Attitudes towards and evaluation of medical emergency teams: a survey of trainees in intensive care medicine.

A survey was conducted to explore the perception of intensive care registrars on the impact of activities outside the intensive care unit (ICU), particularly in medical emergency teams, on their training and the care of patients. An anonymous mail-out survey was sent to 356 trainees registered with the Joint Faculty of Intensive Care Medicine, half of whom were determined to be involved in ICU duties. No patients were involved and respondents participated voluntarily. The main outcome measures were barriers and predictors of satisfaction with ICU training. One-hundred-and-thirty-six (38%) trainees responded. Seventy-eight percent had participated in a medical emergency team, of whom 99% of respondents stated the medical emergency team included an ICU registrar but rarely (3%) an ICU consultant. Sixty-six percent of respondents reported that medical emergency team involvement had a positive effect on training but 77% reported little or no supervision of team duties. While trainees did not believe they spent too much time performing medical emergency team duties, the time spent on medical emergency teams at night, when ICU staffing levels are at their lowest, was the same as during the day. Serious concern was expressed about the negative impact of medical emergency team activities on their ability to care for ICU patients and the additional stress on ICU medical and nursing staff Overall, ICU trainees regarded participation in a medical emergency team as positive on training and on patient care in wards, but other results have resource implications for the provision of clinical emergency response systems, care of patients in ICUs and the training of the future intensive care workforce.

Group A streptococcal skin infection outbreak in an abattoir: lessons for prevention.

During a group A streptococcus (GAS) outbreak 21 abattoir workers developed skin infections. The unusual outbreak strain (emm 108.1) was cultured from five workers and four persons in the community with links to the abattoir. The attack rate was 26% in the lamb line. Communal nailbrushes were neither routinely disinfected nor changed, and had high bacterial counts. A cohort study found a higher risk from working in the gutting area and getting cuts on hands more than weekly. Despite high bacterial counts daily nailbrush use had a lower risk, as did always wearing disposable gloves. Working in the gutting area (OR 11.44) and nailbrush use at least once a day (OR 0.04) were significant in the multivariate model. Transmission of infection is likely to have occurred on carcasses. GAS infection among abattoir workers was once common. Simple hygiene measures, such as nailbrush use, may reduce the impact of future outbreaks.

Analysis of the genomic region containing the tammar wallaby (Macropus eugenii) orthologues of MHC class III genes.

Major histocompatibility complex (MHC) molecules are central to development and regulation of the immune system in all jawed vertebrates. MHC class III cytokine genes from the tumor necrosis factor core family, including tumor necrosis factor (TNF) and lymphotoxin alpha and beta (LTA, LTB), are well studied in human and mouse. Orthologues have been identified in several other eutherian species and the cDNA sequences have been reported for a model marsupial, the tammar wallaby. Comparative genomics can help to determine gene function, to understand the evolution of a gene or gene family, and to identify potential regulatory regions. We therefore cloned the genomic region containing the tammar LTB, TNF, and LTA orthologues by "genome walking", using primers designed from known tammar sequences and regions conserved in other species. We isolated two tammar BAC clones containing all three genes. These tammar genes show similar intergenic distances and the same transcriptional orientation as in human and mouse. Gene structures and sequences are also very conserved. By comparing the tammar, human and mouse genomic sequences we were able to identify candidate regulatory regions for these genes in mammals. Full length sequencing of BACs containing the three genes has been partially completed, and reveals the presence of a number of other tammar MHC III orthologues in this region.

Survey, characterization and susceptibility to fusidic acid of Staphylococcus aureus in the Carmarthen area.

