A simple and inexpensive point-of-care test for hepatitis B surface antigen detection: serological and molecular evaluation

Early identification of chronic hepatitis B is important for optimal disease management and prevention of transmission. Cost and lack of access to commercial hepatitis B surface antigen (HBsAg) immunoassays can compromise the effectiveness of HBV screening in resource-limited settings and among marginalized populations. High-quality point-of-care (POC) testing may improve HBV diagnosis in these situations. Currently available POC HBsAg assays are often limited in sensitivity. We evaluated the NanoSign(®) HBs POC chromatographic immunoassay for its ability to detect HBsAg of different genotypes and with substitutions in the 'a' determinant. Thirty-seven serum samples from patients with HBV infection, covering HBV genotypes A-G, were assessed for HBsAg titre with the Roche Elecsys HBsAg II quantification assay and with the POC assay. The POC assay reliably detected HBsAg at a concentration of at least 50 IU/mL for all genotypes, and at lower concentrations for some genotypes. Eight samples with substitutions in the HBV 'a' determinant were reliably detected after a 1/100 dilution. The POC strips were used to screen serum samples from 297 individuals at risk for HBV in local clinical settings (health fairs and outreach events) in parallel with commercial laboratory HBsAg testing (Quest Diagnostics EIA). POC testing was 73.7% sensitive and 97.8% specific for detection of HBsAg. Although the POC test demonstrated high sensitivity over a range of genotypes, false negatives were frequent in a clinical setting. Nevertheless, the POC assay offers advantages for testing in both developed and resource-limited countries due to its low cost (0.50$) and immediately available results.

Gamma ray measurements with photoconductive detectors using a dense plasma focus

Photons in the MeV range emitted from the dense plasma focus (DPF) at the NSTec North Las Vegas Facility have been measured with both neutron-damaged GaAs and natural diamond photoconductive detectors (PCDs). The DPF creates or "pinches" plasmas of various gases (e.g., H2, D2, Ne, Ar., etc.) that have enough energy to create MeV photons from either bremsstrahlung and/or (n,n(')) reactions if D2 gas is used. The high bandwidth of the PCDs enabled the first ever measurement of the fast micro-pinches present in DPF plasmas. Comparisons between a slower more conventional scintillator/photomultiplier tube based nuclear physics detectors were made to validate the response of the PCDs to fast intense MeV photon signals. Significant discrepancies in the diamond PCD responses were evident.

Multicenter retrospective analysis of metastatic colorectal cancer (CRC) with high-level microsatellite instability (MSI-H)

BACKGROUND

The microsatellite instability-high (MSI-H) phenotype, present in 15% of early colorectal cancer (CRC), confers good prognosis. MSI-H metastatic CRC is rare and its impact on outcomes is unknown. We describe survival outcomes and the impact of chemotherapy, metastatectomy, and BRAF V600E mutation status in the largest reported cohort of MSI-H metastatic colorectal cancer (CRC).

PATIENTS AND METHODS

A retrospective review of 55 MSI-H metastatic CRC patients from two institutions, Royal Melbourne Hospital (Australia) and The University of Texas MD Anderson Cancer Center (United States), was conducted. Statistical analyses utilized Kaplan-Meier method, Log-rank test, and Cox proportional hazards models.

RESULTS

Median age was 67 years (20-90), 58% had poor differentiation, and 45% had stage IV disease at presentation. Median overall survival (OS) from metastatic disease was 15.4 months. Thirteen patients underwent R0/R1 metastatectomies, with median OS from metastatectomy 33.8 months. Thirty-one patients received first-line systemic chemotherapy for metastatic disease with median OS from the start of chemotherapy 11.5 months. No statistically significant difference in progression-free survival or OS was seen between fluoropyrimidine, oxaliplatin, or irinotecan based chemotherapy. BRAF V600E mutation was present in 14 of 47 patients (30%). BRAF V600E patients demonstrated significantly worse median OS; 10.1 versus 17.3 months, P = 0.03. In multivariate analyses, BRAF V600E mutants had worse OS (HR 4.04; P = 0.005), while patients undergoing metastatectomy (HR 0.11; P = <0.001) and patients who initially presented as stage IV disease had improved OS (HR 0.27; P = 0.003).

