The effect of a senior preceptorship on the adaptive competencies of community college nursing students.

A pre-post design was used to examine the effect of a senior preceptorship experience on the adaptive competencies, environmental press perceptions and learning styles of 55 third-year community college nursing students. Kolb's experiential learning theory provided the framework for the study. Subjects rated their concrete and abstract competencies and the importance of divergent and convergent competencies significantly higher following the preceptorship. They also felt that the preceptorship experience contributed significantly more to their competency development than their weekly clinical experiences during the year. Contrary to expectations, administration of the Learning Style Inventory LSI-1976 and LSI-1985 produced inconsistent classifications of subjects' learning styles. Implications for nursing are described.

Effect of Mycobacterium leprae in peripheral nerve trunk on the evolution of skin lesions.

Comparative histological studies were made of a) 41 peripheral nerve lesions and the skin in the area of supply, and b) 12 peripheral nerve lesions and concurrent but unrelated skin lesions. In the first study, small, relatively early, histologically classifiable skin lesions were found in all cases, even though there were no clinical lesions. In every case the lesion was centered on a dermal nerve. In some cases disruption of the perineurium was associated with emergence of the lesion into the dermis and a small silent local reaction. It was concluded that there was a descending spread of the disease down the neural pathway to the dermis, although it was not necessarily associated with transport of bacilli. Although the first study showed a discrepancy in the classification between skin and nerve lesions in nearly 50% of the cases (as previously reported), the second study showed no discrepancies. It is suggested that discrepancies are relatively uncommon, and that those in the first study are exceptional. The probable explanation is that microreactions in the nerve trunks had caused a shift in classification, which was not yet reflected in the immature skin lesions. In the second study, the mature skin lesions had reached immunological equilibrium. Discrepancies in classification between skin and nerve lesions, as between concurrent skin lesions, are the result of reaction. Attention is drawn to the probable role of subliminal reactions in the evolution of infections.

The cellular exudate--Mycobacterium leprae relationship and the critical reading of skin smears.

A careful reading of conventionally stained Ziehl-Neelsen skin smear preparations in leprosy provides a number of insights into the patient's situation, including his approximate position in the spectrum. This data serves as a cross-check on the primary results of the smear examination, and aids their interpretation for the purposes of diagnosis, assessment of the response to chemotherapy and the possible onset of relapse.

Rationale for the histological spectrum of tuberculosis. A basis for classification.

There is need to re-appraise the cellular response to Mycobacterium tuberculosis. Histological analysis of 54 untreated patients with established disease demonstrated a continuous spectrum of tissue responses in which six groups correlated with evidence of resistance to bacterial multiplication. A predominance of cases in the two middle groups (82%) signified an immunological equilibrium in middle grade resistant patients that is absent in related diseases such as leprosy and cutaneous leishmaniasis. The dominant feature was necrosis, which increased progressively across the spectrum. Its form varied from minimal fibrinoid change, through fine eosinophilic necrosis, to basophilic necrosis characterized by neutrophil karyorrhexis, and finally to an almost acellular lesion with many bacilli. Cytological differentiation of the granuloma was of subsidiary significance, mature epithelioid cells being found only in high resistant cases. No correlation was found for the number of lymphocytes. This classification is thought to be an accurate reflection of the immune state in relation to antigenic load. It raises a hitherto unconsidered possibility that "caseation", a loosely applied macroscopic term, may embrace immunologically distinct states. The classification of multiple lesions was consistent. Histology offers a promising basis for further immunopathological investigation.

Events surrounding the recognition of Mycobacterium leprae in nerves.