OBJECTIVE: This retrospective study was designed to investigate the possible reasons for an apparent increase in fusidic acid resistance among Staphylococcus aureus. MATERIALS AND METHODS: The Datastore records of the Communicable Disease Surveillance Centre, Wales, UK were reviewed in conjunction with information concerning the prescribing of fusidic acid. RESULTS: During the 5 year study period (1997-2001), a rise in the incidence of fusidic acid resistance was noted, particularly among paediatric patients presenting with infected eczema and impetigo, which may be related to the observed increase in prescriptions of topical fusidic acid. Extended phenotypic and genotypic characterization of a limited number (n=31) of isolates from 2002 showed that fusidic acid-resistant strains of S. aureus were typically from patients with impetigo and isolates fell into a single clonal group. Conversely, isolates from other skin disease (eczema, dermatitis and abscesses) were usually susceptible to fusidic acid and proved a diverse group. CONCLUSION: This study provides valuable data on the prevalence of fusidic acid-resistant S. aureus, the genetic background of the strains, and their association with clinical disease in both the healthcare environment and community setting in the catchment area served by the Laboratory.

Multi-system Infection with Nocardia farcinica-therapy with linezolid and minocycline.

We describe a case of disseminated infection with a multiple-resistant strain of Nocardia farcinica, probably resulting from direct inoculation during a road traffic accident. Initial presentation was with pulmonary symptoms, with subsequent development of cutaneous, renal, soft tissue and cerebral involvement. Precise microbiological diagnosis was delayed. Once sensitivity test results were available, the patient was stabilised on linezolid and minocycline. Premature withdrawal of therapy at one month resulted in recrudescence of infection, requiring re-institution of treatment. Linezolid was discontinued after a total of 4 months, because of evidence of myelosuppression and visual impairment, which subsequently improved. Monotherapy with minocycline was continued for a total of 12 months. The patient now remains well.

Granulomatous peritonitis in hydatid disease.

We report a rare case of persisting granulomatous inflammation within the peritoneal cavity due to previous leakage from a liver hydatid cyst, with the granulomata bearing hooklets originating from protosolices of Echinococcus granulosus. The patient was treated with a full three-month course of albendazole. We believe this represents a rare case of 'pseudotuberculous peritonitis'.

Bilateral vocal cord palsy following interscalene brachial plexus nerve block.

Acute respiratory complications of an interscalene brachial plexus block include ipsilateral phrenic nerve and recurrent laryngeal nerve palsies. A 71-year-old woman who had undergone a total thyroidectomy for papillary carcinoma 35 years ago was administered a right interscalene brachial plexus block for a shoulder hemi-arthroplasty. Subsequently she developed acute respiratory distress associated with marked stridor secondary to an acute right vocal cord palsy, which was superimposed on what was assumed to be a preexisting left-sided vocal cord palsy. On extubation the patient was noted to develop stridor again necessitating reintubation and tracheostomy was performed two weeks later. The vocal cord palsies failed to resolve over the subsequent 18-month follow-up. We describe this case to highlight the significant risk of this procedure in patients with preexisting or suspected contralateral vocal cord palsy.

cDNA cloning of the polymeric immunoglobulin receptor of the marsupial Macropus eugenii (tammar wallaby).

cDNA encoding a marsupial polymeric immunoglobulin receptor (pIgR) was isolated from Macropus eugenii (tammar wallaby) mammary lymph node primarily by reverse transcriptase coupled polymerase chain reaction (RT-PCR) and rapid amplification of cDNA ends (RACE) PCR. This resulted in a 5' truncated clone and, in order to obtain the full-length sequence, genomic walking PCR was utilized. The complete sequence consists of 2696 bp of cDNA and encodes a predicted polypeptide of 732 amino acids. The wallaby sequence is highly conserved in relation to the only other reported marsupial pIgR sequence, that of Trichosurus vulpecula (brushtail possum), having a nucleotide identity of 86.7% and a deduced amino acid identity of 79.9%. The wallaby nucleotide sequence also has a moderate degree of similarity with the pIgR sequences of eutherian mammals, being most similar to that of the rat, with an identity of 63.1%. At the amino acid level, in comparison to eutherian sequences, the wallaby pIgR is most similar to that of humans with an identity of 52.6%. pIgR phylogenetic trees were constructed for tammar wallaby, brushtail possum and several eutherian mammal cDNA and deduced amino acid sequences. In both DNA and protein analyses, the eutherian sequences formed a sister clade to the exclusion of the marsupial sequences, in agreement with the current view of mammalian evolution.

