Changes in subarachnoid hemorrhage mortality, incidence, and case fatality in New Zealand between 1981-1983 and 1991-1993

BACKGROUND AND PURPOSE: As with total stroke, mortality rates from subarachnoid hemorrhage (SAH) have declined in New Zealand since the mid-1970s. Data from the Auckland Region Stroke studies allow an understanding of reasons for the change, as SAH incidence and 28-day case fatality rates were measured as part of population-based stroke registers. METHODS: National death registrations were used to describe the trends in mortality rates from SAH (International Classification of Diseases [ICD] code 430) among men and women in New Zealand. Changes in incidence and case fatality rates were determined from 2 large-scale population-based stroke registries carried out in 1981-1983 and 10 years later in Auckland. Similar methodology and case ascertainment techniques were used in both studies. RESULTS: The mortality rates from SAH declined in both men and women after the mid-1970s. The mortality rate remained higher among women than men. The incidence of SAH was lower in 1991-1993 (11.3 per 100,000) compared with 1981-1983 (14.6 per 100,000). In the younger age groups, the decrease was mostly due to a lower incidence among men, whereas in the older age groups women older than 65 years had a lower incidence. There was no consistent change in case fatality rates between the 2 periods in either men or women. CONCLUSIONS: Mortality rates from SAH have decreased in both men and women. This decrease may be explained by a decrease in the incidence of SAH, because case fatality rates showed no change.     

Malpractice litigation against child and adolescent psychiatry residency programs, 1981-1991

A national survey was conducted to investigate malpractice litigation at United States child and adolescent psychiatry residency programs between 1981 and 1991. Fourteen percent of the directors of child and adolescent psychiatry reported at least one malpractice claim during this period. The highest percentage of lawsuits reported was in the northeast. Suicide and sexual abuse of latency age patients by other patients accounted for the most litigation. The mean monetary award was $167,000, and the largest award was $500,000 for discharge of a patient who killed his mother. There has been an increase in malpractice litigation during the past 10 years. Risk management strategies should be implemented to address areas of liability in child and adolescent psychiatry training programs.     

Age incidence of meningococcal infection England and Wales, 1984-1991

Gene transfer with vectors derived from murine retroviruses is restricted to cells which are proliferating and synthesizing DNA at the time of infection. This suggests that retroviral-mediated gene transfer might permit targeting of gene integration into malignant cells in organs composed mainly of quiescent nonproliferating cells, such as in the brain. Accordingly, selective introduction of genes encoding for susceptibility to otherwise nontoxic drugs ("suicide" genes) into proliferating brain tumors may be used to treat this cancer. We investigated the efficacy and dynamics of in vivo transduction of growing brain tumors with the herpes simplex-thymidine kinase gene followed by administration of the antiviral drug ganciclovir. Ganciclovir is phosphorylated by thymidine kinase to toxic triphosphates that interfere with DNA synthesis, resulting in the preferential death of the transduced tumor cells. Rats inoculated with 4 x 10(4) 9L gliosarcoma cells into the frontal lobe were treated 7 days later with an intratumoral stereotaxic injection of murine fibroblasts (NIH 3T3 cells) that were producing a retroviral vector containing the herpes simplex-thymidine kinase gene. Controls received vector producer and nonproducer NIH 3T3 cell lines containing the Escherichia coli lacZ (beta-galactosidase) gene as well as nonproducer NIH 3T3 cells containing the thymidine kinase gene. The animals were rested for 7 days to allow time for in situ transduction of the proliferating tumor cells with the herpes-thymidine kinase retroviral vector. The animals were then treated with ganciclovir, 15 mg/kg i.p. twice a day for 14 days. Gliomas receiving an injection of 3-5 x 10(6) thymidine kinase producer cells regressed completely in 23 of 30 rats given ganciclovir therapy, while 25 of 26 control rats developed large tumors. Intratumoral injection of a lower concentration of thymidine kinase vector producer cells (1.8 x 10(6)) resulted in a lower frequency of tumor regression (5 of 13 rats). To estimate the efficiency of in vivo gene transfer, 9L brain tumors were given injections of 5 x 10(6) beta-galactosidase vector producer cells. 5-Bromo-4-chloro-3-indolyl-beta-D-galactopyranaside staining revealed maximal staining of beta-galactosidase within the tumor 7-14 days after injection of the vector producer cells. In vivo transduction rates in harvested tumors ranged from 10 to 70%. There was no evidence of transduction of the surrounding normal neural tissue. Occasional blood vessel endothelial cells within or adjacent to the tumor were observed to be 5-bromo-4- chloro-3-indolyl-beta-D-galactopyranaside positive.(ABSTRACT TRUNCATED AT 400 WORDS)     

