Assessment of COVID-19 outbreaks in long-term care facilities.

BACKGROUND: The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the USA during summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCFs) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities. AIM: To describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant. METHODS: Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analysed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures. FINDINGS: During April 22nd to July 29th, 2021, 159 COVID-19 cases among 72 staff members and 87 residents were identified in 10 LTCFs. More than 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact-tracing efforts from a sample of the facilities suggest that staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities. CONCLUSION: Data showed that vaccination rates varied between staff cases and resident cases in facilities with high-burden outbreaks. Differences were identified in mitigation practices in at least two facilities.

Realigning the conventional routes of transmission: an improved model for occupational exposure assessment and infection prevention.

Current recommendations for standard and transmission-based precautions in place for patients who are suspected or known to be infected or colonized with infectious agents are best suited to prevent the transfer of micro-organisms to other patients - that is, to prevent the acquisition of a healthcare-associated infection, rather than to protect the healthcare worker from self-contamination resulting in a potential occupationally acquired infection. This article reviews current recommended infection prevention and control practices and offers a framework for better protection and controls from an occupational health point of view. We offer a model with two exposure routes - contact and aerosol - resulting from work activities and environments, shifting the focus away from particular pathogenic micro-organisms' typical methods for spreading to patients or to other non-workers in hospital and community settings.

Enhancement by retinyl acetate of hormone-induced mammary tumorigenesis in female GR/A mice.

Feeding of retinyl acetate (82 mg/kg ration) for 13-16 weeks to estrone- and progesterone-treated nulliparous and multiparous inbred GR/A mice resulted in a substantial increase in the incidence of mammary carcinomas. Mammary carcinoma incidence in nulliparous control and retinoid-fed mice in experiment #1 was 22/65 (34%) and 37/65 (57%) (P less than 0.05), respectively; in experiment #2, 27/48 (56%) and 37/48 (77%) (P less than 0.05), respectively. Mammary carcinoma incidence in multiparous control and retinoid-fed mice in experiment #1 was 13/30 (43%) and 23/30 (77%) (P less than 0.05), respectively; in experiment #2, 19/19 (100%) and 19/19 (100%), respectively. The purported chemopreventive activities of retinyl acetate in murine mammary tumorigenesis were not demonstrated in this study; indeed, the vitamin A analog appeared to enhance this oncogenic process in the steroid hormone-treated GR mouse mammary cancer model.

Inhibition of mammary tumorigenesis in carcinogen-treated Lewis rats by suppression of prolactin secretion.

One hundred sixty-eight female Lewis rats were treated intragastrically with 10 mg 7,12-dimethylbenz[a]anthracene at 56 and 63 days of age. Pituitary prolactin secretion was suppressed in one-half of these rats by daily sc administrations of 2-bromoergocryptine mesylate (CB-154; 0.4 mg/100 g body wt) from 29 to 90 days of age (series 1) and from 90 to 140 days of age (series 2). Treatment with CB-154 was initiated prior to the onset of palpable mammary carcinomas. Control rats were given injections of saline. Inguinal mammary glands were excised from 10 control and 10 CB-154-treated rats at the cessation of saline and CB-154 treatments and examined for hyperplastic nodules (HN). The remaining rats were palpated weekly for mammary carcinomas (MC) and killed at 200 days of age. Mean number of HN per rat, mean number of MC per rat, and percent of rats with MC were, respectively: series 1--controls, 0.6, 1.5, and 68; CB-154 treatment, 0.5, 1.1, and 62; series 2--controls, 10.4, 2.0, and 94; CB-154 treatment, 5.1, 1.1, and 56. The number of HN and MC was only slightly reduced in rats when prolactin was suppressed during carcinogen treatment (series 1) but markedly reduced when prolactin was suppressed after carcinogen treatment (series 2). These results provide evidence that prolactin is involved in the early development of mammary dysplasias in the carcinogen-treated female Lewis rat.

Synergistic effect of chronic prolactin suppression and retinoid treatment in the prophylaxis of N-methyl-N-nitrosourea-induced mammary tumorigenesis in female Sprague-Dawley rats.

