Inhibition of αvβ5 Integrin Attenuates Vascular Permeability and Protects against Renal Ischemia-Reperfusion Injury

Ischemia-reperfusion injury (IRI) is a leading cause of AKI. This common clinical complication lacks effective therapies and can lead to the development of CKD. The αvβ5 integrin may have an important role in acute injury, including septic shock and acute lung injury. To examine its function in AKI, we utilized a specific function-blocking antibody to inhibit αvβ5 in a rat model of renal IRI. Pretreatment with this anti-αvβ5 antibody significantly reduced serum creatinine levels, diminished renal damage detected by histopathologic evaluation, and decreased levels of injury biomarkers. Notably, therapeutic treatment with the αvβ5 antibody 8 hours after IRI also provided protection from injury. Global gene expression profiling of post-ischemic kidneys showed that αvβ5 inhibition affected established injury markers and induced pathway alterations previously shown to be protective. Intravital imaging of post-ischemic kidneys revealed reduced vascular leak with αvβ5 antibody treatment. Immunostaining for αvβ5 in the kidney detected evident expression in perivascular cells, with negligible expression in the endothelium. Studies in a three-dimensional microfluidics system identified a pericyte-dependent role for αvβ5 in modulating vascular leak. Additional studies showed αvβ5 functions in the adhesion and migration of kidney pericytes in vitro Initial studies monitoring renal blood flow after IRI did not find significant effects with αvβ5 inhibition; however, future studies should explore the contribution of vasomotor effects. These studies identify a role for αvβ5 in modulating injury-induced renal vascular leak, possibly through effects on pericyte adhesion and migration, and reveal αvβ5 inhibition as a promising therapeutic strategy for AKI.

Transforming growth factor-β1 sustains the survival of Foxp3(+) regulatory cells during late phase of oropharyngeal candidiasis infection

As CD4(+)CD25(+)Foxp3(+) regulatory T cells (Tregs) play crucial immunomodulatory roles during infections, one key question is how these cells are controlled during antimicrobial immune responses. Mechanisms controlling their homeostasis are central to ensure efficient protection against pathogens, as well as to control infection-associated immunopathology. Here we studied how their viability is regulated in the context of mouse oropharyngeal candidiasis (OPC) infection, and found that these cells show increased protection from apoptosis during late phase of infection and reinfection. Tregs underwent reduced cell death because they are refractory to T cell receptor restimulation-induced cell death (RICD). We confirmed their resistance to RICD, using mouse and human Tregs in vitro, and by inducing α-CD3 antibody-mediated apoptosis in vivo. The enhanced viability is dependent on increased transforming growth factor-β1 (TGF-β1) signaling that results in upregulation of cFLIP (cellular FLICE (FADD-like IL-1β-converting enzyme)-inhibitory protein) in Tregs. Protection from cell death is abrogated in the absence of TGF-β1 signaling in Tregs during OPC infection. Taken together, our data unravel the previously unrecognized role of TGF-β1 in promoting Treg viability, coinciding with the pronounced immunomodulatory role of these cells during later phase of OPC infection, and possibly other mucosal infections.

JC Polyomavirus Abundance and Distribution in Progressive Multifocal Leukoencephalopathy (PML) Brain Tissue Implicates Myelin Sheath in Intracerebral Dissemination of Infection

Over half of adults are seropositive for JC polyomavirus (JCV), but rare individuals develop progressive multifocal leukoencephalopathy (PML), a demyelinating JCV infection of the central nervous system. Previously, PML was primarily seen in immunosuppressed patients with AIDS or certain cancers, but it has recently emerged as a drug safety issue through its association with diverse immunomodulatory therapies. To better understand the relationship between the JCV life cycle and PML pathology, we studied autopsy brain tissue from a 70-year-old psoriasis patient on the integrin alpha-L inhibitor efalizumab following a ~2 month clinical course of PML. Sequence analysis of lesional brain tissue identified PML-associated viral mutations in regulatory (non-coding control region) DNA, capsid protein VP1, and the regulatory agnoprotein, as well as 9 novel mutations in capsid protein VP2, indicating rampant viral evolution. Nine samples, including three gross PML lesions and normal-appearing adjacent tissues, were characterized by histopathology and subject to quantitative genomic, proteomic, and molecular localization analyses. We observed a striking correlation between the spatial extent of demyelination, axonal destruction, and dispersion of JCV along white matter myelin sheath. Our observations in this case, as well as in a case of PML-like disease in an immunocompromised rhesus macaque, suggest that long-range spread of polyomavirus and axonal destruction in PML might involve extracellular association between virus and the white matter myelin sheath.

