Influence of procedural factors on patient procedural pain in relation to diagnostic lumbar puncture.

OBJECTIVE: The aim of this study is to investigate the influence of local anesthetic (LA), operator experience level and needle type on patient procedural pain in relation to diagnostic lumbar puncture (LP). METHODS: LP was performed with either a 22 gauge traumatic needle (22 TN) or a 22 gauge atraumatic needle (22 ATN). Immediately after LP patients documented a procedural pain score (PPS) on a 10-point Likert scale. Use of LA, needle type, anesthetic time interval (ATI), number of needle insertions and the LP operator experience level were registered. ATI was defined as the time from administration of LA to first needle insertion. RESULTS: 104 patients had the LP procedure performed by 66 physicians (40 novices and 26 experienced physicians). Patients having the procedure performed by novices had a lower PPS of 2.56 if LA was administered compared to a higher PPS of 5.80 if LA was not administered (P = .046). Among experienced physicians there was no difference in PPS regardless of administration of LA. If novices administered LA, patient PPS was equal to patients having the procedure performed by an experienced operator. If novices performed the procedure with a 22 TN PPS decreased with increasing ATI (P = .01). No similar correlation was identified with the 22 ATN. CONCLUSION: Our study suggests that LP operator experience level, the needle type used and ATI may influence patient PPS. Further studies are necessary for final conclusions. These studies must consider these factors to avoid fault conclusions.

Streptococcus pneumoniae antibody titres in patients with primary antibody deficiency receiving intravenous immunoglobulin (IVIG) compared to subcutaneous immunoglobulin (SCIG).

Intravenous immunoglobulin (IVIG) and subcutaneous immunoglobulin (SCIG) are effective in the treatment of patients with primary antibody deficiency disorders (PAD). The purpose of this study was to evaluate Streptococcus pneumoniae (Spn) antibody titres to 14 serotypes in patients receiving IVIG compared to SCIG and to correlate Spn antibody levels to clinical outcome. The doses of immunoglobulin (Ig)G/kg/month were similar in both IVIG and SCIG groups. In 11 patients treated with IVIG, Spn antibody titres were ≥ 1·3 µg/ml to 99·4 ± 2·1% of the 14 serotypes at peak IVIG but decreased to 66·9 ± 19·8% at trough IVIG. Loss of Spn titres ≥ 1·3 µg/ml was most frequent for Spn serotypes 1, 4, 9V and 23. This correlated with lower Spn antibody titres to these serotypes at peak IVIG compared to the other serotypes. In 13 patients treated with SCIG, Spn antibody titres were protective to 58·2 ± 23·3% of the serotypes 3-5 days after infusion, similar to trough IVIG. Similarly, the Spn serotypes with the least protective percentages were the same as the ones observed in trough IVIG. There were no annualized serious bacterial infections (aSBI) in either group. However, there were significantly decreased annualized other infections (aOI) in the SCIG group compared to the IVIG-treated group, 0·8 ± 0·7 versus 2·2 ± 1·2 infections/patient/year (P = 0·004). Breakthrough aOI did not correlate with protective or higher serum Spn antibody titres.

Current state and future perspectives of the Latin American Society for Immunodeficiencies (LASID).

Primary immunodeficiencies (PID) are genetic diseases that affect the immune system and for the last 20 years, the Latin American Society for Immunodeficiencies (LASID) has been promoting initiatives in awareness, research, diagnosis, and treatment for the affected patients in Latin America. These initiatives have resulted in the development of programmes such as the LASID Registry (with 4900 patients registered as of January 2014), fellowships in basic and clinical research, PID summer schools, biannual meetings, and scientific reports, amongst others. These achievements highlight the critical role that LASID plays as a scientific organisation in promoting science, research and education in this field in Latin America. However, challenges remain in some of these areas and the Society must envision additional strategies to tackle them for the benefit of the patients. In June 2013, a group of experts in the field met to discuss the contributions of LASID to the initiatives of PID in Latin America, and this article summarises the current state and future perspectives of this society and its role in the advance of PIDs in Latin America.

Guidelines for the use of human immunoglobulin therapy in patients with primary immunodeficiencies in Latin America.