Two hundred forty Sprague-Dawley rats were treated i.v. with 2.5 or 1.25 mg of N-methyl-N-nitrosourea (MNU) per 100 g body weight at 50 and 57 days of age. At 60 days of age, rats given either dose were divided into 4 groups (30 rats/group) and treated as follows: Group 1, controls; Group 2, 0.4 mg 2-bromo-alpha-ergocryptine (CB-154) per 100 g body weight injected s.c. once daily; Group 3, retinyl acetate (328 mg/kg diet) fed daily; and Group 4, CB-154 and retinyl acetate treatments combined. Rats that received the 2.5-mg dose of MNU were treated for 129 days; those that received the 1.25-mg dose of MNU were treated for 175 days. The rats that were treated with the high dose of MNU were maintained without any treatment for an additional 13 weeks, after which they were sacrificed. The rats that were treated with the low dose of the carcinogen were sacrificed immediately after treatment. All rats were palpated once weekly for palpable mammary tumors. The number of rats with mammary tumors and the total number of mammary tumors at cessation of treatments were, respectively, as follows. MNU (2.5 mg): Group 1, 22 of 30 (73%), 82: Group 2, 11 of 30 (37%), 17; Group 3, 11 of 30 (37%), 19: Group 4, 2 of 30 (7%), 2. MNU (1.25 mg): Group 1, 8 of 30 (27%), 14; Group 2, 4 of 30 (13%), 5; Group 3, 3 of 30 (10%), 4; Group 4, 0 of 30, (0%), 0. Thus, chronic CB-154 treatment or retinyl acetate feeding markedly reduced the percentage of rates bearing mammary tumors and the total number of mammary tumors. The combined treatments were superior to either treatment alone, inasmuch as mammary tumorigenesis was nearly completely blocked in the rats of Group 4 that received the 2.5-mg dose of MNU and was totally blocked in the rats of Group 4 that received the 1.25-mg dose of MNU. Retinyl acetate feeding or CB-154-induced prolactin suppression appear to be equally effective treatments in the prophylaxis of MNU-induced mammary tumorigenesis in rats; the combined modality, however, appears to be far superior than either treatment alone.

Augmented capillary leak during isolated hepatic perfusion (IHP) occurs via tumor necrosis factor-independent mechanisms.

Isolated organ perfusion of the liver or extremity with tumor necrosis factor (TNF) and melphalan results in regression of bulky tumors in the majority of patients. The efficacy of TNF in this setting is not known, although data suggest that it may exert antitumor effects primarily on tumor-associated neovasculature. We studied the effects of TNF on capillary leak in liver and tumor tissue during isolated hepatic perfusion (IHP) with melphalan. Twenty-seven patients with unresectable cancer confined to the liver underwent a 60-min hyperthermic IHP using 1.5 mg/kg melphalan alone (n = 7) or with 1.0 mg of TNF (n = 20). Complete vascular isolation was confirmed in all patients using an intraoperative leak monitoring I-131 radiolabeled albumin technique. Samples of tumor and liver were collected just prior to and immediately after IHP. There was no difference in I-131 radiolabeled cpm/g of tissue (cpm) in liver versus tumor at baseline (P2 = 0.44). After IHP, I-131 albumin cpm were higher in tumor versus liver (10,999 +/- 1,976 versus 3,821 +/- 780, respectively; P2 < 0.005). However, I-131 albumin cpm in tumor were not effected by TNF (11,636 +/- 2,518 with TNF versus 9,180 +/- 2,674 without TNF; P2 = 0.59). TNF did not affect melphalan concentrations in tumor (1,883 +/- 540 ng/g versus 1,854 +/- 861 ng/g without TNF; P2 = 0.9). Capillary leak, as reflected by diffusion of I-131 radiolabeled albumin into the interstitial space, is comparable in liver and tumor before IHP but is significantly higher in tumor after IHP. The increased diffusion in the capillary tumor bed must occur through TNF-independent mechanisms such as intrinsic features of tumor neovasculature, hyperthermia, or other unrecognized perfusion-related factors. These data indicate that TNF must continue to be critically evaluated in clinical trials before it is routinely used with melphalan in isolated organ perfusion.

