Case reports: acute hookworm infection: an unusual cause of profuse watery diarrhoea in returned travellers.

We describe 3 returned travellers who developed profuse watery diarrhoea associated with marked blood eosinophilia. Delayed appearance of ova in stool samples caused difficulty in establishing diagnoses of acute hookworm infection. Low activity of ivermectin against hookworm resulted in failure of empiric treatment with this agent prior to parasitological diagnosis.

Single-tube, nested PCR for the diagnosis of human brucellosis in Kuwait.

The polymerase chain reaction (PCR) offers a sensitive and specific way of detecting microbial DNA in clinical samples. The aims of the present study were to develop an assay, based on a single-tube, nested PCR, for identifying Brucella in samples of human blood and then to explore the use of this test in diagnosis. The primers chosen were derived from IS711, the insertion sequence gene found in all species of Brucella. The assay amplified a 52-bp final product which was detected colorimetrically. The PCR was sensitive and specific, giving positive reactions with 14 strains of Brucella from five species. The lower limit of detection in vitro was 30 organisms. There were no false-positive reactions either with a range of bacteria known to evoke serological cross-reactions with Brucella (Vibrio cholerae, Yersinia enterocolitica, Serratia marcescens, Haemophilus influenzae, Pseudomonas aeruginosa and Escherichia coli K12) or with organisms producing similar clinical syndromes (Mycobacterium tuberculosis and Salmonella typhi). The results of a preliminary field trial of the assay in Kuwait indicate that the assay may be a valuable technique in the diagnosis of human brucellosis, meriting further study with larger numbers of cases. All 28 subjects with brucellosis (diagnosed on the basis of typical clinical features and confirmed by positive serology and, in three cases, by positive blood cultures) were PCR-positive whereas 28 healthy controls and 28 patients with febrile illness attributable to infections other than brucellosis were PCR-negative.

Blood pressure monitoring with home monitors versus mercury sphygmomanometer.

OBJECTIVE: To determine the accuracy of three automatic monitors (arm, wrist, finger) for blood pressure measurement manufactured by Omron compared with a standard mercury sphygmomanometer. PRIMRY END POINT: Difference in the mean blood pressure readings from each monitor; the secondary end point was difference in pulse readings. DESIGN: A single-visit, crossover trial tested each device twice on the left arm of each participant; the average of the two readings was recorded. The pulse readings from each monitor were also recorded. ANOVA was used to compare mean blood pressure readings and pulse readings from each device. RESULTS: A total of 55 persons (mean age 53 y; 36 women) met inclusion criteria and completed the study. The mean systolic and diastolic readings obtained from the electronic arm unit were comparable to the mercury readings (124.4/78.02 vs. 129.45/77.87 mm Hg, respectively; p > 0.05 for both readings). The mean results obtained from the wrist and finger monitors differed significantly from those of the mercury readings (145.44/89.58 and 113.94/69.07 mm Hg, respectively; p < 0.05 for both monitors compared with control). No difference was measured in the mean pulse readings between the comparisons (p = 0.72). The absolute difference in systolic and diastolic blood pressure readings from control varied the least wih the arm monitor. CONCLUSIONS: Compared with the mercury sphygmomanometer, the arm monitor was the most accurate in measuring blood pressure. The wrist and finger monitors resulted in statistically significant mean systolic and diastolic differences compared with the mercury sphygmomanometer.

A study of 235 cases of human brucellosis in Sana'a, Republic of Yemen.

We studied the clinical characteristics of brucellosis among all patients with brucellosis referred to the Central Health Laboratory from the main hospitals in Sana'a during a 2-year period (1992-93) (235 adults and children). A history was taken from each patient and clinical examination, general laboratory tests and brucellosis laboratory tests carried out. The overall clinical picture of brucellosis in this study is very similar to that reported by other workers in this geographical area. Awareness of the presenting features and the realization that brucellosis should be part of the differential diagnosis of febrile patients with enlarged liver, spleen and lymph nodes will lead to an increasing index of suspicion for this disease.

