Pregnancy outcomes in women with or without placental malaria infection.

OBJECTIVE: To assess delivery outcomes in women with placental malaria who presented at public hospitals in Kisumu, a holoendemic region in western Kenya. METHODS: A cross-sectional study using both histology and molecular biology was conducted with 90 consecutive pregnant women who presented at 3 hospitals during a 2-week period. Data collectors completed standardized questionnaires using each patient's hospital record and physical examination results, and registered birth indices such as weight, head circumference, and weight-head ratio. Malaria infection of the placenta was assessed using a molecular biology approach (for genomic differences among parasite species) as well as histology techniques. Of the 5 histologic classes of placental infection, class 1 corresponds to active infection and class 4 to past infection; class 2 and 3 to active chronic infection; and class 5 to uninfected individuals. Plasmodium species typing was determined by polymerase chain reaction amplification of the parasite's genome. RESULTS: In newborns at term, low birth weight was directly associated with classes 2 and 4 of placental infection (P = 0.053 and P = 0.003, respectively), and differences in birth weight remained significant between the 5 classes (P < 0.001) even after adjusting for parity and mother's age. Plasmodium falciparum was the only detected parasite. CONCLUSIONS: In Kisumu, infection with P. falciparum is an important cause of low birth weight and morbidity when it is associated with histologic classes 2 and 4 of placental infection. Moreover, polymerase chain reaction assays should be supported by ministries of health as an ancillary method of collecting data for malaria control during pregnancy and providing a baseline for future interventions.

Evaluation of the immunochromatographic CORIS Giardia-Strip test for rapid diagnosis of Giardia lamblia.

The aim of this study was to evaluate the performance of the CORIS Giardia-Strip test (CORIS Bioconcept, Gembloux, Belgium) as a rapid initial method for the routine diagnosis of giardiasis. Compared to a commercial ELISA-coproantigen test (ProSpect Giardia-ELISA-microplate assay; Remel, Lenexa, KS, USA), the commercial strip test had a sensitivity of 58%, a specificity of 99%, a positive predictive value of 93% and a negative predictive value of 93% (n=158). These results are comparable to those obtained using microscopy of direct wet-mounted stool. Since the CORIS Giardia-Strip test is simpler to perform, it can replace direct wet-mounted stool microscopy for the rapid diagnosis of giardiasis; however, its sensitivity is inferior to that of other immunochromatographic antigen detection tests and fresh stool samples are required for its use. Nevertheless, the results suggest that a positive CORIS Giardia-Strip test outcome does not need confirmation, while samples with negative results should be re-examined using another, more sensitive, test.

Comparison of different PCR protocols for the detection and diagnosis of Plasmodium falciparum.

An assessment of differing PCR protocols for the diagnosis of Plasmodium falciparum infection was performed on samples from an area of holoendemic malaria transmission in western Burkina Faso. The PCR protocols had generally high sensitivities (>92%) and specificities (>69%), but the negative predictive values (NPV) were moderate and differed widely among the PCR protocols tested. These PCR protocols that amplified either the P. falciparum pfcrt gene or the small subunit ribosomal DNA were the most reliable diagnostic tools. However, the moderate NPV imply that more than one PCR protocol should be used for diagnosis in holoendemic areas.

A human schwannoma cell line supports the in vitro adhesion of Plasmodium falciparum infected erythrocytes to chondroitin-4-sulfate.

The paucity of human cell lines expressing defined receptors for the cytoadhesion of erythrocytes infected with the human malarial parasite Plasmodium falciparumhas hampered the investigation of this important virulence property. Here, we investigate a permanent cell line derived from a human, malignant schwannoma, termed HMS-97, and show that this cell line expresses chondroitin-4-sulfate as the only surface receptor to which P. falciparum-infected erythrocytes can cytoadhere. Other common receptors for parasite adhesion, including CD36, vascular cellular adhesion molecule-1 (VCAM), intercellular adhesion molecule-1 (ICAM-1), and E-selectin are absent. Thus, HMS-97 cells are a useful tool for the study of P. falciparum adhesion to chondoitin-4-sulfate, the main receptor for parasite sequestration in the placenta. As chondoitin-4-sulfate can be readily cleaved from the cells, HMS-97 cells are also an ideal system for expressing recombinant adhesion receptors and studying their function in binding assays.

Y2K medical disaster preparedness in New York City: confidence of emergency department directors in their ability to respond.

