Manual differential cell counts help predict bacterial infection. A multivariate analysis

We developed logistic regression models that combine information from the automated CBC and manual 100-cell differential counts to predict bacterial infection. The logistic models were fitted from a case group of 116 patients with proven bacterial infection and a control group of 930 presumably uninfected outpatients. A 4-variable, 15-parameter model, which includes automated absolute neutrophil, manual band, and manual immature granulocyte counts, performed best with a receiver operating characteristic (ROC) curve area of 89%. A more practical 2-variable model including automated absolute neutrophil and manual band counts performed almost as well with an ROC curve area of 86%. The automated neutrophil count-only model is less informative with an ROC curve area of 78%. The combined information from automated and manual differential cell counts more accurately predicts bacterial infection than automated counting alone. Despite these modest improvements, the high cost of manual differential cell counts dictates careful patient selection. The supplemental information gained from manual differential counts is most useful for patients with low to normal neutrophil counts (8,000/microL [8.0 x 10(9)/L] or less). Further studies are indicated to determine the characteristic patient populations deriving maximal benefit from this information.

Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.)

BACKGROUND

We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease (CAD).

METHODS

We performed a controlled random group assignment trial in 4 community outpatient clinics. The Dietary Intervention and Evaluation Trial randomized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program's Step II-III diet plan (n=48) or an experimental group that received meal plans, recipes, and nutritional information during monthly group office sessions (n=49). Both groups received lipid-lowering medications and were followed-up over 12 months. We assessed dietary intake, fasting lipid profiles, hemoglobin A1C levels, and per member per month (PMPM) expense data.

RESULTS

Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year (P=.0072; P=.0001; P=.0004). The total PMPM expenses decreased for both groups (38% for the experimental group and 10% for the control group), but the cost difference was statistically nonsignificant (P=.2975). Both groups noted low-density lipoprotein reductions, significant only in the experimental group (P=.0035).

CONCLUSIONS

Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels. Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format.

Diaper dermatitis: a therapeutic dilemma. Results of a double-blind placebo controlled trial of miconazole nitrate 0.25%

Diaper dermatitis, an acute inflammation of the skin in the diaper area, is the most common dermatologic disorder of infancy. This placebo-controlled, randomized, double-blind, parallel-group trial compared the efficacy and safety of miconazole nitrate 0.25% in a zinc oxide/petrolatum base with that of the ointment base alone in treating acute diaper dermatitis in infants and evaluated the role of Candida albicans in the response to treatment. Infants age 2-13 months with diaper rash were treated with either miconazole nitrate 0.25% (N = 101) or ointment base (N = 101) for 7 days. Although improvement in rash from baseline was seen in both treatment groups on days 3, 5, and 7, patients receiving miconazole nitrate 0.25% had significantly fewer rash sites and lower mean total rash scores on days 5 and 7 (p < 0.001). In the miconazole nitrate 0.25% group, improvement was most marked among those with moderate or severe diaper dermatitis at baseline and among patients whose baseline rashes were positive for C. albicans. Treatment with miconazole nitrate 0.25% was as safe as with ointment base alone. Miconazole nitrate 0.25% ointment is a safe and effective treatment for diaper dermatitis in infants.

Fomepizole for the treatment of methanol poisoning

BACKGROUND

Methanol poisoning may result in metabolic acidosis, blindness, and death. The inhibition of alcohol dehydrogenase is fundamental to the treatment of methanol poisoning. We performed a multicenter study to evaluate fomepizole, an inhibitor of alcohol dehydrogenase, in the treatment of patients with methanol poisoning.

METHODS

We administered intravenous fomepizole to 11 consecutive patients who presented with methanol poisoning at a participating center. Serial clinical and laboratory studies, including measurements of plasma formic acid and fomepizole, were performed. The outcomes measured were the preservation of visual acuity, the resolution of metabolic acidosis, the inhibition of formic acid production, the achievment of therapeutic plasma concentrations of fomepizole with the dosing regimen, residual illness or disability, and death.

RESULTS

Plasma formic acid concentrations were detectable in eight patients, and these concentrations were closely correlated with the initial arterial pH values (r=0.92, P<0.001). In response to fomepizole, plasma formic acid concentrations fell and metabolic abnormalities resolved in all patients. Nine patients survived. Seven patients initially had visual abnormalities, but at the end of the trial no surviving patient had any detectable visual deficits related to methanol poisoning. Fomepizole had few adverse effects. The two patients who died had anoxic brain injury that was present at the time of enrollment. During treatment, methanol had an elimination half-life of 54 hours.

