DNA shuffling of subgenomic sequences of subtilisin

DNA family shuffling of 26 protease genes was used to create a library of chimeric proteases that was screened for four distinct enzymatic properties. Multiple clones were identified that were significantly improved over any of the parental enzymes for each individual property. Family shuffling, also known as molecular breeding, efficiently created all of the combinations of parental properties, producing a great diversity of property combinations in the progeny enzymes. Thus, molecular breeding, like classical breeding, is a powerful tool for recombining existing diversity to tailor biological systems for multiple functional parameters.

Prevalence of Trypanosoma cruzi and Leishmania chagasi infection and risk factors in a Colombian indigenous population

This study was carried out in order to obtain base-line data concerning the epidemiology of American Visceral Leishmaniasis and Chagas' Disease in an indigenous population with whom the government is starting a dwelling improvement programme. Information was collected from 242 dwellings (1,440 people), by means of house to house interviews about socio-economic and environmental factors associated with Leishmania chagasi and Trypanosoma cruzi transmission risk. A leishmanin skin test was applied to 385 people and 454 blood samples were collected on filter paper in order to detect L. chagasi antibodies by ELISA and IFAT and T. cruzi antibodies by ELISA. T. cruzi seroprevalence was 8.7% by ELISA, L. chagasi was 4.6% and 5.1% by IFAT and ELISA, respectively. ELISA sensitivity and specificity for L. chagasi antibodies were 57% and 97.5% respectively, as compared to the IFAT. Leishmanin skin test positivity was 19%. L. chagasi infection prevalence, being defined as a positive result in the three-immunodiagnostic tests, was 17.1%. Additionally, 2.7% of the population studied was positive to both L. chagasi and T. cruzi, showing a possible cross-reaction. L. chagasi and T. cruzi seropositivity increased with age, while no association with gender was observed. Age (p<0.007), number of inhabitants (p<0. 05), floor material (p<0.03) and recognition of vector (p<0.01) were associated with T. cruzi infection, whilst age ( p<0.007) and dwelling improvement (p<0.02) were associated with L. chagasi infection. It is necessary to evaluate the long-term impact of the dwelling improvement programme on these parasitic infections in this community.

Waist circumference values in Spanish children--gender related differences

OBJECTIVE

To obtain reference values of the waist circumference in Spanish children, and to investigate their dependence on age and gender.

DESIGN

Cross-sectional study.

SETTING

General school-age population.

SUBJECTS

A representative sample of the schools in Zaragoza, Spain, was drawn from seven schools. The population selected comprised 1728 children with ages ranging from 6.0-14.9y. Of the original sample, 368 children (21.29%) were excluded because of chronic diseases or refusal. Finally, 1360 children and adolescents: 701 boys and 659 girls, were studied.

INTERVENTIONS

Waist and hip circumferences were measured with an unelastic tape.

RESULTS

Waist circumference tended to be higher in males than in females and this difference was significant after 11.5y. In general, hip circumference was higher in females than in males (statistically significant differences at 7.5, 10.5, 12.5 and 13.5 y). In general, percentile values of waist circumference were higher in males than in females, especially after 12.5 y. Difference between males and females on percentile 95 at 14.5 y was 7.6 cm. Hip was greater than waist in both sexes, and the two curves run nearly parallel in males. In females, while hip enlarges continuously, waist shows the reverse tendency between 11.5 and 14.5 y.

CONCLUSIONS

Waist circumference showed higher values in boys than in girls, especially after 11.5 y, and waist values increase with age both in males and females. These findings justify the use of age and gender specific reference standards.

Improving performance through change: an academic medical center's experience

In order to perform at peak efficiency and effectiveness, health care organizations must be change-adept. Increased scrutiny by consumers, payers, and regulatory agencies is but one of the drivers necessitating change. This article discusses methodologies for improving performance and promoting continued success in an academic medical center.

