Diagnosing coeliac disease by rectal gluten challenge: a prospective study based on immunopathology, computerized image analysis and logistic regression analysis.

The purpose of this study was to evaluate the use of rectal gluten challenge in the diagnosis of coeliac disease. A total of 103 patients with features suggestive of this diagnosis were prospectively enrolled into the study; a diagnosis of coeliac disease was based on strictly defined criteria used in judging the proximal jejunal biopsy. On that basis, 45 out of the 103 patients were deemed to have coeliac disease. A slurry of gluten powder in physiological saline was introduced into the rectum, and biopsies taken before and at 2 h or 4 h after the challenge were examined immunohistochemically by computerized image analysis. Cell counts were analysed by logistic regression, and the best equations were obtained for each challenge group. The 2 h challenge yielded diagnostic sensitivity and specificity of 69.6% and 78.6% respectively. The 4 h challenge provided sensitivity and specificity of 100% and 100% respectively. These results were compared with other clinical diagnostic predictors,including anti-endomysial antibodies, which yielded diagnostic sensitivity and specificity of 70% and 98% respectively. It is concluded that a 4 h rectal challenge is a highly sensitive means of identifying gluten-sensitized individuals, and would be of particular value in cases showing negative antibody screening or equivocal biopsy appearances.

A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective.

A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral--126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar--almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was 52.85 Pounds for those in urban areas and 59.93 Pounds per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was 47.13 Pounds for urban patients and 48.77 Pounds for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.

Qualitative investigation of the meanings of eating fruits and vegetables for adult couples.

OBJECTIVE: The purpose of this study was to develop a substantive theory expressing the meanings couples associated with eating fruits and vegetables. DESIGN: This inductive qualitative study was based on a grounded theory approach and employed the constant comparison method of data analysis. Data were collected using semistructured individual interviews and a life history approach. SUBJECTS: Ten adult couples, aged 20 to 60 years, with and without children, all of whom were born in North America, were recruited using modified snowball sampling. RESULTS: Two overarching themes emerged. The "should syndrome" describes a morality concerning fruit and vegetable consumption arising from a tension between the low status of these foods in participants' childhood homes and their contemporary idealized status. The creation of couple gastronomies expresses couples'efforts to construct their own food norms and practices within a context of changes in social norms and fruit and vegetable availability. The substantive theory, making choices that balance their lives, conveys the dynamic processes involved in participants' fruit and vegetable choices. IMPLICATIONS: Future research will determine the transferability of the "should syndrome" and new couples' receptiveness to trying new fruits and vegetables. Understanding the changing contexts of food choice may help nutrition professionals better support healthful eating.

Nutrient removal with methanol as a carbon source full-scale continuous inflow SBR application.

Methanol was applied to a full-scale continuous inflow SBR, as a carbon source for denitrification and possible phosphorus removal. This research was conducted at the District of Kent Wastewater Treatment Plant in Agassiz, British Columbia, Canada. This plant employs two SBR's working in parallel; one unit was used as a control, without the addition of methanol. There was no difference in the overall total nitrogen removal efficiency through methanol addition, however,the additional carbon source significantly shortened the denitrification reaction time in the existing reactor. The high nitrogen removal efficiency, with or without methanol addition, was primarily due to the advantages provided by continuous-flow SBR carbon loading. The phosphorus removal efficiency in the experimental SBR was also consistently higher than in the control SBR. The solids production from methanol addition wa s estimated to vary between 0.18 and 0.29gVSS/gCH3OH. Methanol addition also had an influence on the settling qualities of the sludge.

Heart health Hamilton-Wentworth survey: programming implications.