Thymidine kinase-deleted vaccinia virus expressing purine nucleoside phosphorylase as a vector for tumor-directed gene therapy.

Tumor-directed gene therapy faces many obstacles. Lack of tissue targeting and low in vivo transduction efficiency represent some of the limitations for a successful therapeutic outcome. A thymidine kinase-deleted mutant vaccinia virus has been shown in marker studies to replicate selectively in tumor tissue in animal models. Purine nucleoside phosphorylase (PNP), from E. coli, converts the nontoxic prodrug 6-methylpurine deoxyriboside (6-MPDR) to the toxic purine 6-methylpurine. In this study, we investigated the cytotoxic properties of PNP, expressed by an optimized synthetic early/late promoter in a vaccinia virus (vMPPNP). In vitro cytotoxicity of psoralen-inactivated vMPPNP (1 microg of psoralen, 4 min of LWUV [365 nm]) at the maximum tolerated dose (MTD) of 6-MPDR (80 microM) reduced cell viability by day 3 to 1.7%. At an MOI of 0.002, replication-competent vMPPNP and 6-MPDR (80 microM) caused reduction of cell viability to 19.8% within 4 days. Furthermore, there was complete abrogation of viral replication after intracellular conversion of prodrug into the active toxin. The potency of such a system was similar among all histologies tested. Finally, the cytotoxic efficacy has been shown to be more rapid and complete than that of cytosine deaminase (CD), a more established enzyme/prodrug system. When virus was delivered intraperitoneally into athymic mice with hepatic metastases, followed by administration of prodrug, there was a significant prolongation of survival and a 30% cure rate. In summary, owing to its tumor-targeting capabilities, high transduction efficiency, and high gene expression, a vaccinia virus expressing PNP could prove to be a potent and valuable vector for tumor-targeted gene therapy.

Augmentation of melanoma-specific gene expression using a tandem melanocyte-specific enhancer results in increased cytotoxicity of the purine nucleoside phosphorylase gene in melanoma.

The lineage-specific human tyrosinase promoter has been used to successfully target gene expression at the transcriptional level to melanoma cells. The tyrosinase promoter, alone and in combination with a single, or a dual, tandem melanocyte-specific enhancer, was used to regulate expression of the firefly luciferase reporter gene. Transient transfections of these tissue-specific luciferase constructs in human and murine melanoma (Pmel, B16mel) and colon carcinoma (WiDr, MC38) cell lines resulted in melanoma-specific luciferase expression that was amplified 5- and 500-fold with the addition of a single or double enhancer, respectively, to the tyrosinase promoter. When the double enhancer-promoter construct expressed the highly toxic Escherichia coli purine nucleoside phosphorylase (PNP) gene, transfection of the same cell lines followed by administration of the prodrug 6-methyl purine deoxyriboside (6-MPDR) at a concentration of 50 microM caused melanoma-specific in vitro cell killing. Within 5 days after prodrug administration methylthiazol-tetrazolium (MTT) cytotoxicity assays showed that only 15 and 9% of Pmel and B16mel cells, respectively, remained viable compared with controls. This effect was highly specific, as 90 and 96% of WiDr and MC38 colon carcinoma cells remained viable 5 days after identical treatment. This effect was a direct result of increased tissue-specific conversion of 6-MPDR to the toxic metabolite 6-methylpurine (6-MP), as documented by HPLC analysis of culture supernatants. These results show that the dual tandem melanocyte-specific enhancer provides powerful amplification of the transcriptional targeting of gene expression afforded by use of the tyrosinase promoter. This amplification translates into increased, highly specific cytotoxicity to melanoma by the PNP/6-MPDR enzyme/prodrug system and, therefore, has potential efficacy in the use of gene therapy for the treatment of metastatic melanoma.

Vaccinia as a vector for tumor-directed gene therapy: biodistribution of a thymidine kinase-deleted mutant.

