The medical schools outcomes database project: Australian medical student characteristics

BACKGROUND

Global medical workforce requirements highlight the need for effective workforce planning, with the overall aims being to alleviate doctor shortages and prevent maldistribution. The Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project provides a foundation for evaluating outcomes of medical education programs against specified workforce objectives (including rural and areas of workforce needs), assisting in medical workforce planning, and provision of a national research resource. This paper describes the methodology and baseline results for the MSOD project.

METHODS

The MSOD Project is a prospective longitudinal multiple-cohort study. The project invites all commencing and completing Australian medical students to complete short questionnaires. Participants are then asked to participate in four follow-up surveys at 1, 3, 5 and 8 years after graduation.

RESULTS

Since 2005, 30,635 responses for medical students (22,126 commencing students and 8,509 completing students) in Australia have been collected. To date, overall eligible cohort response rates are 91% for commencing students, and 83% for completing students. Eighty three percent of completing medical student respondents had also completed a commencing questionnaire.Approximately 80% of medical students at Australian medical schools are Australian citizens. Australian medical schools have only small proportions of Indigenous students. One third of medical students speak a language other than English at home.The top three vocational choices for commencing medical students were surgery, paediatrics and child health and general practice. The top three vocational choices for completing students were surgery, adult medicine/ physician, and general practice. Overall, 75.7% of medical students changed their first career preference from commencement to exit from medical school.Most commencing and completing medical students wish to have their future medical practice in capital cities or in major urban centers. Only 8.1% of commencing students and 4.6% of completing students stated an intention to have their future medical practice in smaller towns and small communities.

CONCLUSIONS

The MSOD longitudinal project is now an established national resource that is beginning to generate significant research outputs, along with providing key information for workforce planning and policy makers. The project has now expanded to enrol New Zealand medical students.

Pandemic influenza and community preparedness

OBJECTIVES

We aimed to examine community knowledge about and attitudes toward the threat of pandemic influenza and assess the community acceptability of strategies to reduce its effect.

METHODS

We conducted computer-aided telephone interviews in 2007 with a cross-sectional sample of rural and metropolitan residents of South Australia.

RESULTS

Of 1975 households interviewed, half (50.2%) had never heard of pandemic influenza or were unaware of its meaning. Only 10% of respondents were extremely concerned about the threat of pandemic influenza. Respondents identified children as the highest priority for vaccination, if supplies were limited; they ranked politicians and teachers as the lowest priority. Although only 61.7% of respondents agreed with a policy of home isolation, 98.2% agreed if it was part of a national strategy. Respondents considered television to be the best means of educating the community.

CONCLUSION

s. Community knowledge about pandemic influenza is poor despite widespread concern. Public education about pandemic influenza is essential if strategies to reduce the impact of the disease are to be effective.

Varicella immunisation practice: Implications for provision of a recommended, non-funded vaccine

AIM

In Australia in 2003 a two-tiered immunisation schedule was introduced consisting of funded (National Immunisation Program) and non-funded but recommended vaccines (Best Practice Schedule), including varicella vaccine. The aim of this study was to examine immunisation practice when a vaccine is recommended but not funded by Government.

METHODS

A survey was sent to 600 randomly selected general practitioners (GPs) in South Australia between June and August 2005, prior to provision of Federal funding for varicella vaccine.

RESULTS

Although varicella was considered an important disease to prevent by 89% of GPs, only 25% of GPs always discussed the non-funded immunisation with parents at the time of a routine immunisation visit. Female GPs were more likely to discuss immunisation with recommended, non-funded vaccines than male GPs. Those who were supportive of varicella prevention were more likely to discuss immunisation with the non-funded vaccine. GPs who always provided information about the disease were more likely to have parents accept their advice about varicella vaccine (62.7%) than those who never provided information (40%). GPs reported parental refusal of varicella vaccine was due to the cost and perception that varicella is a mild disease.

CONCLUSIONS

The results of this study showed variability in prescribing practices for a non-funded vaccine. Recommending a vaccine without provision of funding may lead to 'mixed messages' for immunisation providers and parents with resultant low coverage. Funding a vaccine is likely to reduce variability in provision of the vaccine and improve coverage in the community.

A novel combined Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus-toxoid conjugate vaccine is immunogenic and induces immune memory when co-administered with DTPa-HBV-IPV and conjugate pneumococcal vaccines in infants

Immunogenicity and safety of a novel combined Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus-toxoid conjugate vaccine (Hib-MenCY-TT) candidate was evaluated when co-administered with DTPa-HBV-IPV(Pediarix)+PCV7(Prevnar) at 2-4-6 months of age. Anti-PRP concentrations >or= 1.0 microg/mL were observed in 92.9-98.7%, rSBA-MenC/Y titres >or= 1:8 in >98%, rSBA-MenC/Y titres >or= 1:128 in >95.8 and >89.9% subjects. PRP and MenC responses were similar to respective controls (ActHIB and Menjugate) including for antibody persistence. Response to co-administered vaccines was not impaired. Polysaccharide challenge (PRP, PSC, PSY at 11-14 months of age) evidenced immune memory was induced for Hib, MenC/Y conjugate components. The safety profile of Hib-MenCY-TT was similar to controls. Hib-MenCY-TT administered according to the current US Hib vaccine schedule has the potential to induce protective antibodies against Hib and meningococcal-CY disease in infants and toddlers.

