Serial measurements of hematologic counts during the active phase of human granulocytic ehrlichiosis.

To describe the changes that occur in blood count parameters during the natural course of human granulocytic ehrlichiosis, we designed a retrospective cross-sectional case study of 144 patients with human granulocytic ehrlichiosis and matched controls who had a different acute febrile illness. Patients from New York State and the upper Midwest were evaluated from June 1990 through December 1998. Routine complete blood counts and manual differential leukocyte counts of peripheral blood were performed on blood samples that were collected during the active illness, and values were recorded until the day of treatment with an active antibiotic drug. Thrombocytopenia was observed more frequently than was leukopenia, and the risk of having ehrlichiosis varied inversely with the granulocyte count and the platelet count. Patients with ehrlichiosis displayed relative and absolute lymphopenia and had a significant increase in band neutrophil counts during the first week of illness. Knowledge of characteristic complete blood count patterns that occur during active ehrlichiosis may help clinicians to identify patients who should be evaluated specifically for ehrlichiosis and who should receive empiric antibiotic treatment with doxycycline.

Effect of treatment of Helicobacter pylori infection on rosacea.

OBJECTIVE: To evaluate the clearing and intensity of symptoms of rosacea 60 days after the treatment of Helicobacter pylori infection. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: The dermatology section of a large multispecialty clinic in the North Central United States. PARTICIPANTS: Men and women older than 25 years with active signs of rosacea who tested positive for H pylori with both the rapid whole blood test and the urea breath test. INTERVENTION: Treatment of H pylori infection with 14-day therapy using clarithromycin. 500 mg orally 3 times a day, and omeprazole, 40 mg orally once a day. MAIN OUTCOME VARIABLES: The extent and intensity of rosacea as measured by the number of papules and pustules and the extent and intensity of erythema and telangiectasia. RESULTS: Three hundred twenty patients presented with rosacea. For 50 patients, the results of a urea breath test were positive for H pylori, and 44 patients were enrolled in the study. Rosacea abated in almost all patients, but none were cured. Notably, lessening of rosacea for patients treated for H pylori was not significantly better than for the control cohort. CONCLUSIONS: Rosacea abated in most participants in this study, whether they were in the treatment or the control cohort. There was no statistical difference when the results of active treatment were compared with those of placebo. Treating H pylori infection has no short-term beneficial effect on the symptoms of rosacea to support the suggested causal association between H pylori infection and rosacea.

Community-based screening for childhood lead poisoning. Identification of risk factors and susceptible populations in Duluth.

The purpose of this matched case-controlled study was to identify local risk factors and susceptible populations for childhood lead poisoning in Duluth, Minnesota. We mailed questionnaires to the parents of 20 children with known elevated capillary lead levels > or = 10 micrograms/dL; 76 age-matched controls had capillary lead levels < 10 micrograms/dL. The study identified these risk factors for elevated capillary lead levels in children: not attending daycare, having nonwhite parents, living in rental property in central Duluth, and moving with family three or more times in the previous five years. We conclude that these risk factors are related to socioeconomics. Minority children and children living in poverty in the Duluth area should be screened for lead poisoning according to the Centers for Disease Control and Prevention screening guidelines for high-risk lead exposure.

Seroprevalence of human granulocytic ehrlichiosis among permanent residents of northwestern Wisconsin.

Four-hundred seventy-five permanent residents of Wisconsin were tested for antibodies to the agent of human granulocytic ehrlichiosis (HGE) by indirect immunofluorescent antibody (IFA) testing with Ehrlichia equi as antigen marker. Each resident completed a standard survey questionnaire about outdoor activities, animal and tick exposure, and any febrile illness during the preceding 12 months. Seventy-one serum samples (14.9%) contained E. equi antibodies. The mean IFA titer for seropositive residents was 250 (range, 80-10,240). Seropositive residents were older than seronegative ones (62 vs. 56 years; P = .019). None of the seropositive residents had a history suggestive of ehrlichiosis. There was no association between the IFA test outcome and specific demographic variables or history of tick bites. HGE appears to be a common subclinical or mild infection among residents in northwestern Wisconsin.

Endoscopic surveillance of Barrett's esophagus: a cost-effectiveness comparison with mammographic surveillance for breast cancer.