CONCLUSIONS

Patients with MSI-H metastatic CRC do not appear to have improved outcomes. BRAF V600E mutation is a poor prognostic factor in MSI-H metastatic CRC.

Preliminary analysis of the cost-effectiveness of the National Bowel Cancer Screening Program: demonstrating the potential value of comprehensive real world data

BACKGROUND/AIM

The complexity and cost of treating cancer patients is escalating rapidly and increasingly difficult decisions are being made regarding which interventions provide value for money. BioGrid Australia supports collection and analysis of comprehensive treatment and outcome data across multiple sites. Here, we use preliminary data regarding the National Bowel Cancer Screening Program (NBCSP) and stage-specific treatment costs for colorectal cancer (CRC) to demonstrate the potential value of real world data for cost-effectiveness analyses (CEA).

METHODS

Data regarding the impact of NBCSP on stage at diagnosis were combined with stage-specific CRC treatment costs and existing literature. An incremental CEA was undertaken from a government healthcare perspective, comparing NBCSP with no screening. The 2008 invited population (n= 681,915) was modelled in both scenarios. Effectiveness was expressed as CRC-related life years saved (LYS). Costs and benefits were discounted at 3% per annum.

RESULTS

Over the lifetime and relative to no screening, NBCSP was predicted to save 1265 life years, prevent 225 CRC cases and cost an additional $48.3 million, equivalent to a cost-effectiveness ratio of $38,217 per LYS. A scenario analysis assuming full participation improved this to $23,395.

CONCLUSIONS

This preliminary CEA based largely on contemporary real world data suggests population-based faecal occult blood test screening for CRC is attractive. Planned ongoing data collection will enable repeated analyses over time, using the same methodology in the same patient populations, permitting an accurate analysis of the impact of new therapies and changing practice. Similar CEA using real world data related to other disease types and interventions appears desirable.

Cytochrome P450-derived eicosanoids and vascular dysfunction in coronary artery disease patients

OBJECTIVE

Accumulating preclinical and epidemiologic evidence has emerged to suggest that modulation of cytochrome P450 (CYP)-mediated eicosanoid metabolism may be a viable vascular protective therapeutic strategy for the secondary prevention of coronary artery disease (CAD). The functional relationship between CYP-derived eicosanoid metabolite levels and vascular dysfunction in humans with established CAD, however, has not been evaluated. Therefore, we characterized the relationship between inter-individual variation in soluble epoxide hydrolase (sEH) and CYP ω-hydroxylase metabolism and established vascular function phenotypes predictive of prognosis in a cohort of patients with atherosclerotic cardiovascular disease.

METHODS

Plasma epoxyeicosatrienoic acid (EET), dihydroxyeicosatrienoic acid (DHET), and 20-hydroxyeicosatetraenoic acid (20-HETE) levels were quantified by HPLC-MS/MS in 106 patients with stable, angiographically-confirmed CAD. Relationships between biomarkers of CYP-mediated eicosanoid metabolism and vascular function phenotypes were evaluated by Pearson's correlation.

RESULTS

A significant inverse association was observed between 20-HETE levels (a biomarker of CYP ω-hydroxylase metabolism) and brachial artery flow-mediated dilation (r = -0.255, p = 0.010). An inverse association was also observed between 14,15-EET:DHET ratios (a biomarker of sEH metabolism) and both monocyte chemoattractant protein-1 levels (r = -0.252, p = 0.009) and a consolidated cellular adhesion molecule 'score' reflecting the levels of E-selectin and P-selectin (r = -0.216, p = 0.027). No associations with C-reactive protein or epithelial neutrophil-activating protein-78 levels were observed.

CONCLUSIONS

Collectively, these findings demonstrate that enhanced CYP ω-hydroxylase and sEH metabolic function are associated with more advanced endothelial dysfunction and vascular inflammation, respectively, in patients with established atherosclerotic cardiovascular disease. These findings lay the foundation for future clinical research in this area.

