Toxic inhalation of sodium metabisulphite by-products from a shipping container.

Logistics workers who handle cargo containers are at risk of toxic inhalation injuries, although prevalence and severities of these injuries are not well characterized. We report on a previously healthy 37-year-old supervisor who was acutely exposed to sodium metabisulphite and its thermal degradation by-products during a routine inspection of a shipping container. The employee developed chemical pneumonitis with acute non-cardiogenic pulmonary oedema and subsequent severe reactive airway dysfunction syndrome.

Generalized method for adaptive randomization in clinical trials.

A flexible, generalized method of treatment allocation is proposed. The method uses a set of controlling parameters that enables the generic algorithm to produce a family of possible outcomes ranging from simple randomization to deterministic allocation. The method controls balance at stratum level, stratification level and overall without detriment to the predictability of the method. The paper lists the desirable characteristics of allocation methods and shows that the proposed method fulfils the majority and is easy to use in the clinical context, once the coding has been established. An explanation of the method for 2, 3 and 4 treatment group allocations is given. Simulations demonstrate the flexibility of the method.

Incredible Years parent training support for foster carers in Wales: a multi-centre feasibility study.

BACKGROUND: the incidence of conduct disorder in young children is 10% in the general population and 37% among fostered children. Up to 40% of untreated children diagnosed with conduct disorder develop problems later in life including drug misuse, criminal and violent behaviour. There are more than 80,000 looked after children in the UK, with 5000 in Wales. Challenging child behaviour is the main reason for placement breakdown and has huge cost implications as challenging children cost up to 10 times more in service use than children without conduct disorder. The Incredible Years (IY) evidence-based parenting programme is an effective, low cost solution in improving child behaviour and social competence in 'conventional' families and thus has the potential to support foster carers in managing difficult behaviours. Our main aims were to establish: • The feasibility of delivery and the effectiveness of the IY parenting programme in supporting carers in managing difficult behaviour in looked after children. • Service use costs for foster carers and looked after child. METHODS: This was a 12-month trial platform study with 46 foster carers in three authorities in Wales. Carers were allocated 2:1 intervention to waiting-list control. Validated measures were used to assess 'parenting' competency, carers' depression levels, child behaviour and service use. Measures were administered at baseline and 6-month follow-up. Intervention carers received the programme between baseline and follow-up. RESULTS: Analyses showed a significant reduction in child problem behaviour and improvement in carers' depression levels for intervention families at follow-up, compared with control. Unexpectedly, there was a significant improvement in control carers' self-reported 'parenting' strategies. Special education was the greatest service cost for looked after children. CONCLUSIONS: Initial foster carer training could incorporate the IY programme to support carers in establishing positive relationships and managing difficult child behaviour. Programme participation may lead to reduced service use and improved placement stability.

Religion and psychosis: the effects of the Welsh religious revival in 1904-1905.

BACKGROUND: Psychotic symptoms have been linked to religious experience, but empirical evidence is scarce. We have investigated the impact of the Welsh religious revival (RR) of 1904-1905 on the number of admissions to the regional psychiatric hospital, their diagnostic features and lifelong course. METHOD: All case-notes of patients admitted to the North Wales Hospital between 1902 and 1907 were included. RESULTS: There was a significant increase in admissions for brief polymorphic psychoses (BPP; ICD-10: F23.0 and F23.1) in the revival years, but the number of first admissions for other mental disorders did not change. The vast majority of BPP admissions were linked to a revival meeting and did not result in further admissions. CONCLUSIONS: Intensive religious experience can lead to transient psychotic episodes. Our data also support the view that BPP triggered by life events rarely lead to chronic mental illness, distinguishing them from other psychoses and supporting the validity of the concept of reactive psychosis.

Treatment fidelity as a predictor of behaviour change in parents attending group-based parent training.

BACKGROUND: Change in parenting skills, particularly increased positive parenting, has been identified as the key component of successful evidence-based parent training (PT), playing a causal role in subsequent child behaviour change for both prevention and treatment of Conduct Disorder. The amount of change in parenting skills observed after PT varies and may be accounted for by both the content of the programme and by the level of PT implementer process skills. Such variation in implementer skills is an important component in the assessment of treatment fidelity, itself an essential factor in successful intervention outcome. AIMS: To establish whether the Leader Observation Tool, a reliable and valid process skills fidelity measure, can predict change in parenting skills after attendance on the Incredible Years PT programme. RESULTS: Positive leader skills categories of the Leader Observation Tool significantly predicted change in both parent-reported and independently observed parenting skills behaviour, which in turn, predicted change in child behaviour outcome. CONCLUSIONS: Delivering an intervention with a high level of treatment fidelity not only preserves the behaviour change mechanisms of the intervention, but can also predict parental behaviour change, which itself predicts child behaviour change as a result of treatment.

