Burden of respiratory syncytial virus disease across the lifespan in Australia and New Zealand: a scoping review

OBJECTIVES

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory tract infection in young children worldwide. RSV is increasingly associated with severe respiratory disease in people aged >65 years. The heterogeneous landscape of RSV in Australia and New Zealand makes generalisation of results from global studies to local contexts difficult. Given the changing landscape of RSV, we aimed to examine the existing literature on the burden of RSV disease and identify evidence gaps in Australia and New Zealand.

STUDY DESIGN

Scoping review.

METHODS

We designed a scoping review protocol and searched the Web of Science and Scopus databases for eligible peer-reviewed publications. Data from eligible studies were charted and summarised in tabular and narrative form.

RESULTS

Of the 153 eligible publications identified, 123 investigated RSV disease in a hospital setting and six in primary care. Only six studies reported the economic burden of disease, all of which estimated direct healthcare costs associated with treatment and/or hospitalisation; no studies quantified the indirect costs or costs to families.

CONCLUSIONS

In this scoping review, we describe the effect of RSV disease in several high-risk populations, including children and adults. An improved understanding of the RSV burden of disease, both in primary care settings and economically, within the local context will assist with the implementation of preventative strategies, including vaccination programmes. Future studies to determine the true burden of RSV-associated morbidity, mortality and economic burden across the entire patient journey and among different healthcare settings will help prioritise emerging RSV therapeutics.

A randomised controlled trial of SMS messaging and calendar reminders to improve vaccination timeliness in infants

BACKGROUND

The effectiveness of SMS reminders in improving vaccination coverage has been assessed previously, with effectiveness varying between settings. However, there are very few studies on their effect on the timeliness of vaccination.

DESIGN

Unblinded, randomised controlled trial with blocked sampling.

METHODS

1594 Australian infants and young children were recruited to assess the impact of (1) SMS reminders only, (2) a personalised calendar, (3) SMS reminder and personalised calendar and (4) no intervention, on receipt of vaccine within 30 days of the due date. Outcomes were measured for receipt of vaccines due at 2, 4, 6, 12 and 18 months of age. A post-hoc assessment was also conducted of the impact of a new national "No jab No Pay" policy introduced during the trial, which removed philosophical objections as an exemption for financial penalties for non-vaccination.

RESULTS

There was a statistically significant improvement in on-time vaccination only at the 12 month schedule point amongst infants who received SMS reminders alone (RR 1.09, 95% CI 1.01-1.18) or in combination with a personalised calendar (1.11, CI 1.03-1.20) compared to controls. This impact was limited to participants who had received one or more previous doses late. No statistically significant impacts of calendar interventions alone were seen. There was a high rate of on-time compliance amongst control participants - 95%, 86%, 80%, 74% at the 4, 6, 12 and 18 month schedule points respectively, which increased more than 10 percentage points after implementation of the "No Jab, No Pay" policy.

CONCLUSIONS

SMS reminders are more effective in improving timeliness where pre-existing compliance is lower, but the 18 month schedule point appeared to be less amenable to intervention. Australia and New Zealand Clinical Trial Registration No. ACTRN12614000970640.

P2468Clinical and cardiac structural differences between paroxysmal and persistent/permanent non-valvular atrial fibrillation

Background

Atrial Fibrillation (AF) is a heterogeneous condition and is traditionally classified by duration (paroxysmal, persistent and permanent). There is a relationship between AF and left atrial (LA) remodeling, with increased likelihood of AF recurrence and maintenance with increasing LA volumes.

Purpose

To assess clinical and cardiac structural differences between the subtypes of AF.

Methods

We examined 1247 (68±13.4y; 50% men) consecutive admissions presenting to our institution with the primary diagnosis of AF. Repeat admissions (n=263) were excluded. Of remaining 984 subjects, a majority had diagnosed paroxysmal (72.2%), with lower numbers of persistent (23.4%) and permanent (4.4%) AF. Echo parameters of cardiac chamber size and function were examined in a subset of subjects with complete echo (n=646) performed during incident hospital admission.

Results

There were significantly higher rates of diabetes mellitus (p=0.03), ischaemic heart disease (IHD; p=0.04) and peripheral vascular disease (PVD; p=0.02) in those with persistent/permanent AF compared to paroxysmal AF. No significant differences in age (p=0.19), BMI (p=0.42), OSA (p=0.05), or hypertension (p=0.76) was noted. There were significant differences in left ventricular (LV) mass and systolic function, LA size and function between the two groups (Table 1). Receiver operator curve analysis revealed that LAEF was a discriminator for persistent/permanent AF with an area under the curve of 0.689 (95% CI, 0.646 to 0.732; p<0.001).

Echo parameters in AF subtype Echocardiographic Parameters Paroxysmal AF (n=433) Persistent and Permanent AF (n=213) Significance (p value) LVEDD (cm) 4.8±3.0 5.0±0.9 0.29 LVESD (cm) 3.3±1.3 3.7±1.1 <0.01 IVS thickness (cm) 1.2±0.7 1.1±0.3 0.44 PW thickness (cm) 1.1±0.7 1.1±0.2 0.77 LV mass (g) 92.3±28.3 108.2±35.3 <0.01 LVEF (%) 56.1±14.1 47.4±16.8 <0.01 LA Expansion Index 89.4±69.1 53.4±40.3 <0.01 Min LA Volume indexed (ml/m2) 18.9±17.2 27.3±20.6 0.01 Max LA Volume indexed (ml/m2) 32.5±19.2 37.7±15.3 <0.01 LAEF (%) 41.8±16.4 31.5±13.6 <0.01

Conclusions

Our results suggest diabetes, IHD and PVD are associated with persistent/permanent AF. Additionally, greater LA remodeling and reduced atrial function was noted in this group, suggestive of an association between duration of AF electrical burden and LA remodeling and function.

Retrospective cost-effectiveness of the 23-valent pneumococcal polysaccharide vaccination program in Australia

BACKGROUND

The Australian infant pneumococcal vaccination program was funded in 2005 using the 7-valent pneumococcal conjugate vaccine (PCV7) and the 13-valent conjugate vaccine (PCV13) in 2011. The PCV7 and PCV13 programs resulted in herd immunity effects across all age-groups, including older adults. Coincident with the introduction of the PCV7 program in 2005, 23-valent pneumococcal polysaccharide vaccine (PPV23) was funded for all Australian adults aged over 65 years.

METHODS

A multi-cohort Markov model with a cycle length of one year was developed to retrospectively evaluate the cost-effectiveness of the PPV23 immunisation program from 2005 to 2015. The analysis was performed from the healthcare system perspective with costs and quality-adjusted life years discounted at 5% annually. The incremental cost-effectiveness ratio (ICER) for PPV23 doses provided from 2005 to 2015 was calculated separately for each year when compared to no vaccination. Parameter uncertainty was explored using deterministic and probabilistic sensitivity analysis.

RESULTS

It was estimated that PPV23 doses given out over the 11-year period from 2005 to 2015 prevented 771 hospitalisations and 99 deaths from invasive pneumococcal disease (IPD). However, the estimated IPD cases and deaths prevented by PPV23 declined by more than 50% over this period (e.g. from 12.9 deaths for doses given out in 2005 to 6.1 in 2015), likely driven by herd effects from infant PCV programs. The estimated ICER over the period 2005 to 2015 was approximately A$224,000/QALY gained compared to no vaccination. When examined per year, the ICER for each individual year worsened from $140,000/QALY in 2005 to $238,000/QALY in 2011 to $286,000/QALY in 2015.

CONCLUSION

The cost-effectiveness of the PPV23 program in older Australians was estimated to have worsened over time. It is unlikely to have been cost-effective, unless PPV23 provided protection against non-invasive pneumococcal pneumonia and/or a low vaccine price was negotiated. A key policy priority should be to review of the future use of PPV23 in Australia, which is likely to be more cost-effective in certain high-risk groups.

