Knowledge, attitudes and practices regarding rabies risk in community members and healthcare professionals: Pétionville, Haiti, 2013.

Haiti has the highest human rabies burden in the Western Hemisphere. There is no published literature describing the public's perceptions of rabies in Haiti, information that is critical to developing effective interventions and government policies. We conducted a knowledge, attitudes and practices survey of 550 community members and 116 health professionals in Pétionville, Haiti in 2013 to understand the perception of rabies in these populations. The majority of respondents (85%) knew that dogs were the primary reservoir for rabies, yet only 1% were aware that bats and mongooses could transmit rabies. Animal bites were recognized as a mechanism of rabies transmission by 77% of the population and 76% were aware that the disease could be prevented by vaccination. Of 172 persons reporting a bite, only 37% sought medical treatment. The annual bite incidence rate in respondents was 0·9%. Only 31% of bite victims reported that they started the rabies vaccination series. Only 38% of respondents reported that their dog had been vaccinated against rabies. The majority of medical professionals recognized that dogs were the main reservoir for rabies (98%), but only 28% reported bats and 14% reported mongooses as posing a risk for rabies infection. Bites were reported as a mechanism of rabies transmission by 73% of respondents; exposure to saliva was reported by 20%. Thirty-four percent of medical professionals reported they would wash a bite wound with soap and water and 2·8% specifically mentioned rabies vaccination as a component of post-bite treatment. The majority of healthcare professionals recommended some form of rabies assessment for biting animals; 68·9% recommended a 14-day observation period, 60·4% recommended a veterinary consultation, and 13·2% recommended checking the vaccination status of the animal. Fewer than 15% of healthcare professionals had ever received training on rabies prevention and 77% did not know where to go to procure rabies vaccine for bite victims. Both study populations had a high level of knowledge about the primary reservoir for rabies and the mode of transmission. However, there is a need to improve the level of knowledge regarding the importance of seeking medical care for dog bites and additional training on rabies prevention for healthcare professionals. Distribution channels for rabies vaccines should be evaluated, as the majority of healthcare providers did not know where rabies vaccines could be obtained. Canine rabies vaccination is the primary intervention for rabies control programmes, yet most owned dogs in this population were not vaccinated.

Maternal influenza and birth outcomes: systematic review of comparative studies.

BACKGROUND: Although pregnant women are considered at high risk for severe influenza disease, comparative studies of maternal influenza and birth outcomes have not been comprehensively summarised. OBJECTIVE: To review comparative studies evaluating maternal influenza disease and birth outcomes. SEARCH STRATEGY: We searched bibliographic databases from inception to December 2014. SELECTION CRITERIA: Studies of preterm birth, small-for-gestational-age (SGA) birth or fetal death, comparing women with and without clinical influenza illness or laboratory-confirmed influenza infection during pregnancy. DATA COLLECTION AND ANALYSIS: Two reviewers independently abstracted data and assessed study quality. MAIN RESULTS: Heterogeneity across 16 studies reporting preterm birth precluded meta-analysis. In a subgroup of the highest-quality studies, two reported significantly increased preterm birth (risk ratios (RR) from 2.4 to 4.0) following severe 2009 pandemic H1N1 (pH1N1) influenza illness, whereas those assessing mild-to-moderate pH1N1 or seasonal influenza found no association. Five studies of SGA birth showed no discernible patterns with respect to influenza disease severity (pooled odds ratio 1.24; 95% CI 0.96-1.59). Two fetal death studies were of sufficient quality and size to permit meaningful interpretation. Both reported an increased risk of fetal death following maternal pH1N1 disease (RR 1.9 for mild-to-moderate disease and 4.2 for severe disease). CONCLUSIONS: Comparative studies of preterm birth, SGA birth and fetal death following maternal influenza disease are limited in number and quality. An association between severe pH1N1 disease and preterm birth and fetal death was reported by several studies; however, these limited data do not permit firm conclusions on the magnitude of any association. TWEETABLE ABSTRACT: Comparative studies are limited in quality but suggest severe pandemic H1N1 influenza increases preterm birth.