Antibodies are an essential component of the adaptative immune response and hold long-term memory of the immunological experiences throughout life. Antibody defects represent approximately half of the well-known primary immunodeficiencies requiring immunoglobulin replacement therapy. In this article, the authors review the current indications and therapeutic protocols in the Latin American environment. Immunoglobulin replacement therapy has been a safe procedure that induces dramatic positive changes in the clinical outcome of patients who carry antibody defects.

A Case Report on Product Rotation to Manage Severe Lysinibacillus sphaericus Resistance in Culex pipiens from Salt Lake City, Utah.

The Salt Lake City Mosquito Abatement District (SLCMAD) detected a 20,000-fold resistance to Lysinibacillus sphaericus (Lsph) in Culex pipiens occurring in catch basins of Salt Lake City during 2016. In response, SLCMAD suspended use of Lsph and rotated use of spinosyn and s-methoprene products for the next three years. At the end of the third year, Lsph was evaluated again and efficacy similar to susceptible colony strains. During the second year of Lsph use, technicians observed lack of control of larvae at some urban sites. Bioassays performed during 2021 showed recurrence of some resistance to Lsph to varying degrees across SLCMAD urban areas. The rapidity with which resistant phenotypes reemerged clarifies that SLCMAD cannot in the near future rely on repeated use of Lsph, even after suspending use for three years and using within-season product rotations. Prior reports in other research groups have found long-term selection to Lsph, as is the case at SLCMAD, to not regress in spite of halting use of the products. However, our findings offer some optimism that regression may be relatively quick. More operational review is needed, and future work should characterize resistance alleles in field populations. Collectively, there is a lack of concrete data supporting the prevailing assumptions from adjacent industries that were adopted into mosquito abatement. We provide this short note as additional guidance for mosquito and vector control districts weighing options to remediate Lsph resistance.

Do it yourself: 3D-printed miniature CDC trap for adult mosquito (Diptera: Culicidae) surveillance.

The central component of mosquito and vector surveillance programs globally is the adult mosquito trap, which is intended to collect host-seeking mosquitoes. The miniature CDC trap is a widely distributed trap style in part due to its relative affordability and compact nature. Despite already being a simple trap, in-house production methods, such as 3D printing, could improve the accessibility of the CDC trap by eliminating some of the supply chain variables. We present here several trials with the Salt Lake City (SLC) trap, a three-dimensional (3D) printed trap design. Functional assessments were made on secondary components and found no statistically significant differences when comparing CO2 line height (above vs. below fan), battery types (sealed lead acid vs. USB battery pack), and trap body collection shape (funnel body vs. simple/straight body). The SLC trap was compared directly to a commercial equivalent, the ABC trap, with comparative assessment on species diversity and evenness in collections and found to be statistically equivalent on all metrics. Methods also detail an accompanying optional transport system for a pressurized CO2/regulator set-up, should a practitioner elect not to use dry ice. Our final design is presented here with the publicly published stereolithography (STL) files and a detailed outline of the transport container system. Alternative models are available for in-house manufacture of mosquito traps, and we contribute these designs in an effort to stimulate further growth in vector surveillance.

Evaluation of An Aerial Application of Duet Hd® Against Aedes Dorsalis and Culex Tarsalis in Rural Habitats of the Great Salt Lake, Utah.

The Salt Lake City Mosquito Abatement District (SLCMAD) has been conducting aerial applications using an organophosphate insecticide against adult mosquitoes for several decades. In order to evaluate a potential rotation product, aerial applications of Duet HD™, a pyrethroid, were conducted under operational conditions against wild populations of Aedes dorsalis and Culex tarsalis and against colony strains of Cx. pipiens and Cx. quinquefasciatus. The erratic wind patterns of the greater Salt Lake area did not prevent sufficient droplet deposition flux at 9 monitoring locations spread across a 5,120-acre (2,072 ha) spray block within rural habitats. Three separate aerial application trials showed great efficacy against Ae. dorsalis. In contrast, Cx. tarsalis exhibited inconsistent treatment-associated mortalities, suggesting the presence of less susceptible or resistant field populations as a result of spillover from agricultural or residential pyrethroid usage. Bottle bioassays to diagnose pyrethroid resistance using field-collected Cx. tarsalis indicated that some populations of this species, especially those closest to urban edges, failed to show adequate mortality in resistance assays. Despite challenging weather conditions, Duet HD worked reasonably well against susceptible mosquito species, and it may provide a crucial role as an alternative for organophosphate applications within specific and sensitive areas. However, its area-wide adoption into control applications by the SLCMAD could be problematic due to reduced impacts on the most important arboviral vector species, Cx. tarsalis, in this area. This study demonstrates the importance of testing mosquito control products under different operational environments and against potentially resistant mosquito populations by municipal mosquito control districts.