This telephone survey (n = 601) provided baseline data for the development and evaluation of cardiovascular disease (CVD) prevention programming in the City of Hamilton. Questions covered health history, awareness of CVD risk factors, hypertension control, smoking, dietary fat knowledge, physical activity, and preferred sources of health promotion information. Body mass index values over 25 kg/m2 were calculated for 55.2% of respondents (n = 439). Smoking and poor diet were the most frequently reported CVD risk factors. Lack of time was the main barrier to increased physical activity for nearly 54% of respondents. Print media (55%) and physicians (36%) were preferred sources of healthy eating information, while physical activity information was most likely to be sought from recreation centres (37%) and print media (34%). Smokers who wished to quit would consult a physician. In the City of Hamilton, CVD prevention programming should support healthy body weights through promotion of active lifestyles and healthy eating.

A comparison of real-time and store-and-forward teledermatology: a cost-benefit study.

BACKGROUND: Increasing use of teledermatology should be based on demonstration of favourable accuracy and cost-benefit analysis for the different methods of use of this technique. Objectives To evaluate the clinical efficacy and cost-effectiveness of real-time and store-and-forward teledermatology. METHODS: Patients attended their own health centre and in the company of a general practitioner (GP) were seen by a hospital dermatologist over the videolink (real-time). Before the videolink consultation commenced, the GP took instant photographs of the skin lesion and posted them along with a standard referral letter to a different hospital dermatologist (store-and-forward). In total, 96 patients were seen by both real-time and store-and-forward teledermatology. Comparative diagnoses, clinical management plans, clinical outcomes and associated costs were made between the two types of teledermatology consultation. RESULTS: There was agreement between the videolink diagnosis and the still image diagnosis in 51% of cases. The same or similar management plan was recommended at both types of consultation in 44% of cases. Following the store-and-forward consultation the dermatologist recommended that 69% of patients required at least one hospital appointment compared with 45% of those patients seen in real-time. The net societal cost of the initial real-time consultation was pound132.10 per patient compared with £26.90 per patient for the initial store-and-forward consultation. CONCLUSIONS: The store-and-forward consultation was cheaper, but less clinically efficient, compared with the real-time consultation. The absence of interaction in a store-and-forward consultation limits the dermatologist's ability to obtain clinically useful information in order to diagnose and manage a patient satisfactorily.

A randomized controlled trial to assess the clinical effectiveness of both realtime and store-and-forward teledermatology compared with conventional care.

The clinical effectiveness of realtime teledermatology, store-and-forward teledermatology and conventional outpatient dermatological care were evaluated in a randomized control trial. A total of 204 patients took part--102 patients were randomized to the realtime teledermatology consultation, 96 of whose cases were also referred using a store-and-forward technique, and 102 to the conventional outpatient consultation. There were no differences in the reported clinical outcomes of realtime teledermatology and conventional dermatology. Of those randomized to the realtime teledermatology consultation, 46% required at least one subsequent hospital appointment compared with 45% of those randomized to the conventional outpatient consultation. In contrast, the dermatologist requested a subsequent hospital appointment for 69% of those seen by store-and-forward teledermatology. An analysis of costs showed that realtime teledermatology was clinically feasible but more expensive than conventional care, while the store-and-forward teledermatology consultation was less expensive but its clinical usefulness was limited. Sensitivity analysis indicated that realtime teledermatology was as economical as conventional care when less artificial assumptions were made about equipment utilization, costs and travel distances to hospital.

Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis.

OBJECTIVES: Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance. DESIGN: Randomised controlled trial with a minimum follow up of three months. SETTING: Four health centres (two urban, two rural) and two regional hospitals. SUBJECTS: 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation. MAIN OUTCOME MEASURES: Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care. RESULTS: No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was pound132.10 per patient for teledermatology and pound48.73 for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal. CONCLUSIONS: Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care.

Patient cost-benefit analysis of teledermatology measured in a randomized control trial.

A randomized controlled trial of the costs and benefits of teledermatology consultations compared with traditional hospital consultations was carried out. Over a nine-month period, 197 patients were referred from general practice for a dermatological opinion, 98 for a teledermatology consultation and 99 for a hospital consultation. Eighty patients required an additional subsequent hospital appointment. Patients were asked to complete an economic questionnaire after each consultation, and 164 questionnaires were returned: 62% of those randomized to the teledermatology consultation responded compared with 58% of those randomized to the hospital consultation. Patients seen by teledermatology at their own health centre had shorter distances to travel and spent less time overall attending the appointment compared with those seen at the hospital. However, the teledermatology consultations were more time-consuming for the general practitioner and dermatologist. These findings indicate that teledermatology has more benefits for the patient than for the health-care delivery team.