Epidermal naevus syndrome and hypophosphataemic rickets: description of a patient with central nervous system anomalies and review of the literature

The epidermal naevus syndrome (ENS) is a rare dermatological condition consisting of congenital epidermal nevi associated with anomalies in the central nervous system, bones, eyes, hear or genito-urinary system. We report a new case of ENS associated with hypophosphataemic rickets. The girl was born with a mixed-type epidermal naevus and skeletal anomalies. Hypophosphataemic rickets was diagnosed at the age of 2.5 years. At 14 years of age. MRI of the head demonstrated right brain hypotrophy, a left temporal arachnoid cyst and asymmetric lateral ventricles. We reviewed the literature and found 13 reported cases of ENS associated with hypophosphataemic rickets. Conclusion We report a further patient with epidermal naevus syndrome and hypophosphataemic rickets, followed from birth to the age of 15 years, who had structural central nervous system anomalies with normal intellectual functioning. A comprehensive neurological work up is recommended in patients with epidermal naevus syndrome.

Severe malformations in males from families with osteopathia striata with cranial sclerosis

Osteopathia striata with cranial sclerosis (OS-CS) is a bone dysplasia characterized by longitudinal striations of the long bones and sclerosis of the craniofacial bones. Affected patients show macrocephaly, ocular hypertelorism, frontal bossing, broad nasal bridge and abnormalities of the palate. Anomalies such as hearing loss, congenital heart defect, vertebral anomalies and mental impairment have also been reported. Pedigree analysis has suggested an autosomal dominant inheritance, but a recent report of a family with significantly more affected males than females suggested the possibility of X-linked inheritance. Here we describe a new family with OS-CS (the twelfth in the literature) with four affected individuals (two males and two females) spanning three generations. The affected male in the third generation was stillborn with multiple congenital anomalies, whereas the other three affected individuals had mild features. This family may represent another example of X-linked OS-CS where the mutated gene(s) is more severe in males.

Skinfold thickness measurements are better predictors of body fat percentage than body mass index in male Spanish children and adolescents

OBJECTIVE

To develop equations, from some simple anthropometric measurements, for the prediction of body density from underwater weighing in male spanish children and adolescents.

SUBJECTS

One hundred and seventy-five males, aged 7.0-16.9 y, participated in this study, they were recruited from primary and secondary schools.

MEASUREMENTS

Body weight and height and skinfold thicknesses by anthropometry, body density by underwater weighing.

RESULTS

Correlations between body density and body mass index (BMI) were high until 14.0-16.9y. Correlations between body density and log sigma 4 skinfolds were higher than those with BMI at all ages. Log sigma 4 skinfolds explained between 61% (14.0-16.9 y) and 68% (11.0-13.9 y) of the body density variance. Regression equations for body density from BMI and triceps skinfold thickness explained between 51% (14.0-16.9y) and 68% (7.0-10.9 y) of the body density variance.

CONCLUSIONS

The best estimators of body density in the children and adolescents studied were log sigma 4 skinfolds and a combination of BMI and triceps skinfold.

Fat distribution in obese and nonobese children and adolescents

BACKGROUND

It is not known whether fat deposition in obese children and adolescents occurs in the body's central or peripheral regions.

METHODS

A representative sample of children was drawn from the schools of Zaragoza, Spain. The population selected comprised 1728 children ranging in ages from 6 to 14.9 years. Of the original sample, 368 children (21.29%) were excluded because of chronic diseases or refusal to participate. The waist-to-hip circumference ratio and the triceps-to-subscapular skin-fold thickness ratio were calculated and served as indexes of body fat distribution. The children were divided into tertiles according to standard deviation score of body mass index.

RESULTS

Both in boys and in girls, waist-to-hip circumference ratio was higher in tertile 3 than in the other two tertiles, and triceps-to-subscapular skinfold thickness ratio was lower in tertile 3 than in the other two tertiles. Waist-to-hip circumference ratio was higher and triceps-to-subscapular skinfold thickness ratio was lower in obese than in nonobese children and adolescents of both sexes.

