Newborn screening for biotinidase deficiency in Brazil: biochemical and molecular characterizations

Biotinidase deficiency is an inherited metabolic disorder characterized by neurological and cutaneous symptoms. Fortunately, it can be treated and the symptoms prevented by oral administration of the vitamin biotin. Using dried blood-soaked filter paper cards, biotinidase activity was determined in the sera of 225,136 newborns in Brazil. Mutation analysis performed on DNA from 21 babies with low serum biotinidase activity confirmed that 3 had profound biotinidase deficiency (less than 10% of mean normal sera biotinidase activity), 10 had partial biotinidase deficiency (10 to 30% of mean normal serum activity), 1 was homozygous for partial biotinidase deficiency, 4 were heterozygous for either profound or partial deficiency, and 3 were normal. Variability in serum enzyme activities and discrepancies with mutation analyses were probably due to inappropriate handling and storage of samples sent to the laboratory. Obtaining an appropriate control serum at the same time as that of the suspected child will undoubtedly decrease the false-positive rate (0.09%). Mutation analysis can be used to confirm the genotype of these children. The estimated incidence of biotinidase deficiency in Brazil is about 1 in 9,000, higher than in most other countries. Screening and treatment of biotinidase deficiency are effective and warranted. These results strongly suggest that biotinidase deficiency should be included in the newborn mass screening program of Brazil.

Quality assessments of HMO diagnosis databases used to monitor childhood vaccine safety

OBJECTIVE

To assess the quality of automated diagnoses extracted from medical care databases by the Vaccine Safety Datalink (VSD) study.

METHODS

Two methods are used to assess quality of VSD diagnosis data. The first method compares common automated and abstracted diagnostic categories ("outcomes") in 1-2% simple random samples of study populations. The second method estimates positive predictive values of automated diagnosis codes used to identify potential cases of rare conditions (e.g., acute ataxia) for inclusion in nested case-control medical record abstraction studies.

RESULTS

There was good agreement (64-68%) between automated and abstracted outcomes in the 1-2% simple random samples at 3 of the 4 VSD sites and poor agreement (44%) at 1 site. Overall at 3 sites, 56% of children with automated cerebella ataxia codes (ICD-9 = 334) and 22% with "lack of coordination" codes (ICD-9 = 781.3) met objective clinical criteria for acute ataxia.

CONCLUSIONS

The misclassification error rates for automated screening outcomes substantially reduce the power of screening analyses and limit usefulness of screening analyses to moderate to strong vaccine-outcome associations. Medical record verification of outcomes is needed for definitive assessments.

Effects of GRF in early gestation on foetal development in Large White and Genex-Meishan gilts

The effects of growth hormone-releasing factor (GRF), given in early gestation, on reproductive traits, foetal development and pre-weaning growth of piglets from two breeds were studied. Large White (LW, n = 26) and Genex-Meishan (GM, containing 50% Meishan genes, n = 37) pregnant gilts were divided in two groups: (1) saline injections (n = 33) and, (2) injections of 6.66 µg kg-1 of a GRF analogue (n = 30), given thrice daily from days 18 to 33 of gestation. Jugular blood samples were collected on days 17, 34 and 109 of gestation and were assayed for various hormones and metabolites. Thirty-six gilts were slaughtered on day 110 of gestation and uterine, foetal and placental measurements were obtained. The other 27 gilts farrowed. There was a day × treatment interaction (P < 0.001) for glucose, insulin, free fatty acids (FFA) and insulin-like growth factor I (IGF-I), with values being greater on day 34 in gilts receiving GRF. The increase in insulin concentration was greater in LW- than in GM-treated gilts (P = 0.02). Exogenous GRF increased foetal weight in LW litters only (1.13 ± 0.04 vs. 1.05 ± 0.03 kg; P = 0.04) whereas fat content of carcasses tended to be lower only in foetuses of treated GM gilts (5.3 ± 0.2 vs. 5.8 ± 0.2%; P = 0.1). Weight of the longissimus muscle and its fibre number were not influenced by GRF. Furthermore, growth of piglets to 28 d was not affected by GRF treatment (P > 0.1). In conclusion, GRF given in early gestation seems to have different effects in LW and GM litters, yet it does not alter pre-weaning growth rate. Key words: Molybdenum, molybdenosis, copper, mine tailings, reclamation, animal health

Safety of neonatal hepatitis B vaccine administration

OBJECTIVE

To determine whether hepatitis B vaccination of newborns increases the incidence of fever and/or suspected sepsis.

METHODS

A prospective clinical study was undertaken at the Kaiser Permanente San Francisco Medical Center involving normal full term newborns born between November 1, 1991, and April 30, 1994. During this time 3302 infants were vaccinated within 21 days of birth with hepatitis B vaccine, and 2353 were not. Clinical and demographic data were collected from Kaiser Permanente's existing clinical information systems, and laboratory data for blood and cerebrospinal fluid (CSF) cultures were obtained from the comprehensive automated regional laboratory reporting system.

RESULTS

There were no significant differences between vaccinated and unvaccinated newborns in the proportion of infants who received care for fever (0.8% vaccinated and 1.1% unvaccinated, P = 0.28), allergic reactions, seizures or other neurologic events in the first 21 days of life. Vaccinated newborns were significantly less likely to undergo microbiologic evaluation for possible sepsis. Among vaccinated newborns 4.0% had blood cultures and 1.6% had CSF cultures. Among infants who were not vaccinated 8.3% had blood cultures and 1.6% had CSF cultures (P <0.001 for both tests).

CONCLUSION

This study found no evidence that newborn hepatitis B vaccination is associated with an increase in the number of febrile episodes, sepsis evaluations or allergic or neurologic events. In addition our data did not support any increase in medical procedures attributed to receipt of hepatitis B vaccine.