Pediatric blood cultures.

The clinical and laboratory issues important in pediatric blood cultures are similar to those in adult blood cultures with a few noteworthy exceptions. The collection of an uncontaminated specimen and an ample volume of blood is more difficult, especially in neonates. In addition, children often have previously received oral antibiotics or a broad-spectrum parenteral antibiotic. The relative frequencies of the pathogens causing bacteremia in children are different in important ways from in adults. Haemophilus influenzae b, although much less common than in the past, is still an important pediatric pathogen. Meningococcemia is relatively more common in children than in adults, and enterobacteriaceae and anaerobes are relatively less common. Group B streptococci, E. coli, coagulase-negative staphylococci, and Candida sp. are the principal pathogens in neonates. More changes in the distribution of blood-borne pathogens can be expected in the future with the introduction of new or more effective vaccines against the pneumococcus, meningococcus, and, possibly, group B streptococcus. In suspected community-acquired bacteremia in otherwise normal children, a single aerobic blood culture of adequate volume is sufficient. Sick neonates, hospitalized children with indwelling intravascular devices, and immunocompromised children may need multiple blood cultures, paired cultures from an indwelling vascular catheter and a peripheral vein, or use of special media. There is no single optimal system for pediatric blood cultures. The BACTEC systems have been adopted as a single system in many hospitals serving both children and adults because of the favorable results reported in children and the preference of using a single automated system. To maximize the detection of bacteremia and fungemia, some laboratories may wish to combine a BACTEC system with a second complementary system, such as the Isolator. Anaerobic, mycobacterial, and other special blood culture media should be reserved for selected patients.

Immunogenicity and safety of Haemophilus influenzae type b-tetanus protein conjugate vaccine alone or mixed with diphtheria-tetanus-pertussis vaccine in infants.

Haemophilus capsular polysaccharide-tetanus toxoid conjugate (PRP-T) and diphtheria-tetanus-pertussis (DTP) vaccines were administered in a single syringe (group 1) or separate syringes (group 2) to 284 infants at 2, 4, and 6 months of age. Group 1 infants had a slightly greater incidence of local reactions. Systemic reactions were similar. The geometric mean titers of polyribosylribitol phosphate (PRP) serum antibody concentrations after the third dose of PRP-T vaccine were 4.8 and 4.3 micrograms/ml for groups 1 and 2, respectively. Antibody responses to DTP antigens were also similar. The immunogenicity and safety of the PRP-T and DTP vaccines are equivalent when the vaccines are administered in separate syringes or the same syringe to infants.

Effects of amrinone on thrombin-induced platelet-derived growth factor-like protein secretion from endothelial cells.

Endothelial cells (EC) secrete platelet-derived growth factor (PDGF)-like protein, which is a potent mitogen to smooth muscle and connective tissue cells. The purpose of this study was to determine if amrinone, a phosphodiesterase inhibitor, could inhibit PDGF-like protein secretion on the basis of its ability to increase cAMP. Human umbilical artery endothelial cells (HUAEC) (n = 7) were preincubated for 4 h with amrinone (10 micrograms/mL) before coincubation with thrombin (10 IU/mL) and amrinone (10 micrograms/mL) for 18 h. The supernatant was then assayed for the presence of both PDGF-like protein by using a competitive 125I-PDGF radioreceptor inhibition assay, and cAMP by using an RIA. Thrombin-induced PDGF-like protein secretion from HUAEC was significantly inhibited by amrinone (7.8 +/- 1.6 fmol/10(6) EC) when compared with thrombin alone (12.1 +/- 2.4 fmol/10(6) EC) (p less than 0.05). Amrinone alone had no effect on baseline PDGF-like protein secretion. Amrinone inhibition of thrombin-induced PDGF-like protein secretion was comparable whether amrinone was added to HUAEC 4 or 0 h before thrombin, and it was dose dependent with a maximal inhibition of 82.7% by amrinone (160 micrograms/mL). In contrast, IL-1 alpha (10 micrograms/mL) and tumor necrosis factor (100 ng/mL) induced less secretion of PDGF-like protein from HUAEC, and this secretion was not inhibited by amrinone. Amrinone (10 micrograms/mL) significantly increased secretion of cAMP from HUAEC from a baseline value of 6.4 +/- 0.4 pmol/10(6) EC to 10.6 +/- 0.1 pmol/10(6) EC (p less than 0.01). We conclude that amrinone inhibits thrombin-induced PDGF-like protein secretion from HUAEC.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative evaluation of radiometric tryptic soy broth versus radiometric tryptic soy broth with 10% sucrose for detection of bacteremia and fungemia in pediatric patients.