Small molecule mediated inhibition of RORγ-dependent gene expression and autoimmune disease pathology in vivo

Retinoic acid receptor-related orphan nuclear receptor γ (RORγ) orchestrates a pro-inflammatory gene expression programme in multiple lymphocyte lineages including T helper type 17 (Th17) cells, γδ T cells, innate lymphoid cells and lymphoid tissue inducer cells. There is compelling evidence that RORγ-expressing cells are relevant targets for therapeutic intervention in the treatment of autoimmune and inflammatory diseases. Unlike Th17 cells, where RORγ expression is induced under specific pro-inflammatory conditions, γδ T cells and other innate-like immune cells express RORγ in the steady state. Small molecule mediated disruption of RORγ function in cells with pre-existing RORγ transcriptional complexes represents a significant and challenging pharmacological hurdle. We present data demonstrating that a novel, selective and potent small molecule RORγ inhibitor can block the RORγ-dependent gene expression programme in both Th17 cells and RORγ-expressing γδ T cells as well as a disease-relevant subset of human RORγ-expressing memory T cells. Importantly, systemic administration of this inhibitor in vivo limits pathology in an innate lymphocyte-driven mouse model of psoriasis.

Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009–2011

Diagnoses of Shigella flexneri in the United Kingdom (UK) are usually travel-related. However, since 2009, there has been an overall increase in UK-acquired cases. The Health Protection Agency has been investigating a national outbreak of S. flexneri detected in 2011 and which is still ongoing. Cases occurred mostly in men who have sex with men and were of serotype 3a. The investigation aimed at obtaining epidemiological data to inform targeted outbreak management and control.

Ongoing outbreak of Shigella flexneri serotype 3a in men who have sex with men in England and Wales, data from 2009-2011

Diagnoses of Shigella flexneri in the United Kingdom (UK) are usually travel-related. However, since 2009, there has been an overall increase in UK-acquired cases. The Health Protection Agency has been investigating a national outbreak of S. flexneri detected in 2011 and which is still ongoing. Cases occurred mostly in men who have sex with men and were of serotype 3a. The investigation aimed at obtaining epidemiological data to inform targeted outbreak management and control.

The Use of Immunohistochemistry for Biomarker Assessment—Can It Compete with Other Technologies?

A morphology-based assay such as immunohistochemistry (IHC) should be a highly effective means to define the expression of a target molecule of interest, especially if the target is a protein. However, over the past decade, IHC as a platform for biomarkers has been challenged by more quantitative molecular assays with reference standards but that lack morphologic context. For IHC to be considered a “top-tier” biomarker assay, it must provide truly quantitative data on par with non-morphologic assays, which means it needs to be run with reference standards. However, creating such standards for IHC will require optimizing all aspects of tissue collection, fixation, section thickness, morphologic criteria for assessment, staining processes, digitization of images, and image analysis. This will also require anatomic pathology to evolve from a discipline that is descriptive to one that is quantitative. A major step in this transformation will be replacing traditional ocular microscopes with computer monitors and whole slide images, for without digitization, there can be no accurate quantitation; without quantitation, there can be no standardization; and without standardization, the value of morphology-based IHC assays will not be realized.

A foodborne outbreak of Salmonella Bareilly in the United Kingdom, 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

The theory of planned behavior and binge drinking: assessing the impact of binge drinker prototypes

The present study assessed the value of including prototype perceptions within the theory of planned behavior (TPB) when predicting young people's binge drinking intentions and behavior. Undergraduate students (N=94) completed questionnaires assessing the main constructs of the TPB as well as measures of prototype evaluation and prototype similarity. Binge drinking behavior was assessed at one-week follow-up (N=79). The TPB explained 58% of the variance in binge drinking intentions and 22% of the variance in binge drinking at one-week follow-up. The prototype perception measures explained additional variance in both binge drinking intentions (DeltaR(2)=.04) and behavior (DeltaR(2)=.09), although only prototype similarity emerged as a significant predictor. In addition, a significant interaction was found between prototype similarity and subjective norm in relation to the prediction of binge drinking behavior, suggesting that the perception of supportive norms may enhance the impact of prototype perceptions on health-risk behavior. The implications of the findings for interventions to encourage more appropriate drinking behavior are outlined.

