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Public discourse concerning current vaccination recommendations has dramatically increased. The current battle is not new, having had a lengthy foreshadowing during the 19th and early 20th centuries. Over a 30-year period, a concerted effort to limit the use of smallpox vaccine grew at the very time typhoid vaccines were being developed and advocated for widespread prevention. As a long time advocate for widespread smallpox vaccination and a supporter of the newly tested typhoid vaccine, Sir William Osler entered the public debate at the beginning of World War I. Osler was asked to address the officers and men in the British army on the need for typhoid vaccination. His speech entitled "Bacilli and Bullets" outlined the medical reasons for getting inoculated against typhoid. Osler's strong support for typhoid vaccination of the British troops was met by opposition in Parliament but not by most of the troops. Osler's arguments in support of vaccination failed to respond to the concept of "conscientious objection," which was central to the antivaccinationists' argument. Similar arguments are being propounded by current antivaccination groups. [ABSTRACT FROM AUTHOR]

Background Surgery in the beach chair position (BCP) may reduce cerebral blood flow and oxygenation, resulting in neurological injuries. The authors tested the hypothesis that a ventilation strategy designed to achieve end-tidal carbon dioxide (ECO2′) values of 40–42 mm Hg would increase cerebral oxygenation (SctO2) during BCP shoulder surgery compared with a ventilation strategy designed to achieve ECO2′ values of 30–32 mm Hg. Methods Seventy patients undergoing shoulder surgery in the BCP with general anaesthesia were enrolled in this randomized controlled trial. Mechanical ventilation was adjusted to maintain an ECO2′ of 30–32 mm Hg in the control group and an ECO2′ of 40–42 mm Hg in the study group. Cerebral oxygenation was monitored continuously in the operating theatre using near-infrared spectroscopy. Baseline haemodynamics and SctO2 were obtained before induction of anaesthesia, and these values were then measured and recorded continuously from induction of anaesthesia until tracheal extubation. The number of cerebral desaturation events (CDEs) (defined as a ≥20% reduction in SctO2 from baseline values) was recorded. Results No significant differences between the groups were observed in haemodynamic variables or phenylephrine interventions during the surgical procedure. SctO2 values were significantly higher in the study 40–42 group throughout the intraoperative period (P<0.01). In addition, the incidence of CDEs was lower in the study 40–42 group (8.8%) compared with the control 30–32 group (55.6%, P<0.0001). Conclusions Cerebral oxygenation is significantly improved during BCP surgery when ventilation is adjusted to maintain ECO2′ at 40–42 mm Hg compared with 30–32 mm Hg. Clinical trial registration ClinicalTrials.gov NCT01546636. [ABSTRACT FROM AUTHOR]

The increase in immigration to the United States is associated with diseases, such as amebiasis, that are endemic to developing countries. We retrospectively reviewed 49 public-hospital patients with hepatic amebiasis occurring between 1985 and 1995. Most patients were immigrants (47) from Latin America (43), male (43), and young (mean age, 39.8 years). Symptoms noted by more than half were abdominal pain and fever. Ultrasonography showed single lesions in 70% and right-sided involvement in 85%. Serologies against Entamoeba histolytica were noted in 86%. After treatment, the median interval from admission to defervescence was 2 days, to normalization of white cell count 3 days, and to resolution of abdominal pain 4 days. Morbidity (one case of pericarditis) and mortality (one death in a cirrhotic man) were low. Hepatic amebiasis continues to be diagnosed in the United States, primarily among Hispanic and Asian immigrants. When appropriately considered, current diagnostic and therapeutic modalities result in rapid improvement and excellent outcome. [ABSTRACT FROM AUTHOR]

To evaluate the late effects of chronic pulmonary regurgitation against the putative benefits from the current surgical trend of primary repair of tetralogy of Fallot with a transannular patch in infancy, 10 patients > 10 years after early primary repair and 7 matched normal controls underwent exercise stress test and cine magnetic resonance imaging assessment of ventricular functions. Right ventricular impaired diastolic function and decreased exercise capacity, both significantly associated with pulmonary regurgitation in patients, indicated that early primary repair of tetralogy may not prevent late ventricular dysfunction and diminished exercise performance if chronic regurgitation results from right ventricular outflow tract reconstruction. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety and immunogenicity of a human immunodeficiency virus type 1 (HIV-1) recombinant envelope glycoprotein (rgp 160) candidate vaccine in humans.Subjects: Healthy adults (72) who were seronegative for HIV-1 were randomly assigned to one of four groups.Interventions: The subjects were randomly assigned to receive 40 or 80 micrograms of rgp 160, 10 micrograms of hepatitis B vaccine, or placebo in three doses (on days 0, 30, and 180), with an elective, nonblinded administration of a fourth dose on day 540.Measurements and Main Results: Neither clinical nor laboratory toxicity was encountered during a follow-up period exceeding 21 months. No effect of immunization was noted on lymphocyte counts, mitogenic responses, or delayed-type hypersensitivity. Serum antibody responses to HIV envelope proteins detected by Western blot were seen in 30 of 33 subjects (91%; 95% CI, 71% to 97%) receiving either 40- or 80-micrograms doses of rgp160 and were most commonly of weakly reactive intensity. Responses were first noted by Western blot after the second dose. They markedly increased in frequency after the third dose and declined over the next 12 to 18 months. The administration of a fourth dose resulted in homologous neutralizing activity in sera from 5 to 24 subjects (21%; CI, 7% to 37%) as well as in complement-mediated antibody-dependent enhancement in sera from 6 of 24 subjects (25%; CI, 10% to 42%). Antibody responses were detected by enzyme-linked immunosorbent assay (ELISA) less frequently than by Western blot, and these responses persisted for a shorter time.Conclusions: The administration of rgp160 was well tolerated and safe, resulted in a high rate of antibody response by Western blot after the administration of the third and fourth doses, and generated serum neutralizing activity and complement-mediated antibody-dependent enhancement in some subjects after the fourth dose. [ABSTRACT FROM AUTHOR]

Varicella-zoster virus infection has been implicated in a broad range of neurologic complications. In Hispanic immigrants, primary varicella often appears in adolescents and young adults. We describe the case of a 20-year-old Hispanic man with vasculitis and stroke after primary varicella infection. An association between varicella infection and vasculitis is increasingly being described and should be considered in the evaluation of stroke in young adults. [ABSTRACT FROM AUTHOR]