Histological examination and immunocytochemistry of Schwann cells, macrophages, and mycobacterial antigen were used to study 48 nerves of untreated patients with leprosy. None of the patients was in reaction clinically, but microreactions, involving small clusters of Schwann cells and macrophages in all cases except LL, were marked by progressive degradation of acid-fast bacilli (AFB). This was thought to be the response to the recognition of mycobacterial antigen. In the first phase, the disintegration of one or more Schwann cells caused the release of AFB, accompanied by subacute inflammation. In the second phase, as edema and cellular infiltration subsided, the necrosis of Schwann cells was replaced by granuloma formation, mycobacterial antigen being in a soluble form. Myelinated cells harbored few degraded AFB, and there was evidence that antigen-associated myelin hastened the death of Schwann cells. Only then did antigen become immunologically detectable to induce an inflammatory response whose clearance and resolution was impeded by the restraint on cellular movement due to the structure of neural tissue. These developments were sporadic but continuous. AFB and antigen released by disintegrating Schwann cells were ingested by regenerating Schwann cells and by macrophages, producing a self-perpetuating cycle which might involve either small areas or the greater part of a fascicle, and could conceivably progress to a generalized reaction.

Classification of nerves is modified by the delayed recognition of Mycobacterium leprae.

Biopsies of 42 concurrent nerve and skin lesions across the spectrum of leprosy were classified and compared histologically and bacteriologically. Observations were made as follows: a) The bacterial load was higher in nerve than in skin lesions of the same histological classification, and it was higher in nerve than in concurrent skin lesions irrespective of classification, although not at the lepromatous pole. b) There was some discrepancy between the histological classification of nerve and skin lesions in half the cases. Skin classification appeared to represent the general tissue response and, insofar as discrepancies existed, the skin classification was thought to give the better evaluation. Nerve classification was subject to minor variations of a random nature which were thought to be the outcome of local reactions due to the build up of antigen as a result of delayed recognition in an immunologically protected situation. Upgrading or downgrading ensued locally, depending on the level of antigen at the time of its detection. In such cases, the corresponding skin classification was usually BT, which occupied a critical point in the spectrum. A certain autonomy of the response between lesions of skin and nerve suggests an explanation for downgrading reactions. Although Mycobacterium leprae, alone among mycobacteria, has some sort of affinity for Schwann cells, it is the role of the nerves as protected sites which is fundamental to the course of the disease.

Histochemical demonstration of mycobacterial antigen, specific antibody and complement in the lesions of tuberculosis.

Lesions were studied histochemically for mycobacterial antigen, its specific antibody and complement in 31 patients with recently-diagnosed tuberculosis. The results were related to a histological spectrum that correlated with bacterial load. The form, localization and persistence of antigen were found to be as significant as the amount. In high-resistant cases, the antigen was mainly soluble, a form which was non-toxic when ingested by macrophages but associated with tissue damage when bound to connective tissue. There was no close contact between plasma cells and antigen. However, in cases with moderate resistance, where plasma cells and antigen intermingled freely, necrosis with karyorrhexis and polymorph infiltration was associated with deposition of antigen, antibody and complement at the same sites, indicating the probability of immune complex formation in these lesions. In low-resistant cases, extensive necrosis was attributed partly to high levels of extracellular antigen. The correlation between immunological circumstances and the manifold forms of necrosis validated these forms as the basis for a histological spectrum in tuberculosis.

Monocyte recruitment, antigen degradation and localization in cutaneous leishmaniasis.

The relationship between the destruction of Leishmania, the recruitment of monocytes and macrophage activity in the lesions of cutaneous leishmaniasis (CL) was studied in 53 biopsies representing the phases of evolution of the infection. Lysozyme, amastigotes and their degradation products were located by their specific antibodies. A rising level of monocyte influx was found to correlate with the degradation and solubilization of antigen, a falling level with final clearance. Differences in the results supported the previous concept of macrophage activation and macrophage lysis as alternative mechanisms for the elimination of Leishmania. Macrophage activation appeared to coincide with re-phagocytosis of externalized antigenic products of different type and origin. Macrophage lysis was a fully effective mechanism only when the antigen was contained within a focalized granuloma before mass lysis. Failing this, degradation and clearance of antigen were incomplete, and residues were sequestered on the periphery of the lesion where they bound to collagen and epidermis with consequential tissue damage. Antigen was demonstrated on the surface of lightly parasitized macrophages but not heavily infected ones. Other cells bound antigen without ingesting it, a process which might allow antigen presentation though it would also favour survival of parasites within the cell.

