The role of adherence in tuberculosis HIV-positive patients treated in ambulatory regimen

Adherence to antituberculosis treatment, a major determinant of outcome, is of special concern in human immunodeficiency virus (HIV)-positive patients. However, tuberculosis death in HIV-positive patients remains higher than in HIV-negative patients, regardless of adherence. To assess determinants for an unfavourable tuberculosis outcome (defined as no cure or death), and determinants for nonadherence to antituberculosis treatment, 70 HIV-positive patients with tuberculosis referred to an outpatient centre were studied. Patient outcome was compared according to HIV risk factors, other opportunistic diseases, antiretroviral drugs use, current i.v. drugs use, a methadone programme participation, tuberculosis features, treatment characteristics and adherence. Adherent and non-adherent patient characteristics were also compared. An unfavourable outcome occurred in 22.9% of patients and 32.9% were nonadherent with therapy. Nonadherence was the only independent determinant for an unfavourable outcome. Adherence was independently associated with current i.v. drug use, treatment complications and use of methadone. This study confirms that human immunodeficiency virus-infected patients, treated as outpatients, have high rates of nonadherence and that adherence is the strongest determinant for tuberculosis outcome. Independently of the current use of drugs, a methadone programme improves adherence to treatment.

[Human resources and the health system in Brazil]

This article discusses some questions related to human resources that act on Brazilian health system. At the beginning, it identifies the trends on health human resources in the last years. Then it shows on a brief discussion the health system reform, pointing out changes in the health model design through the implementation of the Family Health Program. This program tries to reorder the health care model, bringing the primary health care, in order to substitute the traditional model, designed to the cure of diseases and centered on hospitals. It also points out important changes on work conditions, such as: doctors' and dentists' no liberal work, low salaries, consultations paid by the HMO's, flexibilization of work, loss of work guarantees. Finally, it identifies serious problems in the Family Health Program, especially those related to the instability of work process and decreasing of social protection of workers who act on this program.

Identification of clinical staphylococcal isolates from humans by internal transcribed spacer PCR

The emergence of coagulase-negative staphylococci not only as human pathogens but also as reservoirs of antibiotic resistance determinants requires the deployment and development of methods for their rapid and reliable identification. Internal transcribed spacer-PCR (ITS-PCR) was used to identify a collection of 617 clinical staphylococcal isolates. The amplicons were resolved in high-resolution agarose gels and visually compared with the patterns obtained for the control strains of 29 staphylococcal species. Of the 617 isolates studied, 592 (95.95%) were identified by ITS-PCR and included 11 species: 302 isolates of Staphylococcus epidermidis, 157 of S. haemolyticus, 79 of S. aureus, 21 of S. hominis, 14 of S. saprophyticus, 8 of S. warneri, 6 of S. simulans, 2 of S. lugdunensis, and 1 each of S. caprae, S. carnosus, and S. cohnii. All species analyzed had unique ITS-PCR patterns, although some were very similar, namely, the group S. saprophyticus, S. cohnii, S. gallinarum, S. xylosus, S. lentus, S. equorum, and S. chromogenes, the pair S. schleiferi and S. vitulus, and the pair S. piscifermentans and S. carnosus. Four species, S. aureus, S. caprae, S. haemolyticus, and S. lugdunensis, showed polymorphisms on their ITS-PCR patterns. ITS-PCR proved to be a valuable alternative for the identification of staphylococci, offering, within the same response time and at lower cost, higher reliability than the currently available commercial systems.

Comparison of virologic, immunologic, and clinical response to five different initial protease inhibitor-containing and nevirapine-containing regimens

CONTEXT

The effectiveness of different protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors outside the setting of clinical trials has not been well described.

OBJECTIVES

To compare five different PI-and nevirapine (NVP)-containing regimens on virologic, immunologic, and clinical outcomes and treatment discontinuation.

DESIGN AND SETTING

Observational cohort study based on an HIV clinic in London.

PATIENTS

A total of 690 patients who received either saquinavir hard gel (SQV HG) (n = 183), indinavir (IDV) (n = 189), nelfinavir (NFV) (n = 109), ritonavir (RTV) (n = 42), ritonavir with saquinavir hard gel (RTV/SQV HG) (n = 45), or NVP (n = 122) as part of an initial PI-or NVP-containing treatment regimen between November 1994 and December 1998. A total of 351 (51%) patients had prior exposure to nucleoside reverse transcriptase inhibitors (NRTIs).

MAIN OUTCOME MEASURES

The main outcome measures were virologic undetectability, subsequent virologic rebound, CD4 cell count rise, development of AIDS, and treatment discontinuation. All analyses were stratified for year of initiation of the PI-or NVP-containing regimen.

RESULTS

Overall, 63% of patients attained an undetectable viral load (VL) within 6 months of starting their PI or NVP regimen. The adjusted relative hazard (95% confidence interval [CI]) for an undetectable VL relative to SQV HG was (in rank order): 2.77 (CI: 1.84-4.17) for NFV, 2.54 (CI: 1.81-3.57) for IDV, 2.43 (CI: 1.52-3.87) for RTV, 2.08 (CI: 1.28-3.37) for RTV/SQV HG, and 1.96 (CI: 1.35-2.85) for NVP. Forty-nine percent of patients experienced VL rebound within 12 months of initial attainment of undetectability, but relative to SQV HG, this did not differ significantly across the different PI and NVP regimens. The CD4 cell count response and rate of AIDS events were also similar across the different regimens. No independent predictors of VL undetectability were identified, but prior NRTI exposure was associated with VL rebound, and a lower baseline VL and CD4 cell count were associated with a reduced CD4 count response. The frequency (95% CI) of treatment discontinuation differed across the regimens; at 6 months, it was lowest for NFV (18% [CI: 13%-24%]), IDV (25% [CI: 22%-29%]), and NVP (28% [CI: 22%-34%]) and highest for RTV (41% [CI: 31%-52%]) and SQV HG (52% [CI: 48%-57%]).