A drug rape case involving triazolam detected in hair and urine.

In recent years, there has been heightened awareness regarding the use of drugs to modify a person's behavior to facilitate crime. A drug rape case involving the potent, short-acting sedative triazolam will be presented. On three occasions, the victim consumed green tea and chocolate before being massaged and ultimately sexually abused. Screening for alcohol, commonly used drugs and illicit substances in blood and urine sampled during the forensic examination 20 h after the last incident, was negative. Consequently, hair samples for chemical analysis were taken from the assaulted individual 34 days after the last incidents. The hair was cut into three 2-cm segments (0-6 cm) that were washed, dissolved in extraction solvent and screened and verified by ultra performance liquid chromatography coupled with time of flight mass spectrometry (UPLC-TOF-MS) and with tandem mass spectrometry (UPLC-MS/MS), respectively. In the 2-cm hair segment corresponding to the period of the alleged assaults, the presence of the sedative triazolam was revealed at a concentration of 1.0 pg/mg hair. The preserved urine sample, taken 20 h after the last incident, was reanalyzed by UPLC-MS/MS for metabolites of triazolam, and 39 µg/l α-hydroxytriazolam was detected in the hydrolyzed urine. This case illustrates that hair is a valuable forensic specimen in situations where natural processes have eliminated the drug from typical biological specimens due to delays in the crime being reported. Furthermore, it was possible to verify the hair finding with a urine sample by detection of a metabolite of triazolam.

Advancing the management of primary immunodeficiency diseases in Latin America: Latin American Society for Immunodeficiencies (LASID) Initiatives.

Primary immunodeficiency diseases (PIDD) are associated with significant morbidity and mortality and result in a significant public health burden. This is in part due to the lack of appropriate diagnosis and treatment of these patients. It is critical that governments become aware of this problem and provide necessary resources to reduce this impact on health care systems. Leading physicians in their respective countries must be supported by their own governments in order to implement tools and provide education and thus improve the diagnosis and treatment of PIDD. The Latin American Society of Primary Immunodeficiencies (LASID) has initiated a large number of activities aimed at achieving these goals, including the establishment of a PIDD registry, development of educational programmes and guidelines, and the introduction of a PIDD fellowship programme. These initiatives are positively impacting the identification and appropriate treatment of patients with PIDD in Latin America. Nevertheless, much remains to be done to ensure that every person with PIDD receives proper therapy.

Adaptive polymer fiber neural device for drug delivery and enlarged illumination angle for neuromodulation.

Objective. Optical fiber devices constitute significant tools for the modulation and interrogation of neuronal circuitry in the mid and deep brain regions. The illuminated brain area during neuromodulation has a direct impact on the spatio-temporal properties of the brain activity and depends solely on the material and geometrical characteristics of the optical fibers. In the present work, we developed two different flexible polymer optical fibers (POFs) with integrated microfluidic channels (MFCs) and an ultra-high numerical aperture (UHNA) for enlarging the illumination angle to achieve efficient neuromodulation.Approach. Three distinct thermoplastic polymers: polysulfone, polycarbonate, and fluorinated ethylene propylene were used to fabricate two step-index UHNA POF neural devices using a scalable thermal drawing process. The POFs were characterized in terms of their illumination map as well as their fluid delivery capability in phantom and adult rat brain slices. Main results.A 100-fold reduced bending stiffness of the proposed fiber devices compared to their commercially available counterparts has been found. The integrated MFCs can controllably deliver dye (trypan blue) on-demand over a wide range of injection rates spanning from 10 nl min-1to 1000 nl min-1. Compared with commercial silica fibers, the proposed UHNA POFs exhibited an increased illumination area by 17% and 21% under 470 and 650 nm wavelength, respectively. In addition, a fluorescent light recording experiment has been conducted to demonstrate the ability of our UHNA POFs to be used as optical waveguides in fiber photometry.Significance. Our results overcome the current technological limitations of fiber implants that have limited illumination area and we suggest that soft neural fiber devices can be developed using different custom designs for illumination, collection, and photometry applications. We anticipate our work to pave the way towards the development of next-generation functional optical fibers for neuroscience.