What are the most sensitive and specific sign and symptom combinations for influenza in patients hospitalized with acute respiratory illness? Results from western Kenya, January 2007-July 2010.

Influenza causes severe illness and deaths, and global surveillance systems use different clinical case definitions to identify patients for diagnostic testing. We used data collected during January 2007-July 2010 at hospital-based influenza surveillance sites in western Kenya to calculate sensitivity, specificity, positive predictive value, and negative predictive value for eight clinical sign/symptom combinations in hospitalized patients with acute respiratory illnesses, including severe acute respiratory illness (SARI) (persons aged 2-59 months: cough or difficulty breathing with an elevated respiratory rate or a danger sign; persons aged ≥5 years: temperature ≥38 °C, difficulty breathing, and cough or sore throat) and influenza-like illness (ILI) (all ages: temperature ≥38 °C and cough or sore throat). Overall, 4800 persons aged ≥2 months were tested for influenza; 416 (9%) had laboratory-confirmed influenza infections. The symptom combination of cough with fever (subjective or measured ≥38 °C) had high sensitivity [87·0%, 95% confidence interval (CI) 83·3-88·9], and ILI had high specificity (70·0%, 95% CI 68·6-71·3). The case definition combining cough and any fever is a simple, sensitive case definition for influenza in hospitalized persons of all age groups, whereas the ILI case definition is the most specific. The SARI case definition did not maximize sensitivity or specificity.

Results from the first 30 months of national sentinel surveillance for influenza in Tanzania, 2008-2010.

Limited data exist on the burden of influenza in developing countries. In 2008, in order to better understand the epidemiology of influenza virus infection in Tanzania, the Tanzanian Ministry of Health and Social Welfare created a sentinel surveillance system for influenza. At 5 hospitals across the country, patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI) had oropharyngeal and nasopharyngeal samples collected. At the National Influenza Center in Dar es Salaam, specimens were tested for influenza using real-time polymerase chain reaction tests. From May 2008 through November 2010, a total of 1794 samples were collected from 5 sentinel sites, of which 61% were from patients with ILI and 39% were from patients with SARI. Of all ILI and SARI samples, 8.0% were positive for influenza; 6.9% yielded influenza A virus, and 1.1% yielded influenza B virus. Most influenza A virus was subtype H3, which circulated in nearly every month of 2010. The proportion of influenza-positive cases was similar among ILI (8.5%) and SARI (7.3%) patients (P = .39). In multivariate logistic regression, influenza-positive SARI cases were more likely than influenza-negative SARI cases to have had rhonchi (adjusted OR [aOR], 2.31; 95% confidence interval [CI], 1.14-4.67), nasal discharge (aOR, 4.57; 95% CI, 1.30-16.10), and stridor (aOR, 2.63; 95% CI, 1.17-5.90). Influenza-positive ILI patients had a longer duration of fever on presentation, compared with influenza-negative ILI patients (median, 4 vs 3 days; P = .004). Otherwise, there was no difference in signs or symptoms among influenza-positive and influenza-negative ILI patients. During 2.5 years of surveillance for influenza at 5 geographically disbursed sites in Tanzania, we found that influenza circulated year-round. Surveillance should continue in order to fully understand the seasonality and epidemiology of influenza in Tanzania.

Forearm hemodynamics and responses to exercise in middle-aged adult-onset diabetic patients.

Much of the difficulty in assessing the progress of diabetic angiopathy and effects of experimental modes of therapy arises from the lack of quick, simple, inexpensive, and noninvasive tests to perform on the circulatory system of human subjects. We report here on values obtained by the use of mercury-in-rubber strain gauge plethysmography on 15 middle-aged, adult-onset diabetics who had minimal clinical evidence of microangiopathy. Standard tests are described for assessing forearm vascular function at rest, during tonic exercise of the fingers, and after interrupted repetitive exercise of the fingers. When matched against a similar aged nondiabetic group, the diabetics had slightly higher forearm vascular resistance at each level of exercise, a marked reduction (approximately 50 per cent) in capillary filtration coefficient, which is believed to be related to vascular filtering surface area, and a slight reduction in venous capacitance at all levels of exercise. The method of mercury-in-rubber strain gauge venous occlusion plethysmography provides the clinician with a sensitive and inexpensive tool with which to follow the evolution of angiopathy in diabetic patients.

