficile antigens differed significantly. This difference might reflect the ability of the host to mount an immune response and might be a factor influencing whether a patient develops disease due to this organism. The ability to detect differences in immunoglobulin levels might also help differentiate infection from colonization.

Transverse myelitis complicating systemic lupus erythematosus: treatment including hydroxychloroquine. Case report

Transverse myelitis has been cited as a rare and unusual complication of systemic lupus erythematosus (SLE). A review of the literature reveals only 10 cases of transverse myelitis as the initial presentation of SLE, and only one with reported benefits from antimalarial therapy. The case of a 30-year-old woman is reviewed. She presented to the emergency room with complaints of hypogastric and low back pain. The ensuing course was one of frank urinary retention and rapidly progressing quadriparesis. Magnetic resonance imaging of the spine revealed marked edema of the cervical and thoracic spine. A diagnosis of SLE was based on positive antinuclear antibodies and leukopenia. The patient was treated with high dose methylprednisolone, plasmapheresis and pulse cyclophosphamide for 3 months. Subsequently, treatment was begun with hydroxychloroquine, and significant improvement in her neurologic and functional status was achieved after 1 month of therapy. Ten months after her onset of symptoms, the patient suffered an acute exacerbation of paraparesis and urinary retention. Again, she improved clinically after high dose methylprednisolone and pulse cyclophosphamide for 1 month. Hydroxychloroquine was continued throughout the duration of therapy.

Endopeptidase inhibition and intestinal antigen processing in mice

The role of gastrointestinal digestive processes in the systemic availability of ingested protein antigens was examined by feeding the trypsin inhibitor aprotinin intragastrically to mice and measuring uptake of ovalbumin and 14C-polyethylene glycol (MW 4000) from the gastrointestinal tract. Trypsin and chymotrypsin activities in the intestinal lumen were significantly reduced by aprotinin feeding. Aprotinin slowed stomach emptying, but radioimmunoassays for immunoreactive ovalbumin in the serum of mice prefed aprotinin showed 12-fold elevations within 1 hr after ovalbumin feeding. Uptake of a nonmetabolized macromolecular probe, 14C-polyethylene glycol-4000, increased less than two-fold when fed with aprotinin under the same conditions, indicating that the increased uptake of immunoreactive ovalbumin was not due to changes in intestinal permeability. The results show that inhibition of luminal proteolysis caused significant increases in the serum concentration of immunoreactive ovalbumin, indicating that acute inhibition of luminal proteases permits larger quantities of relatively intact protein to interact with mucosal absorptive surfaces. These results support the hypothesis that pancreatic proteases modulate antigen absorption from the lumen in adult animals.

Inhibition of orally-induced immune tolerance in mice by prefeeding an endopeptidase inhibitor

Intragastric feeding of T-dependent protein antigens to mice induces substantial systemic tolerance in specific antibody and cell-mediated immune responses. To evaluate the role of gastrointestinal digestion in this phenomenon, the trypsin inhibitor aprotinin was fed to adult BDF1 mice prior to tolerogenic feedings of ovalbumin or human gamma globulin. As assessed by measurement of protein-specific antibody responses, aprotinin significantly reduced tolerance induced by feeding carrier protein, but not tolerance induced by parenteral antigen injection. Aprotinin also reduced oral tolerance to ovalbumin as measured by delayed-type hypersensitivity and T cell proliferative responses. However, aprotinin did not alter antibody tolerance to a carrier-associated hapten in the same animals. Feeding of human gamma globulin concomitantly with aprotinin induced specific antibody responses without further immunization, and reduced subsequent tolerance. Aprotinin also increased the level of immunologically detectable ovalbumin found in the serum following antigen feeding. The data support the hypothesis that aprotinin indirectly mediated changes in specific stimuli available to the lymphoid system as a result of alterations in gastrointestinal processing of fed antigens rather than to direct effects of aprotinin upon systemic immune responses.

The effect of the entry hole for an intramedullary nail on the strength of the proximal femur

We used 15 pairs of femora from fresh human cadavers to study the effects of the size and location of the entry hole for an intramedullary nail on the strength of the femur. Right femora were used as controls. Left femora in group 1 had a 10 mm entry hole in the 'ideal' location in the piriformis fossa. Group 2 had a 14 mm entry hole in the same position and group 3 had a 14 mm entry hole anterior to this on the superior aspect of the femoral neck. Femora were equipped with strain gauges and loaded to failure in compression. There was reduced stiffness and load to failure in group 3 specimens, suggesting that the location of the hole was more important than its size.

Split tolerance of Th1 and Th2 cells in tolerance to Theiler's murine encephalomyelitis virus

Theiler's murine encephalomyelitis virus (TMEV) produces a chronic, inflammatory demyelinating disease in susceptible mouse strains that is used as a model for multiple sclerosis. Because disease susceptibility correlates temporally with the development of virus-specific delayed-type hypersensitivity (DTH) responses, we studied methods and mechanisms by which virus-specific DTH could be specifically inhibited. The intravenous injection of UV-inactivated TMEV coupled to syngeneic splenocytes via a carbodiimide linkage (TMEV-SP), prior to immunization, induced a significant degree of tolerance in virus-specific helper (Th) cells as determined by decreased DTH and T cell proliferative responses, and decreased interleukin (IL)-2 and interferon (IFN)-gamma protein and mRNA levels. In contrast to the reduced levels of Th1-specific lymphokine mRNA levels, IL-4-specific mRNA levels in response to virus stimulation were not affected in tolerant mice. Surprisingly, the total anti-TMEV antibody response in DTH tolerant mice was enhanced 20-100-fold over sham-tolerized controls and was composed of reduced levels of anti-virus IgG2a, but dramatically increased levels of anti-virus IgG1. The "split-tolerance" was antigen specific, dependent on the concentrations of TMEV and carbodiimide used in the coupling procedure, and varied with the number of coupled syngeneic splenocytes administered. The fixative effects of carbodiimide on antigen-presenting function were necessary for the induction of DTH tolerance with TMEV-SP, since intravenous administration of virus coupled to splenocytes via a biotin-avidin linkage led to enhanced virus-specific antibody responses, but was unable to inhibit DTH unless concomitantly fixed with carbodiimide. Collectively, the data indicate that Th1 cells (mediating DTH, IL-2 and IFN-gamma production, and helper function for IgG2a production) were specifically anergized, with concomitant stimulation of Th2 cells (producing IL-4 and mediating helper function for IgG1 antibody production).

