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We describe a modification of the most probable number (MPN) method for rapid enumeration of antimicrobial-resistant Escherichia coli bacteria in aqueous environmental samples. E. coli (total and antimicrobial-resistant) bacteria were enumerated in effluent samples from a hospital (n = 17) and municipal sewers upstream (n = 5) and downstream (n = 5) from the hospital, effluent samples from throughout the treatment process (n = 4), and treated effluent samples (n = 13). Effluent downstream from the hospital contained a higher proportion of antimicrobial-resistant E. coli than that upstream from the hospital. Wastewater treatment reduced the numbers of E. coli bacteria (total and antimicrobial resistant); however, antimicrobial-resistant E. coli was not eliminated, and E. coli resistant to cefotaxime (including extended-spectrum beta-lactamase [ESBL] producers), ciprofloxacin, and cefoxitin was present in treated effluent samples.

On January 12, 2010, a major earthquake in Haiti resulted in approximately 212 000 deaths, 300 000 injuries, and more than 1.2 million internally displaced people, making it the most devastating disaster in Haiti's recorded history. Six academic medical centers from the city of Chicago established an interinstitutional collaborative initiative, the Chicago Medical Response, in partnership with nongovernmental organizations (NGOs) in Haiti that provided a sustainable response, sending medical teams to Haiti on a weekly basis for several months. More than 475 medical volunteers were identified, of whom 158 were deployed to Haiti by April 1, 2010. This article presents the shared experiences, observations, and lessons learned by all of the participating institutions. Specifically, it describes the factors that provided the framework for the collaborative initiative, the communication networks that contributed to the ongoing response, the operational aspects of deploying successive medical teams, and the benefits to the institutions as well as to the NGOs and Haitian medical system, along with the challenges facing those institutions individually and collectively. Academic medical institutions can provide a major reservoir of highly qualified volunteer medical personnel that complement the needs of NGOs in disasters for a sustainable medical response. Support of such collaborative initiatives is required to ensure generalizability and sustainability.

Left ventricular rupture may occur as a complication of acute myocardial infarction and is associated with significant morbidity and mortality. The risk associated with impending rupture of the left ventricular free wall has not been quantified but it is likely a predisposing factor to complete rupture. Few cases of impending rupture of the left ventricular free wall have been discussed in the literature; we present one such case and describe simple operative management with an autologous pericardial patch and subsequent outcome.

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18-bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine-related cases, measuring hospital mortality and long-term survival in early 2009. Cocaine-related admissions increased from around one annually in 2003-05 to 10 in 2007. Their median (IQR [range]) age was 25 (21-35 [17-47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11-27 [5-36]) and length of intensive care stay was 5 (3-9 [1-16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow-up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.

Many noted clinicians and educators led the development of nurse anesthesia as a profession during the first half of the 20th century. Betty E. Lank, CRNA, a nurse anesthetist at Children's Hospital Boston, Massachusetts, for 34 years, devoted her professional life to the delivery and advancement of pediatric anesthesia. She is credited with many contributions including the first use of cyclopropane for infant anesthesia, developing pediatric-sized anesthesia masks and ventilation bags, and instituting standards for specialized postanesthesia recovery areas. Lank recorded her anesthesia experiences in various nursing publications and shared her knowledge with colleagues at professional meetings. Her accomplishments make her a notable figure in the early history of pediatric anesthesia, and her dedication helped forge the foundation for anesthesia at Children's Hospital Boston.

A process evaluation of nurses' implementation of an infant-feeding counseling protocol was conducted for the Breastfeeding, Antiretroviral and Nutrition (BAN) Study, a prevention of mother-to-child transmission of HIV clinical trial in Lilongwe, Malawi. Six trained nurses counseled HIV-infected mothers to exclusively breastfeed for 24 weeks postpartum and to stop breastfeeding within an additional four weeks. Implementation data were collected via direct observations of 123 infant feeding counseling sessions (30 antenatal and 93 postnatal) and interviews with each nurse. Analysis included calculating a percent adherence to checklists and conducting a content analysis for the observation and interview data. Nurses were implementing the protocol at an average adherence level of 90% or above. Although not detailed in the protocol, nurses appropriately counseled mothers on their actual or intended formula milk usage after weaning. Results indicate that nurses implemented the protocol as designed. Results will help to interpret the BAN Study's outcomes.