Defective vasodilation response to exercise in cutaneous precapillary vessels in diabetic humans.

Although anatomic abnormalities in capillary structure are well described in diabetes mellitus, physiologic responses of diabetic microcirculation are less clear. This study addresses whether cutaneous vasodilation occurs normally in diabetic subjects in response to a standard exercise of underlying muscle. The methods involve a washout analysis from forearm skin of the fast-moving isotope 133Xe and the diffusion-limited marker 111In-diethylenetriamine pentaacetic acid. Twenty-four normotensive type II diabetic patients of age (mean +/- SE) 59 +/- 1.4 yr were age and weight matched with 24 controls. Control subjects increased flow 50.6 +/- 6.4%, which was not different from the increase in diabetic subjects of 52.7 +/- 7.6%. Permeability-surface-area product (PS) increased in control subjects from 1.77 +/- 0.20 ml.min-1.100 g-1 to 3.79 +/- 0.50 (2P = .0001), whereas diabetic subjects did not show a change in PS (3.29 +/- 0.35 to 2.69 +/- 0.31). Resting PS was higher in diabetic than control subjects (P = .0003), perhaps indicating an already recruited capillary bed. During repetitive exercise, control subjects increased capillary density 125 +/- 27% (2P = .0001) above basal with a nonsignificant 14 +/- 8.4% decrease in mean capillary blood flow. Diabetic subjects responded with a nonsignificant decrease in capillary density and a significant 139 +/- 38% increase in capillary blood flow (2P = .001). It is concluded that, although overall vasodilation occurs normally in diabetic cutaneous circulation, the mechanism is different from the normal response in that flow increases by augmentation of capillary flow rather than by recruitment. This is consistent with the thesis promulgated by others that diabetic precapillary vessels have depressed vasodilatory responses or are already maximally vasodilated. The ability of diabetic subjects to vasodilate by augmentation was not correlated with years of diabetes or use of insulin and only slightly negatively correlated with random blood glucose levels (r = -.423, P less than .05).

Comparison of measurement methods for capillary basement membrane thickness. Collapsed-ellipse technique.

Both the grid method of Siperstein et al. (tSIP) and the minimum-points method of Williamson et al. (tWIL) for measurement of capillary basement membrane thickness are inaccurate for assessing mean true membrane thickness of a give section (tTRUE) for various reasons, including errors in selectivity, sensitivity, and geometry. In general, it is agreed that tSIP greater than tTRUE greater than tWIL, but estimates of tTRUE beyond this have not been made. In this study, a collapsed-ellipse method for approximating tTRUE is presented that measures thickness by areas (tEA). One hundred-twenty capillaries from the forearm skin of 12 diabetic subjects and 12 age-matched controls were measured to examine these concepts. We found that, whereas tWIL was up to 63% below tTRUE, tEA was less than 30% too low. Although tSIP, tWIL, and tEA did not distinguish between diabetic and normal subjects, tEA and tWIL measurements had highly predictable and small errors, and tSIP had unpredictable ranges of error, especially when tSIP was low.

Relationships between microvascular function and capillary structure in diabetic and nondiabetic human skin.