Pertussis, pertussis vaccine, and care of exposed persons

BACKGROUND: Pertussis is a highly contagious bacterial infection caused by Bordetella pertussis. Before routine vaccination against pertussis was available, most persons were infected during childhood. After widespread vaccination, however, the incidence of pertussis in the United States dropped by more than 95 percent, though localized outbreaks continue to occur. METHODS: A multidisciplinary team developed a set of review articles as part of continuing medical education modules in the Teaching Immunization in Medical Education (TIME) Project. The team developed the materials using expert judgment and selected materials from the literature and the Centers for Disease Control and Prevention (CDC). The first step was the creation of specific learning objectives that used the spectrum of Bloom's taxonomy, when possible. After the materials were developed, they were pilot-tested and revised. Subsequently they underwent summative evaluation by field-testing the materials with 24 other primary care physicians. Then the materials were reviewed by the CDC and national vaccine experts and revised based on their comments. RESULTS AND CONCLUSIONS: The efficacy of whole-cell pertussis vaccine is about 70 to 90 percent, though local adverse events are common. Since 1990 several purified, acellular pertussis vaccines have been developed that have one quarter to one half of the common adverse events associated with whole-cell vaccine and have similar efficacy rates. The incidence of pertussis can be further reduced by increasing age-appropriate vaccination rates.     

Age standardized incidence rates of oral cancer in South Africa, 1988-1991

While numbers of papers on oral cancer in South Africa have been published, there have been very few studies on standardized morbidity rates. This paper has developed data collected by the National Cancer Registry from the entire country for the four year period 1988-1991 to present frequency, age standardized incidence rates (ASIRs) and life-time risk (LR) for histologically-diagnosed intra-oral cancers in female and male Asian, black, coloured and white South Africans. During this period 5396 cases of oral cancer were diagnosed in a total number of 157,307 cancer cases (3.4 per cent) excluding squamous cell carcinoma (SCC) and basal cell carcinoma (BSC) of the skin. Intra-oral cancer in all South African females and males accounted, respectively, for 1.8 per cent and 5.0 per cent of all cancers. There was a male preponderance in black, coloured and white groups but females were affected more frequently than men among Asians. The incidence in Asian women (6.66) was higher than those of the women in any of the other population groups, whereas the lowest incidence was found in black women (1.75). The incidence rate in coloured men was particularly high (13.13) whereas the incidence in white males (8.06) was not substantially lower than among black males (9.05). Differences between the eight groups were not significant (X2 = 6.24, df = 3, p > 0.1). The Cumulative Life Time Risk (LR) of developing intra-oral cancer for males and females in the four population groups ranged from 1:65 in coloured males to 1:455 for black females. Gender differences in LR in both black and coloured groups, signals substantial differences in exposure to known carcinogens for this disease. It is disturbing to note that the incidence in the period 1988-1991 was higher in Indian women that it was in 1964-1966, and that educative preventive measures have failed. Similarly, the incidence of intra-oral cancer in coloured men of 13.13 is substantially higher than the figure of 8.8 reported in 1979. If this is an accurately reflected trend, then a major educative programme needs to be pursued in this direction if the relative risk of one in 65 is to be reduced.     

Systemic vasculitis: classification and serologic diagnosis

Cardiovascular morbidity and mortality in hemodialyzed patients are increased due to the frequently abnormal lipid metabolism. It has been reported that this abnormal lipid metabolism could be partially corrected by some highly permeable membranes, such as polysulfone or cellulose triacetate. We investigated the influence of 4 months of dialysis with a polyamide membrane upon the course of lipid parameters in 6 patients presenting a hypertriglyceridemia > 2 mmol/l while on bicarbonate dialysis with a cellulose membrane. Lipid parameters improved after 4 months of hemodialysis with a polyamide membrane. Serum triglyceride and cholesterol levels decreased, while HDL cholesterol and HDL levels rose significantly (p < 0.05). Apolipoprotein B decreased significantly (p < 0.05). Following heparin administration, lipoprotein lipase activity improved (p < 0.02), associated with a decrease apolipoprotein C3 (p < 0.05). The fractional clearance rate of triglycerides rose significantly (p < 0.01). The use of highly permeable polyamide membranes results in a significant improvement in lipid disturbances of dialysis patients due to an increased lipoprotein lipase activity, induced perhaps by the removal of circulating inhibitors such as apolipoprotein C3.     