Heparin-binding outer membrane protein of chlamydiae

As an intracellular pathogen, the mechanism by which Chlamydia invade eukaryotic cells represents a cornerstone to understanding chlamydial biology. The ability of chlamydiae specifically to bind heparan sulphate or heparin and the association of this ability to bind and enter mammalian host cells was approached by searching experimentally for chlamydial outer membrane proteins that bind heparin. The 60 000 molecular weight cysteine-rich outer membrane complex protein, OmcB, bound heparin. The ability of OmcB to bind heparin was supported by mapping the region of the protein with heparin-binding capacity and demonstrating that an OmcB synthetic 20-mer peptide from this region specifically bound heparin. Surface localization of OmcB was shown using monospecific antisera specific to the 20-mer OmcB peptide that bound the surfaces of elementary bodies (EB) and by heparin-binding peptide cross-linking of EB surface proteins.

Interleukin-15 is the main mediator of lymphocyte proliferation in cultures mixed with human kidney tubular epithelial cells

BACKGROUND

Interleukin- (IL) 15 is a potent non-T cell-derived cytokine with IL-2-like activities. Elevated levels of IL-15 expression were observed in biopsies of acutely rejected human kidney grafts. We tested the role of IL-15 in mixed lymphocyte kidney reaction (MLKR) and the effects of immunosuppressive drugs on this reaction.

METHODS

Primary cultures of human tubular epithelial cells (TEC) were stimulated by interferon-gamma and treated with cyclosporin A (CsA, 10-1000 ng/ml), rapamycin (Rapa, 2.5-10 ng/ml), and dexamethasone (Dex, 10-10-10-7 M). IL-15 levels were measured by ELISA. To induce MLKR, we seeded OKT3-prestimulated allogenic human peripheral blood mononuclear cells (PBMC) on a monolayer of TEC in the presence of CsA (25-250 ng/ml), Rapa (0.25-1 ng/ml), and Dex (10-10-10-7 M). PBMC proliferation was quantified by 3H-thymidine incorporation.

RESULTS

CsA, Dex, and Rapa had no effect on IL-15 production by TEC. The presence of TEC induced marked proliferation of PBMC. Pretreatment of TEC with IFN-gamma enhanced MLKR in direct correlation with the increased IL-15 levels. MLKR was blocked by anti-IL-15, but not significantly by anti-IL-2 monoclonal antibody. Contrary to Rapa and Dex, CsA failed to inhibit MLKR CONCLUSIONS: IL-15 is a major mediator of lymphocyte proliferation in MLKR. Its production by TEC was unaffected by CsA, Rapa, and Dex. However, IL-15 activity is effectively inhibited by Rapa and Dex but not by CsA. The diversity in the effects of the various drugs is probably related to the different mechanisms. Our results support the possible involvement of renal IL-15 in graft rejection and suggest that resistance to CsA treatment is related to its failure to decrease IL-15 activity.

An optical fibre sensor for in situ measurement of external species in fluids based on artificial neural network pattern recognition

An optical fibre sensor system capable of detecting contaminants (e.g. particles, inorganic or organic species) in water and other fluids is reported. In this article experimental results are presented for a single optical fibre sensor located at a distance of 150 m from the transmitter/receiver of the system. The fibre is addressed using an optical time domain reflectometer (OTDR) in order to achieve the spatial resolution (along the fibre length) necessary for this investigation. Novel signal processing techniques involving artificial neural networks and pattern recognition have been applied to the signals arising from the sensor in order to allow cross-sensitivity effects, e.g. from fouling due to calcification, to be extracted from the real measurand, e.g. alcohol content.

A comprehensive screening program in South Brazil

We present the experience and figures about a screening program in South Brazil carried on in Porto Alegre, capital of the Southern Brazilian State. We present the tests performed routinely in our laboratory, the prevalence of some diseases and tests for infectious diseases to be added in the most comprehensive regional program in our country.

Persistent tyrosinemia detected by thin-layer chromatography

Screening for tyrosinemia is not routinely performed worldwide. Using a low expense thin-layer chromatography (TLC) for amino acids we detected a high frequency of transient tyrosinemia with secondary hyperphenylalaninemia in some newborns. Serum follow up showed the need to introduce adequate therapy in these babies.

Incidence and hospitalization rates of varicella and herpes zoster before varicella vaccine introduction: a baseline assessment of the shifting epidemiology of varicella disease

BACKGROUND

A 15-year postmarketing evaluation of the impact of varicella vaccine on the age distribution of varicella disease is being conducted at Kaiser Permanente Medical Care Program, Northern California (KPMCP). We report on a baseline assessment of the age-specific incidence and hospitalization rates of varicella and herpes zoster that was conducted before vaccine introduction.

METHODS

To assess the annual incidence of varicella, a telephone survey was conducted in a random sample of approximately 8,000 youths 5 to 19 years of age. The annual incidence of hospitalizations for varicella and herpes zoster in 1994 was assessed with the use of the computerized database at KPMCP.

RESULTS

Varicella annual incidence was 10.3% in 5- to 9-year-olds, 1.9% in 10- to 14-year-olds and 1.2% in the 15- to 19-year age groups, respectively. Hospitalization rates among the entire KPMCP membership were 2.6 and 2.1 per 100,000 person years for varicella and zoster, respectively. Varicella incidence in the 15- to 19-year age group was higher among African-Americans than among Caucasians.

CONCLUSIONS

Varicella rates were similar in the 5- to 9- and 10- to 14-year age groups to rates from other published studies conducted in 1972 to 1978, 1980 to 1988 and 1990 to 1992; however, the rate in 15- to 19-year-olds was 2 to 4 times higher than published rates in the same age category.

Measles-mumps-rubella and other measles-containing vaccines do not increase the risk for inflammatory bowel disease: a case-control study from the Vaccine Safety Datalink project

CONTEXT

A link between measles virus-containing vaccines and inflammatory bowel disease (IBD) has been suggested by recent studies.

OBJECTIVE

To address whether receipt or timing of measles-containing vaccine (MCV) increases risk for IBD.

DESIGN

A case-control study.

SETTING

Four large health maintenance organizations (HMOs) that are part of the Centers for Disease Control and Prevention's Vaccine Safety Datalink project.

