The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke.

OBJECTIVE: To investigate the sensitivity of three commonly used functional outcome measures to detect change over time in subjects receiving inpatient rehabilitation post stroke. DESIGN: Subjects were assessed within one week of admission and one week of discharge from an inpatient rehabilitation facility. Several parameters of sensitivity were calculated, including floor and ceiling effects, the percentage of subjects showing no change and the effect size of the change between admission and discharge. SETTING: The medical rehabilitation ward of an inpatient rehabilitation facility. SUBJECTS: Seventy-eight subjects receiving inpatient rehabilitation following a first or recurrent stroke. MEASURES: Five-metre walk, comfortable pace (gait speed), the Berg Balance Scale and the Motor Assessment Scale. RESULTS: Sixty-one subjects had complete admission and discharge data. Gait speed and the Berg Balance Scale were both sensitive to change and demonstrated large effect sizes. The Motor Assessment Scale item five also showed a large effect size and was able to detect change amongst lower functioning subjects. The other items of the Motor Assessment Scale were less useful, in particular, the effect sizes for upper extremity change scores were small (d=0.36-0.5) and the majority of subjects (44.3-63.9%) showed no change over time on these measures. CONCLUSION: Gait speed, the Berg Balance Scale and the Motor Assessment Scale item five were sensitive to change over time in this sample.

Immunological response to Vibrio cholerae O1 infection and an oral cholera vaccine among Peruvians.

A 'double-blind', randomized, placebo controlled study of an oral inactivated whole cell plus recombinant B subunit (WC/rBS) cholera vaccine was conducted during February-March 1992 in Peru in 346 military recruits, 307 (89%) of whom received 2 oral doses of vaccine or Escherichia coli K12 placebo, 2 weeks apart. Paired serum samples were obtained from 155 (50%) of the recipients of 2 doses. An epidemic of cholera took place between doses. No difference in cholera attack rates was detected between vaccine and placebo recipients after one dose (8% versus 14%). Seroconversion (4-fold or higher increase in vibriocidal antibody titres) was detected in 90% and 80% of vaccine and placebo recipients, respectively, with low pre-existing vibriocidal titres (< 0.01). The anti-cholera toxin seroconversion rate among those with low pre-existing titres was higher in vaccinated subjects (97%) than in placebo recipients (68%) (P < 0.01). Administration of 2 doses of WC/rBS vaccine concomitantly with natural V. cholerae O1 infection enhanced the serum anti-cholera toxin response. The immune response to the whole cell component of the vaccine was reduced by high pre-existing vibriocidal antibody titres.

Diarrheal disease in Peru after the introduction of cholera.

Surveillance was conducted one day each week from December 1992 through May 1993 to determine the clinical features and etiology of diarrhea among a population in a suburban community of Lima, Peru. Patients who had had three or more loose stools during the previous 24 hr were enrolled at a clinic located in the community or at a nearby regional hospital. A total of 143 cases of diarrhea were detected for an overall rate of 7.1 cases per 1,000 population. The enteropathogens isolated were Vibrio cholerae 01 (31%), enterotoxigenic Escherichia coli (22%), and Salmonella, Shigella, Campylobacter, and Aeromonas species (10%). Specimens from the remaining cases were negative for enteropathogens. All isolates of V. cholerae were susceptible to tetracycline, doxycycline, nalidixic acid, norfloxacin, trimethoprim-sulfamethoxazole, trimethoprim, gentamicin, chloramphenicol, and cephalothin. Cases of diarrhea associated with V. cholerae were more common among adults, and more likely to experience severe dehydration and require hospitalization than the non-cholera cases. Data indicated that among the cases diagnosed, V. cholerae and enterotoxigenic E. coli were the more common causes of diarrhea in a suburban community of Lima during the summer season.

Proposal of Afipia gen. nov., with Afipia felis sp. nov. (formerly the cat scratch disease bacillus), Afipia clevelandensis sp. nov. (formerly the Cleveland Clinic Foundation strain), Afipia broomeae sp. nov., and three unnamed genospecies.

On the basis of phenotypic characterization and DNA relatedness determinations, the genus Afipia gen. nov., which contains six species, is described. The type species is Afipia felis sp. nov. (the cat scratch disease bacillus). Afipia clevelandensis sp. nov., Afipia broomeae sp. nov., and three unnamed not associated with cat-borne disease. All but one strain (Afipia genospecies 3) were isolated from human wound and respiratory sources. All Afipia species are gram-negative, oxidase-positive, nonfermentative rods in the alpha-2 subgroup of the class Proteobacteria. They are motile by means of a single flagellum. They grow on buffered charcoal-yeast extract agar and nutrient broth, but rarely on MacConkey agar, at 25 and 30 degrees C. They are urease positive; but they are negative in reactions for hemolysis, indole production, H2S production (triple sugar iron agar), gelatin hydrolysis, esculin hydrolysis, and peptonization of litmus milk. They do not produce acid oxidatively from D-glucose, lactose, maltose, or sucrose. The major cell wall fatty acids are 11-methyloctadec-12-enoic (CBr19:1), cis-octadec-11-enoic (C18:1omega7c), and generally, 9,10-methylenehexadecanote and 11,12-methyleneoctadecanoate; and there are only trace amounts of hydroxy acids. The guanineplus-cytosine content is 61.5 to 69 mol%. A. felis is positive for nitrate reduction and is delayed positive for acid production from D-xylose, but it is catalase negative. A. clevelandensis is negative in all of these tests. A. broomeae is weakly positive for catalase production and acid production from D-xylose, but it is negative for nitrate reduction.