Macrophage-parasite interaction in the lesions of cutaneous leishmaniasis. An ultrastructural study.

Localized cutaneous infections with Leishmania, which demonstrate complex host-parasite interactions, were studied ultrastructurally in 16 patients at phases ranging from onset to resolution. In the early lesions the host macrophages were 1) heavily parasitized and vesiculated, 2) undifferentiated, or 3) large and active, with fewer organisms. Progressive activation and epithelioid transformation of incoming monocytes was associated with the elimination of parasites. Killing and degradation appeared to take place simultaneously within the phagolysosome, but lysosomal fusion did not prevent survival into the activated cell stage. Host cell lysis, the alternative mechanism of parasite elimination, was accomplished following contact of the macrophage with plasma cells or its engulfment by a large granular cell. Lysis was either sporadic, proceeding from the periphery, or total in a central mass; and in each case macrophage lysis was preceded by connective tissue damage. The externalized parasites appeared to enhance both the activation and lytic processes, but degraded extracellular organisms were associated with dendritic-like cells more than with macrophages. This needs further study.

Immunological factors in nasal mucosa of patients with leprosy--immunoperoxidase study.

The nature of the sub epithelial zone was established. S.E. shows IgG and IgM activity in tuberculoid group. Lepromatous group did not show any IgM or IgG response. IgE activity was seen in the lepromatous region in exudate and on the surfaces of Macrophages. Lysozyme activity was seen in the mucous acini of lepromatous leprosy.

Lysozyme as a measure of cellular dynamics in the lesions of leprosy.

The levels and distribution of lysozyme-positive cells and exudate were studied in leprosy lesions through the spectrum, in untreated and treated patients, in relapse and in reactions. Altogether 124 skin biopsies were examined by the immunoperoxidase technique. Monocytes, neutrophil-polymorphs and mast cells were the most conspicuous cells seen. Lysozyme proved to be a useful means of indexing renewal of these cells in the lesions. Peak numbers of monocytes were seen in lesions of active lepromatous leprosy (LL) and of tuberculoid leprosy (TT), at poles of opposite immunological performance. In TT the stimulus for recruitment was delayed hypersensitivity (DH). A decline in DH from TT towards the middle of the spectrum, mid-borderline, was accompanied by a fall in monocyte level. Furthermore, reacting lesions due to enhanced DH also had increased numbers of monocytes. On the other hand reactions associated with immunological deterioration were similar to active lepromatous leprosy (LL) and monocyte influx was raised in response to the stimulus of free multiplication of bacilli in both cases. In TT delayed hypersensitivity acted also to promote the rapid transformation of monocytes to epithelioid and giant cells all of which were strongly positive for lysozyme. This was in contrast to much lower levels in histologically similar macrophage-epithelioid cells of BT granulomas. Lysozyme synthesis was not seen in macrophages after ingestion of M. leprae. Early foamy change was made conspicuous by lysozyme deposited in phagocytic vacuoles, but old foam cells in regressing lepromas were negative. Lysozyme bound to dead extracellular M. leprae but not to viable or intracellular organisms. Dead bacilli or immune complexes appeared to be the stimulus for neutrophil-polymorph recruitment, mainly in reactions.

Exacerbation reactions in hyperactive lepromatous leprosy.

Exacerbation reactions (ER) are acute reactions occurring locally in histoid or other highly active lepromatous lesions with an exceptionally heavy bacterial load. Clinically, they are almost silent although they may cause ulceration and the release of viable bacilli. Histologically, the influx of polymorph neutrophils and coincident macrophage degeneration mimic erythema nodosum leprosum (ENL). Later, the signs of increased permeability or necrosis of small blood vessels and mast cell degranulation are differential features. The predominant immunoglobulin is IgE, and the main complement component is C1q, C3 being mostly undetectable. The reactions appear to be mediated in part by reagins (although eosinophils are not seen). Immune complexes probably form at antigen excess. Of equal importance may be the release from highly activated macrophages and neutrophils of hydrolases and proteases, which are capable of degrading connective tissue and other cell surfaces. This report is based on a histopathological and an immunocytological study of 13 exacerbation reactions in comparison with nonreacting hyperactive lesions and with ENL. The results support the view that the essential feature of histoid lesions is their hyperactivity.