Increasing the adjustment success of the disabled African American

Adjustment to a physically disabling condition is a challenge for any patient who confronts a future of severe impairment and limited mobility. The emotional trauma is usually devastating at least until the initial shock of the disability dissipates. For the disabled African-American patient, the physical and psychic pain are compounded by personal and social factors not experienced in similar intensity by other disabled patients. A conceptual framework for better understanding the nature of the forces that impinge on the ability of the disabled African-American patient to adjust and an understanding of the impact of multi-level systems on the life of the disabled African-American is provided. The influence of racism, be it intentional or unintentional, is explained as it relates to the services and the attitudes of health care systems. The family as a significant and vital system is discussed as the major contributor to the successful adjustment of African-American disabled persons.

A simple medium for the primary isolation of Haemophilus ducreyi

Two simple, inexpensive media containing gonococcal agar-base, supplemented with 5% Fildes' extract and either chocolated or unchocolated horse blood (GC-FHBC or GC-FHB) were compared with the standard gonococcal agar-based (GC-HgS) and Mueller-Hinton agar-based media (MH-HB) normally used for primary isolation of Haemophilus ducreyi from presumptive chancroid lesions. Overall, Haemophilus ducreyi was recovered from 162 of 178 (91%) samples from primary chancroid lesions. As a single isolation medium GC-HgS proved the most sensitive with an isolation rate of 80% followed by GC-FHB (75%), MH-HB and GC-FHC (both 71%). Use of a combination of GC-HgS and MH-HB resulted in isolation of Haemophilus ducreyi in 160 of 178 cases (90%). Since GC-FHB is approximately one-quarter the cost of the combination and half the cost of GC-HgS or MH-HB alone, this medium could prove suitable for diagnostic purposes in developing countries where chancroid is endemic.

Knowledge of nephrologists and patients about autosomal dominant polycystic kidney disease (ADPKD)

Because of the availability of presymptomatic testing for autosomal dominant polycystic kidney disease (ADPKD), we assessed the response of nephrologists, patients, and at-risk relatives to the introduction of a genetic counselling program for ADPKD. Fifty-six of seventy-six nephrologists responded. Ninety-eight percent reported 'generally' telling their patients that the disease was hereditary, but fewer reported screening relatives (81% for children and 70% for siblings and parents). Ninety percent were interested in referring patients to the service. Fourteen of the 24 patients in one renal clinic and 18 of their at-risk relatives were interviewed. Ten of the patients but only five of the relatives stated that the disease was hereditary. The precise mechanism of inheritance was poorly understood by most patients and relatives. Of 21 patients offered genetic counselling, nine made appointments to see the genetic counsellor. There remains a large gap between advancing technology and the delivery of information to at-risk populations.

Urticaria and angioedema

Urticaria and angioedema are commonly seen in the outpatient setting. Their pathogenesis involves complex cellular and humoral factors. Diagnosis depends on historical information such as duration of symptoms, exacerbating factors, and atopy. While many etiologic factors have been implicated, in most chronic cases no specific etiology is found. This article reviews physical and hereditary syndromes and discusses therapeutic regimens based on the duration and severity of symptoms.

The psychophysiological investigation of multiple personality disorder: review and update

In 1984 Putnam reviewed the literature on the psychophysiological investigation of multiple personality disorder (MPD). Since his review, a large number of studies have been conducted and reported in the literature and at professional conferences. Currently, psychophysiologic differences reported in the literature include changes in cerebral electrical activity, cerebral blood flow, galvanic skin response, skin temperature, event-related potentials, neuroendocrine profiles, thyroid function, response to medication, perception, visual functioning, visual evoked potentials, and in voice, posture, and motor behavior. We review the new research on the psychophysiological investigation of MPD from published, unpublished, and ongoing studies, and we attempt to place current findings into a conceptual framework. We have noted findings from unpublished and ongoing studies, and, perhaps unfortunately, they represent a large amount of the data presently available. We conclude with a critical analysis of current research methodology and suggestions for future research.

Induction of active and adoptive relapsing experimental autoimmune encephalomyelitis (EAE) using an encephalitogenic epitope of proteolipid protein

Proteolipid protein (PLP) is a major component of the central nervous system (CNS) myelin membrane and has been shown to induce acute experimental autoimmune encephalomyelitis (EAE) in genetically susceptible animals. Here we describe conditions by which a relapsing-remitting form of EAE can be reliably induced in SJL/J mice either actively immunized with the major encephalitogenic PLP peptide, PLP13-151(S), or following adoptive transfer of PLP139-151(S)-specific T cells. The disease follows a reliable relapsing-remitting course with acute clinical signs first appearing 6-20 days after priming or transfer and relapses first appearing at 30-45 days. The initial onset of disease correlates with delayed-type hypersensitivity (DTH) reactivity specific for PLP139-151(S), in the apparent absence of T cell reactivity to the major myelin basic protein (MBP) peptide. Histologically, both the active and adoptive forms of the disease are characterized by extensive mononuclear cell infiltration and severe demyelination of the CNS. These results suggest that T cell responses specific for PLP139-151(S) are sufficient to induce clinical and histological R-EAE in SJL/J mice. This model should prove useful for examination of the cellular and molecular events involved in clinical relapses and perhaps in determining the role of PLP-specific T cell responses in multiple sclerosis (MS).