Flu vaccination in nursing homes: a survey of nursing-home managers

BACKGROUND

This article describes the findings of a survey of nursing-home managers in the Sefton area of Merseyside about flu vaccination in their nursing homes during the 2002/2003 flu vaccination campaign. This followed concerns expressed that significant numbers of nursing-home residents may not have been offered the vaccine during the annual campaign.

METHODS

A survey of all nursing homes in Sefton carried out in April 2003.

RESULTS

Forty-three nursing homes participated in the study. Survey results showed considerable variation in practice with regard to the organization of flu vaccination and consequently considerable variation in the outcomes achieved with regard to the number of residents vaccinated. Residents are more likely to be offered vaccination in some homes than others. The size of the home and the number of qualified staff may be influential. Some homes report uncertainty related to the issues of consent and anaphylaxis and problems obtaining vaccine prescriptions. However, attitudes of nursing-home managers may also be important.

Latitudinal variation in the prevalence of multiple sclerosis in Ireland, an effect of genetic diversity

BACKGROUND

Northern Ireland has a high and rising prevalence rate of multiple sclerosis (MS). The most recent survey in 1996 found a rate of 168.7/100 000. Recorded prevalence rates for the south of Ireland, including County Wexford, have been markedly lower and seemed to suggest the existence of a prevalence gradient within the island.

OBJECTIVES

To compare the prevalence of multiple sclerosis in Co. Wexford in the south east of Ireland and Co. Donegal in the north west, and to establish whether a variation in prevalence of MS exists within Ireland.

METHODS

Patients were referred from multiple sources. Review of clinical case records and/or patient examination confirmed the diagnosis.

RESULTS

In Co. Wexford, 126 patients were found to have clinically definite or probable multiple sclerosis with a prevalence rate of 120.7/100 000 (95% confidence intervals (CI) 100.6 to 143.8), which is similar to other areas of similar latitude within the British Isles. In Co. Donegal, 240 people had clinically definite or probable MS with a prevalence rate of 184.6/100 000 (95% CI 162.0 to 209.5). The difference in prevalence rates is statistically significant (Z = 3.94, p = <0.001).

CONCLUSION

There is a latitudinal variation in the prevalence rate of MS between the north and the south of Ireland. The increased prevalence of MS seen in Co. Wexford is likely to represent better case ascertainment and improved diagnostic accuracy rather than an actual increase in prevalence. The north/south variation in prevalence may represent a variation in the genetic predisposition to MS between the background populations of the two counties.

Opioid switching to improve pain relief and drug tolerability

BACKGROUND

Patients with cancer, and increasingly chronic non-cancer pain frequently require strong opioids for pain relief. Morphine is the first-line strong opioid of choice for these patients. While most achieve adequate analgesia with morphine, a significant minority either suffer intolerable side-effects, inadequate pain relief, or both. For these patients switching to an alternative opioid is becoming established clinical practice. However, the evidence for the effectiveness of opioid switching does not appear to be established.

OBJECTIVES

The aim of this review was to investigate the usefulness of opioid switching for patients with pain.

SEARCH STRATEGY

Randomised trials that assessed opioid rotation, switching, or substitution in adults or children with acute or chronic pain were sought through electronic databases and by handsearching relevant journals. Date of the most recent search: January 2003.

SELECTION CRITERIA

The search strategy retrieved no randomised controlled trials, and therefore no studies were available to enable a quantitative synthesis that would assess the effectiveness of the strategy of opioid switching.

DATA COLLECTION AND ANALYSIS

Given the lack of RCTs, the review examined all case reports, uncontrolled, and retrospective studies in an attempt to determine the current level of evidence.

MAIN RESULTS

Fifty-two reports were identified, comprising 23 case reports, 15 retrospective studies/audits and 14 prospective uncontrolled studies. The majority of the reports used morphine as first-line opioid and the most frequently used second-line opioid was methadone. All reports, apart from one, concluded that opioid switching is a useful clinical manoeuvre for improving pain control and/or reducing opioid-related side-effects.

REVIEWERS' CONCLUSIONS

For patients with inadequate pain relief and intolerable opioid-related toxicity/adverse effects, a switch to an alternative opioid may be the only option for symptomatic relief. However, the evidence to support the practice of opioid switching is largely anecdotal or based on observational and uncontrolled studies. Randomised trials, including 'N of 1' studies, where a patient acts as their own control, are needed: firstly, to establish the true effectiveness of this clinical practice; secondly, to determine which opioid should be used first-line or second-line; and thirdly, to standardise conversion ratios when switching from one opioid to another.