CONCLUSIONS

Although PI- and NVP-containing regimens were similar in their CD4 cell count response and rates of subsequent VL rebound, differences were observed in time to VL undetectability and discontinuation rates relative to SQV HG. SQV HG was consistently inferior to the other PIs and NVP. The use of NFV and IDV was associated with the highest rates of undetectability, and together with NVP, the lowest rates of discontinuation.

Quantitation of cyclosporin A in whole blood by liquid chromatography/stable isotope dilution electrospray ionization mass spectrometry

Therapy with cyclosporin A (CsA) for immunosuppression after organ transplantation requires monitoring of its levels in blood owing to the narrow therapeutic index of the drug and to the high inter-individual variability of the drug absorption and metabolism. We describe the preparation of CsA labelled with stable isotopes ((13)C and (2)H) with an isotopic enrichment of about 99% using labelled glucose and its use as internal standard for quantification of CsA blood levels by isotope dilution/electrospray ionization mass spectrometry. The method was found to be linear in the tested range (1-1000 ng) with and without the matrix. The accuracy of the bracketting calibration curves prepared using 100 ng ml(-1) labelled CsA was within +/-1.7% (bias). The results confirmed the usefulness of the procedure as a reference method for the external quality assessment of the field methods for the evaluation of CsA blood concentration, the imprecision (relative standard deviation) and accuracy (bias) being <2%.

Appropriateness of emergency department visits in a Portuguese university hospital

STUDY OBJECTIVE

There are no studies in Portugal supporting a common claim that most emergency department visits are inappropriate. The aim of this study was to determine the prevalence of and to evaluate factors associated with an appropriate ED visit in a major public hospital.

METHODS

A cross-sectional prospective study was performed at a public university hospital ED. Data for demographic variables, duration of complaint, transfer from other medical sources, and previous medical care for the same complaints were collected by interviewing all patients who arrived at the ED within a consecutive period of at least 24 hours. Data for diagnostic tests, treatment performed, and final patient destination were collected by triage records review. An appropriate ED visit was defined by explicit criteria: interhospital transfer, patient death at the ED, hospitalization, and diagnostic tests or treatments performed.

RESULTS

The study included 5,818 adult patients. The prevalence of an appropriate ED visit, by use of our criteria, was 68.7%. Sex was an effect modifier. According to this study, determinants of an appropriate visit for men and women were age 60 years or older and complaints of 24 hours or less and in women but not in men, retired from work and with arrival between midnight and 8 AM.

CONCLUSIONS

In a university hospital in Oporto, the majority of ED visits were appropriate according to explicit criteria. Some variables may be associated with appropriateness of ED visits. A duration of the complaint 24 hours or less along with an arrival between midnight and 8 AM in women and age 60 years or older in men were the most important determinants.

Training needs of psychiatric intensive care staff

AIM

A survey was carried out to identify the education and training needs of psychiatric intensive care staff and the preferred type of training course. Demand for a specific psychiatric intensive care unit (PICU)/lowsecure training course was also examined.

METHOD

A convenience sample was taken from delegates attending a National Association of Psychiatric Intensive Care Units (NAPICUs) conference. Questionnaires were given to 130 delegates and a mail-shot was sent to ward managers on 13 PICUs in London.

RESULTS

The findings were that staff wanted further training in four main areas: the management of violence and aggression; psychological therapies; communication and engagement skills; and rapid tranquillisation. Most respondents indicated that they would like a course developed specifically for PICU staff at degree level in modular format.

CONCLUSION

This small-scale study highlights the need for further provision of training for PICU staff and provides an insight into their education and training needs. The findings could have significant implications for developing new approaches to education and training for practitioners working with severely ill psychiatric patients.

Laparoscopic cryoablation of a metastatic carcinoid tumor

Carcinoid tumors are rare, slow-growing neuroendocrine neoplasms that can cause a carcinoid syndrome. The majority of carcinoid syndromes are the result of multiple hepatic metastases and are usually unresectable. Medical therapy has not proven effective and often causes intolerable side effects. Cryoablation has emerged as a promising treatment for various hepatic lesions when resection is not an option and medical therapy has been exhausted. With the addition of laparoscopy, surgeons now possess a new technique to treat primary and various secondary liver lesions. We report for the first time laparoscopic cryoablation for the treatment of a carcinoid metastatic to the liver.

Resting murine neutrophils express functional alpha 4 integrins that signal through Src family kinases