PATIENTS OR OTHER PARTICIPANTS

A total of 155 persons with codes from International Classification of Diseases, Ninth Revision specific for IBD, born between 1958 and 1989 and enrolled from birth to the onset of disease, were identified. Up to 5 controls were matched by sex, HMO, and birth year.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Risk for IBD, Crohn's disease, and ulcerative colitis.

RESULTS

Past vaccination was not associated with an increased risk for Crohn's disease (odds ratio [OR] for measles-mumps-rubella vaccine [MMR], 0.4; 95% confidence interval [CI], 0.08-2.0), ulcerative colitis (OR, 0.8; 95% CI, 0.18-3.56), or IBD (OR, 0.59; 95% CI, 0.21-1.68). Risk for IBD was not increased among children vaccinated who were younger than 12 months (OR for MMR, 0.61; 95% CI, 0.15-2.45) or aged 12 to 18 months (OR, 0.86; 95% CI, 0.28-2.59) relative to unvaccinated children. Children vaccinated with MMR who were older than 18 months were at significantly decreased risk for IBD (OR, 0.16; 95% CI, 0.04-0.68). Neither past vaccination nor age at vaccination with other MCV was associated with increased risk for Crohn's disease, ulcerative colitis, or IBD. Risk for Crohn's disease, ulcerative colitis, or IBD was not elevated in the time immediately following vaccination with either vaccine.

CONCLUSIONS

Vaccination with MMR or other MCV, or the timing of vaccination early in life, did not increase the risk for IBD.

A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension

OBJECT

The object of our study was to determine, in children with traumatic brain injury and sustained intracranial hypertension, whether very early decompressive craniectomy improves control of intracranial hypertension and longterm function and quality of life.

METHODS

All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomized to standardized management alone or standardized management plus cerebral decompression. A decompressive bitemporal craniectomy was performed at a median of 19.2 h (range 7.3-29.3 h) from the time of injury. ICP was recorded hourly via an intraventricular catheter. Compared with the ICP before randomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomization in the control group, and 8.98 mmHg lower in the 48 hours after craniectomy in the decompression group (P=0.057). Outcome was assessed 6 months after injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the control group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracranial hypertension are treated with a combination of very early decompressive craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, and functional outcome and quality of life may be better than in children treated with medical management alone (P=0.046; owing to multiple significance testing P <0.0221 is required for statistical significance). This pilot study suggests that very early decompressive craniectomy may be indicated in the treatment of traumatic brain injury.

AMPA-receptor blockade within the RVLM modulates cardiovascular responses via glutamate during peripheral stimuli

We investigated the effects of AMPA-receptor blockade in the rostral ventrolateral medulla (RVLM) on cardiovascular responses and extracellular concentrations of glutamate during two different types of stimuli that activate peripheral Adelta - and C-fiber polymodal nociceptors using anesthetized rats. First, mechanical stimulation was achieved by applying a bilateral hindpaw pinch for 5 s, and second, thermal stimulation was evoked by immersing bilaterally the hindpaw metatarsi in a 52 degrees C hot water bath for 4 s. Mechanical stimulation increased mean arterial pressure (MAP) by 23 +/- 1 mmHg and heart rate (HR) by 25 +/- 3 bpm (n= 8). Thermal stimuli increased MAP by 32 +/- 3 mmHg and HR by 27 +/- 4 bpm (n= 8). After controlled generation of mechanical or thermal stimulation, 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; 1.0 microM) was microdialysed bilaterally into the RVLM for 30 min. Administration of CNQX attenuated MAP and HR responses during a subsequent mechanical but not during thermal stimulation. Analyses of extracellular concentrations of glutamate within the RVLM bilaterally revealed an increase of this neurotransmitter within the RVLM during mechanical noxious stimulation. Concomitant with attenuation of the cardiovascular responses, glutamate concentrations were also decreased during the mechanical stimulation after administration of CNQX. These results demonstrate that the AMPA-receptor blockade within the RVLM that attenuates cardiovascular responses during mechanical stimulation is associated with a reduction in extracellular levels of glutamate. In addition, it appears that AMPA receptors in the RVLM do not play a role in mediating cardiovascular responses during thermal stimulation.

Gel clot LAL assay in the initial management of peritoneal dialysis patients with peritonitis: a retrospective study

BACKGROUND

Indiscriminate use of broad-spectrum antibiotic treatment of peritonitis in peritoneal dialysis patients may have either unwanted side-effects or contribute to the development of antibiotic resistance. This may be avoided by improved diagnosis at presentation. The Limulus amoebocyte lysate assay is a convenient test detecting bacterial endotoxins or fungal beta glucans. This study evaluates a qualitative Limulus amoebocyte lysate test as a diagnostic tool used at presentation of a peritoneal dialysis patient with peritonitis.

METHODS

One-hundred and eleven episodes of peritonitis in peritoneal dialysis patients have been analysed retrospectively. Limulus amoebocyte lysate results at presentation were compared with culture results. A Limulus amoebocyte lysate assay was performed using a commercial kit by incubating a mixture of dialysate effluent and Limulus amoebocyte lysate reagent at 37 degrees C. The development of a stable solid clot was considered positive. The specificity and sensitivity of the test were calculated.

RESULTS

The specificity of the Limulus amoebocyte lysate assay was found to be 98% and the sensitivity 74%. Limulus amoebocyte lysate assay was false-negative in 13 cases of Gram-negative peritonitis (22%). Limulus amoebocyte lysate was positive in three of seven cases of fungal peritonitis. The study included one case each with false-positive Limulus amoebocyte lysate and with culture-negative peritonitis.

CONCLUSIONS

The Limulus amoebocyte lysate assay is a convenient and valuable diagnostic tool for excluding Gram-positive peritonitis in peritoneal dialysis patients. This allows more specific antibiotic treatment at presentation and may avoid the development of bacterial resistance. A negative Limulus amoebocyte lysate test is not reliable for the exclusion of Gram-negative peritonitis. In the absence of a positive culture result 48 h after presentation, accompanied by a delayed response to treatment, a positive Limulus amoebocyte lysate assay may indicate the presence of fungus. This justifies early empiric antifungal treatment before definitive culture results are made available. Routine Limulus amoebocyte lysate assay of dialysate effluent from continuous ambulatory peritoneal dialysis patients presenting with peritonitis is recommended.