Evaluation of the population dose to the UK population from the National Health Service Breast Screening Programme.

In the United Kingdom National Health Service Breast Screening Programme (NHSBSP), women aged between 50 and 70 y are invited for mammography every 3 y. Screening histories for each woman, over four screening rounds, were analysed. Data from five screening programmes were used to select 57,425 women into the study. Cases were selected on the basis of being between the ages of 50 and 53 at the start of the NHSBSP (i.e. between 1989 and 1992). Assessment of the outcome for each screening round for each woman involved assigning a simple outcome code. Each of the possible pathways through the four screening rounds was analysed. This comprises of 500 possible pathways. This data enabled the following information to be determined: (i) The number of times a woman attended the screening programme. (ii) The number of women referred for assessment at each screening round. This information may be used to deduce the population dose to this group of women averaged over four screening rounds. Patient doses have been monitored since the programme's inception and are typically 4.5 mGy for two-view screening. It is possible to determine the mean glandular dose received by this cohort of women over four screening rounds by multiplying the number of examinations by the mean glandular dose for a typical woman. Allowance has to be made for the number of projections taken at each screening round. Once a woman has been screened, she may be invited back for further assessment if an abnormality is found on her mammogram. A stereotactic attachment is used to determine where to place the biopsy device. Although the dose received during a normal screening mammogram is well known, the dose for a stereotactic procedure and other assessment procedures is less well known, partly because only a small part of the breast is directly irradiated during stereotaxis. However, the woman may have multiple exposures during this stage. A prospective survey of doses was completed to deduce the mean glandular dose at the first assessment stage and during stereotaxis. Numbers of films, including magnification films taken at first-stage assessment were established in the North East of England and Scotland by means of a postal survey. Average total mean glandular dose was deduced using previous survey data for the screening programme and a multiplying factor to allow for magnification film dose. On average 1.6 full field and 0.15 collimated contact films are taken for each woman (with 2.25 and 0.75 mGy film(-1)), 1.0 full field and 0.9 collimated magnification views. The mean magnification film dose to the assessed breast was 5.0 and 1.7 mGy for a collimated magnification film. A survey of 134 women at screening centres in the North East of England was performed to deduce the mean glandular dose from digital stereotaxis which is almost universally used in breast screening. A typical woman received a dose to the assessed breast of 4.5 mGy with a range of 1.3-17 mGy. This data may be used to deduce the total mean glandular dose over four screening rounds including the assessment stages. The estimated mean glandular dose to a typical woman invited to the screening programme is approximately 16 mGy, when allowance for attendance rate and assessment rate over each screening round is made. The mean glandular dose to the population is approximately 4700 Sv y(-1).

Avian cathepsin B cDNA: sequence and demonstration that mRNAs of two sizes are produced in cell types producing large quantities of the enzyme.

Overlapping cDNA fragments encoding avian cathepsin B were cloned from an osteoclast cDNA library and sequenced. The primary structure of the prepro enzyme deduced from this sequence has 340 amino acids. The mature portion of the enzyme is 80% identical with murine cathepsin B; regions found in other papain superfamily enzymes are conserved. In osteoclasts and cultured macrophages, which produce large quantities of cathepsin B, mRNAs of 1.8 and 2.4 kb are produced in approximately equal quantities, while cells producing smaller quantities of the enzyme produce predominantly the 2.4 kb form. This variation in mRNAs suggests transcriptional differences related to production of large quantities of the enzyme.

Factors influencing the prevalence of trypanosome infection of Glossina pallidipes on the Ruvu flood plain of Eastern Tanzania.