Evaluation of cytochrome P450-derived eicosanoids in humans with stable atherosclerotic cardiovascular disease

OBJECTIVE

Preclinical and genetic epidemiologic studies suggest that modulating cytochrome P450 (CYP)-mediated arachidonic acid metabolism may have therapeutic utility in the management of coronary artery disease (CAD). However, predictors of inter-individual variation in CYP-derived eicosanoid metabolites in CAD patients have not been evaluated to date. Therefore, the primary objective was to identify clinical factors that influence CYP epoxygenase, soluble epoxide hydrolase (sEH), and CYP ω-hydroxylase metabolism in patients with established CAD.

METHODS

Plasma levels of epoxyeicosatrienoic acids (EETs), dihydroxyeicosatrienoic acids (DHETs), and 20-hydroxyeicosatetraenoic acid (20-HETE) were quantified by HPLC-MS/MS in a population of patients with stable, angiographically confirmed CAD (N=82) and healthy volunteers from the local community (N=36). Predictors of CYP epoxygenase, sEH, and CYP ω-hydroxylase metabolic function were evaluated by regression.

RESULTS

Obesity was significantly associated with low plasma EET levels and 14,15-EET:14,15-DHET ratios. Age, diabetes, and cigarette smoking also were significantly associated with CYP epoxygenase and sEH metabolic activity, while only renin-angiotensin system inhibitor use was associated with CYP ω-hydroxylase metabolic activity. Compared to healthy volunteers, both obese and non-obese CAD patients had significantly higher plasma EETs (P<0.01) and epoxide:diol ratios (P<0.01), whereas no difference in 20-HETE levels was observed (P=NS).

CONCLUSIONS

Collectively, these findings suggest that CYP-mediated eicosanoid metabolism is dysregulated in certain subsets of CAD patients, and demonstrate that biomarkers of CYP epoxygenase and sEH, but not CYP ω-hydroxylase, metabolism are altered in stable CAD patients relative to healthy individuals. Future studies are necessary to determine the therapeutic utility of modulating these pathways in patients with CAD.

Relation between digital peripheral arterial tonometry and brachial artery ultrasound measures of vascular function in patients with coronary artery disease and in healthy volunteers

Digital peripheral arterial tonometry (PAT) is an emerging, noninvasive method to assess vascular function. The physiology underlying this phenotype, however, remains unclear. Therefore, we evaluated the relation between digital PAT and established brachial artery ultrasound measures of vascular function under basal conditions and after reactive hyperemia. Using a cross-sectional study design, digital PAT and brachial artery ultrasonography with pulsed wave Doppler were simultaneously completed at baseline and after reactive hyperemia in both those with established coronary artery disease (n = 99) and healthy volunteers with low cardiovascular disease risk (n = 40). Under basal conditions, the digital pulse volume amplitude demonstrated a significant positive correlation with the brachial artery velocity-time integral that was independent of the arterial diameter, in both the healthy volunteer (r(s) = 0.64, p <0.001) and coronary artery disease (r(s) = 0.63, p <0.001) cohorts. Similar positive relations were observed with the baseline brachial artery blood flow velocity and blood flow. In contrast, no relation between the reactive hyperemia-evoked digital PAT ratio and either brachial artery flow-mediated dilation or shear stress was observed in either cohort (p = NS). In conclusion, these findings demonstrate that the digital PAT measures of vascular function more closely reflect basal blood flow in the brachial artery than reactive hyperemia-induced changes in the arterial diameter or flow velocity, and the presence of vascular disease does not modify the physiology underlying the digital PAT phenotype.

Insight into psoriasis management: commercial perspectives for the U.S. psoriasis market

Psoriasis is a chronic skin condition that has a significant impact on quality of life, self-esteem and comorbidities. Management of this condition is complicated and heavily influenced by psychosocial and economic realities. Addressing psychosocial and treatment education issues can be facilitated by use of the National Psoriasis Foundation. Localized disease is generally treated with topical treatment for which good generic medications are available. Somewhat higher priced branded vehicles are helpful for enhancing patients' treatment adherence, and may help avoid the need for far more toxic and expensive systemic treatment. Patients with extensive disease are best managed with phototherapy as a first-line option, and there is room for improvement in how insurers promote the use of this approach. Biologic treatments continue to offer new, safer options for patients with severe disease, albeit at higher cost. This review addresses practical issues in psoriasis management that would be of interest to organizations that are involved in the delivery of care for patients with psoriasis, such as managed care pharmacists and pharmaceutical companies that develop products for psoriasis.