Tumor-directed gene therapy, such as "suicide gene" therapy, requires high levels of gene expression in a high percentage of tumor cells in vivo to be effective. Current vector strategies have been ineffective in achieving these goals. This report introduces the attenuated (thymidine kinase (TK)-negative) replication-competent vaccinia virus (VV) as a potential vector for tumor-directed gene therapy by studying the biodistribution of VV in animal tumor models. A TK-deleted recombinant VV (Western Reserve strain) expressing luciferase on a synthetic promoter was constructed. Luciferase activity was measured in vitro after transduction of a variety of human and murine tumor cell lines and in vivo after intraperitoneal (i.p.) delivery in C57BL/6 mice with 7-day i.p. tumors (10(6) MC-38 cells). Three other in vivo tumor models were examined for tumor-specific gene expression after intravenous delivery of VV (human melanoma in nude mice, adenocarcinoma liver metastasis in immunocompetent mice, and subcutaneous sarcoma in the rat). In addition, a replication-incompetent vaccinia (1 microg of psoralen and ultraviolet light, 365 nm, 4 minutes) was tested in vitro and in vivo and compared with active virus. Luciferase activity in i.p. tumors at 4 days after i.p. injection of VV was >7000-fold higher than lung, >3000-fold higher than liver, and >250-fold higher than ovary. In addition, intravenous injection of VV resulted in markedly higher tumor luciferase activity compared with any other organ in every model tested (up to 188,000-fold higher than liver and 77,000-fold higher than lung). Inactivation of the virus resulted in negligible gene expression in vivo. In summary, VV has a high transduction efficiency in tumor cells with high levels of gene expression. The results suggest a selective in vivo replication of TK-deleted VV in tumor cells. Replication competent, TK-deleted VV appears to be an ideal vector for testing the in vivo delivery of toxic genes to tumor cells.

Late effects in children treated with radiation therapy for Wilms' tumor.

PURPOSE: To determine the frequency and types of late effects in children receiving radiation therapy (RT) for Wilms' tumor. MATERIALS AND METHODS: From 1968 to 1994, 55 children received megavoltage RT at our institution as part of treatment for Wilms' tumor. A total of 42 (76.4%) have survived and have a minimum follow-up of 5 years. There were 25 female and 17 male patients with a median age at diagnosis of 48 months (range, 7-126 months). There were 12 Stage I, eight Stage II, 15 Stage III, six Stage IV, and one Stage V patient. RT was delivered to the hemiabdomen in 36 and whole abdomen in six patients. RT dose was 1000-1200 cGy (Group A) in 12, 1201-2399 cGy (Group B) in 11, and 2400-4000 cGy (Group C) in 19. Whole-lung RT was delivered to 13 patients either at diagnosis or pulmonary relapse. All patients received chemotherapy; the most common agents were actinomycin-D/vincristine/adriamycin in 13 and actinomycin-D/vincristine in 18. Median follow-up was 181 months (range, 60-306 months). RESULTS: Of 42 patients, 13 (31.0%) did not have late effects of treatment. The number of patients who developed muscular hypoplasia, limb length inequality, kyphosis, and iliac wing hypoplasia were seven (16.7%), five (11.9%), three (7.1%), and three (7.1%), respectively. Scoliosis was seen in 18 (42.9%) with only one patient requiring orthopedic intervention. Median time to development of scoliosis was 102 months, with a range of 16-146 months. The actuarial incidence of scoliosis at 5, 10, and 15 years after RT was 4.8 +/- 3.3%, 51.8 +/- 9.0%, and 56.7 +/- 9.3%, respectively. Only one of 12 Group A patients developed scoliosis. The 10- and 15-year actuarial incidences of scoliosis for Group A and B patients were 37.7 +/- 12.4% and 37.7 +/- 12.4%, whereas for Group C patients the incidences were 65.8 +/- 12.0% and 74.4 +/- 11. 7% (p = 0.03, log rank test). The actuarial incidence of bowel obstruction at 5, 10, and 15 years was 9.5 +/- 4.5%, 13.0 +/- 5.6%, and 17.0 +/- 6.5%. Of 23 patients, five irradiated within 10 days of surgery and one of 19 irradiated after 10 days developed bowel obstruction (p = 0.09, log rank test). Three patients developed hypertension with normal blood urea nitrogen (BUN) and creatinine levels; another patient had chronic renal insufficiency in a nonirradiated kidney. One patient developed diffuse interstitial pneumonitis. Of the 19 female patients who have reached puberty, three have given birth, and 15 have regular and one has irregular menstrual periods. Four patients developed benign neoplasms; three were in the RT field (two osteochondroma, one lipoma) and one outside (cervical intraepithelial neoplasia II). There were three second malignancies (chronic myelogenous leukemia at 9 years, osteosarcoma at 11 years, and breast cancer at 25 years after initial diagnosis of nephroblastoma); both solid malignancies occurred in the RT field. CONCLUSIONS: Late effects of therapy were seen in more than two thirds of children treated for Wilms' tumor. Children treated with lower doses (<2400 cGy) had a lower incidence of scoliosis compared with those who received more than 2400 cGy. There is also a suggestion that the incidence is lower in patients who received 1000-1200 cGy. Severe physical and functional deformity from RT was uncommon.