There is mounting evidence that alpha(4) (CD49d) integrins are involved in neutrophil recruitment and function during inflammatory responses. We report that all resting murine neutrophils derived from bone marrow or peripheral blood express easily detectable levels of alpha(4) integrins on their surface. These alpha(4) integrins were functional, as demonstrated by stimulation of respiratory burst when neutrophils adhered to surfaces coated with the murine vascular cell adhesion molecule-1 (mVCAM-1). Adhesion occurred via alpha(4) integrins, as preincubation of neutrophils with an anti-alpha(4)-specific Ab inhibited attachment to mVCAM-1. Direct cross-linking of the alpha(4) integrin subunit by surface-bound mAbs also elicited superoxide release and release of the secondary granule marker, lactoferrin. The functional responses that occurred downstream of alpha(4) integrin cross-linking required signaling by Src family kinases. Neutrophils derived from hck(-/-)fgr(-/-)lyn(-/-) triple-knockout or hck(-/-)fgr(-/-) double-knockout mice failed to undergo respiratory burst when plated on mVCAM-1. Triple mutant neutrophils were also defective in release of both superoxide and lactoferrin when plated on surfaces coated with mAbs directed against alpha(4). Correlated with impaired alpha(4)-induced functional responses, triple-mutant neutrophils also failed to spread and tightly adhere to anti-alpha(4) mAb-coated surfaces. This is the first direct evidence that functional alpha(4) integrins are expressed by murine PMNs, and that these surface molecules can mediate cellular responses such as tight adhesion, spreading, sustained respiratory burst, and specific granule release in vitro. Moreover the alpha(4) integrins, like all other integrins tested, use the Src family kinases to transduce intracellular signals.

Transesophageal echocardiography in the assessment of patients presenting with ischemic cerebral events without previous evidence of a cardiac source of emboli

Transesophageal echocardiography (TEE) is accepted as a valuable tool in the evaluation of ischemic stroke patients, particularly in the young and in cases of unknown cause. However, the real clinical impact of additional TEE data remains to be defined.

PURPOSE

The aim of this study was to present our experience with TEE in ischemic stroke patients without previous evidence of a cardiac source of emboli.

METHODS

From March 1991 to June 2000 we studied 172 patients (80 males, 92 females, mean age 43 +/- 12 years presenting with a transient ischemic attack or a recent cerebral infarction who had no previous evidence by clinical assessment, electrocardiogram and transthoracic echocardiography of a cardiac of emboli source. The population was divided into two groups: Group A--age < or = 45 years, n = 101 (43 males, 58 females, mean age 34 +/- 7 years) and Group B--age > 45 years, n = 71 (36 males, 35 females, mean age 54 +/- 7 years). Information was gathered from clinical records. In every case TEE included Doppler color flow imaging and multiple contrast injections (agitated saline) with and without Valsalva maneuver.

RESULTS

A potential cardiac of emboli source was found in 29% of the patients, with a higher prevalence in the older group (group A--25%, Group B--35%, ns). Atrial septal abnormalities accounted for most of the detected findings (23 patent foramen ovale, 17 atrial septal aneurysms and two atrial septal defects, representing altogether 71% of the findings). The other detected anomalies were distributed as follows: aortic plaques--six, mitral valve prolapse--five vegetations--four, thrombus in left atrial appendage--two. Only six patients (3.5%) had abnormalities which in themselves determined a specific approach, which were found mostly in the older group (Group A--two vegetations; Group B--two vegetations, two thrombi).

CONCLUSIONS

TEE identified additional findings with possible embolic potential in a considerable number of cases, the majority of which were of a debatable cause-effect relation. A higher diagnostic yield and clinical relevance was found in older patients, which argues against age being used as a selective criterion for it. Our experience suggests that routine TEE in this setting is of questionable value and has little impact on clinical management, for which reason TEE referral should be decided on an individual patient basis.

Isolation of the melanoma-associated antigen p23 using antibody phage display

The general responsiveness of human melanoma to immunotherapy has been well established, but active immunotherapy of melanoma has been hampered by insufficient information on the immunogenicity of melanoma-associated Ags in patients. In this study, we isolated a recombinant phage-Fab clone (A10-5) from a phage-Fab library derived from the B cells of a melanoma patient in remission after immunotherapy. Purified A10-5 Fab bound at high levels to cultured melanoma cell lines and to tissue sections of metastatic and vertical growth phase primary melanoma, but not to radial growth phase primary melanoma, nevi, or normal skin. A10-5 Fab bound to both the surface and the cytoplasm of cultured melanoma cells, but only to the cytoplasm of cultured fibroblasts. Western blot analysis revealed A10-5 Fab reactivity with a 33- and a 23-kDa glycoprotein under nonreducing conditions, and with a 23-kDa protein only under reducing conditions. A cDNA with an open reading frame predicted to encode a 23-kDa protein was cloned by screening a melanoma cell cDNA library with A10-5 Fab. This protein (p23) is the human homologue of the murine tumor transplantation Ag P198 that interacts with the cytoplasmic domain of ErbB-3 expressed by melanoma cells. Thus, the Ab phage display method has identified a novel, stage-specific melanoma-associated Ag that may have therapeutic and diagnostic value.

[Dementia as a result of dural vascular malformation]

A case of dementia can result from encephalopathy caused by venous hypertension, produced by a dural vascular malformation (DVM). The authors describe one tentorial DVM with sinusal venous drainage and retrograde reflux to the cerebral veins (type II), that originated a leukoencephalopathy, and a progressive demential symptomatology. This demential status partially regressed after surgical treatment.

Light propagation through birefringent, nonlinear media with deep gratings

We present a theory that includes birefringence in the description of one-dimensional photonic band-gap materials with a Kerr nonlinearity. The Bloch functions in the absence of nonlinearity completely characterize the linear problem, for deep as well as shallow gratings, and the method of multiple scales is used to include the effects of nonlinearity and finite optical pulse length. We derive two sets of equations appropriate in different frequency regimes, a set of coupled mode equations and a set of coupled nonlinear Schrodinger equations; we investigate the connections between these equations and where their regimes of validity overlap. Finally, we use our results to describe energy exchange between polarization modes in a birefringent medium.