Koilocytes indicate a role for human papilloma virus in breast cancer

BACKGROUND

High-risk human papilloma viruses (HPVs) are candidates as causal viruses in breast cancer. The scientific challenge is to determine whether HPVs are causal and not merely passengers or parasites. Studies of HPV-related koilocytes in breast cancer offer an opportunity to address this crucial issue. Koilocytes are epithelial cells characterised by perinuclear haloes surrounding condensed nuclei and are commonly present in cervical intraepithelial neoplasia. Koilocytosis is accepted as pathognomonic (characteristic of a particular disease) of HPV infection. The aim of this investigation is to determine whether putative koilocytes in normal and malignant breast tissues are because of HPV infection.

METHODS

Archival formalin-fixed normal and malignant breast specimens were investigated by histology, in situ PCR with confirmation of the findings by standard PCR and sequencing of the products, plus immunohistochemistry to identify HPV E6 oncoproteins.

RESULTS

human papilloma virus-associated koilocytes were present in normal breast skin and lobules and in the breast skin and cancer tissue of patients with ductal carcinoma in situ (DCIS) and invasive ductal carcinomas (IDCs).

INTERPRETATION

As koilocytes are known to be the precursors of some HPV-associated cervical cancer, it follows that HPVs may be causally associated with breast cancer.

Genome of Geobacter sulfurreducens: metal reduction in subsurface environments

The complete genome sequence of Geobacter sulfurreducens, a delta-proteobacterium, reveals unsuspected capabilities, including evidence of aerobic metabolism, one-carbon and complex carbon metabolism, motility, and chemotactic behavior. These characteristics, coupled with the possession of many two-component sensors and many c-type cytochromes, reveal an ability to create alternative, redundant, electron transport networks and offer insights into the process of metal ion reduction in subsurface environments. As well as playing roles in the global cycling of metals and carbon, this organism clearly has the potential for use in bioremediation of radioactive metals and in the generation of electricity.

Role of mobile DNA in the evolution of vancomycin-resistant Enterococcus faecalis

The complete genome sequence of Enterococcus faecalis V583, a vancomycin-resistant clinical isolate, revealed that more than a quarter of the genome consists of probable mobile or foreign DNA. One of the predicted mobile elements is a previously unknown vanB vancomycin-resistance conjugative transposon. Three plasmids were identified, including two pheromone-sensing conjugative plasmids, one encoding a previously undescribed pheromone inhibitor. The apparent propensity for the incorporation of mobile elements probably contributed to the rapid acquisition and dissemination of drug resistance in the enterococci.

Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year

OBJECTIVE

To assess the prognosis of patients with acute ischemic stroke who require mechanical ventilation and to determine early factors influencing mortality.

DESIGN

Prospective observational study.

SETTING

Medical intensive care unit with a cerebrovascular emergency unit in a university-affiliated hospital.

PATIENTS

Fifty-eight consecutive patients (mean age 65+/-13 years) requiring mechanical ventilation in the early course of an acute ischemic stroke.

MEASUREMENTS AND RESULTS

Clinical data were recorded before intubation according to a standardized procedure. Mortality and functional outcome were assessed after a 1-year follow-up. Mechanical ventilation was started within 48 h after admission in 53 patients (91.4%). The mean duration of ventilation was similar in survivors (9.7+/-9.0 days) and non-survivors (8.6+/-8.7 days). Mortality was 72.4% at 1 year. Among the 16 survivors, none were in a persistent vegetative state and 11 had a Barthel index of 60, reflecting good functional status. Bilateral absence of corneal reflex and bilateral absence of pupillary light reflex had a positive predictive value of death of 1 (95% CI 0.78-1.00 and 0.74-1.00, respectively). After Cox regression analysis, presence of stupor or coma (OR 2.6, 95% CI 1.5-5.0), bilateral absence of corneal reflex before intubation (OR 3.4, 95% CI 1.4-8.7) and presence of ischemic cardiopathy (OR 2.8, 95% CI 1.4-5.5) were independent predictors of mortality.