Epidemiology of retinal detachment.

A survey of rhegmatogenous retinal detachment during 1976 was conducted on the population of Iowa. The annual incidences (per 100,000 populations) of four types of detachment were determined: nontraumatic phakic (6.1), traumatic phakic (1.0), nontraumatic aphakic (4.9), and traumatic aphakic (0.4). The incidences of nontraumatic phakic detachment for men and women were similar, although there was a preponderance of women that reflected their greater representation in the general population. The proportions of men were significantly higher in traumatic detachments compared with nontraumatic detachments. Men tended to be younger than women for all types of detachment; however, only in nontraumatic aphakic detachment was there a significant difference between mean ages. There was an insignificant preponderance of right eye involvement in all four detachment groups.

Visual function abnormalities in central serous retinopathy.

Eighteen patients with central serous retinopathy (CSR) underwent a battery of visual function tests when first seen and after resolution of the subretinal fluid. Eyes with CSR had minimal relative afferent pupillary defects, reduced critical flicker-fusion thresholds, prolonged visual evoked potential (VEP) latencies, increased errors on the Farnsworth-Munsell 100-hue (FM 100) test, and depressed central visual fields (Octopus). The afferent pupillary defect and critical flicker-fusion thresholds were the first to improve after resolution of the subretinal fluid. Next in rate of improvement were the visual acuity, the VEP latency, and the FM 100 test results. The threshold of the central Octopus at fixation improved the slowest and was still abnormal during long-term follow-up, indicating a prolonged depression in the threshold of central field sensitivity after resolution of the CSR. Many of these abnormalities are also seen in patients with optic nerve disease.

Critical evaluation of the cocaine test in the diagnosis of Horner's syndrome.

We evaluated the effectiveness of the cocaine test for diagnosing Horner's syndrome. The test was administered to 119 patients with a diagnosis of Horner's syndrome and to 50 normal subjects. We compared the cocaine-induced anisocoria in the two groups by measuring photographs of the pupils. We found the cocaine test to be highly effective in separating normal subjects from patients with Horner's syndrome. The chances of having Horner's syndrome increased with the amount of cocaine-induced anisocoria. Through the use of logistic regression analysis, we determined the odds ratio of having Horner's syndrome compared with not having it for each 0.1-mm increment of anisocoria measured after cocaine administration. A postcocaine anisocoria value of 0.8 mm gave a mean odds ratio of approximately 1050:1 that Horner's syndrome was present (lower 95% confidence limit = 37:1). We found that simply measuring the postcocaine anisocoria provided a better prediction of Horner's syndrome than taking the trouble to calculate the net change in anisocoria. Odds ratios should help the clinician decide if the result of a cocaine test is indicative of Horner's syndrome.

Intraarterial calcium stimulation and intraoperative ultrasonography in the localization and resection of insulinomas.