OBJECTIVE: Endoscopic surveillance of Barrett's esophagus is commonly practiced to detect malignancy in an early and curable stage. However, the cost-effectiveness of this practice has been questioned. To clarify this issue, we undertook a cost analysis of endoscopic surveillance to detect adenocarcinoma in Barrett's esophagus compared with mammography used to detect occult carcinoma of the breast, a widely accepted cancer surveillance technique. METHODS: The rate of esophageal adenocarcinoma detected by endoscopic surveillance was calculated for Duluth Clinic patients with Barrett's esophagus seen from 1980 to 1995 and compared with published rates. The rate of occult breast cancer detection was calculated for all women undergoing surveillance mammography at the Duluth Clinic for the year 1994 and compared with published rates. Costs for screening studies and therapy for cancer treatment for both cancers were calculated based on clinical results and assumptions regarding outcomes derived from published reports, and the costs were compared. RESULTS: Endoscopic surveillance of 149 patients with benign Barrett's esophagus was performed for a total of 510 patient-yr, during which time seven patients developed adenocarcinoma, an incidence of one case per 73 patient-yr of follow-up. Occult breast cancer was detected in 50 of 12,537 mammograms, a detection rate of 0.4%. The incidences in both cases were comparable to published figures. The costs of detecting a case of adenocarcinoma in Barrett's esophagus and occult breast cancer were $37,928 and $54,513, respectively, and those for treatment resulting in cure were $83,340 and $83,292. Cost per life-yr saved was $4,151 for adenocarcinoma in Barrett's esophagus and $57,926 for breast cancer. CONCLUSION: Endoscopic surveillance of patients with Barrett's esophagus compares favorably with the common practice of surveillance mammography to detect early breast cancer, and should therefore be considered to be as cost-effective as surveillance mammography.

Nutrition education and mega-dose vitamin A supplementation in Nepal.

Two approaches to improve vitamin A nutriture are compared: nutrition education and mega-dose capsule distribution. The impact of these programmes on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality are compared for approximately 40,000 children who were assigned to either intervention cohorts or a control group from 75 sites within seven districts in two ecological settings (Terai, or lowland, and hills) of Nepal. Twenty-four months after the implementation of the project, the reduction of risk of xerophthalmia was greater among children of mothers who were able to identify vitamin A-rich foods [relative risk (RR) = 0.25; 95% CI = 0.10-0.62] than among children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at two years was reduced for both the nutrition education cohort (RR = 0.64; 95% CI = 0.48-0.86) and capsule distribution cohort (RR = 0.57; 95% CI = 0.42-0.77). The nutrition education program, however, was more expensive to deliver than the capsule distribution programme. High rates of participation in the supplementation programme were achieved within a short period. The nutrition education message spread rapidly throughout the study population, although practice was slower to change. Where maternal literacy was low and channels of communication were limited, the capsule programme appeared to be more cost-effective. However, economies of scale for nationwide programmes exist for nutrition education programmes that do not exist for capsule distribution programmes. A comprehensive national programme requires both dietary supplementation and nutrition education.

Serological evidence of human granulocytic ehrlichiosis in Norway.

Human granulocytic ehriichoisis was first described in 1994. This tick-transmitted illness is increasingly recognized in the USA as well as in Europe in areas where ixodes ticks and Lyme borreliosis are endemic. Blood samples from 58 Norwegian patients with physician-diagnosed Lyme borreliosis were examined for the presence of antibodies to Ehrlichia equi, a surrogate marker of the agent of human granulocytic ehrlichiosis. The results indicated that 10.2% of the patients may have been co-infected with human granulocytic ehrlichiosis and Lyme borreliosis. Human granulocytic ehrlichiosis appears to be established in southern Norway.

Objective assessment of gastroesophageal reflux after short esophagomyotomy for achalasia with the use of manometry and pH monitoring.