Pulmonary haemosiderosis with juvenile idiopathic arthritis in a Malaysian child

A rare case of childhood pulmonary haemosiderosis with juvenile idiopathic arthritis is discussed, with particular reference to treatment with hydroxychloroquine and sildenafil for pulmonary hypertension which occurs secondary to this disease.

DTPa-HBV-IPV vaccine for primary vaccination of infants

AIM

Combined vaccines have an increasingly important role to play in delivering these antigens acceptably. We describe the immunogenicity and reactogenicity of a combined DTPa-HBV-IPV vaccine (diphtheria, tetanus, acellular pertussis, hepatitis B, inactivated poliovirus (DTPa-HBV-IPV: Infanrix penta) ) when administered for the primary vaccination of infants resulting from a study where the primary objective was to demonstrate non-inferiority of the immune response induced by DTPa-HBV-IPV using an industrial-scale IPV production process.

METHODS

Three hundred and fourteen infants received primary immunisation with DTPa-HBV-IPV at 2, 4 and 6 months of age. Routine Haemophilus influenzae immunisation was performed at 2 and 4 months of age at a separate injection site. Blood samples were taken at 2 and 7 months of age. Reactogenicity was assessed using diary cards for 7 days after each dose.

RESULTS

One month after the primary course, at least 98.9% of subjects achieved seroprotective antibody concentrations/titres against diphtheria, tetanus, hepatitis-B and polio types 1, 2 and 3. More than 97% had a vaccine response to pertussis antigens. The incidence of local injection site reactions after DTPa-HBV-IPV was similar to that for the Haemophilus influenzae vaccine site. General reactions of Grade 3 intensity were uncommon.

CONCLUSIONS

The DTPa-HBV-IPV vaccine is a new combination of vaccines previously available separately, with established effectiveness and safety profiles. Combined vaccines reduce storage requirements and minimise the number of injections required, thereby reducing distress for infants and parents. DTPa-HBV-IPV was immunogenic with an acceptable safety profile and could replace separate administration of DTPa, HBV and IPV vaccines in infants.

A cross-sectional survey to assess community attitudes to introduction of Human Papillomavirus vaccine

OBJECTIVE

A vaccine to prevent human papilloma virus (HPV) infection has been licensed recently in the United States of America and Australia. The aim of this study was to assess community attitudes to the introduction of HPV vaccine in the State of South Australia.

METHODS

A cross-sectional survey was conducted by computer-aided telephone interviews in February 2006. The survey assessed adult and parental attitudes to the introduction of HPV vaccine to provide protection against a sexually transmitted disease caused by HPV and against cervical cancer. Two thousand interviews were conducted in metropolitan and rural households.

RESULTS

Two per cent of respondents knew that persistent HPV infection caused cervical cancer and a further 7% were aware that the cause was viral. The majority of adults interviewed (83%) considered that both men and women should receive HPV vaccine and 77% of parents agreed that they would have their child/children immunised. Parents were mainly concerned about possible side effects of the vaccine (66%), with only 0.2% being concerned about discussing a sexually transmitted disease with their children and 5% being concerned that use of the vaccine may lead to promiscuity.

IMPLICATIONS

Our findings suggest that public health education campaigns for HPV vaccination will find a majority of parents receptive to their children being vaccinated, but attention must be paid to appropriate explanation about HPV infection as the cause of cervical cancer and education about the safety of the HPV vaccine.

A comparison of booster immunisation with a combination DTPa-IPV vaccine or DTPa plus IPV in separate injections when co-administered with MMR, at age 4–6 years

This study evaluated GSK's combined DTPa-IPV vaccine (Infanrix-IPV) given as a fifth consecutive acellular pertussis booster dose in conjunction with the second dose of MMR vaccine (Priorix) in children aged 4-6 years. The immunogenicity and reactogenicity of this vaccine regimen was compared with separate injections of DTPa and IPV when given concomitantly with MMR. A cohort of 362 children previously primed with four doses of DTPa and OPV, and a single dose of MMR were randomized to receive either DTPa-IPV+MMR (N=181) or DTPa+IPV+MMR (N=181). Antibody concentrations were measured prior to and 1 month after the booster dose. After immunisation all subjects from both groups had seroprotective antibody levels against diphtheria, tetanus and the three poliovirus serotypes, > or = 96% showed vaccine response to PT, FHA and PRN, all were seropositive to mumps and rubella, and all but one subject were seropositive to measles. Immunogenicity results for each component antigen were similar for DTPa-IPV and separately co-administered DTPa and IPV. Local reactions were common with 24.0% and 31.1% of children experiencing swelling >50mm at the DTPa-IPV and DTPa injection sites, respectively. The DTPa-IPV combination did not increase the incidence or intensity of adverse events compared with separately administered DTPa+IPV. The response to the concomitantly administered MMR vaccine was similar in the two groups and similar to previously reported responses for a second dose of MMR. This combined DTPa-IPV vaccine has a similar reactogenicity profile to DTPa, is immunogenic when given as a booster dose at 4-6 years of age, and has no impact on the immunogenicity of a co-administered second dose of MMR vaccine.

Effect of dietary nucleotide supplementation on growth and immune function in term infants: a randomized controlled trial

OBJECTIVE

To examine the effect of nucleotide (NT)-supplemented cow's milk-based formula on growth and biochemical indices of immune function in healthy infants.

