A comparison of antibody testing, permeability testing, and zonulin levels with small-bowel biopsy in celiac disease patients on a gluten-free diet.

Active celiac disease is associated with positive endomysial (EMA) and tissue transglutaminase (TTG) antibodies, elevated zonulin levels, and increased intestinal permeability. There is little known about what happens to these immunologic and structural abnormalities in patients on a gluten-free diet and their correlation with small-bowel biopsy changes. Adult patients previously diagnosed with celiac disease and on a gluten-free diet for greater than 1 year were considered for the study. All patients underwent the following: measurement of EMA and TTG antibodies, serum zonulin levels, intestinal permeability (IP) testing with lactulose/mannitol ratios, food diary analysis for gluten ingestion and small- bowel biopsy. A total of 21 patients on a gluten-free diet for a mean of 9.7 years completed the study. There were ten patients who had normalization of intestinal biopsies, IP and TTG, and EM antibodies. Six patients had Marsh type 2 or 3 lesions and all had either abnormal IP (5/6) or TTG antibody (4/6). In patients with Marsh type 3 lesions, there was a correlation between IP and zonulin levels. A subgroup of patients with celiac disease on a gluten-free diet has complete normalization of intestinal biopsies, intestinal permeability defects, and antibody levels. Patients with Marsh type 3 lesions have abnormal TTG antibodies and intestinal permeability with zonulin levels that correlate with IP. These abnormalities may be due to continued gluten ingestion. Further study is needed to determine the clinical utility of TTG antibodies and IP testing in following patients with celiac disease.

Tetanus: critical implications for nursing.

In the United States today, tetanus is a rare disease. However, when it occurs, it can be a highly challenging situation for all members of the healthcare team. The majority of care during the course of the disease is supportive. The availability of personnel trained in managing cardiorespiratory emergencies and sustained mechanical ventilation in the ICU environment can have a beneficial effect on patients' outcomes. An awareness of the potential complications of tetanus can hasten recovery and maintain the patient's preexisting quality of life.

The use of gaming strategies in a transcultural setting.

Saudi Arabia's vast economic resources have enabled the development of state-of-the-art hospitals. Nurses recruited from around the world staff these hospitals creating one of the most multicultural practice settings in the world. Ethnic, educational, and experiential diversity; language and communication barriers; and alternative ways of knowing and learning challenge nurse educators to be more creative and explore opportunities for greater participation and learning among various cultural groups. Gaming, as a teaching-learning strategy for multicultural participants, affords the necessary flexibility and nonthreatening atmosphere which facilitates positive interactions among different, and often competing, communication patterns and learning styles. This article explores how and why gaming is as an effective educational strategy in a transcultural setting.

Your questions answered about tuberculin skin testing.

1. To understand TB skin testing, it is necessary to have a basic understanding of the disease process and the role of the immune system. 2. The Mantoux test is the tuberculin skin test of choice, the intermediate strength (5 TU) being the most commonly used. 3. Either the palpation method or the ball-point pen technique may be used to measure induration that results from TB skin testing. An induration of 10 mm or greater is considered significant. 4. TB skin testing should be administered regardless of patient history of BCG vaccination. To eliminate the confusion caused by the booster phenomenon, a two-step procedure is recommended for individuals who at initial screening have an induration of 5 to 9 mm.

An employee health service in Saudi Arabia.

Health services for employees of this 500-bed tertiary care hospital include programs normally available to employees at hospitals in the United States. These programs include primary care, health promotion, health surveillance, and pre-employment health screening. The most pervasive influence on the health care provided is Islam. Saudi Arabia is a conservative Muslim country and all health care activities must be accomplished within the religious and cultural norms of the country. Communicable diseases endemic to this part of the world are of special concern in employee health. Special programs are in place for the prevention and control of tuberculosis, hepatitis B, brucellosis, ophthalmic chlamydia, malaria, and meningococcal disease.

Intestinal permeability in long-term follow-up of patients with celiac disease on a gluten-free diet.

Intestinal permeability is frequently abnormal in patients with celiac disease. The long-term effect of a gluten-free diet on intestinal permeability and the correlation of intestinal permeability with a gluten-free diet are not known. The objectives of this study were to determine the responses of intestinal permeability and antibody testing to gluten free diet and the degree of correlation of these measurements with gluten ingestion. In this prospective study, patients with celiac disease were divided into three groups based on length of time on a gluten-free diet: Group A, < 1 month; Group B, 1 month-1 year; Group C, > 1 year. Patients in Groups B and C were tested at baseline and at 4-12 weeks later for the following: lactulose/mannitol intestinal permeability, endomysial antibody, and 3-day food record. Permeability tests were also performed in Group A and control subjects. Intestinal permeability was elevated in newly diagnosed celiac disease and in individuals on a gluten-free diet for less than 1 year. Intestinal permeability was normal in 80% at visit 1 and 87% at visit 2 in individuals with celiac disease on a gluten-free diet for more than a year. Trace gluten ingestion was associated with increased intestinal permeability on visit 2 (P = 0.0480). The sensitivity of detecting gluten ingestion as measured by a 3-day food record was higher for permeability testing (29 and 36%) compared with endomysial antibody testing (18 and 18%) for visits 1 and 2, respectively. Intestinal permeability normalizes in the majority of individuals with celiac disease on a gluten-free diet. Gluten ingestion as measured by a 3-day food record correlates with intestinal permeability measurements. The role of permeability testing in the follow-up of patients with celiac disease warrants further investigation.