Regulation of the effector stages of experimental autoimmune encephalomyelitis via neuroantigen-specific tolerance induction. II. Fine specificity of effector T cell inhibition

Ag-specific tolerance induced by the i.v. administration of splenocytes coupled with mouse spinal cord homogenate, containing a mixture of myelin Ag, dramatically inhibits development and expression of clinical and histologic signs of both active and adoptive forms of relapsing experimental autoimmune encephalomyelitis (R-EAE) in the SJL/J host. Here we examined the dose-dependency, route of tolerogen administration, and fine neuroantigen specificity of inhibition of adoptive R-EAE. Expression of clinical R-EAE induced by a polyclonal population of bovine myelin basic protein (MBP)-specific effector T cells was dramatically inhibited in a dose-dependent manner following the i.v., but not s.c. or i.p., injection of MBP-coupled splenocytes. The exquisite Ag specificity of the inhibition was evident by the observation that splenocytes coupled with intact bovine MBP or species variants of MBP homologous with bovine MBP within the major encephalitogenic region (amino acids 84-104), but not with proteolipid protein or mouse kidney homogenate, were able to suppress disease expression. Splenocytes coupled with the MBP84-104 peptide, containing a nested set of the major SJL/J encephalitogenic epitopes, completely inhibited peptide-specific T cell responses, but only partially inhibited the expression of disease transferred by T cells specific for intact MBP, suggesting the participation of T cell responses specific for additional MBP determinants in disease pathogenesis. However, splenocytes coupled with previously identified minor SJL/J encephalitogenic epitopes (MBP91-104 or MBP17-27), or with the Lewis rat major encephalitogenic epitope (MBP68-86), did not suppress disease expression. Collectively, the results demonstrate that MBP84-104-specific T cells and T cells specific for an as yet unidentified MBP epitope(s) contribute to the pathology of R-EAE. In addition, the results demonstrate that peptide-specific tolerance induction appears to have potential for the treatment of T cell-mediated inflammatory diseases.

Regulation of the effector stages of experimental autoimmune encephalomyelitis via neuroantigen-specific tolerance induction. II. Fine specificity of effector T cell inhibition

Ag-specific tolerance induced by the i.v. administration of splenocytes coupled with mouse spinal cord homogenate, containing a mixture of myelin Ag, dramatically inhibits development and expression of clinical and histologic signs of both active and adoptive forms of relapsing experimental autoimmune encephalomyelitis (R-EAE) in the SJL/J host. Here we examined the dose-dependency, route of tolerogen administration, and fine neuroantigen specificity of inhibition of adoptive R-EAE. Expression of clinical R-EAE induced by a polyclonal population of bovine myelin basic protein (MBP)-specific effector T cells was dramatically inhibited in a dose-dependent manner following the i.v., but not s.c. or i.p., injection of MBP-coupled splenocytes. The exquisite Ag specificity of the inhibition was evident by the observation that splenocytes coupled with intact bovine MBP or species variants of MBP homologous with bovine MBP within the major encephalitogenic region (amino acids 84-104), but not with proteolipid protein or mouse kidney homogenate, were able to suppress disease expression. Splenocytes coupled with the MBP84-104 peptide, containing a nested set of the major SJL/J encephalitogenic epitopes, completely inhibited peptide-specific T cell responses, but only partially inhibited the expression of disease transferred by T cells specific for intact MBP, suggesting the participation of T cell responses specific for additional MBP determinants in disease pathogenesis. However, splenocytes coupled with previously identified minor SJL/J encephalitogenic epitopes (MBP91-104 or MBP17-27), or with the Lewis rat major encephalitogenic epitope (MBP68-86), did not suppress disease expression. Collectively, the results demonstrate that MBP84-104-specific T cells and T cells specific for an as yet unidentified MBP epitope(s) contribute to the pathology of R-EAE. In addition, the results demonstrate that peptide-specific tolerance induction appears to have potential for the treatment of T cell-mediated inflammatory diseases.

Antigen-specific inhibition of the adoptive transfer of experimental autoimmune enceophalomyelitis in Lewis rats

The efficacy of antigen-specific immunoregulation as a treatment for the efferent limb of an autoimmune disease was tested in a rat model of adoptive experimental autoimmune encephalomyelitis (EAE). Lewis rats receiving 4-5 x 10(7) guinea pig (GP) myelin basic protein (MBP)-activated lymph node T cell blasts from GPMBP/CFA sensitized donors routinely show clinical signs of disease 5-6 days post transfer. Intravenous injection of GPMBP coupled to syngeneic splenocytes using the chemical cross-linker carbodiimide was effective in completely abrogating the expression of clinical EAE in rats that received MBP-specific T cells 2 days previously. Partial inhibition was also observed in rats injected as early as day 0 (the same day as MBP-specific T cell transfer) and as late as 1 day prior to the onset of clinical signs (days 4-5 post transfer). Unresponsiveness was shown to be dose-dependent, dependent on the route of injection of the neuroantigen-coupled splenocytes, and was antigen-specific. Splenocytes coupled with GP or rat MBP (which are identical within the major encephalitogenic GP68-86 Lewis rat determinant with the exception of the residue at position 80) were equally efficient at eliminating disease expression in recipients of GPMBP-specific T cells. In contrast, splenocytes coupled with bovine or rabbit MBP (which differ significantly from GPMBP within the 68-86 region) had no inhibitory effect. The antigen specificity of the tolerance induction was also illustrated by the fact that splenocytes coupled with GP68-86, but not those coupled with the truncated GP68-84 peptide, induced profound unresponsiveness. Interestingly, de novo antigen processing by the antigen-coupled cells did not appear to be necessary as the inclusion of antigen processing inhibitors had no effect on inhibition of disease. However, the use of the carbodiimide coupling reagent was critical for the induction of unresponsiveness as essentially equivalent amounts of 125I-labelled MBP were bound in its presence or absence, but only splenocytes incubated in the presence of both MBP and carbodiimide inhibited clinical expression of disease. Antigen-specific tolerance is thus an effective means of inhibiting expression of clinical disease in the rat EAE model, and a powerful tool for determining the fine epitope specificity of encephalitogenic T cells.