CONCLUSIONS

Systematic withholding of endotracheal intubation in patients with AIS is not recommended. Careful and rigorous neurologic examination, including assessment of brain stem reflexes, might help to identify patients with a very high probability of death despite mechanical ventilation.

A prospective survey of nutritional support practices in intensive care unit patients: what is prescribed? What is delivered?

OBJECTIVES

To assess the amount of nutrients delivered, prescribed, and required for critically ill patients and to identify the reasons for discrepancies between prescriptions and requirements and between prescriptions and actual delivery of nutrition.

DESIGN

Prospective cohort study.

SETTING

Twelve-bed medical intensive care unit in a university-affiliated general hospital.

PATIENTS

Fifty-one consecutive patients, receiving nutritional support either enterally or intravenously for > or = 2 days. We followed patients for the first 14 days of nutritional delivery.

MEASUREMENTS AND MAIN RESULTS

The amount of calories prescribed and the amount actually delivered were recorded daily and compared with the theoretical energy requirements. A combined regimen of enteral and parenteral nutrition was administered on 58% of the 484 nutrition days analyzed, and 63.5% of total caloric intake was delivered enterally. Seventy-eight percent of the mean caloric amount required was prescribed, and 71% was effectively delivered. The amount of calories actually delivered compared with the amount prescribed was significantly lower in enteral than in parenteral administration (86.8% vs. 112.4%, p < .001). Discrepancies between prescription and delivery of enterally administered nutrients were attributable to interruptions caused by digestive intolerance (27.7%, mean daily wasted volume 641 mL), airway management (30.8%, wasted volume 745 mL), and diagnostic procedures (26.6%, wasted volume 567 mL). Factors significantly associated with a low prescription rate of nutritional support were the administration of vasoactive drugs, central venous catheterization, and the need for extrarenal replacement.

CONCLUSIONS

An inadequate delivery of enteral nutrition and a low rate of nutrition prescription resulted in low caloric intake in our intensive care unit patients. A large volume of enterally administered nutrients was wasted because of inadequate timing in stopping and restarting enteral feeding. The inverse correlation between the prescription rate of nutrition and the intensity of care required suggests that physicians need to pay more attention to providing appropriate nutritional support for the most severely ill patients.

"Colonization pressure" and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit

OBJECTIVE

To determine the roles of "colonization pressure," work load or patient severity in patient acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs).

DESIGN

Prospectively collected data from October 1996 through December 1998.

SETTING

A 12-bed medical ICU in a university-affiliated general hospital.

PATIENTS

Patients with risk factors for MRSA admitted to the ICU were screened within 72 hours of admission and weekly thereafter. MRSA was considered imported if detected during the first 72 hours of admission and nosocomial if detected only thereafter. Three screening strategies were used on admission during three consecutive periods.

INTERVENTIONS

The unit of time chosen for measurements was the week. Weekly colonization pressure (WCP) was defined as the number of MRSA-carrier patient-days/total number of patient-days. Patient severity (number of deaths, Simplified Acute Physiologic Score [SAPS] II), work load (number of admis sions, Omega score), and colonization pressure (number of MRSA carriers at the time of admission, WCP) were compared with the number of MRSA-nosocomial cases during the following week.

RESULTS

Of the 1,016 patients admitted over 116 weeks, 691 (68%) were screened. MRSA was imported in 91 (8.9%) admitted patients (13.1% of screened patients) and nosocomial in 46 (4.5%). The number of MRSA-nosocomial cases was correlated to the SAPS II (P=.007), the Omega 3 score (P=.007), the number of MRSA-imported cases (P=.01), WCP (P<.0001), and the screening period (P<.0001). In multivariate analysis, WCP was the only independent predictive factor for MRSA acquisition (P=.0002). Above 30% of WCP, the risk of acquisition of MRSA was approximately fivefold times higher (relative risk, 4.9; 95% confidence interval, 1.2-19.9; P<.0001).