Despite the commonly held view that abnormalities in capillary morphology, in particular thickening of the capillary basement membrane, are partly responsible for diabetic ischemia, few studies have correlated anatomic and hemodynamic variables in the same diabetic subjects. In a previous study of 24 type II (non-insulin-dependent) diabetic subjects and 24 age-matched control subjects, we showed that a standard finger exercise vasodilated cutaneous forearm vessels nearly equally (51%), but the postarteriolar flow responded differently between groups. Nondiabetic subjects increased flow by recruitment of capillaries, whereas diabetic subjects did so by capillary flow augmentation. Moreover, resting permeability-surface area product (PS) to pentetic acid was 85% higher in diabetic than nondiabetic subjects. In this study, these same subjects had their forearm skin biopsied and examined morphometrically by electron microscopy for capillary radius, basement membrane thickness, endothelial cell density, and a folding index of luminal membrane reduplication. All morphological variables were correlated stepwise in a saturated, analysis of covariance model with the physiological results. The correlations were sparse and specifically excluded basement membrane thickness. The highest r2 value was .432 between resting PS and a ratio of capillary density to endothelial cell number per capillary. These studies show little evidence that diabetic microvascular physiological variables are tightly connected to morphometric changes except for minor permeability changes, which rise with capillary density and decrease with endothelial cell number. Because PS to pentetic acid is increased in diabetic subjects at any level of capillary density, it seems reasonable that permeability may be increased above that of nondiabetic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of an enzyme-linked immunosorbent assay with radioimmunoassay for the measurement of pneumococcal capsular polysaccharide antibodies.

An enzyme-linked immunosorbent assay (ELISA) has been developed to measure antibodies against pneumococcal polysaccharides of the IgA, IgG and IgM isotypes. Antibodies against pneumococcal polysaccharide types 1, 3, 6A, 8 and 9N were measured by ELISA and radioimmunoassay. Similar antibody responses were observed when comparing both assays. The study included 39 persons at high risk of developing pneumococcal infection and 13 healthy adults. Within 1 month after immunization IgM was the principle isotype. After 1 month, IgG was the principle isotype. Very low levels of IgA were detected in the post-immunization serum. The ELISA procedure described can be used to study the immune response to pneumococcal vaccines.

A comparison of antibody concentration measured by mouse protection assay and radioimmunoassay in sera from patients at high risk of developing pneumococcal disease.

The radioimmunoassay (RIA) of pneumococcal capsular polysaccharide antibodies is dependent on the association of radiolabeled antigen and pneumococcal antibody. However, it is not known whether the ability of the antibody to complex with antigen correlates with in vivo protection against infection. A method for evaluating protective ability of antibody vis-à-vis binding ability is to passively transfer a measured quantity of antibody into recipient mice followed by a lethal challenge with virulent pneumococci. Protection against a fatal outcome is then correlated with the amount of antibody (as measured by RIA) passively transferred. This comparison of quantitation by RIA and biological protection in mice was performed on 30 sera from humans. The sera were obtained from vaccinated healthy persons and vaccinated persons at high risk of developing pneumococcal infection, including people with nephrotic syndrome, chronic obstructive pulmonary disease and various forms of cancer. The results of these studies indicate that antibody as measured by RIA correlates with protective antibody against pneumococcal infection. These studies were conducted on pneumococcal serotype 3.

Oral clonidine loading for rapid control of hypertension.

In order to determine the efficacy and safety of oral clonidine loading to control hypertension rapidly, 15 patients received 0.1 or 0.2 mg clonidine initially followed by hourly doses of 0.1 mg until the blood pressure was substantially reduced or until a total of 0.5 mg had been given. Twelve (80%) responded with a reduction in mean blood pressure of 33 +/- 3 (SE) mm Hg in an average time of 2.25 hr. Side effects were minimal. Four of the 5 patients hospitalized solely for purposes of blood pressure control responded to clonidine loading and were discharged the next day. Clonidine loading proved to be safe and effective for rapid control of hypertension and may be preferred to intravenous antihypertensives for some indications.

Ethane production rates and minute ventilation.