Pollen calendar of the city of Salamanca (Spain). Aeropalynological analysis for 1981-1982 and 1991-1992

We report a study on the contents of airborne pollen in the city of Salamanca (Spain) aimed at establishing a pollen calendar for the city for the yearly periods of maximum concentrations, relating these with quantifiable atmospheric variables over two two-year periods with an interval of 10 years between them: 1981-82 and 1991-92. The pollen was captured with Burkard spore-traps, based on Hirst's volumetric method. Determinations were made daily and were used to make preparations, previously stained with basic fuscin, for study under light microscopy at x 1,000 magnification. 946 preparations were analyzed, corresponding to the same number of days distributed over 150 weeks of the periods studied. The results afforded the identification of 48 different types of pollen grain: Grasses (Poaceae), Olea europea (olive), Quercus rotundifolia (Holm-oak), other Quercus spp. (Q. pyrenaica, Q. suber, Q. faginea, etc.), Cupressaceae (Cupressus sempervivens, C. arizonica, Juniperus communis etc.), Plantago (Plantago lanceolata, Plantago media, etc.), Pinaceae (Pinus communis, Abies alba, etc.), Rumex sp. (osier), Urtica dioica (nettle), Parietaria (Parietaria officinalis, P. judaica), Chenopodio-Amaranthaceae (Chenopodium sp., Amaranthus sp., Salsola kali, etc.), Artemisia vulgaris (Artemisia), other Compositae (Taraxacum officinalis, Hellianthus sp. etc.), Castanea sativa (Chestnut), Ligustrum sp. (privet), Betula sp. (birch), Alnus sp. (common alder), Fraxinus sp (ash), Populus sp. (poplar), Salix sp. (willow), Ulmus sp. (elm), Platanus sp. (plantain, plane), Carex sp. (sweet flag), Erica sp. (common heather), Leguminosae or Fabaceae:--Papillionaceae (Medicago sp.; Cercis sp., Robina sp.)--Cesalpinoideae Acacia sp. (Acacia),--Mimosoideae: Sophora japonica, Umbelliferae (Foeniculum sp., Cirsium sp., etc.), Centaurea sp., Cistus sp. (rock rose), Typha sp (bulrush), Mirtaceae (Myrtus communis), Juglans regia (Walnut), Galium verum, Filipendula sp. (spirea/drop wort), Rosaceae (Pyrus sp., Prunus sp., etc.), Tilia sp. (Linden), Morus sp. (mulberry), Taxus baccata (yew), Papaveraceae (Papaver rhoeas etc.), Labiata (Lavandula sp.), Cannabaceae (Humulus sp. etc.), Liliaceae (Lilium sp.), Echium sp. (viper's bugloss). The most abundant taxa, detected in the highest quantities (grains/m3 air), by order of counting were as follows: holm-oak, olive, grasses, Plantago and Parietaria. With the data obtained we have established a pollen calendar for Salamanca and report the period in which each type of pollen is found along the years and the periods with the highest airborne concentrations of such pollens. The diversity and the spectrum of the pollen in the city of Salamanca correspond to the typical plant communities found on the dehesas (large ranges of grasslands) of Castile, where Salamanca is located, although the wind directions and the peculiar climatic characteristics of the area govern the peaks of maximum presence of the different taxa. As examples, in the case of olive, which is cultivated at some distance from the city, its maximum presence coincides with south-westerly winds; in the case of grasses, the peaks of maximum counts coincide with a sharp rise in mean temperature, close to or higher than 20 degrees C and between five and six weeks after rainfall equal to or greater than 5 L/m2.     