CONCLUSION

Acquisition of MRSA in ICU patients is strongly and independently influenced by colonization pressure.

prx-1 functions cooperatively with another paired-related homeobox gene, prx-2, to maintain cell fates within the craniofacial mesenchyme

The paired-related homeobox gene, prx-1, is expressed in the postmigratory cranial mesenchyme of all facial prominences and is required for the formation of proximal first arch derivatives. We introduced lacZ into the prx-1 locus to study the developmental fate of cells destined to express prx-1 in the prx-1 mutant background. lacZ was normally expressed in prx-1(neo); prx-1(lacZ)mutant craniofacial mesenchyme up until 11.5 d.p.c. At later time points, lacZ expression was lost from structures that are defective in the prx-1(neo) mutant mice. A related gene, prx-2, demonstrated overlapping expression with prx-1. To test the idea that prx-1 and prx-2 perform redundant functions, we generated prx-1(neo;)prx-2 compound mutant mice. Double mutant mice had novel phenotypes in which the rostral aspect of the mandible was defective, the mandibular incisor arrested as a single, bud-stage tooth germ and Meckel's cartilage was absent. Expression of two markers for tooth development, pax9 and patched, were downregulated. Using a transgene that marks a subset of prx-1-expressing cells in the craniofacial mesenchyme, we showed that cells within the hyoid arch take on the properties of the first branchial arch. These data suggest that prx-1 and prx-2 coordinately regulate gene expression in cells that contribute to the distal aspects of the mandibular arch mesenchyme and that prx-1 and prx-2 play a role in the maintenance of cell fate within the craniofacial mesenchyme.

Predicting the outcome in elderly patients of hospital admission for acute care in Paris, France: construction and initial validation of a simplex index

OBJECTIVE

To develop a simple index able to identify at an early stage those elderly patients at high risk of requiring discharge to a residential or nursing home after admission to hospital for acute care. For these patients, early discharge planning might lead to a more effective management and reduce the length of hospitalisation.

DESIGN, SETTING, AND PATIENTS

This was a prospective study conducted in two teaching hospitals in Paris, France. A total of 510 consecutive patients was included. They were aged 75 years or more and had been admitted to acute medical care units through the emergency department.

MEASUREMENTS

Demographic data, social support, physical disability, mental disability, and pathologic status were assessed shortly after admission (within 24-48 hours).

MAIN OUTCOME MEASURES

Outcome of hospitalisation was defined as discharge to home or residential/nursing home.

RESULTS

The index, developed by multiple logistic regression, included six variables: the wish of patients' principal career about their returning home after acute hospitalisation, presence of a chronic condition, ability to perform toileting, ability to know the name of the hospital or the city, their age, and their living arrangements. The sensitivity of the index in identifying patients at high risk of requiring discharge to a residential/nursing home was 74.4%, the specificity 63.8% the positive predictive value was 57.8%, and the negative predictive value was 80.6%.

CONCLUSIONS

The simple index, using data available very early in the course of hospitalisation, provides an accurate prediction of the hospitalisation outcome. The performance of the index should be tested in other populations and the practical benefits of risk screening should be assessed in a controlled trial to evaluate whether the intervention is useful and without any adverse effects.

Enhanced vasodilation to acetylcholine in athletes is associated with lower plasma cholesterol