Ethane quantitated in the expired alveolar gas is a noninvasive measure of free radical activity. This method has been criticized for lack of control of minute ventilation (VE) in spontaneously breathing animals, although ethane, which is poorly soluble in tissues, should not be affected by changes in VE. We measured ethane elimination rates in six strain 13 guinea pigs (GP13) during spontaneous room air breathing and in six room air breathing, pentobarbital-anesthetized, tracheostomized, externally warmed, mechanically ventilated GP13s at various levels of VE. In the ventilated animals, weight0.75/VE (metabolic activity corrected for VE) was a linear function of arterial CO2 tension (PaCO2) drawn from arterial line (r = 0.72, P less than 0.005). However, weight0.75/VE did not correlate with ethane elimination rates (r = 0.12, not significant). The mean (+/- SD) ethane elimination rates in the spontaneously breathing animals was 3.15 +/- 0.96 pmol.min-1.100 g-1 and was not significantly different from the mean rate in the mechanically ventilated animals (3.11 +/- 1.37) over a range of VE's. These data demonstrate that ethane elimination rates are not affected by changes in VE and are unaffected by pentobarbital anesthesia.

Source of ethane in expirate of rats ventilated with 100% oxygen.

Ethane in alveolar expirate may have its source in organs other than the lung and be transported to the lung for elimination. We determined ethane production rates in rats (group I) ventilated with hydrocarbon-free air (HFA) before and after exsanguination. To determine whether the lung is the source of increased ethane production during exposure to 100% O2, we measured ethane in the expirate of nine exsanguinated, Sprague-Dawley rats (group II) mechanically ventilated with HFA and then with 100% O2. In all nine animals, ethane elimination rates on 100% O2 increased compared with HFA values. In five of the nine rats, HFA ventilation was reinstated after O2 (group III). In all five, ethane elimination fell with HFA ventilation compared with the value on 100%. Six rats with circulation intact were ventilated with HFA and then 100% O2 (group IV). Ethane production rate for group IV animals breathing HFA was not significantly different from the exsanguinated animals in group II while ventilated with HFA. The mean increase in ethane production for the group II animals was not significantly different from the group IV animals. Lung slices from four other rats (group V) were incubated in saline at 37 degrees C with FeCl2 (10 mg) added to enhance free radical formation. Paired lung samples from the same rat were incubated with either HFA or 100% O2. Headspace gas was analyzed chromatographically for ethane at 120 min. Mean ethane in the O2 samples was higher than for HFA. Rat lung tissue is the main source of increased ethane production during 100% O2 exposure.

Recurrence rate of ABO hemolytic disease of the newborn.

ABO hemolytic disease of the newborn is a common and potentially severe disease. It can cause hyperbilirubinemia and anemia in the infant. A review of 230 primigravid mothers of affected offspring is presented. Evaluation of their subsequent pregnancies showed a recurrence rate of 88% in those infants at risk for the disease (of same blood type as their index sibling), with 62% of the affected infants requiring therapy. Guidelines for antenatal counseling are presented.

Pharmacokinetics of an immediate-release oral formulation of Fampridine (4-aminopyridine) in normal subjects and patients with spinal cord injury.

Plasma concentration profiles of the K+ channel-blocking compound Fampridine were obtained from (1) control subjects (n = 6) following oral administration of doses of 10, 15, 20, and 25 mg and (2) patients with spinal cord injury (SCI) (n = 11) following a single oral dose of 10 mg of an immediate-release formulation. Plasma concentrations were determined using a reversed-phase ion-pair high-performance liquid chromatography (HPLC) assay with ultraviolet light detection employing liquid extraction. The drug was rapidly absorbed with a tmax approximately 1 hour for both groups; tmax was independent of dose. Cmax and AUC0-infinity were linearly related to dose, and t 1/2 was 3 to 4 hours for both groups. There were no obvious differences in the (10-mg) plasma concentration profiles between control subjects and SCI patients. The drug was well tolerated, with only mild and transient side effects of light-headedness, dysesthesias, and dizziness.

Uremia with low serum creatinine-an entity produced by marked creatinine secretion.

Two patients are presented who were uremic requiring dialysis despite steady state serum creatinine levels (Cr) of 4.0 and 4.4 mg percent. Their blood urea nitrogen/creatinine (BUN/Cr) ratios of 54 and 44 were shown to be due to excessive creatinine secretion and urea reabsorption. Evaluation of serum creatinine alone may occasionally give misleading information regarding the level of renal function. If clinical evidence of uremia is present while serum creatinine value is relatively low, measurement of glomerular filtration rate (GFR) by Na-iothalamate 125I (OIT) or inulin is essential.