IgG subclass responses to Theiler's murine encephalomyelitis virus infection and immunization suggest a dominant role for Th1 cells in susceptible mouse strains

Inbred mouse strains differ in susceptibility to Theiler's murine encephalomyelitis virus (TMEV)-induced demyelinating disease. A strong correlation between disease susceptibility and delayed-type hypersensitivity (DTH) has been previously demonstrated, but no strong correlation between disease susceptibility and total anti-TMEV ELISA titres was shown. Since both DTH and IgG2a antibody production are regulated by CD4+ Th1 cells, we investigated three strains of mice to determine whether antivirus IgG2a antibody levels, like DTH in previous studies, correlated with disease susceptibility. Susceptible SJL/J, intermediately susceptible C3H/HeJ, and resistant C57BL/6 mice were infected intracerebrally (i.c.) with the BeAn strain of TMEV and monitored for clinical signs of demyelination and for levels of TMEV-specific antibody of different IgG subclasses using a particle concentration fluorescence immunoassay (PCFIA). Resistant C57BL/6 mice were found to have significantly lower concentrations of total anti-TMEV antibody than susceptible SJL/J mice and intermediately susceptible C3H/HeJ mice show variable antibody responses. A predominance of anti-TMEV IgG2a (Th1 regulated) antibody was seen in susceptible and intermediately susceptible mice, whereas resistant mice displayed a predominant anti-TMEV IgG1 (Th2 regulated) response accompanied by a marked deficiency of IgG2a. In contrast, immunization of C57BL/6 mice with UV-inactivated TMEV in adjuvant revealed that this strain was not defective either in its ability to generate high levels of anti-TMEV antibody or in its ability to produce IgG2a antibody. These results suggest that the antivirus IgG subclass profile is dependent upon the immunization route, virus viability and/or the use of adjuvant and that the levels of antivirus subclasses may be predictive of disease susceptibility.

Delayed nasal mucociliary clearance in patients with nonallergic rhinitis and nasal eosinophilia

This study investigated nasal mucociliary clearance as related to nasal eosinophilia in nonallergic rhinitis patients using the technique of nasal saccharin challenge. Fifty-six consecutive patients with nonallergic rhinitis were evaluated with nasal cytology and saccharin challenge. A saccharin challenge time of greater than 25 minutes was considered abnormal. Twelve of 56 patients (21.4%) had nasal eosinophilia. Fifteen of 56 patients (26.8%) had prolonged nasal circulation times greater than 25 minutes, indicating delayed mucociliary clearance. Although 7 of 12 patients (58.3%) with nasal eosinophilia had delayed mucociliary clearance, only 8 of 44 patients (18.2%) without eosinophilia had circulation times longer than 25 minutes. The correlation of nasal eosinophilia with prolongation of the nasal circulation time is statistically significant (chi square 5.84, P = .0156). We postulate that damage to the nasal mucociliary system may be an etiologic factor for a subset of patients with nonallergic rhinitis and that this damage may be mediated by eosinophils.

Sexually transmitted disease surveillance in a child abuse clinic

The sexually transmitted disease surveillance system instituted at the Child Abuse and Neglect (CAN) clinic of the Transvaal Memorial Institute for Child Health and Development was evaluated after 1 year. The presenting complaint of the vast majority of the 227 patients was sexual abuse. In more than half (52%), child abuse was medically proven, and it was highly suspected in another 18%. In only 6% did no abuse take place. About half the patients suffered non-penetrative sexual abuse, 40% penetrative abuse and 10% suffered non-sexual abuse. Smears for gonorrhoea were positive in 2 out of 152 patients; for Chlamydia in 1 out of 140; for Gardnerella and Trichomonas in 2 and 1 case, respectively. Syphilis serology yielded 3 positive results out of 162, and hepatitis B, 6 out of 143. No positive results were found in tests for HIV and herpes. With the exception of hepatitis B tests, all positive results occurred in children considered on clinical grounds to have medically proven or highly suspected sexual abuse. These results will allow modification of the surveillance system and testing of those children more likely to test positive, while doing fewer tests overall.

Antigen-specific tolerance as a therapy for experimental autoimmune encephalomyelitis

The effects of neuroantigen-specific tolerance on the induction and effector stages of EAE were examined. Tolerance induced by the i.v. injection of syngeneic splenocytes coupled with purified neuroantigens or encephalitogenic peptides of MBP and PLP using ethylene carbodiimide was extremely effective in both prevention and treatment of acute and relapsing forms of EAE in Lewis rats and SJL/J mice. The unresponsiveness is rapidly-induced, dose-dependent, long-lasting, efficient, MHC class II-restricted, and exquisitely antigen-specific. This procedure targets only effector cells bearing clonotypic receptors specific for the autoantigen/autoepitope and thus does not depend upon the autoimmune response being dominated by a restricted T cell repertoire. Moreover, it does not require that the response to the autoantigen be dominated by recognition of a specific epitope(s) within a particular autoantigen, or even the identification of the specific autoantigen. The results also demonstrate the usefulness of peripheral tolerance induced by antigen-coupled syngeneic splenocytes for identifying the fine specificity of autoimmune T cell responses which appear to change during the progression of relapsing EAE. Thus, this technique offers major advantages over many other currently employed immunoregulatory strategies and is therefore relevant for establishment of therapeutic protocols for the antigen-specific treatment of human T cell-dependent autoimmune disorders.

Blood histamine levels following graded cold challenge in atypical acquired cold urticaria

Acquired cold urticaria with a negative cold stimulation test has been described in seven patients in whom the standard ice cube test did not induce localized urticaria. Subsequent total body cold exposure induced a generalized urticaria. A patient with this syndrome is presented where blood histamine levels rose from 9 to 60 micrograms/dL after a negative local cold stimulation test and from 60 to 90 micrograms/dL after total body cold exposure. Urticaria occurred only after generalized cold exposure. Blood histamine levels following the ice cube test may represent a sensitive method to diagnose this form of atypical acquired cold urticaria, without subjecting the patient to the risk of anaphylaxis reported following total body cold exposure.

Specific immunoregulation of the induction and effector stages of relapsing EAE via neuroantigen-specific tolerance induction

The effects of neuroantigen-specific tolerance on the induction and effector stages of relapsing experimental autoimmune encephalomyelitis (R-EAE) were examined. The incidence of clinical and histologic signs of active MSCH-induced R-EAE, and accompanying neuroantigen-specific DTH responses, were dramatically reduced in SJL/J mice tolerized via the i.v. injection of syngeneic splenocytes coupled with MSCH, PLP, or encephalitogenic PLP peptides 7-14 days before priming. MBP-specific tolerance was not effective in preventing active R-EAE. In contrast to MSCH-induced active R-EAE, treatment of recipient mice with splenocytes coupled with MBP and the encephalitogenic MBP 84-104 peptide, but not with PLP, suppressed of clinical signs of adoptive R-EAE mediated by MBP-specific effector T cells in a dose-dependent manner. Neuroantigen-coupled splenocytes were also efficient in treating established disease as tolerization of SJL/J mice after the first incidence of clinical disease significantly reduced the incidence and severity of subsequent paralytic relapses. Antigen-specific tolerance thus provides a powerful approach for the prevention and/or treatment of autoimmune disease.