Coloured overlays, text, and texture

In four studies children were asked to read aloud a passage of randomly ordered common words with and without a coloured sheet of plastic (overlay) placed upon the page. The children's rate of reading increased with the overlay, for some children more than for others. The children were also asked to undertake a test of texture segmentation in which targets consisting of a structured texture had to be distinguished from within a random background texture. The texture segmentation was improved when the overlay was used, again for some children more than for others. The improvement in texture segmentation was, in general, correlated with the improvement in rate of reading. Slower readers were generally poorer at texture segmentation. The implications for reading, for texture segmentation, and for clinical tests of vision are discussed.

Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group

OBJECTIVE

To determine the efficacy, safety and immunogenicity of the heptavalent CRM197 pneumococcal conjugate vaccine against invasive disease caused by vaccine serotypes and to determine the effectiveness of this vaccine against clinical episodes of otitis media.

METHODS

The Wyeth Lederle Heptavalent CRM197 (PCV) was given to infants at 2, 4, 6 and 12 to 15 months of age in a double blind trial; 37,868 children were randomly assigned 1:1 to receive either the pneumococcal conjugate vaccine or meningococcus type C CRM197 conjugate. The primary study outcome was invasive disease caused by vaccine serotype. Other outcomes included overall impact on invasive disease regardless of serotype, effectiveness against clinical otitis media visits and episodes, impact against frequent and severe otitis media and ventilatory tube placement. In addition the serotype-specific efficacy against otitis media was estimated in an analysis of spontaneously draining ears.

RESULTS

In the interim analysis in August, 1998, 17 of the 17 cases of invasive disease caused by vaccine serotype in fully vaccinated children and 5 of 5 of partially vaccinated cases occurred in the control group for a vaccine efficacy of 100%. Blinded case ascertainment was continued until April, 1999. As of that time 40 fully vaccinated cases of invasive disease caused by vaccine serotype had been identified, all but 1 in controls for an efficacy of 97.4% (95% confidence interval, 82.7 to 99.9%), and 52 cases, all but 3 in controls in the intent-to-treat analysis for an efficacy of 93.9% (95% confidence interval, 79.6 to 98.5%). There was no evidence of any increase of disease caused by nonvaccine serotypes. Efficacy for otitis media against visits, episodes, frequent otitis and ventilatory tube placement was 8.9, 7.0, 9.3 and 20.1% with P < 0.04 for all. In the analysis of spontaneously draining ears, serotype-specific effectiveness was 66.7%.

CONCLUSION

This heptavalent pneumococcal conjugate appears to be highly effective in preventing invasive disease in young children and to have a significant impact on otitis media.

Postmarketing evaluation of the safety and effectiveness of varicella vaccine

BACKGROUND

The Oka strain of live attenuated varicella virus was licensed for use in healthy children in the United States in March, 1995. We report a postmarketing evaluation of the short term safety of this vaccine within Kaiser Permanente.

METHODS

After licensure varicella vaccination was introduced into the preventive care program of the Northern California Kaiser Permanente Medical Care Program. Potential adverse events after vaccination with varicella vaccine were identified from automated clinical databases of hospitalizations, emergency room visits and clinic visits. Deaths were identified from automated clinical databases at Kaiser as well as from the State death records for California. To evaluate safety, rates of diagnosis-specific events in the risk periods were compared with the rates of such diagnosis-specific events in two self control and one historical control period.

RESULTS

During the study period of April 1, 1995, to December 31, 1996, a total of 89753 adults and children received varicella vaccine. A total of 3200 relative risks were calculated, and of these 5 hospital diagnostic categories, 9 emergency visit diagnostic categories and 30 outpatient diagnostic categories demonstrated at least 1 relative risk with a P value of <0.05 in 1 or more age groups and in comparisons with 1 control period or more. The p value for these tests was not adjusted for multiple comparisons. Of these categories 14 demonstrated an increased risk either in more than 1 age group or against more than 1 comparison group. These categories included elective procedures, febrile seizure, febrile illness, well child, acute gastroenteritis, varicella, congenital anomaly, "rule out sepsis," trauma, viral syndrome, apnea, back pain, congenital valvular heart disease and vision evaluation for glasses. Of these the outcomes of elective procedure, congenital anomaly, congenital valvular heart disease, well child and vision evaluation for glasses were judged not to have a biologically plausible association with vaccination. A second diagnostic grouping included febrile illness, viral illness, febrile seizure and "rule out sepsis." In an analysis of these events which adjusted for the concomitant administration of M-M-R(II) vaccine, none of the associations was statistically associated with receipt of varicella vaccine. The diagnostic category of "rule out sepsis" still had a relative risk of 1.95 with P = 0.02. None of the children in the "rule out sepsis" category had positive bacteriologic cultures from any other normally sterile site. Because of the large number of gastroenteritis cases, we reviewed a random sample of 100 exposed and 100 unexposed cases. From this review no consistent time association or clustering of any of these events was seen in the exposed follow-up time interval. Only gastroenteritis and negative evaluations for sepsis were thought to be possibly associated with receipt of varicella vaccine. Although there was a statistically significant increased risk over the entire 30 day-period, there was no clustering of these events within the 30-day window.

CONCLUSION

In this study population of 89753 children and adults, the varicella vaccine (Oka strain, Merck) appeared to have a favorable safety profile. In addition rates of varicella-like rash and of breakthrough cases were both low and consistent with the rates observed in prelicensure studies.