Molecular cloning of four lambda light chain cDNAs from the Australian brushtail possum Trichosurus vulpecula.

A brushtail possum mesenteric lymph node cDNA library was screened with a grey short-tail opossum Clambda probe and four immunoglobulin lambda cDNAs were isolated. Two of the isolated clones (L5 and L10) contained identical framework 4 regions and constant regions (but different variable regions), suggesting that the possum lambda locus is organized as multiple J-C pairs--a feature seen in the opossum and placental mammals. The cloning of the lambda light chain cDNAs signifies the completion of the basic molecular characterization of the brushtail possum immunoglobulin repertoire. The availability of this sequence data will allow extensive analysis of the immune response of the brushtail possum at the molecular level, as well as the development of specific immunological reagents for detection of immunoglobulin molecules at the protein level.

Molecular characterisation of the tammar wallaby (Macropus eugenii) CD3 epsilon chain cDNA.

The cDNA encoding the epsilon chain of the tammar wallaby CD3 complex (CD3epsilon) was isolated by PCR. This is the first CD3 component to be cloned in a marsupial. The tammar wallaby cDNA coding region was 61.7 and 63.0% identical to the human and mouse cDNA coding sequences, respectively. Similarly, the predicted amino acid sequence was 56.5 and 52.9% identical to the human and mouse sequences. When compared with other known CD3epsilon peptide sequences, the most conserved region of the tammar wallaby CD3epsilon chain peptide was the cytoplasmic domain and the least conserved was the extracellular portion. Phylogenetic reconstruction based on the deduced amino acid sequence placed the tammar wallaby sequence in its expected position outside of all the eutherian mammals.

Components of length growth variation in infants from the same population but different environments.

Growth in length of infants in Khartoum is profoundly related to whether or not their mothers are in paid employment. Some of this relationship appears to be due to levels of infectious disease, which are much higher in the infants of working mothers. Exponential decay curves do not fit longitudinal measurements of length growth particularly well in either group of infants, but they do yield distinctive temporal patterns of residuals. Simulation demonstrates that these patterns accord with a "catch-down" form of growth in infants of working mothers and a "catch-up" form in infants of housewives. Attempts to allow for these phenomena by providing for the opportunity of a single pulse of negative sine form in the former and a similar pulse of positive sine form in the latter reduces the level of residuals and tends to reduce temporal pattern in them. Most strikingly, it leads to average growth curves for the two groups of children becoming almost identical. It is hypothesized that these decay curves represent the underlying curves of infant growth in Khartoum free from the effects of environmental variation.

Further characterization of T cell receptor chains of marsupials.

cDNA clones encoding T cell receptor alpha (TCRalpha) and beta (TCRbeta) from the South American opossum, Monodelphis domestica were isolated and characterized. A single clone isolated encoding a TCRalpha chain was full length, containing the complete V (variable), J (joining) and C (constant) regions. Three partial cDNA clones were isolated for TCRbeta which contained complete C sequences. Phylogenetic analysis of the TCR Valpha revealed that the M. domestica sequence and a sequence from the Australian brushtail possum, Trichosurus vulpecula, belong to separate Valpha families and intersperse with sequences from eutherian mammals. Similar to results described for marsupial and eutherian light chains, diversity at the V region of the TCR is ancient and maintained. In contrast phylogenetic analysis of the TCR Calpha and Cbeta sequences from M. domestica, T. vulpecula, and other vertebrates revealed that the marsupial TCR C grouped together forming a sister group to eutherian mammals.

Growth of specific muscle strength between 6 and 18 years in contrasting socioeconomic conditions.