The role of an antireflux procedure as an adjunct to esophagomyotomy for achalasia remains a subject of controversy. Little objective documentation exists of this operation's effect on sphincteric competence and the degree of postoperative gastroesophageal reflux. This report of esophageal manometry and 24-hour pH monitoring on 14 patients with esophageal achalasia whom we had previously treated by a short esophagomyotomy without an antireflux procedure provides such documentation. Esophagomyotomy reduced lower esophageal sphincter pressure by 12% to 71% (mean 41%) from a preoperative mean of 26.7 mm Hg to a postoperative mean of 14.6 mm Hg. The number of postoperative episodes of acid reflux per patient in 24 hours was fewer than 29 (normal < 49) in 13 patients, with a median of 12 episodes for the entire group. Esophageal acid exposure, measured as percentage of total time with pH less than 4.0 (normal < 4.5%), was below 4.5% in 10 patients, six of whom had values less than 1%. Among the four patients with values greater than 4.5%, only one had a temporal correlation of symptoms with an episode of acid reflux. Multivariate analysis showed that esophageal acid exposure time correlated only with the level of residual lower esophageal sphincter pressure during the relaxation phase of deglutition. A pressure less than 8 mm Hg was predictive of normal acid contact time (p < 0.001). Mean lower esophageal sphincter pressure, percent reduction in lower esophageal sphincter amplitude, postoperative vector volume, and length of the lower esophageal sphincter did not significantly correlate with amount of esophageal acid exposure. We conclude that a short esophagomyotomy without an antireflux procedure results in a competent lower esophageal sphincter in most patients. Increased esophageal acid exposure, when it occurs, is due to slow clearance of esophageal acid from relatively few reflux episodes and is more likely to occur when there is a high residual pressure during deglutition after myotomy. These findings suggest that the addition of an antireflux procedure to a short esophagomyotomy would not be expected to improve clinical results.

Clinical and laboratory characteristics of human granulocytic ehrlichiosis.

OBJECTIVE: To characterize the clinical and laboratory features observed in patients with human granulocytic ehrlichiosis (HGE) and evaluate the utility of the diagnostic tools used to confirm the diagnosis. DESIGN: Retrospective case study of 41 patients with laboratory-diagnosed HGE. SETTING: A total of 228 patients from Minnesota and Wisconsin were evaluated between June 1990 and May 1995. METHODS: Cases were presumptively identified by a history of an influenzalike illness acquired in an area known to be endemic for ticks. Diagnostic laboratory testing included microscopic examination of Wright-stained peripheral blood smears for presence of neutrophilic morulae, polymerase chain reaction (PCR) analysis of acute-phase blood samples for the Ehrlichia phagocytophila/Ehrlichia equi group DNA, and evaluation of serological responses by indirect immunofluorescent antibody assay (IFA), using E equi as antigen. RESULTS: All patients presented with a temperature of at least 37.6 degrees C, and most had headache, myalgias, chills, and varying combinations of leukopenia, anemia, and thrombocytopenia. Eighty percent of the patients tested demonstrated morulae in the cytoplasm of peripheral blood neutrophils. Only 16 of 37 patients tested by PCR were positive for HGE, whereas serum IFA assays of acute or convalescent blood samples detected antibodies against E equi in 38 of 40 patients tested. Two patients died, and the calculated case fatality rate was 4.9%. CONCLUSIONS: Human granulocytic ehrlichiosis is being increasingly recognized in Wisconsin and Minnesota. A more severe illness is associated with increased age, anemia, increased percentage of neutrophils and decreased percentage of lymphocytes in peripheral blood, and presence of morulae in neutrophils. The differential diagnosis for patients who develop an influenzalike illness following a tick bite should include HGE. Microscopic examination of the acute-phase blood smear to detect neutrophilic morulae is currently the quickest and most practical screening method for diagnosing HGE in the upper Midwest.

Impact of nutrition education and mega-dose vitamin A supplementation on the health of children in Nepal.

The impact on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality of two alternative approaches-nutrition education and mega-dose capsule distribution (6-12-month-olds: 100,000 IU; 1-5-year-olds: 200,000 IU)-in communities in Nepal are compared. Approximately 40,000 children from 75 locations in seven districts in two ecological settings (lowland and hills) took part in the study and were randomly allocated to intervention cohorts or a control group. At 24 months after the implementation of the project the reduction of risk for xerophthalmia was greater among children whose mothers were able to identify vitamin-A-rich foods (relative risk (RR) = 0.25; 95% confidence interval (CI) = 0.10-0.62) than among the children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at 2 years was reduced for both the nutrition education (RR = 0.64; 95% Cl = 0.48-0.86) and capsule distribution (RR = 0.57; 95% CI = 0.42-0.77) cohorts. The nutrition education programme was, however, more expensive to deliver than the capsule distribution programme. High rates of participation for children in the supplementation programme were achieved quickly. The nutrition education messages also spread rapidly throughout the study population (regardless of intervention cohort assignment). Practices, however, were slower to change. In communities where maternal literacy was low and channels of communication were limited the capsule distribution programme appeared to be more economical. However, there are economies of scale for nationwide education programmes that do not exist for capsule distribution programmes. Although nutrition education provides economies of scale and the promise of long-term sustainability, a comprehensive national programme requires both dietary supplementation and nutrition education components.