Interstitial space - the forgotten organ.

The interstitial space (ISS) can be thought of as an organ of translocation. Defined in this way the concentration of any substance in the ISS is equal to the ratio of an input to a clearance function. When substances accumulate, there is a disturbance of one or both functions. The three phase anatomy of the ISS give it unique properties including a high resistance to bulk flow, normal or even augmented diffusion of small ions, marked restriction to macromolecular transport, and some specificity for binding certain substances. Depositional disease in the interstitium can be approached in terms of minimizing the input function or maximizing the clearance function of the deposited substance. In the near future the clinician will have access to importance physical parameters of the ISS.

Computed tomographic scanning of cervical spine fractures: does it influence treatment?

OBJECTIVE: To determine whether the superior sensitivity of computed tomography (CT) results in changes in treatment plans for cervical spine fractures that have been diagnosed on plain films alone. DESIGN: Retrospective review of radiographic studies for cervical spine trauma. SETTING/PARTICIPANTS: An orthopaedic spine surgeon (SS), an orthopaedic traumatologist (OT), an orthopaedic spine fellow (SF), and an orthopaedic chief resident (CR) were independently presented thirty-nine cases of cervical spine trauma imaged with adequate plain radiographs and with CT. MAIN OUTCOME MEASURES: Agreement was measured by calculation of kappa coefficients. RESULTS: The detection rate of total fractures on plain radiographs alone ranged from 47 percent to 71 percent, and the diagnosis changed an average 53 percent of cases. Change in treatment plans ranged from 10 percent (SS) to 46 percent (CR) of cases. Of these changes, undertreatment occurred as follows: SS =3 percent, OT =8 percent, SF =36 percent, and CR = 46 percent. The mean kappa coefficient for intraobserver agreement of treatment plans was 0.69. The experienced observers demonstrated "excellent" agreement with an average kappa coefficient of 0.85, whereas the mean coefficient for inexperienced observers was 0.54 or "moderate" agreement. Complete diagnostic agreement occurred between the experienced observers after review of both the plain films and CT scans. The interobserver agreement of treatment plans for the experienced observers increased from 0.79 to 0.88. CONCLUSIONS: CT scanning afforded additional information for all observers. Experienced observers can reliably determine treatment plans for cervical spine trauma diagnosed on plain films alone, whereas inexperienced observers are less reliable. For the experienced observers, interobserver agreement on treatment plans increased after the addition of CT.

Epidural angiolipoma with spinal cord compression.

A case of epidural angiolipoma is reported. This tumor rarely occurs in the spinal canal. The most common location is in the thoracic region, and its histogenesis is probably congenital.

Acetylcholine "tightens" peripheral capillaries independently of pressure effects.

We previously showed that acetylcholine (ACh) infused into the abdominal aorta of dogs at a rate of 127 micrograms ACh min-1 caused an increase in lumbar trunk lymph flow (L) of 35% while protein clearance into the lymph (LR) remained unchanged. These effects were accounted for by a 34% increase in reflection coefficient (sigma) and a 54% increase in permeability-surface area product (PS). Since arterial pressure decreased, it was possible that the decrease in arterial pressure was responsible for observed changes. The current study was undertaken to test this possibility. Seven female dogs were anesthetized and prepared in the same manner as the previous study except that control abdominal aortic pressure was reduced with an aortic balloon to a mean of 81 mmHg. As ACh was infused, the balloon pressure was released so that the mean pressure for all dogs rose to 96 mmHg. The findings indicated that ACh produced a 24% increase in L (P less than .004) while LR was unaffected. In a similar fashion to the results of the previous study, sigma increased 43% (P less than .0000) and PS rose 51% (P less than 008). These results clearly dissociate the effects of acetylcholine on permeability from any effects on arterial pressure and indicate a more direct effect of acetylcholine on the permeable segment. The results also suggest a general response of the capillary or postcapillary venule to vasodilation which restricts accession of protein into the interstitium during unloading of the vasculature by the process of edema formation.