Association between anticoagulant therapy, exacerbations and mortality in a Danish cohort of patients with Chronic Obstructive Pulmonary Disease.

OBJECTIVES: Pulmonary Embolism has been frequently reported in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AE-COPD). The study aimed to determine whether COPD patients who receive anticoagulant (AC) therapy have a reduced risk of hospitalization due to AE-COPD and death. METHODS: This nationwide population-based study was based on data from the Danish Register of COPD (DrCOPD), which contains complete data on COPD outpatients between 1st January 2010 and 31st December 2018. National registers were used to obtain information regarding comorbidities and vital status. Propensity-score matching and Cox proportional hazards models were used to assess AE-COPD and death after one year. RESULTS: The study cohort consisted of 58,067 patients with COPD. Of these, 5194 patients were on AC therapy. The population was matched 1:1 based on clinical confounders and AC therapy, resulting in two groups of 5180 patients. We found no association between AC therapy and AE-COPD or all-cause mortality in the propensity-score matched population (HR 1.03, 95% CI 0.96-1.10, p = 0.37). These findings were confirmed in a competing risk analysis. In the sensitivity analysis, we performed an adjusted analysis of the complete cohort and found a slightly increased risk of AE-COPD or death in patients treated with AC therapy. This study found a low incidence of pulmonary embolisms and deep venous thrombosis in both groups. CONCLUSIONS: AC therapy was not associated with the risk of hospitalization due to AE-COPD or all-cause mortality.

Critical issues and needs in management of primary immunodeficiency diseases in Latin America.

Experts from six Latin American countries met to discuss critical issues and needs in the diagnosis and management of primary immunodeficiency diseases (PIDD). The diagnosis of PIDD is generally made following referral to an immunology centre located in a major city, but many paediatricians and general practitioners are not sufficiently trained to suspect PIDD in the first place. Access to laboratory testing is generally limited, and only some screening tests are typically covered by government health programmes. Specialised diagnostic tests are generally not reimbursed. Access to treatment varies by country reflecting differences in healthcare systems and reimbursement policies. An online PIDD Registry Programme for Latin America has been available since 2009, which will provide information about PIDD epidemiology in the region. Additional collaboration across countries appears feasible in at least two areas: a laboratory network to facilitate the diagnosis of PIDD, and educational programmes to improve PIDD awareness. In total, these collaborations should make it possible to advance the diagnosis and management of PIDD in Latin America.

Primary immunodeficiency diseases in Latin America: proceedings of the Second Latin American Society for Immunodeficiencies (LASID) Advisory Board.

Early diagnosis and appropriate therapy are essential for the best prognosis and quality of life in patients with primary immunodeficiency diseases (PIDDs). Experts from several Latin American countries have been meeting on a regular basis as part of an ongoing effort to improve the diagnosis and treatment of PIDD in this region. Three programmes are in development that will expand education and training and improve access to testing facilities throughout Latin America. These programmes are: an educational outreach programme (The L-Project); an immunology fellowship programme; and the establishment of a laboratory network to expand access to testing facilities. This report provides the status of these programmes based on the most recent discussions and describes the next steps toward full implementation of these programmes.

A parent training model for toilet training children with autism.

BACKGROUND: Azrin & Foxx pioneered an intensive toilet training protocol for individuals with intellectual disability living in a residential setting. Since the development of the Rapid Toilet Training (RTT) protocol, many have replicated the efficacy, most notably in educational and outpatient treatment settings, but often training over longer periods of time. This study presents data from a parent training model that replicates Azrin and Foxx's results and training time. METHOD: This multiple baseline across subjects design study employs an ABA design where two boys diagnosed with autism were toilet trained using a modified Azrin & Foxx intensive teaching protocol. The first subject, a 4-year-old boy, did not have a history of attempted toilet training. The second subject, a 6-year-old boy, demonstrated a history of failed toilet training attempts in both the home and school settings. The trainings were conducted in the home setting where a novel parent-training approach was implemented. RESULTS: Participant 1 was continent at the end of the second day of training, and completely toilet trained (including initiation and communication) by day 10 of the intervention. Participant 2 was continent after day 1 and completely toilet trained by day 5 of the intervention. CONCLUSIONS: Long-term follow-up demonstrates maintenance of skills 3 years post training. Social validity via parent satisfaction was assessed. Limitations to the current study and recommendations for future research were discussed.