The role of timeliness in the cost-effectiveness of older adult vaccination: A case study of pneumococcal conjugate vaccine in Australia

While the impact of the timeliness of vaccine administration has been well-studied for childhood vaccinations, there has been little detailed quantitative analysis on the potential impact of the timeliness of vaccinations in older adults. The aim of this study was to explore the impact of implementing more realistic observed uptake distributions, taking into the account reduced vaccine efficacy but higher pneumococcal disease burden with increasing age beyond 65 years. A multi-cohort Markov model was constructed to evaluate the cost-effectiveness of a pneumococcal (PCV13) immunisation program in Australia, assuming two different uptake modelling approaches. The approach using an estimate of observed uptake was compared with a scenario in which the total cumulative uptake was delivered at the recommended age of vaccination. We found these two approaches produced different results both in terms of cases prevented and cost-effectiveness. The impact of the non-timely uptake in adult programs may sometimes have positive and other times negative effects, depending on several factors including the age-specific disease rates and the duration of vaccine protection. Our study highlights the importance of using realistic assumptions around uptake (including non-timely vaccination) when estimating the impact of vaccination in adults.

Treatment of non-cavitary pulmonary tuberculosis with shortened fluoroquinolone-based regimens: a meta-analysis

SETTING

Several recent trials evaluating 4-month fluoroquinolone (FQ) containing regimens found that none of the experimental regimens were non-inferior to standard 6-month therapy in treating patients with drug-susceptible pulmonary tuberculosis (PTB).

OBJECTIVE

To answer whether FQ-containing duration-shortened regimens are non-inferior to standard therapy in the treatment of patients with non-cavitary PTB.

DESIGN

Systematic review of all randomized and quasi-randomized trials that substituted an FQ into standard therapy for less than 6 months' duration to treat drug-susceptible, non-cavitary PTB. Non-inferiority was based on a 6% margin of difference.

RESULTS

Of 4594 total participants in the three trials that met the inclusion criteria, 1066 patients had non-cavitary disease. The pooled difference in unfavorable outcomes was 5% (95%CI -3 to 13) in patients with non-cavitary disease treated with FQ-containing regimens vs. standard therapy. In subgroup analyses, the pooled difference in unfavorable outcomes was 1% (95%CI -3 to 5) when comparing the daily form of intervention regimen with standard therapy, and -1% (95%CI -5 to 4) between regimens replacing ethambutol (EMB) with an FQ and standard therapy. No difference in risk of adverse events was noted.

CONCLUSION

Daily administered 4-month regimens with substitution of EMB by an FQ may be non-inferior to standard therapy in patients with culture-confirmed, non-cavitary, drug-susceptible PTB.

A randomised double-blind placebo-controlled pilot trial of a combined extract of sage, rosemary and melissa, traditional herbal medicines, on the enhancement of memory in normal healthy subjects, including influence of age

OBJECTIVE

To evaluate for the first time the effects of a combination of sage, rosemary and melissa (Salvia officinalis L., Rosmarinus officinalis L. and Melissa officinalis L.; SRM), traditional European medicines, on verbal recall in normal healthy subjects. To devise a suitable study design for assessing the clinical efficacy of traditional herbal medicines for memory and brain function.

METHODS

Forty-four normal healthy subjects (mean age 61 ± 9.26y SD; m/f 6/38) participated in this study. A double-blind, randomised, placebo-controlled pilot study was performed with subjects randomised into an active and placebo group. The study consisted of a single 2-week term ethanol extract of SRM that was chemically-characterised using high resolution LC-UV-MS/MS analysis. Immediate and delayed word recall were used to assess memory after taking SRM or placebo (ethanol extract of Myrrhis odorata (L.) Scop.). In addition analysis was performed with subjects divided into younger and older subgroups (≤ 62 years mean age n = 26: SRM n = 10, Placebo n = 16; ≥ 63 years n = 19: SRM n = 13, Placebo n = 6).

RESULTS

Overall there were no significant differences between treatment and placebo change from baseline for immediate or delayed word recall. However subgroup analysis showed significant improvements to delayed word recall in the under 63 year age group (p < 0.0123) with Cohen's effect size d = 0.92. No adverse effects were observed.

CONCLUSION

This pilot study indicates that an oral preparation of SRM at the selected dose and for the period of administration is more effective than a placebo in supported verbal episodic memory in healthy subjects under 63 years of age. Short- and long- term supplementation with SRM extract merits more robust investigation as an adjunctive treatment for patients with Alzheimer's disease and in the general ageing population. The study design proved a simple cost effective trial protocol to test the efficacy of herbal medicines on verbal episodic memory, with future studies including broader cognitive assessment.

Beyond expectations: Post-implementation data shows rotavirus vaccination is likely cost-saving in Australia

BACKGROUND

Universal vaccination against rotavirus was included in the funded Australian National Immunisation Program in July 2007. Predictive cost-effectiveness models assessed the program before introduction.

METHODS

We conducted a retrospective economic evaluation of the Australian rotavirus program using national level post-implementation data on vaccine uptake, before-after measures of program impact and published estimates of excess intussusception cases. These data were used as inputs into a multi-cohort compartmental model which assigned cost and quality of life estimates to relevant health states, adopting a healthcare payer perspective. The primary outcome was discounted cost per quality adjusted life year gained, including or excluding unspecified acute gastroenteritis (AGE) hospitalisations.

RESULTS

Relative to the baseline period (1997-2006), over the 6years (2007-2012) after implementation of the rotavirus program, we estimated that ∼77,000 hospitalisations (17,000 coded rotavirus and 60,000 unspecified AGE) and ∼3 deaths were prevented, compared with an estimated excess of 78 cases of intussusception. Approximately 90% of hospitalisations prevented were in children <5years, with evidence of herd protection in older age groups. The program was cost-saving when observed changes (declines) in both hospitalisations coded as rotavirus and as unspecified AGE were attributed to the rotavirus vaccine program. The adverse impact of estimated excess cases of intussusception was far outweighed by the benefits of the program.

CONCLUSION

The inclusion of herd impact and declines in unspecified AGE hospitalisations resulted in the value for money achieved by the Australian rotavirus immunisation program being substantially greater than predicted bypre-implementation models, despite the potential increased cases of intussusception. This Australian experience is likely to be relevant to high-income countries yet to implement rotavirus vaccination programs.

Cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) in older Australians

BACKGROUND

The 23-valent pneumococcal polysaccharide vaccine (PPV23) has been funded under the Australia National Immunisation Program (NIP) since January 2005 for those aged >65years and other risk groups. In 2016, PCV13 was accepted by the Pharmaceutical Benefits Advisory Committee (PBAC) as a replacement for a single dose of PPV23 in older Australian adults.

METHODS

A single-cohort deterministic multi-compartment (Markov) model was developed describing the transition of the population between different invasive and non-invasive pneumococcal disease related health states. We applied a healthcare system perspective with costs (Australian dollars, A$) and health effects (measured in quality adjusted life-years, QALYs) attached to model states and discounted at 5% annually. We explored replacement of PPV23 with PCV13 at 65years as well as other age based vaccination strategies. Parameter uncertainty was explored using deterministic and probabilistic sensitivity analysis.

RESULTS

In a single cohort, we estimated PCV13 vaccination at the age of 65years to cost ∼A$11,120,000 and prevent 39 hospitalisations and 6 deaths from invasive pneumococcal disease and 180 hospitalisations and 10 deaths from community acquired pneumonia. The PCV13 program had an incremental cost-effectiveness ratio of ∼A$88,100 per QALY gained when compared to a no-vaccination, whereas PPV23 was ∼A$297,200 per QALY gained. To fall under a cost-effectiveness threshold of A$60,000 per QALY, PCV13 would have to be priced below ∼A$46 per dose. The cost-effectiveness of PCV13 in comparison to PPV23 was ∼A$35,300 per QALY gained.