DESIGN

Randomized controlled trial (RCT) of formula-fed term infants allocated to control formula with an innate level of NT at 10 mg/l (n = 102), or formula fortified with NT at 33.5 mg/l (n = 98). A parallel group of 125 breastfed infants followed the same protocol as a reference.

OUTCOME MEASURES

Growth was assessed at enrolment, 7 weeks, 4 months and 7 months of age. Natural killer cell activity, cytokine production and lymphocyte subpopulations were assessed at 7 weeks of age. Antibody responses to diphtheria toxoid, tetanus toxoid and Haemophilus influenzae type b (Hib) immunizations were measured at 7 months of age.

RESULTS

NT supplementation did not influence the growth of formula fed infants or any markers of immunity measured at 7 weeks of age. Antibody responses to tetanus toxoid were higher in the NT-supplemented group (n = 68) compared with the control group (n = 70) at 7 months of age (median (5th, 95% percentile): 1.57(0.42, 3.43) vs 1.01(0.41, 4.66) IU/ml, P < 0.03). A difference between treatments was seen in response to diphtheria toxoid but this effect disappeared when adjusted for hepatitis B immunization at birth. There was no effect of treatment on antibody responses to Hib immunization.

CONCLUSIONS

Supplementation of formulas with NT at 33.5 mg/l resulted in a modest improvement in antibody response consistent with RCTs that used higher levels of NT supplementation. Whether this translates to clinical benefits in well-nourished infants requires further study.

SPONSORSHIP

Supported by a grant from Wyeth Nutrition. Dr Makrides was supported by an RD Wright Fellowship from the National Health and Medical Research Council of Australia and Dr Gibson was partially supported by the MS McLeod Research Trust and a Senior Research Fellowship from the National Health and Medical Research Council of Australia.

Safety and immunogenicity of a combined DTPa–IPV vaccine administered as a booster from 4 years of age: A review

A combined DTPa-IPV booster vaccine was administered as a 4th or 5th dose after DTPa or DTPw priming. Over 99% vaccines developed antibody levels considered to be protective to diphtheria, tetanus and poliovirus, and >95% mounted a response to acellular pertussis antigens. Rectal temperature >39.5 degrees C was observed in at most 3.2% of vaccinees. Swelling >50 mm occurred in 24% of DTPa-primed compared to 5.5% of DTPw-primed children. Large swelling involving the entire upper arm (extending to involve the elbow joint) was reported for up to 1.2% of DTPa-primed subjects, which is consistent with literature reports for other DTPa vaccines.

Reactogenicity and immunogenicity profile of a two-dose combined hepatitis A and B vaccine in 1-11-year-old children

This study was conducted to compare the reactogenicity, immunogenicity and safety of a combined two-dose (0, 6 months) hepatitis A and B vaccine (720ELU HAV, 20 mcg HBsAg) with the established three-dose (0, 1 and 6 months) hepatitis A and B vaccine (360ELU HAV, 10 mcg HBsAg). A total of 511 children aged 1-11 years who had not previously received a hepatitis A or B vaccine were enrolled in the study. Both vaccines were well tolerated, and were shown to be safe and immunogenic. The analysis, stratified according to two age groups (1-5 year and 6-11-year-old children) demonstrated that the reactogenicity profile of the two-dose schedule was at least as good as that of the established schedule. Both vaccines and schedules provided at least 98% seroprotection against hepatitis B and 100% seroconversion against hepatitis A, 1 month after the end of the vaccination course (Month 7).

Uptake of varicella vaccine—a cross sectional survey of parental attitudes to nationally recommended but unfunded varicella immunisation

The aim of this study was to assess the uptake of varicella vaccine in South Australian children under circumstances where varicella immunisation is recommended, but is not funded by Government. The study examined the main reasons that determined a parent's decision whether or not to have their child immunised with varicella vaccine. A cross-sectional survey was conducted by Computer Aided Telephone Interviews (CATI) in June 2004. Data were obtained from 613 households containing 1148 children aged from birth to 17 years of age. Statistical analyses were performed using data weighted to the South Australian population. Six hundred and eighty children (55.7%) had a history of varicella infection and 446 children (42.0%) had received varicella vaccine (weighted data). The most common reasons cited for not having children immunised included lack of knowledge about the vaccine and cost. One year after inclusion of varicella vaccine in the Australian Standard Vaccination Schedule there is evidence of incomplete coverage in children in South Australia due to absence of government funding for vaccine provision.

Juvenile arthritis-associated uveitis: visual outcomes and prognosis

BACKGROUND

The current issues in the management of uveitis associated with juvenile arthritis revolve mainly around the treatment of mild disease and how to treat patients with more severe disease. The aims of this study were to determine the incidence of uveitis in a cohort of patients with juvenile arthritis as well as the nature of treatment and the risk factors for visual loss.

METHODS

Review of the charts of 71 patients with juvenile arthritis, as defined by the American Academy of Rheumatology, seen between 1992 and 2001 at a combined rheumatology and ophthalmology clinic. Information collected included the patient's sex, age at diagnosis of arthritis and uveitis, and date of diagnosis of arthritis and uveitis. The rheumatologic diagnosis, results of serologic testing, and details of systemic and topical treatments were also recorded.