Pseudomonas aeruginosa and risk of death and exacerbations in patients with chronic obstructive pulmonary disease: an observational cohort study of 22 053 patients.

OBJECTIVES: The role of Pseudomonas aeruginosa in the long-term prognosis of chronic obstructive pulmonary disease (COPD) is unknown. The purpose of this study was to determine whether P. aeruginosa is associated with increased risk of exacerbations or death in patients with COPD. METHODS: This is a multiregional epidemiological study based on complete data on COPD outpatients between 1 January 2010 and 31 October 2017 and corresponding microbiology and national register data. Time-dependent Cox proportional hazards models and propensity matching was used to estimate hospitalization-demanding exacerbations and death after 2 years, separately and in combination. RESULTS: A total of 22 053 COPD outpatients were followed for a median of 1082 days (interquartile-range: 427-1862). P. aeruginosa was present in 905 (4.1%) patients. During 730 days of follow-up, P. aeruginosa strongly and independently predicted an increased risk of hospitalization for exacerbation or all-cause death (HR 2.8, 95%CI 2.2-3.6; p <0.0001) and all-cause death (HR 2.7, 95%CI 2.3-3.4; p <0.0001) in analyses adjusted for known and suspected confounders. The signal remained unchanged in unadjusted analyses as well as propensity-matched subgroup analyses. Among patients 'ever colonized' with P. aeruginosa, the incidence of hospital-demanding exacerbations doubled after the time of the first colonization. CONCLUSIONS: COPD patients in whom P. aeruginosa can be cultured from the airways had a markedly increased risk of exacerbations and death. It is still not clear whether this risk can be reduced by offering patients targeted antipseudomonal antibiotics. A randomized trial is currently recruiting patients to clarify this (ClinicalTrials.gov: NCT03262142).

Clinical consequences of hospital variation in use of oral anticoagulant therapy after first-time admission for atrial fibrillation.

OBJECTIVE: To analyse how hospital factors influence the use of oral anticoagulants (OAC) in atrial fibrillation (AF) patients and address the clinical consequences of hospital variation in OAC use. DESIGN AND SUBJECTS: By linkage of nationwide Danish administrative registers we conducted an observational study including all patients with a first-time hospitalization for AF between 1995 and 2004 as well as prescription claims for OAC. Multivariable logistic regression analysis was used to evaluate hospital factors associated with prescription of OAC therapy. Cox proportional-hazard models were used to estimate the risk of re-hospitalization for thromboembolism and haemorrhagic stroke with respect to discharge from a low, intermediate, or high OAC use hospital. RESULTS: Overall 40,133 (37%) out of 108,504 patients received OAC; ranging from 17% to 50% between the hospitals with the lowest and highest OAC use, respectively. Cardiology departments had the highest use of OAC, but neither tertiary university hospitals nor high volume hospitals had higher OAC use than local community hospitals and low volume hospitals. Risk of a thromboembolic event was significantly increased amongst patients from hospitals with a low OAC use (hazard ratio 1.16, confidence interval 1.10-1.22). Notably, higher OAC use was not associated with a higher risk of haemorrhagic stroke. CONCLUSION: In Denmark between 1995 and 2004, there was a major hospital variation in AF patients receiving OAC, and consequently, more thromboembolic events were observed amongst patients from low OAC use hospitals. Our study emphasizes the need for a continued vigilance on implementation of international AF management guidelines.

6th International Immunoglobulin Symposium: poster presentations.

The posters presented at the 6th International Immunoglobulin Symposium covered a wide range of fields and included both basic science and clinical research. From the abstracts accepted for poster presentation, 12 abstracts were selected for oral presentations in three parallel sessions on immunodeficiencies, autoimmunity and basic research. The immunodeficiency presentations dealt with novel, rare class-switch recombination (CSR) deficiencies, attenuation of adverse events following IVIg treatment, association of immunoglobulin (Ig)G trough levels and protection against acute infection in patients with X-linked agammaglobulinaemia (XLA) and common variable immunodeficiency (CVID), and the reduction of class-switched memory B cells in patients with specific antibody deficiency (SAD). The impact of intravenous immunoglobulin on fetal alloimmune thrombocytopenia, pregnancy and postpartum-related relapses in multiple sclerosis and refractory myositis, as well as experiences with subcutaneous immunoglobulin in patients with multi-focal motor neuropathy, were the topics presented in the autoimmunity session. The interaction of dendritic cell (DC)-SIGN and alpha2,6-sialylated IgG Fc and its impact on human DCs, the enrichment of sialylated IgG in plasma-derived IgG, as wells as prion surveillance and monitoring of anti-measles titres in immunoglobulin products, were covered in the basic science session. In summary, the presentations illustrated the breadth of immunoglobulin therapy usage and highlighted the progress that is being made in diverse areas of basic and clinical research, extending our understanding of the mechanisms of immunoglobulin action and contributing to improved patient care.