Lung matrix incorporation of plasma fibronectin reduces vascular permeability in postsurgical bacteremia

Plasma fibronectin (pFN) can incorporate into the lung extracellular matrix (ECM) as well as enhance hepatic cell phagocytic removal of bloodborne microparticulate debris that can contribute to lung vascular injury. Treatment of human pFN (hFN) with N-ethylmaleimide (NEM) blocks its ECM incorporation but not its ability to augment phagocytosis. Using hFN purified from fresh human plasma cryoprecipitate, we compared the effect of NEM-treated hFN versus normal hFN on lung transvascular protein clearance (TVPC) in postoperative bacteremic sheep to determine whether the ability of hFN to attenuate the increase in lung endothelial permeability required its ECM incorporation. Sheep with lung lymph fistulas were infused with a sublethal dose of Pseudomonas aeruginosa (5 x 10(8)) 48 h after surgery. In the first study, sheep received either FN-rich human cryoprecipitate, FN-deficient cryoprecipitate, FN purified from cryoprecipitate (hFN), FN-deficient cryoprecipitate reconstituted with purified hFN, or the sterile saline diluent. In the second study, sheep received either 200 mg of purified hFN (group I), 200 mg of NEM-treated hFN (group II), or the saline diluent (group III). In the first study, the increase in TVPC after bacterial challenge was attenuated by FN-rich cryoprecipitate, hFN, or reconstituted FN-deficient cryoprecipitate (P < 0.05) but not by saline and FN-deficient cryoprecipitate. In the second study, TVPC increased by 2 h (P < 0.05) and peaked over 4-8 h (P < 0.05) at 380-420% above baseline in postoperative bacteremic sheep given the diluent (group III). In contrast, intravenous infusion of hFN, but not of NEM-treated hFN, significantly (P < 0.05) attenuated this increase of lung protein clearance. Thus the ability for the intravenously infused purified pFN to attenuate the increase in lung endothelial protein permeability in sheep during postsurgical bacteremia appears to require its ECM incorporation into the interstitial ECM of the lung.

Setting up a school asthma clinic

There is a high level of non-compliance with medication among teenagers with asthma. A school asthma clinic was set up to reduce non-compliance by encouraging adolescents to take control of their asthma management. A reduction in asthma-related problems was noted at the school.

Endothelial cell DNA transfer and expression using petri dish electroporation and the nonreplicating vaccinia virus/T7 RNA polymerase hybrid system

The nonreplicating vaccinia virus MVA/T7 RNA polymerase hybrid system was tested with Petri dish electroporation for ectopic gene expression in human umbilical vein endothelial cells (HUVECs). A range of voltages (150-450 V), pulse times (10-40 ms), DNA concentrations (0-20 microg/ml) and infection levels (0-15 multiplicities of infection) were tested for effects on T7 promoter-directed chloramphenicol acetyltransferase (CAT) activity after MVA/T7RP infection. MVA/T7RP-directed expression was transient and at least 10 000-fold in excess of nonviral, cytomegalovirus enhancer-directed expression. Use of a Petri dish electrode with the MVA/T7RP system showed increased viability compared with a cuvette electrode. Overexpression of interleukin-2 alpha subunit (IL2Ralpha) pro- tein followed by anti-IL2Ralpha-directed magnetic immunoaffinity cell sorting allowed isolation of the transfected population. The high fidelity of cellular sorting was shown by segregation of CAT activity in the IL2Ralpha-sorted population after transfection of T7 promoter-directed bicistronic IL2Ralpha/CAT DNA. Expression of a panel of proteins including the fluorophore green fluorescent protein as detected by fluorescence microscopy and p21cip1, p27kip1, pp60c-src, FGF-1, pRb, p107 and pRb2/p130 proteins was also achieved. Thus, use of the nonreplicating vaccinia virus/T7 RNA polymerase expression system with Petri dish electroporation is feasible for certain applications for the manipulation of HUVECs by gene transfer.

cut-1-like genes are present in the filarial nematodes, Brugia pahangi and Brugia malayi, and, as in other nematodes, code for components of the cuticle

A fragment of a cut-1 like gene from the filarial nematode Brugia pahangi (designated Bp-cut-1) was isolated by PCR from genomic DNA. The sequence was used to design primers for use in RT-PCR and resulted in the isolation of a cDNA fragment from larvae in the process of the L3-L4 moult. Screening of a B. malayi genomic library identified a single clone, Bm-cut-1. Using primers designed from the Brugia sequences, semi-quantitative RT-PCR was carried out on 11 different life cycle stages chosen to cover periods around the moult and inter-moult periods. This analysis demonstrated that the cut-1 mRNA was most abundant preceding the moult, consistent with its function as a cuticular protein. Immuno-gold electron microscopy using an affinity purified antiserum raised to the highly conserved region of Ascaris CUT-1 confirmed that the protein was restricted to a tight band in the median layer of the cuticle. Despite the fact that no transcripts could be detected in mature adult worms by RT-PCR, immuno-gold microscopy revealed staining of the microfilarial cuticle within the uterus of the adult female worm, suggesting that other cut-1-like genes are present in Brugia.

[Transient neonatal tyrosinemia: a frequent abnormality]

OBJECTIVE: To evaluate the frequency of transient neonatal tyrosinemia, with or without secondary hyperphenylalaninemia,observed through neonatal screening for metabolic disorders, andthe need of monitoration and intervention with drugs and/or specialdiet in selected cases. METHODS: 457.870 dried blood samples obtained by heel stickfrom 3 to 20 days old babies were qualitatively evaluated by aminoacid thin-layer chromatography. Positive cases were quantitativelyconfirmed in serum samples by fluorimetric measurement of tyrosineand phenylalanine. RESULTS: 1.231 dried blood samples displayed positive resultsfor tyrosine in the cromatographic evaluation. The fluorimetricserum analysis disclosed normal levels of tyrosine and phenylalaninein 822 patients. The remained 409 patients showed hightyrosine levels and were placed in three groups according to thetyrosine concentration. In 118 of these cases serum phenylalaninewas also increased. CONCLUCIONS: Transient neonatal tyrosinemia is a very frequentdisorder in neonates (1/372); in some cases very high levels werefound, not only of tyrosine but also phenylalanine. As this findingis not yet accepted as absolutely harmless, the monitoration of thissituation and the use of measures to lower the tyrosine and phenylalaninelevels should be considered by the pediatrician.