RESULTS

There were 47 girls and 24 boys ranging in age from 16 months to 13 years. The median age at diagnosis of juvenile arthritis was 4 years and 1 month. Twenty-seven patients (38%) had uveitis. The median age at uveitis onset was 5.9 years, with an average interval of 18 months from the diagnosis of arthritis; 11 patients had uveitis at the time of arthritis diagnosis. There was a positive relation between anti-nuclear antibody positivity and the development of uveitis (p < 0.05). Thirteen (48%) of the 27 patients with uveitis had mild anterior segment inflammation, with fewer than 25 cells in the anterior chamber. This group had spontaneous resolution of uveitis without topical therapy. All the patients without uveitis had a final visual acuity of 6/9 or better. Five of the patients with uveitis had a final visual acuity of 6/36 or worse. Cataract was the most common complication affecting visual outcome. Cataract extraction initially improved the visual acuity, but posterior segment complications and glaucoma compromised the final visual outcome.

INTERPRETATION

We found an incidence of uveitis of 38% with long-term follow-up of patients with juvenile arthritis; the uveitis was diagnosed an average of 18 months after the arthritis. Almost half of the patients with uveitis had minor anterior segment inflammation. These patients did not receive topical treatment and had good visual outcomes. Patients with uveitis at the time of diagnosis of arthritis tended to have a worse visual prognosis and experienced persistent uveitis despite treatment. In this series, cataract extraction was beneficial in improving visual acuity immediately postoperatively, but posterior segment changes and glaucoma may compromise final visual outcomes.

Evaluation of Combined Live, Attenuated Respiratory Syncytial Virus and Parainfluenza 3 Virus Vaccines in Infants and Young Children

We evaluated a combination respiratory syncytial virus (RSV) and parainfluenza 3 virus (PIV3) live, attenuated intranasal vaccine for safety, viral replication, and immunogenicity in doubly seronegative children 6-18 months old. RSV cpts-248/404 and PIV3-cp45 vaccines were combined in a dose of 10(5) plaque-forming units of each per 0.5-mL dose and compared with monovalent vaccines or placebo. The virus shedding pattern of RSV was not different between monovalent RSV cpts-248/404 vaccine and combination vaccine. Modest reductions in the shedding of PIV3-cp45 vaccine virus were found after the administration of RSV cpts-248/404 and PIV3-cp45 vaccine, relative to monovalent PIV3 vaccine; 16 (76%) of 21 children given combination vaccine shed PIV3-cp45 versus 11 (92%) of 12 of those given monovalent PIV3 vaccine. Both vaccines were immunogenic, and antibody responses were similar between the monovalent groups and the combination group. Combined RSV/PV3 vaccine is feasible for simultaneous administration, and further studies are warranted.

The association between maternal ratings of child health interviews and maternal and child characteristics

BACKGROUND

Doctors develop the skills needed to interview parents and children in paediatric settings by practice and by receiving feedback during their medical training. Interviewed parents are ideally placed to provide evaluations of these skills. If parents, as consumers of health care services, are to be consulted, it is important to determine whether factors other than interview skills affect their evaluations.

OBJECTIVES

Our aim was to examine the relationship between maternal satisfaction ratings of student doctor interviews, and maternal and child characteristics.

METHODS

Sixty mothers of children attending the paediatric medical out-patient clinic at the Women's and Children's Hospital, South Australia were allocated randomly to rate one of four video-taped final year student doctor interviews (15 mothers per interview). The level of skills displayed by the student doctor differed in each interview. Maternal satisfaction was measured using the Medical Interview Satisfaction Scale (MISS) and the Interpersonal Skills Rating Scale (IPS), and interview ratings were compared for a number of maternal and child characteristics.

RESULTS

No significant associations were observed between maternal satisfaction ratings and any maternal or child characteristics other than lower satisfaction associated with previous experience of a real student doctor interview (P <0.01). The interview seen by mothers predicted 53% (MISS) and 65% (IPS) of the variance in maternal satisfaction ratings. After controlling for the interview type, the maternal and child characteristics studied predicted 17% additional variance in MISS scores and 7% in IPS scores.

CONCLUSION

The quality of the interview skills demonstrated was the principle determinant of maternal satisfaction ratings.

Medical students taking the role of the mother in paediatric interview evaluation

BACKGROUND

Medical students develop the skills required to interview parents and children through practice and by receiving feedback. Parental perceptions of medical student skills in child health interviews can be used to enhance student learning.

OBJECTIVES

To integrate maternal perspectives of medical student interviews into student learning, and to compare student and maternal evaluations of simulated medical student interviews.

METHODS

A sample of 45 medical students viewed 2 standardised videotapes in which a 'medical student' interviewed the mother of a sick child. The videotapes demonstrated contrasting levels of 'student' clinical competence and patient-centeredness. After each interview students were asked to rate their satisfaction and recall of information as if they were the mother in the interview. Student satisfaction was measured using the Interpersonal Skills Rating Scale (IPS). Recall of interview information was assessed by questionnaire, with student answers coded independently before analysis. Following both videotapes, students reviewed transcripts of the interviews and discussed their evaluations. Student responses were compared with maternal satisfaction and recall responses after viewing of the same videotapes.

RESULTS

Student IPS ratings were higher following the high clinical competence, high patient-centred interview (P < 0.0001). Student recall of specific information was greater for some items following the high clinical competence, high patient-centred interview, but was lower for others. Maternal and student satisfaction and recall were similar following the 2 interviews.