Active maturation-promoting factor is present in mature mouse oocytes.

Cytoplasmic extracts of meiotically mature mouse oocytes were injected into immature Xenopus laevis oocytes, which underwent germinal vesicle breakdown within 2 h. Germinal vesicle breakdown was not inhibited by incubation of the Xenopus oocytes in cycloheximide (20 micrograms/ml). Identically prepared extracts of meiotically immature mouse oocytes, arrested at the germinal vesicle stage by dibutyryl cyclic AMP (100 micrograms/ml), did not induce germinal vesicle breakdown in Xenopus oocytes. The results show that maturation-promoting factor activity appears during the course of oocyte maturation in the mouse.

Influence of Prior Psychiatric Disorders on the Treatment Course of Gynaecological Cancer - A Nationwide Cohort Study.

AIMS: To examine the influence of pre-existing psychiatric disorder on the choice of treatment in patients with gynaecological cancer. MATERIALS AND METHODS: The analyses were based on all patients who underwent surgical treatment for endometrial, ovarian or cervical cancer who were registered in the Danish Gynecological Cancer Database in the years 2007-2014 (3059 patients with ovarian cancer, 5100 patients with endometrial cancer and 1150 with cervical cancer). Logistic regression model and Cox regression model, adjusted for relevant confounders, were used to estimate the effect of pre-existing psychiatric disorder on the course of cancer treatment. Our outcomes were (i) presurgical oncological treatment, (ii) macroradical surgery for patients with ovarian cancer, (iii) radiation/chemotherapy within 30 days and 100 days after surgery and (iv) time from surgery to first oncological treatment. RESULTS: In the group of patients with ovarian cancer, more patients with a psychiatric disorder received macroradical surgery versus patients without a psychiatric disorder, corresponding to an adjusted odds ratio of 1.24 (95% confidence interval 0.62-2.41) and the chance for having oncological treatment within 100 days was odds ratio = 1.26 (95% confidence interval 0.77-2.10). As for patients with endometrial cancer, all outcome estimates were close to unity. The adjusted odds ratio for oncological treatment within 30 days after surgery in patients with cervical cancer with a history of psychiatric disorder was 0.20 (95% confidence interval 0.03-1.54). CONCLUSIONS: We did not find any significant differences in the treatment of ovarian and endometrial cancer in patients with pre-existing psychiatric diagnoses. When it comes to oncological treatment, we suggest that increased attention should be paid to patients with cervical cancer having a pre-existing psychiatric diagnosis.

Genetic diversity and population structuring of Schistosoma mansoni in a Brazilian village.

The digenean trematode Schistosoma mansoni is responsible for chronic schistosomiasis worldwide, and in Brazil alone an estimated 35 million people are at risk. To evaluate epidemiological patterns among human definitive hosts, we assessed genetic diversity and population subdivision of S. mansoni infrapopulations in human hosts from the highly endemic village of Virgem das Graças in the state of Minas Gerais, Brazil. We believe this is the largest such survey to date. Genetic diversity of parasites, measured over eight polymorphic microsatellite loci, was relatively high and standard measures of inbreeding indicated that the population was panmictic. Furthermore, there was no significant isolation-by-distance of parasite infrapopulations, and measures of population subdivision indicated significant but low to moderate levels of population differentiation. We conclude that patients within this village sample from a broad range of schistosome genetic diversity and effectively act as "genetic mixing bowls" for the parasites. These results contrast with those previously observed in the Brazilian village of Melqui ades and thus provide the opportunity for comparisons of environmental and epidemiological differences that are likely to influence host-parasite coevolution and parasite transmission.