CONCLUSION

In comparison to no-vaccination, we found PCV13 use in those aged 65years was unlikely to be cost-effective unless the vaccine price was below A$46 or a longer duration of protection can be established. However, we found that in comparison to the PPV23, vaccination with PCV13 was cost-effective. This partly reflects the poor value for money estimated for PPV23 use in Australia.

The Video Interaction Guidance approach applied to teaching communication skills in dentistry

PURPOSE

To examine dentists' views of a novel video review technique to improve communication skills in complex clinical situations.

MATERIALS AND METHODS

Dentists (n = 3) participated in a video review known as Video Interaction Guidance to encourage more attuned interactions with their patients (n = 4). Part of this process is to identify where dentists and patients reacted positively and effectively. Each dentist was presented with short segments of video footage taken during an appointment with a patient with intellectual disabilities and communication difficulties. Having observed their interactions with patients, dentists were asked to reflect on their communication strategies with the assistance of a trained VIG specialist.

RESULTS

Dentists reflected that their VIG session had been insightful and considered the review process as beneficial to communication skills training in dentistry. They believed that this technique could significantly improve the way dentists interact and communicate with patients. The VIG sessions increased their awareness of the communication strategies they use with their patients and were perceived as neither uncomfortable nor threatening.

DISCUSSION

The VIG session was beneficial in this exploratory investigation because the dentists could identify when their interactions were most effective. Awareness of their non-verbal communication strategies and the need to adopt these behaviours frequently were identified as key benefits of this training approach. One dentist suggested that the video review method was supportive because it was undertaken by a behavioural scientist rather than a professional counterpart.

CONCLUSION

Some evidence supports the VIG approach in this specialist area of communication skills and dental training.

Retrospective economic evaluation of childhood 7-valent pneumococcal conjugate vaccination in Australia: Uncertain herd impact on pneumonia critical

BACKGROUND

Retrospective cost-effectiveness analyses of vaccination programs using routinely collected post-implementation data are sparse by comparison with pre-program analyses. We performed a retrospective economic evaluation of the childhood 7-valent pneumococcal conjugate vaccine (PCV7) program in Australia.

METHODS

We developed a deterministic multi-compartment model that describes health states related to invasive and non-invasive pneumococcal disease. Costs (Australian dollars, A$) and health effects (quality-adjusted life years, QALYs) were attached to model states. The perspective for costs was that of the healthcare system and government. Where possible, we used observed changes in the disease rates from national surveillance and healthcare databases to estimate the impact of the PCV7 program (2005-2010). We stratified our cost-effectiveness results into alternative scenarios which differed by the outcome states included. Parameter uncertainty was explored using probabilistic sensitivity analysis.

RESULTS

The PCV7 program was estimated to have prevented ∼5900 hospitalisations and ∼160 deaths from invasive pneumococcal disease (IPD). Approximately half of these were prevented in adults via herd protection. The incremental cost-effectiveness ratio was ∼A$161,000 per QALY gained when including only IPD-related outcomes. The cost-effectiveness of PCV7 remained in the range A$88,000-$122,000 when changes in various non-invasive disease states were included. The inclusion of observed changes in adult non-invasive pneumonia deaths substantially improved cost-effectiveness (∼A$9000 per QALY gained).

CONCLUSION

Using the initial vaccine price negotiated for Australia, the PCV7 program was unlikely to have been cost-effective (at conventional thresholds) unless observed reductions in non-invasive pneumonia deaths in the elderly are attributed to it. Further analyses are required to explore this finding, which has significant implications for the incremental benefit achievable by adult PCV programs.

General practice encounters following seasonal influenza vaccination as a proxy measure of early-onset adverse events

BACKGROUND

In 2010, use of seasonal trivalent influenza vaccine (TIV) in children <5 years of age was suspended in Australia following reports of vaccine-related febrile convulsions. We investigated the utility of data on primary care [general practice (GP)] consultations for any reason within three days of receipt of influenza vaccine as recorded on the Australian Childhood Immunisation Register (ACIR) as a means of signal detection.

METHODS

Data on GP consultations were obtained from Medicare Australia (Australian Government Department of Human Services) for children recorded on the ACIR as receiving either TIV or monovalent influenza vaccine. Rates of GP consultation by day following ACIR-recorded receipt of influenza vaccine were compared by year (2008-2010), vaccine type, age and region.

RESULTS

In 2010, GP encounter rates on the day after receipt of the TIV manufactured by bioCSL (formerly CSL Biotherapies (Fluvax(®)) were significantly higher than both bioCSL TIVs in the previous two years [rate ratio (RR) 1.9; 95% CI: 1.7-2.2] and Sanofi Pasteur TIV, Vaxigrip(®) [RR 1.6, 95% CI 1.4-1.7] in 2009-2010. Encounter rates were also higher than for CSL Monovalent influenza vaccine, Panvax(®) [RR 1.9, 95% CI 1.7-2.2] in 2009-2010. These findings were robust to adjustment for age group (≤ 2, >2 years) and region (Western Australia vs other Australian states/territories).

CONCLUSIONS

A primary care consultation on the day after vaccine receipt is a reasonable proxy for early reactogenicity and has potential for use in various settings.

Economic evaluations of implemented vaccination programmes: key methodological challenges in retrospective analyses

Post-implementation evaluation should play an important role in assessing the success of public health programmes; however, the value for money achieved by vaccine programmes after introduction has received relatively little attention to date. In this article we explore the methodological challenges in these analyses and offer direction for future evaluations in the area. We identify alternative approaches to addressing these challenges, which include the estimation of disease changes attributable to vaccination efforts, the hypothetical no vaccination comparator scenario and the full benefit achieved by implemented vaccination programmes. We also outline other important considerations such as the evolution of prices over time. Further work needs to be done to explore these issues and to determine how the application of different approaches may impact on the results of evaluations in various circumstances. As retrospective analyses are likely to become more frequent and influential, it is important that both the benefits and the limitations of post-implementation evaluations are recognised and understood. We argue that it would be useful to establish a methodological framework to provide standards and guidance on how to undertake such analyses in the future.

The value of end-of-treatment chest radiograph in predicting pulmonary tuberculosis relapse

SETTING

Patients with cavitary pulmonary tuberculosis (TB) on baseline chest radiograph (CXR) who remain culture-positive after 8 weeks of treatment are at high risk of relapse. The role of end-of-treatment (EOT) CXR in predicting relapse is unclear.

OBJECTIVE

To determine whether EOT CXR independently predicts TB relapse.

DESIGN

We conducted a secondary analysis of a randomized trial of intermittent treatment using rifapentine in the continuation phase of TB treatment among 1004 human immunodeficiency virus seronegative adults with culture-proven pulmonary TB.

RESULTS

Relapse occurred in 17.3% of subjects with persistent cavity on EOT CXR, in 7.6% of subjects with a cavity that resolved by EOT, and 2.5% (P=0.002 for trend) of subjects who never had a cavity. In multivariable analysis, patients with persistent cavity on EOT CXR were significantly more likely to relapse than patients with no cavity on baseline or 2-month CXR (hazard ratio [HR] 4.22, 95%CI 2.00-8.91), and were more likely to relapse than subjects whose early cavity had resolved by EOT CXR (HR 1.92, 95%CI 1.09-3.39).

CONCLUSION

A persistent cavity after 6 months of TB treatment was independently associated with disease relapse after controlling for other variables. EOT CXR may help predict those likely to relapse.