CONCLUSION

Students and mothers agreed on the qualities of a successful interview. Experiencing an interview through the 'eyes' of a mother provided students with valuable insights regarding interview skills.

Phase 2 evaluation of parainfluenza type 3 cold passage mutant 45 live attenuated vaccine in healthy children 6-18 months old

A phase 2 evaluation of live attenuated parainfluenza type 3 (PIV3)-cold passage mutant 45 (cp45) vaccine was conducted in 380 children 6-18 months old; 226 children (59%) were seronegative for PIV3. Of the 226 seronegative children, 114 received PIV3-cp45 vaccine, and 112 received placebo. No significant difference in the occurrence of adverse events (i.e., runny nose, cough, or temperature > or =38 degrees C) was noted during the 14 days after vaccination. There was no difference between groups in the occurrence of acute otitis media or serous otitis media. Paired serum samples were available for 109 of the seronegative vaccine recipients and for 110 of the seronegative placebo recipients; 84% of seronegative vaccine recipients developed a > or =4-fold increase in antibody titers. The geometric mean antibody titer after vaccination was 1 : 25 in the vaccine group and <1 : 4 in the placebo group. PIV3-cp45 vaccine was safe and immunogenic in seronegative children and should be evaluated for efficacy in a phase 3 field trial.

Festschrift for Professor Margaret Burgess AO

In honour of the retirement of our director Margaret Burgess, National Centre for Immunisation Research and Surveillance (NCIRS) held a Festschrift on 5th to 6th February 2004. The themes of the event were Vaccines for the 21st Century and Congenital and Neonatal Infections. International guests attended the Festschrift, as well as over 180 colleagues and co-workers from across Australia. A summary of the presentations over these two fascinating days is provided herein.

Medical student interviewing: a randomized trial of patient-centredness and clinical competence

BACKGROUND

It is widely accepted that the quality of doctor interviewing skills is an important determinant of health care outcomes. Two interviewing skills contributing significantly to optimal health outcomes are the clinical competence of the interviewer and the use of patient-centred techniques. However, the relative importance of these to health outcomes is unknown.

OBJECTIVE

The purpose of this study was to examine the relative effect on maternal recall and satisfaction of medical student clinical competence and use of patient-centred interview techniques.

METHODS

Sixty-nine mothers of children attending the Paediatric Medical Out-patient Clinic, Women's and Children's Hospital, South Australia agreed to participate in the study, with 60 successfully completing the study. They viewed two of four standardized 'medical student' interview videotapes in which the level of clinical competence and patient-centredness were varied independently. All other interview variables were controlled. Each mother rated the interviews by questionnaire (balanced incomplete block design, each interview rated by 30 mothers). Maternal satisfaction with the 'student' interview was measured using the Medical Interview Satisfaction Scale (MISS) and the Interpersonal Skills Rating Scale (IPS). Maternal recall of interview information was assessed by questionnaire, with maternal answers coded independently before analysis.

RESULTS

Significant, independent effects of clinical competence and patient-centredness were observed with both MISS (F = 42.1, P < 0.0001) and IPS (F = 49.3, P < 0.0001) scores. The effect of clinical competence was stronger than that of patient-centredness. Maternal recall for specific information was greater for some items following the more clinically competent interviews, but was lower for others. There was no association between maternal recall and the level of patient-centredness demonstrated by the 'student'.

CONCLUSION

Clinical competence was a more significant determinant of maternal evaluations of medical student interviews and maternal recall of information than was patient-centredness. High levels of both patient-centredness and clinical competence were associated with the highest maternal satisfaction.

Reactogenicity and immunogenicity of a live attenuated tetravalent measles-mumps-rubella-varicella (MMRV) vaccine

In countries where routine varicella vaccination is implemented, it is usually given at the same age as that recommended for measles-mumps-rubella (MMR) vaccination. A combined multivalent measles-mumps-rubella-varicella (MMRV) vaccine would offer the convenience of a single injection and facilitate implementation of varicella vaccination into routine childhood immunisation schedules. We evaluated the immunogenicity and reactogenicity of a tetravalent MMRV candidate vaccine compared to an extemporaneous mix of a measles-mumps-rubella vaccine and varicella vaccine (MMR/V), and to a measles-mumps-rubella (MMR) vaccine alone. A multicentre study was conducted in which a total of 240 healthy children aged 12 months (80 per group) were randomised to receive MMRV, MMR/V, or MMR alone. Active surveillance for adverse events was undertaken for 43 days post-vaccination. Blood samples were taken prior to vaccination and at 60 days post-vaccination. There were no significant differences between groups in rates of pain, redness, or swelling at the site of vaccination. There was no significant difference in the rate of any fever (axillary temperature >or=37.5 degrees C) and grade 3 fever (axillary temperature >39.0 degrees C) between the groups receiving MMRV and MMR during the 43-day follow-up period. Although, a significant increase was found for fever of any cause with onset between days 0 and 14 for MMRV compared to the MMR group, there was no significant difference in grade 3 fever rates during the same period. With respect to immunogenicity, MMRV and MMR/V demonstrated similar seroconversion rates to each component compared to MMR alone, with at least 91.9% of subjects in all groups seroconverting to each vaccine component 60 days after vaccination. Decreased GMTs for varicella antibody at day 60 indicated that there may have been inhibition of this response compared to MMR/V. This tetravalent MMRV candidate vaccine showed promising results, although further examination of the possible increase in minor fever and decreased varicella immunogenicity should be assessed in future studies.