We investigated a change in vascular reactivity as a potential adaptive mechanism to chronic exercise. The study consisted of 2 separate protocols with 10 male athletes and 10 age-matched sedentary male control subjects participating in each. Protocol 1 investigated forearm blood flow responses to intra-arterial infusions of acetylcholine and sodium nitroprusside by use of venous occlusion plethysmography. Protocol 2 used identical techniques to study responses to norepinephrine, angiotensin II (ANG II), and NG-monomethyl-L-arginine (L-NMMA). The percent reduction in forearm vascular resistance to acetylcholine was significantly greater in the athletic compared with the sedentary group (multivariate analysis of variance for repeated measures, P = 0.03). Covariance analysis suggested that the lower total cholesterol level of the athletic group (P = 0.03) may contribute to their enhanced responsiveness to acetylcholine. There were no differences between athletic and sedentary groups in the forearm vascular resistance responses to norepinephrine, ANG II, sodium nitroprusside, or L-NMMA. These data support the hypothesis that long-term endurance training is associated with enhanced endothelium-dependent dilator reserve due to altered lipoprotein levels in athletes. This finding may have therapeutic application in conditions of elevated cholesterol and impaired vasodilator capacity including hypertension, hypercholesterolemia, atherosclerosis, and cardiac failure.

Returning home after acute hospitalization in two French teaching hospitals: predictive value of patients' and relatives' wishes

Identifying elderly patients who are unable to return home immediately after acute hospitalization is difficult. For these patients, early planning of discharge might reduce the length of hospitalization. We conducted a cohort study to investigate the roles of patients' characteristics and patients' and principal carers' wishes about patients returning home in predicting the outcome of hospitalization for 510 patients aged 75 years or more admitted to acute medical care units via the emergency departments of two teaching hospitals in Paris (France). Patients' characteristics and patients' and principal carers' wishes were investigated within 24-48 hours of admission. The outcome of hospitalization was defined as discharge to home or residential/nursing home. The opposition of the principal carer to a patient returning home was the most powerful predictor of discharge to a residential/nursing home. Advanced age, living alone, disability in Activities of Daily Living, altered mental state and presence of a chronic condition fatal within 4 years were also independently associated with discharge to a residential/nursing home. The patient's wishes were predictive in univariate but not in multivariate analysis. These results suggest that the principal carer's wishes about a patient returning home might be taken into consideration early in a hospital stay for more effective discharge planning.

Analysis of viral RNA persistence in seawater by reverse transcriptase-PCR

It is important to determine the stability of naked viral RNA in seawater, since false-positive results can occur when reverse transcriptase-PCR (RT-PCR) is used to detect viruses if the RT-PCR amplifies free RNA instead of RNA from intact viruses. An acid guanidinium thiocyanate-phenol-chloroform method was used to extract total RNA from a filtered poliovirus cell culture suspension. The sensitivity of detection in this viral RNA study was 600 fg when RT-PCR was used. The extracted total RNA was seeded into filtered and unfiltered seawater, and the resulting preparations were incubated at 4 degrees C and at room temperature (23 +/- 1 degrees C). Our results showed that the seeded RNA was more stable in filtered seawater than in unfiltered seawater at both temperatures. The viral RNA could not be detected by the RT-PCR after 2 days of incubation in unfiltered seawater and after 28 days of incubation in filter-sterilized seawater. Therefore, because of the relatively short life of viral RNA in natural water, the detection of virus in environmental samples by the RT-PCR was mainly due to the presence of well-protected viral particles and not due to the presence of naked viral RNA.

Detection of poliovirus, hepatitis A virus, and rotavirus from sewage and ocean water by triplex reverse transcriptase PCR

A triplex reverse transcriptase PCR (RT-PCR) was developed to simultaneously detect poliovirus, hepatitis A virus (HAV), and rotavirus in sewage and ocean water. Sewage and ocean water samples seeded with the three different viruses were concentrated by ultrafiltration. The unseeded ocean water and sewage samples were concentrated by vortex flow filtration and/or ultrafiltration. Random hexamers and a rotavirus downstream primer were used to initiate reverse transcription. Three different sets of primers specific for poliovirus, HAV, and rotavirus cDNAs were mixed in the PCR mixture to amplify the target DNA. Three distinct amplified DNA products representing poliovirus, HAV, and rotavirus were identified by gel electrophoresis as 394-, 192-, and 278-bp sequences, respectively. Dot blot and Southern analyses were used to confirm the amplified products for each virus present in the environmental samples. Except for poliovirus, the sensitivity of triplex RT-PCR for the detection of rotavirus and HAV was found to be similar to that of monoplex RT-PCR, which uses only one set of primers to amplify a single type of virus. The triplex RT-PCR has greater advantages over monoplex RT-PCR for virus detection, namely, the rapid turnaround time and cost effectiveness.