Atrial fibrillation associated with autonomic dysreflexia

Autonomic dysreflexia is an acute disorder of autonomic homeostasis occurring in persons with spinal cord lesions above the major splanchnic sympathetic outflow. Atrial fibrillation is a serious cardiac arrhythmia characterized by disorganized atrial depolarization and an irregular ventricular response. Previously reported complications of autonomic dysreflexia have included seizures, strokes and cardiac arrhythmias other than atrial fibrillation. We present a 60-yr-old man with C-5 incomplete quadriplegia in whom atrial fibrillation was apparently induced by an episode of autonomic dysreflexia. Mechanisms by which autonomic dysreflexia may cause this arrhythmia include altered cardiac autonomic tone as well as atrial distention. The simultaneous occurrence of autonomic dysreflexia and atrial fibrillation poses special diagnostic problems and treatment risks. Atrial fibrillation incidence increases with age in the general population. With the aging of the spinal cord-injured population, we expect to see more episodes of atrial fibrillation associated with autonomic dysreflexia.

Successful treatment of paralytic relapses in adoptive experimental autoimmune encephalomyelitis via neuroantigen-specific tolerance

We have previously demonstrated that Ag-specific tolerance induced by the i.v. administration of splenocytes coupled with neuroantigens, such as mouse spinal cord homogenate, myelin basic protein (MBP), and proteolipid protein, and their encephalitogenic peptides, results in dramatic inhibition of clinical and histologic signs of both actively induced and adoptively transferred relapsing experimental autoimmune encephalomyelitis (R-EAE). We report here that the administration of splenocytes coupled with mouse spinal cord homogenate (i.e., a mixture of neuroantigens), after the first paralytic episode of adoptive R-EAE triggered by MBP-specific T cells but before the appearance of the first relapse, effectively reduced the onset and severity of all subsequent relapses, as determined by both clinical and pathologic criteria. In contrast, the i.v. administration of splenocytes coupled with MBP (i.e., the specificity of the initiating T cell response), under similar conditions, effectively inhibited the initial clinical relapse, but subsequent relapses occurred with the same incidence rate and severity as those in control animals. Collectively, these results demonstrate that neuroantigen-specific tolerance is effective at specifically down-regulating an ongoing autoimmune response. This may have potential clinical applicability for treatment of autoimmune diseases. The results also support the hypothesis that the neuroantigen specificity of later relapses of R-EAE may be due to effector T cells with specificities different from those that triggered the initial clinical episode. Thus, potential therapy for the advanced stages of R-EAE, and perhaps other autoimmune diseases, may have to be directed not simply against the effector cells initiating the disease but also against effector cells with differing specificities recruited as a result of tissue damage occurring in the initial acute disease.

Successful treatment of paralytic relapses in adoptive experimental autoimmune encephalomyelitis via neuroantigen-specific tolerance

We have previously demonstrated that Ag-specific tolerance induced by the i.v. administration of splenocytes coupled with neuroantigens, such as mouse spinal cord homogenate, myelin basic protein (MBP), and proteolipid protein, and their encephalitogenic peptides, results in dramatic inhibition of clinical and histologic signs of both actively induced and adoptively transferred relapsing experimental autoimmune encephalomyelitis (R-EAE). We report here that the administration of splenocytes coupled with mouse spinal cord homogenate (i.e., a mixture of neuroantigens), after the first paralytic episode of adoptive R-EAE triggered by MBP-specific T cells but before the appearance of the first relapse, effectively reduced the onset and severity of all subsequent relapses, as determined by both clinical and pathologic criteria. In contrast, the i.v. administration of splenocytes coupled with MBP (i.e., the specificity of the initiating T cell response), under similar conditions, effectively inhibited the initial clinical relapse, but subsequent relapses occurred with the same incidence rate and severity as those in control animals. Collectively, these results demonstrate that neuroantigen-specific tolerance is effective at specifically down-regulating an ongoing autoimmune response. This may have potential clinical applicability for treatment of autoimmune diseases. The results also support the hypothesis that the neuroantigen specificity of later relapses of R-EAE may be due to effector T cells with specificities different from those that triggered the initial clinical episode. Thus, potential therapy for the advanced stages of R-EAE, and perhaps other autoimmune diseases, may have to be directed not simply against the effector cells initiating the disease but also against effector cells with differing specificities recruited as a result of tissue damage occurring in the initial acute disease.

The 5' noncoding sequences from a less virulent Theiler's virus dramatically attenuate GDVII neurovirulence

RNA transcripts derived from recombinant chimeras between the highly virulent GDVII virus and the less virulent BeAn virus were constructed to study the molecular pathogenesis of Theiler's murine encephalomyelitis virus infection. The presence of the BeAn 5' noncoding sequences in chimera 2 (BeAn 5' noncoding sequences joined with the GDVII nucleotides encoding the polyprotein and present in the 3' end) resulted in dramatic attenuation of GDVII neurovirulence and development of poliomyelitis in mice. This reduced neurovirulence was associated with slower virus growth and lower peak titers in the brain and spinal cord than with parental GDVII virus replication. On the other hand, the sites of replication following chimera 2 infection were the same as those seen in GDVII-infected mice; the distribution of virus antigen and histopathological changes indicated that chimera 2 replicates in neurons in the brain, e.g., in the neocortex, hippocampus, caudate putamen, and brain stem, as well as in anterior-horn cells in the spinal cord. Chimera 2 was efficiently cleared from the mouse central nervous system by day 30 postinfection, in marked contrast to the persistence of the BeAn parent in the central nervous system. This suggests that elements in the BeAn sequences that encode the polyprotein or are present in the 3' noncoding region are necessary for viral persistence. It is of interest that chimera 2-infected mice developed localized inflammatory, demyelinating lesions which were detected at day 28 postinfection but these lesions did not become larger with time. Thus, virus persistence appears to be required for maintenance and progression of immune-mediated demyelination. If the demyelinating lesions become sufficiently large, clinical signs and disease may develop.

Prevalence of back pain among radiation therapists

Low back pain among radiation therapists appears to be positively associated with age, time working as a radiation therapist and a number of other factors including level of fitness and perceived stress levels. These are the authors' findings from a pilot survey they conducted of radiation therapists employed in eight radiation oncology departments.