Medical student interviewing skills and mother-reported satisfaction and recall

BACKGROUND

Providing feedback to medical students about their interviewing skills is an important component of teaching programmes. There is very little information about mothers' views of medical student consultations in paediatrics, and in particular about what mothers consider to be the key elements of a successful consultation. Patient-centred interviewing is a model which emphasizes the active seeking of patient views. In association with appropriate clinical skills, it is reported to promote improved health outcomes.

OBJECTIVES

To examine whether greater medical student clinical competence and more frequent use of patient-centred techniques is associated with higher maternal satisfaction, higher maternal rating of the medical student's interpersonal skills, and greater maternal recall of relevant diagnosis and treatment recommendations.

METHOD

Two standardized 'medical student' videotaped interviews were created based on actual senior medical student consultations. Interview A demonstrated both higher student clinical competence and higher patient-centredness compared with interview B. Both videotaped interviews were viewed and then rated, using a questionnaire, by 11 mothers attending a teaching general practice.

RESULTS

Significantly higher mean scores, indicating greater maternal satisfaction, were associated with interview A (P < 0.01 for all measures). Accurate recall for diagnosis and management was also significantly greater after interview A (mean diagnosis recall, interview A 35%, interview B 14%, P < 0.01; mean management recall, interview A 95%, interview B 57%, P < 0.01).

CONCLUSIONS

Maternal satisfaction and recall were higher following a more clinically competent and patient-centred medical student interview. Maternal ratings of student interviews could be used as an additional method of assessment as well as providing feedback to medical students on their interview skills development.

Restricted polymorphism of the mannose-binding lectin gene of indigenous Australians

Mannose-binding lectin (MBL) is an important complement-activating protein of the human innate immune system. Deficiency of MBL is associated with an increased risk of various infections and arises from three structural gene mutations in exon 1 (variants B, C and D) and/or the presence of a low efficiency promoter. The C allele is found in sub-Saharan Africa whereas the B allele is found elsewhere, suggesting that these mutations occurred after the suggested hominid migration out of Africa [100-150 000 years before present (BP)]. Paradoxically, these alleles may have a selective advantage in protection against intracellular pathogens and occur at particularly high frequencies in sub-Saharan Africa (C variant) and South America (B variant). Since hominids reached Australia at least 50 000 years ago, a study of MBL polymorphisms in the indigenous population was of interest. Using heteroduplex technology we found a paucity of MBL structural gene mutations in two population groups from geographically distinct regions. Of 293 individuals tested, 289 were wild-type and four were heterozygous for either the B or D allele. In each individual with an MBL mutation the HLA haplotype profile suggested some Caucasian admixture. We also found a restricted range of MBL promoter haplotypes and the serum MBL levels were higher than those of any other ethnic group studied to date (median 3.07 microg/ml). Our data suggest that the B mutation probably arose between 50 000 and 20 000 BP. Its absence from the founder gene pool of indigenous Australians may also partly explain their vulnerability to intracellular infections such as tuberculosis.

Somatic mutation of immunoglobulin V(H)6 genes in human infants

Infants respond to antigen by making antibody that is generally of low affinity for antigen. Somatic hypermutation of immunoglobulin genes, and selection of cells expressing mutations with improved affinity for antigen, are the molecular and cellular processes underlying the maturation of antibody affinity. We have reported previously that neonates and infants up to 2 months of age, including individuals undergoing strong immunological challenge, show very few mutated V(H)6 sequences, with low mutation frequencies in mutated sequences, and little evidence of selection. We have now examined immunoglobulin genes from healthy infants between 2 and 10 months old for mutation and evidence of selection. In this age group, the proportion of V(H)6 sequences which are mutated and the mutation frequency in mutated sequences increase with age. There is evidence of selection from 6 months old. These results indicate that the process of affinity maturation, which depends on cognate T-B cell interaction and functional germinal centres, is approaching maturity from 6 months old.

Interleukin 2 receptor regulation and IL-2 function in the human infant

IL-2 receptor is expressed at low levels on adult blood lymphocytes, and at lower levels on cord blood cells. IL-2 receptor alpha and beta chain expression increases gradually from 0-18 months of age. The level of soluble CD25 (IL-2 receptor alpha chain) has been reported to be elevated in cord blood. Quantitative RT-PCR showed that adult cells express 10 times as much CD25 mRNA as cord cells. Cord plasma showed only a marginal ability to strip CD25 from the membrane. To assess the functional consequences of low IL-2 receptor expression, cord and adult cells were activated in vitro. The response was stimulus-dependent, but cord cells upregulated CD25 readily. Cord and adult cells proliferated in an IL-2-dependent assay to a similar extent. Infants suffering acute infection showed marginally higher levels of membrane CD25 expression than infants without overt infection. Thus neonatal and infant lymphocytes express lower levels of IL-2 receptors than adult cells, reflecting lower mRNA concentrations at least for CD25; they are able to up-regulate receptors in response to in vitro stimulation and are able to respond in vitro to IL-2-dependent stimulation; however in vivo there may be a dampening down of the IL-2 system in infancy.