BACKGROUND: Standard imaging studies (computed tomography, magnetic resonance imaging, somatostatin receptor scintigraphy, ultrasonography, and angiography) correctly localize insulinomas in less than 50% of patients and provide no information about the feasibility of enucleation based on proximity of tumor to pancreatic duct. We reviewed our experience with intraarterial calcium stimulation (Ca-Stim) and intraoperative ultrasonography (IOUS) to localize and guide management of insulinomas. METHODS: Thirty-six patients (14 men, 22 women, median age 44 years) with insulinomas were treated between August 1989 and June 1996. Preoperative imaging studies were obtained. Patients underwent abdominal exploration with IOUS. Fourteen were evaluated by a surgeon blinded to preoperative imaging results. RESULTS: Tumors (4 to 50 mm) were resected by enucleation (67%) or partial pancreatectomy (33%); all were cured. Sensitivities of computed tomography, magnetic resonance imaging, somatostatin receptor scintigraphy, ultrasonography, angiography, and Ca-Stim in localizing insulinomas were 24%, 45%, 17%, 13%, 43%, and 94%, respectively. Tumors were identified by blinded surgical exploration with IOUS in 12 of 14 patients (86%). CONCLUSIONS: All insulinomas were identified before operation; however sensitivity of individual noninvasive tests was low (less than 50%). In contrast, Ca-Stim was correct in 94% of cases, thus allowing a focused pancreatic exploration and obviating use of blind distal pancreatectomy. IOUS can then be used to guide safe enucleation.

Descriptive epidemiology of local public health systems.

This article, presented at the Research and Measurement of Public Health Core Functions Science Symposium sponsored by the Centers for Disease Control and Prevention (CDC) in June 1994, provides selected data from the 1992-1993 National Profile of Local Health Departments. The National Association of County and City Health Officials (NACCHO), in cooperation with the CDC Public Health Practice Program Office, recently completed the 1992-1993 National Profile of Local Health Departments. This study describes public health at the local level and updates the first Profile study, conducted in 1989. The study population included 2,888 local health departments (LHDs) in the United States. Responses were received from 72% of LHDs. Comparisons are made with the 1990 Profile where available. This article provides a selected overview of the information contained in the 1992-1993 Profile and includes structure of LHDs, top agency executive, staffing, expenditures, and planning. The findings have important ramifications for community health planners and policy makers at all levels. With the ongoing potential for change in the U.S. health care system, reliable data establishing baselines and monitoring trends in public health at the local level are important. The information in this report, and the 1992-1993 National Profile of Local Health Departments, updates and expands the available knowledge of LHD structures and activities.

The incidence and significance of hemostatic abnormalities in patients with head injuries.

Abnormal coagulation and fibrinolysis is a frequent complication in patients with head injury. This complication can be severe enough to lead to hemorrhage or thrombosis. A study was undertaken to determine if the hemostatic abnormalities are reliable indicators of outcome. Hemostasis in 269 patients with head injuries alone was screened using platelet count (PC), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin clotting time (TCT), fibrinogen assay (FIB), level of fibrin-fibrinogen degradation products (FDP), and disseminated intravascular coagulation (DIC) score in the first 24 hours after injury. Test results were compared with the outcome (discharged or dead) in the entire group and in subgroups divided on the basis of the severity of injury as determined by the Glasgow coma score (GCS). Increased consumptive coagulopathy at admission, as reflected in the DIC score, predicts the outcome of head-injured patients with a high degree of accuracy. The degree of increase of the initial FDP level and prolongation of TCT also correlated positively with the outcome. Prolongation of the APTT correlated strongly with unfavorable outcome in a large group of patients, and in a small group, markedly accelerated APTT also predicted death. Stepwise logistic regression analysis demonstrated that GCS, FDP level, and DIC score predicted outcome. Other tests did not provide additional predictive value. Abnormal hemostasis frequently complicates the course of patients with head injuries. This study demonstrates that hemostasis tests are predictors of outcome in these patients.

Diagnostic evaluation of patients with blunt abdominal trauma: a decision analysis.