Missense mutation R1066C in the second transmembrane domain of CFTR causes a severe cystic fibrosis phenotype: study of 19 heterozygous and 2 homozygous patients

We report the clinical features of 21 unrelated cystic fibrosis (CF) patients from Portugal and Spain, who carry the mutation R1066C in the CFTR gene. The current age of the patients was higher in the R1066C/any mutation group (P < 0.01), as compared to the deltaF508/deltaF508 group. Poor values for lung radiological involvement (Chrispin-Norman) and general status (Shwachman-Kulcycki) were observed in the R1066C/any mutation group (P < 0.005 and P < 0.0004). A slightly, but not significantly worse lung function was found in the R1066C/any mutation group when compared with the deltaF508/deltaF508 patients. No significant differences were detected regarding the age at diagnosis, sweat Cl-values, or percentiles of height and weight between the two groups. Neither were significant differences observed regarding sex, meconium ileus (4.7% vs. 11.1%), dehydration (10.5% vs. 14.7%), or pancreatic insufficiency (PI) (100% vs. 97.8%). The proportion of patients with lung colonization by bacterial pathogens was slightly, but not significantly higher in the R1066C/any mutation group (70.0%), as compared with the deltaF508/deltaF508 group (57.5%). Other clinical complications were significantly more frequent in the R1066C/any mutation patients(P < 0.02) than in the deltaF508/deltaF508 group. The two homozygous R1066C/R1066C patients died at the ages of 3 months and 7 years. The data presented in this study clearly demonstrate that the R1066C mutation is responsible for a severe phenotype similar to that observed in homozygous deltaF508 patients. The poor clinical scores and complications of patients with the R1066C mutation are probably related to their slightly longer survival.

Mutagenic activity of glycine upon nitrosation in the presence of chloride and human gastric juice: a possible role in gastric carcinogenesis

The mutagenic activity of glycine upon nitrosation was studied in the Ames tester strains TA98, TA100, TA102, and TA104. The results obtained show that glycine at acidic pH values and in the presence of Cl- can react with nitrite giving rise to genotoxic compounds to the tester strains used. When these experiments were carried out in the presence of gastric juice the genotoxicity observed was associated with the Cl- concentration in the different gastric juice samples. The nature and the mechanism of genetic lesion induced by the ultimate genotoxicant arising from the nitrosation of glycine are not fully understood. Primary amines (e.g., amino acids) have been described as potential alkylating agents after nitrosation. However, in our experimental conditions these alkylating activities were not detected, suggesting that other mechanisms could be involved in the genetic lesion induced by nitrosated glycine. The influence of Cl- in the genotoxic activity of glycine and other primary amines upon nitrosation and its possible involvement in the etiology of gastric cancer are discussed.

Identification of sulfonylureas in serum by electrospray mass spectrometry

Identification of sulfonylureas in serum is important in the diagnosis of hypoglycemic crisis of unknown origin. Methods based on HPLC with UV or fluorescence detection may give false positive results. Mass spectrometry may successfully avoid this problem. The described method allows the simultaneous identification and quantification of tolbutamide, chlorpropamide, glibenclamide, and glipizide in human serum using one of the tested sulfonylureas as the internal standard. Serum purification is carried out by solid-phase extraction with ENVI-C18 cartridges and samples are analyzed by liquid chromatography-electrospray mass spectrometry. For all drugs, the limit of detection and the limit of quantification are about 2 and 10 ng/ml, respectively.

Bragg-grating-enhanced polarization instabilities

Experiments demonstrate a dramatic decrease in polarization-instability threshold as an optical pulse is tuned near the short-wavelength edge of the photonic bandgap formed by a fiber Bragg grating. These enhanced nonlinear interactions and birefringent effects are modeled with coupled-mode numerical simulations. Nonlinearities are shown to increase much more rapidly than the effective birefringence as the pulse wavelength approaches the bandgap edge.

[Isolated infective endocarditis of pulmonary valve in patient with interventricular septal defect]

A case of isolated infective endocarditis of the pulmonary valve in a patient with known subpulmonary interventricular septal defect that had, as major complication pulmonary septic embolization, was reported by the authors. The disease followed an insidious course, diagnosed by the presence of vegetations in the echocardiogram, some of them larger than 1 cm. They were found in the right ventricular infundibulum and in the pulmonary valve leaflets. The isolation of Estreptococcus viridans in blood cultures has confirmed the diagnosis. In spite of appropriate antimicrobial therapy, according to the antibiogram data (with Ampicillin and Gentamicin), fever lasted for more than three weeks. This event suggested medical treatment failure and the possibility of surgery was considered. However, the endocarditis eventually healed with medical therapy alone, and this unusual course with prolonged fever was presumed to be caused by lung metastatic infection secondary to septic embolization. This complication is relatively common, but lung involvement is usually a subclinical event, not responsible for such persistent fever, as happened in the case now reported. We emphasize the rarity of this case, the unusual clinical course and the discussion concerning the therapeutic options.

Robust template matching for affine resistant image watermarks

Digital watermarks have been proposed as a method for discouraging illicit copying and distribution of copyrighted material. This paper describes a method for the secure and robust copyright protection of digital images. We present an approach for embedding a digital watermark into an image using the Fourier transform. To this watermark is added a template in the Fourier transform domain to render the method robust against general linear transformations. We detail a new algorithm based on polar maps for the accurate and efficient recovery of the template in an image which has undergone a general affine transformation. We also present results which demonstrate the robustness of the method against some common image processing operations such as compression, rotation, scaling, and aspect ratio changes.

