A randomized comparison of oral misoprostol versus Foley catheter and oxytocin for induction of labor at term.

OBJECTIVE: We sought to compare the efficacy and safety of oral misoprostol administered to patients with the efficacy and safety in a control group treated with a Foley catheter and oxytocin for induction of labor. STUDY DESIGN: Two hundred patients requiring induction of labor at term with a Bishop score of

Effects of environmental tobacco smoke on objective measures of voice production.

OBJECTIVE: The effects of passive smoking on the voice and laryngeal structures of 20 female passive smokers and 20 age-matched nonsmokers were examined. METHODS: The voice evaluation consisted of acoustic, aerodynamic, and videostroboscopic analyses. RESULTS: Three passive smokers displayed mild edema or erythema. Passive smokers had higher mean flow rates and shorter mean maximum phonation times during sustained vowels at comfortable, low-, and high-pitch levels. However, means were only outside normal limits and significantly different from nonsmokers at high pitch. Variables such as the number of years and hours per day subjects were exposed to environmental tobacco smoke were considered. CONCLUSION: The majority of the variables indicated that vocal fold structure and function were not adversely altered by exposure to passive smoke. Differences between these results and clinical observations are highlighted.

Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group.

A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation. However, some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial. We carried out a prospective, randomized, multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and standard weaning parameters. Patients were randomly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways: with a T-tube system or with pressure support ventilation of 7 cm H2O. If a patient had signs of poor tolerance at any time during the trial, mechanical ventilation was reinstituted. Patients without these features at the end of the trial were extubated. Of the 246 patients assigned to the T-tube group, 192 successfully completed the trial and were extubated; 36 of them required reintubation. Of the 238 patients in the group receiving pressure support ventilation, 205 were extubated and 38 of them required reintubation. The percentage of patients who remained extubated after 48 h was not different between the two groups (63% T-tube, 70% pressure support ventilation, p = 0.14). The percentage of patients falling the trial was significantly higher when the T-tube was used (22 versus 14%, p = 0.03). Clinical evolution during the trial was not different in patients reintubated and successfully extubated. ICU mortality among reintubated patients was significantly higher than in successfully extubated patients (27 versus 2.6%, p < 0.001). Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing.

The prevalence of IgG antibodies to spotted-fever group rickettsiae among urban and rural dwelling children in southern Israel.

The prevalence of IgG antibodies to spotted-fever group rickettsiae was studied in a sample of 1,055 healthy children aged 2-17 years, residents of the desert Negev region of southern Israel. Groups of children from 5 different places of residency were tested: (1) urban children from the city of Beer-Sheva; (2) children from Omer, a suburb of the city; (3) children from rural communes ("kibbutz"); (4) children from small agricultural settlements ("moshav"); and (5) seminomadic bedouin children. Overall 40 sera (3.8%) were positive by the indirect immunofluorescent antibody assay at a titer of 40. The prevalence rate was 3.6% in males and 4.0% in females. Age-specific prevalence rates for the 2-5, 6-9, 10-13 and 14-17 year old groups were 2.0, 5.4, 4.1 and 3.6% respectively. The prevalence rates by place of residency were: urban 3.3%, suburban 3.3%, "kibbutz" 3.8%, "moshav" 5.1% and seminomadic children 3.3%, and did not differ by socio-economic status as measured by degree of crowding. The results indicate that spotted fever is endemic in all human habitats in the Negev region. Our data do not support association to sex or socio-economic status of the children tested. Lack of cumulative prevalence rates with increasing age suggests that antibodies may wane to undetectable levels in the years following the infection.

Clinical and laboratory findings of spotted fever in Israeli children.

In a prospective study of 70 Israeli children with spotted fever the major clinical features were fever (100%), skin rash (98.5%), myalgia (54%) and vomiting (40%). Thrombocytopenia (75%) and hyponatremia (62.5%) were common, but were not associated with increased mortality. Antibodies to Rickettsia conorii were detected by the indirect immunofluorescent antibody assay. In one patient Rickettsia was grown from blood. Contacts with dogs were reported in 17 of 40 patients questioned, and in only 2 was a canine tick bite obvious. Hospitalization was required in 11 (16%) patients. There was 1 fatality. The rickettsia responsible for spotted fever in Israel appears to be an antigenic variant of R. conorii. Early recognition and treatment of this disease permits rapid eradication of the rickettsiae and facilitates complete recovery.

Serological cross-reactions between Rickettsia typhi, Proteus vulgaris OX19, and Legionella bozemanii in a series of febrile patients.