CONCLUSIONS

Fomepizole appears to be safe and effective in the treatment of methanol poisoning.

An Observation Of Cat Predation Upon An Eastern Blossom Bat Syconycteris Australis

WITH a body weight of 15 - 19 g and a mean headbody length of just over 60 mm (Churchill 1998), the eastern blossom bat Syconycteris australis is one of the smallest members of the sub-order Megachiroptera. Within Australia S. australis is restricted in distribution to the east coast from Cape York in Queensland to near Forster on the mid-north coast of New South Wales (NSW) (Law 1994a). Habitat requirements include both rainforest and/or wet sclerophyll forest for roosting purposes and proximal areas of heathland for foraging (Law 1993). The species survives on a diet of nectar and pollen and is heavily dependent upon Banksia integrifolia inflorescences during the winter months (Law 1994b, 1996; Coburn 1995). Blossom bats are generally regarded as solitary and exhibit strong fidelity to their feeding areas (Law 1993), although movements of up to 30 km have been reported (Law 1996).

Nodularin uptake by seafood during a cyanobacterial bloom

The problem of blue-green algal toxin contamination of recreational waters and drinking water catchments is well described, as is the potential contamination of associated seafood. Algal contamination of Victorian waterways is now a widespread annual occurrence and, in some regions, the intersection of blooms and commercial fishing threatens the food safety of large numbers of people. Toxin levels which produce no observed adverse effect in animal studies were used to derive safe tolerable daily intake levels. These 'acceptable levels' were then modified to protect against potential acute health risks associated with short-term exposures. National food surveys were used to derive likely seafood intakes and thus, in combination with 'safe toxin levels', health alert levels for seafood were formulated. During the summer of 2001 a bloom of Nodularia spumigena occurred in the Gippsland Lakes area of Southern Victoria. During the bloom, seafood samples were collected and nodularin concentrations were estimated. Nodularin concentrations reached levels of concern in mussels and in prawn viscera at cell counts as low as 30,000 cells/ml. Nodularin concentrations in the flesh of finfish remained low. Boiling the seafood redistributed toxin between viscera and flesh. The results were used to restrict some seafood harvesting.

A molecular biomarker system for assessing the health of coral (Montastraea faveolata) during heat stress

Using a novel molecular biomaker system (MBS), we assessed the physiological status of coral (Montastraea faveolata) challenged by heat stress by assaying specific cellular and molecular parameters. This technology is particularly relevant for corals because heat stress is thought to be an essential component of coral bleaching. This phenomenon is widely believed to be responsible for coral mortality worldwide, particularly during 1997-1998. Specific parameters of coral cellular physiology were assayed using the MBS that are indicative of a nonstressed or stressed condition. The MBS distinguished the separate and combined effects of heat and light on the 2 coral symbionts, a scleractinian coral and a dinoflagellate algae (zooxanthellae). This technology aids in the accurate diagnosis of coral condition because each parameter is physiologically well understood. Finally, the MBS technology is relatively inexpensive, easy to implement, and precise, and it can be quickly adapted to a high-throughout robotic system for mass sample analysis.

Success of ERCP at a referral center after a previously unsuccessful attempt

BACKGROUND

The diagnostic and therapeutic success of endoscopic retrograde cholangiopancreatography (ERCP) depends on a number of factors. When an attempt at ERCP fails, the physician must decide whether to repeat the procedure, rely on another imaging procedure (noninvasive or invasive), or refer to another endoscopist/center. Our aim in this prospective study was to determine the role of a second attempt at ERCP at a referral ERCP center.

METHODS

Five hundred sixty-two patients were referred for ERCP after having undergone a previous unsuccessful attempt to visualize the clinically relevant duct(s).

RESULTS

The overall success in visualizing the desired duct was 96.4% (542 of 562). Advanced techniques for cannulation were used in 41% (229 of 562). Anatomic abnormalities possibly contributing to the previous lack of success were present in 27% of cases. ERCP with or without manometry identified a cause or potential cause for the signs and symptoms in 86% of patients. Sixty complications occurred in 57 patients (10.1%). ERCP was unsuccessful in 20 patients (3.6%).