Impaired arterial baroreceptor sensitivity before tilt-induced syncope

Autonomic dysfunction seems to play a central role in the pathophysiology of neurocardiogenic syncope (NCS) but conflicting data have recently become available. We evaluated autonomic nervous system (ANS) function (heart rate variability (HRV), systolic blood pressure variability (SBPV) and baroreceptor gain (BRG)) and non-invasive haemodynamics (cardiac output and total peripheral resistance) in patients with neurocardiogenic syncope. Retrospectively, we evaluated 12 NCS patients (positive head-up tilt without pharmacological provocation) in the basal state and at initial tilt, 12 non-NCS patients with tilt-negative syncope and 12 aged-matched normal controls. Prospectively, we evaluated 16 NCS patients to analyse the haemodynamics and ANS activity throughout the tilt test (beginning of tilt and before syncope occurs). HRV and SBPV were accessed by fast Fourier transforms (FFT) and spontaneous BRG by temporal sequences, slope and a index. Modelflow was used to quantify the non-invasive haemodynamics. None of the autonomic and haemodynamic parameters at baseline or in the first 10 min of tilt was different among the respective NCS, non-NCS syncope and normal control groups, except for SBP, which was higher at baseline in controls. Throughout the tilt test in the prospective NCS group, the heart rate increased (88-95 beats x min(-1), P<0.05), systolic blood pressure decreased (123-109 mmHg, P<0.01), and arterial baroreceptor gain was reduced (7.6 to 5.5 ms mmHg(-1), P<0.01) and the absolute high frequency component of HRV (HF HRV) decreased (150-80 ms(-2), P<0.05), before syncope occurred. There was no change in the low frequency component of HRV (LF HRV), SBPV, cardiac output (CO) or total peripheral resistance (TPR). Tilt-induced syncope could not be predicted by non-invasive haemodynamic or autonomic parameters at rest or in the initial minutes of tilt. The decrease in arterial baroreceptor gain could be a precocious expression of the transient autonomic dysfunction that characterizes the occurrence of neurocardiogenic syncope.

Diagnosis of fibromatosis colli by fine needle aspiration (FNA) cytology

This study presents eight cases of fibromatosis colli accurately diagnosed by FNA cytology. Fibromatosis colli is a rare fibroblastic lesion that manifests in the sternocleidomastoid muscle during the first to second months after birth. The tumours varied in size from 1 to 3 cm and engaged the lower, middle as well as the upper part of the sternocleidomastoid muscle. The FNA cytology smears showed mostly mature fibroblasts in a background of pink granular material and fragments of striated muscle fibres with degeneration. The cytological presentation together with the typical clinical setting will allow a definitive and accurate diagnosis, avoiding surgery.

[The initial loss of consciousness in spontaneous subarachnoid hemorrhage. What does it mean?]

BACKGROUND AND PURPOSE

Poor outcome and rebleeding, after admission to hospital of patients with spontaneous subarachnoid hemorrhage (SAH) has been found to be predicted by loss of consciousness at ictus (LOCi). In this study, we assessed the clinical and neuro-radiological significance of the LOCi in non-traumatic SAH.

PATIENTS AND METHODS

The authors retrospectively studied 102 patients with SAH admitted to S. João Hospital between January 1, 1989 and December 31, 1992, who were divided into two groups with and without LOCi and compared according to clinical and imaging features.

RESULTS

Loss of consciousness at ictus was statistically associated with an age over 52 years (odds ratio, 2.9; 95% confidence interval, 1.1-7.8); a Hunt and Hess Scale score > ou = 3 (4.4; 1.6-12.3); finding of subarachnoid blood on initial cranial CT scan (5.5; 1.4-26.3); existence of aneurysm (3.4; 1.3-8.9); a Glasgow Outcome Scale score > ou = 3 (4.69; 1.6-14.1). A poor clinical condition on admission (5.2;1.8-14.5) and existence of aneurysm (4.1; 1.6-10.6) were the only two findings shown to have an independent power of significant association with loss of consciousness at ictus, using logistic regression analysis, with LOCi as a dependent variable.

CONCLUSIONS

In this study, LOCi has independent predictive power for a poor neurologic condition on admission and for the finding of aneurysm on angiogram. Loss of consciousness at ictus may be explained by the direct impact of the initial hemorrhage on the brain from a large tear in the aneurysmal wall, causing a quick rise in intracranial pressure (with LOCi) but a relatively short bleeding time.

[Fatal liver necrosis due to allopurinol]

Allopurinol hypersensitivity syndrome (AHS) is a severe reaction which is potentially lethal. Exanthematous rash, fever, eosinophilia, and other severe reactions such as toxic epidermal necrolysis, acute vasculitis, and severe hepatic and renal dysfunctions are manifestations of this syndrome. The authors report a case of lethal massive hepatic necrosis due to allopurinol in a patient with the asymptomatic hyperuricemia. They also describe the risk factors most frequently associated with the development of AHS and the strategy for its prevention and consequent reduction of the mortality associated with this syndrome.

Nonlinear pulse propagation in birefringent fiber Bragg gratings

We present two sets of equations to describe nonlinear pulse propagation in a birefringent fiber Bragg grating. The first set uses a coupled-mode formalism to describe light in or near the photonic band gap of the grating. The second set is a pair of coupled nonlinear Schroedinger equations. We use these equations to examine viable switching experiments in the presence of birefringence. We show how the birefringence can both aid and hinder device applications.