Amphetamines in hair by enzyme-linked immunosorbent assay

Human hair was collected from the occipital crown region of the head from several subjects; these hair samples were presumptively positive for amphetamines by a previously evaluated immunoassay. Hair was washed briefly with methanol to remove external contamination, then extracted with hot methanol for 2 h to recover the drugs. The extracts were evaporated to dryness, reconstituted in buffer, and analyzed using a new enzyme-linked immunosorbent assay (ELISA) technique adapted for the detection of amphetamines in hair. Gas chromatography-mass spectrometry was used as the reference technique. Cross-reactivity of several related compounds was evaluated by equating the inverse of the ligand concentration at 50% antibody binding to the affinity constant for each compound. The ratio of a compound's affinity constant to that for d-methamphetamine was used to derive percent crossreactivity. These experiments yielded values of 30.8% for d-amphetamine, 7.4% for I-methamphetamine, 4.3% for phentermine, 2.9% for I-amphetamine, and <1% for ephedrine, methylenedioxyamphetamine, and methylenedioxymethamphetamine. Cross-reactivity of unrelated compounds was found to be non-existent. The optimum cutoff concentration was determined by receiver operating characteristic curve analysis to be 300 pg/mg and the observed limit of detection was 60 pg/mg. Intra-assay precision at 300 pg/mg was 3.3% (coefficient of variation, CV), and the interassay CV was 10.5%. The sensitivity and specificity of the method were 83% and 92%, respectively.

Use of an objective structured clinical examination in evaluating student performance

BACKGROUND AND OBJECTIVES

The objective structured clinical exam (OSCE) is increasingly being used to evaluate student clinical performance. However, scant literature exists pertinent to this approach in evaluating family medicine clerkship performance. In this study, we assess 8 years' experience with a family medicine clerkship OSCE.

METHODS

Eight annual clerkship OSCEs and the performance of 696 students are described. Comparisons of faculty evaluation, written exam, and OSCE performance are made for 335 students. Post-OSCE student and faculty feedback regarding OSCE validity and utility is also presented.

RESULTS

Student performance is highest in medical history taking and physical examination and lowest in information-sharing stations. OSCE results appear to be relatively consistent on a year-to-year basis. OSCE, faculty evaluation, and written exam results have low overall levels of correlation, particularly in assessing performance that differs substantially from the mean. Students and faculty agree that the OSCE experience reflects skills that students should possess, but there is less agreement that the OSCE reflects clerkship-related learning and actual student performance. Both students and faculty derive insight from the OSCE regarding the definition of specific learning needs.

CONCLUSIONS

The family medicine clerkship OSCE we describe appears to provide consistent measures of student performance. Although content validity is high, further assessment is needed to assure construct validity. The OSCE experience provides students with a rich resource for defining clerkship-related learning needs. Study results strongly suggest that OSCEs, faculty evaluations, and written exams provide differing measures of student performance. The reasons for these differences merit further exploration.

A novel member of the transforming growth factor-beta (TGF-beta) superfamily from the filarial nematodes Brugia malayi and B. pahangi

Transforming growth factor-beta (TGF-beta) superfamily genes encode products controlling pattern formation, cell differentiation, and immune-mediated inflammation. Members of this superfamily are known in multicellular organisms from mammals to the model nematode Caenorhabditis elegans. Using PCR with oligonucleotides complementary to highly conserved motifs in the TGF-beta superfamily, we first isolated a genomic clone from the filarial nematode Brugia malayi. This gene, termed Bm-tgh-1 (TGF-beta homolog-1), spans 2.5 kb of genomic DNA and contains seven exons. Transcripts of this gene are poorly represented in cDNA libraries, but a full-length cDNA was isolated by RACE from B. pahangi (Bp-tgh-1). The tgh-1 genes from the two species are >98% identical at the nucleotide and amino acid levels, differing at 18/1576 base pairs and 5/428 amino acids; all nonsynonymous substitutions are in the long N-terminal propeptide. They show a high level of similarity throughout all seven exons to a C. elegans gene on cosmid T25F10. Homology to other members of the TGF-beta superfamily is restricted to the C-terminal domain which contains the mature active protein. Key features shared with other members of the superfamily include the tetrabasic proteolytic cleavage site to release an active C-terminal peptide, seven cysteines arrayed in identical fashion, and conserved sequence motifs. tgh-1 is most similar to the BMP-1 subfamily involved in developmental signaling in nematodes, insects, and vertebrates. RT-PCR on first-strand cDNA from both Brugia species, with primers specific to the 3' end, showed that tgh-1 is not expressed in the microfilarial stage, but is detectable in the mosquito-derived infective larvae and is maximal in maturing parasites around the time of molting in the mammalian host. Adult parasites show a relatively low level of expression. The identification of tgh-1, and its preferential expression in developing parasites, suggests that it may be involved in key developmental events in the complex filarial life cycle.

Prolonged use of coloured overlays for classroom reading

Ninety-three children in a primary school and 59 children in two first-year classes of a secondary school were asked individually to observe a paragraph of random letters arranged to resemble text, and to compare the perceptual effects on its clarity of coloured plastic sheets overlaid on the text. A total of 29 colours were compared using 10 coloured plastic sheets and 19 pairwise combinations of sheets, one superimposed on another. The resulting colours sampled CIE 1976 hue angle (huv) and saturation (suv) systematically and efficiently. All the children who reported beneficial perceptual effects (53 per cent) were given their preferred overlay or combination of overlays to use as and when they wished. When the children were examined three months later the children tended to choose a colour similar to one they had chosen previously. Ten months later, 22 per cent of those offered the overlaps were still using them of their own volition. These children, but not those who had ceased to use their overlay(s), read randomly ordered simple words more quickly with their overlay than without. In a second independent group of children referred to the Norfolk Sensory Support Service, who used overlays routinely, the reading speed was similar with a grey or clear overlay; and slower than with the chosen coloured overlay, suggesting that reduction of contrast was not the critical factor. In a third independent group of children in a primary school in Kent, the increase in reading speed with the chosen overlay predicted the children who continued to use their overlay during the ensuing eight weeks.