PIP: The effectiveness of two approaches to vitamin A deficiency prevention--nutrition education and mega-dose capsule distribution--was compared in a 3-year study involving almost 40,000 children 6 months to 10 years of age from seven ecologically diverse districts in Nepal. The nutrition education program promoted increased intake of vitamin A-rich foods during the dry season, serving wild greens, and primary health care service utilization. At baseline, 44.9% of the study villages did not have any cases of Bitot's spots; by the third year, 65.5% were free of this sign of vitamin A deficiency. 85% of community risk variation was explained by agricultural patterns, market food availability, household income, maternal literacy, sanitation, and the village's average nutritional status. At 12 months, capsule distribution had reduced the risk of new Bitot's spots by 55% (relative risk (RR), 0.45; 95% confidence interval (CI), 0.33-0.60); however, its impact had declined by 24 months and was non-significant at 36 months. At 24 months, the reduction of risk for xerophthalmia was greatest among children whose mothers were able to identify vitamin A-rich foods (RR, 0.25; 95% CI, 0.10-0.62) and were literate (RR, 0.06; 95% CI, 0.01-0.42). By 24 months, child mortality risk had declined in both the nutrition education (RR, 0.64; 95% CI, 0.48-0.86) and capsule distribution (RR, 0.57; 95% CI, 0.42-0.77) groups. Although the effects of both programs were similar, the capsule program achieved higher coverage rates at a lower cost while the educational intervention provided economies of scale and potential for long-term sustainability. Most feasible would be a comprehensive national program that included both these components as well as maternal literacy training.

Intestinal helminths and xerophthalmia in Nepal. A case-control study.

The study reports on 25 cases of xerophthalmia among children 6-120 months of age and single controls for which faecal egg counts were available as proxy for hookworm and Ascaris lumbricoides infection. The selection of cases and controls was performed by ophthalmic assistants. Controls were healthy children matched for sex, age, and neighbourhood of residence. Faecal analyses were performed by Kato thick-smear technique, recording the number of eggs of hookworm and A. lumbricoides. The xerophthalmia cases had a significantly higher prevalence (P < 0.05) and intensity (P < 0.01) of infection, as expressed by the presence and number of A. lumbricoides eggs per gram of faeces, respectively, compared with the control group. Hookworm eggs were not detected in the faecal specimens of any of the cases or controls. This study demonstrates the importance of A. lumbricoides as a risk factor for ocular signs of vitamin A deficiency. Reduction of prevalence and intensity of A. lumbricoides infection may reduce the incidence of xerophthalmia in the community with its potential sequels of blindness, morbidity, and mortality.

Ascariasis, hookworm infection and serum retinol amongst children in Nepal.

The study reports on the association between serum retinol levels and prevalence of two intestinal helminths in a random sample of 592 children, 6-120 months of age. Faecal analyses were performed by Kato thick-smear technique, recording the presence of hookworm and Ascaris lumbricoides eggs. Serum retinol levels were determined by high pressure liquid chromatography (HPLC) and expressed in micrograms/dl. The presence of Ascaris lumbricoides eggs was associated with lower levels of serum retinol in children below 60 months of age (p < 0.05). The presence of hookworm eggs was not associated with lower levels of serum retinol in any age group. In addition children who received at least one course of mebendazole during the past 12 months recorded higher serum retinol levels than children who did not receive it (p < 0.01).

The impact of vitamin A supplementation on morbidity: a randomized community intervention trial.

A randomized community trial investigated the impact of vitamin A supplementation on symptoms of respiratory and enteric infections among Indonesian children aged 1 to 5 years. A sample of 450 villages had been randomized into 229 villages that received vitamin A distribution and 221 that were observed as controls. The prevalence rates of cough, fever, and diarrhea were reduced in the treatment villages compared with the control villages by 8%, 5%, and 11%, respectively, but the reduction was not statistically significant. These results indicate that vitamin A supplements did not produce a substantial reduction in these symptoms, in spite of a reported reduction in all-cause mortality.

Nutritional and household risk factors for xerophthalmia in Aceh, Indonesia: a case-control study. The Aceh Study Group.