Prospective study of bacterial meningitis in North East Thames region, 1991-3, during introduction of Haemophilus influenzae vaccine

OBJECTIVE: To describe the epidemiology of primary bacterial meningitis in the North East Thames region over a three year period before and during the introduction of the vaccine for Haemophilus influenzae type b. DESIGN: Analysis of information on cases of primary bacterial meningitis identified by microbiology laboratories in the region, with collection of case data by questionnaire. MAIN OUTCOME MEASURES: Annual incidence rates for types of meningitis according to age and ethnic group. RESULTS: The annual incidence rates for the three major causes of bacterial meningitis in the general population were 1.9/100,000 for Neisseria meningitidis, 1.6/100,000 for Haemophilus influenzae before vaccination, and 1.0/100,000 for Streptococcus pneumoniae. Higher rates of H influenzae meningitis were found in Asians compared with white people (3.6/100,000 v 1.5/100,000, P = 0.01). As a result of the vaccine programme introduced in October 1992 the number of cases of H influenzae meningitis in children under 5 years has fallen by 87%. CONCLUSIONS: Bacterial meningitis is a serious problem especially in preschool children. There are differences in the incidence of some causes of bacterial meningitis in different ethnic groups; with H influenzae type b being significantly more common among black and Asian people than among white people. The immunisation programme for H influenzae type b in the North East Thames region has been successful in reducing the incidence of this type of meningitis in Asian and white populations. The numbers were too small to evaluate in the black population.     

Evaluation of a multivalent Pasteurella haemolytica vaccine in bighorn sheep: safety and serologic responses

We examined effects of a multivalent Pasteurella haemolytica vaccine (serotypes A1, A2, T10) on humoral immune responses and P. haemolytica isolation rates in bighorn sheep (Ovis canadensis). Thirty captive bighorns, divided into groups of three on the basis of age, sex, and previous history of pneumonic pasteurellosis, received 0, 1, or 2 vaccine doses. Mild, transient lameness in most bighorns 1 day after initial vaccination was the only adverse effect observed. Oropharyngeal (> or = 75%) and nasal (< or = 50%) isolation rates for P. haemolytica did not differ among treatment groups. Ten of 36 distinguishable biogroup variants accounted for about 87% of the 464 P. haemolytica isolates from bighorns, but prevalences of specific biogroups were not affected by vaccination. Bighorns receiving 1 or 2 vaccine doses showed marked elevations in leukotoxin neutralizing antibody titers beginning 1 wk after vaccination. Agglutinating antibody titers to serotype A1 and A2 surface antigens were also elevated in vaccinated bighorns within 2 wk after vaccination; agglutinating antibody titers to serotype T10 surface antigens were relatively high in all three groups but appeared unaffected by vaccination. Vaccination 7 to 14 wk prior to parturition elevated leukotoxin neutralizing antibody titers in colostrum, but neither leukotoxin neutralizing nor serotype A1 surface antigen agglutinating antibody titers differed through 16 wk of age among lambs born to dams from different vaccine dose groups. Our data demonstrate that this multivalent P. haemolytica vaccine is safe and stimulates marked antibody responses in bighorn sheep. Further evaluation of this vaccine as a tool in preventing and managing pasteurellosis in bighorn sheep appears warranted.     

Hepatitis C: Part I. Routine serologic testing and diagnosis

Hepatitis C, which is caused by the hepatitis C virus (HCV), is a major public health problem in the United States. HCV is most efficiently transmitted through large or repeated percutaneous exposures to blood. Most patients with acute HCV infection develop persistent infection, and 70 percent of patients develop chronic hepatitis. HCV-associated chronic liver disease results in 8,000 to 10,000 deaths per year, and the annual costs of acute and chronic hepatitis C exceed $600 million. An estimated 3.9 million Americans are currently infected with HCV, but most of these persons are asymptomatic and do not know they are infected. To identify them, primary health care professionals should obtain a history of high-risk practices associated with the transmission of HCV and other bloodborne pathogens from all patients. Routine testing is currently recommended only in patients who are most likely to be infected with HCV.     