CONCLUSIONS

Increased adiposity may be accompanied by an increase of fat depot in the abdominal region. In obese children and adolescents, fat deposition seems to occur in the body's central regions.

Reference values of gastric intramucosal pH in children

To determine the reference values of gastric intramucosal pH (pHi) by tonometry in paediatric patients, we studied 17 children (nine males, eight females) with no systemic or gastrointestinal disease, aged six months to 12 years undergoing minor reconstructive surgery. Following anaesthetic induction a sigmoid tonometry catheter was inserted (Tonometrics, Inc.) into the stomach of the patients under direct vision. All children were normoventilated and were haemodynamically stable. After an equilibration period of 30 min, gastric pHi was calculated by applying the Henderson-Hasselbalch equation on the PCO2 obtained with the tonometer and the bicarbonate from the arterial blood gas analysis. The mean gastric pHi in our patients was 7.35 +/- 0.06 (SD). The normal pHi in the general population is estimated to be 7.31-7.40, with a confidence interval of 99%. No correlation was found between pHi and arterial pH, bicarbonate or base excess. Under conditions of normal ventilation and haemodynamic stability, healthy children during general anaesthesia have gastric intramucosal values similar to those of adults.

Indices of body fat distribution in Spanish children aged 4.0 to 14.9 years

BACKGROUND

Reference values for the main indices of body fat distribution in children are not available.

METHODS

The study population comprised 1638 Caucasian children and adolescents: 848 boys and 790 girls, with ages ranging from 4.0 to 14.9 years, and living in the central part of Spain (Provincia de Zaragoza). The waist-to-hip circumference ratio and the triceps-to-subscapular skinfold thickness ratio were measured.

RESULTS

In boys, mean waist-to-hip circumference ratio ranges from 0.834, at 13.5 years, to 0.896 at 4.5 years. In girls, waist-to-hip circumference ratio ranges from 0.756, at 14.5 years, to 0.877, at 4.5 years. We observed a decrease of waist-to-hip circumference ratio with age, especially in girls. In boys, triceps-to-subscapular skinfold thickness ratio ranges from 1.360, at age 14.5, to 1.704, at age 5.5. In girls, triceps-to-subscapular skinfold thickness ratio ranges from 1.468, at age 13.5, to 1.727, at age 9.5. We observed a decrease with age only in boys.

CONCLUSIONS

We present reference values for the main indices of body fat distribution, which could be useful in clinical practice. However, research is needed that will compare these indices with data on body fat distribution obtained by a gold standard method, such as computed tomography or magnetic resonance imaging.

Pro-ACT II: integrating utilization management, discharge planning, and nursing case management into the outcomes manager role

Building on redesign efforts that created case management, clinical care technicians, support service hosts, and pharmacy technician roles, this redesign focused on integrating case management, utilization management, and discharge planning functions into a new outcomes manager role. The authors describe the process of developing and implementing the new role and outline specific actions that eliminated redundancy and inefficiency. Results of the evaluation of the project are reviewed, including full-time equivalent and salary savings and employee and physician satisfaction improvements.

Connatal herpes zoster

We describe a case of connatal herpes zoster present in a newborn girl whose mother had been exposed to varicella infection during the seventh month of pregnancy. A few minutes after delivery, the newborn was examined for an erythematous maculopapular rash with clear grouped vesicles involving the right L2-L4 dermatome. She was given varicella zoster immunoglobulin and oral and topical acyclovir, and all the skin lesions were completely healed eight days later. This report emphasizes one aspect of the relationship between maternal exposure to varicella zoster virus infection and the occurrence of connatal shingles, the benign course of the disease in this case, and the favorable response to acyclovir therapy in neonates.

