Booster effect of tuberculin testing in healthy 6-year-old school children vaccinated with Bacillus Calmette-Guérin at birth in Santiago, Chile.

In order to determine whether tuberculin testing caused a booster effect in children vaccinated with Bacillus Calmette-Guérin (BCG) at birth, we studied forty 6-year-olds by repeat tuberculin testing 2 weeks later on the contralateral forearm. All children were healthy and had no known exposure to tuberculosis. None of the children had a history of mycobacteriosis other than tuberculosis. The mean induration was 2.3 +/- 1.8 mm for the first tuberculin reaction and 7.6 +/- 3.3 mm for the second tuberculin reaction (P less than 0.005). Four children had positive reactions (greater than or equal to 10 mm) to the first purified protein derivative test; 18 children were positive upon retesting. Eleven of these latter children had increases of at least 6 mm from reactions less than 10 mm to greater than or equal to 10 mm. The size of the BCG scar was significantly correlated to the size of both the first and second purified protein derivative reactions (P less than 0.01), suggesting that the increased reactivity upon retesting was a consequence of sensitization induced by BCG vaccination 6 years earlier. All children remained healthy after this study was completed. Retesting of tuberculin reactivity within 2 weeks in BCG-vaccinated children with reactions less than 10 mm will produce reactions greater than 10 mm in some healthy children who may not require antituberculosis treatment.

The impact of patient education about the effect of zidovudine on HIV perinatal transmission: knowledge gain, attitudes, and behavioral intent among women with and at risk of HIV.

The termination of the perinatal HIV transmission trial, ACTG 076, by the Data Safety and Monitoring Board in February 1994 because of the efficacy of zidovudine (ZDV) in substantially reducing maternal-infant HIV transmission has created a considerable need for efficacious patient education approaches and materials for women with and at risk of HIV infection. Complexities surrounding patients' decisions to use ZDV in accordance with the treatment arm protocol of this study must be communicated to women, especially the consequences for both themselves and their potential children. In March 1994, a public-private partnership was formed to develop and test the impact of patient education information on 076 and to explore cultural differences in decision-making surrounding ZDV use during pregnancy. Objectives were (1) to develop an efficacious patient informational booklet on the results of ACTG 076 and (2) to determine the differential attitudes and behavioral intentions of women toward taking AZT during pregnancy. A multi-disciplinary group of providers and researchers developed the patient education booklet and field-tested it in five New York City area sites. Subjects were a multiethnic group of women of childbearing age who were predominantly HIV-positive or at risk of HIV infection (n = 120). This 076 education resulted in a substantial increase in intention to use ZDV to reduce perinatal transmission despite full disclosure of the unknowns (P < .001). There were differences in knowledge acquired between racial/ethnic groups, which must be viewed cautiously since the study did not assess socioeconomic status adequately. Attitudes toward ZDV (P < .05), trust in health care providers (P < .03), and opinions on whether testing should be voluntary (P < .02) also varied by race/ethnicity. Medical Subject Headings (MeSH): perinatal transmission, AIDS education, pregnancy, HIV, ACTG 076.

Passive transfer of autoantibodies from a patient with mutilating epidermolysis bullosa acquisita induces specific alterations in the skin of neonatal mice.

BACKGROUND: Epidermolysis bullosa acquisita is a subepidermal bullous disease characterized by IgG autoantibodies directed against type VII collagen in anchoring fibrils. These autoantibodies are believed to play an important role in the pathogenesis of sub-lamina densa blister formation in this disease. OBSERVATIONS: We describe a patient with epidermolysis bullosa acquisita who has developed mutilating acral involvement with early syndactyly and extensive scarring lesions of the scalp. The patient's serum contains IgG autoantibodies that bind the dermal side of 1-mol/L sodium chloride-separated human skin (at a titer up to 5120), as determined by indirect immunofluorescence microscopy, and type VII collagen, as determined by immunoblot. The severity of this patient's disease and the height of his immune response to type VII collagen prompted us to assess the pathogenicity of his autoantibodies in a murine model. Purified IgG from our patient (or that from a healthy volunteer who served as a control) was administered subcutaneously to BALB/c mice (10 mg/g of body weight) on 2 consecutive days. Light microscopy of normal-appearing skin showed pronounced dermal edema and a dense granulocyte-rich infiltrate in the superficial dermis. Deposits of human IgG, murine C3, and the membrane attack complex of complement were found in the epidermal basement membrane of all experimental mice. Immunogold electron microscopy demonstrated that deposits of human IgG in an experimental subject were localized to anchoring fibrils. Serum samples from mice receiving IgG antibodies from our patient had high titers of circulating antibodies directed against the dermal side of 1-mol/L sodium chloride-separated human skin (titer, 640 to 1280). Light, immunofluorescence, and immunogold electron microscopic studies did not detect such specific alterations in any control mice. CONCLUSIONS: Acquired autoimmunity to type VII collagen in patients with epidermolysis bullosa acquisita may result in a clinical phenotype closely resembling that observed in patients with dystrophic epidermolysis bullosa. Passive transfer of purified IgG autoantibodies from a patient with severe epidermolysis bullosa acquisita to BALB/c mice produces histologic and immunopathologic alterations consistent with those seen in patients with this disease.

Malpractice in Pennsylvania.

The author presents facts about professional liability. Although the article discusses professional liability of physicians in Pennsylvania, its scope is larger and offers general legal principles germane to dental practitioners throughout the United States. The author stresses that the advice of counsel should always be sought whenever legal problems arise.

Perinatally transmitted HIV infection. Supporting the helpers.

Nurses find that caring for clients with HIV disease can be exceptionally rewarding but can also be stressful and frustrating. Stressors in HIV work arise both from specific issues related to HIV and from more generic concerns arising from caring for clients with a chronic illness in an environment of limited resources. This article describes sources of stress for nurses and personal institutional factors that can lead to burnout as well as positive aspects of HIV nursing. Institutional strategies that can decrease stress and support nurses' practice are described. Group support and individual strategies, including humor and spirituality, offer interventions that can help nurses maintain energy and enthusiasm for nursing practice with HIV clients.

Prevention of perinatal HIV transmission.

Preventing perinatal HIV transmission is a multistep, multidisciplinary process that includes ensuring women's access to early prenatal care, acquiring knowledge about the HIV status of pregnant women, educating them regarding HIV infection and its transmission, and prescribing antiretroviral agents to women with HIV infection and to the HIV-exposed neonate and ensuring their consistent use. It also includes mobilizing social and supportive services for these patients and their families. The collaborative nature of this care and treatment options available are discussed in this article.

A performance-based management system to reduce prematurity and low birth weight.

A performance system is a management tool for ensuring that programs accomplish their objectives. Using Delphi and nominal group process techniques, the authors established objectives for a system to reduce prematurity and low birth weight. A task force consisting of state, regional, and local public health personnel, consultants from the Centers for Disease Control, and faculty from the School of Public Health then developed the activities, standards, and guidelines of the performance system. Finally, an assessment tool for evaluation of the system was designed. The system, which is intended to complement initiatives to improve the medical care of maternity patients, should be useful to maternity clinic managers and supervisors who wish to develop performance standards specifically targeted to the achievement of objectives for reducing prematurity and low birth weight.