We report the pattern of infection of Glossina pallidipes with Trypanosoma vivax and T. congolense at a site in the Coast region of eastern Tanzania, studied between November 1993 and December 1994. Of the 2315 flies dissected 114 (4.9%) were T. congolense positive, 77 (3.3%) were T. vivax positive and 2 (0.1%) were T. brucei positive. Fly age was determined by the pteridine fluorescence method. Prevalence of infection was most strongly affected by month and the linear effect of age with the interaction of month and age having an effect for T. congolense-type infections. Sex and sex by month also have some predictive capacity when data for T. congolense and T. vivax-type infections are combined. In contrast to other similar studies our results suggest that the infection rate is non-linearly related to age of the tsetse fly, with older flies having progressively more chance of infection. The potential biological factors underpinning these interactions are discussed.

The role of temperature and nutritional status in flight initiation by Triatoma infestans.

Flight initiation in Triatoma infestans is associated with low nutritional status and increases with rising temperature; it appears to be largely independent of bug age and sex. A predictive model for the probability of flight initiation was constructed based on weight:length ratios of the bugs and maximum ambient temperature, both of which can be ascertained in the field. The model accurately predicted the proportion of bugs initiating flight in > 85% of the groups used in our study. The predictive equation was found to give significant fits with two independent data sets. From our results it might be expected that flight would be rare during colder (< 20 degrees C) months but that 5-10% of the normal population of an infested house would fly on any given night during the hotter months when temperatures approach 30 degrees C. If bug nutritional status falls significantly, this proportion could be expected to rise to 30%.

Use of cue configuration geometry for spatial orientation in human infants (Homo sapiens).

Research with both rats and human infants has found that after inertial disorientation, the geometry of an enclosed environment is used in preference over distinctive featural information during goal localization. Infants (Homo sapiens, 18-24 months) were presented with a toy search task involving inertial disorientation in 1 of 2 conditions. In the identical condition, 4 identical hiding boxes in a rectangular formation were set within a circular enclosure. In the distinctive condition, 4 distinctive hiding boxes were used. Infants searched the goal box and its rotational equivalent significantly more than would be expected by chance in the identical condition, showing that they were sensitive to the geometric configuration of the array of boxes. Unlike the results of studies using a rectangular enclosure, however, in the distinctive condition, infants searched at the correct location significantly more than at other locations.

Accuracy of task recall for epidemiological exposure assessment to construction noise.

AIMS: To validate the accuracy of construction worker recall of task and environment based information; and to evaluate the effect of task recall on estimates of noise exposure. METHODS: A cohort of 25 construction workers recorded tasks daily and had dosimetry measurements weekly for six weeks. Worker recall of tasks reported on the daily activity cards was validated with research observations and compared directly to task recall at a six month interview. RESULTS: The mean L(EQ) noise exposure level (dBA) from dosimeter measurements was 89.9 (n = 61) and 83.3 (n = 47) for carpenters and electricians, respectively. The percentage time at tasks reported during the interview was compared to that calculated from daily activity cards; only 2/22 tasks were different at the nominal 5% significance level. The accuracy, based on bias and precision, of percentage time reported for tasks from the interview was 53-100% (median 91%). For carpenters, the difference in noise estimates derived from activity cards (mean 91.9 dBA) was not different from those derived from the questionnaire (mean 91.7 dBA). This trend held for electricians as well. For all subjects, noise estimates derived from the activity card and the questionnaire were strongly correlated with dosimetry measurements. The average difference between the noise estimate derived from the questionnaire and dosimetry measurements was 2.0 dBA, and was independent of the actual exposure level. CONCLUSIONS: Six months after tasks were performed, construction workers were able to accurately recall the percentage time they spent at various tasks. Estimates of noise exposure based on long term recall (questionnaire) were no different from estimates derived from daily activity cards and were strongly correlated with dosimetry measurements, overestimating the level on average by 2.0 dBA.

Clinical update on rhinoscleroma.

Rhinoscleroma is recognized more frequently now because of the recent influx of immigrants from endemic Central America. This chronic infectious disease presents with three overlapping clinical stages and can involve any part of the respiratory tract. A review of the clinical presentation leads to a patient evaluation plan consisting of physical examination and radiographic studies. A highly sensitive and specific method is introduced for identification of Klebsiella rhinoscleromatis in the biopsy specimen using the immunoperoxidase technique. A study of the immune status of the patient revealed general immunological competence except in effective phagocytosis of the organism by the Mikulicz cells. The choice of chronic antibiotic therapy should be guided by individual patient consideration with respect to age and sex. Repeat biopsies help determine the duration of antibiotic therapy. Relapses do occur and close observation is the key to long-term follow-up of the patient.