The association of respiratory viruses, temperature, and other climatic parameters with the incidence of invasive pneumococcal disease in Sydney, Australia

BACKGROUND

Increases in incidence of invasive pneumococcal disease (IPD) during the colder months of the year in temperate regions are well recognized, but few detailed studies of possible interactions are available. We examined the relationship between virus activity, climatic parameters, and IPD during a winter in which there were separate peak incidences of influenza and respiratory syncytial virus (RSV) infection.

METHODS

We performed an ecological study that correlated population-based data on IPD and respiratory virus activity in the year 2000 in metropolitan New South Wales, Australia, with climatic parameters, including weekly mean maximum and minimum temperature, relative humidity, rainfall, and wind speed.

RESULTS

In children, RSV activity was significantly positively correlated with IPD activity (r = 0.578; P = .002) but not with influenza virus activity. There was a weak inverse relationship between parainfluenza virus activity and IPD activity (r = -0.401; P = .043) and a stronger inverse relationship between weekly mean maximum temperature (r = -0.458; P = .001), weekly mean minimum temperature (r = -0.437; P = .001), and IPD activity. In adults, there was no significant correlation between RSV or influenza virus activity alone and IPD, but the combination of RSV and influenza was significantly correlated with IPD (r = 0.481; P = .013).

CONCLUSIONS

This study suggests that RSV infection and influenza contribute to IPD incidence peaks differently for children than for adults. Data from other geographic areas and more rigorous study designs are required to confirm these findings.

Epiglottitis in Sydney before and after the introduction of vaccination againstHaemophilus influenzaetype b disease

BACKGROUND

Acute epiglottitis due to infection with Haemophilus influenzae type b (Hib) is much less common in children following the introduction of Hib vaccination; however, adult epiglottitis cases have not decreased. In addition, epiglottitis hospitalizations are consistently more numerous than notifications and the reason for this is not clear.

AIMS

To more accurately describe the clinical, aetiological and epidemiological features of epiglottitis and to ascertain the accuracy of hospitalization data in an era of widespread Hib vaccination.

METHODS

Medical records in 11 public hospitals in three area health services in New South Wales with a principal or stay diagnosis (International Classification of Diseases (ICD)-9-CM or ICD-10-AM code) of acute epiglottitis between July 1990 and June 1992 (prior to Hib vaccination = pre-vaccine era) and July 1998 and June 2000 (widespread Hib vaccination = vaccine era) were reviewed. Case definitions of epiglottitis were applied.

RESULTS

One hundred and forty-two records were identified (114 pre-vaccine era and 28 vaccine era). Incorrect coding was more common in vaccine era records (32 vs 7%). Of correctly coded records, adults over 20 years old comprised the majority in the vaccine era (84 vs 17%). Hib bacteraemia was identified in 62% of cases in the pre-vaccine era compared to no cases in the vaccine era, despite equivalent blood cultures being taken between the two eras (84 vs 74%). Streptococcus pneumoniae was the only other organism isolated. Three deaths were recorded (1 child, 2 adults), all in the pre-vaccine era.

CONCLUSIONS

Acute epiglottitis hospitalizations in the current Hib vaccine era are predominantly in adults, and rarely are Hib or other causative organisms identified, although microbiological data are often incomplete. The discrepancy between hospitalization and notification data appears to be due to misclassification of hospitalization records.

Diagnostic testing and discharge coding for whooping cough in a children's hospital

OBJECTIVE

To evaluate the diagnostic pathways for whooping cough in a large urban paediatric hospital to inform assessment of the relative merits of notification and hospitalization data for measuring pertussis disease burden in Australian children.

METHODS

All laboratory requests for Bordetella pertussis (BP) culture or serology between 30 June 1997 and 30 June 1999 were reviewed and cross-checked against discharge diagnoses with International Classification of Disease (ICD) codes A37.0, 033.0 (whooping cough due to BP) or 37.9, 033.9 (whooping cough due to unspecified organisms). Culture-positive (CP) cases were defined as a positive culture or polymerase chain reaction for BP. Culture-negative (CN) cases either fulfilled the current Australian clinical case definition (>/=14 days of cough with one or more of paroxysms, whoop, post-tussive vomiting), or had a cough illness with either positive BP serology or documented contact with an individual coughing for >14 days. In infants <6-months-old, a coughing illness with apnoea and negative investigations for other causes was also accepted. Culture positive and CN cases were cross-referenced with notification data.

RESULTS

During the study period, laboratory tests for BP were performed in 677 children, of whom 230 were hospitalized and 71 (31%) had an eligible ICD code at discharge; 29 were CP, 40 CN, and two (3%) were misclassified. A further 14 CP children were not admitted. Although 61 hospitalized cases (88%) fulfilled notification criteria, including 32 (80%) of CN cases, only 26 (90%) of CP and eight (20%) of CN cases were notified.

CONCLUSIONS

Notifications substantially under-enumerate hospitalized infant cases, especially those without positive laboratory tests. Hospital discharge data add significantly to surveillance for pertussis, particularly in infancy where most severe cases occur.

Surveillance of pneumococcal disease in Australian states and territories

Information on pneumococcal disease, including immunisation programs, and optimum future surveillance in each Australian State and Territory were discussed at the Pneumococcal Disease in Australia Workshop on 26-27 March 1999. Workshop participants further expanded on the surveillance aspects of the Workshop in this report. Most participants favoured notification by laboratories of pneumococcal isolates from sterile sites, to provide baseline surveillance data before immunisation programs are fully implemented. It was also thought that trends in antimicrobial resistance should be notified.

Novel speech patterns and the treatment of stuttering

Variants of rhythmic speech and legato speech have been used for centuries to treat stuttering. Despite considerable empirical and theoretical inquiry, the reason for the effectiveness of these novel speech patterns in suppressing stuttering is unknown. Recent acoustic research conducted at the University of Sydney suggests that a reduction in the variability of syllabic stress is a critical feature of these two speech patterns, and that this reduction suppresses stuttering by stabilizing the speech motor system. This paper reviews what is known about rhythmic speech and legato speech from this perspective, and the theoretical and clinical implications of reconceptualizing them in this way are discussed.

"I do not care for a lunatic's role": modes of regulation and resistance inside the Colquitz Mental Home, British Columbia, 1919-33

This article chronicles the experiences of 100 male patients who were confined at the Provincial Mental Home, Colquitz, Vancouver Island between 1919 and 1933. Through an analysis of clinical records and other sources,I reconstruct the organizational and human environment that prevailed at Colquitz during the tenure of its first lay supervisor, Granby Farrant; I chart the diverse modes of discipline through which officials sought to maintain the institutional regimen; and I document the efforts undertaken by patients to resist authority, transcend their surroundings, and seek redemption and hope both inside and beyond the Colquitz wall.

Treatment of irritable bowel syndrome with Chinese herbal medicine: a randomized controlled trial

CONTEXT

Irritable bowel syndrome (IBS) is a common functional bowel disorder for which there is no reliable medical treatment.

OBJECTIVE

To determine whether Chinese herbal medicine (CHM) is of any benefit in the treatment of IBS.

DESIGN

Randomized, double-blind, placebo-controlled trial conducted during 1996 through 1997.

SETTING

Patients were recruited through 2 teaching hospitals and 5 private practices of gastroenterologists, and received CHM in 3 Chinese herbal clinics.

PATIENTS

A total of 116 patients who fulfilled the Rome criteria, an established standard for diagnosis of IBS.

INTERVENTION

Patients were randomly allocated to 1 of 3 treatment groups: individualized Chinese herbal formulations (n = 38), a standard Chinese herbal formulation (n = 43), or placebo (n = 35). Patients received 5 capsules 3 times daily for 16 weeks and were evaluated regularly by a traditional Chinese herbalist and by a gastroenterologist. Patients, gastroenterologists, and herbalists were all blinded to treatment group.