Transforming growth factor beta 1 binding and receptor kinetics in fetal mouse lung fibroblasts

TGFbeta1 inhibits fetal lung maturation in vitro. As TGFbeta1 is present in fetal lung, mechanisms must exist to overcome this inhibition and allow late gestation maturation to progress. We studied the ontogeny of TGFbeta1 binding, and TGFbeta receptor kinetics and subtypes in primary cultures of fetal mouse lung fibroblasts from Day 16 to Day 18 of gestation. TGFbeta1 specific binding in fetal lung fibroblasts declined with advancing gestation. The decrease occurred earlier, and was more pronounced in female fibroblasts (50% decrease) than in the male fibroblasts (29% decrease). Dihydrotestosterone treatment of Day 18 female fibroblasts resulted in a dose-dependent increase in TGFbeta1 binding. Scatchard analysis revealed a decline in receptor number with advancing gestation (Day 16 female Bmax: 7.3 x 10(-16); Day 18 female Bmax: 5.5 x 10[-16]) whereas binding affinities remained constant. Affinity labeling followed by chemical cross-linking and autoradiography showed the three known TGFbeta receptor subtypes at both Days 16 and 18 of gestation. The relative abundance of nonsignaling Type III receptors in comparison to signaling Type II and Type I receptors was increased at Day 18 versus Day 16. Incorporation of [3H]thymidine into DNA after treatment with TGFbeta1 changed from Day 16 to Day 18, consistent with changes previously reported between fetal and adult lung fibroblasts. We conclude that as fetal mouse lung maturation progresses, TGFbeta receptor number decreases in fibroblasts, the relative proportion of nonsignaling versus signaling receptor types increases, and the response to TGFbeta1 stimulation changes. These changes may contribute to overcoming TGFbeta1 inhibition of lung maturation.

Cytomegalovirus enteritis in a premature infant

BACKGROUND/PURPOSE

Up to 2.5% of newborn infants are cytomegalovirus (CMV) positive at birth. Five percent will be symptomatic at birth, including cytomegalic inclusion disease. Symptoms such as hearing loss and mental retardation will ultimately develop in 15%.

METHODS

The authors describe a case of CMV enteritis in a 2.2-kg newborn that presented as necrotizing enterocolitis (NEC) and subsequently developed a colonic stricture.

RESULTS

There are four reports of neonatal CMV enteritis in the nonEnglish-language literature. Cytomegalovirus enteritis has become prevalent among the immunosuppressed pediatric and adult patient population.

CONCLUSIONS

We propose the addition of CMV to the list of pathogens responsible for NEC. A review of neonatal CMV infection is provided.

Cardosin A, an abundant aspartic proteinase, accumulates in protein storage vacuoles in the stigmatic papillae of Cynara cardunculus L

The function of aspartic proteinases (EC 3.4.23) present in flowers of Cynara species is still unknown. Cardosin A, as a highly abundant aspartic proteinase from Cynara cardunculus L., a relative of the artichoke, is synthesised as a zymogen and subsequently undergoes proteolytic processing, yielding the mature and active enzyme. Here we report the study of the expression and localization of cardosin A, as a first approach to address the question of its physiological relevance. A polyclonal antibody specific for cardosin A was raised against a synthetic peptide corresponding to an amino acid sequence of the enzyme. This antibody was used to study the organ-specific, tissue-specific and subcellular localization of cardosin A by immunoblotting, tissue printing and immunogold electron microscopy. The results showed that expression of cardosin A is highly restricted to the pistils, and that the enzyme accumulates mainly in protein storage vacuoles of the stigmatic papillae. Cardosin A is also present, although much less abundantly, in the vacuoles of the cells of the epidermis of the style. In view of these results, the possible physiological roles of cardosin A are discussed, namely an involvement in defense mechanisms or pollen-pistil interaction, as well as in flower senescence.

Prenatal diagnosis of partial trisomy 2q. Case report

A case of partial trisomy 2(q21q33) detected by cordocentesis at 27 weeks' gestation in a polymalformed fetus is described. This is the second case of a prenatally detected de novo duplication of 2q and the first involving the region referred to above.

A survey of the attitudes of chronic psychiatric patients living in the community toward their medication

Because non-compliance with antipsychotic drug therapy is both common and associated with a substantially increased risk of acute relapse, depot medication must be preferred for most schizophrenic out-patients. Yet there is a perception that depot medication is unpopular among patients. In the survey of out-patients reported here, the great majority of patients receiving either oral or depot neuroleptics (with or without oral augmentation) would, given a free choice, elect to continue with their present dose form (94% and 87%, respectively). In virtually all cases, the choice of route was made by the treating physician and readily accepted by the patient. These findings suggest that physicians should more often recommend and prescribe depot medication when antipsychotic maintenance therapy is indicated.

Cytotoxic T-cell clone against rectal carcinoma induced by stimulation of a patient's peripheral blood mononuclear cells with autologous cultured tumor cells

In an effort to establish cytolytic T lymphocytes (CTLs) against colorectal carcinoma (CRC) by stimulating patients' lymphocytes with autologous tumor cells, we used peripheral blood mononuclear cells (PBMC) from a patient with minimal residual rectal carcinoma following removal of the primary lesion and involved regional lymph nodes as a source to generate CTLs in culture. A CTL line and clone were established from the patient's PBMC following stimulation of PBMC with autologous, cultured tumor cells and interleukin-2. The CTL line and the clone consisted predominantly of CD4+ lymphocytes. The CTL clone expressed two T-cell receptor variable alpha chains (V alpha11 and V alpha22) and one beta chain (Vbeta14). The cytokine secretion pattern of the CTL line was of the Th1-type. Both the CTL line and the clone lysed the autologous rectal carcinoma cells, but not the allogeneic, partially human lymphocyte antigen (HLA)-matched or nonmatched CRC cells, autologous Epstein-Barr virus-transformed B cells, K562 (natural killer target) cells or Daudi (lymphokine-activated killer target) cells. Lysis of autologous tumor cells most likely was HLA class I-restricted. Our unique success in generating CTLs against this tumor type may rest in the inclusion of a patient with minimal residual, rather than advanced, disease.