Identifying the specific genetic characteristics of successfully transmitted variants may prove central to the development of effective vaccine and microbicide interventions. Although human immunodeficiency virus transmission is associated with a population bottleneck, the extent to which different factors influence the diversity of transmitted viruses is unclear. We estimate here the number of transmitted variants in 69 heterosexual men and women with primary subtype C infections. From 1,505 env sequences obtained using a single genome amplification approach we show that 78% of infections involved single variant transmission and 22% involved multiple variant transmissions (median of 3). We found evidence for mutations selected for cytotoxic-T-lymphocyte or antibody escape and a high prevalence of recombination in individuals infected with multiple variants representing another potential escape pathway in these individuals. In a combined analysis of 171 subtype B and C transmission events, we found that infection with more than one variant does not follow a Poisson distribution, indicating that transmission of individual virions cannot be seen as independent events, each occurring with low probability. While most transmissions resulted from a single infectious unit, multiple variant transmissions represent a significant fraction of transmission events, suggesting that there may be important mechanistic differences between these groups that are not yet understood.

Cambodians have the lowest breastfeeding initiation rate of any racial/ethnic group in Massachusetts. One barrier to breastfeeding is a lack of hospital foods that allow women to follow a traditional diet postpartum. We examined whether a culturally acceptable menu for new Cambodian mothers would increase breastfeeding initiation in the hospital. After a staff training program on breastfeeding, and the creation of a Cambodian menu, initiation rates increased significantly more in Cambodians than in non-Cambodians. Pre intervention, breastfeeding initiation was 16.7% (2/12) among Cambodians, compared to 60.6% (106/175) among non-Cambodians (P = 0.003). Post intervention, there was no significant difference between breastfeeding initiation rates among Cambodian women (66.7%; 8/12) compared to non-Cambodians (68.9%; 104/151) (P = 0.874).

Objectives: This study was conducted to compare viral dynamics in blood and semen between subjects with antibody negative, acute HIV-1 infection and other subjects with later stages of infection., Design: A prospective cohort study was embedded within a cross-sectional study of HIV screening in a Lilongwe, Malawi STD clinic., Methods: Blood samples from HIV antibody negative or indeterminate volunteers were used to detect HIV RNA in plasma using a pooling strategy. Blood and seminal plasma HIV-1 RNA concentrations were measured over 16 weeks., Results: Sixteen men with acute HIV infection and 25 men with chronic HIV infection were studied. Blood viral load in subjects with acute HIV infection was highest about 17 days after infection (mean +/- SE, 6.9 +/- 0.5 log10 copies/ml), while semen viral load peaked about 30 days after infection (4.5 +/- 0.4 log10 copies/ml). Semen viral load declined by 1.7 log10 to a nadir by week 10 of HIV infection. Semen and blood viral loads were more stable in chronically infected subjects over 16 weeks. Higher semen levels of HIV RNA were noted in subjects with low CD4 cell counts., Conclusions: These results provide a biological explanation for reported increases in HIV transmission during the very early (acute) and late stages of infection. Recognizing temporal differences in HIV shedding in the genital tract is important in the development of effective HIV prevention strategies.

The aim of this article is to highlight the link between bisphosphonates and osteonecrotic lesions of the jaws ("osteochemonecrosis") and to alert general practitioners to the implications these drugs may have on their day-to-day practice. We review the use of this class of drug, the indications for which have widened recently, describe their effect on bone metabolism and outline the proposed mechanism for bisphosphonate-induced osteochemonecrosis. Predisposing and initiating factors and management are outlined, and suggestions made as to how the dental profession can help with this increasingly prevalent problem.

The increase in morbidity and mortality due to end-stage liver disease has fueled recent guidelines that recommend consideration of treatment for hepatitis C in human immunodeficiency virus (HIV)-infected patients. Unfortunately, studies indicate that few patients coinfected with HIV and hepatitis C virus (HCV) are treated for their underlying hepatitis because of ongoing substance abuse, depression, chaotic lifestyles, homelessness, and perceived nonadherence. The structured environment of the prison system enables clinicians to provide complicated therapies for HCV to HIV-infected patients in combination with substance abuse programs. Furthermore, adherence to and adverse effects of therapy can be closely monitored. Offering treatment for HCV infection during incarceration to HIV-seropositive persons is highly efficient and targets underserved minority patients who have limited access to care in the community.

Inability to recognize incident infection has traditionally limited both scientific and public health approaches to HIV disease. Recently, some laboratories have begun adding HIV nucleic acid amplification testing to HIV diagnostic testing algorithms so that acute (antibody-negative) HIV infections can be routinely detected within the first 1-3 weeks of exposure. In this review article, we will highlight critical opportunities for HIV treatment and prevention that are presented by these diagnostic strategies.