Relationship between immunoinflammatory proteins containing sialic acid and low-density lipoprotein serum concentrations

The aim of this study was to investigate the relationship between sialoglycoproteins and the lipoprotein profile in a group of children with different levels of low-density lipoprotein cholesterol. We have studied 177 children of 132 families who were sent to our Pediatric Lipid Research Clinic because of serum cholesterol concentrations higher than 5.17 mmol/l. At the time of diagnosis, we analyzed the serum lipoprotein profile and the sialoglycoproteins: alpha 1-antitrypsin, acid alpha 1-glycoprotein, haptoglobin, alpha 2-macroglobulin, transferrin, IgA, IgG, IgM, complement C3 component and ceruloplasmin. At 7.0 to 10.9 years, alpha 1-glycoprotein serum concentrations were higher in the high risk group than in the moderate risk group (P < 0.05). At 2.0 to 6.9 years, IgA and IgM serum concentrations were higher in the moderate risk group than in the low risk group (P < 0.05 and P < 0.01, respectively), and IgG and IgM serum concentrations were also higher in the high risk group than in the low risk group (P < 0.05). Our results seems to reflect a general reaction to injury or inflammation which could be associated with the atherosclerotic process.

Lymphocyte T subset counts in children with elevated low-density lipoprotein cholesterol levels

The aim of this study was to determine blood lymphocyte T subset counts in children with elevated levels of low-density lipoprotein cholesterol. We studied 107 children, ages 2.0 to 15.9 years, from 79 families who were referred to our Lipid Research Clinic because total cholesterol serum levels higher than 200 mg/dl had been detected in at least one child. At the time of diagnosis we analyzed serum lipoprotein profile and blood lymphocyte T subsets (CD3, CD4 and CD8). Children were classified according to LDL-C levels into three groups: (1) normal, if levels were between the 5th and 75th percentiles (50 and 125 mg/dl, respectively); (2) at moderate risk, if levels were between the 75th and 95th percentiles (125 and 150 mg/dl, respectively); and (3) at high risk, if levels were above the 95th percentile (150 mg/dl). In children aged 2.0 to 6.9 years, all lymphocyte T subset counts were higher in the high risk group than in the normal group (P < 0.05 and P < 0.01). In children aged 11.0 to 15.9 years, the CD4 subset count was also significantly higher in the high risk group in the other two groups (P < 0.05 and P < 0.01). These results are in agreement with pathologic findings in the atheromatous plaque.

Improvement of scleredema associated with IgA multiple myeloma after chemotherapy

The presence of a monoclonal gammopathy in patients with chronic scleredema is a recently described, unusual association of unknown significance. There have been very occasional reports of multiple myeloma in such patients. We now report a patient with long-standing scleredema who developed an IgA-kappa multiple myeloma. Once chemotherapy for the myeloproliferative disorder was instituted, scleredema improved significantly, suggesting a pathogenetic link between the two conditions.

Sclerosteosis in a Spanish male: first report in a person of Mediterranean origin

We report the first observation of sclerosteosis in Spain. To the best of our knowledge, this is the first case of sclerosteosis in a person of Mediterranean origin with no known Dutch ancestors. He has the characteristic phenotype of the disease with right facial nerve palsy and syndactyly and the typical radiological features, including generalised bone sclerosis and cortical widening of the tubular bones.

Priming with GHRH (1-29) NH2: an aid in differential diagnosis between hypothalamic and pituitary deficiencies