Fatal adenovirus pneumonia in a newborn identified by electron microscopy and in situ hybridization.

A male infant born at 25 weeks' gestation died at 2 weeks of age from progressive respiratory insufficiency, metabolic acidosis, and renal failure. Autopsy revealed extensive hemorrhage and necrosis in the lungs, as well as hyaline membrane disease. Alveolar and bronchiolar lining cells contained frequent intranuclear inclusions visible by light microscopy that corresponded to arrays of icosahedral particles suggestive of adenovirus by electron microscopy. Confirmation of overwhelming adenovirus infection was made with in situ DNA hybridization. This case demonstrates the advantage of DNA probe analysis for retrospective diagnosis when no adequate specimen is available for culture or antigen detection. This case is also unusual in that a premature newborn had severe adenovirus infection.

Culture-proved disseminated cat-scratch disease in acquired immunodeficiency syndrome.

A male homosexual (positive for the human immunodeficiency virus) with a recent cat scratch developed fever, epitrochlear and axillary lymphadenopathy, and retinitis. Subsequently, he developed skin (epitheloid hemangioma) and mucosal lesions (Kaposi's sarcoma), multiple liver abscesses, and pleural effusion. Warthin-Starry stains and/or electron micrographs of lymph nodes and skin lesions demonstrated bacilli characteristic of those associated with cat-scratch disease. Cultures of lymph node, pleural fluid, and liver abscess specimens yielded organisms believed to be the causative agent of cat-scratch disease. We believe that disseminated cat-scratch disease may become an indicator of opportunistic infection signaling acquired immunodeficiency syndrome in a patient who is positive for the human immunodeficiency virus.

Epithelioid haemangioma-like vascular proliferation in AIDS: manifestation of cat scratch disease bacillus infection?

Papular and nodular skin lesions that clinically resembled Kaposi sarcoma, but histologically showed a distinct epithelioid haemangioma-like appearance, were noted in seven patients with the acquired immunodeficiency syndrome. Clusters of bacteria that had the structure of gram-negative rods were identified within each of the vascular proliferations by electron microscopy. The bacteria did not stain with the Brown-Brenn, acid-fast, or other histochemical stains for infectious organisms, but did stain with Warthin-Starry--ie, the staining profile was that described for the cat scratch disease (CSD) bacillus. Immunoperoxidase staining, using antisera raised in rabbits against cultured CSD bacillus, showed a positive reaction with the bacterium in all five cases tested. The two surviving patients have both given histories of having been scratched by a cat. In several patients, the vascular lesions regressed after therapy with antibiotics appropriate for CSD bacillus infection.

Cat-scratch disease. Isolation and culture of the bacterial agent.

A gram-negative bacterium or its cell wall-defective variants were isolated from lymph nodes of ten patients with cat-scratch disease. Cultured bacteria were morphologically identical to vegetative and wall-defective forms seen in human tissues. Three of seven patients with recent cat-scratch disease had fourfold or greater rises in antibody titer against the cultured bacteria; the remaining four patients had maximum titers of 1:32 to 1:128. Rabbit antiserum to cultured bacilli reacted in immunoperoxidase stains with vegetative and wall-defective cat-scratch disease bacilli in lymph node, skin, or conjunctiva and with vegetative or wall-defective bacteria isolated from ten patients. Vegetative bacteria produced lesions in the skin of an armadillo identical to early lesions in human skin. Vegetative bacteria were recovered from the lesions in the armadillo.

Systemic cat scratch disease: report of 23 patients with prolonged or recurrent severe bacterial infection.

Over a seven-year period, we identified 23 patients who had prolonged or recurrent, severe, systemic, cat-scratch disease (CSD). Compared with the usual, benign course in 1,038 patients with typical CSD, the course in these 23 patients included prolonged (two or more weeks) morbidity (fever, malaise, fatigue, myalgia, arthralgia, skin eruptions, weight loss, and splenomegaly). Five patients with systemic CSD had either neuroretinitis, pleurisy, arthralgia or arthritis, splenic abscesses, and mediastinal masses or enlarged nodes of the head of the pancreas. Recurrent CSD in two of three adults was confirmed by finding typical CSD bacilli in lymph nodes removed during separate episodes. The majority of patients were adult males, and all patients recovered completely without sequelae. Histopathologic studies of five skin and 18 lymph node biopsy specimens were diagnostic. CSD bacilli were detected in lymph nodes from 15 patients and in the primary skin lesions of four patients. CSD bacilli were found in both skin and lymph nodes of three patients.