OBJECTIVES: To study the preparedness New York City for large scale medical disasters using the Year 2000 (Y2K) New Years Eve weekend as a model. METHODS: Surveys were sent to the directors of 51 of the 9-1-1-receiving hospitals in New York City before and after the Y2K weekend. Inquiries were made regarding hospital activities, contingencies, protocols, and confidence levels in the ability to manage critical incidents, including weapons of mass destruction (WMD) events. Additional information was collected from New York City governmental agencies regarding their coordination and preparedness. RESULTS: The pre-Y2K survey identified that 97.8% had contingencies for loss of essential services, 87.0% instituted their disaster plan in advance, 90.0% utilized an Incident Command System, and 73.9% had a live, mock Y2K drill. Potential terrorism influenced Y2K preparedness in 84.8%. The post-Y2K survey indicated that the threat of terrorism influenced future preparedness in 73.3%; 73.3% had specific protocols for chemical; 62.2% for biological events; 51.1% were not or only slightly confident in their ability to manage any potential WMD incidents; and 62.2% felt very or moderately confident in their ability to manage victims of a chemical event, but only 35.6% felt similarly about victims of a biological incident. Moreover, 80% felt there should be government standards for hospital preparedness for events involving WMD, and 84% felt there should be government standards for personal protective and DECON equipment. In addition, 82.2% would require a moderate to significant amount of funding to effect the standards. Citywide disaster management was coordinated through the Mayor's Office of Emergency Management. CONCLUSIONS: Although hospitals were on a heightened state of alert, emergency department directors were not confident in their ability to evaluate and manage victims of WMD incidents, especially biological exposures. The New York City experience is an example for the rest of the nation to underscore the need for further training and education of preparedness plans for WMD events. Federally supported education and training is available and is essential to improve the response to WMD threats.

Towards a rational malaria management at district hospital level: exploratory case series of febrile adult patients in a holoendemic area of Tanzania.

One hundred and sixty eight febrile adult outpatients were investigated at St Francis Designated District Hospital in fakara, a holoendemic area in Tanzania. We wanted to assess the potential anamnestic and clinical risk indicators for malaria and to establish a rational strategy for malaria management. Blood slide investigations showed that 14% of all patients were positive for P. falciparum. All the positive cases were found during the rainy season. No reliable criteria for malaria were found in the history taking and physical examinations. Signs and symptoms of respiratory tract infection such as difficulties during breathing, sore throat, chest pain, cough, pathological findings in lung auscultation and combinations of these were negatively associated with malaria parasitaemia. The same was true for lymph node swelling and a clinical diagnosis other than malaria. Quality control of blood slide results from the hospital revealed a sensitivity of 55%, a specificity of 72%, and positive and negative predictive values of 24% and 91%. The main recommendations for malaria management in adults were to improve the quality of blood slide examinations and to use a different diagnostic strategy during the dry and rainy seasons. During the dry season blood slides of febrile adult patients should only be performed if there is a suspicion of malaria and antimalarial drugs should only be administered if blood slide results are positive. During the rainy season all febrile adults without obvious cause of fever other than malaria should be treated with antimalarials without previous blood slide examination.

Critical incident stress and challenges for the emergency workplace.

A formal response to all levels of critical incidents that are potentially psychologically disturbing is needed. This response is needed for small-scale and large-scale incidents, such as natural or manmade disasters. Health care providers at all levels should be encouraged to participate in wellness programs and to understand workplace stressors. Critical incident stress debriefing teams have a valuable role in preventing posttraumatic stress disorder. Procedures for establishing response teams are presented, and future directions are discussed.

The use of analgesics in patients with acute abdominal pain.

Analgesics in patients with acute abdominal pain are often withheld for fear that they may change physical examination findings and thus may be unsafe. We conducted a randomized, prospective, placebo-controlled trial to investigate changes in physical examination following the administration of placebo, 5 mg, or 10 mg of morphine to 49 patients with acute abdominal pain. One patient was withdrawn secondary to inadequate documentation. Of the 48 patients who completed the trial, a statistically significant change in physical examination was noted in both groups receiving analgesics, but not in the placebo group. No adverse events or delays in diagnosis were attributed to the administration of analgesics. We conclude that physical examination does change after the administration of analgesics in patients with acute abdominal pain and that a larger study is needed to evaluate analgesic safety in this subpopulation of emergency department patients.

Disaster medicine.

The American College of Emergency Physicians defines a medical disaster as occurring when the destructive effects of natural or man-made forces overwhelm the ability of a particular region to meet the demand for health care. The science of disaster medicine is continually improving, and significant progress has been made in defining how to provide a comprehensive response to disaster sites. The management of a disaster involves an activation phase, followed by the implementation and recovery phases. The success of each phase depends on coordinated on-site and off-site communication systems. This paper presents an overview of this new subspecialty and discusses the fundamental components of an effective disaster response.