CONCLUSIONS

The cannulation success rate and diagnostic yield of further ERCP with an acceptable complication rate warrant consideration of referral to centers with available resources and expertise.

Anti-CD4 monoclonal antibody treatment of moderate to severe psoriasis vulgaris: results of a pilot, multicenter, multiple-dose, placebo-controlled study

BACKGROUND

OKTcdr4a (IMUCLONE) is a humanized anti-CD4 IgG4 monoclonal antibody that retains the binding and in vitro immunosuppressive properties of the parent murine antibody. Psoriasis is a chronic disease for which treatment with multiple doses of monoclonal antibodies is likely to be required for adequate control.

OBJECTIVE

This study was performed to test the efficacy and safety of OKTcdr4a, given in sequential courses over a period of several weeks, in the treatment of moderate to severe psoriasis vulgaris.

METHODS

Twenty-eight patients (45.6 +/- 10.1 years of age) were studied, with a mean pretreatment Psoriasis Area and Severity Index (PASI) score of 18.3. In the first double-blind phase of the study, patients were randomized to receive OKTcdr4a as a 225 mg/course (low dose), 750 mg/course (high dose), or placebo divided into 3 identical infusions over a 5-day period. After 42 days, patients who met the criteria for re-treatment with OKTcdr4a were re-treated with the 750 mg/course in an open phase of the study.

RESULTS

After the double-blind course of treatment, the mean PASI decreased by 11% in the placebo group, by 4% in the low-dose group, and by 17% in the high-dose group at 15 days. Twenty patients met the criteria for re-treatment (ie, did not experience a decrease in PASI score of 50% at 42 days). They were re-treated with OKTcdr4a at 43 days with the 750 mg/course in the open phase of the study. By day 99, the mean PASI score decreased from 19.9 at baseline to 17 in those patients who had received either placebo or low-dose OKTcdr4a followed by high-dose OKTcdr4a. In contrast, the mean PASI score decreased from 17.4 at baseline to only 7.7 in those patients who had received high-dose OKTcdr4a for both courses. Sustained CD4 saturation was not necessary for sustained clinical response. No patients had significant changes in circulating CD4(+) T-cell counts. The infusions were well tolerated.

CONCLUSION

Targeting CD4 using sequential treatments with a humanized monoclonal antibody (OKTcdr4a) may offer another therapeutic option for the treatment of moderate to severe psoriasis.

Government policies as a threat to health: findings from two Toronto community quality of life studies

Community members, service providers, and elected representatives in two Toronto communities were asked to identify community factors influencing the health of community members. Many of the identified barriers to health related to government policies and actions. Cutbacks in federal transfers to provinces and provincial cutbacks in funding for agencies, reductions in social assistance, ending of new social housing, and other policy changes were seen as negatively impacting the health of the community and its members. These perceptions were remarkably consistent with emerging findings concerning the determinants of health. Implications for public health practice were considered.

Interprofessional education in ethics at an academic health sciences center

The authors relate their experiences with interprofessional teaching of ethics at the University of Colorado Health Sciences Center, describing the history, planning, content, and structure of a required ethics course and discussing its role in the institution's plan to create more interprofessional education opportunities. The authors describe both the benefits of teaching ethics on an interprofessional basis and the challenges they encountered in launching the course. Challenges included responding to diverse and divergent faculty and student reactions, controlling a curriculum across schools, and learning how to think about education in interprofessional rather than profession-specific ways. Included in the discussion are the results obtained with various evaluation tools designed and assessed by the Office of Education on the campus, to which students and faculty responded the first time the course was offered.

Avocadofurans and their tetrahydrofuran analogues: comparison of growth inhibitory and insecticidal activity

The importance of the double bonds in the furan ring of avocadofurans with relation to their insecticidal activity was examined. The insecticidal activity of two naturally occurring avocadofurans, 2-(pentadecyl)furan and 2-(heptadecyl)furan, was compared to the toxicity of five tetrahydrofurans with alkyl chains at position 2 and varying side chains from 14 to 18 carbons. We found that eliminating the sites of unsaturation in the furan ring of avocadofurans significantly reduced the detrimental effects on the mortality and growth of the generalist insect herbivore Spodoptera exigua. In 7-day bioassays, S. exigua larvae were significantly more affected when fed a diet containing avocadofurans as compared to a larvae fed diet treated with the analogous tetrahydrofurans. Although larvae fed with the tetrahydrofurans showed reduced growth as compared to controls, larval mortality was not significantly increased. We conclude that the double bonds in the furan ring of avocadofurans play an important role in their insecticidal effects.