MAIN OUTCOME MEASURES

Change in total bowel symptom scale scores and global improvement assessed by patients and gastroenterologists and change in the degree of interference in life caused by IBS symptoms assessed by patients.

RESULTS

Compared with patients in the placebo group, patients in the active treatment groups (standard and individualized CHM) had significant improvement in bowel symptom scores as rated by patients (P=.03) and by gastroenterologists (P=.001), and significant global improvement as rated by patients (P=.007) and by gastroenterologists (P=.002). Patients reported that treatment significantly reduced the degree of interference with life caused by IBS symptoms (P=.03). Chinese herbal formulations individually tailored to the patient proved no more effective than standard CHM treatment. On follow-up 14 weeks after completion of treatment, only the individualized CHM treatment group maintained improvement.

CONCLUSION

Chinese herbal formulations appear to offer improvement in symptoms for some patients with IBS.

Remote sensing of multi-level wind fields with high-energy airborne scanning coherent Doppler lidar

The atmospheric lidar remote sensing groups of NOAA Environmental Technology Laboratory, NASA Marshall Space Flight Center, and Jet Propulsion Laboratory have developed and flown a scanning, 1 Joule per pulse, CO2 coherent Doppler lidar capable of mapping a three-dimensional volume of atmospheric winds and aerosol backscatter in the planetary boundary layer, free troposphere, and lower stratosphere. Applications include the study of severe and non-severe atmospheric flows, intercomparisons with other sensors, and the simulation of prospective satellite Doppler lidar wind profilers. Examples of wind measurements are given for the marine boundary layer and near the coastline of the western United States.

Exercise-induced bronchospasm: a pilot survey in Nairobi school children

Exercise-induced bronchospasm (EIB), a common feature of asthma in children, has been used as the outcome measure in community-based surveys of childhood asthma to circumvent difficulties arising from relative lack of objectivity in the use of questionnaires in communities with different cultural and language orientations. We report here the results of the first community-based study of childhood asthma in Kenya using EIB as the outcome measurement. The data was collected in a pilot study to develop methodology for a larger subsequent study. The survey targeted grade four children in five Nairobi City Council school each representing a neighbourhood social economic status (SES). Out of 597 eligible, 408 children took part in the study (68% participation rate). EIB defined as decline in FEV1 of 15% or more, post-exercise was found in 10.5% (95% CI; 10.3, 10.7) of the children studied, the highest rate reported so far in Africa. While boys were more likely to exhibit EIB compared to girls, the prevalence of EIB tended to decrease with age, especially among children residing in low SES neighbourhoods where the EIB prevalence rates tended to be lower compared to those among children from higher SES neighbourhoods. However, none of these differences was statistically significant. This study confirms the feasibility of undertaking exercise challenge tests in the African context and we recommend that additional studies of similar nature be carried out in other populations of Africa to explore the potential of using an exercise test as a marker of asthma in epidemiologic studies.

Height phobia and biases in the interpretation of bodily sensations: some links between acrophobia and agoraphobia

The present study was designed to investigate some of the factors that might underlie the commonly found association between agoraphobia and fear of heights (acrophobia). The results showed that measures of acrophobia are highly associated with the tendency to interpret ambiguous bodily sensations as threatening, and with an increased tendency to report bodily sensations of anxiety. These features of acrophobia did not appear to be characteristics found in phobic states in general, nor did measures of acrophobia show any significant relationship to the tendency to interpret external and social stimuli as threatening. These findings suggest that the frequently found co-morbidity between agoraphobia and acrophobia may be linked to cognitive biases in the discrimination and interpretation of bodily sensations that agoraphobia and acrophobia share in common. In addition, the present findings also generate testable hypotheses about the aetiology of acrophobia.

Bacille Calmette-Guérin vaccination and incidence of IDDM in Montreal, Canada

OBJECTIVE

To describe the association between Bacille Calmette-Guérin (BCG) vaccination and IDDM development in two different case-control series (A and B) in Montreal.

RESEARCH DESIGN AND METHODS

Case-control series A comprised 93 IDDM cases and 2,903 control subjects who participated in a community-based tuberculin reactivity survey and who belonged to the same birth cohorts and areas of residence as the IDDM cases, Case-control series B comprised 249 IDDM cases and 431 age- and sex-matched friends and neighborhood control subjects.

RESULTS

In series A, the BCG vaccination prevalence among cases and control subjects was 21.5% (95% CI 13.2-29.8%) and 22.3% (95% CI 20.8-23.8%), respectively. The odds ratio (OR) for IDDM associated with BCG vaccination was 1.09 (95% CI 0.62-1.91), after adjusting for the birth cohorts and areas of residence. The vaccination prevalence in series B was 17.7% (95% CI 13.0-22.4%) among cases and 15.1% (95% CI 11.7-18.5%) among control subjects. The OR for IDDM due to BCG vaccination was 1.26 (95% CI 0.79-2.02), taking into account the matched sets. Only one case (3.3%) from series B who had been vaccinated at birth was diagnosed by age 5, compared with 52 cases (24.5%) who had not been vaccinated (P < 0.01).

CONCLUSIONS

The lower proportion of birth-vaccinated IDDM cases diagnosed at a very young age, compared with nonvaccinated cases, possibly reflects a temporary boost of the immune functions after vaccination. However, as a whole, results from these analyses fail to support a protective role of BCG vaccination against juvenile-onset IDDM.

The effect of interferon-alpha on the pituitary-adrenal axis

This report concerns the use of a minimum stress animal model for evaluating the neuromodulatory effects of interferon-alpha (IFN-alpha). Male Sprague-Dawley rats, 350-450 g, received jugular catheters and were habituated to handling and sampling arenas. These procedures will minimize stress usually associated with i.v. injections and blood sampling. Natural rat IFN-alpha/beta (RaIFN-alpha/beta) endotoxin free (Lee Biomolecular Research Laboratories, San Diego, CA) or recombinant human IFN-alpha, (rHuIFN-alpha) (a gift from Hoffman La Roche, Nutley, NJ) was injected into rats via catheter at various IFN concentrations. Controls were injected with either (1) vehicle (saline), (2) human or bovine serum albumin in saline, or (3) heat-denatured RaIFN-alpha/beta. Experiments were begun (0 h) at about 0900 h, and blood samples were withdrawn at intervals up to 2 h after IFN or control injections and replaced by the same volume of saline. The concentrations of corticosterone and ACTH in peripheral plasma were measured by radioimmunoassay. Both IFN, when injected at concentrations of 300 or 600 U/g body weight (U/gbw), stimulated an increase above 0 h levels of both hormones in the same animals. Additionally, the stimulation was also evident when compared with plasma hormone levels in animals injected with control substance in a parallel time course. After administration of 150 U/gbw of either IFN, only the increase in the blood corticosterone was significant. These studies demonstrate that both homospecific (RaIFN-alpha/beta) and heterospecific (rHuIFN-alpha) IFN preparations are capable of stimulating the pituitary-adrenal axis.

Measuring ventilation of patient care areas in hospitals. Description of a new protocol

It has been recommended that ventilation of health care facilities should be monitored regularly to reduce the risk of nosocomial transmission of tuberculosis. We developed a simple method to measure air-change rates and direction of airflow in patient care areas. Pure carbon dioxide (CO2) was released at 13.5 L/min for 5 min, then measured for 30 min within the room and outside in the hallway. Smoke tubes were also used to measure direction of airflow. Doors and windows (if openable) were manipulated. This protocol, when conducted in five offices in 30 patients care areas in two hospitals, provided good mixing and reproducible decay curves, with less than 15% coefficient of variation for repeated measures over a wide range of air-change rates. Manipulation of door and/or window produced significant changes in air-change rates and airflow direction, although calculated air-change rates were more variable. Smoke tube measurements were inconsistent, agreed poorly with evidence of CO2 movement from room to hall, and were strongly affected by room to hallway temperature differentials. CO2 release and measurement proved to be a simple, yet reliable, method to measure air-change rates and the effect of door or window manipulation. Smoke tube measurements were not reliable to characterize direction of airflow.