Background: Acute (antibody-negative) HIV infection is associated with high transmission potential but is rarely recognized., Design: Cross-sectional study., Methods: We examined the prevalence and predictors of acute HIV infection among 1361 consecutive male outpatients attending sexually transmitted disease (STD; n = 929) and dermatology (n = 432) clinics in Lilongwe, Malawi. Serum specimens negative for HIV antibodies were screened by HIV RNA PCR using a highly specific pooling/resolution testing algorithm., Results: Five-hundred and fifty-three men (40.6%) were HIV antibody positive and 24 (1.8%) had acute HIV infection; 23 of 24 acutely infected men were from the STD clinic, where they represented 4.5% of all HIV antibody-negative men and 5.0% of all HIV infections. HIV RNA levels for acutely infected men were significantly higher [median (interquartile range), 6.10 (5.19-6.54) log10 HIV RNA copies/ml] than for 58 HIV antibody-positive men [4.42 (3.91-4.95) log10 copies/ml; P < 0.0001]. The factor most strongly associated with acute HIV infection was STD clinic attendance: (odds ratio, 15.2; 95% confidence interval, 2.04-113.0). In multivariate analysis considering only STD patients, factors associated with acute HIV infection included inguinal adenopathy, genital ulceration and age 24-26 years, the age stratum associated with peak incidence of HIV infection among Malawian men., Conclusions: Traditional HIV antibody tests alone are not sufficient to exclude HIV infection among men with acute STD in Malawi due to a surprising proportion of acute HIV infections in this population. Alternative screening methods are required for diagnosis of acute HIV infection; such screening could be important for research and for prevention of the sexual transmission of HIV in select populations.

In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery in which intrathecal morphine was administered. Each patient received intrathecal morphine 0.3 mg prior to induction, followed by a standard anaesthetic. The patients were randomly allocated to one of two groups. One group received 100 mg of rectal diclofenac immediately post-induction. Patients receiving diclofenac had significantly lower pruritus scores at 30 min (p = 0.0076), 2, 4, 8 and 24 h postoperatively, as well as significantly reduced pain scores at each time point (p < 0.0001 at each study interval). Morphine consumption in the first 24 h was also significantly lower in this group. In conclusion, rectal administration of diclofenac significantly reduces the incidence and severity of postoperative pruritus. It also significantly reduces pain and further analgesic requirements postoperatively.

In a previous study we found that blurred edges presented in peripheral vision look sharper than when they are looked at directly, a phenomenon we have called peripheral sharpness overconstancy (Galvin et al. (1997). Vision Research, 37, 2035-2039). In the current study we show that when visibility of the stimulus edges is compromised by very brief presentations, we can demonstrate sharpness overconstancy for static, foveal viewing. We also test whether the degree of sharpening is a function of the current visual context, but find no difference between the peripheral sharpness overconstancy (at 24 degrees eccentricity) of edges measured in a blurred context and that measured in a sharp context. We conclude that if the visual system does carry a template for sharp edges which contributes to edge appearance when visibility is poor, then that template is resistant to changes in context.

Adapalene 0.1% gel (Differin gel) is a recently introduced topical treatment for mild to moderate acne which has been demonstrated to be much better tolerated and at least as effective as tretinoin 0.025% gel. We compared the tolerance of adapalene 0.1% gel with six different formulations and concentrations of tretinoin. A total of 55 healthy human subjects were enrolled in two controlled, randomized, observer blinded, intraindividual comparison studies. In the first study, adapalene 0.1% gel was evaluated for its 21-day cumulative irritation potential compared with tretinoin 0.025%, 0.05% and 0.1% cream, tretinoin 0.01% and 0.025% gel, and petrolatum (control). In the second study, adapalene 0.1% gel was evaluated for its 21-day cumulative irritation potential compared with tretinoin 0.025%, 0.05% and 0.1% cream, tretinoin 0.1% gel microsphere, and petrolatum (control). In both studies, cumulative irritation scores helped to define three groups of common irritancy potential, with significant differences between each group. In study A, the three groups were in descending order of irritancy: tretinoin 0.1% cream and tretinoin 0.05% cream; tretinoin 0.025% gel, tretinoin 0.01% gel and tretinoin 0.025% cream; adapalene 0.1% gel and petrolatum (control). In study B, the three groups were in descending order of irritancy: tretinoin 0.1% cream; tretinoin 0.05% cream, tretinoin 0.025% cream and tretinoin 0.1% gel microsphere; adapalene 0.1% gel and petrolatum (control). The experimental results show that adapalene 0.1% gel is significantly better tolerated than any of six formulations of tretinoin, including two gels, three creams and a microsphere formulation, ranging in potency from 0.01% to 0.1%.