A comparative evaluation of tretinoin gel microsphere, 0.1%, versus tretinoin cream, 0.025%, in reducing facial shine

Tretinoin gel microsphere, 0.1%, is a highly effective anti-acne medication formulated with sponge-like microspheres encapsulating the active ingredient, tretinoin. In addition to minimizing cutaneous irritation, this system may also reduce facial shine. This single-center, double-blind, half-face study evaluated the potential of tretinoin gel microsphere, 0.1%, to reduce the appearance of facial shine compared to tretinoin cream, 0.025%. Thirty-five subjects (ages 12 to 24 years) with moderate acne vulgaris and moderate facial oiliness, were evaluated after 4 consecutive days of product use. On sides treated with tretinoin gel microsphere, 0.1%, investigators found significantly reduced facial shine at 3 and 6 hours posttreatment. Subjects' self-evaluations revealed a significant reduction in facial shine at 3 hours posttreatment. Photographic analyses showed reductions in facial shine for both treatments, but decreases were greater on tretinoin gel microsphere, 0.1%-treated sides. Both therapies were well tolerated, and no adverse events occurred. Tretinoin gel microsphere, 0.1%, has the added benefit of reducing the appearance of facial shine, which is a frequent concern in acne patients.

Severe acro-renal-uterine-mandibular syndrome

Although limb and renal defects occur together in a variety of patterns of multiple malformations, familial cases of acro-renal disorders are rare. In 1980, Halal et al. ¿Am J Med Genet 5:277-284 described two sisters with unusual limb deficiencies, renal anomalies, and mandibular hypoplasia and termed this condition acro-renal-mandibular syndrome. A girl reported earlier by Fitch and Lachance ¿1972; Can Med Assoc J 107:653-656 had similarly limb and renal findings, but an apparently normal jaw. We document three sibs with unusual limb deficiencies, renal agenesis, uterine anomalies in the two females, and orofacial defects, who clearly have a similar but more severe type of acrorenal disorder, apparently inherited as an autosomal recessive condition. The sibs with limb deficiencies and renal agenesis reported by Hennekam et al. ¿1994; Am J Med Genet 53:102-107 appear to be additional cases of this very rare disorder, the pathogenesis of which may be related to abnormal epithelial-mesenchymal interactions.

Diagnosis of human immunodeficiency virus type 1 infection with different subtypes using rapid tests

We evaluated six rapid tests for their sensitivity and specificity in diagnosing human immunodeficiency virus type 1 (HIV-1) infection using 241 specimens (172 HIV-1 positive, 69 HIV-1 negative) representing different HIV-1 subtypes (A [n = 40], B [n = 47], C [n = 28], E [n = 42], and F [n = 7]). HIVCHEK, Multispot, RTD and SeroStrip were 100% sensitive and specific. Capillus failed to identify two of eight subtype C specimens (overall sensitivity of 98. 85%), while the SUDS test (the only test approved by the Food and Drug Administration) gave false-positive results for 5 of 69 seronegative specimens (specificity of 93.24%). Our results suggest that although rapid tests perform well in general, it may be prudent to evaluate a rapid test for sensitivity and specificity in a local population prior to its widespread use.

Impairment of brain mitochondrial function by hydrogen peroxide

Hydrogen peroxide, at concentrations comparable to those observed under some pathological conditions, produced a concentration-dependent inhibition of state 3 (ADP-stimulated) and uncoupled mitochondrial respiratory activity. The ADP:O ratio was also substantially reduced. In contrast, the organic peroxide, t-butylhydroperoxide at the same concentrations produced no significant changes in respiratory activity. Intramitochondrial glutathione was oxidised to a similar extent in the presence of hydrogen peroxide or t-butylhydroperoxide. Thus, changes in this endogenous antioxidant apparently did not underlie the different responses to these peroxides. The effects of hydrogen peroxide were not altered by deferoxamine indicating that the extramitochondrial generation of hydroxyl radicals was not likely to be involved. However, modifications arising from the generation of hydroxyl radicals within the mitochondria remain a likely contributor to the observed deleterious effects on respiratory function. The inhibitory effects of hydrogen peroxide were greatest when pyruvate plus malate were present as respiratory substrates. Lesser inhibition was seen with glutamate plus malate and no significant inhibitory effects were detected in the presence of succinate. The findings suggest that mitochondrial components involved in pyruvate oxidation were particularly sensitive to the hydrogen peroxide treatment. However, no significant change was seen in activity of either the pyruvate dehydrogenase complex or NADH-ubiquinone oxidoreductase (complex I) when measured directly following treatment of the mitochondria with hydrogen peroxide.