Construction and validation of risk assessments in a six-year follow-up of forensic patients: a tridimensional analysis

Evaluations of risk were conducted for 162 Canadian mentally disordered criminal defendants through the assembly of actuarial data, scores from special-to-purpose psychometric instruments, and scaled global predictions of dangerousness to others by clinicians and nonclinical raters. Violent conduct by participants was tracked across legal and medical institutions and the community for a subsequent 6 years, with aggregate violence base rates reaching 62%. Decisions about risk were strongly associated with participant attributes and presentations during forensic interviews, but neither linear regression equations involving background and scale items nor direct discretionary judgments could account for more than 25% of variance in the frequency of outcome violence. Predictive accuracy maximized after 3 years, and was strongest for hospital-based violence. Professional clinicians were no more accurate than nonclinical raters. Implications of these findings for the sociolegal control of violence, and for the resurgent "second generation" of risk research, are explored.

Community-based tuberculin screening in Montreal: a cost-outcome description

OBJECTIVES

This study describes the costs and outcomes of community-based tuberculin screening programs conducted between 1987 and 1991 in Montreal, Quebec, Canada.

METHODS

Follow-up information was abstracted from hospital records of all reactors detected in tuberculin screening of students in grades 6 and 10, of first-year health professional students, and of workers aged 18 to 25 in a number of workforces. Screening costs were estimated directly from survey records, and follow-up costs were estimated from the annual financial report of the Montreal Chest Hospital for 1989/90.

RESULTS

Of 7669 persons tested, 782 (10.2%) had positive results and 757 (9.9%) were referred to a clinic. Of those, 525 (6.8% of the original 7669) reported, 293 (3.8%) were prescribed therapy, and 154 (2.0%) were compliant. In Canadian dollars, screening cost $5.70 per person tested and $56 per tuberculin reactor detected, but follow-up of reactors accounted for 73% of the total program cost of $13,455 to $18,753 per case of tuberculosis prevented.

CONCLUSIONS

Because of high rates of patient and provider noncompliance, a tuberculin screening program was much less cost-effective than anticipated. Screening costs must be targeted to the highest risk populations, and compliance with recommendations for preventive therapy must be maximized.

Home environment and asthma in Kenyan schoolchildren: a case-control study

BACKGROUND

There is increasing evidence that environmental factors contribute to the development of asthma, so the relationship was studied between home environment factors and asthma among school children of varying socioeconomic backgrounds living in a developing country.

METHODS

A case-control study was performed in participants of a prevalence survey which included 77 schoolchildren with asthma (defined by a history of wheeze, doctor diagnosis, or a decline in FEV1 of > or = 10% at five or 10 minutes after exercise) and 77 age and gender matched controls. Subjects were selected from 402 school children aged 9-11 years attending five primary schools in the city of Nairobi who participated in a prevalence survey of asthma. Visits were made to the homes of cases and controls and visual inspection of the home environment was made using a checklist. A questionnaire regarding supplemental salt intake, parental occupation, cooking fuels, and health of all children in the family was administered by an interviewer.

RESULTS

In multivariate analysis the following factors were associated with asthma: damage caused by dampness in the child's sleeping area (adjusted odds ratio (OR) 4.9; 95% confidence interval (CI) 2.0 to 11.7), air pollution in the home (OR 2.5; 95% CI 2.0 to 6.4), presence of rugs or carpets in child's bedroom (OR 3.6; 95% CI 1.5 to 8.5). Children with asthma reported a supplemental mean daily salt intake of 817 mg compared with 483 mg in controls.

CONCLUSIONS

Home environmental factors appear to be strongly associated with asthma in schoolchildren in a developing nation. These findings suggest a number of hypotheses for further studies.

The effect of war on tuberculosis. Results of a tuberculin survey among displaced persons in El Salvador and a review of the literature

SETTING

During wartime, civilian populations usually experience a drop in caloric intake, disruption of housing, and a diminution in availability of medical services. These disturbances might be expected to result in increased reactivation of tuberculosis, which may result in increased transmission. Such privations occurred in El Salvador during its 1980-92 civil war, particularly among the 20% of the population, or over 1 million people, who were displaced.

OBJECTIVE

(1) To estimate the rate of transmission of tuberculosis among displaced Salvadorians prior to and during the war, and (2) to compare this result with experience in the literature.

DESIGN

(1) A tuberculin survey was conducted in El Salvador in July 1992 among all residents aged 1-30 years in 12 communities of formerly displaced persons. (2) The English language literature on tuberculosis during wartime was reviewed.

RESULTS

(1) Overall, 21.2% of the non-BCG vaccinated had significant tuberculin reactions, equivalent to an annual risk of infection of 2.3%. The trend in the annual risk of infection was upward over the latter 6 years of the war, stable over the first 6 years, and was downward prior to the war years. The estimated incidence of smear positive pulmonary tuberculosis was 125 per 100,000 or 3 times the reported rate for El Salvador. (2) A review of the literature showed consistent evidence for increased morbidity and mortality from tuberculosis during wartime. Increased transmission was suggested by those studies showing a rise in both incidence of tuberculous meningitis during war years and excess morbidity and mortality many years after a war. Two major population-based studies found no evidence of increased transmission based on the calculated annual risk of infection; however other studies examining younger or more severely affected populations, or following more prolonged wars, detected an apparent increase in the transmission of tuberculosis.

CONCLUSIONS

Conditions of war are associated with a rapid increase in morbidity and mortality from tuberculosis, which appears to result in increased transmission among populations most severely affected by war. This increased transmission will result in increased morbidity and mortality for many years, underscoring the need for improved tuberculosis control in the post-war period in countries such as El Salvador that have been devastated by war.

Factors affecting compliance with preventive treatment for tuberculosis at Mistassini Lake, Quebec, Canada

Non-compliance is the most important cause of failure of anti-tuberculous therapy throughout the world. In 1990 and 1991, an outbreak of tuberculosis occurred on the Mistassini Cree territory in Northern Quebec, Canada, and a number of cases of active tuberculosis occurred among known tuberculin-positive contacts who were non-compliant with preventive therapy. To better understand the factors affecting compliance with preventive treatment, a review of patients prescribed preventive treatment over the past 10 y was conducted. A freely-translated, interviewer-administered questionnaire was used to measure personal/lifestyle factors and knowledge/attitudes about tuberculosis. Clinic dossiers were reviewed to assess compliance. One hundred and two (102) subjects prescribed preventive treatment between 1981 and 1991 were interviewed, of whom 33.7% were judged to have been compliant. The most significant factor associated with compliance with preventive therapy was year of therapy. Between 1981 and 1985, 78% completed treatment, compared to less than 20% since 1986 (p < .0001). The major factor identified as associated with this sudden change was a shift in responsibility for tuberculosis treatment follow-up from native community health workers to non-native nurses in 1985/86. We conclude that tuberculosis control programs must be tailored to take into account the importance of cultural factors in promoting compliance with therapy.

The booster effect in two-step tuberculin testing among young adults in Montreal

OBJECTIVES

No consensus exists regarding the definition and interpretation of a significant boosting reaction after sequential tuberculin testing. The booster phenomenon is thought to represent remote tuberculous infection where tuberculin reactivity has waned, but it has also been described among persons with previous exposure to other mycobacteria or Bacille Calmette-Guérin (BCG) vaccine. We studied the factors affecting the booster phenomenon among Canadian-born young adults to determine the definition that would maximize sensitivity and specificity of a positive booster reaction in these persons.