The influence of sex, age, and socioeconomic conditions on specific grip strength of 6-18-year-old individuals was studied among 1,704 males and 1,956 females belonging to the so-called "Cape Coloured" community in the western part of South Africa. Half of the participants of both sexes came from communities in the Greater Cape Town area where living conditions are comparable to those of middle-class First World communities (high SES). The other half came from the poorest rural communities of Klein Karoo (low SES). Arm circumferences, triceps skinfold thickness, and grip strength of the right and of the left hand were greater in individuals from high SES at all ages. Females within each SES group had skinfolds thicker than males, especially at older ages, and were weaker. Specific grip strength (SS), estimated as grip strength per unit area of cross section of the fat-free arm, increased with age in each group, was greater in males, and was significantly lower in low SES groups, than in the high SES ones, especially during and after puberty. It seems that SES difference in SS will persist into adulthood. Sexual differences in SS can be attributed to hormonal differences; while the SS increase with age and the difference between SES groups find no clear explanation in current theories of muscle growth and development. Since the speed of neuromuscular reaction observed in our participants is slower among low SES individuals, it seems that the difference in neuromuscular control of strength may be responsible for our findings. Differences in muscle metabolism and hormonal regulation must also be considered.

Characterisation of the kappa light chain of the brushtail possum (Trichosurus vulpecula).

Two full length cDNA sequences encoding the kappa light chain of the Australian marsupial, Trichosurus vulpecula, the brushtail possum, were isolated from a mesenteric lymph node cDNA library. The constant regions (Ckappa) of the two light chains were identical, but the variable (Vkappa) and joining (Jkappa) regions were different. At the amino acid level, possum Ckappa was most similar to Ckappa of an American marsupial, Monodelphis domestica (75%), with similarity to eutherian Ckappa ranging from 47 to 63%. The availability of molecular data will enable the development of immunological reagents for studying immune responses and disease in marsupials, thereby aiding conservation strategies and veterinary medicine.

Identification of canine coronavirus strains from feces by S gene nested PCR and molecular characterization of a new Australian isolate.

A nested PCR (nPCR) assay for the detection of canine coronavirus (CCV) in fecal samples is described. The target sequence for the assay was a 514-bp fragment within the spike (S) glycoprotein gene. The sensitivity of the assay is extremely high, detecting as little as 25 50% tissue culture infective doses per g of unprocessed feces. A clinical trial using dogs challenged orally with CCV SA4 and CCV NVSL was used to compare viral isolation and the nPCR assay as detection techniques over a 2-week period of infection. Virus isolation detected CCV shedding from day 4 to 9 postchallenge, while the nPCR assay detected CCV shedding from day 4 to 13 postchallenge. Cloning and sequencing of the nPCR assay product enabled investigation of the evolutionary relationships between strains within the S gene. The simple and rapid procedure described here makes this assay an ideal alternative technique to electron microscopy and viral isolation in cell culture for detection of CCV shedding in feces. The described assay also provides a method of identifying new strains of CCV without the complicated and time-consuming practice of raising antibodies to individual strains. This is illustrated by the identification, for the first time, of an Australian isolate of CCV (UWSMN-1).

Cloning of the MHC class II DRB cDNA from the brushtail possum (Trichosurus vulpecula).

The cell-surface glycoproteins encoded by the major histocompatibility complex (MHC) bind to processed foreign antigens and present them to T lymphocytes. Two classes of MHC molecules and their corresponding gene sequences have been extensively studied in eutherian mammals and birds, but data on the marsupial MHC are limited. Marsupials split from eutherian mammals about 125 million years ago and represent a distinct branch in mammalian evolution. Here the cDNA cloning of MHC class II genes of the brushtail possums (Trichosurus vulpecula) is reported. The sequences obtained were found to be relatively conserved when compared to the red-necked wallaby (Macropus rufogriseus) and an South American marsupial, Monodelphis domestica. The T. vulpecula sequence shared an average overall sequence identity of 75.4% at the deduced amino acid level with M. rufogriseus and M. domestica, respectively.