More than 80% of children with growth hormone deficiency (GHD) respond with a rise in growth hormone levels when given 1 microgram/kg body weight of growth hormone-releasing hormone (GHRH) in an i.v. bolus. We conducted a study to determine whether the failure of the remaining 20% to respond to GHRH is due to a pituitary deficiency or a secondary effect associated with chronically understimulated somatotrophs. We administered GHRH to "prime" 16 short-statured children (> 2 SD) presenting delayed growth (< 4 cm/year), who had not responded initially when given a single dose of GHRH. Priming consisted of administering GHRH (1-29) NH2 (5 micrograms/kg body weight, s.c.) for six consecutive days. Plasma GH response was studied again after an i.v. injection of 1 microgram/kg body weight of GHRH (1-29) NH2 on the seventh morning. On the basis of these results we were able to separate our patients into two groups: a) responders to priming (n = 8), whose GH responses to pharmacological and acute GHRH tests were < 10 ng/ml, with a 12-hour sleep secretion < 3 ng/ml/min. Priming increased the plasma GH response to acute GHRH in all the children in this group (6.0 +/- 2.1 ng/ml to 18.0 +/- 5.4 ng/ml; p < 0.001); b) non-responders to priming (n = 8), whose GH responses to pharmacological and acute GHRH tests were also < 10 ng/ml, with 12-hour sleep secretion < 3 ng/ml/min, but in whom priming with GH did not increase the plasma GH response (5.5 +/- 2.8 ng/ml to 6.2 +/- 2.9 ng/ml; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[The costs for a health center in relation to its activities]

OBJECTIVE

To establish a system of attributing costs of Health Centres (HC) in the Primary Care network in function of health care activity.

DESIGN

Crossover study with a descriptive component.

SETTING

Management. Primary Care.

PATIENTS OR OTHER PARTICIPANTS

22 Health Centres open during December 1991 within the Health Area.

MEASUREMENTS AND MAIN RESULTS

Two groups for cost attribution per Health Centre were agreed: articles from Chapter II relating to health care activity and Pharmacy spending-->costs relating to activity (CRA); the remaining articles from Chapter II and Chapter I (staff payments)-->costs not relating to activity (CNRA). Costs relating to activity made up 62.51% of the total cost per HC (2.72% articles from Chapter II and 59.79% Pharmacy). The remaining 37.49% corresponded to costs not relating to activity (1.38% to the remaining articles from Chapter II and 36.11% to staff payments).

CONCLUSIONS

We consider that the attribution of costs in function of the activity per HC is useful for the planning and management of Area resources and assists the application of efficiency criteria in Health Centres.

[Magnetic resonance in Hallevorden-Spatz disease]

The Hallevorden-Spatz disease should be suspected in children or young people with motor, pyramidal or extrapyramidal symptomatology and deterioration of superior functions specially upon the existence of family history. Pathognomonic diagnosis may only be obtained by necropsy but magnetic resonance images, although not pathognomic, are sufficiently characteristics to strongly support the diagnosis. Four cases of Hallevorden-Spatz disease are presented with special emphasis on the MR images characteristic of this disease.

Usefulness of serum apolipoprotein B levels for screening children with primary dyslipoproteinemias

OBJECTIVE

To assess the use of serum apolipoprotein B levels for screening children with primary dyslipoproteinemia (those with elevated levels of low-density lipoprotein cholesterol [LDL-C]) and to know the types of dyslipoproteinemias we can identify.

DESIGN

Criterion standard.

SETTING

Referral center.

PARTICIPANTS

We have studied 267 children. Of these, 31 had parents with dyslipoproteinemia, 38 had parents with ischemic heart disease, and 43 had hypercholesterolemia detected by routine analyses. One hundred fifty-five were considered healthy children and comprised the control group.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sensitivity was 87% for total serum cholesterol levels and 73% for serum apolipoprotein B levels. Of the children studied, 31 had elevated levels of serum LDL-C. The types of dyslipoproteinemia in children with both elevated levels of serum LDL-C and apolipoprotein B consisted of heterozygous familial hypercholesterolemia, found in 12 (50%) of 24 patients; familial combined hyperlipidemia, found in 11 (46%) of 24 patients; and polygenic hypercholesterolemia, found in one (4%) of 24 patients.

CONCLUSIONS

Serum apolipoprotein B level appears to be a good tool for screening children with elevated levels of LDL-C and is equivalent to using total serum cholesterol levels. In children with elevated serum LDL-C and apolipoprotein B levels, we can identify not only patients with heterozygous familial hypercholesterolemia but also those with familial combined hyperlipidemia or polygenic hypercholesterolemia.