The spectrum of primary immunodeficiency disorders in Australia

BACKGROUND

Primary immunodeficiency disorders (PIDs) are uncommon conditions that require specialized immunologic services for diagnosis and management. It is difficult to estimate the prevalence of these disorders from routinely collected health statistics.

OBJECTIVE

We attempted to describe the prevalence of PID in Australia and the requirements for specific therapies, such as intravenous immunoglobulin, ascertained from a national register of PID.

METHODS

A national longitudinal cross-sectional survey of patients with PID under the care of clinical immunologists was established by the Australasian Society of Allergy and Clinical Immunology in 1990. Details of diagnosis and therapy were provided for patients with major PIDs including symptomatic IgA, IgG subclass, and complement deficiencies. Subjects with asymptomatic IgA deficiency were not included. The clinical features of the first 500 cases enrolled in the register were analyzed.

RESULTS

The most frequent type of PID was predominant antibody deficiency (71%). Common variable immunodeficiency, usually first seen as an antibody deficiency, was the single most common disorder with an estimated prevalence of 0.77/100,000 in the general population. Other types of PID were infrequent, and of these, severe combined immunodeficiency accounted for 5.2% of cases. The estimated prevalence of all forms of chronic granulomatous disease was 0.08/100,000. The national prevalence of all PID cases ascertained from the register was 2.1/100,000, with variation between the larger states ranging from 1.18 to 4.57/100,000. Half (247) of the patients were receiving intravenous immunoglobulin therapy with a median duration of care of 5 to 9 years for the different antibody deficiencies. There was also variation in the patterns of intravenous immunoglobulin use across the country. No new forms of PID were encountered.

CONCLUSION

This study highlights the requirement for the continuing provision of immunoglobulin as replacement therapy for these patients. In addition, the register documents a cohort of patients with PID whose long-term response to current therapy can be evaluated prospectively.

Maternal immunization with Haemophilus influenzae type b polysaccharide-tetanus protein conjugate vaccine in The Gambia

OBJECTIVE

To evaluate maternal responses to Haemophilus influenzae type b (Hib) polysaccharide-tetanus protein conjugate (polyribosylribitol phosphate-tetanus or PRP-T) given to pregnant Gambian women, the transplacental transfer of antibody, and the effect of maternal immunization on infant responses to the vaccine.

DESIGN

An open, randomized immunogenicity study.

SETTING

A busy urban health center in The Gambia.

STUDY PARTICIPANTS

A total of 451 pregnant women enrolled during the third trimester of pregnancy.

INTERVENTION

Study participants were randomized to three groups. In one group, mothers were given PRP-T during the third trimester and their infants were given PRP-T at 2, 3, and 4 months of age. In the second group, mothers received PRP-T and infants were given inactivated poliovirus vaccine. In the third group, mothers received meningococcal A and C vaccine, and their infants received PRP-T.

MAIN OUTCOME MEASURES

Anti-PRP antibody measurements of maternal cord, and infant blood.

RESULTS

Vaccinated women had a marked increase in total anti-PRP antibody (geometric mean titer 9.0 micrograms/mL), which was greatest in women in their first or second pregnancy. Previous tetanus vaccination during the same pregnancy and high concentrations of antitetanus antibody were associated with lower anti-PRP responses. In infants of PRP-T recipients, cord blood anti-PRP IgG concentrations were 61% of simultaneous maternal concentrations. In vaccinated infants of vaccinated mothers, geometric mean anti-PRP antibody concentrations at birth, 2 months of age, and 5 months of age were 1.92, 0.35 and 2.84 micrograms/mL, respectively, while in vaccinated infants of unvaccinated mothers, the corresponding concentrations were 0.29, 0.12, and 3.91 micrograms/mL. At 2 months of age, 60% of infants of vaccinated mothers and 26% of infants of unvaccinated mothers had anti-PRP antibody concentrations considered to be protective (>0.15 micrograms/mL).

CONCLUSIONS

In areas where much invasive Hib disease occurs in infants younger than 6 months, maternal immunization may help to reduce the risk of Hib disease in infants too young for immunization.

Expression of cytokine receptors by human cord blood lymphocytes: comparison with adult blood lymphocytes

The expression of receptors for several cytokines (IL 2, IL-4, IL-6, IL-7, tumor necrosis factor, and interferon-gamma) was examined in human cord blood cells in comparison with adult blood cells. A previously described high sensitivity immunofluorescence procedure was used to render the low levels of receptor measurable. Cord blood lymphocytes expressed measurable levels of most cytokine receptors, but expression tended to be lower than in adult blood cells. Examination of different lymphocyte subpopulations revealed a complex pattern with some cell types expressing particular receptors equivalent to adult levels. Cord and adult blood monocytes expressed similar cytokine receptor profiles. Receptor expression in cord lymphocytes could be regulated by activation. The results provide indications as to the relative activities of different cytokines in the development of the immune system in the neonate.