OBJECTIVES: Using decision analysis, to compare the expected utility (EU) of diagnostic peritoneal lavage (DPL), computed tomography (CT), and ultrasonography (US) to determine the optimal modality for the evaluation of blunt abdominal trauma (BAT) in hemodynamically stable adults. METHODS: Data points for the decision analysis were obtained from three sources: 1) prevalence of BAT and the sensitivity and specificity of each diagnostic modality were determined through a criteria-based review of the literature; 2) rate of BAT necessitating immediate intervention, perioperative complication rate, and operative mortality rate were calculated using data from the authors' institution's trauma registry; and 3) outcome utilities were determined by telephone survey of adults in a random sample of households in the region. The decision tree was constructed and evaluated in standard fashion. For each diagnostic modality, the authors calculated the EU using the minimum, mean, and maximum sensitivity and specificity across a range of prevalence. Mean outcome utilities were used for each branch of the tree when calculating the EU. RESULTS: The EU of CT was consistently lower than the EUs of DPL and US at all levels of prevalence. However, the rank order of the EUs of US and DPL varied with the prevalence of BAT. When the prevalence was <30%, the EU of US was higher than that for DPL. When the prevalence was 30-40%, the EUs were similar. When the prevalence was >40%, the EU of US was less than that of DPL. CONCLUSIONS: Among institutions operating under constraints similar to those used in this model, the optimal diagnostic modality for the evaluation of BAT can be determined based on the sensitivity and specificity of the modality at their institution and the prevalence of BAT in their patient population.

Childhood Guillain-Barré syndrome: clinical and electrophysiologic features predictive of outcome.

The hospital records of 27 children with the diagnosis of Guillain-Barré syndrome were retrospectively reviewed. Based on the time to recovery, patients were divided into two groups: group 1 consisted of children whose times to complete or partial recovery extended beyond 2 months from onset of the disease; group 2 consisted of children who attained a full recovery within 2 months from onset of the disease. The clinical and electrophysiologic features of the two groups were statistically compared for their predictive value of outcome. Three clinical features (maximum disability score at presentation, intubation, and cranial nerve involvement) were predictive of poor outcome, whereas one electrophysiologic feature (conduction block) was predictive of favorable outcome. There was also a significant correlation between maximum disability score at presentation and the probability of intubation.

Temporal variations of glandular kallikrein, protein and amylase in mixed human saliva.

Variations in the level of glandular kallikrein in human saliva may reflect physiological changes. Diurnal or circadian variations of many salivary components are important in relating changes in such components to oral or systemic conditions especially as most clinical studies are conducted between 0800 and 1700 h. Whole saliva was collected from 14 healthy young subjects at 0800, 1100, 1400 and 1700 h on two Fridays. Samples were centrifuged at 10,000 g for 10 min at 4 degrees C and the supernatant fractions stored at -20 degrees C. The enzymic activity of kallikrein was measured with D-valylleucylarginine-p-nitro-anilide as substrate. The activity of alpha-amylase and the total protein concentration (biuret) were also determined. Results were analysed in a repeated-measures design: there were no significant differences in kallikrein levels either within days or across days. There were significant differences for total protein and alpha-amylase levels within days but, in general, not across days. Minimal individual levels for protein and alpha-amylase were mostly at 0800 h; maxima were generally at 1400 or 1700 h. Kallikrein levels had no marked pattern of maximal or minimal distribution.

The creation and repair of diaphragmatic hernia in fetal lambs: morphology of the type II alveolar cell.

A model for creating and repairing diaphragmatic hernia in fetal lambs has been developed. Morphometric studies of the type II alveolar cells were carried out in three groups of term lambs. The upper lobes only were sampled. Morphometric analysis of the 30 type II cells from each lobe showed that while there were no differences between the left upper lobe (LUL) and right upper lobe (RUL) cells in normal lambs, there were significant differences between sides in the experimental groups. In lambs with a nonrepaired diaphragmatic hernia (DH) the type II cells were significantly smaller in the LUL compared with the RUL. In lambs with a repaired DH, the LUL type II cells were significantly larger than those in the RUL. There were some trends when the groups were compared, but in general they did not reach statistical significance. These findings suggest that local factors profoundly influence the development of these cells.