The sera of 19 patients with a febrile disease of undetermined etiology were positive in the indirect immunofluorescence assay (IFA) to Legionella bozemanii serogroup 1 (Lb) and Rickettsia typhi (Rt). To both antigens, high titers of IgG-class and IgM-class antibodies were demonstrated. Several of the patients also had positive IFA and Weil-Felix reactions to Proteus vulgaris OX19 (PX 19). A sharp reduction of the serotiters to all three antigens was achieved by absorption of the sera with any one of the organisms. We demonstrated, by crossed immunoelectrophoresis with an Lb extract and a rabbit reference anti-Lb serum, that a heat-stable and trypsin-resistant antigen (antigen no. 1) reacted consistently with patients' sera that had been incorporated into an intermediate gel. Sera from five patients with high-titer IFA reactions to Rt, but no reaction to Lb, showed no interaction with antigen no. 1.

Prevalence of antibodies to Legionella species in a series of patients in Israel.

A collection of serum specimens from 77 patients at various hospitals or clinics in Israel was used to determine the usefulness of the enzyme-linked immunosorbent assay (ELISA) with a multivalent antigen for the detection of legionella antibodies. Rickettsial infection rather than legionellosis was suspected in most of these patients. The multivalent antigen was derived from Legionella pneumophila serogroups 1-6, L. bozemanii WIGA, and L. micdadei TATLOCK. A preliminary test of the multivalent antigen with specific rabbit antisera had shown that homologous reactions were not appreciably reduced in strength or specificity by the presence of the heterologous antigens. The results with the human sera revealed that 28 patients (36%) had reciprocal dilution titers greater than or equal to 1,280 and 43 (56%) had titers greater than or equal to 320. Tests with univalent antigens identified L. bozemanii as the only or principal antigen reacting with 13 of these sera. In contrast to the sera reacting with other legionella antigens, the great majority (11 of 13) of L. bozemanii-positive sera reacted also with Rickettsia typhi. The data suggest that most, but not all, reactions with L. bozemanii were elicited by a cross-reacting R. typhi antigen. These results were confirmed by cross-absorption tests.

Spotted fever and murine typhus in the Negev desert region of Israel, 1981.

During 1981, 52 cases of rickettsiosis caused by the spotted fever group of rickettsiae were reported in a population of 250 000 living in the Negev desert region of Israel. Retrospectively, at least 5 of these cases were serologically shown to have been caused by Rickettsia typhi, the agent of murine typhus. Most cases of rickettsial disease occurred in the summer months and one half of all cases occurred in children aged 9 years or less. While the specificity of a physician's diagnosis of the rickettsial diseases appears to be high (i.e., few cases of other diseases are misdiagnosed as either spotted fever or murine typhus), the sensitivity of the physician's diagnosis may be lower (i.e., many cases of these diseases presenting as fevers of unknown origin are not diagnosed as rickettsial disease). These findings may also be important for other countries of the region.

Rickettsial antibody prevalence in southern Israel: IgG antibodies to Coxiella burnetii, Rickettsia typhi, and spotted fever group rickettsiae among urban- and rural-dwelling and Bedouin women.

A retrospective serological survey was carried out using sera obtained from women at childbirth in the southern desert region of Israel to determine exposure experience to three rickettsial agents: Coxiella burnetii, Rickettsia typhi, and spotted fever group rickettsiae. Using the indirect fluorescent antibody method for determining IgG antibodies, it was found that about 40% of all sera examined demonstrated antibodies to one or more rickettsiae. Bedouin women appeared to be at greater risk of having antibodies to C. burnetii and spotted fever group rickettsiae than did Jewish residents of Beersheba, agricultural settlements, and development towns. The residents of development towns appeared to be at lower risk of developing antibodies to spotted fever group rickettsiae than did other populations sampled. Possible reasons for these differences are discussed.

Preparation and use of erythrocyte-globulin conjugates to Lassa virus in reversed passive hemagglutination and inhibition.

Conditions were defined for functional covalent coupling of anti-Lassa virus globulins to glutaraldehyde-fixed chicken erythrocytes. Tolylene-2,4-diisocyanate in a reaction mixture containing not more than 0.01 M NaCl produced uniformly good conjugates which were used in reversed passive hemagglutination (RPH) and reversed passive hemagglutination inhibition (RPHI) tests to detect Lassa virus antigens in infected cell cultures and specific antigens in Vero cell cultures. Identical results were obtained with this method and with immunofluorescent-antibody (IFA) staining in the detection and identification of Lassa virus isolated from human and rodent specimens from West Africa. The RPHI method was equal to IFA for serological diagnosis of acute human Lassa virus infection and superior to IFA, complement fixation, and a radioimmunoassay procedure for detection of Lassa virus antibodies in a human population where this infection is endemic.