Biotechnology-based odour control: design criteria and performance data

As neighbouring areas continue to encroach upon wastewater treatment plants, there is an increasing need for odour control to mitigate potential negative offsite odorous impacts. One technology that is gaining widespread acceptance is biotechnology, which utilises the inherent ability of certain microorganisms to biodegrade offensive odorous compounds. Two main advantages of this form of treatment over other odour control technologies include the absence of hazardous chemicals and relatively low operation and maintenance requirements. The purpose of this paper is to provide information related to odour control design criteria used in sizing/selecting biotechnology-based odour control technologies, and to provide odour removal performance data obtained from several different biotechnology-based odour control systems. CH2M HILL has collected biotechnology-based odour control performance data over the last several years in order to track the continued performance of various biofilters and biotowers over time. Specifically, odour removal performance data have been collected from soil-, organic- and inorganic-media biofilters and inert inorganic media biotowers. Results indicate that biotechnology-based odour control is a viable and consistent technology capable of achieving high removal performance for odour and hydrogen sulphide. It is anticipated that the information presented in this paper will be of interest to anyone involved with odour control technology evaluation/selection or design review.

Modelling to assist in wastewater collection system odour and corrosion potential evaluations

Odour emissions and corrosion concerns can be a constant focus for many wastewater treatment and collection system owners, usually from the first day that their collection systems begin operation. Many sewer systems are reaching the end of their useful life, or have experienced either odour or corrosion issues. This paper shows a link between odour generation and corrosion potential, and how modelling can be used to assist in odour/corrosion assessments of existing wastewater collection systems. A model has been developed that is capable of predicting liquid-phase sulphide generation and subsequent release to overlying sewer headspace as hydrogen sulphide (H2S), where it can be the source of either odour or corrosion problems. This paper presents an overview of the model, and uses a case study involving both odour and corrosion issues to demonstrate the utility in modelling. The model was used to identify potential locations within the system where odour/corrosion may be problematic, as well as assisting in the evaluation of potential odour control alternatives.

Role for microphthalmia transcription factor in the diagnosis of metastatic malignant melanoma

Microphthalmia transcription factor (Mitf), a protein critical for the embryonic development and postnatal viability of melanocytes, is a master lineage regulator and modulates extracellular signals. Recently, an anti-Mitf antibody, D5, was shown to be both a sensitive and a specific marker of epithelioid melanoma. Those data suggested that Mitf expression was specific for melanocytic differentiation because it was not detected in six different carcinoma types. To broaden the spectrum of melanomatous and nonmelanomatous tumors tested with this antibody, the authors investigated the sensitivity and specificity of the D5 anti-Mitf antibody in 36 metastatic melanomas and 102 nonmelanomatous tumors. Twenty-nine of 36 (81%) melanomas examined were reactive for D5. Of these, 29 of 32 (91%) epithelioid melanomas were reactive, whereas all 4 melanomas with spindle cell morphology were nonreactive. Six of 102 (5.8%) nonmelanomatous tumors (1 breast carcinoma, 1 malignant mixed mullerian tumor, 2 renal cell carcinomas, and 2 leiomyosarcomas) were reactive for D5. All melanomas were reactive for S-100 protein (a criteria for inclusion in the study), whereas 8 of 102 (7.8%) of nonmelanomatous tumors were reactive. Twenty-five of 36 melanomas (69%) were reactive for HMB-45, whereas no nonmelanomatous tumors were reactive. Twenty-one of 28 (75%) melanomas were reactive for Melan-A. Reactivity for Melan-A was detected in 5 of 102 (4.9%) nonmelanomatous tumors. As with D5, HMB-45 and Melan-A failed to detect all spindle-cell melanomas. Results of this study confirm that D5 is a sensitive marker for epithelioid melanomas; however, the authors found D5 neither quite as sensitive nor quite as specific as in previous studies. Nevertheless, the authors believe that positive staining for D5 when taken in clinical, histologic, and immunohistochemical context may be diagnostically useful. In particular, D5 is helpful in the evaluation of epithelioid neoplasms, but not spindle-cell tumors.

Hydromorphone for acute and chronic pain

BACKGROUND

While morphine is the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable morphine-related toxicity. For these patients alternatives such as hydromorphone are recommended. However, there appear to be gaps in our understanding of the efficacy and potency of hydromorphone.

OBJECTIVES

This review explores and assesses the evidence for the efficacy of hydromorphone in the management of pain.

SEARCH STRATEGY

Randomised trials which included hydromorphone were sought using electronic databases and by handsearching relevant journals. Date of the most recent search: February 2000.