Government policies as a threat to health: findings from two Toronto community quality of life studies

Community members, service providers, and elected representatives in two Toronto communities were asked to identify community factors influencing the health of community members. Many of the identified barriers to health related to government policies and actions. Cutbacks in federal transfers to provinces and provincial cutbacks in funding for agencies, reductions in social assistance, ending of new social housing, and other policy changes were seen as negatively impacting the health of the community and its members. These perceptions were remarkably consistent with emerging findings concerning the determinants of health. Implications for public health practice were considered.

Construction of a high-resolution 2.5-Mb transcript map of the human 6p21.2-6p21.3 region immediately centromeric of the major histocompatibility complex

We have constructed a 2.5-Mb physical and transcription map that spans the human 6p21.2-6p21.3 region and includes the centromeric end of the MHC, using a combination of techniques. In total 88 transcription units including exons, cDNAs, and cDNA contigs were characterized and 60 were confidently positioned on the physical map. These include a number of genes encoding nuclear and splicing factors (Ndr kinase, HSU09564, HSRP20); cell cycle, DNA packaging, and apoptosis related [p21, HMGI(Y), BAK]; immune response (CSBP, SAPK4); transcription activators and zinc finger-containing genes (TEF-5, ZNF76); embryogenesis related (Csa-19); cell signaling (DIPP); structural (HSET), and other genes (TULP1, HSPRARD, DEF-6, EO6811, cyclophilin), as well as a number of RP genes and pseudogenes (RPS10, RPS12-like, RPL12-like, RPL35-like). Furthermore, several novel genes (a Br140-like, a G2S-like, a FBN2-like, a ZNF-like, and B1/KIAA0229) have been identified, as well as cDNAs and cDNA contigs. The detailed map of the gene content of this chromosomal segment provides a number of candidate genes, which may be involved in several biological processes that have been associated with this region, such as spermatogenesis, development, embryogenesis, and neoplasia. The data provide useful tools for synteny studies between mice and humans, for genome structure analysis, gene density comparisons, and studies of nucleotide composition, of different isochores and Giemsa light and Giemsa dark bands.

The chromosome 6 sequencing project at the Sanger Centre

Chromosome 6 is probably best known for encoding the major histocompatibility complex (MHC) which is essential to the human immune response. In addition, it has been shown to be associated with many diseases such Schizophrenia, Diabetes, Arthritis, Haemochromatosis, Narcolepsy, Epilepsy, Retinitis Pigmentosa, Deafness, Ovarian Cancer, and many more. Chromosome 6 is about 180 Mb in size and is estimated to encode around 3500 genes of which only about 10% are currently known. It is our aim to map, sequence and annotate the entire chromosome in close collaboration with the chromosome 6 community.

Alveolar capillary dysplasia. Report of a case of prolonged life without extracorporeal membrane oxygenation (ECMO) and review of the literature

We describe an unusual infant with the diagnosis of alveolar capillary dysplasia who had a relatively prolonged life without extracorporeal membrane oxygenation (ECMO). We have used this case as a springboard for a thorough review of the literature. This was a full-term female infant who presented with a picture of persistent pulmonary hypertension of the newborn. She was treated as such, with various ventilatory modes, alkalinizing agents, surfactant therapy, tolazoline, prostacyclin and nitric oxide. Because of the prolonged clinical course the possibility of alveolar capillary dysplasia was raised. The parents refused ECMO. Despite all efforts she progressively deteriorated and died at 22 days of age. Macro- and microscopic examination of the lung at autopsy were diagnostic of alveolar capillary dysplasia. A detailed review of 39 cases published in the literature with comments regarding incidence, etiology, pathophysiology, clinical picture, diagnosis and treatment is presented.