Class II-restricted T cell responses in Theiler's murine encephalomyelitis virus-induced demyelinating disease. IV. Identification of an immunodominant T cell determinant on the N-terminal end of the VP2 capsid protein in susceptible SJL/J mice

Theiler's murine encephalomyelitis virus (TMEV)-induced demyelinating disease serves as a relevant animal model of human multiple sclerosis. Myelin damage induced by TMEV infection appears to be immune mediated. Disease susceptibility correlates best with the temporal development of chronic, high levels of TMEV-specific, MHC class II-restricted delayed-type hypersensitivity (DTH) responses. We have proposed a model wherein these responses result in CNS demyelination via a macrophage-mediated terminal nonspecific bystander response. As virus-specific DTH responses appear to be intimately involved in the pathogenicity of CNS demyelination, it is critical to determine the specificity of these responses so that effector T cells specific for potential pathogenic epitopes can be targeted to serve as the focus of specific immunoregulatory processes. In the current study, the capsid protein specificity of the TMEV-susceptible SJL/J and TMEV-resistant C57BL/6 mouse strains was examined. DTH and Tprlf responses in both infected and immunized SJL/J mice were found to be predominantly directed toward the VP2 capsid protein, specifically to an epitope(s) contained within the N-terminal 150 amino acids of VP2. This same epitope was also found to be dominant in priming SJL/J mice for responses to challenge with intact virions. In contrast, the T cell-mediated responses of TMEV-resistant C57BL/6 mice did not show preferential reactivity towards VP2, because all three major capsid proteins (VP1, VP2, and VP3) elicited responses with essentially equal potency. The relationship of the restricted VP2 T cell epitope to predicted neutralizing antibody sites on the VP2 protein is discussed as is the potential use of this epitope for prevention and/or treatment of TMEV-induced demyelinating disease via the induction of epitope-specific tolerance.

Class II-restricted T cell responses in Theiler's murine encephalomyelitis virus-induced demyelinating disease. IV. Identification of an immunodominant T cell determinant on the N-terminal end of the VP2 capsid protein in susceptible SJL/J mice

Theiler's murine encephalomyelitis virus (TMEV)-induced demyelinating disease serves as a relevant animal model of human multiple sclerosis. Myelin damage induced by TMEV infection appears to be immune mediated. Disease susceptibility correlates best with the temporal development of chronic, high levels of TMEV-specific, MHC class II-restricted delayed-type hypersensitivity (DTH) responses. We have proposed a model wherein these responses result in CNS demyelination via a macrophage-mediated terminal nonspecific bystander response. As virus-specific DTH responses appear to be intimately involved in the pathogenicity of CNS demyelination, it is critical to determine the specificity of these responses so that effector T cells specific for potential pathogenic epitopes can be targeted to serve as the focus of specific immunoregulatory processes. In the current study, the capsid protein specificity of the TMEV-susceptible SJL/J and TMEV-resistant C57BL/6 mouse strains was examined. DTH and Tprlf responses in both infected and immunized SJL/J mice were found to be predominantly directed toward the VP2 capsid protein, specifically to an epitope(s) contained within the N-terminal 150 amino acids of VP2. This same epitope was also found to be dominant in priming SJL/J mice for responses to challenge with intact virions. In contrast, the T cell-mediated responses of TMEV-resistant C57BL/6 mice did not show preferential reactivity towards VP2, because all three major capsid proteins (VP1, VP2, and VP3) elicited responses with essentially equal potency. The relationship of the restricted VP2 T cell epitope to predicted neutralizing antibody sites on the VP2 protein is discussed as is the potential use of this epitope for prevention and/or treatment of TMEV-induced demyelinating disease via the induction of epitope-specific tolerance.

Syphilis serology in patients with primary syphilis and non-treponemal sexually transmitted diseases in southern Africa

The reactivity of a non-specific reagin (RPR) test and a specific treponemal (FTA-ABS) test were determined in 21 patients with primary syphilis, 430 patients with proven non-treponemal genital ulcerations and 719 patients with acute urethritis presenting at a clinic for sexually transmitted diseases in southern Africa. Excluding those 21 cases of primary syphilis, 358 of 1149 tests performed (31%) were found to be reactive by at least one test. The rate of false positive RPR tests was very low (0.02%). Significantly higher rates of seropositivity were detected in patients with genital ulcerations than in patients with acute urethritis. The highest rates were detected among patients with proven lymphogranuloma venereum (34% RPR positive, FTA-ABS positive; 19% RPR negative, FTA-ABS positive). The geometric mean titres (GMT) of positive RPR tests in non-treponemal infections were found to be lower than in darkfield positive cases of genital ulcer disease.

Abuse histories in 102 cases of multiple personality disorder

The authors interviewed 102 individuals with clinical diagnoses of multiple personality disorder at four centres using the Dissociative Disorders Interview Schedule. The patients reported high rates of childhood trauma: 90.2% had been sexually abused, 82.4% physically abused, and 95.1% subjected to one or both forms of child abuse. Over 50% of subjects reported initial physical and sexual abuse before age five. The average duration of both types of abuse was ten years, and numerous different perpetrators were identified. Subjects were equally likely to be physically abused by their mothers or fathers. Sexual abusers were more often male than female, but a substantial amount of sexual abuse was perpetrated by mothers, female relatives, and other females. Multiple personality disorder appears to be a response to chronic trauma originating during a vulnerable period in childhood.

Accuracy of clinical diagnosis of genital ulcer disease

In Africa, establishment of an accurate clinical diagnosis in cases of genital ulcer disease is difficult owing to atypical presentation of ulcerations and mixed infections. This is compounded by the frequent lack of suitable laboratory facilities. In 240 cases of genital ulcer disease among mineworkers in Carletonville, South Africa, this study endeavored to correlate the clinical diagnosis with laboratory findings. Clinical accuracy and positive and negative predictive values were determined for each type of genital ulcer disease encountered. Overall, the accuracy of clinical diagnosis was 68% for single infections, 80% for chancroid, 55% for primary syphilis, 27% for lymphogranuloma venereum (LGV), and 22% for genital herpes. Adequate laboratory facilities are indispensible for the establishment of an accurate etiologic diagnosis of genital ulcer disease and thus the institution of appropriate antimicrobial therapy.