Risk factors for xerophthalmia were assessed in 466 subjects [38% with night blindness (XN), 60% with Bitot's spots (X1B), 2% with corneal xerophthalmia (X2 or X3)] under age 6 y and their village-age-sex-matched control subjects during a community trial. Socioeconomic status and hygiene standards were lowest for households of xerophthalmic children and highest for nonstudy households in the trial population, with values for control households lying in between (P less than 0.001 by linear trend). Risk of xerophthalmia increased with less frequent consumption of dark green leaves, yellow fruits, or egg during weaning, adjusted for current intake and present age [odds ratio (OR) = approximately 3.5]. Exclusion of these same foods from the current diet (except for mango and papaya in older children) was associated with a two- to ninefold excess risk of xerophthalmia, adjusted for weaning influences. Xerophthalmic children aged less than 3 y were generally at higher risk of dietary imbalance than were older children. Xerophthalmia is associated with a chronic, infrequent consumption of key vitamin A foods from weaning through early childhood.

Determinants of community-based coverage: periodic vitamin A supplementation. Aceh Study Group.

Factors related to preschool child receipt of vitamin A during the first year of a semi-annual vitamin A capsule delivery program were investigated in 229 villages in Aceh, Indonesia. Coverage was higher in villages which were more rural and less economically developed. Highest performance was achieved by village distributors who represented the local status quo in this rural area (farmers, or non-farmers with minimum education) rather than more upwardly mobile, highly educated residents. Household or child-level characteristics were not associated with coverage. This information may be useful for planning direct service programs in the community.

Rapid epidemiologic assessment of cataract blindness. The Aravind Rapid Epidemiologic Assessment Staff.

A major constraint to obtaining reliable information about blindness and its causes in developing countries is the limited availability of ophthalmologists for diagnosis in population-based surveys. This study in rural south India assessed the feasibility of using non-ophthalmologists to make diagnoses in a population-based survey. Ten men in their early twenties with 12 years of schooling were recruited and trained as ophthalmic assistants through a six week course in basic ophthalmology. All people aged 40 and older in households in 24 villages were enumerated and invited to have an eye examination. At a central site, 1309 subjects were independently examined by an ophthalmologist and two different ophthalmic assistants. Ophthalmic assistant cataract diagnosis is both sensitive and specific relative to the ophthalmologist's diagnosis. Sensitivity and specificity estimates were used to adjust prevalence estimates obtained from ophthalmic assistant examinations conducted at the central site as well as at the doorstep of sample households. The findings indicate that epidemiologic assessment of cataract blindness can be completed using non-ophthalmologists to diagnose cataract.

Reversal of the effects of aging in soybean seeds.

Accelerated aging predisposed seeds to imbibition injury. Slowing the rate of hydration prevented the loss of germinability due to imbibition injury. Germinability of accelerated aged seeds (50 hours) was increased from 10 to 90% by controlling the rate of imbibition. Slow hydration also prevented seed electrolyte leakage. This may indicate that cell membrane permeability or rupture was a major factor contributing to the loss of germinability after aging.Reversal of the effects of aging (repair) was accomplished by slowly inbibing and then redrying seeds (priming). This treatment lowered steep water conductivity by a factor of 2 to 5. Priming also increased the per cent germination of low vigor seeds. The mechanism of this reversal was probably metabolic because it depended on temperature, seed moisture, and treatment duration.Priming doubled the survival of seeds in the accelerated aging vigor test. The ;rejuvenation' was accepted as evidence for metabolic repair. Since the ;vigor' of seeds was increased by priming, metabolic repair probably included other subcellular components as well as the plasma membrane.

Effect of investments in water supply and sanitation on health status: a threshold-saturation theory.

A general theory on the relationship between water supply and sanitation investments and health, the threshold-saturation theory, is proposed. The theory takes into consideration three variables: health status, socioeconomic status, and sanitation level, and attempts to encompass, for the first time in one general theoretical framework, numerous conflicting empirical findings. The two-tiered S-shaped logistic form of the relationship that is proposed assumes that at the lower end of the socioeconomic spectrum there is a threshold below which investments in community water supplies and/or excreta disposal facilities alone result in little detectable improvement in health status. Similarly, at the higher end of the socioeconomic scale, it is suggested that a point of saturation is reached beyond which further significant health benefits cannot be obtained by investments in conventional community sanitation facilities.A preliminary attempt to validate this model using published data on sanitation level (defined as access to water supply), life expectancy, and adult literacy rates, for 65 developing countries, appears to provide preliminary support for the threshold saturation theory but further empirical validation is required before a quantitative predictive model can be developed.