Although much has been learned about the spatial sampling and filtering properties of peripheral vision, little attention has been paid to the remarkably clear appearance of the peripheral visual field. To study the apparent sharpness of stimuli presented in the periphery, we presented Gaussian blurred horizontal edges at 8.3, 16.6, 24, 32, and 40 deg eccentricity. Observers adjusted the sharpness of a similar edge, viewed foveally, to match the appearance of the peripheral stimulus. All observers matched blurred peripheral stimuli with sharper foveal stimuli. We have called this effect "sharpness overconstancy". For field sizes of 4 deg, there was greater overconstancy at larger eccentricities. Scaling the field size of the peripheral stimuli by a cortical magnification factor produced sharpness overconstancy which was independent of eccentricity. In both cases, there was a slight sharpness underconstancy for peripherally presented edges blurred only slightly. We consider various explanations of peripheral sharpness overconstancy.

Motion reversal effects (the apparent reversal of the direction of motion of a high frequency sinusoidal grating) have been attributed to aliasing by the cone mosaic [Coletta et al. (1990). Vision Research, 30, 1631-1648] and postreceptoral layers [Anderson & Hess (1990). Vision Research, 30, 1507-1515] in human observers. We present data and a new model which suggest that at least two sampling arrays of different densities affect direction discrimination out to 30 degrees eccentricity. The first sampling layer matches anatomical estimates of the cone density. The second sampling layer is too dense to be the parasol cells alone; midget ganglion cells certainly contribute to this task. This is further evidence that motion perception is not mediated exclusively by the magnocellular stream.

Principal components factor analysis, based on scores of 363 college women, confirmed four subscales of the Silencing the Self Scale; however, 5 items loaded differently in the structure of these subscales. Recommendations for scale revision and studies with other populations are suggested.

Corneal epithelial cells synthesize an acidic (55 kDa) K12 and a basic (64 kDa) K3 keratin as their major differentiation products during an advanced stage of differentiation. In this paper, we describe the cDNA cloning of rabbit K12 keratin. We used a 36 base pairs (bp) oligonucleotide corresponding to a consensus sequence of many known acidic keratins as a probe to screen a cDNA library of normal rabbit corneal epithelium. Several partial cDNA clones were isolated. Hybrid-selection showed that the 3'keratin chain-specific portion of the cDNA hybridizes with K12 mRNA. A rabbit antiserum raised against the C-terminus of the cDNA-deduced amino acid sequence recognizes, in immunoblotting, the K12 keratin. In situ hybridization showed that K12 mRNA is present in all cell layers of central corneal epithelium, but in only the suprabasal cells of limbal epithelium indicating a parallel expression pattern between K12 and K3. Cultured rabbit corneal epithelial cells initially synthesize K14/K5 keratins, but later when the cells become heavily stratified they synthesize large quantities of K12 and K3 mRNAs, as detected by Northern blotting. Cultured esophageal epithelial cells do not make K12 mRNA confirming the tissue-specificity of K12 expression. Although it has been suggested that conjunctival epithelial cells can trans-differentiate into a bona fide corneal epithelium, we showed here that cultured conjunctival cells do not synthesize significant amounts of K12/K3 mRNAs. These results strongly suggest that conjunctival epithelial cells, whose differentiation can be modulated significantly by the extracellular matrix, form a lineage intrinsically distinct from the corneal/limbal epithelial lineage.

Although spatial aliasing by the extrafoveal retina can occur under natural viewing conditions, it does not commonly disturb our vision. One possible explanation for this is that real scenes do not have sufficient power in the high frequencies to produce aliasing. We examined whether aliasing distorted the appearance of a high contrast edge, which is a common stimulus in the environment. Observers made a two-interval forced-choice discrimination between low-pass filtered and unfiltered edges at 0, 10, 20, and 40 deg eccentricity. This discrimination could be made only when frequency components were removed below both the cone and ganglion cell Nyquist frequencies at each eccentricity. Since supra-Nyquist frequency components could not be detected in edges, they are incapable of producing aliasing.

Sixty million Americans have hypertension, a major cardiovascular risk factor. Its presence accelerates the atherosclerotic process, producing strokes, heart attacks, heart failure, renal failure, and peripheral vascular disease. This article highlights the historical landmarks in the study of this disease from the first documented measurement of blood pressure in 1733, through the most recent pharmacologic approaches to treatment. In addition, the roles of the kidney and the renin-angiotensin-aldosterone system are examined.

The specificity of scintigraphic scanning in detecting inflammatory sacroiliitis has been investigated. The sacroiliac band profile (R[Band]) was used and a new index (R[SIJ/F]) comparing the sacroiliac joint with the ipsilateral femur is described. Using the R (Band) index the mean value (1.34) for patients with definite sacroiliac disease was no different from that found for control subjects (1.35). There were significant differences using the R(SIJ/F) (7.8 versus 6.4): this ratio alone correlated with age. We conclude that neither technique is sufficiently specific to be of diagnostic value in most instances of low back pain.