SELECTION CRITERIA

RCTs which involved the administration of hydromorphone, for both acute and chronic pain conditions, in adults and children, were included.

DATA COLLECTION AND ANALYSIS

A data extraction form was designed for the purpose of the review. The validity of each trial for inclusion was assessed using criteria described in the Cochrane Handbook. A grade was allocated to each study on the basis of allocation concealment. A checklist was used to assess blinding.

MAIN RESULTS

Forty three studies (2725 subjects) were included in the review. Approximately half of these studies received a low quality score. In addition, the heterogeneity of the studies precluded combination of data and results. A meta-analysis was therefore not possible. Of the 43 included studies, 11 (645 subjects) involved chronic pain conditions (all cancer) and 32 (2080 subjects) acute pain. Three studies were placebo-controlled. Of the remainder, hydromorphone was compared with other opioids (morphine, fentanyl, sufentanyl, meperidine, oxycodone, diamorphine), bupivicaine and with itself, using different formulations. The routes of administration included intravenous, oral, spinal, intramuscular and subcutaneous. Overall, hydromorphone appears to be a potent analgesic. The limited number of studies available suggest that there is little difference between morphine and hydromorphone in terms of analgesic efficacy, adverse effect profile and patient preference. However, as most studies involved small numbers of patients, it is difficult to determine real differences between both drugs. In the context of both acute and chronic pain, the issue of equi-analgesic ratios between morphine and hydromorphone was not resolved.

REVIEWER'S CONCLUSIONS

The studies included in this review were varied in terms of quality and methodology. However, the majority demonstrated that hydromorphone is a potent analgesic, that the clinical effects of hydromorphone appear to be dose-related, and that the adverse effect profile of hydromorphone is similar to that of other mu opioid receptor agonists.

Microphthalmia transcription factor: not a sensitive or specific marker for the diagnosis of desmoplastic melanoma and spindle cell (non-desmoplastic) melanoma

Microphthalmia transcription factor (Mitf), a melanocytic nuclear protein critical for the embryonic development and postnatal viability of melanocytes, is a master lineage regulator and modulates extracellular signals. Recently, Mitf expression was shown to be both a sensitive and specific marker of epithelioid melanoma. Because loss of specific melanocytic markers in melanomas with spindle cell morphology is more common compared with those tumors with epithelioid morphology, we investigated the sensitivity of D5, an anti-Mitf antibody, for diagnosis in this diagnostically problematic subset of melanomas. Twenty of 21 (95%) spindle cell and desmoplastic melanomas examined were reactive for S-100 protein. Only 4 of 21 (19%) spindle cell and desmoplastic melanomas were reactive for HMB-45. Six of 21 tumors (29%) were reactive for D5, including one case that was non-reactive for S-100 and HMB-45. Melan-A reactivity was seen in 2 of 13 cases (15%) studied. Eight of 24 (33%) non-melanocytic spindle cell tumors were reactive for D5, including 4 of 6 dermatofibromas, 1 of 6 schwannomas, 1 of 2 leiomyomas, and 2 of 6 leiomyosarcomas. Although D5 was shown in a previous study to be a highly sensitive and specific marker for epithelioid melanomas, the results of this study show it is not a sensitive or specific marker of spindle cell and desmoplastic melanomas. Nevertheless, we believe that diffuse positive staining for D5 when taken in clinical, histologic and immunohistochemical context may be diagnostically useful in selected cases of melanoma.

Clear cell sarcoma shows immunoreactivity for microphthalmia transcription factor: further evidence for melanocytic differentiation

Microphthalmia transcription factor, a melanocytic nuclear protein critical for the embryonic development and postnatal viability of melanocytes, is a master regulator in modulating extracellular signals. Recently, microphthalmia transcription factor expression was shown to be both a sensitive and specific marker of epithelioid melanoma. We investigated the sensitivity of D5, an anti-microphthalmia transcription factor antibody, for diagnosis of clear cell sarcoma (also known as malignant melanoma of soft parts). Immunoreactivity in a nuclear pattern for D5 was present in 8 of 12 (75%) tumors. D5 staining was strong in three tumors, moderate in two, and weak in three. S-100 protein expression was seen in all 12 cases that had clear cell sarcoma examined. HMB-45 staining was seen in 11 of 12 (92%) tumors. Focal Melan-A positivity was seen in 3 of 7 (43%) tumors. Although D5 was shown in a previous study to be a highly sensitive and specific marker for epithelioid melanomas, the results of this study expand the spectrum of tumors showing immunoreactivity for D5. D5 immunoreactivity in clear cell sarcoma provides further evidence for melanocytic differentiation in this unusual tumor.