Increased interleukin-2 production in response to human type I collagen stimulation in patients with systemic sclerosis.

Peripheral blood mononuclear cells (PBMC) from patients with systemic sclerosis (SSc) produced increased amounts of interleukin-2 (IL-2), in a dose-dependent manner, in response to stimulation with human type I collagen, whereas PBMC from normal subjects did not. At a dose of 50 micrograms human type I collagen/10(6) PBMC, PBMC from SSc patients (n = 17) produced 8 times as much IL-2 as did PBMC from 16 normal subjects (P less than 0.005) and 3 times as much as did PBMC from a group of 13 rheumatoid arthritis patients (P less than 0.05). In contrast, IL-2 production by PBMC after nonspecific stimulation with the mitogen, phytohemagglutinin, did not differ among the SSc, rheumatoid arthritis, and normal control groups. Cell depletion experiments indicated that the IL-2-producing cells in SSc patients are CD4+. Thus, SSc patients have CD4 cells that are specifically sensitized to human type I collagen and can produce increased levels of IL-2. Measurement of IL-2 production stimulated by human type I collagen may be useful in evaluating disease activity, and further investigation of this process may contribute to the delineation of the pathogenesis of SSc.

Altered T cell subpopulations and lymphocytes expressing natural killer cell phenotypes in patients with progressive systemic sclerosis.

Scleroderma (progressive systemic sclerosis [PSS]) is known to be associated with abnormal T cell immunoregulation. In the present study, we evaluated lymphocyte phenotypes in patients with PSS and normal control subjects by flow cytometry and monoclonal antibodies for total T (CD3), T suppressor (CD8), T helper (CD4), T helper-inducer (CDw29), T suppressor-inducer (CD45R), human leukocyte antigen, DR+B (CD19), DR+T, and natural killer subsets, HNK-1 (CD57) and NKH-1 (CD56) cells. Patients with PSS compared to normal subjects had significantly lower percentages of CD3+ (p less than 0.005) and CD8+ (p less than 0.05) (similar to several patients with rheumatoid arthritis also evaluated), as well as CD45R (p less than 0.05), T+DR+ (p less than 0.05), and NKH-1 (CD56) (p less than 0.0005) cells. Patients with PSS with late-limited or generalized disease had lower percentages of CD8+, CD19, NKH-1+, and CDw29, but higher percentages of CD4+, HNK-1, and CD45R cells compared to patients with early stage disease, but these results were not statistically significant. These unique alterations in patients with PSS may prove to be useful in monitoring the stage of disease activity for therapy and further define immunologic defects.

[Effect of different factors on the induction of mimicry antigens of typhoid bacteria]. / Vlilanie razlichnykh faktorov na induktsiiu antigenov mimikrii u briushnotifoznykh bakterii.

The in vitro and in vivo (white mice) studies have shown that female sex hormones, especially folliculin and hexestrol, as well as the deficiency of the T-lymphoid system of the organism in which the microbe is circulating, and also some microbial cell components accelerate the synthesis of S. typhi antigens serologically similar to the antigens of the microorganism. Antibiotics, especially oxacillin and ampicillin, sulfa drugs, especially sulfadimethoxine, inhibit antigenic mimicry in S. typhi. A suggestion is made on the interrelationship between the factors responsible for the mimicry antigens production and those for the formation of hydrogen sulfide.

Participation of the thymus in the mechanism of bacterial discharge in carriers of typhoid bacteria. / Ob uchastii timusa v mekhanizme bakteriovydeleniia u nositelei briushnotifoznykh bakterii

Typhoid carrier state was reproduced in 54 rabbits by the injection of typhoid bacilli into the bone marrow of the femoral bone. The animals were divided into 3 groups. Those in the 1st and 2nd group were hydrocortisone and ATC before the infection, respectively, whereas the 3rd group served as control. The data obtained pointed to the great incidence of prolonged persistence of typhoid bacilli in the bone marrow. A much greater vital disharge of the causative agent with the feces was noted in the animals which before the infection were given hydrocortisone and ATC preparations depressing the functional activity of the thymus. In the second experimental series it was shown that ATC administration to rabbits on the 85th day after their intraosseous infection with typhoid bacilli promoted vital discharge of the causative agent with the feces. Problem of participation of the thymus in the mechanism of bacterial discharge in the carriers of typhoid bacilli are discussed.