Cutaneous leishmaniasis: immune complex formation and necrosis in the acute phase.

Twenty biopsies of lesions of cutaneous leishmaniasis were classified according to the mechanism of parasite elimination, on the basis of macrophage activation (five cases) or macrophage lysis (15 cases). The immunoperoxidase technique was used to demonstrate free Leishmania antigen, immunoglobulins, complement, lysozyme, C-reactive protein, beta-lipoprotein, alpha 1-antitrypsin, alpha 2-macroglobulin, plasminogen and factor VIII, which were quantitated and comparatively assessed. The fall in the parasite load during the course of the infection was associated with rising levels of IgG, IgM and IgE, and of the complement components of the classical pathway. Macrophage lysis supervened when there was an approximate equivalence of antigen and antibody, and was associated with the deposition of immune complex components. Lysis of the acute focal type (C response) was accompanied by a massive liberation of free Leishmania antigen, followed by a fall indicative of parasite elimination. The lysis of small numbers of macrophages scattered diffusely in the lesion, which was slow to reach completion (B response), was less effective and immunologically closer to the non-lytic (A) response. A terminal fall of the immunological factors other than the globulins, suggestive of resolution, was observed mainly in the C response. Lymphocytes may be important in macrophage activation associated with the macrophage A response and in the later stage of the B and C responses. However immunologically induced host-cell lysis is more important than macrophage activation for the elimination of Leishmania in the acute stage of most skin lesions. It is associated with, and may be caused by, the formation in situ of immune complexes of Leishmania antigen and antibody at an appropriate ratio.

Late-stage cutaneous leishmaniasis: immunopathology of tuberculoid lesions in skin and lymph nodes.

Strong development of tuberculoid features in the late stage of cutaneous leishmaniasis presents immunopathological, diagnostic and sometimes therapeutic problems. Only two such cases were identified out of 30 late-stage cases of the disease. They were delineated on histological and immunocytological grounds, and found to present higher levels of Leishmania antigen and lower levels of IgG than the weakly tuberculoid cases. One case showed histological and skin test evidence of delayed-type hypersensitivity; the other case (clinically of the relapsing or recidiva variety) lacked such evidence. Here the residual antigen was segregated at the periphery of the lesion. In three late-stage cases for which lymph node biopsies were available there was a stronger tuberculoid response in lymph node or lymphatic than in the skin lesion. In two cases there was caseation. Germinal follicles were notably active. It is suggested that in cutaneous leishmaniasis a strong tuberculoid response may be associated not so much with immune complex formation (as in the majority of lesions) but with sequestration of antigen at a peripheral site or in the lymphatic apparatus.

C-reactive protein and apoB containing lipoproteins are associated with Mycobacterium leprae in lesions of human leprosy.

Skin biopsies from patients with leprosy across the spectrum from tuberculoid (TT) to lepromatous (LL), including histoid lepromas and erythema nodosum leprosum (ENL) reactions, were stained immunohistochemically for the presence of C-reactive protein (CRP) and the apolipoprotein, apoB. Mycobacterium leprae bacillary material comprising cell walls, cytoplasmic and soluble components was present with increasing abundance towards the lepromatous end of the spectrum and always stained positively with anti-CRP. M. leprae from armadillos did not stain with anti-human CRP indicating that the staining of M. leprae in human tissues was not due to a cross-reaction between anti-CRP and the organism itself. When CRP was present in large amounts apoB was also demonstrated in the same distribution. CRP was detected on bacilli and their degradation products within the cytoplasm of macrophages even in the absence of a raised serum CRP level in some ENL patients and also in two cases of advanced resolving lepromas. These findings demonstrate remarkable persistence of CRP in association with M. leprae in vivo, and raise intriguing questions about the possible role of CRP in relation to the handling of leprosy bacilli.