Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback

Background Interventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia. Methods The intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management. Results Levels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period. Conclusions Improvements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity

The importance of the cellular stress response in the pathogenesis and treatment of type 2 diabetes

Organisms have evolved to survive rigorous environments and are not prepared to thrive in a world of caloric excess and sedentary behavior. A realization that physical exercise (or lack of it) plays a pivotal role in both the pathogenesis and therapy of type 2 diabetes mellitus (t2DM) has led to the provocative concept of therapeutic exercise mimetics. A decade ago, we attempted to simulate the beneficial effects of exercise by treating t2DM patients with 3 weeks of daily hyperthermia, induced by hot tub immersion. The short-term intervention had remarkable success, with a 1 % drop in HbA1, a trend toward weight loss, and improvement in diabetic neuropathic symptoms. An explanation for the beneficial effects of exercise and hyperthermia centers upon their ability to induce the cellular stress response (the heat shock response) and restore cellular homeostasis. Impaired stress response precedes major metabolic defects associated with t2DM and may be a near seminal event in the pathogenesis of the disease, tipping the balance from health into disease. Heat shock protein inducers share metabolic pathways associated with exercise with activation of AMPK, PGC1-a, and sirtuins. Diabetic therapies that induce the stress response, whether via heat, bioactive compounds, or genetic manipulation, improve or prevent all of the morbidities and comorbidities associated with the disease. The agents reduce insulin resistance, inflammatory cytokines, visceral adiposity, and body weight while increasing mitochondrial activity, normalizing membrane structure and lipid composition, and preserving organ function. Therapies restoring the stress response can re-tip the balance from disease into health and address the multifaceted defects associated with the disease

Mortality among patients with tuberculosis requiring intensive care: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>To describe the characteristics of patients with tuberculosis (TB) requiring intensive care and to identify the factors that predicts in-hospital mortality in a city of a developing country with intermediate-to-high TB endemicity.</p> <p>Methods</p> <p>We conducted a retrospective, cohort study, between November 2005 and November 2007. The patients with TB requiring intensive care were included. Predictors of mortality were assessed. The primary outcome was the in-hospital mortality.</p> <p>Results</p> <p>During the study period, 67 patients with TB required intensive care. Of them, 62 (92.5%) had acute respiratory failure and required mechanical ventilation. Forty-four (65.7%) patients died. Coinfection with human immunodeficiency virus was present in 46 (68.7%) patients. Early intensive care unit admission and ventilator-associated pneumonia were independently associated with the in-hospital mortality.</p> <p>Conclusions</p> <p>In this study we found a high mortality rate in TB patients requiring intensive care, especially in those with an early ICU admission.</p

T Cell-Dependence of Lassa Fever Pathogenesis

Lassa virus (LASV), the causative agent of Lassa fever (LF), is endemic in West Africa, accounting for substantial morbidity and mortality. In spite of ongoing research efforts, LF pathogenesis and mechanisms of LASV immune control remain poorly understood. While normal laboratory mice are resistant to LASV, we report that mice expressing humanized instead of murine MHC class I (MHC-I) failed to control LASV infection and develop severe LF. Infection of MHC-I knockout mice confirmed a key role for MHC-I-restricted T cell responses in controlling LASV. Intriguingly we found that T cell depletion in LASV-infected HHD mice prevented disease, irrespective of high-level viremia. Widespread activation of monocyte/macrophage lineage cells, manifest through inducible NO synthase expression, and elevated IL-12p40 serum levels indicated a systemic inflammatory condition. The absence of extensive monocyte/macrophage activation in T cell-depleted mice suggested that T cell responses contribute to deleterious innate inflammatory reactions and LF pathogenesis. Our observations in mice indicate a dual role for T cells, not only protecting from LASV, but also enhancing LF pathogenesis. The possibility of T cell-driven enhancement and immunopathogenesis should be given consideration in future LF vaccine development