The human VASA gene is specifically expressed in the germ cell lineage

To understand the origins and function of the human germ cell lineage and to identify germ cell-specific markers we have isolated a human ortholog of the Drosophila gene vasa. The gene was mapped to human chromosome 5q (near the centromere) by radiation hybrid mapping. We show by Northern analysis of fetal and adult tissues that expression of the human VASA gene is restricted to the ovary and testis and is undetectable in somatic tissues. We generated polyclonal antibodies that bind to the VASA protein in formalin-fixed, paraffin-embedded tissue and characterized VASA protein expression in human germ cells at various stages of development. The VASA protein is cytoplasmic and expressed in migratory primordial germ cells in the region of the gonadal ridge. VASA protein is present in fetal and adult gonadal germ cells in both males and females and is most abundant in spermatocytes and mature oocytes. The gene we have isolated is thus a highly specific marker of germ cells and should be useful for studies of human germ cell determination and function.

Survey of raw egg use by home caterers

Outbreaks of egg related salmonella infection continue to occur despite over ten years of national guidance on this subject. Fifty-four out of 70 registered home caterers in Cheshire responded to a telephone questionnaire, which revealed that a sixth prepared raw egg dishes containing shell eggs, none used pasteurised egg, and advice about storage of eggs and handwashing was not always followed. A postal questionnaire sent to 13 wholesalers and major supermarket chains showed that pasteurised egg was available in large packs from wholesalers but not from supermarkets. It is time to consider new approaches to reinforce advice about pasteurised egg use for raw egg dishes, storage, and measures to prevent cross contamination. These findings have implications for the training of home caterers and the general public.

Investigation of an outbreak of cryptosporidiosis associated with treated surface water finds limits to the value of case control studies

Fifty-two cases of cryptosporidiosis satisfied the case definition employed in investigation of an outbreak in Spring 1996 among residents of the Wirral peninsula supplied by a single water treatment plant using river water. The attack rate among those whose water was supplied solely from the plant was 1.42 per 10,000, compared with 0.42/10,000 among those having some but less than 50% supplied from it. Single oocysts were detected in treated water from this plant on four occasions during the investigation. A case control study did not demonstrate a significant association between illness and water consumption and no obvious failure in water treatment procedures occurred during the relevant period. Nevertheless, according to PHLS criteria, this outbreak was strongly associated with water, as the descriptive epidemiology was consistent and oocysts were detected, albeit in small numbers, in treated water. This paper discusses the value of detection of oocysts and case control studies in investigating waterborne outbreaks of cryptosporidiosis. Populations that normally drink surface water, particularly river water, are thought to be exposed repeatedly to cryptosporidium oocysts and so develop some protective immunity. Case control studies are therefore likely to have less power in the investigation of outbreaks in localities where the population normally drink treated surface water. Although oocysts are often isolated from treated surface waters without being associated with obvious disease in the population, their detection should still be considered in assessing the strength of association of waterborne outbreaks.

Use of self-collected vaginal specimens for detection of Chlamydia trachomatis infection

OBJECTIVE

To evaluate the efficacy of a self-collected vaginal introital specimen, obtained by women using only an instruction booklet as a guide, for the detection of Chlamydia trachomatis using polymerase chain reaction (PCR).

METHODS

Comparison analysis in an Urban hospital clinic, using a convenience sample of 101 women undergoing screening or treatment for C trachomatis infection. Subjects were given an illustrated instruction booklet and were asked to collect a single specimen from the vaginal introitus using the Amplicor collection kit. Cervical and introital specimens then were obtained by clinicians. The presence of C trachomatis in patient-collected versus clinician-collected samples was determined by PCR. Discordant specimens were retested by PCR, using primer pairs to the C trachomatis major outer membrane protein gene, and were screened for the presence of PCR assay inhibitors.

RESULTS

Ninety-nine subjects completed the self-collection. Sixty-two percent were adolescents and 17% spoke English as their second language. Forty-three percent had never used tampons, and 36% had never looked at their own genitals. Twenty-eight cervical specimens (28%), 32 clinician-collected introital specimens (32%), and 33 self-collected introital specimens (33%) were positive for C trachomatis infection. All clinician-collected introital specimens that were positive for C trachomatis and all cervical specimens that were positive for C trachomatis were positive on self-test. Compared with clinician-collected introital specimens, self-collected specimens had a sensitivity of 100% and a specificity of 98.5%. Compared with cervical specimens, self-collected specimens had a sensitivity of 100% and a specificity of 93.4%. After discrepant analysis, self-test had a sensitivity of 100% and a specificity of 94.6% for detection of C trachomatis cervical infection.