A study of 235 cases of human brucellosis in Sana'a, Republic of Yemen

We studied the clinical characteristics of brucellosis among all patients with brucellosis referred to the Central Health Laboratory from the main hospitals in Sana'a during a 2-year period [1992-93] [235 adults and children]. A history was taken from each patient and clinical examination, general laboratory tests and brucellosis laboratory tests carried out. The overall clinical picture of brucellosis in this study is very similar to that reported by other workers in this geographical area. Awareness of the presenting features and the realization that brucellosis should be part of the differential diagnosis of febrile patients with enlarged liver, spleen and lymph nodes will lead to an increasing index of suspicion for this disease

Risk factors for human brucellosis in Yemen: a case control study.

Brucellosis is known to occur in Yemen but its epidemiology has not been extensively studied. The present investigation examined risk factors for human brucellosis in Yemen using a hospital-based case-control study. A total of 235 consecutive patients with brucellosis attending the Central Health Laboratory in Sana'a, Yemen, were matched in respect of age, sex, and place of residence, rural or urban, with 234 controls selected from individuals attending the Central Health Laboratory for unrelated health problems. Clinical information on patients and controls was supplemented with occupational and socio-economic data obtained by interview of cases and controls using a standard questionnaire. After controlling for confounding factors significant risk factors for infection related to occupation as a farmer (OR 2.5 (95% CI 1.4-4.5, P < 0.0001)), shepherd (OR 7.8 (95% CI 1.0-61, P 0.05)) or microbiologist (OR 24.5 (95% CI 2.9-204, P 0.003)); and drinking fresh milk (OR 2.0 (95% CI 1.3-4.3, P 0.001)) and laban (OR 22.7 (95% CI 1.7-4.2 P < 0.0001)). Taking other milk products and offal were not risk factors. Socio-economic and educational factors were also independent risk factors. Occupational, food and socio-economic risk factors significantly confounded one another. Yemen shares some but not all of the risk factors of neighbouring countries. The interrelation between the various factors is complex and studying any one in isolation may give a false impression of its public health significance. Control through education of the population to minimize exposure to, and contact with, animals and their milk and milk products and to boil milk before drinking it or using it to make buttermilk, would be difficult as these would represent such fundamental changes to established patterns of behaviour of this society. Ideally there would be a campaign to control the infection by animal vaccination but the costs and logistic difficulty would be great. Presently there is a clear need for doctors in Yemen to be made aware of the frequency of this infection, the means available for clinical and laboratory diagnosis and effective treatment, while strategies to control the disease in Yemen are formulated and field tested.

Presentation and outcome of 1107 cases of schistosomiasis from Africa diagnosed in a non-endemic country.

Schistosomiasis is found in a significant proportion of returning travellers and immigrants to Britain. This study is a retrospective review of 1107 consecutive cases of schistosomiasis from Africa diagnosed by microscopy or serology presenting to the Hospital for Tropical Diseases, London, UK. 50.4% of cases were asymptomatic. The most common symptom which resolved on treatment was tiredness. Serology was positive in 951 (86%), and ova seen in 45%. Urine dipstick testing was positive for blood in 21% and protein in 15%, with eosinophilia in 44%. In this population urine dipstick, full blood count and serology were all insufficient screening tools used alone. Among patients with full follow-up data 3 months or more after treatment with praziquantel, definite treatment failure occured in 4 of 271 (1.5%), restricting the analysis to those with ova seen at diagnosis. There was no significant difference in treatment failure between 1 and 3 days of treatment. Antibody level was the same or higher than at treatment in 55% of cases seen after about 3 months and 38% after 1 year, confirming it is probably of limited clinical use in detecting treatment failure.

Picking up the pieces.

This paper examines some of the current evidence of stress and burnout among nurses and other health care workers. Even in environments where pay and conditions are good, nurses still experience significant difficulties in healing relationships, stress and burnout sufficient to render them dysfunctional at work. The paper, using the case study of a unit set up to provide care for nurses, examines how the needs of nurses can also be taken into account in the holistic perspective on caring.

Clinical supervision: making it happen.

When owned and governed by those who implement it, clinical supervision can become a living, breathing part of professional working life, and not just another ritual. A multidisciplinary team from Southampton explains.