DESIGN

Point-prevalence survey of initial tuberculin reactions and response to repeated tuberculin testing after 1 to 4 weeks.

SETTING

Community-based study of all students entering health professional training programs at six post-secondary institutions.

MEASUREMENTS

In 1989, 1990, and 1991, students completed self-administered questionnaires, underwent two-step tuberculin testing with purified protein derivative-tuberculin (PPD-T), and had their childhood BCG vaccination status verified. In 1991, students were also tested with purified protein derivative-Battey (PPD-B) (for Mycobacterium intracellulare).

RESULTS

Overall, 74 students (5.2%) had positive booster reactions, which were significantly associated with older age (P < 0.001), larger initial tuberculin reactions (P < 0.001), previous BCG vaccination (P < 0.001), older age when vaccinated (P < 0.02), longer interval from vaccination to testing (P < 0.01), and sensitivity to PPD-B (P < 0.001). Boosting was not associated with the number of BCG vaccinations, sex, or risk factors for tuberculous infection. The pattern, mean, and mode of the frequency distributions of booster reactions among those with BCG vaccination and sensitivity to PPD-B were similar to those with assumed tuberculous infection.

CONCLUSIONS

In young adults, booster reactions due to previous tuberculous infection are uncommon and cannot be distinguished from false-positive reactions due to past exposure to other mycobacteria.

A longitudinal study of the relationships between psychometric test scores, offence history and the plasma concentrations of phenylacetic and 5-hydroxyindoleacetic acids in seven inmates of a prison for the psychiatrically disturbed

1. The plasma concentrations of phenylacetic (PAA) and 5-hydroxyindoleacetic (5HIAA) acids in seven inmates incarcerated in the Regional Psychiatric Centre (Prairies), Correctional Service of Canada, were assessed each weekday for four weeks (i.e., 20 samples each). Psychometric assessments for hostility, anger, depression and anxiety were also performed daily. Mean differences between subjects in psychometric and biochemical measures were subjected to tests of statistical significance. 2. The subject who was clearly most aggressive by offence history/institutional behavior scored significantly highest on scales of anger and hostility and significantly lowest with respect to PAA concentration. It was concluded that PAA may be a trait marker for aggression. 3. Plasma 5HIAA concentrations were invariant between subjects. 4. The psychometric measures were intercorrelated, thus confounding the variables of interest. They also varied little, proving insensitive to subtle mood changes.

The effect of varying levels of outdoor-air supply on the symptoms of sick building syndrome

BACKGROUND

The sick building syndrome is the term given to a constellation of symptoms reported by workers in modern office buildings, hypothesized to occur when the supply of outdoor air is reduced, because of the accumulation of contaminants arising from within the building. We undertook this study to determine the effect of changing the supply of outdoor air in four office buildings on the symptoms reported by workers and their perception of the indoor environment.

METHODS

Within each of three consecutive two-week blocks, the ventilation systems in each building were manipulated, in random order, to deliver to the indoor environment an intended 20 or 50 ft3 (0.57 or 1.4 m3) of outdoor air per minute per person for one week at a time. Each week, the participants, unaware of the experimental intervention, reported symptoms and the indoor environment was thoroughly evaluated.

RESULTS

Of 1838 eligible workers in the four buildings, 1546 (84 percent) participated in the study. The supply of outdoor air averaged 7 percent and 32 percent in the ventilation systems and 30 and 64 ft3 (0.85 and 1.8 m3) per minute per person in the work sites at the lower and higher ventilation levels, respectively. These changes in the supply of outdoor air were not associated with changes in the participants' ratings of the office environment or in symptom frequency (crude odds ratio, 1.0; 95 percent confidence interval, 0.9 to 1.1). After work-site measures of ventilation, temperature, humidity, and air velocity were included in the regression analysis, the adjusted odds ratio was also 1.0 (95 percent confidence interval, 0.8 to 1.2).

CONCLUSIONS

Increases in the supply of outdoor air did not appear to affect workers' perceptions of their office environment or their reporting of symptoms considered typical of the sick building syndrome.

Factors associated with compliance in treatment of tuberculosis

The most important cause of failure of antituberculosis therapy is that the patient does not take the medication as prescribed. To assess this problem, a retrospective review was conducted, using medical and nursing records, of adult patients treated at the tuberculosis clinic of the Montreal Chest Hospital in 1987-1988. In all, 352 patients were identified, of whom 59% were judged to have completed therapy. Completion of therapy was recorded in 92% of those with culture-positive disease, 76% of those with active but culture-negative disease and 54% among the 300 prescribed preventive therapy (P < 0.001). Compliance with preventive therapy was highest among those who had been in contact with an active case, and lowest among those identified through a workforce screening survey (P < 0.01). At the time of the first follow-up visit, patients identified to have suboptimal compliance were more likely to fail to complete therapy (P < 0.001). Compliance was higher among those initially hospitalized, those assessed to have better understanding (P < 0.05), those prescribed 6-9 rather than 12 months of therapy (P < 0.01), and those who returned for follow-up within 4 weeks of initiation of therapy (P < 0.01). Compliance could be improved by enhancing patient understanding, closer follow-up, and shorter therapy, particularly for those at lower risk of reactivation. As well, additional compliance enhancing interventions can be targeted to those patients with suboptimal compliance who can be accurately identified early in the course of therapy.

Factors associated with tuberculin reactivity among the foreign-born in Montreal

Because tuberculosis among the foreign-born is of increasing importance in North America, it has recently been recommended that newly arriving immigrants be tuberculin tested and preventive therapy given to all those with significant reactions. The factors affecting the prevalence of tuberculin reactions were assessed in a community-based tuberculin survey among foreign-born schoolchildren and young adults. Of 1,198 foreign-born who were tuberculin tested, 32.4% had significant tuberculin reactions. False-positive tuberculin reactions due to sensitivity to purified protein derivative (PPD)-B (for Mycobacterium avium) were uncommon and those due to BCG vaccination of importance only among immigrants from countries with low tuberculosis rates. Tuberculin reactions of 10+ mm were associated with tuberculosis rates in the country of origin (p less than or equal to 0.001), age when immigrated (p less than or equal to 0.001), bacillus Calmette-Guérin (BCG) vaccination (p less than or equal to 0.01), and residence in poorer neighborhoods in Montreal (p less than or equal to 0.001), but not with number of years resident in Canada. The booster phenomenon, seen in 16% of those undergoing two-step testing, was most strongly associated with prior BCG vaccination (p less than or equal to 0.001) and also with tuberculosis rates in the country of origin (p less than or equal to 0.08), age of immigration (p less than or equal to 0.01), and number of years resident in Canada (p less than or equal to 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bacille Calmette-Guérin vaccination on tuberculin reactivity

The effect on tuberculin reactivity of bacille Calmette-Guérin vaccination (BCG-V) given 10 to 25 yr earlier was measured among schoolchildren and young adults in Montreal. Of a total eligible population of 8,264 persons, 5,952 were tuberculin tested (72%). The BCG-V status could be verified for 4,629 of 4,969 (93%) participants born in Quebec. Of these, 1,511 (33%) had received BCG-V, 66% of whom had been vaccinated once only in infancy, 23% of whom had been vaccinated once but after infancy, and 11% of whom had been vaccinated twice. Among those vaccinated in infancy, 7.9% had significant tuberculin reactions, compared with 18% among those vaccinated between 1 and 5 yr of age, and 25.4% among those vaccinated after the age of 5 (p less than 0.001). Among those receiving BCG-V in infancy, the prevalence of tuberculin reactions of 10 mm was similar to the nonvaccinated subjects, after accounting for differences in age and socioeconomic status. Among those vaccinated after infancy, tuberculin reactivity was not significantly affected by interval from BCG-V until tuberculin testing nor by repeat BCG-V. We conclude that after an interval of 10 to 25 yr the most important determinant of effect of BCG-V on tuberculin reactivity is age when vaccinated. A significant tuberculin reaction among those who have received BCG-V should be interpreted in light of the age when vaccinated and the expected prevalence of tuberculous infection in the population tested.