Human T-cell leukemia virus type II Rex binding and activity require an intact splice donor site and a specific RNA secondary structure

The human T-cell leukemia virus type II (HTLV-II) regulatory protein Rex augments cytoplasmic levels of unspliced gag-pol mRNA by acting through a Rex-responsive element (RxRE) in the long terminal repeat. Purified Rex protein binds to long terminal repeat mRNA. Here, using an immunobinding assay to measure the binding of Rex protein to mutated RxRE RNAs, we show that efficient Rex binding requires a stem-bulge-loop RNA secondary structure (nucleotides [nt] 465 to 500) and specific sequences both within the stem-bulge (nt 470 to 476) and within a conserved upstream splice donor site (nt 449 to 455). Rex function in a transient transfection expression system correlates with Rex protein-RxRE RNA binding. The ability of HTLV-II Rex to interact directly with the HTLV-II splice donor site suggests that HTLV-II Rex may increase expression of unspliced gag-pol mRNA, in part, by inhibiting splicing.

Extrarenal renin-secreting tumors: insights into hypertension and ovarian renin production

Although renin-secreting tumors are rare, they must be considered in the differential diagnosis of hypertension associated with hypokalemia, which occurs commonly in the hypertensive population. The finding of an ovarian renin-secreting tumor emphasizes the potential importance of the ovary as an extrarenal source of renin; the local ovarian renin-angiotensin system may play a key role in reproductive function by regulating vascular reactivity, local blood flow, steroidogenesis and other physiologic effects. In the illustrative case presented, a renin-secreting ovarian leiomyosarcoma was obtained from a women who presented with hypertension and hypokalemia. Plasma prorenin levels were markedly elevated. Tumor excision was quickly followed by a fall in prorenin levels and tumor recurrence was accompanied by an increase in prorenin levels. Active renin concentration in the tumor homogenates was similar to that found in kidney homogenates while the tissue prorenin concentration was approximately 20 times that found in kidney tissue. When cultured for up to 4 weeks, ovarian tumor cells secreted greater than 95% prorenin. Immunoblot analysis demonstrated that tumor renin had a molecular weight of 47,000, similar to that of human recombinant prorenin. Immunohistochemical staining of tumor tissue with antibodies against human renal renin at the electron microscopic level demonstrated the presence of renin primarily in membrane-bound vesicles and rarely in dense-core secretory granules. These findings suggest that prorenin in this ovarian tumor was secreted by the constitutive pathway, which is mediated by these amorphous vesicles.

Ketamine enhances phase I and phase II neuromuscular block of succinylcholine

The effect of intravenous injection of ketamine 2, 5 and 10 mg.kg-1 on the neuromuscular blocking action of succinylcholine was studied on the indirectly stimulated adductor pollicis muscle twitch of monkeys anaesthetized with 0.5-1.0 per cent halothane in oxygen. Neuromuscular block was quantified by single twitches evoked at 0.1 Hz. The changing nature of neuromuscular block from Phase I to Phase II was monitored periodically by train-of-four fade. In the absence of succinylcholine, ketamine had no consistent neuromuscular effect of its own. In the presence of succinylcholine, ketamine in a dose-dependent manner potentiated both the Phase I and the Phase II neuromuscular blocking effect of succinylcholine. In Phase I, 2 mg.kg-1 of ketamine reduced the ED50 of succinylcholine from 0.46 +/- 0.07 mg.kg-1 to 0.33 +/- 0.06 mg.kg-1 (P less than 0.01), and increased its 25-75 per cent recovery index from 4.0 +/- 0.4 min to 5.3 +/- 0.1 min (P less than 0.01). In Phase II, ketamine in the same dose deepened a steady neuromuscular block maintained by succinylcholine infusion from 48 +/- 3 per cent block to 71 +/- 2 per cent block (P less than 0.01). We concluded that ketamine potentiates the Phase I and the Phase II neuromuscular blocks of succinylcholine.