Efficacy of strength training in prepubescent to early postpubescent males and females: effects of gender and maturity

There has been considerable debate concerning the benefits of children participating in weight training programs. With the potential benefits of such training in specific rehabilitation regimens, the safety/efficacy of weight training is a topic in need of scientific study. Fifty-two experimental and 39 control subjects participated in this study. A 2 x 2 x 2 (gender by treatment by Tanner stage) ANOVA was used to examine pre- to post-test differences in six strength measures, eight anthropometric measures, five motor performance measures, and one flexibility measure associated with participation in a 12-week progressive resistance programme. In addition, safety of the weight training programme was examined. For strength differences, there were two significant main effects favouring strength gains in males and four favouring the experimental group. For anthropometric changes, 3-way interactions occurred that were not easily explained. However, the predominant main effect was treatment; the experimental group generally experienced gains in body segment girths with decreases in skinfold thickness. For motor performance, the experimental group had greater improvements in three of five parameters. The experimental group also had significantly greater gains in flexibility. The weight training programme was associated with only one injury. These findings support the general observation that physical benefits can be gained safely by children who participate in a weight training programme.

Risk of hospitalization because of aseptic meningitis after measles-mumps-rubella vaccination in one- to two-year-old children: an analysis of the Vaccine Safety Datalink (VSD) Project

OBJECTIVE

To assess the level of increased risk, if any, of hospitalizations for aseptic meningitis after Jeryl-Lynn mumps strain measles-mumps-rubella (MMR) vaccine in the Vaccine Safety Datalink population.

STUDY DESIGN

A possible increased risk of aseptic meningitis 8 to 14 days after receipt of MMR was observed in a preliminary screening analysis of automated data from the Vaccine Safety Datalink (VSD) project Year 2 analysis. To further evaluate this association a retrospective 10-year matched case-control study was undertaken in the four health maintenance organizations (HMOs) in the VSD project. Cases ascertained from a broad scan of the automated data were validated against a standard case definition. Two controls matched on age, sex, HMO and HMO membership were assigned per case.

RESULTS

The VSD project involves the cooperative collection of automated vaccination and medical outcome data from four large HMOs that currently have 500,000 children younger than 7 years of age under surveillance. Review of automated screening results from the first 2 years of data revealed a possible increased risk of aseptic meningitis 0 to 14 days after MMR with a relative risk of 3.61 (95% confidence interval, 1.0 to 13.1) although the total number of cases was small. Although the automated data had suggested a possible association of aseptic meningitis with MMR containing the Jeryl-Lynn strain of mumps, review of validated hospitalized cases during the observation period did not reveal evidence of an increased risk of aseptic meningitis after MMR containing the Jeryl-Lynn strain of mumps (odds ratio < 1.0 for all analyses).

CONCLUSION

Although it is recognized that hospitalized cases represent a minority of the total cases of aseptic meningitis, it is reassuring that in this evaluation no increased risk of aseptic meningitis after MMR vaccine was found.

Entomopathogenic nematode (Heterorhabditidae and Steinernematidae) spatial distribution in turfgrass

Understanding the temporal and spatial distribution of entomopathogenic nematodes is essential for determining the role of these insect parasites in soil communities and ultimately for their use in suppression of pest insect populations. We measured the vertical and horizontal distribution of endemic populations of entomopathogenic nematodes (Steinernema carpocapsae and Heterorhabditis bacteriophora) in turfgrass. Vertical distribution was determined by taking soil cores every 3 h from 05.00 to 23.00 h, over 4 days, and dividing the cores into 8, 1 cm deep sections. Steinernema carpocapsae was recovered primarily near the soil surface: 50% of positive sections were recovered in the thatch or first 1 cm of soil. S. carpocapsae recovery was lower during the middle of the day and none were recovered in the upper section. H. bacteriophora was recovered uniformly throughout the top 8 cm of soil and its vertical distribution did not change over the course of the day. Horizontal distribution was measured as the number of nematodes recovered from cores taken from 12 randomly selected 0.3 x 0.8 m sections from within four 15.3 x 15.3 m plots. Samples were collected biweekly over a 9-month period. H. bacteriophora had a patchier distribution than S. carpocapsae and both nematode species had more patchy distributions then their potential hosts. Our results support the hypothesis that these two species of nematode utilize different foraging strategies; S. carpocapsae primarily a surface adapted ambusher and H. bacteriophora as a cruise forager.

Transcription factor AP-2 regulates expression of the dopamine beta-hydroxylase gene

Expression of the gene encoding the neurotransmitter biosynthetic enzyme dopamine beta-hydroxylase (DBH) is regulated in a tissue-specific pattern, and transcription is influenced by environmental stimuli. Using the promoter proximal region of the rat DBH gene and nuclear extracts from SHSY-5Y neuroblastoma cells, a DNA-protein complex was identified that is competitive with oligonucleotides containing the recognition site of transcription factor AP-2. DNase footprint analysis identified an AP-2 binding site between -136 and -115 of the DBH promoter. Mutation of that AP-2 site results in a sevenfold reduction of basal reporter gene expression, but second messenger-stimulated activity is retained. Cotransfection of an AP-2 expression vector and a DBH promoter-reporter construct into cultured cells results in a sixfold stimulation of reporter gene expression, demonstrating the ability of AP-2 to trans-activate the DBH promoter. These results identify a new regulatory element on the rat DBH gene and suggest that the AP-2 site plays a role in maintaining basal levels of DBH transcription.