Effects of industrial respirator wear during exercise in subjects with restrictive lung disease.

Few studies have examined the response of individuals with restrictive lung disease (RLD) to respirator wear. Such information should be of theoretical and practical interest when the need to determine fitness to wear respirators is considered. Seventeen females performed progressive submaximal treadmill exercise. Twelve control subjects with total lung capacity (TLC) = 5.71 +/- .19L (mean +/- SEM) and DLCO = 25.8 +/- 1.0 mL/min/mmHg were compared to five RLD subjects with TLC = 3.70 +/- 0.22 and DLCO = 14.5 +/- 0.7. Mean age, height and weight were similar. Separate exercise trials were performed with no added resistance (NAR), and with 5 cm H2O/L/sec inspiratory and 1.5 cm H2O/L/sec expiratory resistance (R2) to stimulate widely used respiratory masks. Comparisons of exercise data were made at an oxygen consumption of 0.8 L/min. With NAR, RLD subjects had significantly higher minute ventilation (VE) (29.0 vs. 21.2 L/min for controls), higher respiratory rate (RR), and lower tidal volume (VT). Heart rate, end-tidal PCO2 (PETCO2), and mouth pressure swing (Poral) were not different from control values. With R2 compared to NAR, the controls had reduced RR and VE; and increased VT, PETCO2, and Poral. While changes with R2 for the RLD subjects were in the same directions as controls, only the increase in Poral was statistically significant. Analysis of the differences showed that none of the changes with R2 in RLD subjects was different from control changes except for the greater increase in Poral and the smaller increase in VT. The former was explained by the RLD subjects' higher VE and flow rates, and the non-linear nature of R2 at higher flow rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Physiologic effects of a self-contained self-rescuer.

Recently promulgated federal regulations mandate the provision of an emergency, self-contained, oxygen-supplying breathing device (self-contained self-rescuer, SCSR) to all underground coalminers. In order to assist in defining the potential limitations of this new device, we measured the responses of ten healthy coal mine inspectors to submaximal steady-state treadmill exercise with and without the SCSR. During the last minute of exercise, blood oxygen saturation averaged 98.3% and mouth pressure swing 15.6 cm H2O with the device, compared to 94.8% and 10.4 cm H2O without it. Mean respiratory rates were decreased to 25/min with the SCSR from 28/min without it. Blood pressure, core temperature and heart rate were unaffected. We conclude that in healthy individuals on submaximal exercise there is little evidence of a significant adverse effect of the new device.

Influence of appropriate lower extremity orthotic management on ambulation, pain, and fatigue in a postpolio population.

A major functional problem for the postpolio patient is the loss of ambulation ability. A retrospective study of lower extremity orthotic management for ambulation was made of 104 subjects with histories of paralytic poliomyelitis who received treatment and evaluation in a postpolio clinic. Thirty-six patients (35%) had a remote history of a surgical arthrodesis of the ankle. Fifty-six subjects (54%) reported using lower extremity orthoses after the onset of their polio. At initial postpolio clinic evaluation 19 subjects (18%) were using lower extremity orthoses, and all of these patients had a remote history of orthotic use. After clinical evaluation, a new lower extremity orthosis was recommended for 37 subjects (36%). Nine of these patients had never used orthotic devices. New orthoses for a previously braced limb or an additional orthosis for a previously unbraced limb were prescribed more frequently in previously braced patients (28 of 56 vs 9 of 48, p less than 0.02). Seventy-two percent of subjects with ankle fusion required new orthoses; 19% of those without fusion required one (p less than 0.001). A questionnaire returned by 81 subjects (78%) indicated that appropriate orthotic prescription significantly improved the ability to walk, increased perceived walking safety, and reduced knee and overall pain (p = 0.04 to 0.008).

Effects of added resistance to breathing during exercise in obstructive lung disease.

Forty-nine men performed progressive submaximal treadmill exercise to determine the cardiopulmonary and subjective response to added resistance to breathing. Twenty subjects (controls), FEV1/FVC% = 79.2 +/- 1.4 (mean +/- SEM), were compared with 19 mildly obstructed men (OB1), FEV1/FVC% = 66.9 +/- 0.5, and 10 with moderate obstruction (OB2), FEV1/FVC% = 53.7 +/- 1.9. Separate exercise trials were performed with no added resistance (NAR), R1 = 3.5 cm H2O/L/s inspiratory and 1.5 cm H2O/L/s expiratory resistance, and R2 = 5 cm HKO/L/s inspiratory and 1.5 cm H2O/L/s expiratory resistance. Analysis of cardiopulmonary parameters was made at an oxygen consumption rate of VO2 = 1.5 L/min for all 3 obstruction groups at all 3 resistances. With NAR, all 3 groups had similar respiratory rate (RR), tidal volume (VT), minute ventilation (VE), end-tidal PCO2 (PETCO2), respiratory exchange ratio (R), heart rate (HR), and mouth pressure swing (Poral). With both R1 and R2 compared with NAR, control and OB1 subjects (at VO2 = 1.5 L/min) had reduced RR, VE, and R, and increased VT and Poral (p less than 0.01 for all). Changes with added resistance for OB2 subjects were in the same directions, but were significant only for VE and with R1 for RR. Heart rate did not change; PETCO2 increased in control subjects and with R2 in OB1 subjects. Separate analysis showed that except for the smaller increase in PETCO2 in OB2 subjects, none of the changes with added resistance in the OB1 or OB2 groups were different from changes in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)