The Fecal Viral Flora of Wild Rodents

The frequent interactions of rodents with humans make them a common source of zoonotic infections. To obtain an initial unbiased measure of the viral diversity in the enteric tract of wild rodents we sequenced partially purified, randomly amplified viral RNA and DNA in the feces of 105 wild rodents (mouse, vole, and rat) collected in California and Virginia. We identified in decreasing frequency sequences related to the mammalian viruses families Circoviridae, Picobirnaviridae, Picornaviridae, Astroviridae, Parvoviridae, Papillomaviridae, Adenoviridae, and Coronaviridae. Seventeen small circular DNA genomes containing one or two replicase genes distantly related to the Circoviridae representing several potentially new viral families were characterized. In the Picornaviridae family two new candidate genera as well as a close genetic relative of the human pathogen Aichi virus were characterized. Fragments of the first mouse sapelovirus and picobirnaviruses were identified and the first murine astrovirus genome was characterized. A mouse papillomavirus genome and fragments of a novel adenovirus and adenovirus-associated virus were also sequenced. The next largest fraction of the rodent fecal virome was related to insect viruses of the Densoviridae, Iridoviridae, Polydnaviridae, Dicistroviriade, Bromoviridae, and Virgaviridae families followed by plant virus-related sequences in the Nanoviridae, Geminiviridae, Phycodnaviridae, Secoviridae, Partitiviridae, Tymoviridae, Alphaflexiviridae, and Tombusviridae families reflecting the largely insect and plant rodent diet. Phylogenetic analyses of full and partial viral genomes therefore revealed many previously unreported viral species, genera, and families. The close genetic similarities noted between some rodent and human viruses might reflect past zoonoses. This study increases our understanding of the viral diversity in wild rodents and highlights the large number of still uncharacterized viruses in mammals

Vitronectin (S protein) augments the functional activity of monocyte receptors for IgG and complement C3b

Abstract An arginine-glycine-aspartic acid sequence (RGD in the single letter code for amino acids) is present in the cell attachment site of both vitronectin and fibronectin. Inasmuch as fibronectin and synthetic peptides containing RGD enhance ingestion of opsonized particles by monocytes, we investigated the effects of vitronectin on phagocytosis by monocytes of sheep erythrocytes bearing IgG (EA) or complement C3b (EC3b). Peripheral blood monocytes were isolated by countercurrent elutriation and allowed to adhere to slides that had been coated with either vitronectin or fibronectin. Next, EA or EC3b were incubated with the adherent monocytes, and phagocytosis was subsequently quantified. Vitronectin caused the same dose dependent increase in phagocytosis as fibronectin. The augmentation of phagocytosis of EA induced by vitronectin could be inhibited by the F(ab')2 fragments of anti- vitronectin IgG but not by preimmune F(ab')2. The maximum phagocytosis of EA induced by vitronectin could not be enhanced by the addition of fibronectin, suggesting that vitronectin and fibronectin act on the same population of monocytes and that the two proteins stimulate the same mechanism through which the enhanced phagocytosis is mediated. Fibronectin and vitronectin caused a tenfold increase in the attachment of EC3b to monocytes, but phagocytosis was augmented minimally. These studies demonstrate that vitronectin modulates interactions between monocytes and opsonized particles.</jats:p

Vitronectin (S protein) augments the functional activity of monocyte receptors for IgG and complement C3b

An arginine-glycine-aspartic acid sequence (RGD in the single letter code for amino acids) is present in the cell attachment site of both vitronectin and fibronectin. Inasmuch as fibronectin and synthetic peptides containing RGD enhance ingestion of opsonized particles by monocytes, we investigated the effects of vitronectin on phagocytosis by monocytes of sheep erythrocytes bearing IgG (EA) or complement C3b (EC3b). Peripheral blood monocytes were isolated by countercurrent elutriation and allowed to adhere to slides that had been coated with either vitronectin or fibronectin. Next, EA or EC3b were incubated with the adherent monocytes, and phagocytosis was subsequently quantified. Vitronectin caused the same dose dependent increase in phagocytosis as fibronectin. The augmentation of phagocytosis of EA induced by vitronectin could be inhibited by the F(ab')2 fragments of anti- vitronectin IgG but not by preimmune F(ab')2. The maximum phagocytosis of EA induced by vitronectin could not be enhanced by the addition of fibronectin, suggesting that vitronectin and fibronectin act on the same population of monocytes and that the two proteins stimulate the same mechanism through which the enhanced phagocytosis is mediated. Fibronectin and vitronectin caused a tenfold increase in the attachment of EC3b to monocytes, but phagocytosis was augmented minimally. These studies demonstrate that vitronectin modulates interactions between monocytes and opsonized particles.</jats:p