Treatment of selected neuromuscular patients with posterior instrumentation and arthrodesis ending with lumbar pedicle screw anchorage.

STUDY DESIGN: This is a retrospective analysis of 23 patients with severe neuromuscular spinal deformity treated with posterior instrumentation and fusion ending in the lumbar spine. OBJECTIVES: The purposes of this study were to determine the safety and efficacy of stopping posterior instrumentation constructs in the lumbar spine with pedicle screw anchorage. SUMMARY OF BACKGROUND DATA: There are sparse data in the peer-reviewed literature regarding indications and outcomes in patients with neuromuscular disorders for instrumented fusion ended short of the pelvis with transpedicular fixation. METHODS: The average age of patients at surgery was 18.4 years (range, 10-61 years). Additional anterior discectomy and fusion were performed in four patients with large, stiff curves. No patient received anterior instrumentation. Criteria for exclusion of the pelvis from the fusion were less than 15 degrees of pelvic obliquity as a result of a compensatory curve below the major curve(s), the absence of problematic lower extremity contractures, and, often, the potential for ambulation. Process and clinical outcomes and complications were analyzed. RESULTS: Radiographic follow-up was available in 21 patients at an average of 62 months (range, 24-110 months) after surgery. Their average Cobb angle was 71 degrees before surgery, 25 degrees after surgery (64% correction), and 32 degrees at follow-up (54% correction). Their average spinal-pelvic obliquity was 6 degrees before surgery, 5 degrees after surgery, and 6 degrees at follow-up. The average lower instrumented vertebra was lumbar 3.7. Clinical follow-up was available for all 23 patients for an average of 61 months (range, 24-110 months). There were no perioperative deaths, deep wound infections, pseudarthroses, or instrument failures. Outcomes based on responses to questionnaires completed by patient, parent, or caregiver were highly satisfactory in 20 patients (87%), satisfactory in 2 patients (9%) and neither satisfactory nor unsatisfactory in 1 patient (4%). CONCLUSION: Posterior instrumentation and arthrodesis using lumbar lower instrumented vertebra pedicle screw anchorage can be performed safely and effectively, in selected patients patients with scoliosis and minimal pelvic obliquity.

Methods for microcarrier culture of bovine pulmonary artery endothelial cells avoiding the use of enzymes.

Enzymes situated along the luminal surface of pulmonary endothelial cells interact with circulating solutes, notably with vasoactive substances, to regulate the hormonal composition of systemic arterial blood. However, it is becoming clear that the range and complexity of reactions occurring at or near the surface of endothelial cells are greater than previously recognized. In addition, evidence indicates that the quality of cell cultures used to define specific endothelial functions must be carefully controlled, together with development of improved understanding of the effects of long-term culture on pulmonary endothelial cells. We have developed new techniques for the culture of pulmonary endothelial cells which avoid exposure to proteolytic enzymes at both the isolation step and during subculture. A combination of mechanical harvest and culture on microcarrier beads has provided a system for the long-term, large-scale culture of pulmonary endothelial cells, features which to a large extent determine the scope of biochemical studies which can be undertaken.

Localization of angiotensin converting enzyme (kininase II). II. Immunocytochemistry and immunofluorescence.

The cellular and subcellular sites of angiotensin converting enzyme (kininase II) in lung tissue and endothelial cells in culture were examined by immunocytochemical and immunofluorescence techniques. Converting enzyme is capable of inactivating bradykinin and of converting angiotensin I to its potent lower homolog, angiotensin II. Immunocytochemistry at the electron microscope level used goat anti- (pig lung and angiotensin converting enzyme) coupled to 11-MP (11-microperoxidase) via glutaraldehyde or to 8-MP (8-microperoxidase) via a bifunctional active ester, bis-succinyl succinate. The latter conjugate, which does not contain complex polymers, has been characterized in detail in terms of immunoreactivity and peroxidase activity.

How do kinins affect vascular tone?