Enzyme-linked immunosorbent assay for brucella antigen detection in human sera.

A sandwich enzyme-linked immunosorbent assay (ELISA) with monoclonal antibody coupled to the solid phase was evaluated for the detection of brucella antigen in serum samples. Under optimum conditions, 100 brucella cells/well or 10(5) fg/ml of lipopolysaccharide (LPS) were detected in spiked specimens. The standardised assay was performed on 1607 sera from random blood donors, 146 patients with brucellosis, 20 persons in high risk groups and 264 sera from patients with diseases other than brucellosis. Sensitivity was 100% compared with positive blood culture, and 44% compared with serological tests for brucella antibodies. Specificity was 99.5% among random blood donors and 99.2% in the patient population. These data showed a strong agreement between ELISA antigen detection and blood culture for the detection of brucella positive blood samples. Moreover, the results indicated that antigen detection by ELISA could be an acceptable alternative to blood culture for the diagnosis of brucellosis.

Towards a defence of nursing routine and ritual.

Healing routines and rituals have been an essential part of life since time in memorial. Rather than dismiss modern healing rituals because, in many instances, they appear to have no empirically proven manifest function, an argument is proposed in defence of routine and ritual, suggesting that there is an urgent need to explore their meaning or latent function.

A networking approach to clinical supervision.

Clinical supervision offers support in clinical and professional development. This article discusses a number of approaches to supervision and describes the use of a networking model when a nursing development unit was created.

The CIO's position in today's emerging health care system: lessons learned.

The integrated delivery network is a new concept. Using information technology as a rallying point has allowed people to come together in a non-threatening way. They discuss new ideas and possibilities for improving the performance of their individual institution and thus, the entire Network. How quickly and how well business adapts to this new model will dictate long-term viability in the marketplace. Technology will not be the limiting factor to success in this new endeavor. It will be a facilitator that can help the organizational transition from single institutions to an IDN. The challenge is in managing how well personnel accept this change and seek ways to work together in this new endeavor. The ability to perform competently at these new levels comes from the ability to perform as a senior executive, acting in partnership and peer relationships as a facilitator and leader. To manage the change required in these new organizations, there must be common vision, the creation of new roles, agreed upon priorities, flexibility, and standardization when necessary. While there is not one right solution, leadership and shared vision and the ability to deliver are key success factors.

Clinical and laboratory features of patients with loiasis (Loa loa filariasis) in the U.K.

To assess differences between Africans and expatriates, we reviewed records of 100 patients with loiasis presenting to The Hospital for Tropical Diseases, London. Fifty-one were black Africans, and 49 were white expatriates. A history of Calabar swellings was more common amongst expatriates (P = 0.0001, OR 8.1), whilst eyeworm was reported more frequently in Africans (P = 0.0038, OR 4.2). Higher eosinophil levels (P < 0.0001) and filarial antibody levels, whether measured by immunofluorescence (P = 0.047) or ELISA (P < 0.0001) were present in the expatriates. Africans were more likely to have microfilaraemia (P < 0.0025, OR 7.3), and among microfilaraemic patients, Africans had denser microfilaraemia (P = 0.012). The sensitivity of microfilaremia as a screening test for loiasis was 75% in Africans and 29% in expatriates. The sensitivities of filarial antibody tests in Africans and expatriates were 81% and 100% for IFAT, and 28% and 93% for ELISA. Following treatment, 63% of patients were considered cured, 25% were lost to follow-up and 12% had a documented relapse. The differences between the two groups of patients could be caused by differences in the chronicity of loiasis, but other explanations are also discussed.

The need to develop nursing practice through innovation and practice change.

This paper examines some of the strategies that can be used to produce change in nursing. These strategies range from the power-coercive through rational-empirical to the normative-re-educative. Strategies that promote a 'bottom-up' approach are advocated for clinical nursing and some of the principal factors towards success, such as team building, the presence of a clinical leader and planning are indicated. The paper will also expand on what needs to be changed in nursing, and what the purpose of such changes are. It is argued that externally focused efforts of change, such as the organization of care or new practices are only part of the picture. The journey of change also requires an inner exploration of who we are and what are we seeking to achieve in nursing.