Anti-idiotypic antibodies to poliovirus antibodies in commercial immunoglobulin preparations, human serum, and milk

Our previous studies have suggested that fetal antibody production can be induced by maternal antiidiotypic antibodies transferred to the fetus via the placenta. We tested commercial Ig, sera, and milk for the presence of anti-idiotypic antibodies to poliovirus type 1, using affinity chromatography combined with ELISA systems and virus neutralization techniques. Our results indicate that commercial Ig, serum, and milk samples contain antibodies recognizing idiotypic determinants on antibodies to poliovirus. Several lines of evidence support this conclusion. Thus, in an ELISA with poliovirus as a solid phase, binding of specific antibodies could be inhibited by addition of an eluate from the Ig preparation containing anti-idiotypic antibodies against poliovirus type 1. Also, antiidiotypic antibodies from pooled human Ig, serum, and colostrum samples against poliovirus bound directly to solid-phase-attached MAb against poliovirus type 1. In addition, in a competitive inhibition ELISA, where antiidiotypic antibodies isolated from the Ig preparation competed with the poliovirus antigen for binding to monoclonal or polyclonal idiotypic antibodies on the solid phase, inhibition of antigen binding was seen at low antigen concentrations. When single-donor serum or milk was used, this inhibition was even more pronounced and could be demonstrated at almost all antigen concentrations. The finding that anti-idiotypes are present in maternal serum and milk imply, in agreement with our previous studies, that anti-idiotypes may actively induce a specific immune response in the fetus without previous exposure to the antigen by being transferred across the placenta or by being passively transferred to the newborn via mother's milk.

A case of Burkitt's lymphoma presenting with digital ischaemia

Paraneoplastic syndromes are rare in paediatric oncology. This report describes a four-year-old Cantonese child whose sole presenting symptom was acrocyanosis who was found to have Burkitt's lymphoma in association with the presence of positive antinuclear antibodies, antineutrophil cytoplasmic antibodies, antiendothelial antibodies and elevated serum immunoglobulin G concentrations. Digital ischaemia has not been described as a presenting symptom of Burkitt's lymphoma, although this association has been reported in 25 patients with other malignancies.

The CD45RO (p180, UCHL1) marker: complexity of expression in peripheral blood

Analysis of peripheral blood lymphocytes by two- and three-colour high-sensitivity staining with UCHL1 (CD45RO) and other markers shows that the expression of CD45RO on lymphocyte subsets is more complex than is generally supposed. In addition to the populations which express CD45RO and RA in a mutually exclusive manner, up to 30% of cells in adult blood express both markers, at low levels. This "intermediate" population includes CD4-positive cells, and a proportion of these cells express the p55 chain of the IL-2 receptor (CD25), suggesting that they are activated. In cord blood there are few RO-bright cells, but CD45RO is expressed at low intensity on a proportion of cells. Among the CD45RO-bright cells in adult blood at least two subsets can be detected by using MHC Class II and the homing receptor L-selectin as additional markers. This complexity suggests that memory cells are a subset of CD45RO-expressing cells, but that this marker is also found on cells that are activated but not irreversibly "switched" to memory cells.

Quantitation of human serum polymeric IgA, IgA1 and IgA2 immunoglobulin by enzyme immunoassay

This report concerns the relative quantitation of serum polymeric IgA and polymeric IgA subclass concentrations by enzyme immunoassay (EIA). The assay relies on the specific binding of polymeric IgA to secretory component. Competition between pentameric IgM and polymeric IgA for binding to secretory component was observed. Thus, samples were adsorbed for IgM by affinity chromatography before the EIA was performed. The assay was used to determine an age-related range of serum polymeric IgA concentrations and to compare the polymeric IgA concentrations in patients with IgA nephropathy (n = 50) to those of controls (n = 50). The serum concentrations of both polymeric IgA and polymeric IgA1 increased with age reaching adult values of around 12 years of age. Polymeric IgA2 concentrations did not reach adult levels until 18 years of age. The ratio of the polymeric IgA concentration to the total serum IgA concentration was found to be significantly increased in children under 2 years of age compared with those over 4 years of age (Mann-Whitney U-test, P less than 0.01). Patients with IgA nephropathy had significantly increased concentrations of polymeric IgA (P = 0.001) and polymeric IgA1 (P = 0.001) but similar polymeric IgA2 concentrations to controls.

Remission of diarrhoea due to cryptosporidiosis in an immunodeficient child treated with hyperimmune bovine colostrum

A boy aged 6 months who presented with poor weight gain, diarrhoea, and infection with Pneumocystis carinii was found to have congenital hypogammaglobulinaemia, which did not improve despite monthly treatment with intravenous gammaglobulin. At the age of 3 years and 2 months he developed severe vomiting and diarrhoea due to cryptosporidiosis, which failed to respond to conventional treatment. Infusion of hyperimmune bovine colostrum produced against parasite antigen, given by nasogastric tube, was started after symptoms had persisted for three weeks. His vomiting and diarrhoea resolved within five days of treatment, and oocysts were no longer seen in the stools after eight days. Later, however, he developed a rare complication, and oocysts were found in the common bile duct. Hyperimmune bovine colostrum may be useful in the treatment of many patients with immunodeficiency disorders.

Energy intake and weight gain of very low birthweight babies fed raw expressed breast milk

The energy intake and weight gain of low birthweight infants (under 1500 g) fed expressed breast milk were measured. Between the second and fourth weeks of life the mean energy intake was 577 kJ (138 kcals)/kg/day and the mean weekly increase in weight 119 g/week. Feeding energy-rich hind milk to two babies increased their energy intake but had little effect on their rate of weight gain. There appeared to be no correlation between energy intake and weight gain, probably owing to variation in the absorption of nutrients from expressed breast milk. This study forms a basis for a comparison of weight gain in babies fed alternative regimens of artificial milks.

Collapsible washing lines: a strangulation hazard

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