A model system for detection and isolation of a tumor cell surface antigen using antibody phage display

To establish a screening procedure for tumor cell-surface reactive Fabs, we used a model antigen/antibody system including the epidermal growth factor receptor (EGF-R) and the anti-EGF-R monoclonal antibody 425. The 425 Fab was displayed on the surface of M13 filamentous phage. In a screening assay for 425 phage binding to tumor cell surfaces, biotinylated 425-phage bound specifically to EGF-R-positive A431 epidermoid carcinoma cells and not to K562 non-expressor erythroleukemia cells. With a model library, the sensitivity of phage enrichment by phage binding to cell surfaces was one 425-phage in 20,000 unrelated phages after 4 rounds of panning on A431 cells. In a phage tissue screening assay, 425-phage, but not unrelated phage, bound specifically to melanoma cells expressing EGF-R. Epitope and idiotope specificity of 425-phage was demonstrated in phage competition assays, using as targets A431 cells and anti-idiotypic antibodies to monoclonal antibody 425, respectively. Finally, the EGF-R protein was directly isolated from A431 cell extracts, using biotinylated 425-phage. The data obtained with the 425 model library system demonstrate the usefulness of antibody phage display for the rapid identification and isolation of tumor or other disease-related cell surface antigens.

Does pulmonary tuberculosis change with ageing?

SETTING

In most low prevalence countries, tuberculosis has become a disease of the aged; it has recently been suggested that the elderly may present a specific pattern.

OBJECTIVE

To compare clinical, bacteriological and radiological features of pulmonary tuberculosis between young and elderly populations in a high incidence country.

PARTICIPANTS AND METHODS

We retrospectively studied 337 consecutive pulmonary tuberculosis patients without confirmed HIV infection, hospitalised from 1989 to 1993. The clinical, bacteriological and radiological features of the two age groups considered, young adults (< 60 years) and elderly (> or = 60 years), were compared.

RESULTS

Thoracic pain (16.3% vs 32.7%) and fever (27.2% vs 50.6%) were significantly less frequent in the elderly, while the frequency and duration of other symptoms before hospitalisation were similar. After admission, fever remained longer in young patients (P < 0.05). No significant differences were found regarding the general health status at hospitalisation, or associated illnesses (83.7% vs 73.5%; P = 0.068). Radiological lesions not related to the present diagnosis (14.1% vs 2.0%; P < 0.05), and a presumed diagnosis of tuberculosis (11.7% vs 4.1%; P = 0.02) were more frequent in the elderly.

CONCLUSION

This study showed no specific clinical, bacteriological or radiological features between age groups, and does not support the hypothesis of any age-related patterns in pulmonary tuberculosis.

Combinatorial antibodies against human malignant melanoma

The general responsiveness of human melanoma to immunotherapy has been well established, but active immunotherapy of melanoma has been hampered by insufficient information on the immunogenicity of melanoma antigens in patients. We have attempted to identify melanoma-associated antigens recognized by patients' B cells using an antibody phage display approach. Antibody display on filamentous phages allows direct screening of cDNA libraries for expression of cell-surface-reactive antibodies, without the need for antibody production and purification using bacteria or eukaryotic cell systems. This approach was used to identify melanoma-associated cell-surface antigens recognized by patients' B cells. Antibodies produced by the B cells of a melanoma patient (in remission for > 7 years following periodic vaccination with allogeneic melanoma cell vaccine) were displayed as Fabs on the surfaces of filamentous phages. A library of 10(8) phages was absorbed to normal melanocytes, followed by phage binding to and elution from melanoma cells (human lymphocyte antigen nonmatched and vaccine melanoma cells). Phages were further selected for reactivities with tunicamycin-treated melanoma cells. These procedures resulted in a > 10(6)-fold enrichment of tumor-specific phages from the original phage library. One phage-Fab bound to melanoma cells, other tumor cells, and a few normal cells in cultured cell lines and in tissue sections.

Liver transplantation for haemophiliacs with hepatitis C cirrhosis

BACKGROUND

Experience of liver transplantation in haemophiliacs with end stage hepatitis C liver disease is limited and particularly difficult questions are raised when there is also HIV infection.

AIMS

This is the first report in Great Britain to describe the operative replacement therapy and initial outcome in four haemophiliacs with end stage HCV cirrhosis.

PATIENTS

Two patients had factor VIII, one had factor IX, and one had factor X deficiency. One patient had also contracted HIV infection from factor replacement but had no AIDS defining illnesses.

METHODS

Intraoperatively patients were given either factor VIII infusions, factor IX bolus, or fresh frozen plasma, according to formulae devised to calculate exact clotting factor requirements. Baseline preoperative coagulation studies included prothrombin time, activated partial thromboplastin time, fibrinogen concentrations, and factor VIII, IX, and X concentrations. Factor concentrations were then assayed at 12, 24, 48, and 72 hours postoperatively.

RESULTS

Postoperatively all patients had coagulation factor concentrations sustained within the normal ranges by 72 hours unsupported (137, 125, 95, 104 IU/dl), representing de novo synthesis by the graft. Transfusion requirements during the operative and immediate post-transplant period were no greater than those of patients without clotting disorders. Two patients had episodes of bleeding postoperatively, one of which was fatal, occurring at the site of a previous untreated subdural bleed. In both instances the bleeding occurred in the presence of normal concentrations of clotting factor. The remaining three patients are at 6, 6, and 12 months post-transplant and remarkably improved clinically with sustained factor concentrations. One patient has evidence of graft dysfunction from HCV recurrence and all have evidence of recurrent viraemia with HCV on polymerase chain reaction studies.