A comparative study of spectinomycin and erythromycin in the treatment of chancroid

In a randomized, controlled study, 55 patients with genital ulcerations, culture-positive for Haemophilus ducreyi, were treated with a single intramuscular injection of 2 g spectinomycin. A further 61 patients were treated with a five-day oral course of erythromycin base (500 mg, three times daily). Treatment failure occurred in seven patients who received spectinomycin (13%), whilst no treatment failures were recorded among patients who received erythromycin. This difference in efficacy was statistically significant. In contrast, spectinomycin proved significantly more effective than erythromycin in the treatment of the lymphadenopathy associated with primary chancroid lesions.

Regulation of the effector stages of experimental autoimmune encephalomyelitis via neuroantigen-specific tolerance induction

Intravenous administration of neuroantigen-coupled syngeneic splenocytes is an efficient regimen for Ag-specific regulation of relapsing experimental autoimmune encephalomyelitis (R-EAE) at the effector level of the disease process. Treatment of SJL/J mice with splenocytes coupled with mouse spinal cord homogenate (MSCH) or myelin proteolipid protein after immunization with mouse spinal cord homogenate in CFA, but before the onset of clinical signs specifically inhibited the expression of neuroantigen-specific delayed-type hypersensitivity responses and significantly suppressed the onset, severity, and the duration of clinical and histologic signs of R-EAE. In contrast, the clinical course of R-EAE was not affected by tolerization with myelin basic protein-coupled splenocytes, indicating that proteolipid protein-specific responses play the major role in active MSCH-induced R-EAE. To ensure a physical and temporal separation between the inductive and effector stages of the disease process, we also examined the effects of neuroantigen-coupled splenocytes on adoptive R-EAE. Treatment of recipient mice with MSCH-coupled splenocytes up to 6 days after the transfer of MBP-primed lymph node cells induced a dose-dependent, profound, and long-lasting inhibition of clinical and histologic signs of adoptive R-EAE. The demonstration that splenocytes coupled with a heterogeneous mixture of neuroantigens (i.e., MSCH) can inhibit established immune responses suggests that this methodology has potential for regulating ongoing immune responses associated with autoimmune disorders or chronic graft rejection in which the specific (auto)Ag has yet to be identified.

Regulation of the effector stages of experimental autoimmune encephalomyelitis via neuroantigen-specific tolerance induction

Intravenous administration of neuroantigen-coupled syngeneic splenocytes is an efficient regimen for Ag-specific regulation of relapsing experimental autoimmune encephalomyelitis (R-EAE) at the effector level of the disease process. Treatment of SJL/J mice with splenocytes coupled with mouse spinal cord homogenate (MSCH) or myelin proteolipid protein after immunization with mouse spinal cord homogenate in CFA, but before the onset of clinical signs specifically inhibited the expression of neuroantigen-specific delayed-type hypersensitivity responses and significantly suppressed the onset, severity, and the duration of clinical and histologic signs of R-EAE. In contrast, the clinical course of R-EAE was not affected by tolerization with myelin basic protein-coupled splenocytes, indicating that proteolipid protein-specific responses play the major role in active MSCH-induced R-EAE. To ensure a physical and temporal separation between the inductive and effector stages of the disease process, we also examined the effects of neuroantigen-coupled splenocytes on adoptive R-EAE. Treatment of recipient mice with MSCH-coupled splenocytes up to 6 days after the transfer of MBP-primed lymph node cells induced a dose-dependent, profound, and long-lasting inhibition of clinical and histologic signs of adoptive R-EAE. The demonstration that splenocytes coupled with a heterogeneous mixture of neuroantigens (i.e., MSCH) can inhibit established immune responses suggests that this methodology has potential for regulating ongoing immune responses associated with autoimmune disorders or chronic graft rejection in which the specific (auto)Ag has yet to be identified.

Monocytes/macrophages isolated from the mouse central nervous system contain infectious Theiler's murine encephalomyelitis virus (TMEV)

Knowledge of the cells in which Theiler's murine encephalomyelitis virus (TMEV) persists is crucial to understanding the pathogenesis of TMEV-induced demyelinating disease; however, it is still uncertain whether oligodendrocytes or macrophages are the primary target for persistence. In this study, mononuclear cells (MNC) isolated directly from central nervous system (CNS) inflammatory infiltrates of TMEV-infected mice on discontinuous Percoll gradients were found to contain infectious TMEV. Macrophages appeared to be the principal MNC infected as determined by two-color immunofluorescence. Infectious center assay and double immunostaining together indicated the presence and possible synthesis of TMEV in approximately 1 in 225 to 1 in 1000 CNS macrophages, with 1 to 7 PFU produced per macrophage. On the basis of these findings, limited replication in macrophages is consistent with the total CNS virus content detected at any time during the persistent phase of the infection as well as the slow pace of the infection.

Structured interview data on 102 cases of multiple personality disorder from four centers

Patients with multiple personality disorder (N = 102) at four different centers were interviewed with the Dissociative Disorders Interview Schedule. The presenting characteristics of the patients at all four centers were very similar. The clinical profile that emerged included a history of childhood physical and/or sexual abuse in 97 (95.1%) of the cases. The subjects reported an average of 15.2 somatic symptoms, 6.4 Schneiderian symptoms, 10.2 secondary features of the disorder, 5.2 borderline personality disorder criteria, and 5.6 extrasensory experiences; their average score on the Dissociative Experiences Scale was 41.4. The results indicate that multiple personality disorder has a stable, consistent set of features.

Schneiderian symptoms in multiple personality disorder and schizophrenia

We report structured interview data from a series of 102 cases of multiple personality disorder (MPD) diagnosed in four centers. Schneiderian first-rank symptoms of schizophrenia were equally common in all four centers. The average MPD patient had experienced 6.4 Schneiderian symptoms. When these 102 cases are combined with two previously reported series of MPD cases, an average of 4.9 Schneiderian symptoms in 368 cases of MPD is noted. This compares with an average of 1.3 symptoms acknowledged by 1,739 schizophrenics in 10 published series. Schneiderian symptoms are more characteristic of MPD than of schizophrenia.