Measles vaccine effectiveness in standard and early immunization strategies, Niger, 1995

BACKGROUND: An Expanded Programme on Immunization was started in late 1987 in Niger, including vaccination against measles with one dose of standard titer Schwarz vaccine given to infants after 9 months of age. During epidemics an early two-dose strategy was implemented (one dose between 6 and 8 months and one dose after 9 months). From January 1, 1995, until May 7, 1995, 13 892 measles cases were reported in Niamey, Niger. METHODS: A retrospective cohort study was conducted in a crowded area of Niamey at the end of the outbreak to assess the effectiveness of measles vaccine in standard (after 9 months) and early (before 9 months) immunization strategies under field conditions. RESULTS: Highest measles incidence rates were observed among children <1 year of age. Vaccine effectiveness estimates increased with age at vaccination from 78% with a single dose administered at 6 months of age to 95% at 9 months. Vaccine effectiveness with the early two dose strategy was 93%. CONCLUSIONS: Immunization with a single dose of standard titer Schwarz vaccine before 9 months of age provided higher clinical protection than expected from seropositivity studies. The early two dose strategy is justified in contexts where measles incidence is high before 9 months of age. Our results raise the issue of lowering the recommended age for measles vaccination in developing countries.     

Lung cancer--management and outcome in Glasgow, 1991-92

Current practice and outcome for patients with lung cancer were determined by retrospective case note review of a random sample of all lung cancer cases registered for a calendar year and augmented by review of all surgical and radical radiotherapy cases. A total of 262 patients - 231 patients less than 75 years of age and 31 patients more than 75 years of age - represented 83% of the random sample. Eighty-three per cent of patients were seen within 2 weeks of referral. One-third reported symptoms occurring for less than 1 month and one-third had experienced symptoms for more than 3 months. The median time interval from first hospital contact until the making of a management decision was 18 days. The median interval from first contact to surgery was 63 days, and to starting radical radiotherapy 70 days. Histological confirmation was obtained in 69% of patients. Ten per cent of all lung cancer patients were calculated to have received chemotherapy. Five per cent of the whole cohort had definitive surgery and 64% of these were judged to be free of the disease at 3 years. Overall survival was 9% at 3 years, with no differences relating to cell type or area of residence. Many areas of good practice have been identified, but the lack of tumour staging or performance status data, the low proportion receiving chemotherapy or definitive surgery and the poor outcome after radical radiotherapy indicate the need for prospective audit and feedback of results. The long time interval from management decision to surgery and radiotherapy suggests organizational issues which need attention.     

Commercial logging fatalities in Ontario, 1986-1991

Steady progress in the delineation of prognostic factors and the identification of genetic alterations and of potential mechanisms of oncogenesis mark the contributions to the literature on osteosarcoma for the past year. A new cytokine and chemotherapy combination has shown promise, and additional work on chemotherapy regimens containing ifosfamide will undoubtedly stimulate interest in a new generation of randomized clinical trials that will be essential for further refinement of therapy for osteosarcoma.     

Declines in teenage birth rates, 1991-97: national and state patterns

This report presents data on the numbers of teenage births and teenage birth rates for the United States for the period 1950-97 and State-specific birth rates for teenagers for 1991-96. After increasing sharply in the late 1980's, birth rates declined for American teenagers from 1991 through 1997. Rates fell overall by 16 percent for teenagers 15-17 years and by 11 percent for teenagers 18-19 years. Declines were reported for all race and ethnic origin groups, with the largest declines found for black teenagers, especially those aged 15-17 years. Particularly noteworthy has been the 21-percent decline in the rate of second births for teenagers who have had one child. Rates have fallen for first births as well, but the reductions are more modest, about 6 percent. Teenage mothers and their babies continue to be at greater risk of adverse health consequences compared with older mothers, including higher rates of preterm birth and low birthweight. While teenage birth rates vary considerably by State, rates fell in all States in the 1990's with nearly all declines statistically significant. Rates for black and non-Hispanic white teenagers dropped in most States from 1991 to 1996. Birth rate trends for Hispanic teenagers by State were not consistent. The proportion of second and higher order births among all teenage births declined substantially in most States. Data are from the National Center for Health Statistics' (NCHS) National Vital Statistics System.     

