Developing appropriate strategies for EPI: a case study from Mozambique

In 1985 a ‘pulse immunization’ project was begunin southern Mozambique, to overcome the difficulties of deliveringimmunization services in rural areas. The project was closelymonitored in order to determine whether this strategy wouldbe appropriate on a national level. Major inputs were in trainingof both health workers and volunteers, and the development ofa system for communications and defaulter tracing via Mozambique'snetwork of grassroots organizations. By 1987 the project hadachieved 60% coverage of fully immunized children in safe ruralareas of the province, having reduced dropout rates betweenfirst and third doses of DPT/OPV from 49% to 11%. This paperdescribes the process of project development through situationanalysis, project design, implementation, monitoring and evaluation.Conclusions are drawn which may be relevant to other programmesin their attempts to accelerate immunization coverage in a sustainableway.     

Modulation of in vitro eosinophil progenitors by hydrocortisone: role of accessory cells and interleukins

The growth of human eosinophil progenitors (CFU-Eo) and the modulation of growth by hydrocortisone were studied as functions of the presence of lymphocytes and monocytes in marrow cells under study; and the source of colony-stimulating factors, specifically, media conditioned by macrophage-like cell line, GCT; phytohemagglutinin-stimulated mononuclear cells (PHA-LCM); or the T cell line, MO. CFU-Eo growth was greatest in marrow containing accessory cells as compared to marrow depleted of accessory cells; and in marrow treated with phytohemagglutinin-stimulated leukocyte conditioned media (PHA-LCM) or MO (T cell line)-conditioned medium (MO-CM) as compared with GCT cell- conditioned medium (GCT-CM). Hydrocortisone reproducibly inhibited eosinophil progenitor growth in unfractionated marrow stimulated by GCT- CM. This effect was abrogated by admixing irradiated mononuclear cells or T lymphocytes with the target marrow or by adding interleukin 1 or interleukin 2 (IL-1, IL-2). Inhibition by hydrocortisone did not occur when monocyte and T lymphocyte depleted marrow was studied. Unlike GCT- CM, MO-CM and PHA-LCM stimulated equal proportions of eosinophil progenitors in nondepleted and accessory cell-depleted marrow and demonstrated less hydrocortisone inhibition. However, both GCT-CM and PHA-LCM produced in the presence of hydrocortisone stimulated significantly fewer CFU-Eos in both unfractionated and accessory cell- depleted marrow target populations. These results indicate that the growth of CFU-Eo and inhibition of growth by hydrocortisone is a direct function of a monocyte-T cell interaction and probably is mediated through effects on the production/release of eosinophil colony stimulating factor (Eo-CSF).     

Reversal of granulocyte adherence to nylon fibers using local anesthetic agents: possible application to filtration leukapheresis

The effects of the cationic anesthetic agents tetracaine and lidocaine on granulocyte function, morphology, and adherence to nylon fibers were studied in an attempt to improve current methods of granulocyte collection by filtration leukapheresis (FL). When dissolved in acid- citrate-dextrose (ACD) plasma, these drugs significantly increased granulocyte elution from the fibers in a dose-related fashion. Granulocytes exposed to tetracaine and lidocaine remained more than 95% viable, retained normal bactericidal capacity after the drugs were washed from the cells, and had preserved membrane integrity, as evidenced by the normal ultrastructural appearance of tetracaine- exposed cells and an absence of leakage of lysozyme or lactic dehydrogenase. Granulocytes eluted with the anesthetic agents were rounded in shape with a reduction in the number of filopodial cytoplasmic projections and a relative absence of cytoplasmic vacuolization when compared to granulocytes eluted with ACD plasma alone. Dose-related inhibition of phagocytosis and adherence, which was largely reversible after washing the granulocytes, was noted. Greater than 95% of the lidocaine could be removed from the eluate with a single centrifugation and resuspension, indicating that granulocytes prepared by FL with anesthetic-enhanced elution could be potentially transfusable.     

Effect of an equine-movement therapy program on gait, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study

The purpose of this study was to evaluate the effects of an 8-week program of hippotherapy on energy expenditure during walking; on the gait dimensions of stride length, velocity, and cadence; and on performance on the Gross Motor Function Measure (GMFM) in five children with spastic cerebral palsy (CP). A repeated-measures within-subjects design was used consisting of two baseline measurements taken 8 weeks apart, followed by an 8-week intervention period, then a posttest. After hippotherapy, all five children showed a significant decrease (X_r²;=7.6, P<0.05) in energy expenditure during walking and a significant increase (X_r²=7.6, P<0.05) in scores on Dimension E (Walking, Running, and Jumping) of the GMFM. A trend toward increased stride length and decreased cadence was observed. This study suggests that hippotherapy may improve energy expenditure during walking and gross motor function in children with CP.     