Investigation of nosocomial prosthetic valve endocarditis due to antibiotic-resistant Staphylococcus epidermidis

A reservoir of antibiotic-resistant Staphylococcus epidermidis strains in our cardiac surgery unit appeared to be the source of organisms responsible for three cases of early prosthetic valve endocarditis. Staphylococcus epidermidis isolates recovered from the skin of 13 patients before and after surgery were compared. All were typed by plasmid profile, antimicrobial susceptibility and slime production. The three strains from early prosthetic valve endocarditis resembled the antibiotic-resistant nosocomial strains recovered from the skin of eight patients following surgery and the environment of the operating theatres. These strains expressed resistance to oxacillin, gentamicin, kanamycin and tobramycin and most produced slime, whereas those isolated from the skin of patients at the time of admission were predominantly susceptible to antibiotics and few produced slime.

The behavioural properties of CI-988, a selective cholecystokininB receptor antagonist

1. The behavioural effects of a selective cholecystokininB (CCKB) receptor antagonist CI-988 were investigated in rodents. 2. In three rodent tests of anxiety (rat elevated X-maze, rat social interaction test and mouse light/dark box) CI-988 over the dose range 0.001-10.0 mg kg-1, (i.p.) produced an anxiolytic-like action. The magnitude of this effect was similar to that of chlordiazepoxide (CDP). In contrast, the selective CCKA receptor antagonist, devazepide, was inactive. CI-988 also showed anxiolytic-like action in the rat conflict test but the magnitude of this effect was about 2.5 fold less than that of CDP. 3. Central but not peripheral administration of the selective CCKB receptor agonist, pentagastrin, like FG 7142, produced an anxiogenic-like action. 4. The pentagastrin-induced anxiety was dose-dependently antagonized by CI-988, whereas devazepide was inactive. However, ten times higher doses of CI-988 were required to block a similar action of FG 7142. 5. In contrast to CDP, CI-988 up to 3000 fold higher doses than those inducing anxiolysis was inactive in tests measuring sedation and ataxia. It also failed to antagonize pentylenetetrazol-induced tonic seizures. Furthermore, CI-988 did not interact with alcohol or barbiturates. Thus, CI-988 appears to be an anxioselective compound. 6. The anxiolytic-like action of CDP in the rat elevated X-maze was dose-dependently antagonized by flumazenil. In contrast, the benzodiazepine receptor antagonist failed to block a similar effect of CI-988. 7. Thus, CI-988 shows anxiolytic-like activity in several animal models of anxiety. The anxiolytic-like effect of CI-988 involves a novel mechanism of action, that is likely to be mediated by selective antagonism of the brain CCKB receptor. It is suggested that CI-988 should have a better side-effect profile in man than the benzodiazepines.

Thoracoscopy for the diagnosis of pleural disease

OBJECTIVE

To assess the accuracy and safety of thoracoscopy for the evaluation of pleural disease.

DESIGN

Prospective evaluation of patients referred for thoracoscopy.

SETTING

University hospital specializing in chest diseases.

PATIENTS

We studied 102 patients with pleural disease, the cause of which had not been determined after initial investigation, including thoracentesis and needle biopsy. Eighty-six patients had pleural effusion, 11 had pleural mass, and 5 had pleural effusion in association with a known primary lung carcinoma.

INTERVENTION

All patients had thoracoscopy under local anesthesia with mild sedation. Visually directed biopsies were done of parietal pleura.

MEASUREMENTS

We recorded clinical characteristics, laboratory data, findings and duration of thoracoscopy, and any complications associated with the procedure. Hospital and clinic follow-up records were reviewed, and patients were contacted by telephone 12 and 24 months after thoracoscopy to assess their health status.

MAIN RESULTS

One hundred and four thoracoscopies were done in 102 patients. A definitive diagnosis was established in 95 patients: 42 had malignant pleural disease and 53 had benign pleural disease. A diagnosis of benign pleural disease using thoracoscopy could not be confirmed in the remaining 7 patients because of insufficient follow-up information. Overall, thoracoscopy was 96% accurate with a sensitivity of 91%, a specificity of 100% and a negative predictive value of 93% for the diagnosis of pleural malignancy. Thoracoscopy was well tolerated under local anesthesia and entailed hospitalization for less than 24 hours in most cases. No deaths occurred, although 1.9% of patients had major complications, and 5.5% had minor complications.

CONCLUSIONS

Among patients with pleural disease remaining undiagnosed after usual initial investigation, thoracoscopy done under local anesthesia is a rapid, safe, and well-tolerated procedure with an excellent diagnostic yield that is equivalent to that of thoracotomy.

Longitudinal study of inmates of a prison for the psychiatrically disturbed: plasma concentrations of biogenic amine metabolites and amino acids

Plasma concentrations of eight large and neutral amino acids and 10 acidic metabolites of biogenic amines in seven inmates incarcerated in the Regional Psychiatric Centre (Praries), Correctional Service of Canada, were assessed each week day for 4 weeks (i.e., 20 samples each). Measures of central tendency and dispersion of the variables were calculated. The measures are distinctively different in their variability and their normality of distribution. The large and neutral amino acid (LNAA) measures are somewhat less variable, but also less likely to be normally distributed than most acid metabolites. Acid metabolites tend to show consistent interindividual differences that persist over time, with the notable exception of 5-hydroxyindoleacetic acid. LNAA measures tend to show differences across time but not between individuals. The distributional properties of LNAA measures are largely accounted for by the observation of a downward convergence of values of these variables over the 4 weeks of the study.

The discriminative stimulus properties of (+)-HA-966, an antagonist at the glycine/N-methyl-D-aspartate receptor

Using a two-lever operant drug discrimination paradigm, rats have been trained to discriminate between the administration of saline and R-(+)-HA-966 (R-(+)-3-amino-1-hydroxypyrrolid-2-one, 30 mg/kg i.p.) an antagonist at the glycine modulatory site on the N-methyl-D-aspartate (NMDA) receptor/ion channel complex. Drug-appropriate responding was not induced in stimulus generalisation experiments when the non-competitive NMDA receptor antagonist, phencyclidine (PCP, 1-8 mg/kg i.p.) was substituted for (+)-HA-966. Similarly, (+)-HA-966 (6-50 mg/kg i.p.) did not induce drug-appropriate responding in animals trained to discriminate PCP (3 mg/kg i.p.) from saline. The results suggest that the behavioural profile of compounds attenuating the actions of NMDA via blockade of the glycine modulatory site may be substantially different from those acting at the ion channel of the NMDA receptor complex.

Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure

The decision to institute MV in patients with COPD and ARF is difficult because the risk of complications is high and the long-term prognosis is poor. We reviewed our experience with 95 COPD patients with ARF requiring MV. Fifty-five patients required MV for more than two weeks, 72 were weaned successfully, and 59 died within one year of follow-up. Survival was associated with premorbid level of activity (p less than .001), FEV1 (p less than .01), serum albumin level (p less than .05), and severity of dyspnea (p less than .01). Cor pulmonale on ECG, premorbid hypercarbia, and history of left ventricular failure were also more common among those who died. Weaning from MV was associated with premorbid level of activity (p less than .001), FEV1 (p less than .001), albumin level (p less than .05), and negative inspiratory pressure (p less than .001) and respiratory rate during T-piece trial (p less than .01). The duration of intubation was associated only with premorbid level of activity (p less than .01). Predictive models for the weaning success and the one-year survival were developed.