Inhibition of murine relapsing experimental autoimmune encephalomyelitis by immune tolerance to proteolipid protein and its encephalitogenic peptides

Tolerization of SJL/J mice with splenocytes coupled with proteolipid protein (PLP), the major protein component of central nervous system myelin, resulted in dramatic inhibition of relapsing experimental autoimmune encephalomyelitis (R-EAE) induced by mouse spinal cord homogenate (MSCH). Mice tolerized with splenocytes coupled with MSCH (a complex mixture of neuroantigens) or with purified PLP, but not purified myelin basic protein, were resistant to the development of clinical and histologic R-EAE. In addition, mice rendered tolerant to an encephalitogenic peptide of PLP were significantly protected, whereas mice tolerized to a nonencephalitogenic peptide of PLP were highly susceptible, to the induction of MSCH-induced R-EAE. Thus, immune responses directed against encephalitogenic regions of PLP appear to play a major role in the development of R-EAE induced by MSCH in SJL/J mice. These results also indicate that determinant-specific immune tolerance is a feasible approach to the regulation of a disease that involves autoimmune responses to a variety of Ag.

Rapid biotin-avidin method for quantitation of antiviral antibody isotypes

A rapid and efficient method is described for isotype quantitation of antiviral antibodies in mice infected with Theiler's murine encephalomyelitis virus (TMEV). Serum antibodies were reacted with fluorochrome-labeled TMEV in a modified fluid-phase particle concentration fluorescence immunoassay (PCFIA). Biotin and avidin were used to attach anti-immunoglobulin isotype antibodies to polystyrene particles by the separate incubation of biotinylated goat anti-mouse isotypes (IgG1-, IgG2a-, IgG2b-, IgG3-, or IgM-specific) with avidin coupled polystyrene particles. These anti-isotype particles captured the virus-antibody complexes. Mouse myeloma proteins were used to quantitate and standardize isotype profiles of normal mouse serum using fluorescein isothiocyanate (FITC)-labeled, goat anti-mouse isotypes and polystyrene particles coated with goat anti-mouse. These assays quantitated the affinity-purified mouse serum antiviral antibodies for the standardization of antiviral isotype assays. Immunoglobulin of all serum isotypes as well as the amount of virus-specific isotypes can be quantitated rapidly and accurately.

Inhibition of murine relapsing experimental autoimmune encephalomyelitis by immune tolerance to proteolipid protein and its encephalitogenic peptides

Tolerization of SJL/J mice with splenocytes coupled with proteolipid protein (PLP), the major protein component of central nervous system myelin, resulted in dramatic inhibition of relapsing experimental autoimmune encephalomyelitis (R-EAE) induced by mouse spinal cord homogenate (MSCH). Mice tolerized with splenocytes coupled with MSCH (a complex mixture of neuroantigens) or with purified PLP, but not purified myelin basic protein, were resistant to the development of clinical and histologic R-EAE. In addition, mice rendered tolerant to an encephalitogenic peptide of PLP were significantly protected, whereas mice tolerized to a nonencephalitogenic peptide of PLP were highly susceptible, to the induction of MSCH-induced R-EAE. Thus, immune responses directed against encephalitogenic regions of PLP appear to play a major role in the development of R-EAE induced by MSCH in SJL/J mice. These results also indicate that determinant-specific immune tolerance is a feasible approach to the regulation of a disease that involves autoimmune responses to a variety of Ag.

Identification of a locus on mouse chromosome 3 involved in differential susceptibility to Theiler's murine encephalomyelitis virus-induced demyelinating disease

Theiler's virus-induced demyelinating disease results from a chronic infection in the white matter of the central nervous system and provides an excellent model for human multiple sclerosis. Like multiple sclerosis, there are genetic risk factors in disease development, including genes associated with the major histocompatibility complex and with those encoding the beta chain of the T-cell receptor. Comparisons of the susceptible DBA/2 and resistant C57BL/6 strains have indicated an important role for the H-2D locus and for a non-H-2 gene (not involving the beta chain of the T-cell receptor) in differential susceptibility. In the present report, analysis of recombinant-inbred strains (BXD) between the DBA/2 and C57BL/6 strains indicated that this non-H-2 locus is located at the centromeric end of chromosome 3 near (4 +/- 4 centimorgans) the carbonic anhydrase-2 (Car-2) enzyme locus.

Induction of allograft tolerance to the H-Y antigen in adult C57BL/6 mice: differential effects on delayed-type hypersensitivity and cytolytic T-lymphocyte activity

This study describes the induction of allograft tolerance to the "male-specific," minor histocompatibility antigen, H-Y, in adult C57BL/6 female mice, and the effects of this tolerance induction on two immune parameters associated with graft rejection: delayed-type hypersensitivity (DTH) and cytolytic T-lymphocytes (CTL). B6 females tolerized to H-Y, by a single iv injection of C57BL/6 male lymphocytes, exhibited prolonged or permanent survival of B6 male tail skin grafts. Graft-induced DTH against H-Y antigen was reduced or abrogated in tolerized females. Delayed onset of graft rejection in partially tolerant females correlated with delayed onset of DTH, and eventual rejection of grafts was accompanied by an increase in H-Y-specific DTH. In contrast, H-Y-specific CTL activity was not consistent with graft status. These data demonstrate a correlation between H-Y-specific DTH and rejection of male skin grafts by B6 female mice and are most consistent with a major effector role for DTH in chronic graft rejection.

Klebsiella pneumoniae bacteraemia at an urban general hospital

Of 47 patients with Klebsiella pneumoniae bacteraemia admitted to the Hillbrow Hospital, Johannesburg during a period of 18 months, 31 were males and 16 were females. Features predisposing to illness were found in 89.4% patients, chronic alcoholism, neoplastic disease and diabetes mellitus being the most common. Twenty-five infections were acquired in hospital and 22 in the community. Most patients (59.6%) had pneumonia. All isolates of K. pneumoniae were resistant to ampicillin (100%); several (42.6%) were resistant to other antibiotics also. The overall mortality rate was 55.3%. A higher mean initial blood pressure and lower concentrations of serum urea and bilirubin were found in survivors. None of the 28 patients, surviving more than 48 h who received combined therapy with an aminoglycoside and a beta-lactam antibiotic (to which the organism was susceptible) died. Among the remaining patients treated with either an appropriate beta-lactam agent alone, an appropriate aminoglycoside alone or ciprofloxacin the combined mortality rate was 83.3% (P = 0.007).