CONCLUSIONS

Orthotopic liver transplantation should be considered in haemophiliac patients with end stage liver disease from hepatitis C infection with or without concomitant HIV infection. Their clinical condition is likely to be greatly improved by orthotopic liver transplantation and the haemophilia cured with only a small risk of severe graft dysfunction from recurrent HCV infection.

[Arterial hypertension in a patient with cardiac tamponade]

An elevated arterial pressure in cardiac tamponade, although not unusual might postpone the diagnosis of pericardial disease. We reported a case of cardiac tamponade, due to neoplastic infiltration of the pericardium, in which the diagnosis was first suspected by the presence of pulsus paradoxus. The patient presented cardiac tamponade and arterial hypertension simultaneously.

[Sympathetic nervous activity in cirrhosis: the relationship between peripheral hemodynamics and renal function changes]

The relationship between the activity of the sympathetic nervous system and the systemic and peripheral hemodynamic and renal function changes and the antinatriuretic activity in a group of 30 cirrhotic patients and 8 healthy subjects (control group) was investigated. Plasma catecholamines (noradrenaline, adrenaline and dopamine), plasma renin activity, plasma aldosterone concentrations, mean arterial pressure, cardiac output, blood volume, right femoral arterial flow (RFAF) and renal function parameters were determined in all the participants. Cyclic GMP urinary excretion (cV-UGMP) was used as an indirect index of systemic nitric oxide production. The plasma concentration of noradrenaline was greater in the patients than in the control group and was directly correlated with other vasopressor and antinatriuretic systems, RFAF, cV-UGMP, the degree of hepatic failure studied by the Pugh score and was inversely correlated with creatinine clearance and urinary sodium excretion. On Cox regression analysis, only the RFAF, creatinine clearance and plasma adrenaline concentration remained independently associated with plasma noradrenaline levels. Furthermore, plasma noradrenaline was significantly higher in patients with greater hyperdynamic circulation. These results indicate that extrasplanchnic vasodilatation substantially contributes to sympathetic nervous hyperactivity which may significantly influence in the renal function changes observed in these patients.

Otolaryngologic manifestations of multiple pterygium syndrome

Escobar Syndrome, or Multiple Pterygium Syndrome (MPS), is a rare syndrome with multiple congenital anomalies involving the head and neck area and limbs. Affected individuals have multiple pterygia, camptodactyly and/or syndactyly as the main features of this syndrome. Patients with MPS have a characteristic facies, including ptosis, antimongoloid slant of the palpebral fissures, hypertelorism, micrognathia, neck pterygia, and a sad flat, emotionless look to the face. We present a case of MPS recently treated at our institution for the purpose of further describing the clinical features of this syndrome, emphasizing the otolaryngologic manifestations. Increased awareness of MPS will facilitate appropriate management of this syndrome.

A mutation in the ATP binding domain of rho alters its RNA binding properties and uncouples ATP hydrolysis from helicase activity

The Escherichia coli mutant rho201 was originally isolated in a genetic screen for defects in rho-dependent termination. Cloning and sequencing of this gene reveals a single phenylalanine to cysteine mutation at residue 232 in the ATP binding domain of the protein. This mutation significantly alters its RNA binding properties so that it binds trp t', RNA 100-fold weaker than the wild type protein, with a Kd of approximately 1.3 nM. Rho201 binds nonspecific RNA only 3-4-fold less tightly than it binds trp t', while the wild type differential for these same RNAs is 10-20-fold. Curiously, rho201 displays increased secondary site RNA activation, with a Km for ribo(C)10 of 0.6 microM, compared to the wild type value of 3-4 microM. Although rho201 and the wild type protein hydrolyze ATP similarly with poly(C), or trp t' RNA, as cofactors, rho201 has a higher ATPase activity when activated by nonspecific RNA. Physically, rho201 displays an abnormal conformation detectable by mild trypsin digestion. Despite effective ATP hydrolysis, the rho201 mutant is a poor RNA:DNA helicase and terminates inefficiently on trp t'. The single F232C mutation thus appears to uncouple the protein's ATPase activity from its helicase function, so rho can no longer harness available energy for use in subsequent reactions.

Analysis of E. coli rho factor: mutations affecting secondary-site interactions

To define and differentiate primary and secondary RNA binding sites within the linear sequence of the rho protein, we investigated two mutant alleles, rho-115 and rhosuA1. They were first identified as defective in transcription termination in vivo, and later demonstrated to be defective in their interactions with RNA at the primary and secondary sites, respectively. Sequencing of rhosuA1 revealed a single lysine to glutamic acid residue change at position 352 (KE352), while rho-115 carries two mutations, glycine99 to valine (GV99) and a proline235 to histidine (PH235). Proteins carrying single mutations at each of these three positions were purified and their characteristics compared to the wild-type protein. We found both KE352 and GV99 to be defective in secondary-site RNA activation, with Km values for r(C)10 of 100 microM and approximately 650 microM, respectively, compared to the wild-type value of 4 microM. These observed secondary-site defects correlated with decreased helicase and ATPase activities, as well as a loss of transcription termination activity in vitro. By contrast, PH235 was very efficient at interacting with r(C)10 at the secondary site, with a measured Km of 0.5 microM, and displayed the characteristics of a hyperactive rho, as judged by its ATPase, helicase and termination capabilities. Our results show that mutations at three very different locations in the polypeptide can affect secondary-site activation by RNA, and that these interactions play a pivotal role in ATP hydrolysis, helicase activity and transcription termination.