Defecography

Defecography is a technique of examining the rectum and anal canal in which the patient is studied while sitting down rather than recumbent and recordings are obtained both at rest and during straining. The authors describe their findings in 83 patients with dyschezia. Defecation was normal in 28 patients. Prolapse of the anal mucosa was seen in 13 patients and internal procidentia in 23, 12 of whom also had intussusception manifested as rectal prolapse. A deep rectogenital fossa associated with an enterocele was seen in 16 patients; 13 had a proctocele, while fecal retention was seen in 5. Descent of the pelvic floor and changes in the angle between the rectum and anal canal were assessed. The authors recommend defecography as a more physiological means of assessing rectal dysfunction.     

Pulmonary cystic disease: comparison of Pneumocystis carinii pneumatoceles and bullous emphysema due to intravenous drug abuse

A rare pulmonary manifestation of the acquired immunodeficiency syndrome or intravenous (IV) drug abuse is upper lobe cystic disease--pneumatoceles in Pneumocystis carinii pneumonia (PCP) and bullous emphysema in IV drug abuse. Because these disorders overlap, the radiographic findings in 56 patients were compared. During a 12-month period, 16 patients less than 40 years of age were found to have bullous emphysema; the 10 who were IV drug abusers constituted group 1. In the same time period, 40 patients with PCP were encountered; the eight (20%) who had or developed pneumatoceles constituted group 2. In both groups, the conventional radiographic manifestations of upper lobe cystic disease were similar. Eight patients underwent computed tomography of the chest. In five patients with bullous disease, the distribution of the bullous lesions was peripheral, with sparing of the central portions of the lungs. In contrast, PCP pneumatoceles in three patients were dispersed throughout the lung parenchyma.     

A review of the usefulness of D-Dimer in the diagnosis of pulmonary embolism

Pulmonary embolism is a potentially fatal condition that is extremely difficult to accurately diagnose clinically, usually relying on radiological investigations to make the diagnosis. These confirmatory tests are expensive, time consuming and may be associated with considerable morbidity. Thus, the utility of a blood test that reliably makes or refutes the diagnosis is apparent. Most blood tests involve the later stages of thrombolysis. Of these, the D-Dimer tests are the most sensitive, and when combined with monoclonal antibody technology, are of clinical value. Enzyme-linked immunosorbent assay D-Dimer tests have good sensitivity (95%) and moderate specificity (30–45%), but technical considerations prevent their routine use. Latex agglutination tests overcome these technical problems, but their sensitivity is variable (46–100%). Two recently introduced tests show promise. The NYCO-CARD D-Dimer test is a semiquantitative modified enzyme-linked immunosorbent assay test. Relatively few clinical studies have been performed and further validation studies are required. The SimpliRED D-Dimer test uses a new bispecific antibody technique, allows bed-side testing, and has good sensitivity (84–100%) and negative predictive values (92–99%). These tests could be used to screen low risk patients, thus avoiding ventilation-perfusion scans, or in combination with ventilation-perfusion scans and lower limb studies to avoid angiograms in intermediate probability pulmonary embolism patients. Future research will define where these tests show greatest utility, particularly in which patient subgroups, or symptom time intervals.     

The chances that an emergency physician will demonstrate three abdominal aortic aneurysms by ultrasound in the emergency department for credentialing: A statistician's view

The Australasian College for Emergency Medicine requires 15 proctored examinations of the aorta for credentialing in ultrasonography for abdominal aortic aneurysm (AAA). Furthermore, at least three examinations need to be positive for an aneurysm. In the ED where AAA presentations are sporadic, what are the chances that an emergency physician (EP) will have the opportunity to demonstrate three AAAs in the next 12 months? The probability of an event occurring within a given time‐frame can be modelled by the Poisson distribution. Central to the Poisson distribution is the infrequency of the event such as encountering an AAA in the ED. An EP working 30 clinical hours/week in our tertiary‐referral hospital ED can be expected to encounter 15.6 (3.6 symptomatic + 12 asymptomatic) AAA in the next 12 months. The probability of seeing three or more cases during this time is 99.9%. Assuming a proctor can be found for half the cases, the probability of an EP performing proctored ultrasound examinations in at least three AAAs is 98%. This probability drops to 89% if a proctor can be found for only one‐third of cases. For an EP to be almost 100% certain of meeting the credentialing requirements, he/she would need almost 10 proctored ultrasound cases of AAA to be available within his/her shifts during the year. The Poisson distribution has enabled us to model the probability of encountering a given number of AAA in the ED. Analysis such as this may help rationalise the numbers needed for credentialing.