CONCLUSION

Self-collection of introital samples is both sensitive and specific in screening for C trachomatis.

Investigation of tuberculosis in an adolescent. The Outbreak Control Team

In February 1996, sputum smear positive tuberculosis was diagnosed in an adolescent white girl born in the United Kingdom. The investigation was complex because the index case had attended two schools and had a large extended family. The extent of transmission was consistent with "adult" pulmonary disease; eight previously unvaccinated contacts showed evidence of infection: one had proven tuberculosis, four had pulmonary radiological changes and positive Heaf test results, and three had positive Heaf test results. Seven of the eight were family/ household contacts, the eighth was a school contact. Current guidelines for the management of tuberculosis in schools were followed in this investigation and it was concluded that they remain appropriate. The source of infection for the index case was not definitely established. It may have been an adult who presented with active tuberculosis in 1994. The index case had erythema nodosum with a normal chest radiograph in 1993.

A one-year prospective audit of an asthma education programme in an out-patient setting

A prospective randomised trial was performed to evaluate the effectiveness of an asthma education programme administered by an asthma nurse specialist in an out-patient setting. Sixty asthmatic patients (mean age 28.5 years) were enrolled, 30 to a usual care control group and 30 to an education group. The education group underwent an individual education programme lasting at least one hour. The following variables were measured at baseline, one month after the education programme and at one year follow-up: asthma knowledge by MCQ (36 point questionnaire), inhaler technique (7 point scale), peak expiratory flow rate (PEFR) and symptomatology by visual analogue score (0 to 10 score). The education group's inhaler technique and MCQ score both improved significantly at one month, from 5.4 (0.3) (mean [SEM]) to 6.5 (0.3), p < 0.001, and from 7.5 (2.4) to 22 (1.8), p < 0.0001 respectively. Both of these improvements were significantly greater than in the control group, and both were maintained at one year follow-up. The symptom score improved over one year in the education group, from 5.4 (0.6) to 7.6 (0.5), p < 0.05, and was unchanged in the control group. There was no change in the PEFR in either group. This study shows clear objective benefits to an out-patient asthma education programme conducted by an asthma nurse specialist.

Unsuspected self-poisoning with flecainide and alcohol

The death of a 23-year-old man by suicidal flecainide and alcohol poisoning is reported. Flecainide was identified by ultraviolet (UV) spectrophotometry and gas chromatography-mass spectrometry (GC-MS). Flecainide levels, quantitated by high performance liquid chromatography (HPLC) with UV detection were: femoral blood 7.3 mg/L, urine 117 mg/L, stomach contents 19 mg and liver 302 mg/kg. Ethanol levels in femoral blood, urine and vitreous humor were 107, 136 and 113 mg%, respectively. The importance of carefully considering all the available pathological and toxicological data, together with the past medical history and circumstances surrounding the death in poisoning cases is emphasized.

Outcome of an exercise to notify patients treated by an obstetrician/gynaecologist infected with HIV-1

Experience with hepatitis B suggests that the risk of HIV transmission from a health care worker infected with HIV to a patient will be greatest during major surgical procedures. The number of patients worldwide who are known to have undergone such procedures, been notified, and subsequently tested is still too small to be confident that the risk of HIV transmission in these circumstances is negligible. We describe a patient notification exercise, undertaken in the United Kingdom in 1991. Attempts were made to contact 1217 patients, in three health districts (A, B, and C), who had undergone surgical procedures performed by an obstetrician/gynaecologist who was infected with HIV. The exercise aimed to offer the patients reassurance, counselling and--if they wished--HIV testing. One thousand one hundred and forty-two patients (94%) were contacted, and all 520 who elected to be tested were negative for anti-HIV. The proportion of identified patients tested was 63% in district A, 35% in district B, and 61% in district C. Surgical procedures were classified retrospectively according to the likely risk (none, possible, or high) of exposure to the doctor's blood and, therefore, risk of HIV transmission. One hundred and ninety-five of those tested had undergone a procedure that carried a high risk of exposure; 179 had undergone a procedure thought to carry no risk. Patients in districts A and C who had undergone a procedure that carried a high risk of exposure were more likely to be tested than those who had not; 206 patients overall had undergone procedures that carried a high risk of exposure but were not subsequently tested.(ABSTRACT TRUNCATED AT 250 WORDS)