We compared BACTEC radiometric blood culture media with (8B) and without (6B) 10% sucrose for the detection of bacteremia and fungemia in pediatric patients at four university teaching hospitals that used identical methods for obtaining and processing specimens. Overall, the yields of microorganisms from 5,714 blood culture sets were no different in the two media, although a trend was noted favoring 6B for the detection of pneumococci. Speed of detection of positive results was faster in the 6B than in the 8B medium (P less than 0.05), largely due to the faster detection of Staphylococcus aureus in the 6B medium. We conclude that, overall, with pediatric patients the hypertonic 8B radiometric medium has no advantage and that it possibly has a modest disadvantage, compared with isotonic 6B radiometric medium.

Exercise during pregnancy.

Routine exercise has become an accepted component of a healthy lifestyle, and many women want to continue exercising during pregnancy. In most cases, pregnant women can maintain previous levels of activity, while sedentary women can undertake new activities gradually.

Severe facial injuries to infants due to unprovoked attacks by pet ferrets.

Three infants were attacked by pet ferrets and sustained severe facial injuries. Two of the children had their ears bitten off and required reconstructive surgery. The attacks were unprovoked. Two of the children were asleep in their cribs when they were bitten. Although ferrets are increasingly popular pets, we believe that they are not suitable pets for families with small children. Physicians should be aware that ferrets may unpredictably injure infants and that no effective rabies vaccine for ferrets is yet available.

Controlled evaluation of blood culture medium containing gelatin and V-factor-analog for detection of septicemia in children.

Both Neisseria meningitidis and Haemophilus influenzae are important isolates recovered in blood cultures from septicemic children. Sodium polyanetholsulfonate is present in most blood culture media and can inhibit the growth of certain bacteria, including N. meningitidis. The addition of gelatin to blood culture media neutralizes this inhibition. The growth of H. influenzae is enhanced by specific growth factors such as hemin and NAD. The addition of gelatin and V-factor-analog (a proprietary supplement for enhancing the growth of H. influenzae) might have a positive effect on the yield and on the speed of detection of septicemia in children. To evaluate this possibility, we did 4,565 paired comparisons of blood cultured in BACTEC 6B (aerobic) medium with and without the addition of both 1.2% gelatin and V-factor-analog. More aerobic and facultative bacteria grew in the 6B than in the 6B-gelatin-V-factor-analog medium (P less than 0.01). Only seven isolates of Neisseria spp. were recovered during this study period, with the 6B medium performing as well as the supplemented medium. When microorganisms grew in both bottles, they did so at the same time except for H. influenzae and Candida albicans. H. influenzae was recovered earlier from the 6B-gelatin-V-factor-analog bottle (P less than 0.01), with a mean time to detection of 8.5 h compared with 15.9 h for the 6B bottle. C. albicans was recovered earlier from the 6B bottle (P less than 0.02), with a mean time to detection of 34.9 h compared with 71.6 h for the 6B-gelatin-V-factor-analog bottle. We conclude that the 6B medium in its present formulation is superior to bB supplemented with gelatin and V-factor-analog.