Incidence proportion of and risk factors for AIDS patients diagnosed with HIV dementia, central nervous system toxoplasmosis, and cryptococcal meningitis

We undertook this study to determine the incidence proportion of and risk factors for AIDS patients diagnosed with human immunodeficiency virus (HIV) dementia, central nervous system (CNS) toxoplasmosis, and cryptococcal meningitis. A historical cohort of 487 consecutive inpatients with AIDS treated by San Francisco General Hospital inpatient and outpatient services entered the study. We abstracted all available records for demographic information, diagnoses, and dates of death and estimated the incidence proportion of AIDS patients diagnosed with major CNS complications using the Kaplan-Meier method. We used the Cox proportional hazards model to analyze the effect of demographic factors on the hazard (risk per unit time) of diagnosis with these CNS conditions. The estimated incidence proportion of patients diagnosed with HIV dementia within 1 and 2 years of AIDS diagnosis increased from 0.10 to 0.18. Corresponding proportions were 0.10 and 0.19 for CNS toxoplasmosis and 0.10 and 0.14 for cryptococcal meningitis. Only HIV dementia was independently associated with increasing age at AIDS diagnosis (relative hazard [RH] of 2.75 for ages 41-50 [95% confidence interval, 1.08-6.98]; RH of 4.73 for ages > 50 [95% confidence interval, 1.41-15.87]) and with injection drug use (RH of 2.03; 95% confidence interval, 1.19-3.47). HIV dementia, CNS toxoplasmosis, and cryptococcal meningitis are about equally common complications in patients with AIDS, but only HIV dementia is associated with increasing age at AIDS diagnosis and injection drug use.

Managing expectations between patient and nurse

With increasing consumer interest in the cost and quality of healthcare, it is imperative that patients' expectations of nursing care be recognized and managed. This concept is critical to the continued viability of any healthcare institution in the current competitive market. The authors describe the process that one hospital undertook in looking at patient satisfaction with nursing care, the modification of a patient satisfaction tool, and the development of a quality model of care.

The effect of pergolide and MDL 72974 on rat brain CuZn superoxide dismutase

It has previously been shown that both the dopamine receptor agonist, pergolide, and the monoamine oxidase inhibitor, (-)-deprenyl, can cause induction of CuZn superoxide dismutase in the rat striatum. We have now confirmed this effect of pergolide (0.04 mg/kg i.p.) as being localised to the striatum, but not the cerebellum, and shown it to take 3 weeks to develop. Furthermore, we have found that MDL 72974, a more specific monoamine oxidase inhibitor than (-)-deprenyl, failed to bring about such an induction either at a low selective monoamine oxidase B inhibitory dose, or at a higher non-selective dose.

Immunofluorescent analysis of plasma fibronectin incorporation into the lung during acute inflammatory vascular injury

Incorporation of plasma fibronectin into tissues is believed to influence endothelial cell-cell interaction, as well as endothelial cell adhesion to matrix. We used immunofluorescent microscopy coupled with tissue extraction of noncovalently incorporated fibronectin to delineate the time course for matrix incorporation of soluble plasma-derived fibronectin into the lung of sheep during postoperative bacteremia. Adult sheep were surgically prepared with both lung and peripheral lymph fistulas. Sheep were anesthetized 2 days following surgery and injected intravenously with a sublethal dose of live Pseudomonas aeruginosa, which consisted of 5 x 10(8) live organisms suspended in 0.9% saline. Bacterial infusion elicited a 300% increase in lung transvascular protein clearance but no increase in peripheral transvascular protein clearance. Purified dimeric human plasma fibronectin (hFn), used as an "immunologic marker," was then infused intravenously (100 mg/sheep) into two additional groups of sheep (nonbacteremic control group and bacteremic experimental group) and allowed to mix with the plasma pool of endogenous soluble sheep fibronectin (sFn). Incorporation of the plasma-derived hFn into the lung matrix and its distribution in relation to endogenous sheep fibronectin in the matrix was assessed by dual-label immunofluorescence using antibodies specific to either sFn or hFn. Human fibronectin from the vascular compartment codistributed with endogenous sheep fibronectin in the lung matrix. Moreover, its deposition into the lung was markedly increased in postoperative bacteremic sheep compared with nonbacteremic control sheep. Increased hFn deposition in the lung with bacteremia was clearly apparent within 2 h. The hFn deposited in the lung was nonextractable using a heparin-urea tissue extraction buffer, suggesting its rapid covalent cross-linking and incorporation into the lung matrix. Microscopic analysis of serial lung biopsies revealed focal areas of inflammation with an intense mononuclear infiltrate into the lungs by 2 h in the bacteremic sheep. Interstitial edema and vascular endothelial injury were observed by 4 h, with alveolar edema apparent over 6 to 8 h. Thus, postoperative bacteremia results in a rapid incorporation of plasma fibronectin into the lung matrix. This may be a physiologic mechanisms to stabilize the integrity of the lung vascular barrier.

ED1-containing cellular fibronectin release into lung lymph during lung vascular injury with postoperative bacteremia

Fibronectin (Fn) exists in both a soluble and insoluble form. Soluble Fn in plasma and lymph is an opsonic molecule that enhances phagocytic host defense. Insoluble Fn in the subendothelial and extracellular matrix is an adhesive molecule that mediates cell adhesion to substratum. The extracellular matrix of tissues such as the lung contains a mixture of both plasma-derived fibronectin (pFn) as well as locally synthesized cellular fibronectin (cFn). cFn is antigenically related to pFn, but cFn has extra domains (ED1 and ED2) that do not exist in liver synthesized pFn. The purpose of this study was to determine whether ED1-Fn was released into lung lymph before an increase in lung vascular permeability following postoperative bacteremia. Male sheep (n = 8) with surgically prepared lung lymph fistulae were infused intravenously with a sublethal dose (5 x 10(8)) of Pseudomonas aeruginosa 2 days following surgery. Lymph flow (QL), lymph-to-plasma (L/P) total protein ratio, lung protein clearance (QL x L/P), and hemodynamics were measured over 48 h following bacterial challenge. The lymph and plasma ED1-Fn concentrations were determined by enzyme-linked immunosorbent assay (ELISA) using a murine monoclonal antibody specific to the ED1 region of human cFn. There was a rapid rise of ED1-Fn flux in lung lymph which was evident 60 min after the start of bacterial infusion, resulting in a maximum three- to fourfold increase (P < 0.05) in this parameter. In contrast, the ED1-Fn concentration in plasma before bacterial infusion was less than lung lymph and it did not increase over the initial 6 h following bacterial infusion.(ABSTRACT TRUNCATED AT 250 WORDS)