Postmortem changes in blood amitriptyline concentration

Detailed toxicological studies were undertaken on two suicides by amitriptyline overdose, one with salicylate also. In the first case, 10 initial blood samples taken 21 h after body discovery and an estimated 28 1/2 h after overdose had drug concentration (mg/L) ranges of 2.5-12 for amitriptyline (AM), 0.7-3.1 for nortriptyline (NOR), and 81-244 for salicylate (SAL). Ten blood samples taken 42 h later showed corresponding ranges of 1-39 AM, 0.6-7.0 NOR, and 86-310 SAL. Sample haemoglobin concentrations (range, 8.7-23.5 g/dl) did not correlate with drug concentrations. Postmortem increase in pulmonary vein AM concentration occurred more rapidly than in the pulmonary artery, likely reflecting relative ease of diffusion across the vessel walls from lung (AM, 60 mg/kg). In nine tissue samples, drug concentrations (mg/kg) were highest in the liver: AM, 301; and SAL, 670. Considerable drug residue was present in gastric contents, duodenal contents, and seven sequential small bowel contents. In both cases, sanguineous putrefactive pleural fluid showed higher AM concentrations on the left than on the right (2.0 vs 1.4 and 23 vs 16), likely reflecting diffusion from gastric drug residue. The detailed case data illustrate the intensity and complexity of postmortem drug diffusion from reservoirs in solid organs, such as the lungs, and unabsorbed gastric residue, into the blood and putrefactive fluids.

An outbreak of measles in Trafford

In the autumn of 1993 an outbreak of measles occurred in Trafford, Greater Manchester, associated with two junior schools. Thirty-four cases were reported. Twenty-five of the 32 cases whose ages were known were aged between 7 and 11 years. The mean age was 8.6 years, and the median and modal age was 10. Two of the cases had received measles vaccine. Eighteen of the 19 cases who provided samples were confirmed as measles by laboratory tests. The incident showed that extensive resources are needed to investigate such outbreaks and implement control measures, and identified problems with the local child health computer system. The outbreak did, however, provide an opportunity to immunise children within the district who had not previously received measles vaccine. It is important for unprotected siblings of affected children to be vaccinated to prevent the secondary spread of infection, and all cases of measles should be notified promptly so that outbreaks can be identified.

Haemophilus influenzae type b disease in north-west England

A study was made in the north-west of England during 1989 in order to ascertain the incidence of serious Haemophilus influenzae infection, its short-term morbidity and certain characteristics of treatment. The incidence of culture-proven infection was 28 per 100,000 children under 5 years of age. Case fatality was 3%, one of the deaths being in a 6-year-old child. Some of the information obtained will help to assess the cost-effectiveness of the new vaccine to be administered to children in the U.K. The mean length of stay in hospital for all cases was 10 days. Of a total of 87 patients, 20 (23%) were admitted to an intensive therapy unit while five were transferred from a district general hospital to a regional paediatric unit. The estimated average cost per episode of acute care was 2700 pounds. Antibiotic regimens varied considerably.

An outbreak of gastro-intestinal illness caused by eggs containing Salmonella enteritidis phage type 4

Seven of nine people developed gastro-intestinal symptoms between 18 and 27 h after eating a trifle with a topping containing raw eggs. Salmonella enteritidis Phage Type (PT) 4 was isolated both from the faeces of affected persons and from eggs remaining in the same box as those used to prepare the topping. The findings show that eggs being produced and sold in the U.K. still contain S. enteritidis PT4 and that this is continuing to cause human infection.

The action approach. Integrating a community's needs into the corporate planning process

With the city of Detroit in turmoil, Mercy Hospitals and Health Services of Detroit (MHHSD) is trying to assimilate the community's unmet needs into the corporate planning process. Through the Community Assessment of Human Needs process, MHHSD identified the needs of the poor in three of Michigan's most impoverished areas. On the basis of these findings, MHHSD collaborated with the Poverty and Social Reform Institute to form the East Side Initiative, a community planning effort to address the community's unmet needs. An advisory group was established to oversee the East Side Initiative's planning process. The East Side Initiative participants met as one group and in smaller groups to focus on specific needs in the areas of healthcare, crime prevention, substance abuse, education, housing, economic development, and family (social) supports. The proposed action plans of each small group have received approval. In the second phase of the East Side Initiative participants will attempt to obtain the necessary resources to implement the groups' proposed actions.