Pertussis vaccines: past, present and future in Australia

In August 1997, a workshop was convened by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases to consider current issues in the use of pertussis vaccines and implications for the Australian immunisation schedule. Topics covered included the history, efficacy and reactogenicity of whole-cell and acellular vaccines and vaccine schedules. Acellular pertussis vaccine is preferred by the National Health and Medical Research Council for the primary course as well as the 18 month and 4-5 year old childhood doses. At the time of the workshop, a 3-component acellular vaccine (DTPa) had been approved (licensed) in Australia for all doses in the childhood schedule. It was the first vaccine subject to a cost-effectiveness evaluation under the new vaccine funding arrangements. Issues considered in the evaluation of the cost-effectiveness of the vaccine were discussed. These included comparative efficacy, adverse events and compliance, and the question of community as well as individual benefit from the use of the vaccine.     

HIV type 1 subtypes in Malaysia, determined with serologic assays: 1992-1996

We investigated the molecular epidemiology of HIV-1 subtypes in Malaysia among injecting drug users (IDUs) and sexual transmission risk groups, using serologic and genetic techniques. Frozen sera collected at a general hospital, a blood bank, several drug treatment centers, and an STD clinic in Kuala Lumpur, between 1992 and 1996, were investigated retrospectively. V3 peptide serotyping and monomeric gp120 capture serotyping were used to study 89 known HIV-1-infected subjects. The methods differentiate subtypes B, E, and C. V3 peptide and gp120 capture results were comparable. No subtype C-specific reactive sera were found; one specimen was dually reactive for subtypes C and B, using the V3 peptide ELISA; and four were durally reactive for subtypes E and C using this assay. Genotypic analysis of HIV-1 gag RNA in serum was done on a subset of subjects and confirmed serologic findings. HIV-1 subtypes differed significantly by risk category: of 53 IDUs, 29 (55%) were infected with subtype B and 19 (36%) were infected with subtype E, 3 (6%) were dually reactive, and 2 (4%) were not typable. Of 36 persons with heterosexual risks, 29 (81%) were infected with subtype E, 5 (14%) were infected with subtype B, and 2 (5%) were not typable. Persons with IDU risks were significantly more likely to be infected with subtype B than were those with sexual risks (OR 5.89; 95% CI, 1.94-18.54; p < 0.001). Subtypes B and E of HIV-1 appear to predominate in Malaysia; subtype B was more prevalent among IDUs; subtype E was more prevalent among all other groups. These results may have important HIV-1 vaccine implications.     

Experimental infection of pregnant cattle with the vaccine candidate Brucella abortus strain RB51: pathologic, bacteriologic, and serologic findings

To determine the placental tropism and abortigenicity of the vaccine candidate Brucella abortus strain RB51 (SRB51), a rough mutant of the virulent strain 2308, ten Polled Hereford heifers were inoculated intravenously in the 6th month of gestation. Heifers were euthanatized and examined at postinoculation week (PIW) 8 (n = 5) or at full term (n = 5). Four of five infected heifers sampled at PIW 8 and three of four infected heifers at term had placentitis, whereas reproductive tissues of three normal cows used for comparison had no placentitis. Numerous macrophages, immunoreactive for SRB51 antigen, as well as neutrophils, fibrin, and cell debris filled the arcade zone between chorion and maternal septae. Trophoblastic epithelium of the placentomal arcade zone had intracellular bacteria that were immunoreactive for SRB51 antigen. The tips of maternal septa had a lymphoplasmacytic infiltrate with small multifocal erosions and ulcerations of maternal epithelium. SRB51 was cultured from all tissues in which lesions were seen. Placentae of one cow from each group had no placentitis and contained no SRB51. In mammae, interstitial lymphoplasmacytic infiltrates and suppurative infiltrates within alveoli and intralobular ductules were seen in two of five heifers at PIW 8. SRB51 was cultured from liver, spleen, lung, and bronchial lymph nodes in four of five calves at PIW 8 and three of four full-term calves, but no lesions were seen. One near-term heifer had disseminated infection, placentitis, and lymphoplasmacytic endometritis, and delivered a premature weak calf. These results establish that SRB51 is less abortifacient than previously published reports with strain 19, in that only one of four heifers delivered prematurely following intravenous inoculation with SRB51, whereas intravenous inoculation with strain 19 leads to 100% abortion. However, it also shows that SRB51 can infect the bovine placenta, mammary gland, and fetus, can induce placentitis, and, in some cases, can lead to preterm expulsion of the fetus.