Because kinins affect vascular tone, it is assumed that kinins act directly on smooth muscle. However, a direct interaction is difficult to conceive. Vessels containing smooth muscle are lined by a continuous endothelium with tight junctions. In addition, kinins act on endothelial cells to cause the release of prostaglandin-related substances; possibly through receptors. Furthermore, endothelial cells have a great capacity for hydrolyzing kinins to inactive products. Hence, even invoking active transport, less than 1% of kinins might be expected to reach the first layer of smooth muscle cells. However, kinins may not act directly on smooth muscle as endothelial cells and smooth muscle cells form specialized cell contacts. Myoendothelial junctions occur, and we have shown, in pulmonary arterioles, that smooth muscle cells send large numbers of projections into the cytoplasm of the endothelial cells. In addition, smooth muscle cells attach directly to the abluminal surface of endothelial cells, as do pericytes. Thus, there is a morphologic basis by which kinins can affect tone of smooth muscle without acting directly on smooth muscle cells.

Volume assessment of the bovine hoof.

The size of bovine hooves is one factor that may affect their ability to absorb shock. An increase in size could therefore reduce the risk of lameness associated with excessive digit loading. The hooves of 30 mature cattle were assessed by linear measurements with the objective of predicting digit volume, which was measured separately by water displacement. Claw volume was predicted accurately by regression equations including the top hoof width, toe length and heel angle. Replacing toe length and heel angle with the age and weight of the animal also gave an acceptable prediction and would be more appropriate for on-farm measurement. A reasonable prediction could be obtained from the top hoof width alone. Front hooves were larger and had greater heel depth than hind hooves. In 26 of the cattle either the right fore and left rear hooves, or the left fore and right rear hooves, were larger than the other two hooves, indicating that crossed limb laterality (symmetry in diagonally opposed limbs) may be present to a greater degree than has been previously recognised in quadrupeds.

The use of TENS for pruritus relief in the burns patient: an individual case report.

The case report outlines the use of transcutaneous electrical nerve stimulation (TENS) for the relief of pruritus in a 19-year-old patient who had sustained 70% mixed-thickness flame burns. Once healed, two electrodes were applied to the region of most severe itching, which was the lumbar spine. They were applied at 10 AM and remained in place until he went to bed. A visual analog scale (VAS) rating of itching was used to measure the sensation subjectively before application, immediately after application, and 4 hours after continuous application. Readings were taken for 5 consecutive days and then followed up during a 2-week period. At this time the patient discontinued the use of TENS, because itching had decreased significantly. Results showed that between day 1 and day 16 there was a 50% improvement before application and a 100% improvement 4 hours after application of TENS. These results suggest that a study to investigate the effect of TENS for the relief of pruritus in the burn patient would be justified to provide an alternative, noninvasive treatment approach.

The impact of reduced frequency of cage changes on the health of mice housed in ventilated cages.

Our purpose in this investigation was to determine if we could reduce cage changing frequency without adversely affecting the health of mice. We housed mice at three different cage changing frequencies: 7, 14, and 21 days, each at three different cage ventilation rates: 30, 60 and 100 air changes per hour (ACH), for a total of nine experimental conditions. For each condition, we evaluated the health of 12 breeding pairs and 12 breeding trios of C57BL/6J mice for 7 months. Health was assessed by breeding performance, weanling weight and growth, plasma corticosterone levels, immune function, and histological examination of selected organs. Over a period of 4 months, we monitored the cage microenvironment for ammonia and carbon dioxide concentrations, relative humidity, and temperature one day prior to changing the cage. The relative humidity, carbon dioxide concentrations, and temperature of the cages at all conditions were within acceptable levels. Ammonia concentrations remained below 25 ppm (parts per million) in most cages, but, even at higher concentrations, did not adversely affect the health of mice. Frequency of cage changing had only one significant effect; pup mortality with pair matings was greater at the cage changing frequency of 7 days compared with 14 or 21 days. In addition, pup mortality with pair matings was higher at 30 ACH compared with other ventilation rates. In conclusion, under the conditions of this study, cage changes once every 14 days and ventilation rates of 60 ACH provide optimum conditions for animal health and practical husbandry.

Early elective cholecystectomy--an alternative to early cholecystectomy in acute cholecystitis?

Currently there are two forms of management for patients with acute cholecystitis. Conservative treatment during the acute episode and readmission after 6-8 weeks for elective surgery and early cholecystectomy during the emergency admission. An alternative treatment would be elective surgery before the acute episode which should reduce morbidity and mortality. This study has identified those patients who are likely to present with acute biliary disease so that they can be selected for elective surgery shortly after their attendance in outpatients.